Navigating the difficult robotic assisted pyeloplasty.

Pyeloplasty is the gold standard therapy for ureteropelvic junction obstruction. Robotic assisted pyeloplasty has been widely adopted by urologists with and without prior laparoscopic pyeloplasty experience. However, difficult situations encountered during robotic assisted pyeloplasty can significantly add to the difficulty of the operation. This paper provides tips for patient positioning, port placement, robot docking, and intraoperative dissection and repair in patients with the difficult situations of obesity, large floppy liver, difficult to reflect colon (transmesenteric pyeloplasty), crossing vessels, large calculi, and previous attempts at ureteropelvic junction repair. Techniques presented in this paper may aid in the successful completion of robotic assisted pyeloplasty in the face of the difficult situations noted above.