V10-05: Robotic Salvage Pyeloplasty with Buccal Mucosal Onlay Graft – A Simplified Technique
Surgical management of recurrent ureteral pelvic junction (UPJ) obstruction is limited by our ability to create a tension free anastomosis due to ureteral devascularization, fibrosis with renal fixation, and dense stricture formation. A high rate of recurrence leads to progressively complex repairs. Herein, we present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty in the management of recurrent UPJ obstruction.
We present two patients with recurrent left UPJ obstruction. Both previously underwent multiple failed open or robotic pyleoplasties, attempted endoscopic treatment and subsequent management with ureteral stent exchanges. At the time of surgery patients were placed in left lateral flank position and a Foley catheter inserted. Transperitoneal access was obtained with a Veress needle. Extensive adhesiolysis was required. The colon was reflected medially, the kidney, ureter and renal pelvis were exposed and the UPJ identified. The area surrounding the UPJ and proximal ureter were circumferentially dissected. The UPJ was entered and the ureter incised longitudinally from the renal pelvis until healthy, normal caliber ureter was demonstrated distally, with spatulation for at least 1 cm on either end. The defects were measured and found to be 3.5 and 4 cm. 8 Fr double J ureteral stents were placed. Single buccal grafts were harvested from the right inner cheek and measured for the length of the stricture and 1.5-2cm wide. A stay suture was placed to maintain orientation and minimize handling of the ureteral tissue. The graft was delivered to the abdomen and placed as an anterior onlay, over the ureteral and UPJ defect, with two 4-0 running Vicryl sutures. The tension free repair and surgical field was wrapped in omentum after confirming a water tight anastomosis. A JP drain was placed.
Operative times were 280 and 411 minutes. Estimated blood loss was 25-50 mls. The hospital stay was 2 days. Foley catheters and JP drains were removed in the immediate post-operative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency. Both patients have been asymptomatic since stent removal and anticipate follow-up functional renal scans with Lasix in 6 months.
Robotic salvage pyeloplasty with BMG is an attractive alternative technique in the management of recurrent UPJ obstruction demonstrating a tension free, water tight and patent repair. Short term follow up has demonstrated that it is an effective and feasible approach when compared to more extensive and invasive surgical procedures.