V04-07: Robotic-Assisted Ureteroenteric Anastomotic Stricture Repair Using a Side-to-Side Anastomosis and Firefly® Technology
Ureteroenteric anastomotic stricture (UES) is a common long-term complication of urinary diversion occurring in up to 10% of patients. While open UES revision remains the gold standard, it is technically challenging and can be associated with visceral and vascular related injuries. In select cases, a minimally invasive surgical approach utilizing near-infrared laser fluorescence (NIRF) technology (Firefly®) combined with antegrade ureteroscopy may allow for enhanced UES identification and ureter viability assessment. To minimize iliac vessel injury and mobilization related ureteral ischemia, we describe our robotic assisted UES revision technique using a side-to-side anastomosis augmented by NIRF.
A 69 yo male underwent robotic cystoprostatectomy and ileal neobladder for T1 bladder cancer in 2011. A right UES was discovered on surveillance imaging in 2017. Recurrent urothelial carcinoma was excluded and a nephrostomy tube was placed. Intraoperatively, the patient was positioned in a modified flank position and a ureteroscope was advanced through the existing nephrostomy tract to the level of the UES. Veress needle access was achieved in the RUQ and ports were placed lateral to the midline to avoid adhesions from prior laparotomy and 10cm mesh ventral hernia repair. Left ureter, iliac vessels, ileo-ileostomy, and afferent neobladder limb were prospectively identified. White light from the ureteroscope was visualized using NIRF to enhance ureteral identification and level of UES. Limited ureterolysis was performed to minimize risk of iliac vessel injury and preserve ureteral blood supply. The afferent limb was mobilized and advanced to the level of the right ureter. A 3cm ureterotomy extending proximally from UES was performed. Tissue blood supply was confirmed using indocyanine green dye and NIRF. A tension free side-to-side anastomosis with barbed suture and a modified psoas hitch was performed.
Robot dock time was 87 minutes and blood loss was 50mL. The patient was discharged home on POD 2. Cystogram and uretheral catheter removal was performed POD 7 and ureteral stent removal 6 weeks postoperatively. The patient experienced no postoperative complications and follow-up imaging demonstrated no recurrent UES.
Robotic UES repair with NIRF technology using a side-to-side anastomotic technique is a feasible, minimally invasive option for definitive UES repair. Limited ureteral mobilization with afferent neobladder limb advancement may decrease risk of vessel injury and preserve ureteral blood supply.