Fig. 22.1
Revision pyeloplasty after failed previous pyeloplasty. Nephrostogram (left) shows complete occlusion at site of previous anastomosis, and intraoperative view shows strictured ureteropelvic junction (yellow arrow) and previously transposed crossing vessel (white arrow) and surrounding fibrosis
In the largest series to date, an overall 6.6% complication rate was reported by Sivaraman et al. in 168 patients over a 6-year period from three academic centers. A total of 17 complications occurred in 11 patients (6.6%). The most common complication was postoperative ileus followed by blood loss requiring transfusion. Of the three patients that suffered blood loss requiring transfusion, one was due to liver laceration. One patient developed pyelonephritis, which required treatment with parenteral antibiotics. Three patients developed a postoperative anastomotic urine leak, which was managed with prolonged foley catheter and suction drain. All three patients that developed a postoperative urine leak required subsequent retrograde laser endopyelotomy [8].
Hopf et al. further evaluated the long-term outcomes of RALP by retrospectively evaluating 129 cases from a single institution. Overall 5 (3.9%) intraoperative complications and 18 (13.9%) postoperative complications were identified. The intraoperative complications consisted of two bowel serosal injury, one thermal injury to the gallbladder, one airway bleed from intubation, and one unrecoverable robotic malfunction requiring conversion to a standard laparoscopic procedure. Postoperative complications consisted of nine anastomotic urine leaks, five UTIs, and four other unclassified complications. It was observed that patients who did not have a stent had a significantly increased rate of postoperative urine leak compared to patients who had stent-less procedures. On long-term analysis, there were a total of four failures with two patients requiring ipsilateral nephrectomy, one patient requiring long-term indwelling ureteral stent, and 1 patient requiring long-term suppressive antibiotics. It was noted that three of the four failures occurred in patients who had not received a stent [9].
Lucas et al. reviewed factors that would impact outcomes of robotic and laparoscopic pyeloplasty and found that previous endopyelotomy and presence of intraoperative crossing vessels are associated with higher rate of secondary procedures. Interestingly, the authors found that preoperative ureteral stent placement did not impact the efficacy of performing pyeloplasties and was not associated with a higher rate of secondary procedures [10].
Robotic Ureterocalicostomy
Description of Procedure
Although a majority of ureteropelvic junction obstruction cases can be managed by RALP , there are instances such as UPJO with minimal renal pelvis, UPJO with intrarenal pelvis, obstructed horseshoe kidney, and failed prior pyeloplasty that justifies ureterocalicostomy [11, 12]. Korets et al. reported the first robotic ureterocalicostomy procedure [13].
Positioning and placement of robotic trocars is similar to that of RALP. Unlike RALP, the renal vessels are dissected for clamping during lower pole resection. Ultrasound can be used to identify the lower pole calyx. The renal artery is clamped with a laparoscopic bulldog, and the lower pole is excised to access the calyx with suturing of vessels as with partial nephrectomy followed by unclamping. The ureterocaliceal anastomosis is performed with either interrupted or running absorbable suture with antegrade stent placement prior to completion. The proximal ureteral stump is suture-ligated [11–14].
Complications of Robotic Ureterocalycostomy
Robotic-assisted ureterocalycostomies are not performed nearly as frequently as RALPs, as they are generally reserved for rare situations and are a technically more challenging procedure. Chhabra et al. reported the largest study to date, which consists of only five patients. The authors report three postoperative complications consisting of postoperative fevers in two patients and failure in one patient [11].
Further experience is required in order to establish reliable complication rates, but the complications of this procedure would be expected to include the potential complications of pyeloplasty as well as some complications of partial nephrectomy. These would include urine leak, stricture (failure), and others as well as the potential for bleeding, pseudoaneurysm, and arteriovenous malformation as can occur in partial nephrectomy. This would be expected to be more likely if a thick portion of lower pole renal tissue is excised as opposed to when chronic obstruction has led to more cortical thinning with less parenchymal excision necessary, which is more ideal and likely to be successful in ureterocalycostomy.
Robotic Ureteroureterostomy (UU)
Description of Procedure
For short strictures involving the proximal or mid ureter, robotic ureteroureterostomy is an attractive option as the techniques and principles are similar to that of robotic pyeloplasties.
Various strategies have been described for identifying the site of the stricture if an obvious transition point is not evident [15]. An open-ended or balloon catheter can be inserted to the level of the ureteral stricture as localized via retrograde pyelogram and is then secured to a Foley catheter in the bladder. A flexible ureteroscope can also be used in a retrograde fashion if urethral access is maintained during positioning for the robotic procedure, and antegrade ureteroscopy can be performed through a ureterotomy by placing the flexible ureteroscope through one of the abdominal ports.
Patient positioning is similar to that of a robotic pyeloplasty with slight adjustment of trocar placement based upon location of stricture. Mobilization of the ureter is performed proximal and distal to the ureteral stricture for a distance that will allow tension-free anastomosis without overmobilization that could threaten blood supply. The diseased portion of the ureter is then transected and excised followed by spatulation of the healthy ureteral ends and anastomosis with absorbable sutures in interrupted or running fashion with stent placement before completion.
Complications of Robotic Ureteroureterostomy (UU)
The described complications of robotic UU are limited as the procedure has not been extensively performed. Marien et al. reviewed 250 patients who underwent various robotic upper urinary tract reconstructions with a total of 8 patients specifically undergoing robotic UU [16]. Two patients experienced postoperative complications, which were not elaborated upon. Buffi et al. retrospectively reviewed 183 patients who underwent robotic pyeloplasty (n = 145), robotic UU (n = 17), or robotic ureteral reimplantion (n = 21) at four high-volume centers. Three of the 17 patients who underwent robotic UU suffered a postoperative complication but were only of Clavien–Dindo class 1 or 2 [17]. Nevertheless, the expected complications of robotic UU would be expected to include the complications of any robotic procedure as well as the complications of UU, such as urine leak, stricture, or stent complications.
Robotic Surgery for Lower Ureteral Pathologies and Miscellaneous Ureteral Surgery
The principles applied to robotic-assisted surgery for upper ureteral pathologies can similarly be applied to conditions of the distal ureter. Distal ureteral pathology can either be benign or malignant. Benign distal ureteral conditions consist of distal ureteral strictures that may be idiopathic/congenital or iatrogenic (i.e., gynecological surgery). Additionally, if a ureteral complication after gynecological surgery is left undiagnosed, it can result in ureterovaginal fistulae.
Distal ureteral reconstruction can also be performed after distal ureterectomy for transitional cell carcinoma by means of ureteroneocystotomy. This can require psoas hitch or even Boari flap for larger gaps between the healthy end of the ureter and the bladder, which can performed robotically as well.
Robotic Distal Ureteral Reimplantion (RDUR)
Description of Procedure
Patients undergoing RDUR are placed in a low dorsal lithotomy position with port positioning very similar to that commonly used for robotic prostatectomy [2]. Localization of the pathology is similar to that or UU [15]. If the distal ureter is not being excised (i.e., benign disease), a clip is placed on the distal end after transecting the ureter just above the site of pathology. A direct anastomosis to the bladder dome is performed when possible in refluxing or nonrefluxing fashion at the discretion of the surgeon (Fig. 22.2).
Fig. 22.2
Completed robotic ureteral reimplantation (above) with confirmation of healthy blood flow using fluorescence (below)
When needed, a psoas hitch can be performed by mobilizing the bladder and if necessary dividing the contralateral bladder pedicle. When a psoas hitch is performed, it is important to identify and avoid the genitofemoral nerve prior to suturing the posterior bladder wall to the psoas muscle [18].
If a Boari flap is needed to bridge the gap between the bladder and the healthy end of the transected ureter, a broad-based flap of bladder is raised starting near the bladder neck with the base at the dome. This is tubularized and anastomosed without tension to the ureter. The bladder is filled with normal saline via the bladder catheter to test for leakage after reimplantation with or without psoas hitch or after Boari flap.
If performing distal ureterectomy for transitional cell carcinoma of the distal ureter, the above procedure is identical except that the remaining ureteric stump is then excised with a bladder cuff.
Complications of Robotic Distal Ureteral Surgery
Musch et al. retrospectively reviewed 16 patients who underwent robotic-assisted reconstructive surgery of the distal ureter with no intraoperative complications, but they had to convert to open surgery in one patient due to significant peritoneal adhesions from prior pancreatectomy. Twelve of 16 patients had postoperative complications with 10 minor complications (Clavien Grade 1–2) and 2 major complications (Clavien Grade 3b and 4a). Six had postoperative UTIs, one had a corneal abrasion, one had temporary leg weakness secondary to femoral nerve injury , and one had a silent myocardial infarction. One patient had prolonged anastomotic leakage, while another had urinary leakage with subsequent peritonitis. The patient who suffered from prolonged anastomotic leakage developed asymptomatic hydronephrosis from anastomotic stricture.
Miscellaneous Robotic Ureteral Procedures
Robotic Ureterolithotomy
Ureterolithotomy is an option for large ureteral stone burdens when endoscopic management or lithotripsy have failed or would require multiple or complex procedures [19]. Dogra et al. described robotic ureterolithotomy in 16 patients who demonstrated impacted stones within the lower ureter measuring >2 cm. Patients were positioned similar to robotic prostatectomy. A ureterotomy is performed and the stones extracted are placed into a small endocatch bag. A stent is placed as described earlier and the ureterotomy is closed in a running fashion. Dogra et al. reported the largest series of robotic ureterolithotomy to date with no intraoperative or postoperative complications (Fig. 22.3).
