Robot-assisted laparoscopic right ureterectomy with ileal ureter interposition for upper tract urothelial carcinoma

Abstract

Objective

In patients with upper tract urothelial carcinoma confined to the proximal or mid ureter, options for kidney preservation are limited without complex ureteral reconstruction. We demonstrate a technique for robotic right ureterectomy with ileal ureter interposition.

Patient and Surgical Procedure

The patient is a 75-year-old man with bilateral upper tract urothelial carcinoma, in the distal ureter on left and in the proximal-to-mid ureter on right. These were noted to be high grade on endoscopic biopsy. He first underwent uncomplicated robotic left distal ureterectomy with ureteral reimplantation and psoas hitch, with final pathology showing low grade disease. He desired renal preservation, and thus elected for robotic right ureterectomy with ileal ureter interposition to address the right-sided disease.

The patient is placed in flank position with the right side up. The robotic 8 mm ports are placed in the mid-clavicular line, with a 12 mm 4th arm port used to accommodate the robotic stapler. The ureter is dissected free of the surrounding tissue proximally to the renal pelvis and distally to the bladder. Intra-operative ultrasound is used to identify the tumor within the ureteral lumen and mark the proximal margin with a clip. The proximal ureter is then divided. The length of the anticipated ureteral defect is measured with a silk suture. The terminal ileum is marked 15 cm proximal to the ileocecal valve. The measurement suture for the anticipated ureteral defect is then used to mark an appropriate length of ileum, along with a 5 cm ileal discard segment. The robotic stapler is used to divide the planned ileal ureter segment. The bowel anastomosis is completed in a side-to-side fashion with the robotic stapler. The ileal ureteral segment is then anastomosed to the renal pelvis with double-armed 4–0 barbed suture over an 8fr double-J ureteral stent. The robot is then undocked and the patient is repositioned supine with a standard pelvic port configuration. The remainder of the distal ureter is dissected free, and the ureter and bladder cuff are excised. The bladder cuff cystotomy is closed with 3–0 barbed suture. A new cystotomy is made and the distal end of the ileal ureter is anastomosed to the bladder with a double-armed 4–0 barbed suture.

Results

Total operative time was 430 minutes. The patient was discharged on post-operative day two. The ureteral stent was removed after 6 weeks. Final pathology demonstrated a 2 cm segment of low grade non-invasive urothelial carcinoma with focal high-grade areas and negative margins. A 3-month follow up CT scan showed no evidence of disease. Mild right hydronephrosis was present. The patient's renal function was normal.

Conclusion

In appropriately selected patients with upper tract urothelial carcinoma of the proximal or mid ureter, robotic ureteral excision with ileal ureter reconstruction can be an effective treatment if renal preservation is necessary.