Presentation Authors: Chirag Gordhan*, Rebecca Zee, Michael Hsieh, Washington, DC
Introduction: Megaureter is categorized as any combination of nonrefluxing, refluxing, obstructing, or nonobstructing. Classically, nonobstructing megaureter does not progress to obstruction. Management generally includes follow-up imaging and functional studies with intervention at time of disease progression. Intervention includes ureteral stent, endoscopic dilation, or ureteral re-implantation. Kaefer et al. described a technique of distal ureteral dismemberment and direct reimplantation as a temporizing measure. In this paper, we describe a modified Kaefer approach using the DaVinci robot in a 17-year-old male with a left megaureter that evolved from no obstruction to symptomatic obstruction.
Methods: Our patient is a 17-year-old male who was diagnosed with a nonobstructing, nonrefluxing megaureter during childhood. Serial functional imaging confirmed a lack of obstruction. He had no history of UTIs. He recently re-presented with left flank pain. Repeat imaging revealed a persistent megaureter. MAG3 renogram demonstrated preserved function (Left 44%, right 56%) and high grade UVJ obstruction with T1/2 of 41 minutes and 3% upright drainage. Of note, patient complained of flank pain during the post-Lasix portion of the exam. Given these findings we offered surgical correction. _x000D_
After general anesthesia was achieved we performed cystoscopy and retrograde pyelogram that revealed a significantly dilated and tortuous ureter. We attempted stent placement, but due to tortuosity of the ureter we were unsuccessful and a sensor wire was left in place at the mid-ureter. Three robotic ports were placed and the robot was docked. The left distal ureter was mobilized. A ureterotomy was made proximal to the UVJ obstruction. A cystotomy was made next to the ureterotomy. A ureteral stent was advanced over the pre-placed wire through the native ureteral orifice, proximal ureter, out the ureterotomy, and into the cystostomy. This resulted in both ends of the stent in the bladder. A ureterovesical anastomosis was performed. A JP drain and Foley were left in place.
Results: The patient was discharged the next day after discontinuation of drains. Ultrasound at 6 weeks showed resolution of megaureter. MAG3 at 3 months demonstrated preserved renal function with minimal left hydronephrosis and no evidence of obstruction (T1/2 4 minutes). In the office, the patient reported resolution of flank pain and minimal pain with voiding.
Conclusions: The treatment of primary obstructing megaureter remains controversial, however, with careful patient selection a NUC using the DaVinci is a safe, and viable option.