EDUCATION > Educational Programs > E-Learning > Urologic Robotic Surgery

Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of robotic pyeloplasty.
  • State the indications and contraindications for the robotic approach to the treatment of ureteropelvic junction obstruction.
  • Identify the appropriate instruments during robotic pyeloplasty.
  • Describe principles of Robotic Pyeloplasty, difficulties that may be encountered during pyeloplasty, and methods to manage them.
  • Describe complications that can occur during robotic pyeloplasty and methods to prevent and avoid the complications.


Steven M. Lucas, MD
Assistant Professor
Wayne State University
Detroit, MI
Disclosures: Nothing to disclose

Chandru P. Sundaram, MD
Professor of Urology
Director, Residency Program and Minimally Invasive Urologic Surgery
Indiana University School of Medicine
Indianapolis, IN
Disclosures: Nothing to disclose

Raju Thomas, MD, FACS, MHA
Professor and Chairman
Department of Urology
Tulane University of Health Sciences Center
New Orleans, LA
Disclosures: Gulf South Lithotripsy: Board Member, Officer, Trustee; Intuitive Surgical: Meeting Participant or Lecturer; AUA Journal of Urology Editorial Board: Board Member, Officer, Trustee; AUA Annual CME Courses: Meeting Participant or Lecturer; Journal of Endourology: Other: Reviewer; Journal of Urology: Board Member, Officer, Trustee; Urology Gold Journal: Other: Reviewer


Robotic Pyeloplasty


  1. Abstract
  2. Introduction
  3. Indications
  4. Preoperative Preparation
  5. Patient Positioning and Port Placement
  6. Instruments
  7. Mobilization of the UPJ
  8. Anastomosis
  9. Management of Complications
  10. Anomalous or Difficult Cases
  11. Postoperative Monitoring
  12. Results
  13. Conclusion
  14. Tables
  15. Figures
  16. References


Robotic pyeloplasty continues to gain acceptance as a first-line treatment for primary ureteropelvic junction obstruction with success and complication rates that are at least comparable to open or laparoscopic pyeloplasty. Renal reconstruction can be a challenging procedure. Ultimately it requires a widely patent, water-tight, and tension free anastomosis. In this course, we describe the techniques for robotic pyeloplasty, reviewing patient selection and preparation, operative set-up, mobilization of the UPJ, management of crossing vessels (if present), ureteral stent placement, and the anastomosis. In addition, the management of difficult cases is discussed. Finally, the recent results of some of the larger series are reviewed.

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The standard treatment for symptomatic ureteropelvic junction (UPJ) obstruction has been dismembered pyeloplasty. Open pyeloplasty has success rates of over 90%.1 With the improvement in endoscopic and laparoscopic techniques, minimally invasive treatment of UPJ obstruction became possible. While endoscopic treatment (an option for patients with short strictures, moderate hydronephrosis, and good preoperative renal function) has less success for primary obstruction, laparoscopic and robotic pyeloplasty have success rates that are similar to that for open pyeloplasty, while offering reduced postoperative pain and faster recovery.2 Robotic pyeloplasty has made minimally invasive pyeloplasty more accessible, and thus minimally invasive pyeloplasty has quickly become an accepted treatment for UPJ obstruction. Using data from the Nationwide Inpatient Sample, recent studies have continued to document favorable trends and general acceptance of robotic pyeloplasty for management of UPJ obstruction. 3,4

Adequate repair of chronically obstructed UPJ obstruction requires several elements. First, proper patient selection and counseling is essential. Mobilization of the ureteropelvic junction, removing all existing fibrosis, without compromising the viability of the reconstructed tissues is equally important. Finally, proper repair of UPJ obstruction requires a widely spatulated, tension-free anastomosis in a water-tight fashion. In this section, we review the steps, including preoperative preparation, intraoperative set-up, dissection, ureteral stent placement, and anastomosis, and summarize the recent results of robotic pyeloplasty.

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With the decreased long-term success rates of endopyelotomy for primary UPJ obstruction, all primary cases should be considered for pyeloplasty. Indications for correction of UPJ obstruction include patients that have radiographic or endoscopic evidence of obstruction, and present with clinical symptoms including recurrent urinary infection, nephrolithiasis, intractable or episodic pain limiting normal activity, or decreased split renal function. Since there is reliance on radiographic imaging, the diagnosis of UPJ obstruction has some pitfalls. A large renal pelvic stone, by causing edema, can mimic a UPJ obstruction that may resolve after treatment of the stone. Additionally, hydronephrosis does not always imply obstruction, thus a functional study would confirm this, such as a Mag-3 diuretic renal scan.

In many instances where endopyelotomy is less successful, pyeloplasty is a good treatment option. Instances of crossing vessels, severe hydronephrosis, strictures longer than 1cm and diminished renal function should indicate pyeloplasty rather than endopyelotomy. Conversely, very long strictures are not suitable for pyeloplasty either and require ureterocalycostomy or ureteral substitution procedures.

Contraindications to robotic pyeloplasty include an actively infected urinary system. The possibility of a severe infection including pyelonephritis, sepsis, or an intrabdominal abscess is increased when performing a pyeloplasty in this setting. A collecting system filling defect that is not consistent with urolithiasis is also a contraindication for pyeloplasty. Instead, this should indicate a closer examination via ureteroscopy or retrograde pyelogram to identify whether a neoplasm or polyp has developed. Finally, a nonfunctioning kidney, is a contraindication for a pyleoplasty, and is better suited for a nephrectomy if it is causing symptoms.

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Preoperative Preparation

Often patients are suspected of having a UPJ obstruction upon detecting hydronephrosis on upper tract imaging, including either a CT or an ultrasound, performed for flank pain or recurrent urinary infections. In the setting of obstruction and urinary infection, the patient often requires drainage of the obstructed kidney with a stent or percutaneous nephrostomy (PCN) tube, especially if there is evidence of pending sepsis. There is some debate as to whether stent or PCN is preferable, in patients who require drainage. A stent can make subsequent evaluation of the UPJ obstruction difficult, if further functional studies are required. It also is associated with ureteral and bladder discomfort that some patients cannot tolerate and can result in edema and inflammation of the UPJ. A PCN can aid in further study of the UPJ and indicate whether definitive treatment will be helpful in relieving a patient's symptoms. However, it is cumbersome to patients. In our practice most patients who require pre-op drainage are managed with a ureteral stent after obstruction is confirmed.

Anatomic study using a CT without and with IV contrast, including a dedicated arterial phase CT is a preferred method of imaging. Delayed phase CT can help ensure that there is no distal obstruction or ureteral dilation. Some argue that a CT is not absolutely required, and can subject patients to unnecessary radiation. If one is performing a robotic pyeloplasty, the crossing vessels, if there are any, can be identified and managed intraoperatively. Functional imaging, such as a mag-3 renal scan with lasix washout should be used to determine differential renal function and to identify obstruction. Obstruction is usually confirmed in patients with a T1/2 greater than 20min, most reliable in patients older than 1yr.5 In the presence of severe hydronephrosis, the T1/2 can, however, be misleading. Finally, retrograde pyelogram is helpful if the etiology is unclear or distal obstruction is also suspected. This can be performed in the same setting as the repair, at which time a stent can be placed.

Laboratory evaluation includes a urine culture to ensure that no infection is present at the time of the procedure. The patient should be given preoperative intravenous antibiotics at the time of the procedure. A bottle of magnesium citrate is taken the afternoon prior to surgery, with a clear liquid diet following this until midnight, after which the patient is made NPO. A bowel preparation is not performed by some surgeons.

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Patient Positioning and Port Placement

After administration of anesthesia, the patient is positioned with umbilicus at the break of the padded table and the involved flank upward at a 45 degree angle. An axillary role is placed, and the table is slightly flexed. The lower leg is flexed, and the upper leg is straight, with pillows between the legs and foam pad protecting the lower knee and ankle. The upper arm is placed across the shoulders, ensuring enough room to avoid collisions with the most cephalad robotic arm, and is supported with either an armrest or pillows. Alternatively the upper (ipsilateral) arm can placed alongside the patient and securely padded and taped. The lower arm is placed directly lateral from the lower shoulder on an arm rest. The patient is supported with a bean bag or linen rolls. He/she is then secured to the bed with tape in 3 or 4 places, below the knee, mid-thigh, and just below the nipple line. The bed is rotated to make the patient flat for access at the umbilicus. It is then rotated to nearly full flank for the procedure.

Access is obtained at the umbilicus, and a 12mm port is placed here. Lateral to the lateral border of the rectus, two fingerbreadths below the costal margin, an 8mm port is placed. A second 8mm port is placed in the midclavicular line, slightly below the umbilicus. There are 3 different options for camera placement (Figure 1). In the lateral configuration, a 12mm port is placed just off of the tip of the 11th rib (Figure 1A). A 30 degree upward lens is used. A modification of this places the camera more medial, nearly in a line with the 8mm ports, which are spread farther apart
(Figure 1B). Alternatively, a medial camera configuration can be used, in which the robotic camera is placed through the umbilicus and a 30-degree downward lens is used. Keeping the renal pelvis distended facilitates identification of the anatomy. This can be accomplished by clamping the foley, or if there is an external ureteral catheter placed, by filling the pelvis with saline.

We do not typically use the fourth arm to minimize the number of trocars. Retraction and stay sutures are used to facilitate exposure and tissue manipulation.

Alternatively, in a retroperitoneal approach, access is obtained at the tip of the 12th rib, where the robotic camera is placed. Two robotic trocars are then placed: one superior and posterior, at the edge of the quadratus lumborum, and the other 1-2cm inferiorly at the level of the anterior axillary line. A 12mm assistant port is placed just above the iliac crest along the anterior axillary line.

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Typically, a 30 degree upward robotic lens is used initially for a modified lateral or lateral camera position, while a 30 degreee down lens is used for a medial camera position. In the right robotic port, a Hot Shears™ (monopolar curved scissors, Intuitive surgical, Sunnyvale, California) is used. In the left, a PK Dissecting Forceps™ (Intuitive Surgical, Sunnyvale, California) is used. Instead, one could use a Robotic fenestrated bipolar forcepsTM , Prograsp™, or other perferred grasping robotic instrument (Intuitive surgical, Sunnyvale, California). A 4-0 or 5-0 polyglactin, or polydioxanone suture on an Rb-1 or SH needle, with one or two robotic needle drivers is typically used for the anastomosis. Alternatively, a robotic Fine-tissue Forceps™ (Intuitive surgical, Sunnyvale, California) can be used to minimize trauma to the tissue during the anastomosis. Robotic Potts Scissors™ (Intuitive Surgical, Sunnyvale, California) can be used for dividing and spatulating the ureter. The assistant can use a suction irrigator to provide exposure and retraction (Table 1).

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Mobilization of the UPJ

The dissection begins by reflecting the colon medially. Early identification of the ureter well below the kidney allows safe dissection. The ureter is freed in a cephalad manner, taking care to avoid skeletonization or injury to the periureteral vessels. Reflecting the mesentery medial as one proceeds cephalad, crossing lower pole vessels are encountered. These should be mobilized entirely from the UPJ (Figure 2). Small lower pole veins can be divided if extra laxity is needed to completely mobilize the UPJ from the lower pole artery. The anterior and posterior walls of the renal pelvis are entirely mobilized below the main renal vessels until the renal sinus is visualized to facilitate a tension free anastomosis. The lower pole vessels must also be dissected and mobilized thoroughly. Retraction sutures with 2/0 polyglactin on an SH needle can be placed in the Gerota's fascia and perirenal fat to reflect these tissues laterally to allow for improved exposure.

When the entire UPJ is mobilized additional stay sutures can be placed on the pelvis and the ureter to aide in reconstruction. The sutures are placed as follows: 1) on the medial side of the ureter in the stenotic area that is later excised, 2) Medial pelvis, just superior to the area excised, and 3) Lateral edge of the pelvis, superior to the area excised (Figure 3). Division of the UPJ is completed at nearly a 45 degree angle, starting superior to the stenotic segment on the medial surface and proceeding caudally as one divides laterally. The ureter is spatulated further on its lateral edge. The extent of the spatulation can be gauged by determining what area of the ureter can easily reach the pelvis without tension. Adequacy of the ureteral lumen at the apex of the spatulation can be confirmed by passing an 5 or 8Fr. infant feeding tube.

Prior to anastomosis, one must decide whether the crossing vessels, if present, should be transposed. In our experience, the vessel is no longer obstructing in some cases after mobilization, with the vessels lying well above the anastomosis. Further, when some vessels are moved posteriorly they appear to add to the obstruction (Figure 4). Once the UPJ has been adequately mobilized from the vessels, it is recommended that, just prior to the anastomosis, evaluate whether transposing the vessels posteriorly would increase or decrease the tension on or obstruction of the anastomosis.

There is considerable variability in placing a ureteral stent. It can be placed using cystoscopy in a retrograde fashion or placed antegrade via a port or angiocath. Placement of the stent in antegrade fashion can be done during division of the UPJ, (when the posterior wall is still yet intact), after completely dividing the ureter, or during the anastomosis (when the posterior wall is completed).

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The key element in UPJ repair is to create a wide anastomosis without tension. The anastomosis is completed with two sutures running from lateral to medial, approximating the posterior wall first, followed by the anterior wall. A 4-0 polyglactin or polydioxanone suture is typically recommended for the anastomosis. In some pediatric patients we use 5/0 polyglactin on an RB 1 needle. In beginning the anastomosis, we have found it useful to start on the outside of the pelvis, and then suturing this to the most dependent portion of the spatulated ureter in an inside-to-outside fashion. Once the knot is tied, the suture is brought behind the anastomosis and stent. By making an additional suture very close to the first suture in an outside-to-inside fashion on the ureter, the posterior anastomosis is now arranged for an ergonomically easy anastomosis (Figure 5). If there is tension on the first suture, placing interrupted sutures prior to the running posterior layer may reduce tension. When the posterior suture reaches the medial portion of the anastomosis, it is ended with the needle on the outside of the ureter, and the anterior layer is then sutured in a lateral-to-medial fashion and tied to the posterior suture. Before the anastomosis is complete, the pelvis is irrigated with the suction irrigator to eliminate any clots that may collect inside the pelvis or ureter.

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Management of Complications

Major intraoperative complications include injuries to the bowel, vasculature, or surrounding organs. Bowel injury affecting the serosa or small transmural perforations can be fixed via robotic suturing. Larger injuries will require open repair. Similarly, a injury to a large vein or artery can be sutured (or tamponaded if venous bleeding) robotically if good visualization can be maintained. Brisk, uncontrollable bleeding should prompt immediate open conversion. Occasionally, the small lower pole artery can spasm, causing partial renal ischemia which is usually reversible.

Postoperative complications include urine leakage, stent obstruction or migration, and sepsis. In most cases, urine leakage can be managed conservatively with a stent, foley, and a flank drain. In cases where, urine leakage is immediate, early in onset, and high volume, one must be concerned for disruption of the anastomosis, which may need formal repair. A formal imaging test would be helpful to confirm this and to ensure proper positioning of the stent. Abrupt leakage following at least a short period without leaking can signify an obstruction with a clot or migration of the stent. Patients with infection should be treated promptly with antibiotics. Prolonged or late onset fevers may require a CT scan to evaluate for an abscess.

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Anomalous or Difficult Cases

Small Intrarenal Pelvis

In cases with small intrarenal pelvises or high ureteral insertion, dismemberment and reanastomosis can be frought with extra tension. This can be avoided by performing a y-v plasty (Figure 6), which can transpose the UPJ caudally without exploiting the redundant pelvis as often done in a dismembered pyeloplasty. In the classical Y-V plasty, an incision is made on the lateral aspect of the ureter across the stenotic segment. Two horizontal incisions, one anterior and the other posterior, are made on the inferior pelvis. The vertex of the v created by these two incisions is pulled down to the most caudal portion of the incision on the ureter. The anastomosis is completed by closing the wings of the "v" as they travel upward onto the pelvis. A modification of this to incise the anterior portion of the ureter and make the incision on the pelvis on the anterior side, with 1 wing traveling toward the upper calyx, and one traveling toward the lower calyx.

Longer Strictures

Strictures longer than 2 or 3 cm present a challenge for repair. In this situation, it can be difficult to rejoin the ureter and pelvis without tension. A flap pyleoplasty may be needed to bridge the stricture. After incising the ureter in a vertical fashion along the stricture, a flap such as the Scardino-Prince vertical flap or Culp Deweerd spiral flap can be rotated down to cover the length of the incision. Alternatively, a ureterocalicostomy, usually reserved for recurrent, long strictures or strictures with a minimal amount of pelvis for reconstruction, has been reported.16

Renal Stones

Concomitant removal of nonobstructing renal stones has been reported with robotic pyeloplasty. The stones can be grasped with the robotic forceps once the pelvis has been incised. For calyceal stones that are more difficult to reach, a flexible nephroscopy can be placed through an assistant port. The stone is then removed with a basket.

Renal Anomalies: Horseshoe Kidney and Retrocaval Ureter

In the horseshoe kidney, there are often several aberrant vessels present, making this procedure difficult. Additionally, the kidney is often rotated such that the pelvis is more anteriorly placed, relative to the parenchyma. Posterior spatulation of the ureter may be needed to account for the rotation. Laparoscopic repair of a retrocaval ureter can be performed by dissecting the ureter both lateral and medial to the vena cava. The UPJ is dismembered at the lateral edge of the cava, and the ureter is mobilized medial to the vena cava. The horizontal portion lying posterior to the vena cava can be excised if atretic, and the anastomosis performed such that the UPJ is lateral to the vena cava.

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Postoperative Monitoring

Following robotic pyeloplasty, patients are monitored in the hospital for 1 day. A postoperative cephalosporin is administered for 2 doses. The patient has a urethral catheter and 10 or 15 French round bulb suction drain in place. In the morning following surgery, the urethral catheter is removed if the JP output is approximately 100ml per day or less. Elevated drain output prior to or after foley catheter removal can be evaluated for creatinine content. If this is also elevated further investigation and assessment of possible additional drainage to prevent leakage is needed. An abdominal x-ray can confirm stent position. If the drain output remains low, the drain is removed prior to discharge. A stent, if placed, is removed in 4-6 wks, and a functional study is obtained 6wks following stent removal.

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Robotic pyeloplasty for primary UPJ obstruction is associated with success rates greater than 95%. Intraoperative complications are rare with robotic pyeloplasty and postoperatively the risk of complications is <10%. The most common complication after robotic pyeloplasty is urine leak with an incidence of <5%. (Table 2). In the setting of recurrent UPJ obstruction, following open or laparoscopic pyeloplasty or endopyelotomy, robotic pyeloplasty has also proven effective. In this regard, recent investigations have shown success rates of 88-100% for patients undergoing robotic pyeloplasty for secondary UPJ obstruction. 12,14,15

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Safe and effective robotic pyeloplasty depends on adequate mobilization of the UPJ away from fibrotic elements and crossing vessels. A tension-free, wide, and water-tight anastomosis also is necessary for successful outcome. The early success of robotic pyeloplasty is comparable to that of open and laparoscopic pyeloplasty.

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Table 1 – List of instruments




Number of Uses


da Vinci Large needle driver (1)

Intuitive Surgical



da Vinci Hot Shears

Intuitive Surgical




da Vinci PK Dissecting Forceps

Intuitive Surgical

Da Vinci Prograsp, Fenestrated Bipolar


da Vinci Fine Tissue Forceps

Intuitive Surgical



da Vinci Potts Scissors

Intuitive Surgical



Stryke Flow 2 suction irrigator


Disposable suction, laparoscopic kittner

Disposable pump
Reusable metal tip

Table 2



OR time (min)



Mufarrij et al 2008




2 urine leaks
7% major complications
(7/10 were stent migration)

Gupta et al 2009




Gupta et al 2009




3 urine leaks,
2 conversion
1 port site hernia,
1 volvulus

Lucas et al 2012




10% major complications

Niver et al 2012




14% major complications

Sivaraman et al 2012




5% major complications

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Figure 1. Port placement for A) right pyeloplasty-diamond configuration with lateral camera placement, B) left pyeloplasty-modified lateral placement, and C) right pyeloplasty-medial camera placement.

Port placement for A) right pyeloplasty-diamond configuration with lateral camera placement, B) left pyeloplasty-modified lateral placement, and C) right pyeloplasty-medial camera placement.

Figure 2. The crossing vessels are completely mobilized off of the pelvis.

The crossing vessels are completely mobilized off of the pelvis.

Figure 3. Stay sutures placed along the ureter and pelvis can provide handles that aide in dividing the UPJ and in the anastomosis.

Stay sutures placed along the ureter and pelvis can provide handles that aide in dividing the UPJ and in the anastomosis.

Figure 4. Crossing vessel relative to renal pelvis. Placing the anastamosis anterior to the vessels (left) appears to add tension in this case versus leaving the vessels anteriorly and transposing them cephalad (right).

Crossing vessel relative to renal pelvis.  Placing the anastamosis anterior to the vessels (left) appears to add tension in this case versus leaving the vessels anteriorly and transposing them cephalad (right).

Figure 5. Placement of the first stitch (left) on the dependent lateral portion of the pelvis and the vertex of the spatulation. The suture is brought behind the anastomosis and the posterior wall is sutured toward the medial side (right).

Placement of the first stitch (left) on the dependent lateral portion of the pelvis and the vertex of the spatulation.  The suture is brought behind the anastomosis and the posterior wall is sutured toward the medial side (right).

Figure 6. Y-V plasty. The Y-shaped incision is sewn into a V-shape, with the vertex of the Y transposed to the inferior most portion of the incision.

Y-V plasty.  The Y-shaped incision is sewn into a V-shape, with the vertex of the Y transposed to the inferior most portion of the incision.

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  3. Sukumar S, Sun M, Karakiewicz PI, et al. National trends and disparities in the use of minimally invasive adult pyeloplasty. J.Urol. 2012 sep 188(3):913-8.
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  7. Mufarrij PW, Woods M, Shah OD, Palese MA, Berger AD, Thomas R, et al. Robotic dismembered pyeloplasty: a 6-year, multi-institutional experience. J Urol. 2008 Oct;180(4):1391-6.
  8. Gupta NP, Nayyar R, Hemal AK, Mukherjee S, Kumar R, Dogra PN. Outcome analysis of robotic pyeloplasty: a large single-centre experience. BJU Int. 2009 Oct 28.
  9. Patel V. Robotic-assisted laparoscopic dismembered pyeloplasty. Urology. 2005 Jul;66(1):45-9.
  10. Olsen LH, Rawashdeh YF, Jorgensen TM. Pediatric robot assisted retroperitoneoscopic pyeloplasty: a 5-year experience. J Urol. 2007 Nov;178(5):2137-41; discussion 41.
  11. Lucas SM, Sundaram CP, Wolf JS Jr, et al. Factors that impact the outcome of minimally invasive pyeloplasty: results of the muti-institutional laparoscopic and robotic pyeloplasty collaborative group. J Urol 2012 Feb 187(2):522-7
  12. Niver BE, Agalliu I, Bareket R, Mufarrij P, Shah O, Stifelman MD. Analysis of robotic-assisted laparoscopic pyeloplasty for primaryversus secondary repair in 119 consecutive cases. Urology 2012 Mar 79(3): 689-94
  13. Sivaraman A, Leveilee RJ, Patel MB, et al. Robot-assisted laparoscopic dismembered pyeloplasty for ureteropelvic junction obstruction: a multi-institutional experience. Urology 2012 Feb 79(2): 351-5.
  14. Hemal AK, Mishra S, Mukharjee S, Survavanshi M. Robot assisted laparoscopic pyeloplasty in patients of ureteropelvic junction obstruction with previously failed open surgical repair. Int J Urol 2008 Aug 15(8): 74-6.
  15. Lindgren BW, Hagerty J, Meyer T, Cheng EY. Robot-assisted laparoscopic reoperative repair for failed pyeloplasty in children: a safe and highly effective treatment option. J Urol 2012 Sep 188(3): 932-7.


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