V7-08: Robotic Assisted Laparoscopic Retrocaval Ureter Repair
A retrocaval ureter represents a rare congenital cause of ureteral obstruction. Challenges exist in the diagnosis and treatment of this condition. We present our technique for a robotic assisted laparoscopic approach to repair in a 17-year-old patient.
A 17 year old patient presented with gross hematuria and right flank pain. Ultrasound revealed hydronephrosis and proximal hydroureter. An intravenous pyelogram demonstrated significant J hooking in the mid-ureter with a medially displaced distal ureter, which was concerning for a retrocaval ureter. The decision was made to proceed to the OR for repair. A retrograde pyelogram confirmed the diagnosis, and an access catheter was placed in the distal ureter to aid in identification. A 12mm camera port, two 8mm robotic ports and a 5mm assistant port were used.
Surgery was uneventful. Identification of the distal ureter was somewhat challenging, but landmarks, such as the iliac bifurcation allowed for localization. The placement of both robotic ports along the midclavicular line provided maximum access to the distal and proximal segments of the ureter, aiding in our dissection. The ureter was transected proximally and distally to the stenotic segment. The retrocaval portion of the ureter was left in place though in discontinuity. The anastomosis was performed using a 5-0 PDS continuous suture. Operative time was 159 minutes, and EBL was 20mL. A 6x28 JJ internal ureteral stent was left in place for one month. The patient awaits further follow-up.
A robotic-assisted approach to repair of a retrocaval ureter is a safe alternative to the conventional open approach. Identification of the distal ureter can be challenging, but the use of landmarks, such as the iliac bifurcation, as well as selective port placement can assist the dissection.