V1-10: Robot Assisted Transplant Ureteroneocystostomy
Anastomotic ureteral strictures are one of the most common complications after kidney transplantation. Early diagnosis and management is key in preserving graft function. Definite surgical intervention provides durable cure and has a high success rate. However, it is technically challenging and associated with more morbidity due the dense fibrotic tissue around the transplanted ureter. In this video we will describe our technique in performing robot assisted transplant ureteroneocystostomy with a brief description of outcomes in a case series
These procedures were performed through the collaboration of our urology and transplantation surgical teams. The procedure was performed through a transperitoneal approach in lithotomy position. The ports were placed in a similar location to robot assisted radical prostatectomy. This video will highlight the technical aspects of this procedure. These are: (1) Identification of the transplanted ureter. (2) Proximal and distal dissection of the ureter. (3) Techniques of approximation of the distal end of the transplanted ureter to the bladder (4) Urethrovesical anastomosis
Location of the transplanted ureter is variable and can be identified after careful dissection of the paravesical space. This should not be confused with medial the umbilical ligament, vas difference and native ureter. Preoperative stenting and intermittent filling of the bladder during dissection can help identify the ureter. It is important to ensure complete excision of the stenotic ureter to prevent recurrence. Previous balder wall defect should be closed in a water tight fashion to prevent urine leak. A stented, spatulated, tension free, water tight anastomosis should be done with absorbable sutures. In order to bridge the gap between the distal end of the ureter and the bladder the same techniques that are used in non-transplant patients can still be utilized. This includes psoas hitch, release of the contralateral pedicle in addition to release of the transplanted kidney from the anterior abdominal wall. The plane between the transplanted kidney and the anterior abdominal wall is an avascular plane that can be relatively easily to develop. This technique was successfully implemented in three cases with complete resolution of obstruction, no anastomotic leakage and no complications. All patents were discharged on day 1 with a foley catheter for a week. A nephrostogram was performed at 7 days. The stent was removed in 4-6 weeks.
Robot assisted ureteroneocystostomy can be performed with acceptable initial results and the robotic platform provide benefits of early recovery