and Robotic Reconstruction of the Upper Genitourinary Tract

Laparoscopic

Robotic (Intuitive Surgical, Sunnyvale, CA)

5 mm monopolar scissors

8 mm monopolar curved scissors

5 mm Maryland/atraumatic graspers

8 mm Maryland bipolar forceps

5 mm right angle graspers

8 mm Cadiere or Prograsp forceps (optional)

5 mm laparoscopic needle driver × 2

8 mm needle driver × 2

High-definition laparoscopic camera

High-definition 3D camera

10 mm 0° lens

12 mm 0° endoscope

10 mm 30° lens

12 mm 30° endoscope

5 mm trocar

8 mm robotic cannula (2 for DaVinci Si robot; 3 for DaVinci Xi robot

12 mm laparoscopic trocar

12 mm laparoscopic trocar (2 for DaVinci Si robot, camera and assistant ports; 1 for DaVinci Xi robot, assistant port)

5 mm Ligasure (optional)

General equipment

Veress needle

12 mm Visiport laparoscopic trocar (Medtronic, Minneapolis, MN)

Hem-o-lok clip applier (small, medium, large)

Angiographic 5 Fr 100 cm 0.038 in catheter

Amplatz Super Stiff J tip guidewire 0.035 in

Flexible cystoscope

Vessel loop

6 Fr double J stent (length as appropriate)

19 Fr full-flute 4-channel drain

3–0 Vicryl 12 cm SH needle × 3

4–0 Vicryl 12 cm SH needle

3–0 V-Loc V-20 12 cm absorbable suture (optional)

For bowel reconstruction:

Endo-GIA stapler

3.5 mm × 45 cm Endo-GIA staple loads × 4

2–0 Vicryl sutures (dyed and undyed)

Distal Ureter

Defects of the distal ureter may be the result of multiple etiologies, including ischemia, trauma, periureteral fibrosis, malignancy, congenital disorders, and iatrogenic injuries. Currently, iatrogenic injuries account for 2–10% of ureteral strictures and are commonly the result of gynecologic [4–6], endoscopic, or colorectal surgery. Distal ureteral stones and their treatment are also associated with an increased risk of stricture. Tas et al. reported that distal stones may cause ureteral stricture in up to 5.8% of cases and found that larger stones (>1.0 cm) and impacted stones have higher stricture rates [7]. Roberts et al. similarly showed that stones impacted for prolonged periods (greater than 2 months) had a 24% incidence of stricture formation [8]. Currently, with improved endoscopic equipment, the rate of long-term complications from stone treatment in the ureter is now <1% [9]. Urothelial carcinoma in the distal ureter is a relatively uncommon cause of distal ureteral obstruction which may be treated with segmental ureterectomy and ureteral reimplant. Several reports in the urologic literature report this as a safe and effective method in select patients while preserving renal function [10, 11]. In the pediatric population, congenital defects of the distal ureter are the most common etiology requiring surgical correction, but this remains outside the topic of this chapter. In general, most distal ureteral defects may be managed by ureteroureterostomy given that the defect is short and uncomplicated. If the segment of damaged or involved ureter is sufficiently long, additional methods may be incorporated to bridge the gap including a psoas hitch and Boari flap. Table 3.2 outlines the approximate defect lengths that may be bridged with each reconstruction technique.

Table 3.2

Approximate length of involved or damaged distal ureter that may be bridged given each method of reconstruction

Reconstruction technique	Defect lengths (cm)
Ureteroureterostomy	<2
Ureteroneocystostomy	2–5
Psoas hitch	6–10
Boari flap	12–15

Workup of Distal Ureteral Strictures

When evaluating a ureteral stricture, proper imaging is essential to ensure correct treatment planning. A retrograde pyelogram (RPG) and now less commonly an intravenous pyelogram (IVP) accurately define the length and location of a distal stricture. However, antegrade and retrograde studies both may be needed to elucidate the true extent of ureteral involvement (Fig. 3.1). Cross-sectional imaging such as magnetic resonance imaging (MRI) or computed tomography (CT) scan is also useful when evaluating ureteral strictures (Fig. 3.2) and may provide additional information to an IVP or RPG, especially when evaluating extrinsic causes of ureteral obstruction (non-urologic malignancy or fibrosis). In addition, despite their benign appearance, some strictures may be the result of malignancy and may not show the classical filling defect that is customarily seen. If there is any question as to the etiology of the stricture, a workup for malignancy should be undertaken. This should include cytology, ureteroscopy with biopsy if possible, or brushing if biopsy is not feasible. Another critical consideration is the functional status of the ipsilateral renal unit, which can be evaluated using a diuretic renal scan. Impaired function on renal scan <25% has been linked to worse success rates after endoscopic intervention [12], while renal function less than 20% may be an indication for nephrectomy. Indications for ureteral reconstruction include compromised renal function, recurrent pyelonephritis, and pain due to obstruction.

../images/312378_2_En_3_Chapter/312378_2_En_3_Fig1_HTML.jpg — Fig. 3.1

Iatrogenic distal ureteral injury during laparoscopic ablation of endometriosis. (a) The distal extent of ureteral injury (*white arrow*) and the apparent normal proximal ureter (*black arrow*) are seen on retrograde pyelogram (RPG) along with moderate hydronephrosis. (b) An antegrade nephrostogram performed on the same patient shows a greater extent of proximal ureter (*white arrow*) involved than indicated by the RPG

../images/312378_2_En_3_Chapter/312378_2_En_3_Fig2_HTML.jpg — Fig. 3.2

Reconstructed MRI urogram demonstrating a distal right ureteral stricture with associated hydronephrosis due to an iatrogenic surgical injury

Ureteroneocystostomy

Although the literature is mainly limited to case series for ureteroneocystostomy [13–18], these series have shown good overall success with laparoscopic and robotic approaches (Table 3.3). A 3–5 cm segment of distal ureter can be excised and the defect bridged without performing a psoas hitch or Boari flap. This is possible given the posterior trajectory of the ureter upon entering the pelvis, which can be brought anteriorly with ureteral mobilization and mobilization of the bladder if there is sufficient capacity and compliance.

Table 3.3

Robotic and laparoscopic series published for open, laparoscopic, and robotic ureteral reimplant

	N	Reimplant only (no.)	Psoas hitch (no.)	Boari flap (no.)	Follow-up (mo)	Surgical success^a (%)	Etiology	Approach
Wenske et al. [13]	100	24	58	18	49	97	39% TCC	Open
Kozinn^b et al. [14]	24	4	4	2	24	100	40% calculus	Robot
Hemal^b et al. [15]	18	7	1	0	14	100	44% megaureter	Robot
Ogan et al. [16]	6	5	1	0	13	100	66 % iatrogenic	Lap
Soares et al. [17]	11	7	1	2	18	100	40% calculus	Lap
Rassweiler et al. [18]	10	0	6	4	–	100	30 % iatrogenic	Lap

^aOperative success defined by imaging and symptom resolution

^bThese studies did not report the type of reconstruction for all cases

Typically, this procedure is performed via a transperitoneal approach when performed laparoscopically or robotically. The patient is placed in the supine position on the OR table with their legs in spreader bars or in low lithotomy. This allows access to the patient’s urethra and easy docking of the robot. Patient positioning and trocar placement are shown in Fig. 3.3. Insufflation is typically achieved using a Veress needle, of which the exact method of placement will be discussed in other chapters. If performed robotically (Fig. 3.4), the trocar placement is similar to that of a radical prostatectomy, although the robotic trocar contralateral to the involved ureter is moved slightly caudal and medial. Once pneumoperitoneum is established, the colon is reflected medially, and the ureter is identified as it crosses over the iliac vessels. The OR table can be rotated slightly, allowing gravity to help with colon retraction. Once circumferential access is gained to the ureter, a vessel loop is placed around it to allow for atraumatic manipulation. The ureter is then dissected distally to the strictured segment and divided (see Fig. 3.4a). At this time, an evaluation of the ureteral length should be made by extending the ureter to the bladder.

../images/312378_2_En_3_Chapter/312378_2_En_3_Fig3_HTML.jpg — Fig. 3.3

Patient position and trocar placement for right robotic ureteroneocystostomy. Note the left robotic trocar (*orange*) is brought medial and caudal compared to the right (*green*). 12 mm trocars (*blue*) are used as the camera port and the right as a lateral assistant port. A similar port placement is used if performed laparoscopically

../images/312378_2_En_3_Chapter/312378_2_En_3_Fig4_HTML.jpg — Fig. 3.4

Steps in a robotic ureteroneocystostomy. (a) The ureter is dissected to the level of the stricture and divided. A vessel loop aids in atraumatic manipulation. (b) A cystoscope is guided to the insertion point of the ureter and a wire is passed through the detrusor. (c) The ureter is spatulated on its posterior aspect, and the scissors are used to calibrate the inner lumen to ensure no stricture. (d) The anastomosis is completed using a 3-0 Vicryl suture over the wire. A double J stent is placed prior to completing the anastomosis

In most instances, the bladder will need to be mobilized to accommodate a tension-free anastomosis. This is accomplished by releasing the bladder from the anterior abdominal wall and incising the contralateral medial umbilical ligament. In some circumstances, the contralateral superior vesical artery may need to be ligated and transected. Once accomplished, the bladder is then filled with 150–200 mL of saline, and the insertion point of the ureter determined. Our method of ureteroneocystostomy involves using a flexible cystoscope passed through the urethra to identify the new ureteral insertion point from inside the bladder. The back or rigid end of a wire is pushed through the detrusor muscle and secured with a laparoscopic grasper (see Fig. 3.4b). An angiographic catheter is advanced over the wire (Amplatz Super Stiff, Boston Scientific, Marlborough, MA), and the wire is exchanged so the floppy end is advanced through the angiographic catheter and threaded up the ureter. This allows for easy subsequent stent placement. The cystotomy is slightly enlarged, and the ureter is spatulated on its posterior aspect. A spatulation of 1–2 cm may be required. Our preference is to perform a running anastomosis using two 3-0 Vicryl (Ethicon, Somerville, NJ) sutures, one for the lateral wall and one for the medial wall. A drain should be left in place through the lateral assistant port. Complications other than those associated with laparoscopy/robotics in general (e.g., port site hernia) or ureteral reconstruction (recurrent stricture) are uncommon. Though, as the ureter is often identified as it transverses over the bifurcation of the iliac artery, care must be taken to avoid an arterial injury. Table 3.4 provides a brief summary of complications specific to this and each procedure detailed in this chapter.

Table 3.4

Complications unique to laparoscopic and robotic reconstructive procedures of the upper genitourinary tract

Procedure	Complications
Ureteroneocystostomy	Iliac artery injury
Psoas hitch	Genitofemoral nerve entrapment
Boari flap	Limited bladder capacity/compliance
Ureteroureterostomy	Gonadal vessel injury
Retrocaval ureter	Caval injury, duodenal injury
Substitution ureteroplasty	Stensen duct injury, oral infection/abscess
Ureteral Substitution	Bowel leak, metabolic derangements
Nephropexy	Renal parenchymal bleeding

Psoas Hitch

The psoas hitch is an effective method to bridge larger defects in the distal 1/3 of the ureter and can effectively accommodate defects 6–10 cm from the bladder. However, as a general rule, the psoas hitch is not sufficient on its own to bridge defects that extend cephalad to the pelvis. In addition to the standard workup for ureteral strictures, when a psoas hitch is being considered, information about the bladder must be obtained. At minimum, a cystoscopy or cystogram documenting adequate bladder volume should be acquired. If there is concern for a neurogenic pathology, urodynamics may be indicated to document adequate bladder compliance.

If performing the psoas hitch laparoscopically or robotically, the patient position and trocar placement are the same as for ureteroneocystostomy (see Fig. 3.3). The steps for performing a psoas hitch are depicted in Fig. 3.5. The procedure is started with colon mobilization followed by identification and dissection of the ureter. The bladder is mobilized and attachments are divided as needed, which may include the vas deferens or round ligament. In addition, the contralateral superior vesical artery may be divided to increase mobilization. Lastly, an anterior cystotomy made perpendicular to the plane of ureteral insertion and closed parallel can help advance the dome of the bladder to the ureter. This can be done either with a 3-0 Vicryl or an absorbable 3-0 V-Loc (Medtronic, Minneapolis, MN) suture. The bladder dome is then brought to the ipsilateral psoas muscle. This is secured to the psoas fascia using several absorbable (e.g., 2-0 PDS) or nonabsorbable (e.g., silk, Ethibond, or nylon) sutures. Care must be taken to avoid entrapping the genitofemoral nerve which can be avoided by placing the stitches parallel to the psoas muscle fibers and only incorporating the psoas fascia. The ureteroneocystostomy is then performed as previously described with stent placement either at the time of ureteroneocystostomy or at the beginning of the case. Alternatively, some groups report performing the ureteroneocystostomy prior to the psoas hitch.

../images/312378_2_En_3_Chapter/312378_2_En_3_Fig5_HTML.jpg — Fig. 3.5

(a) The bladder is brought to the psoas fascia after mobilization and an anterior neocystostomy is made if additional length is needed. (b) The bladder is tacked to the psoas fascia using a 3-0 Vicryl suture and the neocystostomy is closed

Although limited, reports indicate this to be a successful procedure with a greater than 85% success in adults and children. Advantages to this procedure include its relative simplicity and low complication rate.

Boari Flap

The Boari flap is an additional surgical technique that allows longer segments of damage to the distal ureteral to be bridged. Using this method, segmental defects up to 12–15 cm may be safely managed. As with the psoas hitch, the workup must include a thorough evaluation of the bladder to ensure that it has sufficient capacity and compliance to provide a flap of correct length and not result in a small capacity bladder.

The patient positioning, trocar placement, and dissection of the ureter are the same as for a ureteroneocystostomy (see Fig. 3.3). The bladder is completely dissected off the anterior abdominal wall, and the contralateral bladder attachments are divided as needed. The Boari flap is created by making an incision 2–3 cm from the bladder neck which is extended in an oblique fashion to the dome. The base of the flap should be at minimum 4 cm wide, with the apex being approximately 3 cm wide (Fig. 3.6a). The ratio of flap length to width should not exceed 3:1 to limit ischemia. Once the flap is created, the ureter is passed through a small opening in the distal flap, and a mucosa-to-mucosa anastomosis is performed using 4-0 Monocryl suture (Fig. 3.6b). The distal end of the flap is secured to the psoas muscle. The remainder of the flap is tubularized over a double J stent (Fig. 3.6c). Because of the extensive sewing, a 3-0 V-Loc may be considered for this step. Creating a spiral flap may allow even longer segments of damaged ureter to be bridged (Fig. 3.7). It should be noted that the bladder capacity will be diminished, in some cases greatly, depending on the length of the Boari flap generated. A drain is left through the lateral assistant port.