Presentation Authors: Ziho Lee*, Philadelphia, PA, Neel H Patel, Hackensack, NJ, Jeremy Slawin, New York, NY, Helaine Koster, Hackensack, NJ, Randall A Lee, David M Strauss, Philadelphia, PA, Geolani Dy, New York, NY, Daniel Kim, Hackensack, NJ, Michael J Metro, Philadelphia, PA, Michael Stifelman, Hackensack, NJ, Lee Zhao, New York, NY, Daniel D Eun, Philadelphia, PA
Introduction: Surgical management of radiation-induced distal ureteral strictures (RIDUS) is challenging. Radiation causes fibrosis, which complicates ureteral dissection; and impairs vascularity, which inhibits ureteral healing. Furthermore, these radiation-induced changes may also make psoas hitch and Boari flap (BF) difficult to perform and prone to necrosis. We report our multi-institutional experience with robotic ureteral reimplantation (RUR) in patients with RIDUS.
Methods: We retrospectively reviewed our multi-institutional ureteral reconstruction database to identify patients with RIDUS who underwent RUR at three institutions between 1/2013 and 9/2018. Two major RUR techniques were utilized: end-to-end RUR, which involved transecting the ureter and anastomosing the ureteral end to the bladder; and side-to-side RUR, which involved incising healthy ureter medially above the level of the stricture and anastomosing the medial side of the non-transected ureter to the bladder. A psoas hitch and/or BF were performed, when necessary, to facilitate a tension-free anastomosis. Postoperatively, patients were assessed for: clinical success, the absence of flank pain; and radiological success, the absence of obstruction on imaging.
Results: A total of 15 patients underwent 16 RUR. An end-to-end RUR was performed in 10/15 (66.7%) cases, while a side-to-side RUR was performed in 5/15 (33.3%) cases. The median stricture length was 3 (IQR 2-5) cm. A psoas hitch was used in 8/15 (53.5%) cases, and a psoas hitch and BF were used in 3/15 (20.0%) cases. The median operative time was 180 (IQR 154-222) min, and estimated blood loss was 100 (IQR 50-100) cc. One patient suffered an intraoperative iliac artery injury, which required primary repair. The median length of stay was 2 (IQR 1-2.5) days. There was one major postoperative complication (Clavien >2) in which a urinary leak occurred in a patient who underwent robotic end-to-end reimplantation with psoas hitch and BF. This patient developed necrosis of the BF 2 weeks postoperatively and eventually required supratrigonal cystectomy and ileal conduit formation. At a median follow-up of 9 (IQR 2.5-25) months 15/16 (93.8%) cases were clinically and radiologically successful.
Conclusions: RUR performed in an end-to-end or side-to-side fashion with or without psoas hitch is an effective reconstructive option for RIDUS, and is associated with good intermediate-term outcomes. Despite this, care should be taken when performing a BF in a radiated field.