V10-12: Robotic (Da Vinci Xi) ureteral reimplant with Boari flap
Ureteral reimplant is most commonly performed due to trauma and oncologic disease affecting the distal ureter necessitating removal and reconstruction. The most commonly utilized procedures to aid in ureteral reimplant are the psoas hitch and the Boari bladder flap repair (BFR). Both maneuvers allow more proximal lesions to be treated with implantation instead of nephrectomy. Psoas hitch involves mobilizing the contralateral bladder attachments and securing the bladder dome to the psoas tendon of the affected side. BFR, most commonly performed in conjunction with a psoas hitch, involves incising a section of bladder, rotating it toward the affected ureter and tubularizing it for anastomosis with the remaining healthy ureter. With the open BFR first performed on humans in 1947, minimally invasive techniques have been described in recent years with similar outcomes. Recent advances in robotic technology may increase the feasibility and safety of robotic assisted laparoscopic BFR in selected patients.
We present our experience utilizing the Da Vinci Xi robotic system to perform a robotic assisted BFR.
Our patient is a 64 year-old white male with history of high grade T1 bladder cancer who was found to have blood emanating from the left ureteral orifice on surveillance cystoscopy as well as two filling defects at the junction of the mid and distal ureter on retrograde pyelogram. Due to his baseline history of hypertension, diabetes, and marginal baseline renal function; he elected to undergo robotic left distal ureterectomy with left pelvic lymph node dissection, psoas hitch, BFR and stent placement. Intraoperative cystoscopy and ureteroscopy aided the robotic procedures, and the operation went without complication with an EBL of 200mL. At follow up visit 2 weeks post-operatively, our patient was recovering well, however, cystogram revealed a small leak. At post-operative week 3, CT-Urogram and repeat cystogram revealed leak resolution, and the foley catheter was removed. Ureteral stent was removed at post-operative week 6.
Robotic Boari bladder flap repair is safe and effective in carefully selected patients. Due to the ability to side dock the robot, the Da Vinci Xi robotic system enabled concurrent intraoperative cystoscopy and ureteroscopy. This allows for more accurate identification of the lesion and precise division of the ureter.