Presentation Authors: Michael Avallone, Alan Quach*, Brian Flynn, Aurora, CO
Introduction: Recurrent ureteral strictures have higher complexity for repair compared to initial surgery for ureteral reconstruction. We describe a series of patients treated with robotic assisted laparoscopic (RAL) buccal mucosal graft (BMG) ureteroplasty and demonstrate techniques utilized to improve efficiency in these complex cases.
Methods: Retrospective review was conducted for the initial four cases of RAL ureteroplasty with BMG performed by a single surgeon between July and October 2017. Video recordings of these cases were reviewed to identify techniques utilized to facilitate completion of these complex cases using a RAL approach.
Results: All four cases were completed using RAL approach without need for conversion to an open procedure. Average patient age was 55 years. Two patients had lower ureteral strictures that initially resulted from prior pelvic surgery. Both of these patients developed recurrent lower ureteral strictures after prior ureteroneocystostomy with psoas hitch. The remaining two patients had upper ureteral strictures. One patient had recurrent ureteropelvic junction obstruction after two previous RAL pyeloplasty procedures. The only male patient in the series presented with a proximal ureteral stricture due to nephrolithiasis. Imaging demonstrated absence of dilation of the renal pelvis precluding repair with spiral flap pyeloplasty or primary uretero-ureterostomy. No patients had history of prior radiation therapy. Average operative time was 371 minutes (range 317-485). Median length of hospitalization was 4.5 days (range 3-6). Two patients were re-admitted for treatment of urinary tract infection. Ureteral stents were left in place for 5 weeks post operatively. Preliminary follow up ranging from 7-16 weeks showed no evidence of ureteral stricture recurrence. Intra-operative fluorescence imaging facilitated identification of the ureter in previously operated fields and aided in localization of the region of stricture. Access to the ureter via cystoscopy and ureteroscopy was useful for ureteral stricture identification and ureteral stent placement. Stay suture placement in the ureter served to expose the ureter for ureterotomy, measurement, and suturing of the BMG.
Conclusions: Reconstruction of recurrent upper and lower ureteral strictures is feasible using a RAL approach. We demonstrate techniques that can be utilized to complete these complex procedures with encouraging results in short term follow up.