V7-11: Robot-Assisted Repair of a Circumcaval Ureter in a Child

Video

Introductions and Objectives
Circumcaval Ureter or retrocaval ureter is a rare congenital venous anomaly that results from the posterior cardinal vein persisting as the renal segment of the inferior vena cava (IVC) during development. Ureteral compression by the IVC, psoas muscle and vertebrae results in progressive ureteral obstruction and hydronephrosis. Patients present with flank pain or abdominal pain in the third or fourth decades of life with rare cases occuring in children. We present a video demonstrating a Robot-assisted Pyeloureterostomy ( RAPU) in a child presenting with a symptomatic circumcaval ureter.

Methods
An 11 year-old male presented with intermittent right flank and abdominal pain. Ultrasound revealed right hydronephrosis and a dilated proximal ureter with an “S-shaped” deformity. Nuclear renal scan was suspicious for right renal obstruction. Cystoscopy and retrograde ureteropyelography again demonstrated proximal ureteral dilation and an “S-shaped” deformity of the ureter. A double-J stent was placed. Laparoscopic robot-assisted pyeloureterostomy (RAPU) was performed. A 12 mm umbilical camera port, two 8 mm robotic instrument ports and one 10mm assistant port were placed. The colon was reflected medially. The renal pelvis was identified and the proximal ureter was dissected as it coursed under the inferior vena cava (IVC). The segment of ureter that passed under the IVC was transected and partially excised. This partially excised ureteral segment served as a handle to minimize manipulation during anastomosis. Interrupted 5-0 polygalactin sutures were used to anastomose the ureter anterior to the IVC. A Jackson-Pratt drain was left in place.

Results
Console time was 180 minutes. Blood loss was minimal. The patient tolerated the procedure well and no complications occurred.. The patient was ready for discharge on post-operative day two. The stent was removed six weeks later. At the three month follow-up the patient was asymptomatic and the hydronephrosis had improved significantly.

Conclusions
Symptomatic circumcaval ureter is uncommon in children. With a careful characterization of the anatomy circumcaval ureter is well suited to minimally-invasive repair.

Funding: none