V9-13: Robot-assisted Laparoscopic Flap Pyeloplasty for an Extended Ureteral Stricture: Key Steps and Complications

Video

Introductions and Objectives
Robot-assisted laparoscopic pyeloplasty has been popularized as a minimally invasive technique for the correction of ureteropelvic junction (UPJ) obstruction in adults due to the advantages robotic assistance offers during reconstructive procedures. However, long ureteral strictures present a unique challenge to surgeons as they are often not amenable to the division and re-anastomosis required during conventional dismembered pyeloplasty that may create excess tension on the ureter. This video presents a technique for utilizing a long spiral flap incised from the renal pelvis during nondismembered pyeloplasty to repair a 5 cm ureteral stricture in a symptomatic 24 year old male patient.

Methods
Preoperative retrograde pyelogram and double J ureteral stent placement was performed. Pneumoperitoneum was established and incisions were made to accommodate five trocars which were docked to the da Vinci surgical system. The line of Toldt was divided and colon mobilized from Gerota’s fascia. The urethra was mobilized from the renal pelvis to the iliac vessels, and pyelotomy was performed anteriorly from the renal pelvis through the length of the stricture. The adequacy of the ureteral lumen was evaluated by passing an infant feeding tube alongside the ureteral stent. A long spiral flap was incised laterally from the renal pelvis and rotated so the apex of the flap was sutured to the apex of the spatulation of the ureter. The pelvis was reconstructed and the ureter retubularized by suturing the medial edge of the flap to the lateral edge of the ureter and then the lateral aspect of the flap to the medial aspect of the ureter with multiple running 4-0 Vicryl sutures.

Results
No urine leak from the anastomosis was noted at the end of surgery. Estimated operative blood loss was 30 ml. The patient’s postoperative course was complicated by a small anastomotic urine leak treated with diverting percutaneous nephrostomy tube placed on postoperative day two. The patient was discharged on postoperative day six with a nephrostomy, ureteral stent, and drain in place. Follow-up nephrostogram showed free flow of contrast from the renal pelvis into the bladder; thus, the nephrostomy tube was removed with no recurrence of the patient’s symptoms.

Conclusions
Robot-assisted nondismembered spiral flap pyeloplasty can be effectively utilized to repair extended length ureteral strictures not amenable to other types of pyeloplasty.

Funding: None