V04-03: Repair of an Iatrogenic Right Ureteral Avulsion with Robotic Appendiceal Interposition and Lower Pole Appendicocalicostomy
Although iatrogenic ureteral injuries are rare, they have potentially devastating consequences for both patients and physicians. Long ureteral avulsion injuries are particularly challenging to reconstruct and surgical options generally include autotransplantation and ileal interposition. We report a case of a 51-year-old female who suffered an iatrogenic 15 centimeter right ureteral avulsion during hysteroscopic biopsy who was managed with a robotic right appendiceal interposition and lower pole appendicocalicostomy.
Preoperative concomitant right antegrade and retrograde pyelograms demonstrated a blind-ending intrarenal collecting system and a 3 centimeter distal ureteral stump. After injecting 5 milliliters of indocyanine green (12.5 mg IC-Green [Akorn Inc, Lake Forest, USA] in 5 ml distilled water) into the right nephrostomy tube, near-infrared fluorescence was utilized to assist with intraoperative identification of the collecting system. As the renal pelvis was a fibrotic rind that was unsuitable for use, the lower pole of the kidney was excised to expose and evert healthy calyceal urothelium. In order to facilitate a tensions-free anastomosis, a downward nephropexy and psoas hitch were performed to provide an additional 6-8 centimeters of mobility. After spatulating the proximal and distal ends of the patient&[prime]s 11 centimeter appendix, an appendicocalycostomy and appendicovesicostomy were performed.
Estimated blood loss was 200 milliliters, warm ischemia time was 20 minutes, and total operative time was 602 minutes. There were no postoperative complications (Clavien grade >2). After confirming urinary patency and the absence of extravasation on right antegrade and retrograde pyelograms at 8 weeks postoperatively, the right JJ stent and nephrostomy tubes were removed. Renal scan obtained 6 months postoperatively demonstrated stable right renal function with no evidence of obstruction.
In select cases in which the appendix is of adequate length, appendiceal interposition may be utilized to surgically repair near-complete ureteral avulsions.