V09-04: Robot-Assisted Laparoscopic Pyelotomy & Ileal Ureter Substitution: Video Demonstration
While robot-assisted laparoscopic (RAL) ileal ureter substitution is a known treatment option for managing recurrent ureteral stricture, video documentation of this procedure is lacking. We aim to visually demonstrate the surgical technique used in an RAL pyelotomy & ileal ureter substitution.
We present an 18 year old female with a history of cystinuria, recurrent urolithiasis, chronic kidney disease (stage 3), solitary functioning kidney, recurrent ureteropelvic junction (UPJ) obstruction, and worsening renal function. She had previously undergone multiple procedures for urolithiasis management, a failed laser endopyelotomy, and a failed RAL pyeloplasty. It was elected to perform RAL pyelotomy with removal of renal calculi and ileal ureter substitution to address stenosis at the UPJ and ureter caliber.
The patient was placed in a modified supine position and the da Vinci XI robotic surgical system was docked. Ports were placed in the umbilicus, right lower quadrant, epigastric area, and inferior to the umbilical port, left of the midline. The ureter was dissected out and spatulated laterally through the strictured UPJ. A flexible cystoscope was inserted through a robotic port and multiple renal stones were retrieved. A 26cm segment of ileum was harvested, passed through a window in the colonic mesentery, and anastomosed to the renal pelvis. The native ureter was transected and tied off. A stent was placed antegrade and the distal end of the ileal limb was anastomosed to the bladder wall. Total operative time was nearly 12 hours and estimated blood loss was 100mL. The patient was discharged home in stable condition on post-operative day 7. The ureteral stent was removed at 4 weeks. Post-operative cystogram was without evidence of extravasation. Renal ultrasound obtained 10 months post-operatively demonstrated near-complete resolution of the hydronephrosis with renal parenchymal preservation. The patient demonstrated stable renal function 20 months post-operatively.
This video demonstrates the surgical technique used in an RAL pyelotomy and ileal ureter substitution in the setting of recurrent UPJ obstruction and chronic nephrolithiasis. The patient continues to report excellent results 20 months post-operatively.