Surgical procedure and efficacy of KangDuo robot-assisted pyeloplasty for horseshoe kidney

Introduction

Horseshoe kidney (HSK), the most common renal fusion anomaly with an estimated prevalence of 1 in 500 individuals, presents a unique surgical challenge within urology (1-3). This congenital condition, characterized by an abnormal isthmus connecting the two renal lower poles, aberrant vasculature, and a high ureteral insertion point, predisposes patients to ureteropelvic junction obstruction (UPJO) often requiring surgical repair (4-7).

The surgical management of UPJO in HSK is considered one of the most complex procedures in upper urinary tract reconstruction (8). Historically, open dismembered pyeloplasty has been the gold standard (9). While laparoscopic pyeloplasty (LP) offers a minimally invasive alternative with comparable success rates, its application in HSK cases remains technically demanding due to the aberrant anatomy, limiting its widespread adoption in this specific context (10-15).

Robot-assisted surgery has emerged as a transformative technology that overcomes many limitations of conventional laparoscopy (16-18). Systems like the da Vinci platform provide superior three-dimensional (3D) visualization, enhanced dexterity with wristed instruments, and improved ergonomics, facilitating the precise dissection and suturing required in the complex anatomical landscape of HSK (18-20). However, the high acquisition and operational costs associated with platforms like da Vinci have restricted their accessibility, particularly in resource-conscious settings.

In this context, the Chinese developed KangDuo (KD) surgical robot system represents a significant advancement (21). It offers similar core benefits of robotic assistance—including stable 3D visualization, tremor filtration, and articulated instruments with multiple degrees of freedom—at a substantially reduced cost (22). Preliminary clinical studies have already demonstrated the safety and feasibility of the KD system in various urological procedures (23). However, no study to date has specifically evaluated the KD system for pyeloplasty in the setting of HSK. This study aims to detail the surgical technique and evaluate the clinical efficacy of KD robot-assisted pyeloplasty specifically for the treatment of UPJO in HSK, highlighting its potential as a viable and potentially cost-saving robotic solution for this complex condition. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0586/rc).

Methods

Materials and patients

A total of 14 adult patients with HSK underwent RALDP with KD from March 2021 to December 2025 at the Department of Urology, Peking University First Hospital and the Department of Urology, Peking University First Hospital-Miyun Hospital, Beijing, China. Surgical indications included persistent clinical symptoms, radiographic evidence of obstruction, or renal function deterioration. Exclusion criteria included a history of ipsilateral abdominal surgery, concomitant uncontrolled diseases, pregnancy or lactation, relatively high surgical risk or inability to tolerate surgery, and inability or reluctance to cooperate during follow-up. All data presented in this paper were collected in our database, Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER) and are available from the lead contact upon request. All surgeries were performed by an experienced surgeon using the KangDuo-Surgical-Robot-1000 (KD-SR1000) (Suzhou KangDuo Robot Co., Ltd., China) or KangDuo-Surgical-Robot-2000 (KD-SR2000) (Harbin Sagebot Co., Ltd., China). Among the 14 procedures, 7 were performed using the KD-SR1000 and 7 using the KD-SR2000. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Peking University First Hospital (approval No. 2025-1062). Informed consent was obtained from all the patients.

Surgical procedure

Preoperative preparation

All patients underwent comprehensive preoperative evaluation, including physical examination, ultrasonography, computed tomography urography (CTU) with 3D reconstruction, and diuretic renography (Figure 1). These assessments were utilized to delineate the complex urinary tract anatomy associated with HSK.

Figure 1 Preoperative CTU with three-dimensional reconstruction of a horseshoe kidney. CTU, computed tomography urography.

Trocar placement and robot docking

Following general anesthesia and endotracheal intubation, a 12-mm camera trocar, two to three 8-mm robotic trocars, and two assistant trocars (one 5-mm and one 12-mm) were placed. A “hidden-incision” configuration was adopted, with all port sites positioned below the umbilical horizontal line. The robotic arms were docked from the patient’s head, aligned parallel to the spine, while the assistant stood between the patient’s legs.

Dissection of the ureteropelvic junction

The mesenteric root and the intestine were mobilized to expose the affected ureter, which was circumferentially dissected with careful preservation of its vascular supply (Figure 2A). The obstructive ureteropelvic junction (UPJ) and the dilated renal pelvis were identified and isolated. Preoperative CTU 3D reconstructions provided critical anatomical guidance, enabling cognitive fusion for intraoperative navigation and identification of adjacent vessels (Figure 1). Aberrant crossing vein compressing the UPJ was carefully dissected (Figure 2B). Crossing arteries were managed by suspension or transposition if they contributed to obstruction, with preservation of the lower pole perfusion.

Figure 2 Key steps of the surgical procedure. (A) Dissection of the UPJ. (B) Dissection of an aberrant crossing vein. (C) Incision of the renal pelvis. (D) Extension of the pelvic incision. (E) Insertion of a calibrated catheter into the proximal ureter. (F) Anastomosis of the posterior wall. (G) Closure of the ureteral incision. (H) Insertion of the double-J stent. (I) Closure of the anterior wall. UPJ, ureteropelvic junction.

Pelvic tailoring and ureteral incision

A V-shaped flap was fashioned from the lower pole of the renal pelvis, with its apex directed toward the UPJ (Figure 2C). The dimensions of the flap were determined by the length of the stricture and the degree of hydronephrosis. When present, renal calculi were retrieved under CTU-guided localization using a flexible cystoscope introduced into the renal pelvis and calyces. A longitudinal incision was then made along the posterior ureteral wall, with its length calibrated to match the V-shaped flap for tension-free anastomosis (Figure 2D).

Reconstruction of the UPJ

A calibrated catheter was inserted into the proximal ureter to support suturing, taking care to avoid ureteral trauma (Figure 2E). The first suture was placed between the apex of the pelvic flap and the distal end of the ureterotomy. The posterior wall was anastomosed using a running 5-0 Vicryl suture (Figure 2F). After removing the ureteral catheter, a double-J stent was inserted over a guidewire (Figure 2G,2H). The anterior wall was then closed with a continuous 5-0 Vicryl suture. The UPJ was completely dismembered, and the stenotic ureteral segment together with redundant pelvic tissue were excised (Figure 2I). The renal pelvis was closed with a running suture. Throughout the anastomosis, tissue handling was restricted to the excised areas to prevent ischemia of the urothelium.

Completion

The peritoneum was closed, and a 20-Fr drain was placed near the reconstructed UPJ through a lateral trocar site.

Postoperative management and follow-up

Oral intake was advanced gradually from clear liquids to a regular diet as tolerated. Intravenous antibiotics were administered for the first two postoperative days. A kidney-ureter-bladder (KUB) radiograph was obtained to verify stent and catheter position. The Foley catheter was removed on postoperative day 7. The surgical drain was withdrawn once daily output fell below 50 mL. The double-J stent was removed 2 months after surgery. Follow-up included ultrasonography every 3 months during the first year and annually thereafter. All patients were scheduled to undergo magnetic resonance urography (MRU) at 3 months postoperatively as the primary imaging evaluation for hydronephrosis assessment. For patients with longer follow-up duration, additional MRU was performed at 15 and 27 months postoperatively according to the same institutional protocol. This approach ensured that every patient was evaluated using the same imaging modality (MRU) at the same postoperative time point relative to their own follow-up duration, and that all patients had at least a 3-month postoperative MRU assessment to confirm anatomical resolution of obstruction. Treatment success was evaluated in every patient using a consistent composite endpoint that included all three of the following criteria: (I) symptomatic relief: resolution of preoperative flank pain (asymptomatic patients were considered symptomatically successful); (II) radiographic improvement: demonstrable reduction of hydronephrosis on 3-month postoperative MRU, with no evidence of recurrent obstruction on any subsequent available imaging; and (III) stable or improved renal function: no decline in estimated glomerular filtration rate (eGFR) or serum creatinine at follow-up compared with preoperative baseline.

Statistical analysis

Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as mean ± standard deviation or median (range), as appropriate. Paired t-tests were used to compare preoperative and early postoperative renal function parameters (serum creatinine and eGFR). A two-sided P value <0.05 was considered statistically significant.

Results

The patient characteristics and preoperative details are presented in Table 1. A total of 14 patients were included in this study, comprising 7 males (50%) and 7 females (50%), with a median age of 37 years (range, 22–57 years). The mean body mass index (BMI) was 21.6±3.4 kg/m². The affected side was left in 7 patients (50.0%), right in 4 patients (28.6%), and bilateral in 3 patients (21.4%). The predominant presenting symptom was flank pain, observed in 12 patients (85.7%), while 2 patients (14.3%) were asymptomatic. Concomitant calculi were present in 7 patients (50.0%), and concomitant urinary tract infection (UTI) was noted in 1 patient (7.1%). Five patients (35.7%) had a history of preoperative stent insertion, and 1 patient (7.1%) had undergone prior nephrostomy. No patient had a history of ureteral reconstruction. The mean preoperative serum creatinine level was 77.8±17.3 μmol/L, and the mean preoperative eGFR was 93.8±14.9 mL/min/1.73 m².

Intraoperative details and follow-up results are presented in Table 2. Intraoperatively, 3 patients (21.4%) required additional nephrolithotomy. Crossing veins were encountered in five patients and crossing arteries in four patients. The mean operative time was 200.7±72.9 minutes. The median estimated blood loss (EBL) was 20 mL (range, 20–100 mL). The median time to drainage-tube removal was 3 days (range, 2–4 days), and the median postoperative hospital stay was 5 days (range, 2–7 days). No intraoperative complications or conversions to open surgery occurred.

Postoperatively, the mean serum creatinine level was 69.6±16.6 μmol/L, and the mean eGFR was 104.1±13.2 mL/min/1.73 m². One patient (7.1%) developed a urinary tract infection (Clavien-Dindo Grade II) as a postoperative complication. The median follow-up duration was 17 months (range, 3–56 months). Serial imaging follow-up in selected patients, including preoperative vs. postoperative 3D reconstruction (n=2) and MRU up to 27 months (n=1), demonstrated sustained resolution of hydronephrosis and no evidence of restenosis (Figures 3,4). A representative surgical video (Video 1) demonstrates intraoperative ureteral compression by crossing vessels before pyeloplasty and the released ureter after transposition of the obstructive vessels and completion of the anastomosis (Figure 5). At the last follow-up, the mean serum creatinine level was 77.1±20.3 μmol/L, and the mean eGFR was 97.4±17.8 mL/min/1.73 m². The overall success rate was 100%.

Figure 3 Preoperative and postoperative CTU three-dimensional reconstruction images for Case 4 and Case 5, demonstrating improved hydronephrosis after surgery. CTU, computed tomography urography.

Figure 4 Preoperative and postoperative MRU follow-up images for Case 6 at 3, 15, and 27 months after surgery, demonstrating sustained resolution of hydronephrosis (arrows). MRU, magnetic resonance urography.

Figure 5 Preoperative and postoperative comparison of aberrant vessel compression at the ureteropelvic junction. Preoperative image (A) shows an aberrant artery crossing and compressing the ureteropelvic junction. Postoperative image (B) demonstrates complete relief of vascular compression after surgery.

Discussion

This study demonstrates that KD robot-assisted laparoscopic dismembered pyeloplasty for UPJO in HSK is safe and feasible, with satisfactory mid-term outcomes in a cohort of 14 patients.

UPJO in the setting of HSK presents a formidable surgical challenge due to the complex anatomy involving an abnormal isthmus, aberrant vasculature, renal malrotation, and a caudal renal position (24). While open pyeloplasty remains effective, its success rate in HSK is reportedly lower than in anatomically normal kidneys. LP, though minimally invasive, is hindered by technical difficulties in intracorporeal suturing within this confined and aberrant space, resulting in a steep learning curve. Robotic assistance directly addresses these limitations. This study contributes to the growing body of evidence supporting robotic pyeloplasty for complex UPJO and specifically highlights the successful application of the KD robotic platform in this demanding context.

Technical application of the KD robotic system

The KD robotic platform provided several technical advantages in this complex anatomical setting. The stereoscopic three-dimensional visualization facilitated identification of the aberrant ureteropelvic junction and surrounding vasculature, which is particularly important given the variable vascular anatomy in HSK (25,26). The articulated instruments enabled precise dissection and running suture anastomosis in the deep operative field, allowing for careful preservation of crossing arteries when possible and a tension-free, watertight anastomosis. These features enabled complete dismembered pyeloplasty without isthmectomy in all 14 cases. In this series, 7 procedures were performed using the three-arm KD-SR1000 and 7 using the four-arm KD-SR2000. The latter provided smoother instrument articulation, improved ergonomics, and reduced surgeon fatigue during prolonged suturing, although clinical outcomes were comparable between the two platforms (27).

Our surgical technique incorporated specific modifications well-suited to robotic capabilities. We emphasize the initial anchoring suture between the apex of the ureterotomy and the renal pelvic flap prior to complete dismemberment, a step that maintains orientation and prevents torsion (28,29). Throughout the anastomosis, tissue handling was deliberately restricted to areas planned for excision to minimize trauma to the delicate urothelial edges, a principle easily adhered to with the fine control offered by the robotic instruments.

Comparison with previous da Vinci series

Our institution has extensive experience with both the KD and da Vinci robotic systems for pyeloplasty in HSK, and we have previously published our initial series (30). Notably, that publication was not a pure da Vinci cohort—it included 7 patients operated with the da Vinci Si system and 4 patients with the KD system. Nevertheless, based on our institutional experience with both platforms, we have observed that the KD and da Vinci systems achieve broadly comparable perioperative and functional outcomes for this procedure. Both platforms provided similar operative times, blood loss, and hospital stay; low complication rates; and a 100% success rate at med-term follow-up. Given that the published series was a mixed cohort, a direct statistical comparison between pure KD and pure da Vinci groups is not feasible from our current data. However, the outcomes from our current KD series (n=14) are well aligned with those reported in the literature for the da Vinci system in similar patient populations (18,31,32). A formal comparative study between the KD and da Vinci systems for this specific procedure is ongoing in our center, and we expect to report these results in the near future.

Role of preoperative planning and clinical outcomes

Preoperative planning with CT urography and three-dimensional reconstruction was invaluable. It allowed for detailed anatomical mapping and surgical simulation, which, when combined with the intraoperative precision of the KD system, enhanced the safety and efficacy of the dissection, particularly around vital vascular structures.

All patients achieved symptomatic relief and radiographic improvement of hydronephrosis. Serial imaging in a subset of patients—including preoperative versus postoperative three-dimensional reconstruction (n=2) and MRU follow-up up to 27 months (n=1)—confirmed durable relief of obstruction without restenosis. Mean eGFR improved from 93.8±14.9 preoperatively to 104.1±13.2 mL/min/1.73 m² postoperatively (paired t-test, P<0.05) and remained above baseline at last follow-up (97.4±17.8). Serum creatinine decreased from 77.8±17.3 to 69.6±16.6 μmol/L postoperatively but returned toward baseline at last follow-up (77.1±20.3); these values were not statistically compared with baseline, and the trend of creatinine returning toward baseline is a descriptive observation only. This change likely reflects variations in diet, hydration status, or muscle mass rather than true functional decline, as eGFR remained improved. The overall success rate was 100% at a median follow-up of 17 months. These excellent outcomes were achieved alongside a notably low complication rate, underscoring the safety profile of the procedure.

The primary limitations of this work are its retrospective nature and modest sample size, and the lack of a control group for direct comparison. During the study period, patients received KD robotic surgery free of charge as part of a clinical trial; therefore, a formal cost-effectiveness analysis was not performed. Future prospective, multi-center studies with larger cohorts and direct comparative analyses are warranted to further validate these promising results and to critically assess the learning curve and cost-effectiveness of the KD robotic system in complex urological surgery.

Conclusions

This study presents the largest reported series of robot-assisted pyeloplasty for adult HSK performed using the KD surgical robot. The findings suggest that the KD system provides the necessary technological capabilities—including enhanced visualization, dexterity, and control—to successfully manage one of the most complex scenarios in upper urinary tract reconstruction. Its successful application in this context indicates potential viability as a robotic surgical platform for UPJO in HSK, though larger prospective studies are needed to confirm these findings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0586/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0586/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0586/prf

Funding: This work was supported by the Capital’s Funds for Health Improvement and Research (No. 2024-1-4072); National Key R&D Program of China (No. 2023YFC2413400); Special Fund of China Postdoctoral Science Foundation; the Peking University Medicine Sailing Program for Young Scholars’ Scientific & Technological Innovation; the China Postdoctoral Science Foundation (No. 2025M781888); and National High Level Hospital Clinical Research Funding (“Star of Outlook” Scientific Research Project of Peking University First Hospital (No. 25cz020202-4803112). The funder had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0586/coif). H.J. serves as an Editor-in-Chief of Translational Andrology and Urology from April 2026 to March 2029. Xuesong Li serves as an Editor-in-Chief of Translational Andrology and Urology from March 2026 to March 2029. T.H. reports support from Special Fund of China Postdoctoral Science Foundation; the Peking University Medicine Sailing Program for Young Scholars' Scientific & Technological Innovation; the China Postdoctoral Science Foundation; and National High Level Hospital Clinical Research Funding ("Star of Outlook" Scientific Research Project of Peking University First Hospital. Xuesong Li reports support from the Capital's Funds for Health Improvement and Research and National Key R&D Program of China. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Peking University First Hospital (approval No. 2025-1062). Informed consent was obtained from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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