V570: Robot-assisted Laparoscopic Ureteral Reimplantation with Excisional Tailoring for Refluxing Megaureter

Video

Introduction and Objectives
In this video, we illustrate 3-port robot-assisted laparoscopic ureteral reimplantation with intracorporeal excisional tailoring of megaureter. Previously described minimally invasive techniques for this operation involved either extracorporeal ureteral tailoring or placement of additional laparoscopic ports. We also describe the use of CO2 laser for detrusorotomy during this procedure.

Methods
A 9 year-old boy was evaluated for primary enuresis and found to have right hydroureteronephrosis, Grade V vesicoureteral reflux, and 32% split function of the right kidney. Distally, the right ureteral diameter was 1.6 cm. The patient’s family elected surgical intervention. Cystoscopy was performed, with insertion of a 6 Fr double-J right ureteral stent, and the patient was then taken out of lithotomy position and placed supine. Three laparoscopic ports were introduced. Unique features of our surgical technique include placement of ureteral stay sutures to permit freehand excision of redundant ureter without additional laparoscopic ports. The ureter was closed in a single layer, leaving the ureteral stent in place. CO2 laser (7W) was used for detrusorotomy. The distal ureter was anchored to adjacent detrusor muscle, and detrusorrhaphy was completed with absorbable sutures.

Results
Following ureteral stent removal, sonography demonstrated decreased hydroureteronephrosis, and VCUG confirmed resolution of vesicoureteral reflux. The patient is now asymptomatic.

Conclusions
Minimally invasive approaches to ureteral reimplantation with excisional tailoring have previously been described, both using standard laparoscopy as well as robotic technology. To our knowledge, this is the first description of intracorporeal tailoring via just three laparoscopic ports. Use of fewer ports reduces risks associated with trocar introduction, port-site complications, and cosmetic impact. CO2 laser facilitates precise and hemostatic detrusorotomy; compared to electrocautery, we believe it reduces the risk of bladder mucosal injury and urine leak. Animal studies have demonstrated that it causes less collateral tissue damage. We routinely utilize supine position for robotic ureteral reimplantation, which has a lower risk of neurovascular complications than lithotomy. The technique described in this video is also applicable to reimplantation of obstructed megaureters, with the additional requirements of dismembering the ureter, excising the stenotic segment, and reanastomosis.

Funding: none