V10-06: Robotic Augmented Anastomotic Ureteroplasty with Buccal Mucosa Graft Interposition: A Novel Technique for the Repair of Ureteral Stricture

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Introductions and Objectives
Surgical management of complex proximal ureteral strictures poses a significant challenge. The morbidity of established techniques such as ileal interposition and renal autotransplantion has led to interest in alternatives including buccal mucosa graft ureteroplasty. We previously reported robotic ureteroplasty using buccal mucosa graft as an onlay. We now report robotic ureteroplasty of a transected segment of ureter using buccal mucosa graft in an augmented anastomotic technique.

Methods
We performed a robotic augmented anastomotic buccal mucosa graft ureteroplasty on a 23-year-old male with history of failed pyeloplasty for ureteral obstruction due to injury during a motor vehicle accident. The patient was placed in modified right lateral decubitus position with genitalia prepped in the field to allow access to the bladder. The mouth was draped separately to allow simultaneous harvest of a buccal graft from the left cheek. Port placement was similar to the configuration for robotic pyeloplasty. Excision of the scarred ureteral segment revealed a 2 cm defect. It was determined that end-to-end anastomosis was not feasible due to tension. Therefore, augmented anastomosis was performed. The back walls of the ureter and the renal pelvis were brought together in running fashion. The buccal mucosa graft was then placed on the remaining ventral defect. An omental wrap was used. Ureteroscopy after placement of the graft demonstrated a widely patent ureter. A double-J stent, Jackson-Pratt drain and Foley were placed.

Results
Operative time was 192 minutes and blood loss was 65cc. The patient was discharged on post-operative day 2 with Foley and nephrostomy tube to drainage. Foley was removed at post-operative week 2. Nephrostomy tube was capped and ureteral stent was removed at post-operative week 4. At post-operative week 6, the nephrostomy tube was removed after a nephrostogram demonstrated a patent left ureter. Three months post-operatively, renal ultrasound demonstrated no hydronephrosis and symmetric ureteral jets.

Conclusions
Augmented anastomotic technique analogous to that used in urethral reconstruction can be used in ureteral reconstruction with the application of buccal mucosa graft. The technique is easily adapted in the robotic minimally invasive approach. Further prospective studies are necessary to delineate the efficacy and morbidity of this technique.

Funding: none