A urine culture is typically obtained preoperatively as these patients are at increased risk of either active urinary tract infection or asymptomatic bacteriuria given obstruction and presence of either a nephrostomy tube or ureteral stent. Culture-specific antibiotics should be given for at least three to five days before surgery. Additionally, a bowel preparation to decompress the colon is often used. An example of a regimen would be two doses of magnesium citrate in the afternoon and evening before surgery followed by a Fleet’s enema before bedtime. Lastly, most ureteral injuries secondary to previous pelvic surgery occur in the distal third of the ureter; therefore, the following discussion will include a step-by-step approach to robotically reimplanting the ureter in a patient with a distal ureteral injury.

The patient is positioned in dorsal lithotomy position using Allen stirrups on the operating room table with the arms adducted using sleds (plastic upper extremity limb holders). The operating room table is then placed in maximum Trendelenburg position. The abdomen is shaved, prepped, and draped in a standard sterile fashion. A urinary catheter is inserted per urethra into the bladder and placed to gravity drainage. Pneumoperitoneum is obtained in a standard fashion through any variety of techniques. Typically, the anterior abdominal wall is elevated manually, and a Veress needle is introduced into the abdominal cavity in the right upper quadrant. Low initial pressures of 0–5 mmHg on insufflation at approximately 2 L per minute confirm proper Veress needle position. The abdomen is insufflated to approximately 15 mmHg pressure, where it should remain for the remainder of the laparoscopic portion of the procedure.

The camera trocar is placed just above the umbilicus. Three robotic trocars are placed: two are pararectus median trocars placed approximately 10 cm off the midline and 17 cm from the symphysis pubis bilaterally and the third is placed laterally, approximately two fingerbreadths off the anterior iliac crest, on the side opposite from the ureteral injury. Assistant trocars can be placed on the same side of the ureteral injury. All trocars should be placed under direct vision, if possible. A 30° down or 0° camera lens is ideal, depending on surgeon preference. The robot is now docked between the patient’s legs. Typically, the surgeon will use monopolar scissors in the right hand, any type of bipolar graspers in the left hand, and an athermal grasper in the fourth arm. Figure 14.2 diagrams the standard trocar locations.

The goal of the next phase of the surgery is to expose the ureter and ensure that it has adequate length to reach the dome of the bladder in a tension-free fashion. All peritoneal adhesions blocking access to the ureter and colon should be taken down sharply with care to avoid bowel injury. The posterolateral peritoneum can be opened near the white line of Toldt to expose the ureter as it crosses the iliac vessels. To allow more distal exposure of the ureter, the bladder can be mobilized. This can be performed by incising the peritoneum just lateral to the medial umbilical ligaments and then dividing the urachus. The dissection is carried down towards the pelvis using a combination of sharp and blunt dissection to peel these structures off the anterior abdominal wall. This will mobilize the bladder and allow access to the bladder pedicles. Now the ureter is divided proximal to the injury and the distal end is ligated. Ligation can be performed with any number of materials including absorbable or non-absorbable sutures (such as Vicryl or silk suture) or clips (metal or synthetic polymer). It is our preference to use the Weck^® Hem-o-lok^® Polymer Locking Ligation System . The dissection of the ureter is continued proximally until the ureter is mobile enough to reach the dome of the bladder.

The bladder is filled with 200–300 mL of saline . The dome of the bladder is located and a 3–4 cm detrusorotomy is created, leaving the mucosa intact (the mucosa will bulge if this is done properly). Next, the ureter is spatulated, ensuring that there is healthy, non-strictured ureter present. Next, a 1–1.5 cm cystotomy at the end of the detrusorotomy is made and the corners of the spatulated ureter are anchored at 6’o clock and 12’o clock using two separate 4-0 absorbable (we prefer Monocryl) sutures. One of the Monocryl sutures is run to complete half of the anastomosis. Alternatively, interrupted sutures can be placed to complete half the anastomosis, based on surgeon preference. This provides sufficient strength to prevent tissue from tearing while placing a double-J stent. A double-J ureteral stent loaded over a wire is passed into the proximal ureter and renal pelvis using a standard stent pusher. The robotic instruments allow the wire and stent to be easily manipulated. The wire is removed, and the distal end of the double-J stent is placed through the cystotomy into the bladder using robotic graspers. The second Monocryl suture is now placed in a running (or interrupted) fashion to complete the implant. The bladder is filled to determine the integrity of the anastomosis. If leakage is present, interrupted Monocryl sutures can be used to close any defects. Interrupted Vicryl sutures are used to close the detrusorotomy. A drain should be introduced through one of the ports and placed in a dependent portion of the pelvis.