Single-Port Repair of Obliterated Stricture after Open Cystectomy Using Side-to-Side Reimplant

Abstract

Introduction and Objective:

There is limited literature describing the use of single-port (SP) robot-assisted surgery to repair obliterated ureteral strictures using the side-to-side technique. This video describes the feasibility of using SP robot-assisted surgery for side-to-side ureteral reimplant in a patient with obliterated ureteral stricture after open cystectomy. We highlight our use of cystoscopy and ureteroscopy plus near-infrared fluorescence (NIRF), as an alternative to intraluminal indocyanine green administration, to facilitate identification and dissection of the neobladder conduit and ureter in this complex procedure.

Methods:

Patient is a 67-year-old male with a history of muscle-invasive bladder cancer who underwent open cystectomy with neobladder creation in 2021. He developed postoperative urosepsis and right-sided hydronephrosis. He underwent unsuccessful antegrade stent placement and was left with a nephrostomy tube instead. Preoperative labs, including urine cytology, were unremarkable. Preoperative antegrade pyelogram and loopogram demonstrated right-sided distal ureteral stricture.

Results:

Procedure setup included the patient in a supine position with midepigastric trocar placement, which facilitated takedown of abdominal adhesions and navigation to the right lower quadrant. A ureteroscope was placed through the existing nephrostomy tract, and a cystoscope was placed through the penile urethra. The procedure began with identification and dissection down to the neobladder conduit. This was expedited by using the cystoscope light plus NIRF to intermittently illuminate the conduit in green for the console surgeon. Once the conduit was exposed, the same method was used to identify the ureter, this time using the ureteroscope. Side-to-side reimplant was pursued as the ureter was found to be completely obliterated, adherent to the side wall, and without sign of ureteral tumor per ureteroscope. Operative time was 138 minutes with 10 mL blood loss, and the postoperative course was unremarkable.

Our single-institution data demonstrate a 100% success rate and 100% complication-free rate across 5 SP ureteroenteric anastomosis revisions, with the breakdown of anastomosis type shown in Table 1. Our average operating time is 178.5 (58) minutes, and estimated blood loss is 58 (81.5) mL.

Table 1.

Single-Institution Ureteroenteric Anastomosis Revision Data

	Single port (n = 5)
Operating time, minutes average (std)	178.5 (58)
Estimated blood loss, mL average (std)	58 (81.5)
End-to-end anastomosis	1 (20%)
End-to-side anastomosis	4 (80%)
30-day complications	0 (0%)
Revisions required	0 (0%)

Conclusions:

We demonstrate the feasibility of single-port side-to-side ureteral reimplant for obliterated ureteral stricture as well as display the use of ureteroscopy and cystoscopy plus intraoperative NIRF to improve efficiency of an otherwise complex dissection.

Disclosures:

S.S. and F.P. have no disclosures. M.A. is a consultant for Intuitive Surgical, Ethicon, and BioTissue. M.D.S. is on the Advisory Board of Intuitive Surgical and is a consultant for Vascular Technology.

Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Source of work/study:

Department of Urology, Regina Elena National Cancer Institute, Rome. Department of Urology, Hackensack University Medical Center, Hackensack, NJ. Department of Urology, Hackensack Meridian School of Medicine.

Runtime of video: 4 min 59 sec.