Presentation Authors: Leanna Mah*, Onika Noel, Jennifer Rothschild, Marc Dall'era, Noah Canvasser, Sacramento, CA
Introduction: Management of long ureteral strictures is a challenge in reconstructive urology, with limited options that include ileal ureter, autotransplant, or nephrectomy. Minimally-invasive ileal ureter was first described in 2000, with the first robotic case published in 2008. We present a 41-year-old woman with a right pan-ureteral stricture of unknown etiology, who failed ureteral stent management and was nephrostomy tube dependent. We describe a port placement that allows for completion of the entire operation using the Intuitive da Vinci XiÂ® and Trumpf TruSystemÂ® 7000dV with Table Motion.
Methods: Patient was placed in the left lateral decubitus position. Four robotic ports were placed at the following locations (Figure): (1) 8 mm subcostal port for the right arm (2) 8 mm supra-umbilical port for the camera (3) 8 mm peri-umbilical port for left arm and (4) 8 mm infra-umbilical port for the fourth arm. A 12 mm assistant port was placed medial to the camera. The table was initially tilted to the left 13 degrees, with flexion. Colon and duodenum were mobilized exposing Gerota&[prime]s fascia. The proximal ureter and renal pelvis were isolated. The table was then tilted back to 0 degrees with Trendelenburg position using Table Motion to allow pelvic dissection and complete the ileal portion of the operation. The bladder was mobilized and a psoas hitch was performed. We placed an additional 12 mm port in the ipsilateral lower quadrant to complete the entero-enterostomy. The ileaovesical anastomosis was performed followed by the pyeloileal anastomosis. Drainage included a capped nephrostomy tube, ureteral stent, foley catheter, and an abdominal drain.
Results: Total robot operative time was 335 minutes. Estimated blood loss was 30 ml. The length of hospital stay was 4 days and patient was discharged home without complication. Foley catheter and ureteral stent were removed at 2 and 5 weeks, respectively. Her nephrostomy tube remained capped for 2 additional weeks. Antegrade nephrostogram demonstrated patency of both anastomoses, so the nephrostomy tube was removed.
Conclusions: Robotic ileal ureter is a feasible operation with acceptable morbidity for patients with long ureteral strictures. Using a da Vinci XiÂ® and TruSystemÂ® 7000dV with Table Motion allows for a seamless surgery to limit operative time and surgical delays in select scenarios.