V10-04: Early Robotic Repair of Multifocal Ureteral Perforation After Ureteroscopy
As urologists become more comfortable with robotic surgery, new techniques surface. Minimally invasive approaches for management of iatrogenic ureteral injuries, mostly secondary to gynecologic procedures, have been described previously. Traditional conservative management of ureteral injury, including stent placement, nephrostomy tube, or delayed repair can be morbid and require significant patience on behalf of both the patient and surgeon with potential for a prolonged course to definitive repair. We present a case which demonstrates the feasibility of early robotic repair of a multifocal ureteral injury within 24 hours of ureteroscopic insult, expediting resolution of the patient’s injury.
A 73-year-old male was transferred to our institution with a reported ureteral avlusion with subsequent failure to place a stent or nephrostomy tube. We performed our own retrograde pyelogram and identified what appeared to be a devastating injury to the mid ureter. We were fortunate to pass a wire across the injuries, and a stent was placed to aid with intraoperative identification. A 4-port laparoscopic robotic approach was taken to identify the left kidney and subsequently the left ureter. Gentle dissection around the ureter in the area concerning for injury identified two separate full thickness injuries. The ureter was repaired using running absorbable suture in a tension free, watertight fashion. A drain was placed in the vicinity of the repair bed._x000D_
The patient's discharge was delayed due to postoperative fevers. Workup was negative. He was ultimately discharged with a stent and Foley catheter in place on postoperative day 3. The Foley catheter was removed on postoperative day 7. He underwent cystoscopy with stent removal and retrograde pyelogram 4 weeks after surgery, which revealed a patent ureter. Renal ultrasound at 6 weeks demonstrated no hydronephrosis, and the patient is asymptomatic._x000D_
Based on our initial experience, early robotic repair is a safe and effective modality for management of iatrogenic ureteral injury. The approach and principles of reconstruction are similar to already established techniques. In this case, it also allowed for simultaneous management of the patient’s ureteral stone disease. The initial increased risk of proceeding to a more invasive treatment modality is likely offset by the shortened timeline to stent or nephrostomy tube free status. Further investigation of this approach as well as evaluation of long term outcomes will be critical to establishing this as a standard option for management of iatrogenic ureteral injuries._x000D_