Driving a Robot? Be aware of the flat tire sign
Nicolas Fernandez, MD, PhD, Hailey Silverii, MD, Jennifer Ahn, MD.
Seattle Children's Hospital, Seattle, WA, USA.
Background:The malrotated obstructed kidney presents a unique problem for reconstruction. Outcomes for robotic pyeloplasty for malrotated kidneys are infrequently reported as a separate group in the literature, however in the few studies published, the need for revision operations is high when the index case is approached with the standard dismembered pyeloplasty technique. In this video, we illustrate preoperative identification and technical variations in robot assisted surgical technique.Methods:We performed a retrospective review of patients who underwent robotic pyeloplasty at our institution with malrotated kidneys.Results:We identified 4 cases in 41 robot-assisted pyeloplasties performed during a 3-year period. All cases had a preoperative renal pelvis with a “flat tire” appearance where renal pelvis was compressed against the psoas muscle. Intraoperative findings demonstrate a renal pelvis located behind the kidney with a high insertion of the ureteropelvic junction and no intrinsic ureteral narrowing. Technical surgical modifications include: 1. Thorough mobilization of the entire kidney to expose retro-renal renal pelvis. 2. Ureteropelvic junction orthoplasty. 3 Dismembered pyeloplasty with renal pelvis flaps. 4. Nephropexy and omental patch. Median follow-up is 11 months without any evidence of surgical failure.Conclusions: Recognition of the “flat-tire” sign is of great importance to counsel families and prepare for a more complex surgery. This anatomy is better identified with robot-assisted approach then open techniques. Recommended technical modifications may assist in improving surgical outcomes. Future studies should focus on reporting outcomes separately for patients with kidney malrotation with a "flat tire sign"
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