Presentation Authors: David M Strauss*, Kevin K Yang, Ziho Lee, Aeen M Asghar, Randall A Lee, Michael J Metro, Daniel D Eun, PHILADELPHIA, PA
Introduction: The ileal ureter is a valuable reconstructive technique in the setting of long segment or panureteral stricture disease, adding to the arsenal of ureteral reconstruction options. We demonstrate a case of a robotic-assisted left ileal ureter creation for a 53-year-old female who presented with bilateral ureteral strictures years after being treated for genitourinary tuberculosis. A uretero-ureterostomy was first performed for the right side stricture. This video will focus on repair of the left side.
Methods: Complete assessment of stricture location and length should be performed prior to definitive repair. After adequate antegrade and retrograde pyelography was performed, an open-ended ureteral catheter was left in each ureter for intraoperative access. The patient was positioned in modified left flank, at approximately 30 degrees, and a total of 5 ports were used with the Xi robotic platform. One assistant 12 mm port was additionally placed. After mobilization of the descending colon, left ureterolysis eventually revealed the strictured segment, surrounded by significant retroperitoneal fibrosis. The measured distance from bladder to healthy proximal ureter was approximately 10 cm. A 12 cm segment of ileum, was isolated and a generous tunnel under the sigmoid mesentery and inferior mesenteric artery was created. The ileal segment was carefully passed from the right to the left side of the abdomen via this mesenteric tunnel, keeping with isoperistaltic orientation. An inverted-U cystotomy at the left bladder dome produced a bladder flap followed by the enterovesical anastomosis using a running 3-0 absorbable barbed suture. In this case, the proximal ureter was significantly dilated and it was felt to best perform an ileal ureter interposition to the dilated proximal ureter instead of continued dissection to renal pelvis. A 6 french ureteral stent was placed at the time of ureteroenteric anastomosis using a running 5-0 monofilament absorbable suture.
Results: The patient&[prime]s length of stay was 5 days without perioperative complications. At 2 years follow-up, a furosemide renal scan continues to show no evidence of obstruction with stable split renal function.
Conclusions: Ileal ureters have been well described with open approaches for long segment ureteral strictures. We demonstrate the technique and long-term viability of a robotic-assisted left ileal ureter interposition for a 10 cm ureteral stricture. We highlight the technical maneuvers of dissection, mobilization and anastomoses with a minimally-invasive platform.