Robotic Ureteral Reconstruction Alice Drain, MD, MSa, Min Suk Jun, DO, MSb, Lee C. Zhao, MD, MSa,* KEYWORDS Robot Ureteral stricture Ureteral reimplant Ureteroureterostomy Buccal mucosa Appendiceal flap Ileal ureter Retrocaval ureter KEY POINTS Ureteral strictures should be approached with an algorithmic model with decision of reconstructive technique determined by location, length, and grade. Preoperative evaluation after ureteral rest with antegrade and retrograde ureterogram guides the treatment approach. Attention to preservation of ureteral blood supply is crucial; anatomic knowledge of the vasculature is critical, circumferential dissection should be avoided, and an onlay is preferred over interposition. Ileal ureter remains a salvage option if more minimally invasive techniques are not feasible. INTRODUCTION and etiology. The prevalence of robotic-assisted repair of mid and proximal ureteral strictures has Increasingly sophisticated robotically assisted increased greatly over the past decade with laparoscopic technology and techniques have some now considering it the standard of care.4,5 led to significant advances in the minimally inva- The robot’s magnified view, stereoscopic vision, sive treatment of ureteral strictures. Stricture etiol- freedom of articulation, and availability of adjunct ogies include radiation, iatrogenic injury, trauma, technology such as Indocyanine green and Firefly urolithiasis, and congenitalism. Traditionally, ure- infrared laparoscopy are particularly advanta- teral strictures longer than 2 cm, which are refrac- geous in ureteral repair.6,7 This article describes tory to endoscopic treatment, were treated with the latest advances in the robotic approach to ure- ureteroneocystotomy with or without psoas hitch teral stricture management. or Boari flap, ureteroureterostomy (UU), ileal sub- stitution, or autotransplantation.1 Laparoscopic ureteral reconstruction was first described in DIAGNOSIS 1992 by Nezhat and colleagues,2 who performed a UU, but this procedure was not widely adopted Presenting symptoms of ureteral stricture are owing to the technical challenges of the proced- consistent with renal colic owing to upper tract ure, which requires dissection and precise sutur- obstruction, including flank pain, abdominal pain, ing in a tight working space with limited nausea, vomiting, and pyelonephritis. A computed exposure. Techniques for ureteral stricture repair tomography scan is commonly performed, were first adapted to the robot in 2003 when revealing hydroureteronephrosis with a distinct Yohannes and associates3 performed a ureteral transition point along the ureter without another reimplantation with a Boari flap for a distal stric- obvious cause for obstruction such as a ureteral ture. Middle and proximal ureteral strictures pose calculus. In some cases, the obstruction can be a greater challenge owing to both their location asymptomatic and only incidentally found. Labo- ratory evaluation may reveal worsening renal a NYU Langone Health Department of Urology, 11th Floor, 222 East 41st Street, New York, NY 10017, USA; b Crane CTS, 575 Sir Francis Drake Blvd, Suite 1, Greenbrae, CA 94904, USA * Corresponding author. E-mail address: [email protected] Twitter: @AliceDrainMD (A.D.); @DrMinJun (M.S.J.); @lee_c_zhao (L.C.Z.) Urol Clin N Am 48 (2021) 91–101 https://doi.org/10.1016/j.ucl.2020.09.001 Descargado0094-0143/21/ para BINASSSÓ 2020 Circulaci Elsevier ([email protected]) Inc. All rights reserved. en National Library of Health and Social Security de ClinicalKey.es por Elsevier en febrero 15, urologic.theclinics.com 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. 92 Drain et al function. When patients present acutely, a urolo- nephrostomy tube. If a patient has previously gist will often place a ureteral stent for decompres- been managed with an indwelling ureteral stent, sion. Some patients who would otherwise be good the stent can be used as a target on imaging. Alter- candidates for repair are managed with serial ure- natively, a urethral catheter can be placed and the teral stent exchanges. bladder instilled with irrigation, inducing hydro- nephrosis and providing a larger target for percu- ANATOMY taneous access. At this point, the stent is removed allowing for a period of ureteral rest for The ureters run bilaterally starting posterior to the 4 to 6 weeks, similar to the urethral rest described renal artery, anteriorly along the psoas muscle, for anterior urethral strictures.9 This period will posterior to the gonadal vessels, anterior to the allow for the ureteral stricture to fully declare it- bifurcation of the common iliac artery, and along self.6 After ureteral rest, a renal scan can be per- the medial aspect of the internal iliac artery. The formed to assess function and confirm ureter then courses medially and runs with the hy- obstruction. Nephrectomy may be appropriate pogastric nerves into the endopelvic fascia, for kidneys providing less than 20% split function crossing anterior to the obturator artery, vein, in the setting of recurrent pyelonephritis. After and nerves. In men, the vas deferens loops medi- the period of ureteral rest, further imaging to visu- ally over the ureter at this point, in females the alize the location, length, and grade of stricture ovary and more distally the uterine artery run ante- with an antegrade and retrograde ureterogram riorly. In cases requiring distal ureteral mobiliza- should be performed (Fig. 1). Ureteroscopy may tion, careful dissection of the hypogastric nerves be used to definitively rule out malignancy as the at this point may help to preserve bladder cause of obstruction. At this point, the diagnostic function.8 workup is complete, and the patient is counseled The ureters can be divided into upper ureter, on the findings before definitive repair. A urine cul- extending form the ureteropelvic junction to the ture is collected and treated preoperatively as upper border of the sacrum, the middle ureter, needed. The indwelling nephrostomy tube is a extending from the upper to the lower border of nidus for colonization, and patients are at higher the sacrum, and the lower ureter, which travels risk of bacteremia, funguria, and sepsis. As such, from the pelvis to the bladder. There are important antibiotic coverage is broadened as per the differences in blood supply to these 3 anatomic re- discretion of the surgeon and local guidelines. gions. The upper ureter is supplied by branches Routine bowel preparation is not recommended. arising medially from the renal artery and occa- sionally the abdominal aorta or gonadal artery, PATIENT POSITIONING the mid ureter posteriorly by branches off the com- mon iliac arteries, and the distal ureter laterally by Women are placed in dorsal lithotomy with the the superior vesical artery, a branch off the internal ipsilateral side elevated. Men may be positioned iliac artery. These branches further divide to form a in lateral decubitus. The genitalia and nephros- longitudinal anastomotic plexus along the ureter, tomy tube are included in the sterile field. The pa- and it is important when determining the location tient must be well-secured because for ureteral spatulation and graft onlay to be aware Trendelenburg is often used in cases of distal stric- of arterial supply and minimize disruption. Clini- ture. The endotracheal tube is taped to the low cally when determining approach to stricture side because the buccal graft is harvested from repair, we divide the ureter into the proximal and the top (ipsilateral) side. The mouth is prepped mid ureter and the distal ureter with the distal ure- and draped separately if a buccal mucosal graft ter beginning when the ureter runs over the bifur- is needed. cation of the common iliac artery at the pelvis, which corresponds roughly with the inferior edge PROCEDURAL APPROACH of the sacroiliac joint on imaging. There is a normal anatomic narrowing at the levels of the ureteropel- i. Port placement (Fig. 2) vic junction, iliac vessels, and ureterovesical junc- Obtain access at the midline, superior to the tion, and this must be distinguished on imaging umbilicus. from stricture in preoperative evaluation. Distal stricture: Robotic ports are placed similarly to a robotic cystectomy. The ports PREOPERATIVE PLANNING are placed sufficiently superiorly to allow for bladder manipulation. When there is suspicion for ureteral stricture, we Proximal or mid stricture: Robotic ports are recommend placement of a percutaneous placed vertically along the midclavicular line Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en febrero 15, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. Robotic Ureteral Reconstruction 93 Fig. 1. Antegrade and retrograde pyelograms (A). Right ureter: approximately 10 cm stricture. Note moderate hydronephrosis and hydroureter to proximal ureter with abrupt termination (star) and narrowing of the distal ureter below pelvic brim (arrow). (B) Left ureter: approximately 4 to 5 cm stricture. Note severe hydronephrosis, and moderate hydroureter to mid ureter (star) with abrupt narrowing of the distal ureter below the pelvic brim (arrow). The patient was treated with right ileal ureter and left Boari flap. starting 2 fingerbreadths below