Intraoperative Decision-Making: Thermal Injury During Robotic Pyeloplasty

Objective: To describe how an intraoperative thermal injury to the ureter was handled during a robotic dismembered pyeloplasty.

Methods: The patient was a 5-year-old male who was undergoing robotic dismembered pyeloplasty for a symptomatic left ureteropelvic junction (UPJ) obstruction. The case started with cystoscopy and retrograde ureteral catheter placement prior to moving to the robotic part of the procedure.

Results: During initial proximal ureteral dissection, there was an inadvertent thermal injury to the ureter due to arcing of the activated monopolar scissors via the fenestrated bipolar, which was providing upward ureteral retraction. This was approximately 3 cm from the UPJ. The ureter was immediately pale. The dissection continued, freeing the remainder of the ureter and renal pelvis; however, the injured ureter remained pale and the ureter proximal to this became mottled. There were concerns about ureteral viability. Given the voluminous renal pelvis available, the decision was made to perform a flap pyeloplasty, discarding the proximal ureter and bridging the resulting 3 cm ureteral gap. The patient had a successful repair. The patient's postoperative course was uneventful and his stent was removed 6 weeks later.

Conclusion: While all surgeons hope that operations go as planned, unexpected situations will arise and adaptation to these adversities is required. It is important to recognize thermal injuries, evaluate them repeatedly during the case, and amend the reconstructive repair as necessary given the extent of damage and available tissues.