V03-11: FLEXIBLE URETEROSCOPY-ASSISTED TRANSPERITONEAL ROBOTIC SURGERY FOR THE TREATMENT OF URETERAL STRICTURES: TECHNICAL ASPECTS AND EARLY RESULTS

Video

INTRODUCTION

Ureteral strictures represent one of the most serious reconstructive challenges for urologists. In this video we present three cases of ureteral strictures, managed with a combination of endoscopic and robot-assisted approach. The first two cases were iatrogenic strictures due to previous ureteral endoscopic surgery performed for stone disease, while the last one was an acquired stricture in a patient with endometriosis, after a gynecological procedure

METHODS

The first two patients had nephrostomy tube before surgery, while the third patient has double J ureteral stent to avoid obstructive urophaty. The preoperative work-up was performed with a computed tomography scan, renal scintigraphy and diagnostic ureteroscopy with retrograde pyelography to confirm the position and the length of the stricture. In these cases a combined endoscopic and robot-assisted approach was used. The patients were positioned in the standard flank position. Four robotic trocars were placed in line along the pararectal line. One additional 12 mm assistance trocar and Air Seal trocar were placed. After mobilisation of colon the urether was identified and isolated. The stricture was located in the lower and distal part of the lumbar urether, in the first and second case respectively and in the right pelvic urether in third case. The flexible uretheroscope was backloaded and the distal end of the stricture was easily identified by a transillumination technique. To identify the proximal end of the stricture, Indocianine Green was administrated to the patient. The stricture appeared as a devascularized portion of the ureter and was precisely marked and sectioned with monopolar scissors. A flexibile ureteroscopy was also perfomed up to exclude presence of further strictures. Distal and proximal ureteral ends were spatulated and a termino-terminal tension-free anastomosis was perfomed using two 4-0 Vycril running sutures. Antegrade ureteral stenting was performed before the anastomosis was completed in the first two cases. In the third case a decision was made to perform a uretero-vesical reimplantation with psoas hitch, due to the position and length of the stricture. In this case a double J stent was placed and a Lich-Gregoir anastomosis was performed with double running suture with 4-0 Vicryl

RESULTS

Mean operative time and console time were 186 (SD 11) minutes and 156 (SD 20) minutes, respectively. Mean hospitalization time was 4 days. Uretheral stent was removed after a mean of 4 weeks after surgery. No perioperative complications were reported. 3 month after surgery the CT scan showed a regression of the hydronephrosis and good functional results at renal scintigrapy in all cases

CONCLUSION

The management of ureteral strictures is challenging. This technique is safe and feasible for short strictures up to 2 cm and assure good early functional results

Funding: none