Pure robotic retrocaval ureter repair

Robot-assisted transperitoneal reconstruction of a retrocaval ureter: A report of two cases

A retrocaval ureter (RCU) is a rare cause of congenital ureteral obstruction that often requires surgical repair. We report two cases of RCU in adults treated with robot-assisted laparoscopic surgery. In both cases, we performed robotic ureteroureterostomy with dissection of the entire length of the retrocaval portion of the right ureter without complications. In the second case, renal stone removal was simultaneously performed. The robot-assisted procedure we performed could be considered safe and feasible for the surgical repair of an RCU.

Robot-assisted laparoscopic pyeloplasty for ureteropelvic junction obstruction due to aberrant blood vessel with ipsilateral retrocaval ureter

INTRODUCTION

Ureteropelvic junction obstruction is a common congenital anomaly that causes hydronephrosis but rarely accompanies ipsilateral retrocaval ureter.

CASE PRESENTATION

A 39-year-old woman, who visited to our hospital complaining of worsened right low back pain and fever, was diagnosed with right hydronephrosis due to ureteropelvic junction obstruction by contrast-enhanced computed tomography. Intraoperatively before the planned robot-assisted laparoscopic pyeloplasty, retrograde pyelography was performed to reveal concomitant ipsilateral retrocaval ureter. Laparoscopically, ureteropelvic junction obstruction due to aberrant blood vessel and coexisting retrocaval ureter was confirmed. Transposition of the ureter from posterior to anterior of the inferior vena cava and following dismembered pyeloplasty was performed. Two years after surgery, her right hydronephrosis improved and she had no complain of any symptom.

CONCLUSION

Retrocaval ureter is a rare abnormality; however, combination of preoperative retrograde pyelography and laparoscopic evaluation was important for management of this concomitant abnormality.

Diagnosis and laparoscopic management of retrocaval ureter: A review of the literature and our case series

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The main advantage of minimally invasive techniques for the treatment of retrocaval ureter is less blood loss during surgery.

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Other advantages are shorter hospital stay, less postoperative pain and superior esthetic results.

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Pure laparoscopic treatment (as in our two cases) seems feasible and technically reliable with excellent functional outcome.

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Intracorporeal anastomosis of the ureter remains the main limiting factor.

Objectives

To expose the diagnosis and the different laparoscopic approaches for the surgical management of patients with retrocaval ureter (RCU) and to share our experience on two cases.

Methods

Updated literature review on Pubmed and debating personal experiences including ours (double j stent insertion before the surgery, use of 4 trocards, transperitoneal approach, pyelopyelostomy for the anastomosis…), concerning the laparoscopic treatment of the RCU.

Results

Laparoscopic treatment of RCU is a recommended management for many reasons: less blood loss during the surgery, a shorter hospital stay, less postoperative pain and superior esthetic results with excellent functional results. All of these findings were also a part of our experience on the two reported cases: operative time was 210 and 180 min with no significant bleeding, hospital stay was 48 h post operatively for both patients that were symptom free with no renal dilation after 2 years of close follow up. The main cause of the increased operating time is the intracorporeal anastomosis of the ureter which remains the main limiting factor of the laparoscopic surgery.

Conclusions

The literature review has clearly shown the advantages of minimally invasive techniques for the treatment of retrocaval ureter. Pure laparoscopic treatment (as in our two cases), seems feasible and technically reliable, and should be the standard surgical option for the treatment of RCU.

Laparoscopic and robotic transperitoneal repair of retrocaval ureter: A comparison of the surgical outcomes from two centres with a comprehensive literature review

BACKGROUND

The use of minimally invasive surgical approaches for the repair of retrocaval ureter (RCU) has been increased in time. However, the results of the robotic approach have not yet been compared with those of open or laparoscopic approaches. We aimed to compare the results of laparoscopic and robotic transperitoneal repair of RCU from two centres.

PATIENTS AND METHODS

Initially, we performed a systemic literature search using MEDLINE/PubMed and Google Scholar about the RCU. Finally, a comparison of the efficacy and outcomes of the laparoscopic and robotic transperitoneal approaches for RCU repair was performed with the results of two centers.

RESULTS

The mean age was 27.5 ± 3.6 years. The mean operative time was 147 ± 63.6 min. The median estimated blood loss was 100 (20-423.9) ml. The median drain removing time and hospital stay were 2 (2-3) and 3 (2-4) days, respectively. The mean follow-up period was 17.85 ± 14.6 months. All of the parameters were similar between the laparoscopic and robotic repair groups except for the mean operative time. It was significantly shorter in robotic repair group than those of laparoscopic repair group (P = 0.02). Furthermore, a ureteral stricture of the anastomotic segment was detected in a patient treated with laparoscopy during the follow-up.

CONCLUSIONS

Robotic transperitoneal approach may shorten the operative time enabling a greater comfort in repair of RCU.

Robot-assisted ureteral reconstruction - current status and future directions

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature

Context and Aim:

Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options.

Methods:

From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14–50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years.

Results:

All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage.

Conclusions:

Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.

Minimally Invasive Approach of a Retrocaval Ureter

The retrocaval ureter is a rare congenital entity, classically managed with open pyeloplasty techniques. The experience obtained with the laparoscopic approach of other more frequent causes of ureteropelvic junction (UPJ) obstruction has opened the method for the minimally invasive approach of the retrocaval ureter. In our paper, we describe a clinical case of a right retrocaval ureter managed successfully with laparoscopic dismembered pyeloplasty. The main standpoints of the procedure are described. Our results were similar to others published by other urologic centers, which demonstrates the safety and feasibility of the procedure for this condition.

Transperitoneal Laparoscopic Pyelopyelostomy for Retrocaval Ureter without Excision of the Retrocaval Segment: Experience on Three Cases

Introduction. Retrocaval ureter is a rare congenital anomaly. Open surgery was the classic treatment for this condition. Laparoscopy is currently an admitted procedure to treat many urological diseases. The objective of our study is to present our experience and discuss the safety and the feasibility of transperitoneal laparoscopic pyelopyelostomy for treatment of retrocaval ureter (RCU). Materials and Methods. Three symptomatic patients underwent laparoscopic repair for RCU in our department. The diagnosis was suspected on the computed tomography scan (CT) and confirmed on ascending pyelography. After placement of a JJ stent, and, using the transperitoneal approach, the retro peritoneum was exposed; the ureter was identified in both sides of the vena cava. The retrocaval segment was entirely mobilized and pulled from behind of the vena cava after section of renal pelvis. A pyelopyelostomy was done in a normal anatomic position. Results. All operations were achieved laparoscopically without conversion to open surgery. The mean operative time was 140 minutes (110–190). No intraoperative complication occurred. Blood loss was less than 50 mL in all patients. The mean hospital stay was 5 days (4–6 days). All patients were symptom-free after surgery and had reduction of hydronephrosis in control imagery. Conclusion. Laparoscopy seems safe, feasible, and reproducible in managing retrocaval ureter.

Circumcaval Ureter-the Paradigm Shift in Diagnosis and Management

An anomalous development of infra-renal inferior vena cava leads to circumcaval ureter or preureteral vena cava, a rare congenital anomaly with an autopsy incidence of 0.9 per 1000. We present a case of circumcaval ureter and review the literature with a special emphasis on the paradigm shift seen during the last decade, in diagnostic and management strategies.

Robotic uretero-ureterostomy of the retrocaval ureter without excision of the retrocaval segment

Robotic reconstruction of the retrocaval ureter is gaining momentum as the method of choice for surgically treating this rare condition. Maintaining the retrocaval ureteric segment further facilitates the procedure. We report a case of a 23-year-old man who underwent intraperitoneal robotic resection anastomosis and repositioning of the retrocaval ureter. We also discuss the advantages of this technique.

Retroperitoneal laparoscopic reconstruction for retrocaval ureter: experience and literature review

PURPOSE

We describe surgical techniques and experience with retroperitoneal laparoscopic pyeloureterostomy in five cases of retrocaval ureter (RU). We also report the laparoscopic approach reconstruction for RU from peer-reviewed publications.

PATIENTS AND METHODS

Five patients with RU underwent retroperitoneal laparoscopic pyeloureterostomy. Nuclear renography, intravenous urography (IVU), and ultrasonography follow-up was performed postoperatively. Science Citation Index searches were conducted to identify laparoscopic reconstruction for RU outcomes. Studies published after 1994 were included in the analysis.

RESULTS

Operations were completed successfully and without complications in five patients. The mean operative time was 90.2 ± 34.4 minutes. The mean time needed to insert the Double-J stent and reanastomosis was 51.2 ± 11.4 minutes. Blood loss was minimal. Over a follow-up of 12 to 37 months, hydronephrosis was found to decrease substantially. There were 24 peer-reviewed studies covering a total of 62 patients suitable for inclusion in our final analysis. The most common method for reconstruction of the ureter was ureteroureterostomy, followed by pyeloureterostomy and pyelopyelotomy.

CONCLUSION

Retroperitoneal laparoscopy for RU is a safe and effective procedure that should be considered as a first-line treatment for patients with this anatomic anomaly.

Robot-assisted laparoscopic reconstruction of retrocaval ureter: description and video of technique

Ureteral obstruction secondary to retrocaval ureter is rarely reported in the urologic literature. Symptomatic retrocaval ureters usually present in the 3rd and 4th decade of life. Standard treatment involves ureteroureterostomy approximating the ureter anterior to the vena cava. We describe the initial presentation, imaging, port placement, and operative technique including video presentation of a robot-assisted laparoscopic repair of a retrocaval ureter.

Anomalies of the inferior vena cava and renal veins and implications for renal surgery

Abnormalities of the inferior vena cava (IVC) and renal veins are extremely rare. However, with the increasing use of computed tomography (CT), these anomalies are more frequently diagnosed. The majority of venous anomalies are asymptomatic and they include left sided IVC, duplicated IVC, absent IVC as well as retro-aortic and circumaortic renal veins. The embryological development of the IVC is complex and involves the development and regression of three sets of paired veins. During renal surgery, undiagnosed venous anomalies may lead to major complications. There may be significant hemorrhage or damage to vascular structures. In addition, aberrant vessels may be mistaken for lymphadenopathy and may be biopsied. In this review we discuss the embryology of the IVC and the possible anomalies of IVC and its tributaries paying particular attention to diagnosis and implications for renal surgery.

Laparoscopic transperitoneal pyelopyelostomy and ureteroureterostomy of retrocaval ureter: Report of two cases and review of the literature

We report two cases of retrocaval ureter that were successfully treated by a laparoscopic transperitoneal approach. Presentation of both these cases was with flank pain. Ureteroureterostomy using an intracorporeal suture technique was performed for one, and pyelopyelostomy for the other case. Operative time was 120 min and 110 min, respectively. Pyelopyelostomy was technically easier to perform than ureteroureterostomy that required an extra fourth port insertion to facilitate dissection. With increasing experience with the intracorporeal suturing laparoscopic technique of either pyelopyelostomy or ureteroureterostomy should be the first choice for retrocaval ureter.

Retrocaval ureter with stone in the retrocaval segment of the ureter

Retrocaval ureter is abnormal looping of the proximal ureter behind the inferior vena cava. The aberrant anatomy results in the compression of the ureter causing hydronephrosis. This is a very infrequent cause of hydronephrosis in children. Association of retrocaval ureter with a stone in the looping segment of the ureter is extremely rare. We report one such pediatric case which was diagnosed preoperatively with a review of pediatric-only cases reported in last 5 years.

Laparoendoscopic single-site repair of retrocaval ureter: first case report

OBJECTIVE

We describe a case of retrocaval ureter treated with laparoendoscopic single-site surgery (LESS).

METHODS

A 26-year-old female was referred to our institution with a history of intermittent right-sided flank pain. Radiological imaging demonstrated hydronephrosis, suggesting the presence of a retrocaval ureter. A LESS repair was planned.

RESULTS

Retrograde pyelogram confirmed a classic appearance for retrocaval ureter. A ureteral stent was positioned. The patient was placed in modified flank position. A 2-cm, completely concealed umbilical access was created, through which a single port access platform was positioned. An in-line endoscope was used for visualization. Articulating instruments were used during initial dissection. The entire ureter was mobilized posterior to the vena cava and transected at the caudal-most point where the dilated portion of the proximal ureter ended. The distal ureter was repositioned lateral to the inferior vena cava and spatulated laterally. The proximal ureter was spatulated medially. Two 4-0 Vicryl sutures were used for the ureteroureteral anastomosis. A separate 2-mm grasper placed in the right lower quadrant was used to assist with suture reconstruction. A drain was left through the umbilicus. Blood loss was minimal. Total operative time was 3 hours. The patient was discharged on postoperative day 2. At the 3-month follow-up, diuretic radionuclide scan revealed no evidence of obstruction of the right kidney and the patient was symptom-free.

CONCLUSIONS

Albeit challenging, LESS repair for retrocaval ureter is a feasible procedure that can be considered as a treatment option for this rare anatomic anomaly.

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.