V06-07: Robotic Distal Ureterectomy and Boari flap Ureteroneocystostomy after Aorto-bifemoral bypass
We report our technique of distal ureterectomy with boari flap ureteral re-implantation in previous aorto-bifemoral bypass using the da-Vinci robotic surgical system.
An 80 year old patient (BMI 38) with stage 4 chronic kidney disease (CKD) was noted to have a left mid-ureteral high grade transitional cell carcinoma (TCC) at the location that her ureter was passing between the native iliac artery and an aorto-femoral synthetic graft. Distal ureterectomy with preservation of the contralateral kidney was opted due to the patient's renal insufficiency. The descending colon was reflected medially. The left ureter was dissected proximal and distal to the left aortofemoral bypass graft which was crossing anterior to the ureter. The ureter was transected distally with a bladder cuff. The ureter at the level of the tumor was carefully dissected free of the posterior native iliac artery and the anterior graft. The ureter was transected proximal to the tumor and frozen section demonstrated no tumor at the margin. Due to the short length of ureter remaining, a boari flap ureteroneocystostomy was required for reconstruction. The ureter was able to reach the bladder in a tension-free manner and the ureterovesical anastomosis was completed with interrupted 3-0 polysorb sutures. A 7x24 double J ureteral stent was inserted robotically and the remaining bladder defect was repaired in a watertight fashion with a running 2-0 V-Loc suture.
Overall operative time was 450 min, estimated blood loss was 450 cc and there were no postoperative complications. The patient was discharged on postoperative day 5. Pathology was consistent with T3 high grade urothelial carcinoma. The Foley catheter was removed on postoperative day 14 and the ureteral stent was removed 4 weeks after surgery.
We demonstrate a robotic technique for management of a mid-distal ureteral tumor in the setting of a synthetic aorto-bifemoral bypass graft.