V12-09: Complex Robotic Ureteroplasty Using Buccal Mucosal Onlay Graft for Treatment of 3cm Proximal Ureteral Stricture

Video

Introductions and Objectives
Ureteral strictures of the proximal ureter >2cm pose a difficult management dilemma. Options for repair include ileal ureter bowel interposition, autotransplantation, transureteroureterostomy in situations where the distance can not be bridged by pyeloplasty +/- nephropexy. In this video we present a step-by-step alternative technique for successful use of buccal mucosa for repair of a ureteral stricture.

Methods
A 28-year-old male was referred with an iatrogenic ureteral stricture 3cm and left flank pain. He had undergone multiple prior ureteroscopy for stone disease, the suspected cause of his stricture disease, and two prior endopyelotomies. Cystoscopy and retrograde pyelogram demonstrated a 3 cm stricture at the proximal ureter with a small renal pelvis. The distance from the renal pelvis was too large to have a tension free pyeloplasty. Relative functional decrease from 45% to 40% on the symptomatic side was seen on his nuclear medicine renal scan. The patient was consented for robotic assisted laparoscopic buccal mucosa ureteroplasty.

Results
Buccal mucosa was harvested by otolaryngology and utilized for ureteral reconstruction. Technical steps, emphasized in the video, include the following: 1) Buccal mucosa harvested using Xylocaine with epinephrine; 2) Buccal mucosa fat debrided; 3) Colorenal ligaments divided to reflect bowel medially to expose ureter 4) Vessel loop used as a temporary hitch stitch to elevate, isolate and stabilize ureter; 5) With the robotic camera light dimmed, ureteroscopy is performed to identify the level of the stricture; 6) Stricture incised by making a ventral ureterotomy; 7) Using a running 4-0 Vicryl suture the buccal graft was secured to the ureterotomy as an onlay graft; 8) A double J ureteral stent is placed; 9) An omental wrap around the graft is performed._x000D_ After minimal drain output, the patient was discharged the next morning. The ureteral stent was maintained for 6 weeks. Subsequent ureteroscopy performed at time of removal confirmed resolution of stricture and healthy, well-perfused graft tissue.

Conclusions
This video demonstrates the key steps to perform a successful buccal mucosa onlay graft for treatment of a complex, 3 cm proximal ureteral stricture.

Funding: None