Intra-abdominal access is obtained at the umbilicus through a veress needle and a 12 mm trocar is placed for the camera. The abdomen is insufflated to 14 mm of pressure with 4 L in. For the daVinci surgical system , special 8 mm trocars were placed directly lateral to the umbilical trocar which were inserted undervision. The trocars were placed at least between 8 and 10 cm away in order to prevent the robotic arms from obstructing against each other. An accessory 10 mm port was also placed on the contralateral portion of the abdomen about 2 cm from the midline between the umbilical and subcostal trocars. This trocar is placed contra laterally because the robot comes in the ipsilateral side of obstruction . After that the table was tilted back to the neutral position at which the patient was in complete flank..

The robot was advanced to the patient on the left side and docked to the trocars securely. The camera was introduced through the umbilical trocar and the robotic arms are extended through the daVinci ports. A robotic grasper was placed in both daVinci arm and cautery connected to the right. Dissection was started at the Tolds line & the colon was reflected medially. At the lower pole of the kidney the psoas muscle was exposed and medial dissection identified the stented ureter. The ureter was then dissected cranially to the renal pelvis preserving collateral vessels. The level of UPJ obstruction was identified with crossing aberrant vessel & ballooned pelvis. The renal pelvis was then dissected out of any surrounding fibrous tissue and all crossing vessels preserved. Once the proximal ureter and renal pelvis were fully mobilized the ureter was dismembered at the site of UPJO. Then the articulating robotic scissors was used for lateral spatulation of the ureter. The articulation of the robotic wrist of the scissors allowed for easier spatulation. The renal pelvis was then modified to the appropriate size. The crossing vessel was preserved & moved posterior to the uretero-pelvic anastomosis . Lastly, the anastomosis was performed using robotic needle drivers with interrupted suture with 4-0 absorbable suture ( vicryl on RB1 needle) at the apex of the spatulated ureter, first completing the posterior wall and then the anterior wall. The stent was pushed into the renal pelvis before finishing the anterior line of anastomosis. An abdominal portovac drain was placed. Then, ports were removed under vision & closure of the fascia by J needle 3/0 vicryl, followed by the skin with monocryl interrupted inverted stitch.

Post operatively, the patient was on pain management & antibiotic . The Foley’s was removed at the 3^rd day post operative & the Drain at the 4^th day The patient was discharged at the 5^th day post operative in a good condition. Her follow up in the clinic showed healed port scars.

On follow up 9 months latter , IVP & C.T Showed excellent results., Figure 1 &2.

Figure 1

Figure 1a: IVP, pre- operative

Figure 2

Figure 1b: IVP, post-operative

Figure 3

Figure 2: UPJO features on C.T (excretory phase), notice the aberrant vessel features .A: cut section, B: coronal section, , both pre-operative .

Figure 4