The appendix is a valuable reconstructive tool for robotic surgical management of complex right ureteral stricture disease

Abstract

BackgroundSurgical reconstruction of ureteral strictures is contingent on etiology, location, length and diameter. For lengthy strictures not amenable to ureteroureterostomy or reimplantation, renal autotransplantation or ureteral replacement with ileum and buccal mucosa have been described. Use of appendix was described originally in 1912 [1] with limited small series describing laparoscopic and open approaches [2, 3]. ObjectivesDemonstrate reconstruction of complex right ureteral stricture using appendiceal onlay and interposition. MethodsA robotic platform was utilized to facilitate ureteral identification, characterize tissue perfusion, and identify stricture location. Patient A is a 62yo female with multiple sclerosis who sustained iatrogenic right ureter avulsion. Proximal ureter terminated at L3. Boari flap was inadvisable secondary to neurogenic bladder. Given the patient's inability to self-catheterize if she developed incomplete bladder emptying and the attendant morbidity and risk of a bowel anastomosis in a patient with neurogenic bowel, ileal interposition was not ideal. Therefore, a primary end-to end-anastomosis between proximal ureter and appendiceal flap was performed. Downward nephropexy and psoas hitch achieved a tension-free refluxing anastomosis between appendiceal flap and bladder dome. Patient B is a 48yo female status post radical hysterectomy complicated by ischemic ureteral injury. Ureteral stricture extended 5 cm at the level of the iliac bifurcation. To avoid further devascularization or inadvertent injury to iliac vasculature, the ureter was not mobilized posteriorly. Ventral ureterotomy was extended into healthy proximal and distal ureter. Ureteral plate was adequate (5 mm) with viable perfusion. The appendix was incised along its antimesenteric boarder and onlay flap was performed. ResultsPatients had an uncomplicated postoperative course with hospital stays of 2 and 4 days respectively. Stent was removed at 4 weeks and nephrostomy tube removed at 6 weeks. Functional imaging at last follow up demonstrated patent ureteral reconstruction. ConclusionIn select patients with complex right ureteral stricture, robotic appendiceal reconstruction is a viable solution. Utilization of appendix may obviate need for complex bladder re-configuration or ileal interposition.