laparoscopic repair of ureteropelvic junction obstruction ( upjo ) has become a standard - of - care technique in both children and adults . the increasing availability of surgical robots in large hospitals has resulted in an increase in the number of procedures that are being performed with robotic assistance . however , this widening of indications is often accompanied by doubts about the true benefit of robotic assistance for procedures where laparoscopy potentially provides the same results . once a robot is available , there is a tendency to use robotic assistance rather than perform conventional laparoscopy , and most data comparing the outcomes of laparoscopy and robotics is non - concurrent or multiple surgeon series . we acquired a four - arm da vinci s surgical system in august 2006 , and have been routinely using it for procedures that we originally performed laparoscopically or through open approaches . however , logistic constraints often result in our resorting to conventional laparoscopy , allowing us the opportunity to compare a concurrent cohort of patients undergoing the same surgery by the same surgeon . dismembered pyeloplasty for upjo is the most common surgery where we use conventional laparoscopy ( clp ) and robotic assistance ( ralp ) with almost equal frequency . a chart review was performed of all cases of ralp and clp performed by a single surgeon from september 2006 to july 2010 . all procedures were performed within the same time period and the surgeon had experience of less than 10 clps prior to this period . was based on the availability of the robot on the day the patient was scheduled for surgery . three arms of the four - arm da vinci s surgical system were used with one additional 12 mm port for the assistant . for clps an additional 5 mm port was used for liver retraction in right - sided procedures . all anastomoses in both sets of cases were performed with 5 - 0 polyglactin sutures . a peri - renal drain placed at the end of the procedure was removed when the 24-hour output was less than 50 ml . success was defined as the resolution of symptoms with non - obstructive outflow on the renogram . in the period under review , 30 patients underwent 31 laparoscopic pyeloplasties ( ralp : 19 patients  20 sides ; clp : 11 ) . one patient in the robotic group underwent bilateral simultaneous procedures , which has been previously reported . the operating time ( including docking time ) for robotic procedures was shorter by an average of 20 minutes . however , while 35% of the robotic procedures were performed in under 90 minutes , the minimum time taken for laparoscopy was 110 minutes , with most ( 90% ) being over 120 minutes . there were no complications in either group and the procedures were successful in all patients at the first follow - up scan . on days when the robot was available , often two pyeloplasties were performed in one list . however , on no occasion were two clps performed on the same day . although it was not measured objectively , the principal reason for this was surgeon fatigue after the clp . laparoscopy is one of the most significant advances of the twenty - first century surgical armamentarium , allowing significantly better cosmesis , lower pain , blood loss , and convalescence , with no loss of functional or oncological outcomes . one of the major issues with laparoscopy was the steep learning curve , partly due to the two - dimensional vision and limited movement of instruments . this was particularly evident in reconstructive procedures , which , in urology , consisted mainly of vesicourethral anastomosis and pyeloplasty . robotic assistance available to urology from the early 2000s , helped overcome these major limitations . the initial reports of robotic radical prostatectomy clearly stated the benefit laparoscopy nave surgeons derived from robotic assistance , enabling a wider availability of minimally invasive procedures . once robotic devices became widely available , they began to be used for an increasing number of procedures , which were hitherto routinely performed with conventional laparoscopy , with excellent outcomes . the high costs associated with the robot dampened the enthusiasm for its routine use , particularly when laparoscopy allowed similar outcomes . the data on ralp versus clp has generally been conflicting . a recent meta - analysis by braga et al . they found the operating time in ralp to be shorter by about 10 minutes and the hospital stay to be shorter by about half - a - day . our operating times were 20 minutes shorter on an average , while all other parameters were similar . an interesting finding in our data was that a larger number of robotic procedures tended to be of short duration compared to pure laparoscopic ones . this would suggest a minimum time required in clp that was difficult to further shorten . surgical experience is probably the most important factor in determining the outcomes . among the eight series reviewed by braga et al . , the maximal operating time advantage for robotic assistance was seen in a series where the surgeons had relatively lower laparoscopy experience . the impact of the learning curve on the outcomes of laparoscopic pyeloplasty has been well - established . it is evident that for surgeons who perform few clps or are in the early part of their laparoscopy career , robotic assistance may provide advantages . the strength of our study lies in the fact that it is a single surgeon evaluation of a concurrent cohort , minimizing the impact of the learning curve . this is different from most other single surgeon series where the comparison is non - concurrent.[1114 ] among these comparative studies , bernie et al they compared the outcomes of the first seven cases , each of laparoscopic and robotic pyeloplasties by the same surgeon and found no difference between the two procedures . the clps were performed before embarking on robotic procedures and the experience was thus not comparable . again , this series was not concurrent and the ralps reported were performed before the clps . their results were particularly surprising , as the authors had significant experience in both procedures and should not have been hampered by any learning curve . a significant , unmeasured , parameter noted in our series was of surgeon fatigue . despite only marginally higher operative times , fatigue at the end of a well - performed conventional laparoscopic pyeloplasty discouraged the performance of a second procedure the same day . increasing fatigue results in increased tremor and placing precise sutures can be difficult when the surgeon is tired . this became evident to us when we realized that we were routinely performing more than one reconstructive procedure , pyeloplasty or radical prostatectomy , when robotic assistance was available , while on no day were two clps performed . surgeon fatigue has been a poorly studied phenomenon . although it has been previously documented that laparoscopy is associated with increased risk of injuries to the surgeon , a comparison of the ergonomic outcomes between robotics and laparoscopy for the surgeon would be worth performing . finally , as with previously published studies , we found no significant difference in the outcomes between ralp and conventional pyeloplasty . ultimately , robotic assistance simply refines laparoscopy and does not change the basic surgical approach . there is thus unlikely to be any significant improvement in the outcomes , which are already very good . however , potential benefits to surgeons and busy hospitals would accrue from even marginal decrease in operating time and reduction in surgeon fatigue . both of these have the potential to contribute to a decrease in the overall cost of the procedure and increase its acceptability . it seems ergonomically superior for the surgeon , allowing multiple procedures in the same list .
introduction : the increasing availability of robotic devices has led to an increase in their use for procedures such as pyeloplasty , which have been conventionally performed laparoscopically or through open surgery . 
 we perform both laparoscopic and robotic - assisted pyeloplasty routinely and have compared these techniques in a set of concurrent cohorts , operated by the same surgeon.materials and methods : a chart review was performed of all cases of robot - assisted laparoscopic pyeloplasty ( ralp ) and conventional laparoscopic pyeloplasty ( clp ) performed by a single surgeon , from september 2006 to july 2010 . the choice of procedure depended upon the availability of the robot on the given day . 
 a lateral transperitoneal approach was used in all cases . 
 all anastomoses were stented antegrade . 
 a diuretic renogram was obtained in all patients between six to twelve weeks after stent removal . 
 success was defined as a resolution of symptoms with non - obstructive outflow on the renogram.results:thirty patients underwent 31 laparoscopic pyeloplasties ( 20 ralps and 11 clps ) , with one patient undergoing bilateral simultaneous robotic procedures . 
 the robotic procedures were superior in terms of shorter operating time by 20 minutes on an average . furthermore 
 , 35% of the robotic procedures were performed in under 90 minutes , while the minimum time taken for laparoscopy was 110 minutes . 
 all procedures in both cohorts were successful with no complications in either group . 
 the surgeon recorded subjective ergonomic benefits with the use of the robot.conclusions:robotic assistance helps decrease the operative time for laparoscopic pyeloplasty . 
 it seems ergonomically superior for the surgeon , allowing multiple procedures in the same list . 
 these may be important benefits in busy centers .