V4-11: Step-by-step Robotic Ureteroureterostomy: Tips and Tricks to Optimize Outcomes
VideoIntroductions and Objectives
Mid/proximal ureteral stricture is a complex disease with few treatment options. Ureteroureterostomy is a challenging technique utilized to manage cases not amenable to endoscopic treatment or ureteroneocystostomy. The robotic approach is technically feasible and utilizes the same principles of open ureteral reconstruction. We demonstrate the step-by-step operative technique with emphasis on key steps that are useful to achieve a tension-free anastomosis.
The surgery depicts a 27 year old female with a history of left mid ureteral stone who underwent rigid ureteroscopy and laser lithotripsy for an impacted stone. After stent removal, patient had subsequent pain requiring several secondary procedures. A retrograde pyelogram revealed a 5 mm length stricture in the mid left ureter. The robotic ureteroureterostomy was performed using the following steps:_x000D_ _x000D_ Key step 1: The patient is placed in 60º modified flank position. The table is not flexed as this may place tension on the eventual anastomosis. The ipsilateral arm is positioned on the side of patient, so the robot will not have any clashing with it while performing distal ureter._x000D_ Key step2: All ports are placed in a straight-line configuration as this allows for unobstructed distal ureteral dissection._x000D_ Key step 3: The robot is then docked at a 90º angle, perpendicular to the patient. This configuration allows versatility with proximal and distal dissection of the ureter._x000D_ Key Step 4: The transection must be done directly on the strictured segment. This will ensure that healthy ureteral tissue is not compromised during transection of the affected area. _x000D_ Key step 5: After spatulating the ureteral ends, the proximal and distal ureter are brought into close apposition with at least 2 peri-ureteral sutures. This allows for a tension-free mucosal anastomosis.
In total, 6 patients have undergone robotic ureteroureterostomy. All cases were successful and no patient has required additional procedures. Ipsilateral urine drainage and renal function have improved or remained stable as assessed by diuretic renal scintigraphy for all patients. No radiographic or symptomatic recurrence has been noted in the follow up period over two years.
Ureteroureterostomy using a robotic technique is a feasible and effective surgery, which follows standardized principles in ureteral reconstruction. The demonstrated technique with key steps can simplify this challenging procedure and make it more reproducible.