V04-02: Transnephrostomic ICG Guided Robotic Ureretal Reimplantation for Ureteroileal Strictures after Robotic Cystectomy and Neobladder: step by step technique
In this video we describe our initial experience with robotic ureteral reimplantation for uretero-enteric anastomotic strictures in patients previously treated with robot assisted radical cystectomy and intracorporeal neobladders (RARC-N) with the use of near infrared fluorescence (NIRF) imaging after transnephrostomic injection of indocyanine green (ICG).
From April 2015 to October 2017, 9 consecutive patients underwent robotic ureteral reimplantation in one tertiary referral center. All patients previously underwent RARC-N with the same standardized technique . All patients previously underwent percutaneous nephrostomy and at least one antegrade stenting and stricture dilatation attempt. This was a case of a 64 year old male, with a 2.5 centimeters left ureteral stricture, who underwent RARC-N 10 months ago. As shown in the video, transnephrostomic injection of ICG was performed to identify the lumbar ureter. The ureter was then progressively dissected and encircled with a vessel loop. A gentle traction was applied on the vessel loop and blunt and shurp dissection were alternatively used to develop the dissection plane, with a totally no touch technique. Intravenous ICG was injected and allowed to easily identify the left iliac artery. After iliac vessel identification, the stenotic tract of the ureter was identified and the neobladder opened. The left ureter was transected 1 cm proximally to the stenotic tract, spatulated and approximated to the neobladder flap. Uretero-ileal anastomosis was performed with interrupted 3-0 Monocryl sutures and neobladder Boari flap was closed.
Median time from RARC to uretero-anastomotic stricture diagnosis was 5mo (IQR2-6). Median stricture length was 1,5 cm (IQR 1-2). Median operative time was 140 minutes (IQR 81-155) and median length of stay was 5 days (IQR 3-9). All cases were completed robotically. Neobladder Boari flap was created in all cases. Two patients experienced a Clavien grade 2 complication (one urinary tract infection requiring antibiotics and one blood transfusion, respectively). One patient underwent ileum resection and anastomosis due to perforation. At a median follow-up of 7 mo (IQR 4-25) no patients developed recurrence (CT scan) or worsening of renal function (new onset CKD stage 3b-4).
Robotic eureteral reimplantation for uretero-enteric strictures is a safe and highly effective procedure. Near infrared fluorescence imaging provides an easy guide to identify and progressively dissect the ureter. Thanks to the high success rate and to the excellent functional outcomes, robotic reimplantation has become a first treatment option in our center.