Category: Robotic Surgery: New Techniques - Benign

Introduction & Objective : In this video, we present a case of ureteral revision of an Indiana pouch. The patient is a 61 year old male with a history of radical prostatectomy and adjuvant radiotherapy. Three years after radiotherapy, the patient underwent robotic radical cystectomy and Indiana pouch diversion. 20 months after radical cystectomy, the patient developed left flank pain. CT evaluation revealed left hydronephrosis and a distal ureteral stricture. No evidence of prostate or bladder cancer was observed. The patient was scheduled for left ureteral reimplantation.

Methods : The patient was positioned in the modified lithotomy position. We started the case with an extensive lysis of small bowel adhesions. Indocyanine green (ICG) was injected through the nephrostomy to identify the ureter. Identification of the ureter was followed by dissection from adjacent tissues. We have carefully dissected the ureter towards the distal end. ICG was used to identify the healthy tissue level for anastomosis. Ureter was detached and widely spatulated. The pouch was infused with ICG to help in assessment of the anastomosis site. After the Pouch incision, anastomosis was performed using absorbable sutures. Halfway through the anastomosis we placed a double J stent. Following completion, ICG was used to observe the tissue perfusion at the site of anastomosis.

Results : Surgery was completed in 2:22 hours, with an estimated blood loss of 30 mL. Drain was removed at day 1 and patient was discharged without complications. Double J stent was removed at postoperative 6 weeks. Renal ultrasound was unremarkable at postoperative 5 months.

Conclusions : This video demonstrates a stepwise technique for ureteral reimplantation of an Indiana pouch. These tips with immunofluorescence can be applied to many reconstructive scenarios.

Presenting Author(s)

• 

  Alp Tuna Beksac

  – Fellow, Icahn School of Medicine at Mount Sinai, New York, New York

Author(s)

• AM

  Alberto Martini

  – Fellow, Icahn School of Medicine at Mount Sinai, New York, New York
• 

  Ketan Badani

  – Professor of Urology, Icahn School of Medicine at Mount Sinai, New York, New York