V10-06: Robotic Redo Pyeloplasty: Bridging the Gap with Buccal
Pyeloplasty failure rates have been reported at 5-10%. Management options for failure include redo pyeloplasty, endopyelotomy, ureterocalicostomy, ileal ureter, auto-transplant, and nephrectomy; yet the success rates are highly variable. Buccal mucosa graft is used for reconstruction of the urethra and vagina, and its use has more recently been described in a handful of cases of ureteral reconstruction. Here, we sought to describe our experience with using buccal mucosa graft for robotic redo pyeloplasty in the pediatric population.
A nine-year old patient presented with recurrent pain and obstruction after three prior pyeloplasties. The decision was made to perform left robotic redo pyeloplasty with buccal mucosa graft. Our technique was as follows. With the patient in left plank position, a total of four ports were placed (Figure 1). The colon was mobilized laparoscopically, and once the robot was docked, the ureteropelvic junction was dissected out from surrounding fibrosis. A vertical incision was made on the anterior surface of the renal pelvis through the ureteropelvic junction, until pliable ureter was encountered distally, revealing a 5cm defect. The pre-existing stent was removed, and through a percutaneous 14-gauge angiocath, a new 4.7Frx22cm stent was placed antegrade over a glidewire. Buccal grafts were then harvested from each cheek and defatted. They were delivered via 8mm robotic ports individually, and anastomosed to the anterior surface of the ureter as an onlay graft, with the mucosal side towards the lumen, using running 6-0 PDS suture. Omentum was then quilted over the grafts, using interrupted 5-0 vicryl suture.
The patient's stent was removed 6 weeks post-operatively, and at 3 months after redo robotic pyeloplasty, he is asymptomatic with ultrasound showing decreased hydronephrosis. The same technique (robotic redo pyeloplasty with buccal graft) was used in a 16 year old patient who had failed pyeloplasty and endoscopic management of recurrent ureteropelvic junction obstruction. At 18 months follow-up, she is asymptomatic with improved hydronephrosis on imaging.
Robotic redo pyeloplasty with buccal graft is safe and feasible in the pediatric population. Long-term outcomes need to be assessed.