Presentation Authors: Rachel Shannon*, Deborah L Jacobson, Elizabeth B Yerkes, Edward M Gong, Chicago, IL
Introduction: While robot-assisted laparoscopic (RAL) transplant ureteral reimplantation is a known treatment option for managing transplant vesicoureteral reflux (VUR), video documentation of this procedure is lacking. We aim to visually demonstrate the surgical technique used in a RAL transplant ureteral reimplantation with concurrent creation of a Mitrofanoff catheterizable channel.
Methods: We present a 10 year old male with a history of posterior urethral valves, neurogenic bladder, and end-stage renal disease. He underwent extraperitoneal cadaveric renal transplantation three years prior, but became increasingly intolerant of urethral catheterization and developed renal injury. Videourodynamics revealed grade 3 VUR into the transplant kidney, and renal scarring was present on DMSA. The decision was made to proceed with ureteral reimplantation and creation of a Mitrofanoff.
Results: Pre-procedural cystoscopy was performed and a stent was placed in the transplant ureter. The patient was placed in a modified supine position and the daVinci XI robotic surgical system was docked. Ports were placed in the umbilicus, right lower quadrant, and left lower quadrant without use of an assistant port. The ureter was dissected distally to the level of the bladder. A submucosal detrusor tunnel was created along the anterolateral wall of the bladder, the ureter was dunked into the tunnel, and the tunnel was closed.Mesenteric windows were created and the appendix was ligated then transected. The cecal defect was oversewn. The urachus was transected and its hiatus was closed in two layers. A 3-centimeter detrusor tunnel was developed along the anterior right dome of the bladder. The appendix was spatulated and approximated to a distal cystotomy. The detrusor tunnel was closed. The Mitrofanoff was pulled through the umbilical port, spatulated, and anastamosed. Catheters were left in the Mitrofanoff channel and the urethra. EBL was 30mL and total OR time was 640 minutes. Post-op the patient developed stent malfunction despite radiographic evidence of appropriate stent position. A second ureteral stent was placed with immediate improvement. His stents were subsequently removed and his graft function remains excellent. He is easily catheterizing per Mitrofanoff and is satisfied with the outcome of his repair.
Conclusions: This video demonstrates the surgical technique used in a RAL ureteral reimplantation and creation of Mitrofanoff catheterizable channel in the setting of transplant VUR and neurogenic bladder. The patient continues to report excellent results 5 months post-op.