V7-01: Completely intracorporeal robotic-assisted laparoscopic ileal ureter for diffuse ureteral nephrogenic adenoma
Nephrogenic adenoma (NA) is a rare benign entity with ureteral involvement in children being extremely uncommon. We present a 12-year-old male with cystinuria and recurrent right-sided nephrolithiasis with right flank pain and increasing right-sided hydronephrosis secondary to replacement of the urothelium of the entire right ureter with NA. As focal surgical resection was not feasible in this case, the patient and family elected for robotic-assisted laparoscopic ileal ureter.
The patient began in left lateral decubitus position with robotic port placement similar to other renal surgeries and two additional 12mm assistant ports. After the ureteral dissection, which was complicated by significant inflammation, the patient was repositioned in the supine position and 25cm of ileum 20cm proximal to the ileocecal valve was marked using an umbilical tape and isolated using an endo-GIA stapler. Bowel anastomosis was performed in an intracorporeal fashion utilizing two 60mm endo-GIA loads along the length of our anastomosis. 4-0 polyglactin sutures were used to over-sew the staple line and reinforce the anastomosis. _x000D_ The distal ureter was divided, the stump over-sewn, and the bladder was filled and dissected free. A psoas hitch was performed using 3-0 V-LocTM and the distal ileum was anastomosed to the bladder with running 3-0 polyglactin suture after excising the staple line. The patient was repositioned in the left lateral decubitus position. A hitch stitch facilitated anastomosis of the renal pelvis to the proximal ileum with a 4-0 polyglactin suture. A ureteral stent was placed in an antegrade fashion in addition to a suprapubic tube and an abdominal drain. Robotic time was 10 hours. Estimated blood loss was 10ml. Total incision length was just over 5cm._x000D_
The patient was discharged on postoperative day seven without complication. One month after surgery we performed stent removal, cystogram, and ileal ureteroscopy that revealed patent anastomoses and no evidence of leak. Four weeks after stent removal renal colic had completely resolved with improved hydronephrosis.
To our knowledge, this is the first report of a robotic-assisted laparoscopic ileal ureter in a child. We believe that this approach is feasible and safe in the pediatric population when complete ureteral replacement is needed.