Open and Robotic Techniques for Appendiceal Interposition in Ureteral Stricture Disease

Abstract

Introduction: Robot-assisted techniques for large ureteral strictures usually involve reconstruction with ureteroneocystostomy, Boari flap, psoas hitch, or with intestinal interposition with an ileal segment. These measures are highly involved, add significant operating room time, and have well-known complications. We present a novel robotic technique for management of right-sided ureteral stricture using an appendiceal interposition. Methods: Using the DaVinci XI Robotic System, we utilized standard right-sided port placement similar to a nephrectomy setup. The appendix was identified, dissected free, and stapled off the cecum, making sure to preserve the mesoappendix. The appendix was then serially dilated using feeding tubes and S-dilators over a guidewire. The ureteral segment to be excised was identified using collecting system administration of indocyanine green (ICG) both in antegrade and retrograde manners. Intravenous ICG was also used to help delineate the strictured ureteral segment as well as the appendiceal segment perfusion. An end-to-end anastomosis between appendix and ureteral ends, in a spatulated manner, was then performed over a Double-J stent. This novel approach was compared with a conventional open laparotomy technique, in which an appendix and cecal flap were utilized for a right-sided ureteral interposition. This patient had a previous ileal interposition for stricture disease that required a long segment replacement. The appendix was mobilized, preserving the blood supply, with the cecum to provide additional length. Dilation of the lumen was not required, and an end-to-end anastomosis was performed over a Double-J stent to bridge the gap between renal pelvis and the bladder. Results: The patient tolerated the procedure well. Operative time was 4 hours, and estimated blood loss was found to be less than 50 mL. The patient developed a postoperative MRSA bacteremia that was treated to resolution with antibiotics. A right antegrade nephrostogram at 6 weeks showed opacification of the entire collecting system with free flow of contrast into the bladder over the stent without evidence of a leak. In the open appendiceal–cecal interposition case, there were no postoperative complications, and antegrade nephrostogram at 6 weeks after stent removal illustrated a patent anastomoses, with excellent passage of contrast as well. Conclusions: Robotic appendiceal interposition for right-sided ureteral stricture is a safe alternative approach to management of right-sided mid ureteral stricture disease. The use of intravenous and intracollecting system-administered ICG significantly aids in identification of the diseased segment as well as vascularity to improve surgeon confidence in the healing capability of the interposed appendix and ureteral ends. This approach is comparable with the more traditional open laparotomy technique of appendix substitution. No competing financial interests exist. Runtime of video: 8 mins 16 secs