Category: Robotic Surgery: Upper Tract - Benign

VS16-13 - Robotic-Assisted Augmented Ureteroplasty with Buccal Mucosa Onlay Graft and Downward Nephropexy for Traumatic Ureteral Avulsion Injury

Sun, Sep 23
2:00 PM - 4:00 PM

Introduction & Objective :

The use of robotic-assisted augmented ureteroplasty (RAAU) with buccal mucosal graft is a novel, minimally invasive technique for ureteral stricture management. We report a case of a RAAU with buccal mucosa graft in a patient with a large ureteral injury following trauma.


Methods :

A 45 year-old male developed a large right ureteral avulsion following a motor vehicle accident by which he was struck and carried down the street by a commercial trailer vehicle. He underwent multiple skin debridements and grafting, liver abscess repair, splenectomy, and managed his ureteral defect with a right percutaneous nephrostomy tube. Preoperative retrograde and antegrade pyelogram indicated a 5-7 cm defect. In an attempt to salvage the kidney the patient was taken to the operating room for robotic assisted ureteroplasty with a buccal mucosa graft. Intraoperatively indocyanine green (ICG) was injected within the ureters in a retrograde and antegrade manner which allowed the extent of ureteral defect to be visualized under near-infrared fluorescent imaging. After mobilization of the right ureter, the defect was still too large to overcome to create a tension-free anastomosis. A downward nephropexy was then performed which mobilized the proximal ureter 5cm caudally. The ureteroureteral anastomosis was then completed in a tension free manner by creating a posterior plate with a buccal mucosal onlay graft. This anastomosis and graft were completed with running 5-0 Monocryl over a double J ureteral stent. A vascularized omental flap was lastly created and wrapped around the graft site.


Results :

Console time was 276 min, buccal mucosa harvest time was 40 min and estimated blood loss was 100 mL. There were no intraoperative complications. The hospital length of stay was 2 days.  Right retrograde pyelogram performed 6 weeks post-operatively showed free drainage of contrast through the repair site. The ureteral stent was pulled and continuous efflux was observed at the right ureteral orifice. At 10 weeks post-operative date a nuclear medicine Lasix renogram was performed which showed a T/12 of 8.9 min and 32% function of the right kidney.


Conclusions :

RAAU with buccal mucosa graft is a feasible option for ureteral injury repair which may represent a useful option for reconstructive robotic surgeons.

Eric Y. Cho

Resident
Department of Urology, Temple University Hospital
Philadelphia, Pennsylvania

Eric Y Cho, Urology Resident, Temple University Hospital, Philadelphia, Pennsylvania

Joshua R. Kaplan

Fellow
Department of Urology, Temple University Hospital
Philadelphia, Pennsylvania

Ziho Lee

Resident
Temple University Hospital
Philadelphia, Pennsylvania

Benjamin Waldorf

Fellow
Department of Urology, Temple University Hospital
Philadelphia, Pennsylvania

Andrew Harbin

Fellow
Department of Urology, Temple University Hospital
Philadelphia, Pennsylvania

Jeffrey C. Liu

Associate Professor and Director of Head and Neck Oncologic Surgery
Department of Head and Neck Surgery, Temple University Hospital
Philadelphia, Pennsylvania

Michael J. Metro

Associate Professor and Director of Reconstructive Urology
Department of Urology, Temple University Hospital
Philadelphia, Pennsylvania

Daniel D. Eun

Professor
Temple University
Philadelphia, Pennsylvania

Kevin Yang