V09-10: Multi-Quadrant Hidden Incision Endoscopic Surgery (HIdES) for Pediatric Uretero-Ureterostomy and Distal Ureterectomy
Hidden incision endoscopic surgery (HIdES) has gained increasing acceptance in pediatric robotic pyeloplasty, nephrectomy and ureteral extra-vesical reimplantation cases. In addition to the benefits of laparoscopy (smaller incisions, shorter hospital stays, and decreased pain or narcotic use), HIdES adds significant improvement in cosmetic outcomes while maintaining similar operative times as compared to traditional port placement techniques. In this report, we describe another application of HIdES to perform multi quadrant robotic uretero-ureterostomy and distal ureterectomy using only three hidden incisions.
A 15-month old boy with an antenatal diagnosis of right hydronephrosis, was found to have a duplex kidney on post-natal imaging. Specifically, the upper pole moiety was dilated with associated hydroureter. Voiding cystourethrogram (VCUG) showed a normal urethra, smooth bladder wall, and reflux into a dilated right ureter when voiding. This was suggestive of an ectopic insertion. Nuclear imaging demonstrated an upper pole function of 28% and poor drainage with a t ½ of 40 min. Cystoscopy with retrograde stenting of the lower pole ureter was performed. A HIdES approach was utilized for laparoscopy, with one 8.5mm multipurpose port placed at the umbilicus, and two working ports hidden at the level of a Pfannestiel incision. The upper pole ureter was mobilized, ligated, then spatulated. An end-to-side anastomosis was performed to the stented lower pole ureter. The robot was then rotated, and the same three ports were used to perform the distal ureterectomy to the level of ectopic insertion.
A successful ureteroureterostomy and excision of distal ureter was performed. Operative time was 176 minutes, with 115 minutes of console time. No immediate post-operative issues occurred. The patient required a single dose of narcotics, and was discharged on post-operative day one. His stent was removed on post-operative week six.
HIdES is a safe and technically effective approach for multi quadrant pediatric uretero-ureterostomy and distal ureterectomy in a duplex kidney, with improved cosmetic outcomes compared to traditional port placement.