Robotic-Assisted Ureteral Re-implantation: A Case Series

Abstract

Introduction:

Minimally invasive surgical techniques are currently used for numerous urologic disorders and generally offer decreased morbidity and equivalent outcomes compared with open surgery. There is a relative paucity of data on robot-assisted ureteral re-implantation (RAUR) in adult patients for benign stricture disease.

Patients and Methods:

We retrospectively reviewed our recent experience with mid-/distal ureteral reconstruction at a single tertiary-care center. From 2010 to 2012, 13 consecutive patients presenting with benign obstruction of mid-/distal ureters were managed with RAUR.

Results:

In all cases the operative procedure was undertaken with six-port transperitoneal access, and all procedures were completed robotically. All ureters (left, n=5; right, n=7; bilateral, n=1) were re-implanted in a standard Bricker fashion into the dome of the bladder with (n=8) or without (n=6) a psoas hitch. Catheters were removed 4–11 days postoperatively, and all cystograms were negative for leak. Stents were removed 14–48 days after surgery. All were negative for hydronephrosis. Average follow-up was 10 (range, 2–20) months. There were two grade 1, two grade 2, two grade 3, and no grade 4 or 5 complications in 3 patients.

Conclusions:

RAUR is a safe and effective procedure. Extensive laparoscopic lysis of adhesions represents the primary challenge to an otherwise straightforward minimally invasive surgery. At our institution, RAUR has replaced open ureteral re-implantation as the preferred treatment for benign mid-/distal ureteral stricture disease.

Introduction

Ureteral injury is a recognized complication of abdominopelvic surgery. The overall incidence of ureteral injury following gynecologic surgery is reported to be between 0.5% and 1.5%.¹ In one study hysterectomy accounted for 54% of iatrogenic ureteral injuries, followed by colorectal surgery in 14%.¹ Ureteral injuries are often associated with significant morbidity, including fistula formation, urinoma, the need for a percutaneous nephrostomy, decline in renal function, and single- or multistage surgical intervention.

Traditionally, management of ureteral injuries not amenable to endoscopic manipulation has required open laparotomy and ureteral re-implantation with or without a psoas hitch/Boari flap. The morbidity of open laparotomy can be significant, including blood loss, postoperative pain, ileus, and lengthy hospital stay. Minimally invasive surgical techniques are currently used for numerous urologic problems, offering, in many cases, decreased morbidity and equivalent outcomes compared with open surgery. The advent of the da Vinci^® Surgical System (Intuitive Surgical, Sunnyvale, CA) and EndoWrist^® (Intuitive Surgical) technology has enhanced traditional laparoscopy by facilitating intracorporeal suturing, expanding the role of robotic surgery in urologic reconstruction. Other advantages include three-dimensional vision for the surgeon, magnification (×10), tremor elimination, and motion scaling. There is a relative paucity of data on robot-assisted ureteral re-implantation (RAUR) in adult patients for benign stricture disease. The objective of this article is to report our early experience with RAUR for the management of distal ureteral stricture disease at our institution.

Patients and Methods

After receiving Institutional Review Board approval, we retrospectively reviewed our recent experience with mid-/distal ureteral stricture disease at a single tertiary-care center. From 2010 to 2012, 13 consecutive patients presenting with benign obstruction of mid- or distal ureters (14 ureters) were managed with RAUR. There were 11 females and 2 males in the cohort. Mean patient age was 46 (range, 35–70) years. Mean body mass index was 31 (range, 22–39) kg/m². Etiology of the ureteral obstruction was laparoscopic gynecologic procedure (n=9), open gynecologic procedure (n=2), or robotic prostatectomy (n=2) (Table 1). Five patients had pathology on the left, 7 had it on the right, and 1 had bilateral disease. Surgery was performed by four experienced laparoscopic/robotic surgeons (R.S.L. [n=2], R.W.G. [n=1], J.B.M. [n=9], and S.E.L.W. [n=1]) with the daVinci Surgical System. In all cases, the operative procedure was undertaken using six-port transperitoneal access. All ureters were re-implanted in a standard Bricker fashion with (n=8) or without (n=6) a psoas hitch. Demographic characteristics, peri- and postoperative findings, and clinical/radiographic outcomes were assessed.

Table 1.

Indications for Ureteral Re-implantation

Indication	Number of cases
Prior gynecologic surgery	11
Laparoscopic hysterectomy	6
Laparoscopic-assisted vaginal hysterectomy	1
Laparoscopic oophorectomy	1
Laparoscopic fibroid removal/endometriosis	1
Open gynecologic surgery	2
Robotic prostatectomy	2
Ectopic ureter	1
Ureteral injury from extended PLND	1

PLND, pelvic lymph node dissection.

RAUR at our institution was completed in a similar fashion by all four surgeons. The technique has been well described,² and here we summarize our approach.

The patient is positioned in dorsal lithotomy in a moderate to steep Trendelenburg position, and the robot is docked between the legs. A sterile 16-French Foley catheter is placed into the bladder. Pneumoperitoneum is established with a Veress needle, and trocars are placed. The 12-mm camera port is placed 4 cm above the umbilicus in the midline. Three 8-mm robotic ports are placed: two are placed 9 cm inferolaterally from the midline port on both the right and left sides, and the third is placed on the left, 7 cm lateral to the 8-mm robotic port. A 12-mm assistant port is placed on the right, 7 cm lateral to the 8-mm robotic port. A sixth 5-mm assistant port is placed superolaterally from the midline port (Fig. 1).

FIG. 1.

Placement of ports for robot-assisted laparoscopic distal ureteral surgery using the da Vinci Si four-arm system: camera port at the umbilicus (12 mm), robotic ports (8 mm), assistant port right lower quadrant (12 mm), and suction port (5 mm).

The hemicolon is mobilized along the line of Toldt ipsilateral to the pathology until the psoas muscle is visualized. The ureter is dissected with its blood supply preserved until the strictured segment is encountered. A vessel loop placed around the ureter aids in atraumatic traction and facilitates distal and proximal dissection. The ureter is transected proximal to the stricture and spatulated posterolaterally. A “double-J” stent is placed in a retrograde fashion over a glidewire. The urinary bladder is filled with saline to assist in mobilizing the bladder. The peritoneum is incised, the space of Retzius is entered, and the bladder is mobilized until its upper portion can reach the psoas muscle without tension. If tension-free anastomosis cannot be achieved with bladder mobilization alone, then a psoas hitch or Boari flap is indicated, and three polyglactin 910 (Vicryl^®; Ethicon, Inc., Somerville, NJ) sutures are placed 2 cm apart to secure the bladder to the psoas tendon. The bladder dome is incised approximately 3 cm. Sutures with 3-0 poliglecaprone 25 (Monocryl^®; Ethicon) are used to anchor the ureter to the bladder, and then running 4-0 Monocryl sutures are used to complete the ureterovesical anastomosis. The bladder is filled to test the anastomosis for leakage or tension.

Ureteral stents are always left across the ureterovesical anastomosis postoperatively. A Foley catheter is left in place routinely along with a 15-French Blake drain brought out one of the trocar sites. Drains are removed prior to discharge. Early in our experience, the postoperative care pathway was variable. With time and experience, a more uniform pathway has evolved as follows: the Jackson–Pratt drain is removed on postoperative Day 1 after confirming that fluid creatinine is consistent with serum. The patient is discharged home on postoperative Day 1 if he or she is tolerating a regular diet. An in-office cystogram is performed on postoperative Day 5, and the Foley catheter is removed if there is no leak. The ureteral stent is removed 2 weeks postoperatively. A renal ultrasound is obtained 3 months postoperatively.

Results

All procedures were completed successfully robotically without requiring open conversion. All ureteral injuries were recognized days to several weeks postoperatively. One patient was noted to have a rising creatinine level and unilateral hydronephrosis 1 day after robotic prostatectomy. At the time of cystoscopy, the right ureteral orifice was not identified. Upon robotic exploration, the urethrovesical anastomosis was taken down, and an ectopic ureter was identified presumably as it entered the prostate. Mean time from injury recognition to the time of repair was 95 (range, 1–212) days. Mean overall operative time was 282 (range, 174–418) minutes (Table 2). Extensive laparoscopic lysis of omental and intestinal adhesions was occasionally required (n=4), accounting for postoperative blood loss in 2 cases. Mean estimated blood loss was 123 (range, 20–600) mL.

Table 2.

Perioperative Data

Factor	Value
Patients	13
Ureters	14
Operative time (minutes)	282 (174–418)
Blood loss (mL)	123 (20–600)
Length of hospitalization (days)	2.5 (1–8)
Time until catheter removal (days)	7 (4–11)
Time until cystogram (days)	8 (4–27)
Time until stent removal (days)	31 (14–48)
Duration of follow-up (months)	9.8 (2.3–20)

Data are number of mean (range) as indicated.

Six postoperative complications were noted in 3 patients (23%) (Table 3). Perioperative morbidity included two grade 1 (ileus, pyelonephritis), two grade 2 (blood transfusion), two grade 3 (diagnostic laparoscopy, DeFlux™ [Salix Pharmaceuticals, Raleigh, NC] injection), and no grade 4 or 5 complications (modified Clavien classification system³). One patient had bilateral RAUR and required a transfusion and diagnostic laparoscopy for suspected postoperative bleeding. No active bleeding was identified at laparoscopy, but a moderate amount of clot was evacuated from a region of extensive omental adhesions. The second patient who required a transfusion also had prior open and laparoscopic surgeries and required extensive lysis of adhesions prior to ureteral repair. A third patient developed pyelonephritis 8 weeks after the repair and had symptomatic vesicoureteral reflux. This patient was managed with DeFlux injected submucosally at the level of the ureterovesical anastomosis and is currently asymptomatic.

Table 3.

Clavien–Dindo Complication Classification

Grade	Complication
1 (n=2)	Ileus (n=1)
	Pyelonephritis (n=1)
2 (n=2)	Blood transfusion (n=2)
3 (n=2)	Diagnostic laparoscopy (n=1)
	DeFlux (n=1)
4 (n=0)	NA
5 (n=0)	NA

NA, not applicable.

All patients were discharged at a mean of 2.5 (median, 2; range, 1–8) days postoperatively. Mean time for catheter and ureteral stent removal was 7 and 31 days, respectively. Mean follow-up was 9.8 (range, 2.3–20) months. All patients had a follow-up renal ultrasound (mean, 70 days; range, 34–185 days) after repair; all were negative for hydronephrosis except 1 patient who had transient mild hydronephrosis, which resolved without intervention on follow-up renal ultrasound. All are currently asymptomatic.

Discussion

Open ureteroneocystotomy has been the gold standard approach to benign distal ureteral stricture disease not amenable to endoscopic repair. Re-implantation with a psoas hitch was first described by Zimmerman et al.⁴ in 1960. Harrow⁵ modified this technique with the addition of a submucosal tunnel. The first reported minimally invasive approach to ureteral re-implantation was by Ehrlich et al.⁶ in 1994 in pediatric patients. That same year, Reddy and Evans⁷ described laparoscopic ureteroneocytstotomy in adults. Rassweiler et al.⁸ noted significant advantages of laparoscopic over open re-implantantion in terms of decreased estimated blood loss (370 versus 610 mL), decreased analgesic requirement (4.9 versus 21.5 mg), and shorter hospital stays (9.2 versus 19.1 days). Although the laparoscopic approach was feasible, its use required advanced laparoscopic suturing skills, thus limiting its widespread dissemination. The introduction of the da Vinci Surgical System facilitated intracorporeal suturing and allowed more complex genitourinary reconstruction procedures to be performed. Uberoi et al.⁹ first described robot-assisted ureteroneocystotomy with the psoas hitch combined with distal ureterectomy for mid- and distal ureteral tumors in 2007. Although several series have been published since then, there still remains a paucity of data in the published literature on robotic ureteral re-implantation for benign stricture disease.

In the published series on RAUR,^10–17 the authors have shown that RAUR can be performed with excellent success rates (Table 4). Patil et al.¹⁰ in 2008 were the first to describe their robotic experience with stricture repair and ureteral re-implantation using the psoas hitch in 12 patients from three multinational institutions. They noted decreased blood loss and length of stay with robotic surgery over the open approach. No complications were noted, all were asymptomatic, and none of the patients had radiologic evidence of disease at a mean follow-up of 15 months. Most recently, in 2013, Musch et al.¹¹ reported on their experience with distal ureteral surgery in 16 patients for both malignant (n=5) and benign (n=11) conditions. Although operative times and length of stay were greater, these differences may be due to differences in technique (refluxing versus nonrefluxing) and healthcare systems (United States versus Europe). Perhaps the largest series of distal ureteral surgery to date for benign disease was reported by Isac et al.¹² They retrospectively reviewed their series of 25 patients undergoing RAUR and compared them with 41 patients who underwent open ureteroneocystotomy. They showed a shorter median operative time in the open ureteroneocystotomy group (200 versus 279 minutes), whereas the RAUR group had a shorter hospital stay (median, 3 versus 5 days), less narcotic pain requirement (morphine equivalent, 104.6 versus 290 mg), and less estimated blood loss (100 versus 150 mL). There was no significant difference in the rate of re-operation between groups: RAUR versus open ureteroneocystotomy, 2/25 (7.6%) versus 4/41 (9.7%).

Table 4.

Published Robotic-Assisted Ureteral Re-implantation Case Series for Purely Benign Disease Involving the Distal Ureter in Adults

Reference	Year published	Time period	Journal	Multi- or single institution	Multi- or single surgeon	Number of patients	Procedure	Indications	Age (years)	Operative time (minutes)	Estimated blood loss (mL)	Length of stay (days)	Surgical complications	Follow-up (months)	Findings at follow-up
Patil et al.¹⁰	2008	2004–2006	J Endourol	Multi-institutional	Multi-surgeon	12	12 primary UNC with psoas hitch	10 strictures, 2 ureterovaginal fistulas	41 (19–67)	208 (80–360)	48 (45–108)	4.3 (2–8)	None	15.5	10 normal renal ultrasound, 2 mild hydronephrosis
Shimpf and Wagner¹⁵	2009	2004–2008	JSLS	Single institution	Single surgeon	5^a	2 primary UNC with diverticulectomy, 2 UNC with psoas hitch, 1 UNC with Boari flap	2 ureteral strictures, 2 bladder diverticulum, 1 iatrogenic	63	182	10	2	2/11 (18%): external iliac vein injury repaired robotically (1); persistent bleeding from ureterovesical anastomosis (1)	13	2 patients complaining of flank pain had MAG3 scans postoperatively with T1/2 drainage times of <10 minutes
Williams and Leveillee¹⁶	2009	2005–2007	J Endourol	Single institution	Single surgeon	7 (1 bilateral)	8 primary UNC	3 iatrogenic, 3 stone disease, 1 endometriosis	44	247	110	2	1/7 (14%): recurrent symptoms in 1 patient requiring endoscopic balloon dilation, no further issues	18 (5–31)	No major complications during follow-up. All had MAG3 scans postoperatively with T1/2 drainage times of <20 minutes
Hemal et al.¹⁴	2010	2006–2009	Urology	Multi-institutional	Multi-surgeon	5^b	2 UNC, 2 UNC with VVF repair, 1 UNC with psoas hitch	1 ureteral stricture, 2 VVF repairs, 2 iatrogenic	NR	160	163	2	None	13	No hydronephrosis
Yang et al.¹⁷	2011	2008–2009	J Laparoendoscopic Adv Surg Tech A	Single institution	Single surgeon	2^c	1 UNC with Boari flap, 1 UNC with psoas hitch	1 ureteral endometriosis, 1 iatrogenic	36	NR	75	5	None	2-year follow-up in 1 patient	One patient with no hydronephrosis; 1 lost to follow-up
Kozinn et al.¹³	2012	2005	J Endourol	Single institution	Single surgeon	9 (1 bilateral)	6 primary UNC; 3 psoas hitch and 1 Boari flap	5 stone disease, 4 iatrogenic	49 (27–63)	307	30.6	2.4	None	Up to 24 months	No hydronephrosis
Isac et al.¹²	2013	2000–2010	J Endourol	Single institution	Single surgeon	25	10 primary UNC, 1 tapered UNC, 4 UNC with psoas hitch, 10 UNC with Boari flap	16 stone disease, 4 endometriosis, 5 iatrogenic	49 (40.5–64)	279	100	3	2/25 (7.9%): required reoperation	11.6	Two failures: one requiring open renal autotransplant; one underwent open re-implant, followed by open ileal interposition
Musch et al.¹¹	2013	2009–2013	BJU Int	Single institution	Multi-surgeon	9 (2 bilateral)^d	5 primary UNC, 2 UNC with psoas hitch, 2 UNC with Boari flap	5 iatrogenic, 1 inflammatory, 1 VUR, 1 nonfunctioning renal segment, 1 renal ectopia	59 (39–79)	271 (153–460)	NR	12 (5–35)	5/9 (55.5%): 1 Clavien, 1 Clavien 2, 2 Clavien 3b, 1 Clavien 4a	11 (4–18.2)	Asymptomatic hydronephrosis from anastomotic stricture 13 months after surgery; all others asymptomatic, no hydronephrosis

Age, operative time, estimated blood loss, length of stay, and follow-up are given as mean or mean (range) values as indicated.

Six cases were excluded: urothelial carcinoma.

Thirty-nine cases were excluded: 8 congenital obstructive megaureter, 5 ureteral/bladder carcinoma, 12 proximal ureteral procedures, 10 ablative procedures, 4 miscellaneous.

One case excluded: urothelial carcinoma.

Seven cases were excluded: 5 carcinoma, 1 ureteroureterostomy, 1 ureterolysis.

NR, not reported; UNC, ureteroneocystotomy; VUR, vesicoureteral reflux; VVF, vesicovaginal fistula.

We similarly report on our early experience with RAUR in a series of 13 patients involving 14 re-implants at a single institution. To the best of our knowledge, this series represents the second largest single-institution experiences with adult robotic mid-/distal ureteral reconstruction for purely benign distal ureteral disease. All except 2 patients developed distal ureteral stricture from a prior gynecologic procedure, with the majority (81%) being a laparoscopic gynecologic procedure for benign disease. All procedures were able to be successfully completed robotically without open conversion. Most patients were discharged at a median of 2 days, and all patients had short duration of catheterization without any leak noted on cystogram. We found this was a significant advantage of the robotic approach over published hospital stays for open re-implantation and paralleled recent published case series (Table 4).

In our series we noted an overall 23% complication rate, all of which were grade 3 or less. This is comparable to other published case series, which ranged from 0% to 55%.^10–17 Two patients required a blood transfusion as a result of postoperative bleeding, presumably related to cold dissection through extensive omental adhesions. Given that one of the perceived benefits of robotic surgery is decreased blood loss, the incidence of postoperative blood transfusions in our early experience with RAUR is somewhat disconcerting. Nevertheless, intraoperative blood loss was uniformly low in our series. We have not identified any technical problems unique to the robotic approach that would predispose to postoperative bleeding. Obviously, patients with more complicated surgical history are more likely to have extensive adhesions, and meticulous surgical management of these adhesions is paramount, regardless of surgical approach. One patient in our series developed pyelonephritis and symptomatic vesicoureteral reflux requiring endoscopic DeFlux injection. We routinely perform a refluxing anastomosis unless there is clear reason to perform a nonrefluxing anastomosis (i.e., voiding dysfunction). Although a nonrefluxing anastomosis has been described and may lead to lower rates of pyelonephritis, the trade-off is a potential increased risk of ureteral stenosis.

The limitations of our study include its retrospective design, multiple surgeons, and limited follow-up. Despite these limitations, we feel that RAUR in our hands has provided outcomes comparable to open ureteral reconstruction with low perioperative morbidity and short hospital stay. Considering the morbidity that accompanies an unrecognized ureteral injury and the sensitive nature of these presumably avoidable complications, we are pleased to offer a safe and effective technique that allows patients a quicker return to normal daily function.

Conclusions

RAUR with or without a psoas hitch is safe and effective and is associated with excellent short-term outcomes with minimal postoperative morbidity. Extensive adhesions represent the primary challenge to an otherwise straightforward minimally invasive surgery. At our institution, RAUR has replaced open ureteral re-implantation as the preferred treatment for benign mid- and distal ureteral stricture disease.

Footnotes

Disclosure Statement

No competing financial interests exist.

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