Robot-Assisted Ureteroileal Reimplantation for Postcystectomy Anastomotic Stricture

Abstract

Introduction and Objectives: Ureteroileal anastomatic strictures after robot-assisted radical cystectomy (RARC) occur at a rate of 4% to 9% and pose a challenge in management. Although open surgical repair remains the standard treatment for anastomotic strictures, we present a case of effective postcystectomy robot-assisted laparoscopic ureteroileal reimplantation. Materials and Methods: Our patient is a 65-year-old woman with high-grade muscle-invasive urothelial carcinoma who underwent RARC and intracorporeal ileal conduit urinary diversion. Three months postoperatively, the patient developed recurrent urinary tract infections that necessitated hospital admission for left pyelonephritis. CT scan displayed left hydronephrosis and hydroureter. Antegrade nephrostogram revealed a complete ureteroileal anastomatic stricture, with confirmed severe obstruction on MAG-3 renal scan and left differential renal function of 16%. After failure of endoscopic dilation, the patient underwent exploratory laparoscopy and robot-assisted left ureteral reimplantation. Laparoscopic ports were placed similarly to RARC. We performed a lysis of adhesions and identified the proximal end of the ileal conduit, where the distal ureters were identified among significant fibrosis. We isolated each ureter separately and mobilized the left ureter posterior to the sigmoid colon using sharp dissection. We incised into the proximal end of the ileal conduit and confirmed identification of the left ureter through the protruding preplaced stent. We then ligated the distal most aspect of the left ureter after a frozen section confirmed no recurrence of tumor and advanced a guidewire through the conduit into the left distal ureter and renal pelvis. The ureter was spatulated and we completed a new left ureteroileal anastomosis over a Double-J stent using two running 4-0 Vicryl sutures. Results: Our operative time was just under 4 hours with an estimated blood loss of 100 mL. Jackson–Pratt (JP) drain was maintained until discharge on postoperative day 4. There were no intraoperative or postoperative complications. Five-month follow-up revealed marked improvement of left hydronephrosis on renal ultrasound and absence of obstruction on MAG-3 renal scan with a t½ of 8 minutes. Left renal function stabilized at 19%. Conclusions: Robot-assisted ureteral reimplantation for management of postcystectomy ureteroileal anastomatic stricture is feasible and safe in experienced hands. No competing financial interests exist. Runtime of video: 7 mins 56 secs