Operative Planning

Reconstruction of the upper urinary tract relies on a thorough understanding of a patient’s anatomy related to both disease and anatomic variation. Planning for pyeloplasty should include computed tomography (CT) or magnetic resonance imaging (MRI) with contrast to assess for crossing vessels and delineate hilar anatomy. Diuretic renal scans are useful to assess relative renal function and extent of obstruction. Additionally, if minimally invasive ureterolysis is planned, biopsy of retroperitoneal tissue should be considered before ureteral manipulation to exclude malignancy.

Patients may have a mechanical bowel preparation before reconstructive urologic surgery to increase working space and improve exposure. A bowel preparation may also be useful for upper urinary tract reconstruction if harvesting bowel for ureteral interposition is planned.

The decision to use minimally invasive techniques depends primarily on the surgeon’s preference and experience. Regarding the use of laparoscopy alone versus robotic assistance, few data suggest superiority of one technique over the other. Selection of transperitoneal versus retroperitoneal approaches for reconstruction depends primarily on the surgeon’s preference. Both approaches are safe and effective for upper urinary tract surgery. A comparative study evaluated retroperitoneal robotic pyeloplasty and transperitoneal robotic pyeloplasty. Average operative time was similar, and there were no intraoperative complications. There were two recurrences in the retroperitoneal group and none in the transperitoneal group; notably the recurrences occurred in the first 10 cases. Retroperitoneal access may be safer in patients with extensive prior abdominal surgery and obesity, although disadvantages include limited working space and a potentially steeper learning curve.

Intraoperative Complications

General principles of perioperative care apply to patients having urologic reconstruction and include the use of bilateral sequential compression boots, prophylactic antibiotics, and generous padding for all pressure points.

Complications related to access and pneumoperitoneum are discussed in Chapter 30 . This section describes complications specific to minimally invasive reconstructive procedures and recommendations regarding their management.

Minimally Invasive Pyeloplasty

Laparoscopic pyeloplasty was first described in 1993 and became the standard of care. Robotic assistance was first reported by Sung and colleagues in 1999, and numerous series have been published demonstrating the equivalence or superiority of this technique.

In a series of 147 patients who underwent laparoscopic transperitoneal pyeloplasty, two cases of bowel injury were reported, including a serosal injury to the small bowel and an inadvertently clipped colonic diverticulum. Both injuries were repaired during the same surgical procedure with no sequelae. No intraoperative complications were reported in a large series of patients who underwent extraperitoneal laparoscopic pyeloplasty. In a multi-institutional series of robotic pyeloplasty among 140 patients, a single minor intraoperative splenic laceration was noted and successfully managed with pressure and topical hemostatic agents. In another series of 131 patients, there was only one conversion to open surgery due to technical difficulties. A multiinstitutional study of 168 patients undergoing robotic pyeloplasty reported no intraoperative complications. Notably 21 (13%) of these cases were secondary repairs.

The reported rate of conversion from laparoscopic to open pyeloplasty is ≈1.6%. Rassweiler and associates reported a single conversion in their large series of retroperitoneal laparoscopic pyeloplasty based on significant anastomotic tension and the requirement for open dissection and fixation of the kidney during suturing. Mufarrij and associates reported no open conversions in a series of 140 robotic pyeloplasties, whereas another study noted one open conversion out of 131 cases.

The risk of significant bleeding from laparoscopic or robotic pyeloplasty is low. Inadvertent injury to major vessels may be minimized with good operative planning including CT with contrast to identify crossing vessels or anomalous vascular anatomy. However, in our experience, imaging may not be completely reliable; both false-positive and false-negative results of imaging for relevant vessels may occur.

Laparoscopic suturing is the most challenging aspect of laparoscopic pyeloplasty. Technical complications of suturing (e.g., stricture, urinary extravasation) may be minimized by meticulous technique, but patient-related factors (e.g., history of diabetes, secondary repair) may influence the incidence of these complications. Creating a tension-free anastomosis requires careful intraoperative planning and may decrease the risk of complications related to ureteral ischemia and suture line breakdown. Intraoperative techniques for safely creating more length include downward nephropexy and creation of a “handle” in the renal pelvis to decrease the manipulation of healthy tissue. Traction sutures can also be placed in the ureter or pelvis to decrease manipulation of tissue and decrease the risk of ischemia.

Ureteral stent placement across the anastomosis is essential to minimize the risk of urinary leakage. Complications of stent placement include submucosal tunneling and incomplete advancement into the bladder or kidney, depending on the direction of placement. If anterograde placement is performed, the bladder can be filled with 300 mL of methylene blue; refluxed dye confirms correct distal positioning of the stent. Flexible cystoscopy can also be performed to confirm correct placement of the ureteral stent.

Minimally Invasive Ureteral Reconstruction

Laparoscopic and robotic ureteral reconstruction has been performed in all portions of the ureter for diverse indications including trauma, stricture, neoplasm, and anatomic abnormalities. Procedures have included ureteroureterostomy, ureteral reimplantation with or without psoas hitch, Boari flap, ileal ureter, ureterolysis, and retrocaval ureter repair. A novel procedure using buccal mucosa graft for ureteral repair has been developed.

Laparoscopic ureteroureterostomy was first reported for treatment of infiltrative endometriosis and has been performed without significant intraoperative complications or need for conversion to an open procedure. Robotic approach has also been used safely and successfully for ureteroureterostomy. A unique consideration for ureteroureterostomy relates to the “watershed” blood supply of the midureter and the potentially increased risk of ischemia during manipulation and suturing. Techniques for reducing the risk of ischemia include minimizing the manipulation of tissues (e.g., using traction sutures), minimizing medial dissection of the ureter and potential disruption of the vascular supply, and ensuring that the ureteral edges appear pink and healthy before anastomosis. A new technique developed by Lee and associates was described to reduce the risk of injury to the ureter during surgery and to assist in localizing the ureteral stricture during repair. The authors used indocyanine green in an antegrade and retrograde fashion into the ureter and visualized it using near-infrared fluorescence during repair. A recent modification is the use of indocyanine green intravenously to evaluate tissue perfusion. Ureteral tissue appears dark if poorly perfused and bright green if well perfused. This technique has since been used by other groups to minimize complications related to poor blood supply.

Ureteral stent placement is recommended in all patients having ureteral repair and can be placed preoperatively or intraoperatively in a retrograde fashion or transperitoneally during the surgery. If the ureteral length is insufficient for primary anastomosis, techniques such as psoas hitch or Boari flap can be performed to gain length distally. Buccal mucosa graft ureteroplasty, bowel interposition, or autotransplantation may be necessary if other techniques are unsuccessful. Understanding the patient’s anatomy and extent of disease is essential to ensure appropriate operative planning and management of the patient’s expectations preoperatively.

Despite limited data, evidence indicates that the intraoperative complication risk of ureteral reconstruction is low. No significant intraoperative complications were noted in series of laparoscopic and robotic ureteral reimplantation (for indications including reflux, distal ureter injury, and low-grade distal ureteral urothelial cell carcinoma), Boari flap, ureteroureterostomy, ureterocalicostomy, ileal ureter, and retrocaval ureter repair. One study of robotic ureteroureterostomy in 12 patients reported a liver and gallbladder laceration during robotic port placement due to adhesions which required a concomitant cholecystectomy. Conversion to open was reported in one out of 16 patients who underwent robotic ureteral surgery. The patient had a prior history of pancreatectomy, and open conversion was needed to complete distal ureteral resection with reimplantation and psoas hitch for cancer.

A study compared open, laparoscopic, and robotic ureteral reimplantation in 130 patients. In the laparoscopic group, there was a 5% rate of intraoperative complications including inadvertent ureterotomies repaired primarily, enterotomy requiring small bowel resection, and injury to appendix requiring appendectomy. There was a 2% rate of conversions to open in the laparoscopic cohort, one for small bowel resection and another for technical difficulty. There were no complications or conversions in the robotic or open cohort. Robotic approach allows for better visualization, easier suturing, and improved hemostasis resulting in minimal complications. An additional two studies compared a total of 35 robotic to 65 open ureteral reimplants and found significantly less blood loss and shorter hospital stay for the robotic group. These reports suggest that robotic ureteral reconstruction seems to be at least equivalent to the open approach, but may offer the additional benefits of minimal blood loss and shorter hospital stay.

Minimally Invasive Ureterolysis

Laparoscopic ureterolysis was first reported by Kavoussi and associates in 1992. Laparoscopic dissection within a fibrotic retroperitoneum can be challenging given diminished tactile feedback. However, low morbidity was reported in several series of laparoscopic ureterolysis. Indocyanine green or intraoperative ultrasound can help to identify the ureter if fibrosis obscures retroperitoneal anatomy.

Ureteral injury is one potential complication of laparoscopic ureterolysis. Ureteral injuries should be repaired with either a minimally invasive approach or with an open procedure, based on the extent and location of injury. Omental wrapping or intraperitonealization can be performed to protect the ureteral anastomosis. Rare complications include vascular injury, for example, an iliac vein injury, pneumothorax, and subcutaneous emphysema.

Reported conversion rates to open procedures have been 15% in series of laparoscopic ureterolysis. Conversion has been required secondary to technical difficulty with periureteral fibrosis, vascular injury, and other emergency indications.

Robotic ureterolysis has been safely performed without intraoperative complication. Improved visualization from robotic technology may facilitate identification of the ureter, and the precision of robotic Pott scissors and greater degrees of freedom may facilitate the dissection and potentially decrease the risk of injury.

Minimally Invasive Buccal Mucosa Graft Ureteroplasty

Oral mucosal graft for ureteroplasty was first reported in an animal model in 1984. Ureteral strictures have been treated successfully with buccal mucosa with an open approach. In a study of five patients, buccal mucosa graft was used for strictures between 3.5 cm and 5 cm. There were no intraoperative complications, and at a mean follow-up of 24 months there was a 100% success rate. Robotic buccal mucosal ureteroplasty was done in four patients in one study, and there were no intraoperative complications. Some of the intraoperative maneuvers to ensure a successful repair were as follows: use of an omental flap or a perirenal flap to provide a vascular bed, simultaneous flexible ureteroscopy to localize the stricture, intravenous injection of indocyanine green to identify well-vascularized ureteral tissue, and flexible ureteroscopy during anastomosis to prevent placement of suture into the back wall of the ureter and to confirm a watertight anastomosis.

Minimally Invasive Renal Autotransplantation

A technique of completely intracorporeal renal autotransplantation has been recently described in a patient with long ureteral stricture due to ureteral perforation during endoscopic stone treatment. Warm ischemia time for nephrectomy was 2.3 minutes, while cold ischemia time was 95.5 minutes. Total console time for the surgeon was 334 minutes. The patient was discharged home on postoperative day 1 after a transplant Doppler ultrasound showed patent vascular anastomosis and after removal of Foley catheter and drain. The ureteral stent was removed at 6 weeks. A intravenous urogram 2 weeks after stent removal showed no extravasation or obstruction.

Operative Planning

Reconstruction of the upper urinary tract relies on a thorough understanding of a patient’s anatomy related to both disease and anatomic variation. Planning for pyeloplasty should include computed tomography (CT) or magnetic resonance imaging (MRI) with contrast to assess for crossing vessels and delineate hilar anatomy. Diuretic renal scans are useful to assess relative renal function and extent of obstruction. Additionally, if minimally invasive ureterolysis is planned, biopsy of retroperitoneal tissue should be considered before ureteral manipulation to exclude malignancy.

Patients may have a mechanical bowel preparation before reconstructive urologic surgery to increase working space and improve exposure. A bowel preparation may also be useful for upper urinary tract reconstruction if harvesting bowel for ureteral interposition is planned.

The decision to use minimally invasive techniques depends primarily on the surgeon’s preference and experience. Regarding the use of laparoscopy alone versus robotic assistance, few data suggest superiority of one technique over the other. Selection of transperitoneal versus retroperitoneal approaches for reconstruction depends primarily on the surgeon’s preference. Both approaches are safe and effective for upper urinary tract surgery. A comparative study evaluated retroperitoneal robotic pyeloplasty and transperitoneal robotic pyeloplasty. Average operative time was similar, and there were no intraoperative complications. There were two recurrences in the retroperitoneal group and none in the transperitoneal group; notably the recurrences occurred in the first 10 cases. Retroperitoneal access may be safer in patients with extensive prior abdominal surgery and obesity, although disadvantages include limited working space and a potentially steeper learning curve.

Intraoperative Complications

General principles of perioperative care apply to patients having urologic reconstruction and include the use of bilateral sequential compression boots, prophylactic antibiotics, and generous padding for all pressure points.

Complications related to access and pneumoperitoneum are discussed in Chapter 30 . This section describes complications specific to minimally invasive reconstructive procedures and recommendations regarding their management.

Minimally Invasive Pyeloplasty

Laparoscopic pyeloplasty was first described in 1993 and became the standard of care. Robotic assistance was first reported by Sung and colleagues in 1999, and numerous series have been published demonstrating the equivalence or superiority of this technique.

In a series of 147 patients who underwent laparoscopic transperitoneal pyeloplasty, two cases of bowel injury were reported, including a serosal injury to the small bowel and an inadvertently clipped colonic diverticulum. Both injuries were repaired during the same surgical procedure with no sequelae. No intraoperative complications were reported in a large series of patients who underwent extraperitoneal laparoscopic pyeloplasty. In a multi-institutional series of robotic pyeloplasty among 140 patients, a single minor intraoperative splenic laceration was noted and successfully managed with pressure and topical hemostatic agents. In another series of 131 patients, there was only one conversion to open surgery due to technical difficulties. A multiinstitutional study of 168 patients undergoing robotic pyeloplasty reported no intraoperative complications. Notably 21 (13%) of these cases were secondary repairs.

The reported rate of conversion from laparoscopic to open pyeloplasty is ≈1.6%. Rassweiler and associates reported a single conversion in their large series of retroperitoneal laparoscopic pyeloplasty based on significant anastomotic tension and the requirement for open dissection and fixation of the kidney during suturing. Mufarrij and associates reported no open conversions in a series of 140 robotic pyeloplasties, whereas another study noted one open conversion out of 131 cases.

The risk of significant bleeding from laparoscopic or robotic pyeloplasty is low. Inadvertent injury to major vessels may be minimized with good operative planning including CT with contrast to identify crossing vessels or anomalous vascular anatomy. However, in our experience, imaging may not be completely reliable; both false-positive and false-negative results of imaging for relevant vessels may occur.

Laparoscopic suturing is the most challenging aspect of laparoscopic pyeloplasty. Technical complications of suturing (e.g., stricture, urinary extravasation) may be minimized by meticulous technique, but patient-related factors (e.g., history of diabetes, secondary repair) may influence the incidence of these complications. Creating a tension-free anastomosis requires careful intraoperative planning and may decrease the risk of complications related to ureteral ischemia and suture line breakdown. Intraoperative techniques for safely creating more length include downward nephropexy and creation of a “handle” in the renal pelvis to decrease the manipulation of healthy tissue. Traction sutures can also be placed in the ureter or pelvis to decrease manipulation of tissue and decrease the risk of ischemia.

Ureteral stent placement across the anastomosis is essential to minimize the risk of urinary leakage. Complications of stent placement include submucosal tunneling and incomplete advancement into the bladder or kidney, depending on the direction of placement. If anterograde placement is performed, the bladder can be filled with 300 mL of methylene blue; refluxed dye confirms correct distal positioning of the stent. Flexible cystoscopy can also be performed to confirm correct placement of the ureteral stent.

Minimally Invasive Ureteral Reconstruction

Laparoscopic and robotic ureteral reconstruction has been performed in all portions of the ureter for diverse indications including trauma, stricture, neoplasm, and anatomic abnormalities. Procedures have included ureteroureterostomy, ureteral reimplantation with or without psoas hitch, Boari flap, ileal ureter, ureterolysis, and retrocaval ureter repair. A novel procedure using buccal mucosa graft for ureteral repair has been developed.

Laparoscopic ureteroureterostomy was first reported for treatment of infiltrative endometriosis and has been performed without significant intraoperative complications or need for conversion to an open procedure. Robotic approach has also been used safely and successfully for ureteroureterostomy. A unique consideration for ureteroureterostomy relates to the “watershed” blood supply of the midureter and the potentially increased risk of ischemia during manipulation and suturing. Techniques for reducing the risk of ischemia include minimizing the manipulation of tissues (e.g., using traction sutures), minimizing medial dissection of the ureter and potential disruption of the vascular supply, and ensuring that the ureteral edges appear pink and healthy before anastomosis. A new technique developed by Lee and associates was described to reduce the risk of injury to the ureter during surgery and to assist in localizing the ureteral stricture during repair. The authors used indocyanine green in an antegrade and retrograde fashion into the ureter and visualized it using near-infrared fluorescence during repair. A recent modification is the use of indocyanine green intravenously to evaluate tissue perfusion. Ureteral tissue appears dark if poorly perfused and bright green if well perfused. This technique has since been used by other groups to minimize complications related to poor blood supply.

Ureteral stent placement is recommended in all patients having ureteral repair and can be placed preoperatively or intraoperatively in a retrograde fashion or transperitoneally during the surgery. If the ureteral length is insufficient for primary anastomosis, techniques such as psoas hitch or Boari flap can be performed to gain length distally. Buccal mucosa graft ureteroplasty, bowel interposition, or autotransplantation may be necessary if other techniques are unsuccessful. Understanding the patient’s anatomy and extent of disease is essential to ensure appropriate operative planning and management of the patient’s expectations preoperatively.

Despite limited data, evidence indicates that the intraoperative complication risk of ureteral reconstruction is low. No significant intraoperative complications were noted in series of laparoscopic and robotic ureteral reimplantation (for indications including reflux, distal ureter injury, and low-grade distal ureteral urothelial cell carcinoma), Boari flap, ureteroureterostomy, ureterocalicostomy, ileal ureter, and retrocaval ureter repair. One study of robotic ureteroureterostomy in 12 patients reported a liver and gallbladder laceration during robotic port placement due to adhesions which required a concomitant cholecystectomy. Conversion to open was reported in one out of 16 patients who underwent robotic ureteral surgery. The patient had a prior history of pancreatectomy, and open conversion was needed to complete distal ureteral resection with reimplantation and psoas hitch for cancer.

A study compared open, laparoscopic, and robotic ureteral reimplantation in 130 patients. In the laparoscopic group, there was a 5% rate of intraoperative complications including inadvertent ureterotomies repaired primarily, enterotomy requiring small bowel resection, and injury to appendix requiring appendectomy. There was a 2% rate of conversions to open in the laparoscopic cohort, one for small bowel resection and another for technical difficulty. There were no complications or conversions in the robotic or open cohort. Robotic approach allows for better visualization, easier suturing, and improved hemostasis resulting in minimal complications. An additional two studies compared a total of 35 robotic to 65 open ureteral reimplants and found significantly less blood loss and shorter hospital stay for the robotic group. These reports suggest that robotic ureteral reconstruction seems to be at least equivalent to the open approach, but may offer the additional benefits of minimal blood loss and shorter hospital stay.

Minimally Invasive Ureterolysis

Laparoscopic ureterolysis was first reported by Kavoussi and associates in 1992. Laparoscopic dissection within a fibrotic retroperitoneum can be challenging given diminished tactile feedback. However, low morbidity was reported in several series of laparoscopic ureterolysis. Indocyanine green or intraoperative ultrasound can help to identify the ureter if fibrosis obscures retroperitoneal anatomy.

Ureteral injury is one potential complication of laparoscopic ureterolysis. Ureteral injuries should be repaired with either a minimally invasive approach or with an open procedure, based on the extent and location of injury. Omental wrapping or intraperitonealization can be performed to protect the ureteral anastomosis. Rare complications include vascular injury, for example, an iliac vein injury, pneumothorax, and subcutaneous emphysema.

Reported conversion rates to open procedures have been 15% in series of laparoscopic ureterolysis. Conversion has been required secondary to technical difficulty with periureteral fibrosis, vascular injury, and other emergency indications.

Robotic ureterolysis has been safely performed without intraoperative complication. Improved visualization from robotic technology may facilitate identification of the ureter, and the precision of robotic Pott scissors and greater degrees of freedom may facilitate the dissection and potentially decrease the risk of injury.

Minimally Invasive Buccal Mucosa Graft Ureteroplasty

Oral mucosal graft for ureteroplasty was first reported in an animal model in 1984. Ureteral strictures have been treated successfully with buccal mucosa with an open approach. In a study of five patients, buccal mucosa graft was used for strictures between 3.5 cm and 5 cm. There were no intraoperative complications, and at a mean follow-up of 24 months there was a 100% success rate. Robotic buccal mucosal ureteroplasty was done in four patients in one study, and there were no intraoperative complications. Some of the intraoperative maneuvers to ensure a successful repair were as follows: use of an omental flap or a perirenal flap to provide a vascular bed, simultaneous flexible ureteroscopy to localize the stricture, intravenous injection of indocyanine green to identify well-vascularized ureteral tissue, and flexible ureteroscopy during anastomosis to prevent placement of suture into the back wall of the ureter and to confirm a watertight anastomosis.

Minimally Invasive Renal Autotransplantation

A technique of completely intracorporeal renal autotransplantation has been recently described in a patient with long ureteral stricture due to ureteral perforation during endoscopic stone treatment. Warm ischemia time for nephrectomy was 2.3 minutes, while cold ischemia time was 95.5 minutes. Total console time for the surgeon was 334 minutes. The patient was discharged home on postoperative day 1 after a transplant Doppler ultrasound showed patent vascular anastomosis and after removal of Foley catheter and drain. The ureteral stent was removed at 6 weeks. A intravenous urogram 2 weeks after stent removal showed no extravasation or obstruction.

Minimally Invasive Pyeloplasty

See Table 35.1 for a summary of postoperative complications from major series of robotic pyeloplasty. These studies did not use standardized definitions of complications and thus may not be directly comparable. Minor and major complications were often grouped together in determining the total complication rate in these studies.

The reported postoperative complication rate for laparoscopic pyeloplasty is 2–22%. A meta-analysis of laparoscopic pyeloplasty series revealed an 8% postoperative complication rate including hematoma, urinoma, pyelonephritis, bowel serosal injury, transient ileus, thrombophlebitis, and ureteropelvic junction (UPJ) anastomotic stricture. Increasing experience with laparoscopic pyeloplasty within series revealed decreasing rates of postoperative complications. Extraperitoneal laparoscopic pyeloplasty has published complication rates of ≈13%.

Postoperative complication rates for robotic pyeloplasty have also been low, ranging from 3% to 11%. The complications include urinary tract infection or pyelonephritis, ileus, stent migration or malposition, urine leak, bleeding requiring transfusion, recurrence of obstruction, and complications from operative positioning. Postoperative pyelonephritis may be treated successfully with antibiotics. Stent migration or malposition requires repositioning under general anesthesia. It may be prevented by performing flexible cystoscopy to confirm a curl in the bladder at the time of surgery. Urine leak generally requires diversion of urine with Foley catheter, stent, or nephrostomy tube. If there is a urinoma, percutaneous drain placement into the urinoma in conjunction with diversion of urine may treat the complication. Bleeding may result in the formation of a clot in the renal pelvis requiring stent placement. The renal pelvis should be irrigated before closure to minimize the likelihood of this complication. The failure or recurrence rate is low, but requires repeat pyeloplasty or endopyelotomy. Positioning complications may include gluteal necrosis and rhabdomyolysis. This can be prevented by decreasing operative time and not flexing the table, especially for obese patients, to allow more even distribution of weight. Another rarely reported complication is bowel injury, especially in patients with a history of colitis.

In another series of 92 patients undergoing robotic-assisted laparoscopic pyeloplasty, three patients (3%) had early complications requiring reintervention. The first patient required stent exchange and percutaneous nephrostomy tube placement for a clot-related obstruction of the renal pelvis and colic with urine extravasation; the second patient bled into the collecting system 2 days postoperatively and, despite conservative treatment, required open secondary pyeloplasty; and the third patient, who had excessive urine extravasation after inadequate closure of the renal pelvis, required open repair of the renal pelvis. This last patient had prior treatment of UPJ obstruction but the exact treatment was not mentioned. Two other patients in this series had prior pyeloplasty, and nine had prior endopyelotomy or ureteroscopy, none of whom had significant complications. In a series of 31 patients with robotic-assisted laparoscopic pyeloplasty, one patient had nonfebrile urinary tract infection and one had a urine leak with ileus that was treated nonoperatively.

Bleeding or hematoma formation can occur following minimally invasive pyeloplasty. Soulie and colleagues reported that two of 61 patients developed hematoma in the lumbar fossa following laparoscopic pyeloplasty. Rassweiler and associates reported five cases of postoperative hematoma in 143 patients undergoing laparoscopic pyeloplasty. Hematoma can generally be managed conservatively by following serial hematocrit levels and transfusing as necessary. Hemodynamic instability or a precipitous drop in hematocrit may necessitate urgent reoperation. One may need to drain a hematoma percutaneously at a later point based on persistent symptoms or infection. CT scan is generally the best modality for diagnosing postoperative hematoma. Delayed bleeding can occur as well; in one series, a patient required hospitalization for retroperitoneal bleeding 1 month after laparoscopic pyeloplasty.

Urinoma is another important complication following minimally invasive pyeloplasty. Urine leakage occurs in ≈2.3% of patients undergoing laparoscopic pyeloplasty, and this complication can occur despite meticulous suturing and ureteral stent placement. Urinoma may be indicated by flank or abdominal pain, fever, or elevated liver function tests on the right side. Soulie and colleagues reported that two of 61 patients developed postoperative urinoma. Rassweiler and colleagues reported urinary extravasation in two of 143 patients after laparoscopic pyeloplasty. Secondary pyeloplasty and congenital abnormalities may be risk factors for urinary leakage.

In the early postoperative period, leakage can be detected by persistently elevated drain output and can be confirmed by checking fluid creatinine levels. Drains may be required for a prolonged period if leakage persists. Within a urinoma, drains can be repositioned if necessary, including laparoscopically. If one suspects urinoma after the acute postoperative period, CT with intravenous contrast is the diagnostic modality of choice. Delayed images may be needed to reveal active urine leak. Urinomas can generally be managed conservatively by leaving stents in place to optimize drainage or by replacing stents for ≥2 weeks and then assessing drainage of the upper urinary tract. Placement of a Foley catheter, or leaving the catheter in place, may also decrease pressure on the upper urinary tracts and maximize healing if leakage is noted. Percutaneous drainage of the urinoma may be required if conservative measures fail. Percutaneous drains may be gradually extracted and serial imaging done to ensure resolution of the collection. Reactive pleural effusions can result from urinary leakage abutting the diaphragm; these effusions may require drainage if symptoms develop or if infection is a consideration. The risk of urinary leakage may be reduced by control of suture tension during collecting system closure. Generally, urinary leakage has no significant sequelae, but periureteral scarring can occur. Repeat laparoscopy to suture an insufficiently closed site is rarely necessary but may be performed.

Stent obstruction can occur after minimally invasive pyeloplasty. Rassweiler and colleagues reported that one of 143 patients developed stent obstruction after laparoscopic pyeloplasty. A second stent can be placed, the stent can be changed, or percutaneous nephrostomy tube placement with or without anterograde stenting may be necessary. Stent migration can also occur requiring repositioning through ureteroscopy or removal, depending on timing relative to surgery. If stent migration below the anastomosis is identified late, stenosis may require reoperation. Proper positioning of the double J stent should be carefully confirmed before leaving the operating room, and erring on the side of longer versus shorter ureteral stents may be helpful. Acute obstruction after stent removal may require repeat stenting or nephrostomy tube placement. If a patient presents with ipsilateral flank pain before stent removal, imaging (e.g., kidneys, ureters, bladder) should be performed to ensure the stent is in the proper position.

Stricture at the UPJ following stent removal causes obstruction 2.5–3.6% of the time. Stenting or nephrostomy tube placement may be required to relieve obstruction in these patients depending on symptoms, the presence of infection, and serum creatinine concentrations. Conservative treatment of stricture can be attempted, such as with balloon dilation or endopyelotomy. However, secondary pyeloplasty may ultimately be required, and alternative techniques such as ureterocalicostomy may be necessary depending on the patient’s anatomy (e.g., insufficient renal pelvis for anastomosis). Stents are typically removed 4–6 weeks after repair and the anastomosis evaluated at 6–8 weeks by renal scan or intravenous pyelogram. Depending on the timing of restricturing, this process may be considered a treatment failure or a complication. Success rates for both laparoscopic and robotic pyeloplasty are high, and early restricturing is uncommon. Mufarrij and colleagues reported that three of 140 patients required treatment of recurrent stricture after robotic pyeloplasty; two patients required endopyelotomy and one required repeat pyeloplasty. These investigators attributed these failures most likely to ischemia or technical factors.

Minimally Invasive Ureterolysis

Reported postoperative complications of laparoscopic ureterolysis have been mild and have included prolonged ileus, epididymitis, urinary retention, and port site erythema. In a series of five laparoscopic ureterolysis procedures, one patient had a small perioperative ureteral leak that was managed with prolonged Foley catheter drainage and ureteral stent placement. No postoperative complications occurred after five robotic ureterolysis procedures reported in the same article. A study of 17 robotic ureterolysis cases (21 renal units) reported one case of enterocutaneous fistula due to an unrecognized cautery injury requiring bowel resection.

Postoperative complications of ureterolysis are similar to those listed earlier for pyeloplasty and may include urinary extravasation and ureteral obstruction secondary to recurrent fibrosis or ischemic changes in the ureter. In one study, seven (18%) out of 40 patients undergoing ureterolysis underwent a second surgery for persistent obstruction including endoureterotomy, ureteroureterostomy, ileal ureter, and autotransplantation. Another study showed a similar secondary intervention rate; three of 21 (14%) renal units undergoing robotic ureterolysis required a redo robotic ureterolysis with ureteral reimplantation, robotic ureteroureterostomy, and laser endoureterotomy. Intraperitonealization and omental wrapping can help to decrease the risk of recurrent obstruction, although these procedures may be technically challenging. Efforts should be made to diagnose and treat the underlying cause of fibrosis if possible. Ureteral stent placement may be helpful to minimize the risk of postoperative urinary leak and obstruction.

Unusual complications of ureteral manipulation can occur during ureterolysis. One of our patients developed a midureteral leak after robotic ureterolysis with omental wrapping. Stent placement was performed but the patient had recurrent flank pain and a renal scan demonstrated partial mechanical obstruction. Ureteroscopy revealed a mild midureteral stricture as well as a ureteral diverticulum with a Weck clip within the lumen of the diverticulum that was likely placed during omental wrapping of the ureter in the setting of ureteral perforation and leak. Balloon dilation and stenting were performed and subsequent ureteroscopy revealed sealing of the diverticulum; however, the patient required subsequent laser endoureterotomy and balloon dilation for recurrent stricture.

Minimally Invasive Ureteral Reimplantation

Laparoscopic and robotic ureteral reimplantation have been shown to be safe, with a low postoperative complication rate. No postoperative complications were reported in one small series of patients who underwent laparoscopic reimplantation for distal ureteral stricture refractory to endoscopic management. No major postoperative complications were noted in a small series of patients who underwent distal ureterectomy and reimplantation for low-risk ureteral urothelial cell carcinoma. However, minor complications are not unusual after ureteral reconstruction. A study of 16 patients reported a 75% rate of 90-day postoperative complications. Sixty-two percent of those complications were Clavien grade I–II, including urinary tract infection, pneumonia, ileus, prolonged anastomotic healing, femoral nerve lesion with temporary leg weakness and pain, prolonged abdominal pain, and a corneal erosion. Thirteen percent of the complications were Clavien grade IIIb–IVa, including urinary leak and peritonitis and a silent myocardial infarction. Conversion to open approach is an uncommon intraoperative complication during robotic ureteral reimplantation or ureteroureterostomy and was reported in two out of 16 patients (13%) in one study. This series also had a Clavien grade IIIb complication of unrecognized enterotomy requiring additional surgery. Despite the complications, there was a 100% clinical and radiographic success rate at a mean postoperative follow-up of 6.4 months. A more recent study of 31 patients who underwent ureteral reimplantation also reported a 100% radiographic and symptomatic success rate, with a 13% rate of Clavien grade I–III postoperative complications. The robotic approach has also been used successfully in the challenging cases of post–radical cystectomy ureterointestinal stricture and will be used more often as experience with intracorporeal urinary diversions increases.

Stricture can occur at the site of anastomosis following minimally invasive reimplantation. A study of 61 pediatric patients who underwent robotic extravesical reimplantation of 93 ureters showed a 10% complication rate including 5% rate of ureteral obstruction, 3% rate of urine leak, and 2% rate of readmission for nausea and vomiting. The diagnosis can be made initially with renal ultrasound and then confirmed by excretory urography. Confirmation of drainage at the time of stent removal can minimize the risk of patients who present again with obstruction. Ureteral stent placement is generally indicated to drain the obstructed system, although percutaneous nephrostomy tube placement may be necessary. Stricture can be managed conservatively with dilation, but it may ultimately require anastomotic revision. Obstruction secondary to edema can occur postoperatively and is generally minimized by stenting for 4–6 weeks postoperatively; however, transient obstruction can also occur after stent removal and may require stent replacement for several weeks.

Urinary leakage can occur following ureteral reimplantation and can be managed as discussed earlier with maximal drainage and consideration of percutaneous drain placement. A cystogram should be performed at the time of stent removal to confirm the absence of leak. Reflux into the ureter through the repair confirms patency of the anastomosis, provided a refluxing anastomosis was performed. If a nonrefluxing anastomosis was performed, diuretic renal scan, CT urogram, or an intravenous pyelogram can be performed to confirm the absence of obstruction at the ureterovesical anastomosis.

Minimally Invasive Ureteroureterostomy

The primary postoperative complications of laparoscopic or robotic ureteroureterostomy include anastomotic stricture and urinary leakage. However, published rates of postoperative complications for laparoscopic and robotic ureteroureterostomy have been low. In a small series of ureteroureterostomy for iatrogenic injury of the pelvic ureter, no postoperative complications were noted ≈13 months after surgery. Midureteral strictures have also been repaired laparoscopically with good results and without complications. In a study of robotic ureteral reconstruction, eight patients underwent robotic ureteroureterostomy. There was a 25% Clavien grade III postoperative complication rate; however, there was a 100% radiographic and symptomatic success rate.

Obstructed retrocaval ureter has been repaired by laparoscopic and robotic resection of diseased retrocaval ureter and ureteroureterostomy without postoperative complications. This procedure has been safely performed both transperitoneally and retroperitoneally.

Laparoscopic and robotic ureteral surgery has been reported for upper urinary tract urothelial cell carcinoma and has been shown to be safe. Proximal ureteral segmentectomy and ureteropelvic anastomosis as well as distal ureterectomy with ureteral reimplantation have been performed for low-grade urothelial cell carcinoma without complications. Oncologic outcomes at short-term follow-up have been encouraging in these patients. Patients should be carefully selected for any minimally invasive procedure for management of ureteral malignant disease, and principles of open oncologic surgery should be respected.

Minimally Invasive Boari Flap

Laparoscopic Boari flap has been described for long distal ureteral strictures and has been shown to be safe and effective. In a small series of laparoscopic Boari flap, one patient with a history of pelvic radiation developed urine in the peritoneum after Foley catheter removal. The urinoma did not resolve with reinsertion of the catheter, and the patient required exploratory laparoscopy. Another small study of eight patients who underwent robotic ureteral reimplantation with Boari flap reported one case of anastomotic leakage postoperatively that was managed with prolonged catheterization.

The risk of urine leakage can be minimized by leaving a Foley catheter in place for 7–10 days postoperatively and confirming the absence of a leak with cystography. In patients with a history of pelvic radiation, the Foley catheter should be left in place for ≥2 weeks to maximize healing. Ureteral stents should be left in place for 6 weeks to allow for complete healing of the ureter.

A small series of robotic ureteral reconstruction reported one case of robotic ureteral reimplantation with Boari flap that required conversion to open. One of the larger robotic ureteral reconstruction studies evaluated 55 patients in a single institution who underwent robotic ureteroureterostomy, ureteroneocystotomy with psoas hitch and Boari flap. There were no intraoperative complications, median blood loss was 50 mL, and average hospital stay was 1.6 days. At a median follow-up of 181 days, there were three (5.3%) failures and two (3.6%) postoperative complications. One patient needed exploratory laparotomy for bleeding several hours after the surgery, and another had oxygen desaturation due to multiple comorbidities requiring intensive care unit admission.

Minimally Invasive Buccal Mucosa Ureteroplasty

Two cases of robotic buccal mucosa graft ureteroplasty were reported in a larger study of robotic ureteral reconstruction. Postoperative evaluation was with retrograde pyelogram 4–6 weeks after surgery at the time of stent removal and a Lasix renal scan 2–3 months after stent removal. In both patients, there was resolution of obstruction and symptoms at a mean follow-up of 8 months. In a study of five open ureteral repairs with buccal mucosa, there were two early postoperative complications including fever, which responded to antibiotics and antipyretics, and ileus, which was managed conservatively. Ultrasound done every month and intravenous urography done at 3, 9, and 12 months showed that all repairs remained unobstructed. In another study of seven open buccal mucosa graft ureteroplasties, two patients were found to have impaired drainage at a median follow-up of 18 months. To avoid any postoperative complications, in a study of four cases of robotic buccal mucosa graft ureteroplasty, a cystogram was done before removal of Foley catheter at 2 weeks, a retrograde or antegrade pyelogram prior to removal of stent at 6 weeks, an ultrasound after stent removal, and a renal scan at 3 months to assure patency.

Minimally Invasive Ileal Ureter

The first report of laparoscopic ileal ureter was reported by Gill and associates after laparoscopic ureterectomy for ureteral urothelial cell carcinoma in a patient with a solitary kidney. No complications were associated with this procedure. Complications can arise from bowel manipulation and suturing including ileus, bowel obstruction, and bowel leak. Management of these complications is discussed in Chapter 11 . Five other studies of laparoscopic ileal ureter in 13 total patients have been published. Some of the postoperative complications included internal hernia that required exploratory laparotomy, a urine leak requiring an additional percutaneous drain placement, pneumonia, and an enteric anastomotic leak requiring exploratory laparotomy, bowel resection, and reanastomosis. Two case reports of robotic ileal ureter have been published with no perioperative complications.

Minimally Invasive Ureterocalicostomy

Laparoscopic ureterocalicostomy has been performed without complications. Robotic assistance may significantly facilitate the suturing component of this operation.

Minimally Invasive Transureteroureterostomy

Laparoscopic transureteroureterostomy was reported in a series of three pediatric patients without significant postoperative complications. Leaving a drain near the anastomosis is recommended to ensure the absence of leakage before the Foley catheter is removed. The literature on open transureteroureterostomy indicates an incidence of urinary leakage of ≈6%.

Obstruction of the common ureter is noted infrequently in series of open transureteroureterostomy and has not been reported for laparoscopic transureteroureterostomy. Intraoperatively, a stent can be placed either in the recipient ureter or across the anastomosis, although some investigators argue that stenting the recipient ureter is more useful for maintaining ureteral patency during the anastomosis and for preventing placing sutures through the back wall. Overall, series of open transureteroureterostomy demonstrate a low complication rate and the rare occurrence of obstruction; in skilled hands, laparoscopic or robotic transureteroureterostomy is likely to have a similarly low complication rate.