Minimizing minimally invasive surgery: The 5-mm trocar laparoscopic pyeloplasty

Background and Purpose: Laparoscopic pyeloplasty has evolved into the procedure of choice when definitive repair of the obstructed ureteropelvic junction is contemplated. Its main advantage over the gold standard of open pyeloplasty is decreased morbidity. We have utilized only three 5-mm ports in our last 15 pyeloplasties in an effort to further reduce morbidity and improve acceptance by an often-younger patient population. Patients and Methods: Fifteen consecutive patients underwent laparoscopic transperitoneal pyeloplasty by the 5-mm port technique. Three trocars were utilized, two for the working instruments and one for a 5-mm telescope mounted on a voice-activated robotic arm (AESOP; Intuitive Surgical, Sunnyvale, CA). Three patients required an additional trocar for liver retraction. All patients underwent dismembered pyeloplasty and had indwelling double-pigtail stents placed for 4 to 6 weeks. Results: The mean operative time was 195 minutes (range 120-240 minutes). The average blood loss was 30 mL. None of our patients required open conversion. With a median follow-up of 10 months (range 3-15 months), all 15 patients have shown both subjective (freedom from symptoms) and objective (renal scan) improvement. Conclusion: We believe our technique has further minimized the morbidity of laparoscopic pyeloplasty without compromising the outcome. The 5-mm trocars obviate fascial closure, decrease patient discomfort, and improve cosmesis. Furthermore, the use of the robotic arm eliminates the need for a surgical assistant and makes this an essentially "one-person" procedure.