V2-04: Robotic Buccal Mucosa Graft Ureteroplasty

Video

Introductions and Objectives
Significant morbidity and complications associated with reconstruction of complex upper ureter strictures by ileal interposition or autotransplantation has led to interest in applying the success of buccal graft urethroplasty to the upper urinary tract. Several case reports in the literature suggest this is a feasible reconstruction technique, but to our knowledge it has never been reported in a minimally invasive repair.

Methods
We performed robotic buccal mucosa graft ureteroplasty in a 24 year-old female with history of urolithiasis presenting with a 6cm left proximal ureteral stricture, which developed after a traumatic ureteroscopy. The oral and abdominal procedures were performed synchronously. Patient was intubated orally and positioned in a modified right lateral decubitus lithotomy position, which allowed for access to the bladder. Port placement was similar to the layout for robotic pyeloplasty. The endotracheal tube was secured down to the right side, and the buccal graft was taken from the left side. Dense fibrotic reaction and phlegmon around the stricture necessitated ureterolysis and excision of fibrotic tissue. The graft was cut one centimeter longer than the defect, and sutured in a dorsal onlay fashion. The graft was secured dorsally to an omental flap, which wrapped around the anastomosis. The flexible ureteroscope easily traversed the anastomosis, and minimal leak from pressurized irrigation was observed. A double-J stent, periureteral drain, and foley were placed.

Results
Operative time was 298 minutes and blood loss 75cc. Patient had an uncomplicated recovery. She was discharged on post operative day 3 after drain was removed. Drain creatinine was consistent with serum. Cystogram after 2 weeks revealed excellent graft patency and minimal leak at the distal anastomosis. Foley was removed. Plan is for retrograde pyelogram and stent removal 6 weeks after surgery.

Conclusions
Buccal mucosa graft ureteroplasty is a promising option for complex upper ureter strictures prior to undertaking more complex reconstructions, such as ileal interposition or autotransplantation. This technique is easily applied in minimally invasive surgery. Further study is needed to evaluate efficacy and morbidity compared to more traditional reconstruction techniques.

Funding: none