V03-06: Transection-Free Side-to-Side Distal Ureteral Reimplantation
Distal ureteral strictures pose a potential risk for renal impairment. The surgical gold standard involves ureteroneocystotomy with transection of the ureter. We present the technique of side-to-side anastomosis as a useful treatment option that avoids aggressive distal ureteral dissection and further compromise of blood supply. Additionally, the presence of the native ureteral orifice allows for ureteroscopic access if required.
In this video, we show our robotic surgical technique for side-to-side anastomosis for distal ureteral stricture performed by three genitourinary reconstructive surgeons from three different institutions. Our technique involves the performance of adequate ureterolysis of the healthy, proximal and non-strictured segment. Extensive dissection of the posterior ureter towards the ureterovesical junction is avoided, preventing vascular compromise. Indocyanine dye can be used to demonstrate vascularity prior to anastomosis. A psoas hitch or bladder mobilization can be performed to take tension off prior to performing the anastomosis. A ureterotomy and cystotomy are made to perform a long anastomosis using absorbable suture. Prior to closing the ureteroneocystotomy, a double lumen stent is placed. Lastly, we highlight the use of ureterscopy via the native ureteral orifice in these cases.
Among our institutions, a total of 15 patients underwent a total of 16 robotic distal ureteral side-to-side anastomosis from 2012 to 2018. The median age and body mass index were found to be 64 years (IQR 51 to 68) and 29 (IQR 27 to 34), respectively. The median stricture length for all treated patients was 3 cm (IQR 2.5 to 3.3). Our median operative time and estimated blood loss were 178 mins (IQR 150 to 204) and 50cc (IQR 38 to 100), respectively. The median length of stay was 1 day (IQR 1-2) with a follow-up of 5 months (IQR 4 to 5). A total of 15/16 (93.8%) patients were found to have clinical improvement for pain. All patients with follow-up imaging had radiographic improvement with decrease in hydronephrosis.
A side-to-side ureteral reimplantation for distal ureteral strictures is a feasible and reproducible technique as evidenced by our multi-institutional experience. Furthermore, a non-transecting technique which minimizes dissection and disruption of blood supply may be particularly well suited for radiation induced distal ureteral strictures.