Robot-Assisted Revision of Bilateral Ureteroenteric Anastomotic Strictures

Abstract

Background: The incidence of ureteroenteric stricture (UES) after radical cystectomy is approximately 8%.1–4 UES is often managed with long-term indwelling ureteral stents or nephrostomy tubes, both of which can have a negative impact on quality of life and require frequent exchange. In this video, we are the first to describe bilateral robotic-assisted revision of UES in a neobladder with the assistance of Firefly and Indocyanine Green (ICG). Clinical History: A 66-year-old male underwent an open cystoprostatectomy and open neobladder construction in 2016 due to bladder cancer. Seven years later, he presented with back pain and serum creatinine elevated to 3.5 mg/dL. He had no prior history of radiation. Physical Exam: Physical exam was significant for an intact midline incision from previous procedures. Diagnosis: Imaging revealed stable bilateral hydronephrosis from bilateral UES. Intervention: On presentation, the patient was managed with indwelling nephroureteral stents connected to external drainage. The patient strongly preferred definitive revision to avoid continuous nephroureteral stent exchange. As such, we proceeded with a robotic-assisted revision of bilateral ureteroenteric anastomoses in a neobladder. The surgery began with laparoscopic lysis of adhesions from the previous open procedures. ICG was given through the bilateral nephrostomy tubes to facilitate ureteral and neobladder identification and highlight healthy ureteral tissue. The right ureter was mobilized and resected sharply, and the old ureteral stent was exchanged. The right ureter was then spatulated sharply at the anterior roof, and a cystostomy was made into the afferent limb. A running anastomosis was performed with 4-0 polydioxanone suture and reinforced with 4-0 vicryl suture. The same technique was repeated on the left ureter. Due to the shortened length of the left ureter, it was reimplanted into the top of the afferent chimney, the portion of the neobladder having the most mobility. Bilateral nephrostomy tubes were removed intraoperatively. Follow-Up/Outcomes: The patient's postoperative course was uncomplicated. His serum creatinine normalized to 2.0 mg/dL. He was discharged home on postoperative day 5 with a foley catheter which was removed 10 days later. Both ureteral stents were removed cystoscopically and at 6 months postoperatively, he remains drain and stent free with a stable creatinine of 2.0 mg/dL. His hydronephrosis has also resolved. Overall, bilateral ureteroenteric anastomotic strictures are a significant complication of radical cystectomy and urinary diversion that are rarely documented. In this video, we are the first to validate the usefulness of a conventional robot-assisted system for simultaneous repair of bilateral UES in a neobladder. No competing financial interests exist. Runtime of video: 5 mins 4 secs