V4-02: Robot-assisted Ureteral Reimplantation with the Psoas Hitch technique – Important Surgical Steps

Video

Introductions and Objectives
We present a video showing the most important steps in daVinci® robot-assisted ureteral reimplantation using the psoas hitch technique (RAURPH). In addition, we have analysed the results of our patients who underwent RAURPH.

Methods
Between October 2009 and May 2013 RAURPH (in combination with a Boari flap in five patients) was performed on 14 patients with benign or malignant ureteric disease. The patient and surgical data were gathered prospectively. Follow-up was accomplished by sending questionnaires to the patients.

Results
Distal ureter was resected because of urothelial carcinoma in five patients; in two patients the distal ureter was strictured due to advanced prostate cancer. An inflammatory conglomerate tumour caused the stricture in one patient. Iatrogenic distal ureteric stricture occurred after gynaecological or urological surgery in six patients. RAURPH can be broken down into the following steps: 1) mobilisation of the bladder, 2) preparation of the ureter, 3) fixation of the bladder on the psoas muscle, 4) opening of the bladder, 5) creation of a submucosal tunnel, 6) tension-free vesico-ureteric anastomosis and ureteric stenting, 7) closure of the bladder. The median operative duration (including docking and undocking of the robot) was 227.5 min. There were no intraoperative complications. Complications graded according to the Clavien-Dindo classification occurred in 10 (71.4%) of patients within 90 days of surgery; 9 (90%) of the patients developed minor (grade I–II), and one (10%) major complications (grade IIIb). The median length of the postoperative hospital stay was 8 days. The median follow-up period was 13.42 months. At this time all patients were asymptomatic. One patient showed radiographic signs of a short stricture on the site of ureterovesical anastomosis and underwent successful endoscopic incision.

Conclusions
Die RAURPH is a minimal invasive alternative to open surgery which produced good surgical results in our patient population. We feel that strict implementation of the general principles of open surgery was a major factor in these successful outcomes.

Funding: none