V07-06: Nondismembered ureterocystostomy for obstructing megaureter using the DaVinci Robot
Megaureter is categorized as any combination of nonrefluxing, refluxing, obstructing, or nonobstructing. Classically, nonobstructing megaureter does not progress to obstruction. Management generally includes follow-up imaging and functional studies with intervention at time of disease progression. Intervention includes ureteral stent, endoscopic dilation, or ureteral re-implantation. Kaefer et al. described a technique of distal ureteral dismemberment and direct reimplantation as a temporizing measure. In this paper, we describe a modified Kaefer approach using the DaVinci robot in a 17-year-old male with a left megaureter that evolved from no obstruction to symptomatic obstruction.
Our patient is a 17-year-old male who was diagnosed with a nonobstructing, nonrefluxing megaureter during childhood. Serial functional imaging confirmed a lack of obstruction. He had no history of UTIs. He recently re-presented with left flank pain. Repeat imaging revealed a persistent megaureter. MAG3 renogram demonstrated preserved function (Left 44%, right 56%) and high grade UVJ obstruction with T1/2 of 41 minutes and 3% upright drainage. Of note, patient complained of flank pain during the post-Lasix portion of the exam. Given these findings we offered surgical correction. After general anesthesia was achieved we performed cystoscopy and retrograde pyelogram that revealed a significantly dilated and tortuous ureter. We attempted stent placement, but due to tortuosity of the ureter we were unsuccessful and a sensor wire was left in place at the mid-ureter. Three robotic ports were placed and the robot was docked. The left distal ureter was mobilized. A ureterotomy was made proximal to the UVJ obstruction. A cystotomy was made next to the ureterotomy. A ureteral stent was advanced over the pre-placed wire through the native ureteral orifice, proximal ureter, out the ureterotomy, and into the cystostomy. This resulted in both ends of the stent in the bladder. A ureterovesical anastomosis was performed. A JP drain and Foley were left in place.
The patient was discharged the next day after discontinuation of drains. Ultrasound at 6 weeks showed resolution of megaureter. MAG3 at 3 months demonstrated preserved renal function with minimal left hydronephrosis and no evidence of obstruction (T1/2 4 minutes). In the office, the patient reported resolution of flank pain and minimal pain with voiding.
The treatment of primary obstructing megaureter remains controversial, however, with careful patient selection a NUC using the DaVinci is a safe, and viable option.