V04-06: Complex Robotic-Assisted Laparoscopic Ureteral Reconstruction: Tips and Tricks
Unlike reconstructive oncologic procedures such as partial nephrectomy and radical prostatectomy, only a small portion of complex ureteral reconstruction is approached using robotic-assisted laparoscopy. Reasons for this include the anatomic span of the ureter requiring access to multiple abdominal quadrants, severe periureteral fibrosis, and limited visualization in a &[Prime]hostile&[Prime] retroperitoneum. Recent advances in robotic technology address many of these issues. Here we demonstrate our technique for using robotic-assistance in complex ureteral reconstruction, as well as discuss different tips and tricks.
We present four cases where complex ureteral reconstruction was performed using the da Vinci® robotic surgical system. These include: (1) Scardino-Prince vertical flap pyeloplasty for a 3 centimeter proximal ureteral stricture, (2) ureteroneocystostomy with Boari flap for a midureteral stricture, (3) extravesical ureteral reimplant for symptomatic grade 2 vesicoureteral reflux in an adult, and (4) transplant ureteroneocystostomy for a distal transplant ureteral stricture. The video footage was analyzed and key techniques were identified for inclusion.
Strategies for successful robotic-assisted ureteral reconstruction include use of: (1) barbed suture to ensure a watertight anastomosis during a large reconstruction, (2) stay sutures to serve as extra &[Prime]hands,&[Prime] (3) the single-dock feature of the da Vinci Xi® system to allow access to the entire length of ureter, and (4) intraureteral indocyanine green (ICG) to identify the ureter within periureteral fibrosis, as well as assess ureteral entry and vascularity. Patients in cases 1, 2, and 4 listed above have had their ureteral stents remove and post-operative imaging showed no evidence of stricture recurrence. Postoperative voiding cystourethrogram for patient 3 showed resolution of vesicoureteral reflux.
Novel advancements in successive robotic surgical system generations and adjunct intraoperative tools allow for complex ureteral reconstruction to be successfully completed using minimally-invasive techniques. These tools not only allow for improved post-operative recovery following major reconstruction but, more importantly, make reconstruction safer and easier.