Laparoscopy-Assisted Ureter Interposition by Ileum

Robot-assisted complex urinary tract reconstruction using intestinal segments: redefining the paradigm

Complex urinary tract reconstruction has significantly advanced with the increasing use of robot-assisted procedures. Robotic surgery aims to achieve the same outcomes as open surgery while minimizing morbidity by causing less blood loss, faster postoperative recovery, and reducing complications. This article shares our technique, challenges encountered, and experience of robot-assisted complex urinary tract reconstruction using intestinal segments. Between January 2020 to March 2022, 6 patients who underwent robot-assisted complex urinary tract reconstruction using intestinal segments at our centre were retrospectively reviewed. Demographic, clinical, and operative data were recorded. Patients underwent renal function tests, blood gas analysis, and radiographic imaging in the follow-up. Symptomatic and radiologic relief were the criteria for success. Out of 6 cases, three patients underwent ileal ureter replacement, two combined ileal ureter with augmentation ileo-cystoplasty and one augmentation ileo-cystoplasty alone. The mean age, estimated blood loss, length of hospital stay, and follow-up period were 32.6 years, 110 ± 13.1 mL, 7.0 ± 1.1 days, and 11.3 months, respectively. The indications for surgery were either benign ureteral stricture following lithotripsy or sequelae of genitourinary tuberculosis. No intra-operative complications were found. Clavien-Dindo grade-II and Grade-IIIa were found in three and one patient, respectively. During follow-up, none had compromised renal function or acidosis. Robot-assisted complex urinary tract reconstruction using intestinal segments is safe and offers the advantages of minimally invasive techniques. Techniques demonstrated in this article make these reconstructions feasible with good surgical and clinical outcomes.

Totally intracorporeal robotic ileal ureter replacement: focus on surgical technique and outcomes

BACKGROUND

The aim of the present study was to describe our totally intracorporeal robotic ileal ureter replacement technique, reporting perioperative and mid-term results and compare it with previous similar experiences, specifically focusing on technical considerations.

METHODS

Three patients were submitted to robotic ileal ureter substitution for long ureteral defects in our institution during 2019. The procedures were carried out fully intracorporeally. Two patients received a complete replacement of the urinary tract using an ileal segment, while in one patient the lower ureteral stump was maintained, and an ileal-ureter anastomosis was performed distally. Patients' baseline characteristics, as well as perioperative and mid-term results were collected. A detailed description of the technique is reported and compared with prior similar experiences.

RESULTS

Median operative time was 270 (range 240-300) min. No Clavien-Dindo complication >2 was collected. All patients experienced a fast return to oral intake and canalization. Antegrade pyelography, performed a 1-month follow-up, revealed full passage of the medium contrast in those patients submitted to complete ileal ureter replacement while, in the third one, stenosis at the level of ileal-ureter anastomoses was found.

CONCLUSIONS

Robotic ileal ureter replacement can be performed completely intracorporeal with optimal results and limited complication rate, in selected cases. According to our considerations, specific surgical steps are needed to reduce the risks related to this procedure, including avoiding partial ileal substitution.

Management of long ureteral stenosis: Alternatives to indwelling ureteral stents

OBJECTIF

Evaluate kidney autotransplantation (KAT) and ileal ureter substitution (IUS) practice and outcome as alternatives to indwelling ureteral stents for the management of long ureteral stenosis (US).

MATERIAL

We included all patients treated for US with KAT or IUS in 5 French university urology centers between 2010 and 2018. We excluded US due to urothelial carcinoma. Primary endpoint was the preservation of ipsilateral kidney and renal function without any urinary diversion.

RESULTS

22 patients were treated with KAT (n=8, 36.4%) and IUS (n=14, 63.6%). Mean US length was 4.6cm and 6cm (P=0.52) in KAT and IUS groups respectively. US etiologies were lithiasis, iatrogenic, retroperitoneal fibrosis or extrinsic compression. US level was varied. The surgery was described as difficult because of peritoneal adhesions or major peri-ureteral fibrosis. Mean operating time and hospital stay were 336 and 346minutes (P=0.87) and 8 and 15 days respectively (P=0.001). Postoperative complications were mostly Clavien ≤2 (n=17, 77.3%). Revision surgery was required in the KAT group in 3 cases (37.5%), for textiles, renal vein thrombosis and anastomotic leak, none in the IUS group. The mean follow-up was 15.7 months. All but one (in the KAT group) ipsilateral kidneys were preserved, without renal function impairment (Δcreat +2.1 vs. +2.4μmol/l respectively, P=0.67), nor urinary diversion.

CONCLUSION

KAT and IUS are safe alternatives whose indication depends on surgeons expertise. Our study pointed out the scarcity of this practice suggesting the need to refer patients to expert centers.

LEVEL OF EVIDENCE

3.

Minimally invasive ileal ureter replacement: Comparative analysis of robot-assisted laparoscopic versus conventional laparoscopic surgery

BACKGROUND

This study is an initial comparative analysis of perioperative and intermediate-term functional outcomes between patients who underwent robot-assisted laparoscopic (RALS) or conventional laparoscopic surgery (LS).

MATERIALS AND METHODS

A total of 25 patients who underwent ileal ureter replacement (10 RALS and 15 LS) were followed by functional cine magnetic resonance urography (MRU) combined with a modified Whitaker test. Also, the characteristics, perioperative data and functional outcomes of the patients were compared.

RESULTS

The estimated blood loss, postoperative hospital stay and time to oral intake were significantly lower in the RALS group. At the median 14-month follow-up, all the patients showed improved renal function and were symptom-free, with no signs of leakage or stenosis observed by cine MRU combined with a modified Whitaker test.

CONCLUSIONS

RALS with an extracorporeal bowel resection is feasible and appears to be safe, with quick postoperative recovery and encouraging outcomes.

Hand-assisted laparoscopic ileal ureter substitution for ureteral obstruction after right ureteral rupture: A case report

Iatrogenic ureteral rupture is a serious complication. In the past, ileal ureter substitution was performed with open, laparoscopic, and robot-assisted procedure; however, there are problems with operation invasiveness and difficulty. We present a 72-year-old female whose ureter was completely injured at the ureteropelvic junction and torn longitudinally in full length at the time of transurethral lithotripsy. Although initially she had nephrostomy, we were able to internalize with hand-assisted laparoscopic ileal ureter substitution for obstruction over the full length of the ureter.

Initial Series of Four-Arm Robotic Completely Intracorporeal Ileal Ureter

Ileal ureter formation has been found to be a suitable treatment option for long, chronic ureteral strictures not amendable to less invasive forms of repair. Minimally invasive surgical techniques for this condition have been investigated. We report the first series of robotic completely intracorporeal ileal ureter using a four-arm robotic technique. Three patients underwent this procedure, including one patient with a solitary kidney. All procedures were performed effectively with a median operative time of 450 minutes (range: 420-540) and median estimated blood loss of 100 mL (range: 50-200). Postoperatively, one patient suffered volvulus and subsequent necrosis of small bowel and ileal ureter, which required re-operation and small bowel resection, including the ileal ureter. The other two patients report no surgical complications to date. This early series represents preliminary technical procedure feasibility. Further experience is necessary.

Robotic ileal ureter: a completely intracorporeal technique

INTRODUCTION

The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure.

TECHNICAL CONSIDERATIONS

A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2).

CONCLUSION

Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

Laparoscopic ureteral replacement by Boari flap: multi-institutional experience in 30 cases

INTRODUCTION

The Boari flap is an excellent technique for replacement of distal ureteral injuries. There are few reports with the use of laparoscopic surgery, especially with long term results. Our goal is to present the results of a multi-institutional study of 30 cases.

MATERIAL AND METHODS

We analyzed 30 patients treated between December 2001 and January 2009 who underwent a laparoscopic intracorporeal Boari flap, in three Latin American centers. In all cases the same surgical technique was employed. The database was recorded prospectively and analyzed retrospectively.

RESULTS

The mean age was 43.2 years (range 9 to 71 years). Most were women (22 of 30) with a slight predominance of left-side lesions (17 of 30). The most common cause of ureteral injury was hysterectomy in 14 patients (46.6%) and endoscopic ureterolithotomy in 9 patients (30%). The mean length of ureteral resection was 7 cm. (5 to 20 cm). The average operative time was 161.16 min (90 to 280 min). The average estimated blood loss was 123 mL. (0 to 500 mL), and hospital stay was 4.86 days (2 to 10 days). There were no intraoperative complications or conversion to open surgery. Postoperative complications occurred in 5 patients (16.6%), Clavien 1 in 2 patients (6.6%) and Clavien 3 in three patients (10%). The success rate was 96.6% (29 patients) with a mean follow up of 32 months (5 to 60 months).

CONCLUSIONS

Laparoscopic Boari flap in our hands had good short and long term results.

Primary bladder amyloidosis--case report of a patient with delayed upper urinary tract obstruction 3 years after the diagnosis

Primary bladder amyloidosis is a rare disease. There are approximately 100 reported cases. The lesions can be confused with bladder neoplasm and are characterised histologically by the classical apple green birefringence under polarised light. In this article, we report a 51-year-old lady with known history of primary bladder amyloidosis presenting with gross hydronephrosis 3 years after the first diagnosis. Laparoscopic ileal replacement of bilateral ureters was performed. There was no recurrent ureteric obstruction 2 years after surgery. This case demonstrates the progressive nature of primary amyloidosis of bladder. The diagnosis of primary bladder amyloidosis warrants long-term surveillance of upper urinary tract.