Robot-assisted Ureteroureterostomy Research Articles

Efficacy of Robot-Assisted Ureteroureterostomy in Patients with Complex Ureteral Stricture after Ureteroscopic Lithotripsy.

Ureteral stricture (US) postureteroscopic lithotripsy (URSL) has emerged as a severe complication with the widespread use of laser technology. Furthermore, managing a complex US is challenging. Therefore, this study evaluated the efficacy of robot-assisted ureteroureterostomy (RAUU) in addressing US post-URSL and analyzed the pathology of transected ureteral tissues to identify the risk factors for US. we conducted a prospective cohort study on patients who underwent RAUU for URSL-induced US from April 2021 to May 2023. A total of 14 patients with a mean age of 49.8 years were included in this study. The mean stricture length on radiography was 22.66 ± 7.38 mm. Nine (64.2%) patients had experienced failure with previous interventions. The overall success rate was 92.9%, both clinically and radiographically, without major complications, at a mean follow-up of 12.8 months. The pathological findings revealed microcalcifications and a loss of ureteral mucosa in 57.1% and 28.6% of patients, respectively. The RAUU technique shows promise as a viable option for US post-URSL in appropriately selected patients despite severe pathological changes in the ureter. Therefore, the migration of microcalcifications to the site of ureteral perforation may be a significant factor contributing to US development.

A novel tattooing technique for ureteric strictures in robotic ureteroureterostomy: a non-inferiority analysis.

A novel tattooing technique for ureteric strictures in robotic ureteroureterostomy: a non-inferiority analysis.

A rare indication of robot-assisted uretero-ureterostomy: ovarian vein syndrome

Ovarian vein syndrome is a rare cause of ureteral obstruction. Most of these cases occur during pregnancy likely from the gravid uterus causing ovarian vein dilatation and valvular incompetence. Hormonal changes associated with pregnancy also affect the muscular wall of ureter, causing decrease in tone and may facilitate compression as well. There is a predilection for right side and in thin females. The traditional treatment has been the ligation of ovarian vein and ureterolysis. We report a case of ovarian vein syndrome in a young female which was managed by robot-assisted laparoscopic ovarian vein ligation, resection of stenosed ureteric segment and end-to-end ureterostomy.

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives.

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

Laparoscopic-assisted ureteroureterostomy for duplication anomalies in children.

To describe a novel laparoscopic-assisted technique for ureteroureterostomy for the surgical management of a completely duplicated collecting system with an obstructed and/or ectopic ureter. A camera is placed through a 5-mm infraumbilical port and the duplicated ureters identified and delivered through a small inguinal incision with a laparoscopic Babcock clamp. The ureteroureterostomy is performed in an open fashion. The mean operative time, length of stay, success, and complications of nine patients who underwent this technique were reviewed and compared with a cohort of patients who underwent open ureteroureterostomy at a single institution. In addition, the existing literature on laparoscopic and robot-assisted ureteroureterostomy is reviewed. There were no statistically significant differences in operative time (134 vs 133 min, P=0.950), length of stay (0.32 vs 0.33 days, P=0.929), complications (2 and 2, P=0.574), or rates of success (95% vs 100%, P=1.00) between the open and laparoscopic-assisted ureteroureterostomy groups. In addition, the operative times and length of stay in our laparoscopic cohort were shorter than a majority of the laparoscopic and robotic cases reported in the literature. Laparoscopic-assisted ureteroureterostomy is a successful technique for the management of an ectopic and/or obstructed ureter in a completely duplicated collecting system. This technique combines the speed and ease of the open technique with the improved cosmesis and visualization of a laparoscopic approach and is thus a useful approach for the pediatric urologist.

Laparoendoscopic Management of Midureteral Strictures

The incidence of ureteral strictures has increased worldwide owing to the widespread use of laparoscopic and endourologic procedures. Midureteral strictures can be managed by either an endoscopic approach or surgical reconstruction, including open or minimally invasive (laparoscopic/robotic) techniques. Minimally invasive surgical ureteral reconstruction is gaining in popularity in the management of midureteral strictures. However, only a few studies have been published so far regarding the safety and efficacy of laparoscopic and robotic ureteral reconstruction procedures. Nevertheless, most of the studies have reported at least equivalent outcomes with the open approach. In general, strictures more than 2 cm, injury strictures, and strictures associated either with radiation or with reduced renal function of less than 25% may be managed more appropriately by minimally invasive surgical reconstruction, although the evidence to establish these recommendations is not yet adequate. Defects of 2 to 3 cm in length may be treated with laparoscopic or robot-assisted uretero-ureterostomy, whereas defects of 12 to 15 cm may be managed either via ureteral reimplantation with a Boari flap or via transuretero-ureterostomy in case of low bladder capacity. Cases with more extended defects can be reconstructed with the incorporation of the ileum in ureteral repair.

Ureteral Injuries Sustained During Robot-Assisted Radical Prostatectomy

During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series. From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system. Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively. Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.

Novel Use of Indocyanine Green for Intraoperative, Real-time Localization of Ureteral Stenosis During Robot-assisted Ureteroureterostomy

To present a novel method to intraoperatively localize ureteral strictures during robot-assisted ureteroureterostomy via indocyanine green (ICG) visualization under near-infrared (NIR) light. Seven patients underwent robot-assisted ureteroureterostomy for ureteral stricture by a single surgeon (D.D.E.). Intraoperative localization of ureteral stricture involved instilling ICG (25 mg in 10 mL distilled water) above and below the level of stenosis through a ureteral catheter or a percutaneous nephrostomy tube, or both. The fluorescent tracer was detected as a green color using the NIR modality on the da Vinci Si (Intuitive Surgical, Sunnyvale, CA). All patients consented to off-label use of ICG after full disclosure. Intraoperative ICG injection and visualization under NIR light assisted in the performance of a tension-free anastomosis in all patients. At the time of surgery, mean age was 55.7 ± 12.4 years and mean body mass index was 30.3 ± 5.8 kg/m(2). Mean operative time was 171.3 ± 52.4 minutes, mean estimated blood loss was 175.0 ± 146.5 mL, and mean length of ureteral excision on pathologic analysis was 1.6 ± 0.7 cm. There were no immediate or delayed adverse effects attributable to intraureteral ICG administration. Mean hospital length of stay was 1.6 ± 1.5 days, with no postoperative complications. Mean follow-up was 5.9 ± 1.5 months, and all cases were clinically and radiographically successful at last follow-up. Intraureteral injection of ICG with visualization under NIR light allows for real-time delineation of the ureter. Additionally, ICG administration aids in discerning healthy ureter from diseased tissue, further assisting successful robotic ureteral repair.

Single Surgeon Experience with Robot-Assisted Ureteroureterostomy for Pathologies at the Proximal, Middle, and Distal Ureter in Adults

To describe our initial experience with robot-assisted ureteroureterostomy (RUU) at the proximal, middle, and distal ureter. Twelve consecutive patients underwent RUU by a single surgeon (D.D.E.) between July 2009 and November 2012. Indications included three iatrogenic injuries, two impacted stones, two ureterovaginal fistulas, two idiopathic ureteral strictures refractory to conservative treatment, one primary transitional cell carcinoma of the ureter, one colon cancer metastasis to the ureter, and one invasive endometriosis. There were two proximal, three middle, and seven distal ureteral pathologies. Tension-free anastomosis was achieved in all 12 patients. All patients with proximal and middle ureteral pathology received concomitant downward nephropexy (DN) as a standard part of RUU. Mean age of patients at the time of surgery was 52 years (range 30-69), mean body mass index was 30.0 kg/m(2) (range 21-38), mean operative room time was 190 minutes (range 104-354), mean estimated blood loss was 181 mL (range 50-400), and mean length of excised ureter on pathologic analysis was 2.0 cm (range 1.0-4.5). There was one intraoperative complication in which liver and gallbladder laceration occurred during trocar placement. Mean length of hospital stay was 1.4 days (range 1-5), and there were no postoperative complications. Mean follow up was 10 months (range 3-36). One patient had a ureteral stricture recurrence at 7 months postoperatively that led to renal unit loss and eventual nephrectomy. RUU is feasible, safe, and demonstrates good outcomes for pathologies at the proximal, middle, and distal ureter. Concomitant DN during RUU may assist in achieving a tension-free anastomosis for proximal and middle ureteral repairs.

863 NOVEL USE OF INDOCYANINE GREEN FOR INTRAOPERATIVE, REAL-TIME LOCALIZATION OF URETERAL STENOSIS DURING ROBOT-ASSISTED URETEROURETEROSTOMY

You have accessJournal of UrologyTechnology & Instruments: Robotics: Benign & Malignant Disease (I)1 Apr 2013863 NOVEL USE OF INDOCYANINE GREEN FOR INTRAOPERATIVE, REAL-TIME LOCALIZATION OF URETERAL STENOSIS DURING ROBOT-ASSISTED URETEROURETEROSTOMY Ziho Lee, Christopher Reilly, Elton Llukani, David Lee, and Daniel Eun Ziho LeeZiho Lee Philadelphia, PA More articles by this author , Christopher ReillyChristopher Reilly Philadelphia, PA More articles by this author , Elton LlukaniElton Llukani Philadelphia, PA More articles by this author , David LeeDavid Lee Philadelphia, PA More articles by this author , and Daniel EunDaniel Eun Philadelphia, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.431AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Localization of ureteral stenosis during robot-assisted ureteroureterostomy (RAUU) relies largely on visual cues. This may be particularly difficult in the presence of inflammation or fibrosis, which often accompanies the underlying ureteral pathology and obliterates normal dissection planes. Enhancing the ability to visually distinguish healthy versus scarred ureter during RAUU may assist in ureteral dissection and attaining a tension-free anastomosis. Indocyanine green (ICG), a fluorescent dye, is theoretically well suited for this purpose due to its ability to penetrate tissue. ICG has a high signal to noise ratio when viewed under near infrared (NIR) light, a modality available in the da Vinci Si® (Intuitive Surgical, Sunnyvale, CA). We present a novel method to intraoperatively localize ureteral stenosis via ICG injection. METHODS Six patients underwent RAUU for ureteral stricture (2 proximal, 2 middle, and 2 distal) by a single surgeon (DDE) between June and November 2012. Localization of ureteral stenosis was determined by preoperative retrograde pyelography followed by intraoperative instillation of ICG (25 mg in 10 ml distilled water) above and below the level of stenosis through a ureteral catheter or percutaneous nephrostomy tube. Occlusion of the ureteral catheter or nephrostomy tube minimized ICG drainage. Patients were subsequently positioned for robotic ureteral repair in supine lithotomy or flank position depending on the area of ureteral stenosis. The fluorescent tracer was detected as a green color via the NIR modality on the da Vinci Si®. All patients consented to off-label use of ICG after full disclosure. RESULTS Intraoperative ICG injection and visualization under NIR light allowed for definitive identification of healthy ureter which fluoresced green and devitalized ureter which remained un-fluoresced. A spatulated and tension free anastomosis was successful in all 6 RAUU. Mean age of patients was 58 years (range 39-69), mean BMI was 30 kg/m2 (range 22-38), mean operative time was 177 min (range 104-270), and mean EBL was 170 ml (range 50-400). There were no adverse effects attributable to ICG administration. Mean length of stay was 1.7 days (range 1-5), with no postoperative complications. Mean follow up was 1.25 months (range 0.5-3), and all cases were clinically and radiographically successful at the last follow up examination. Follow up in all patients is ongoing. CONCLUSIONS Intraoperative precise localization of ureteral stenosis is safe and feasible through intraureteral ICG injection. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e356 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ziho Lee Philadelphia, PA More articles by this author Christopher Reilly Philadelphia, PA More articles by this author Elton Llukani Philadelphia, PA More articles by this author David Lee Philadelphia, PA More articles by this author Daniel Eun Philadelphia, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-Assisted Uretero-Ureterostomy for Iatrogenic Lumbar and Iliac Ureteral Stricture: Technical Details and Preliminary Clinical Results

BackgroundAlthough the incidence of iatrogenic ureteral strictures is low, the treatment remains challenging. ObjectiveTo report our technique of robot-assisted uretero-ureterostomy (RAUU) for adults with iatrogenic lumbar and iliac stricture. Design, setting, and participantsA descriptive study was performed by our department. Since April 2009, five patients underwent RAUU: Two patients had developed a lumbar or iliac ureteral stricture following a ureterorenoscopy, one had ureteral catheter positioning, one had colon surgery, and one had resection of retroperitoneal cystic lymphangioma. Preoperative evaluation includes history, computed tomography (CT) scan, and mercaptoacetyltriglycine-3 (MAG3) diuretic renal scan. Surgical procedureA flank position was used for all patients with lumbar stenosis. A supine position with the bed turned 30° was required for iliac stricture. The optical port, two 8-mm robotic ports, and one 5-mm assistant port were used. A precise definition of the site and extension of the stricture was done using the flexible ureterorenoscope. After the stricture resection, the anastomosis was performed with two running sutures on a ureteral double-J stent. MeasurementsSuccess was defined as no postoperative symptoms and evidence of no obstruction at the CT/urography and at the MAG3 scan at 6-mo follow-up. Results and limitationsRAUU was technically feasible in all five patients. Average operating time was 135min, and median hospital stay was 3 d. No significant complications occurred. Absence of stricture recurrence and no reduction of kidney function were confirmed by CT/urography and MAG3 scans. At a mean follow-up of 8 mo, all patients were asymptomatic. The main limitations were the short follow-up and the small sample size. ConclusionsRAUU is feasible and safe for repairing iatrogenic lumbar and iliac ureteral strictures. The flexible ureterorenoscopy is useful to localise the obstruction and to correctly define its site and extension to spare as much ureter as possible.

Robot-assisted Ureteroureterostomy in the Adult: Initial Clinical Series

To report what we believe is the first series of robot-assisted ureteroureterostomy (RAUU) in adults with greater than 24-month follow-up because ureteral stricture disease can be difficult to manage. During 2004-2006, a total of 3 patients were found to have complex ureteral pathology: 2 with refractory symptomatic ureteral strictures and 1 with a complete ureteral transection. After thorough discussion of all available treatment options, these patients agreed to undergo RAUU. All patients had successful primary reanastomosis of the ureter robotically. Average operating room time was 136.6 minutes. Mean hospital stay was 3 days. All patients had ureteral stents placed during the operation. All patients at last follow-up were noted to be pain free with stable T(1/2) on nuclear renal scan. RAUU is a potential treatment option for ureteral strictures in carefully selected patients. These cases may include failed endopyelotomy, refractory ureteral stricture, or cases of ureteral transection in which a ureteral reimplantation may be difficult. The robotic platform provides excellent reconstructive capabilities that may be difficult to obtain for surgeons who are not performing laparoscopic cases in high volume.