Robot-assisted laparoscopic Boari flap ureteral reimplantation

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up

OBJECTIVE

To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data.

PATIENTS AND METHODS

A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed.

RESULTS

The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m² , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature.

CONCLUSION

In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.

The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

A Contemporary Case Series of Complex Surgical Repair of Surgical/Endoscopic Injuries to the Abdominal Ureter

BACKGROUND

Iatrogenic ureteral injuries are devastating complications potentially resulting in irreversible impairment of renal function and/or infectious sequelae. Only few data are available on the management of such injuries to the abdominal ureter.

OBJECTIVE

To report the etiology, perioperative outcomes, and treatment failure rate of different reconstructive surgical interventions for iatrogenic injuries to the abdominal ureter in a contemporary case series.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed consecutive patients who underwent reconstructive surgery for iatrogenic injuries to the abdominal ureter at our academic centers between July 2013 and April 2019. All interventions were performed via either an open or a robot-assisted approach by a single expert surgeon.

SURGICAL PROCEDURE

Different surgical reconstructive procedures, such as Boari bladder flap, ureteroureterostomy, ileal replacement, and pyeloureteroplasty, have been adopted.

MEASUREMENTS

Outcome measures were the etiology of iatrogenic injuries, rate of postoperative complications, and rate of treatment failure, defined as upper urinary tract obstruction requiring permanent urinary drainage.

RESULTS AND LIMITATIONS

Nineteen patients were included. Injuries were consequent to endourological procedures in nine (47.4%), gynecological procedures in two (10.5%), colonic surgery in two (10.5%), vascular surgery in two (10.5%), and other surgeries in four (21.1%) cases. Boari bladder flap was performed in 12 (63.2%), ureteroureterostomy in two (10.5%), ileal substitution in two (10.5%), and pyeloureteroplasty in three (15.8%) cases. Only four (21.1%) procedures were performed robotically. Major postoperative complications were recorded in three (15.8%) patients. After a median follow-up of 16 (interquartile range 12-24) mo, treatment failure was observed in two (15.8%) cases. We accept the limitations of a small retrospective single-surgeon series with preference-based management choice.

CONCLUSIONS

In our series, endourological procedures were the most frequent cause of iatrogenic injuries to the abdominal ureter requiring reconstructive surgery. A Boari bladder flap was the preferred option to bridge extensive ureteral defects. Despite the complexity of such procedures, major postoperative complications were infrequent and treatment failure rate was low.

PATIENT SUMMARY

We report on a contemporary series of patients with disparate iatrogenic injuries to the abdominal ureter requiring complex reconstructive surgery. Despite the difficulty of such procedures, we found that major postoperative complications were infrequent and treatment failure rate was low.

Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience

BACKGROUND

Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation.

OBJECTIVE

To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016.

SURGICAL PROCEDURE

RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%.

CONCLUSIONS

RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures.

PATIENT SUMMARY

We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

Laparoscopic ureteral reimplantation with Boari flap for the management of long- segment ureteral defect: A case series with review of the literature

OBJECTIVE

The incidence of ureteral stricture is showing a rising trend due to increased use of laparoscopic and upper urinary tract endoscopic procedures. Boari flap is the preferred method of repairing long- segment ureteral defects of 8-12 cm. The procedure has undergone change from classical open (transperitoneal and retroperitoneal) method to laparoscopic surgery and recently robotic surgery. Laparoscopic approach is cosmetically appealing, less morbid and with shorter hospital stay. In this case series, we report our experience of performing laparoscopic ureteral reimplantation with Boari flap in 3 patients.

MATERIAL AND METHODS

This prospective study was conducted between January 2011 December 2014. The patients with a long- segment ureteral defect who had undergone laparoscopic Boari flap reconstruction were included in the study. Outcome of laparoscopic ureteral reimplantation with Boari flap for the manangement of long segment ureteral defect was evaluated.

RESULTS

The procedure was performed on 3 patients, and male to female ratio was 1:2. One patient had bilateral and other two patient had left ureteral stricture. The mean length of ureteral stricture was 8.6 cm (range 8.2-9.2 cm). The mean operative time was 206 min (190 to 220 min). The average estimated blood loss was 100 mL (range 90-110 mL) and mean hospital stay was 6 days (range 5 to 7 days). The mean follow up was 19 months (range 17-22 months). None of the patients experienced any complication related to the procedure in perioperative period.

CONCLUSION

Laparoscopic ureteral reimplantation with Boari flap is safe, feasible and has excellent long term results. However, the procedure is technically challenging, requires extensive experience of intracorporeal suturing.

Incidence of Iatrogenic Ureteral Injury During Open and Laparoscopic Colorectal Surgery: A Single Center Experience and Review of the Literature

INTRODUCTION

Iatrogenic ureteral injury is a rare but potentially devastating complication of colorectal surgery. We evaluated the incidence and management of iatrogenic ureteral injuries in colorectal surgery during the transition phase from open to laparoscopic surgery.

MATERIALS AND METHODS

We conducted a retrospective single center study. All patients who underwent colorectal surgery between 2004 and 2014 were evaluated by collecting data of electronic patient charts. Both acute and elective procedures were included.

RESULTS

A total of 3302 colorectal procedures were performed in the study period. Of these, 2817 operations were performed open and 484 laparoscopically. A total of 23 iatrogenic ureteral injuries were identified, of which 5 were found during laparoscopic surgery. The cumulative incidence of ureteral injuries was 0.6% for open procedures and 1.0% for laparoscopic procedures.

CONCLUSIONS

Ureteral injury is a rare complication of colorectal surgery. The incidence might rise with the increasing use of laparoscopy.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BACKGROUND

Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach.

OBJECTIVE

To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014.

SURGICAL PROCEDURE

Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed.

RESULTS AND LIMITATIONS

No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population.

CONCLUSIONS

Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results.

PATIENT SUMMARY

In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Robot-assisted technique for Boari flap ureteric reimplantation: replicating the techniques of open surgery in robotics

OBJECTIVE

To describe our robot-assisted Boari flap ureteric reimplantation (RA-BFUR) technique, Please see Video S1.

METHODS

The RA-BFUR technique is based on the open surgical technique of Übelhör, and the experience includes 11 cases.

RESULTS

Excellent results were achieved after a mean follow-up period of >12 months.

CONCLUSION

The RA-BFUR technique could be considered a safe and effective method of ureteric reimplantation for long distal ureteric strictures.

Robot-assisted surgery for the treatment of upper urinary tract urothelial carcinoma

Robot-assisted laparoscopic surgery is increasingly used in urologic oncologic surgery. Robotic nephroureterectomy is still a relatively new technique. As upper tract urothelial carcinoma is a rare disease, intermediate- and long-term outcome data are scarce. However, robotic nephroureterectomy does seem to offer advantages to open and laparoscopic counterparts, with comparable short-term oncologic and functional outcomes. Here the authors review the robotic surgical management of upper tract urothelial carcinoma, with a review of the steps and tips on making this approach more widely adoptable.

[Avoidance and management of complications in open surgical ureter reconstruction]

Open surgical reconstruction of the ureter is a urological procedure with a potentially high risk of complications. The correct selection of patients and time of operation are important aspects regarding the treatment strategy. Position and length of the affected ureter segment to be reconstructed determine the surgical intervention possibilities. The psoas hitch procedure is a well-established technique for distal reconstruction of the ureter where most iatrogenic injuries occur. In more proximal or complex defects, several procedures are available. Partial or complete replacement of the ureter with bowel is still considered the standard for bridging long ureteral defects but is accompanied with higher intra- and postoperative complication rates. In specific patients and situations, autotransplantation of the kidney and subcutaneous pyelovesical bypasses are clinical options. Using mucosal grafts or tissue engineering may be new therapeutic prospects to cover ureteral defects but the clinical impact still needs to be clarified. All therapeutic strategies share the fact that great surgical expertise and experience are necessary as the operative technique must be mastered to avoid severe complications.

Robot-assisted technique for boari flap ureteral reimplantation: is robot assistance beneficial?

BACKGROUND AND PURPOSE

Ureteral reconstructive surgery necessitates adequate exposure of the ureteral lesion and results in large abdominal incisions. Robot assistance allows the performance of complex ureteral reconstructive surgery through small incisions. The current series includes only cases of Boari flaps performed by robot assistance and attempts to describe in detail the technique, review the literature, as well as to expand the experience in the current literature.

PATIENTS AND METHODS

Eight patients underwent ureteral reimplantation by Boari flap technique. The indications for the performance of the procedure included ureteral stricture from iatrogenic injury in three patients, recurrent ureteral stricture after multiple endoscopic stone management procedures in one patient, ureteral stricture from previous malignant disease in the pelvis or abdomen in three patients, and ureteral stricture due to trauma in one patient. Five cases were located in the left side and three cases in the right side. A variety of parameters were recorded in a prospective database including the time for robot docking and total operative time as well as catheterization and drainage time. The follow-up of the patients included the performance of renal ultrasonography 4 weeks, 3, 6, and 12 months after the procedure.

RESULTS

Mean age of the patients was 50.8 (range 39-62) years and mean body mass index was 26.2 (range 23.22-29.29) kg/m(2). Operative time ranged 115 and 240 (mean 171.9) minutes. Mean blood loss was 161.3 (50-250) mL. Conversion to open surgery did not take place in the current series. No intraoperative complications were observed. Postoperative complications included one case of prolonged anastomotic leakage.

CONCLUSION

The robot-assisted approach is efficient in the performance of ureteral reimplantation with Boari flap. Low blood loss, short catheterization time, low complication rate, and excellent reconstructive outcome are associated with the approach. Robot assistance seems to be beneficial for ureteral reconstructive surgery.

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.

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.

Laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy for adult obstructed megaureter: a novel technique

INTRODUCTION

To describe a novel technique using extracorporeal tailoring and an inverted ureteral nipple to perform laparoscopic transperitoneal ureteral reimplantation for adult obstructed megaureter and our initial experience with 10 patients.

TECHNICAL CONSIDERATIONS

Ten patients (mean age 39.2 years [range, 21-62]) with adult obstructed megaureter underwent transperitoneal laparoscopic ureteral reimplantation by a 3- or 4-port technique. In each case, the affected ureter was freed and delivered out of the peritoneal cavity through the ipsilateral 12-mm port. The lower end of the ureter was tailored by approximately 6 cm, and the tip was folded back onto itself and secured with absorbable sutures to form a nipple. A double-J stent was placed, the entire assembly was carefully replaced into the abdomen, and the ureter was reimplanted into the posterolateral wall of the bladder.

CONCLUSION

Surgery was successful in all the 10 patients without the need for open conversion. At a mean follow-up of 17 months, all patients were asymptomatic, and hydronephrosis was relieved in 9 cases. Laparoscopic ureteral reimplantation with extracorporeal tailoring and direct nipple ureteroneocystostomy is an easy, safe, and effective procedure for adult obstructed megaureter.

Single-surgeon experience with robot-assisted ureteroneocystostomy for distal ureteral pathologies in adults

PURPOSE

To demonstrate our technical approach for robot-assisted ureteroneocystostomy (R-UNC) for benign and malignant distal ureteral pathologies.

MATERIALS AND METHODS

Between January 2009 and January 2013, a total of 10 patients underwent R-UNC in the distal ureter by a single surgeon. Indications for R-UNC were as follows: idiopathic (3), fistula (2), iatrogenic (2), malignancy (2), and chronic vesicoureteral reflux (1).

RESULTS

Tension-free anastomosis was attained in all 10 R-UNC procedures. A psoas hitch was performed in 6/10 cases (60%). Intravesical and extravesical reimplantations were completed in 5/10 (50%) and 5/10 cases (50%), respectively. A nonrefluxing ureter was constructed in 2/10 cases (20%). The patients' mean age was 52.9±16.6 years, their mean body mass index was 30.8±6.3 kg/m(2), the mean operative time was 211.7±69.3 minutes, mean estimated blood loss was 102.5±110.8 mL, and mean length of stay was 2.8±2.3 days. There were no intraoperative complications. There was one Clavien-Dindo grade I and one Clavien-Dindo grade II postoperative complication. The mean postoperative follow-up duration was 28.5±15.5 months. Two patients had recurrence of ureteral strictures at 3 months postoperatively and were managed successfully with balloon dilation.

CONCLUSIONS

Our technique for R-UNC demonstrates good perioperative outcomes. However, underlying periureteral inflammation and pelvic adhesions may predispose patients for stricture recurrence after R-UNC.

Laparoscopic ureteroneocystostomy: modification of current techniques

Purpose

To review the feasibility of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end in various distal ureteral lesions.

Materials and Methods

We conducted a retrospective review of 5 laparoscopic procedures of ureteroneocystostomy with extracorporeal eversion of the ureteral end. Of these, 4 patients (range, 45 to 54 years) had distal ureter stricture or obstruction after gynecological surgeries for endometriosis or a large uterine myoma. One patient (male, 67 years) had low-grade distal ureter cancer. The laparoscopic procedure was combined with cystoscopic insertion of a ureteral stent and extracorporeal eversion of the ureter through the 10-mm port on the affected side.

Results

The laparoscopic ureteral reimplantations with and without a psoas hitch in patients with distal ureteral lesions was successful in all patients. The mean operation time was 137 minutes (range, 104 to 228 minutes). Two patients underwent additional psoas hitch. In all patients, short-term success was confirmed by voiding cystourethrography and intravenous pyelography conducted 3 months after the operation. The mean follow-up of the entire group was 12 months (range, 3 to 30 months). We noted no major or minor complications over the follow-up period.

Conclusions

The technique of laparoscopic ureteroneocystostomy for benign or malignant ureteral strictures continues to evolve. Surgeons should be versatile with various options and technical nuances when dealing with these cases. Simple modifications of laparoscopic ureteroneocystostomy with extracorporeal eversion of the ureteral end, nonreflux extravesical anastomosis, and simultaneous cystoscopy will be crucial to the ease of performance and a successful outcome.

Ureteric injury: a challenging condition to diagnose and manage

Although ureteric injury is relatively uncommon, it is a serious event that can result in intra-abdominal sepsis, renal failure, and loss of the ipsilateral renal unit. Most injuries are iatrogenic and remain undiagnosed until the patient presents with symptoms postoperatively. In addition to compromising patient safety, missed ureteric injuries frequently result in litigation. Over the past 20 years, there has been a rapid uptake of laparoscopic and robotic techniques within urology and other surgical specialties. This trend, coupled with increased use of ureteroscopy, has increased the risk of injury to the ureter. The key to diagnosing and managing a ureteric injury is to have a low threshold for suspecting its presence. Diagnosis can be achieved using retrograde pyelography, ureteroscopy, CT, or intravenous urography. Initial management should involve ureteric stent placement or percutaneous nephrostomy drainage. In selected patients, surgical reconstruction might be the optimal approach. Decisions regarding surgical technique (open, laparoscopic, or robotic) are guided by the clinical situation and surgical expertise available.

Experience with robot assisted laparoscopic surgery for upper and lower benign and malignant ureteral pathologies

OBJECTIVES

To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery.

METHODS

We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated.

RESULTS

The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range: <50-400). There were no urine leaks. Mean drain tube duration was 1.4 days (range: 1-2.5) and mean hospital stay was 2.4 days (range: 1-6). Complications included 1 case of sepsis and 1 antibiotic-induced infection. Average follow-up period was 13.5 months. Operative success as defined by symptom resolution and imaging was 100%.

CONCLUSIONS

RALS is feasible, safe, and an effective option for ureteral pathologies at any level of the ureter with minimal peri-operative morbidity. However, appropriate port placement, patient positioning, and versatile experience of team is critical in handling such cases for better outcomes.