- Email: [email protected]
Robot-assisted Boari flap ureteral reimplantation: Step by step
14th Meeting of the EAU Robotic Urology Section
VE25
Robot-assisted Boari flap ureteral reimplantation: Step by step Eur Urol Suppl 2017; 16(6);e2395
De Groote R. 1 , Goossens M. 1 , De Coninck V. 1 , Larcher A. 2 , De Naeyer G. 1 , Schatteman P. 1 , D'hondt F. 1 , Mottrie A. 1 1
OLV Ziekenhuis Aalst-Asse-Ninove, Dept. of Urology, Aalst, Belgium, 2URI; IRCCS Ospedale San Raffaele, Dept. of Urology, Milan, Italy
Introduction & Objectives: Radical nephroureterectomy (RNU) with bladder cuff removal is considered as the standard of care for the management of upper tract urothelial carcinomas (UTUC). However, RNU could induce unnecessary increased risk of non-cancer related death, by the potential cardiovascular morbidity associated with chronic renal failure. Kidney-sparing surgery for low-risk and selected cases of high-risk UTUC allows sparing the morbidity associated with radical surgery, without compromising oncological outcomes and kidney function. Distal ureterectomy with reïmplantation of the ureter in the bladder (ureteroneocystostomy) is performed as form of kidney-sparing surgery. Ureteroneocystostomy is also the procedure of choice to correct benign distal ureteral injuries or strictures in close proximity to the bladder that measure 3-5 cm. The ureteral defect can be bridged by a vesico-psoas hitch (tacking the posterior bladder wall to the psoas muscle) or Boari bladder flap (tubularization of a flap of bladder to extend from the bladder to the ureteral orifice). A minimally invasive robotic or laparoscopic approach offers advantages as less postoperative pain, less blood loss and quicker recovery. The robotic approach by itself offers the extra benefit of improved dexterity, EndoWrist instrumentation and 3-dimensional visualization with magnification in order to facilitate these technically challenging procedures. The objective of this educational video is to provide a step-by-step overview of this technically challenging procedure and to emphasize the importance of kidney sparing surgery, even in complex cases. Material & Methods: Surgery was performed in a 52-year-old female patient who was diagnosed with hydroureteronephrosis due to a distal ureteral lesion, suspicious for UTUC, following gross haematuria. Ureteral biopsy was negative for neoplasia. A robot-assisted distal ureterectomy with a ureteroneocystostomy using a tubulurized Boari bladder flap was conducted. Surgery was performed by an experienced robotic surgeon in a multidisciplinary setting in a high volume robotic centre using the da Vinci® Si surgical system. Results: The first part of the surgery implicates the upper urinary tract mobilisation in order to gain ureteral length and to bridge the wide ureteral defect towards the bladder. This step is done with the da Vinci® Si surgical system in a side docking fashion. In a later stage, a nephropexy is done to the underlying psoas muscle. Afterwards the robotic system is redocked between the legs of the patient for the part of the operation in the small pelvis. First, the lower urinary tract is isolated with mobilisation of bladder and distal ureter. The diseased ureteral segment is clipped proximally and distally to prevent spilling and is extracted completely including the ureteral orifice. An inverted U-shaped Boari bladder flap is used to bridge the ureteral defect. The ureter is reimplanted in an inlay fashion with an anti-reflux submucosal tunnel mechanism. A double-J stent is left in place for 3 weeks. Post-operative stay was uneventful. Histological analysis showed the lesion to be endometriosis. Conclusions: Robot-assisted Boari flap ureteral reimplantation can be regarded as a technically challenging though safe and feasible treatment option in selected patients with a wide distal ureteric defect. Surgical experience is key to avoid intra- and peri-operative complications and to obtain a good surgical outcome.
Eur Urol Suppl 2017; 16(6);e2395
VE25
Robot-assisted Boari flap ureteral reimplantation: Step by step Eur Urol Suppl 2017; 16(6);e2395
De Groote R. 1 , Goossens M. 1 , De Coninck V. 1 , Larcher A. 2 , De Naeyer G. 1 , Schatteman P. 1 , D'hondt F. 1 , Mottrie A. 1 1
OLV Ziekenhuis Aalst-Asse-Ninove, Dept. of Urology, Aalst, Belgium, 2URI; IRCCS Ospedale San Raffaele, Dept. of Urology, Milan, Italy
Introduction & Objectives: Radical nephroureterectomy (RNU) with bladder cuff removal is considered as the standard of care for the management of upper tract urothelial carcinomas (UTUC). However, RNU could induce unnecessary increased risk of non-cancer related death, by the potential cardiovascular morbidity associated with chronic renal failure. Kidney-sparing surgery for low-risk and selected cases of high-risk UTUC allows sparing the morbidity associated with radical surgery, without compromising oncological outcomes and kidney function. Distal ureterectomy with reïmplantation of the ureter in the bladder (ureteroneocystostomy) is performed as form of kidney-sparing surgery. Ureteroneocystostomy is also the procedure of choice to correct benign distal ureteral injuries or strictures in close proximity to the bladder that measure 3-5 cm. The ureteral defect can be bridged by a vesico-psoas hitch (tacking the posterior bladder wall to the psoas muscle) or Boari bladder flap (tubularization of a flap of bladder to extend from the bladder to the ureteral orifice). A minimally invasive robotic or laparoscopic approach offers advantages as less postoperative pain, less blood loss and quicker recovery. The robotic approach by itself offers the extra benefit of improved dexterity, EndoWrist instrumentation and 3-dimensional visualization with magnification in order to facilitate these technically challenging procedures. The objective of this educational video is to provide a step-by-step overview of this technically challenging procedure and to emphasize the importance of kidney sparing surgery, even in complex cases. Material & Methods: Surgery was performed in a 52-year-old female patient who was diagnosed with hydroureteronephrosis due to a distal ureteral lesion, suspicious for UTUC, following gross haematuria. Ureteral biopsy was negative for neoplasia. A robot-assisted distal ureterectomy with a ureteroneocystostomy using a tubulurized Boari bladder flap was conducted. Surgery was performed by an experienced robotic surgeon in a multidisciplinary setting in a high volume robotic centre using the da Vinci® Si surgical system. Results: The first part of the surgery implicates the upper urinary tract mobilisation in order to gain ureteral length and to bridge the wide ureteral defect towards the bladder. This step is done with the da Vinci® Si surgical system in a side docking fashion. In a later stage, a nephropexy is done to the underlying psoas muscle. Afterwards the robotic system is redocked between the legs of the patient for the part of the operation in the small pelvis. First, the lower urinary tract is isolated with mobilisation of bladder and distal ureter. The diseased ureteral segment is clipped proximally and distally to prevent spilling and is extracted completely including the ureteral orifice. An inverted U-shaped Boari bladder flap is used to bridge the ureteral defect. The ureter is reimplanted in an inlay fashion with an anti-reflux submucosal tunnel mechanism. A double-J stent is left in place for 3 weeks. Post-operative stay was uneventful. Histological analysis showed the lesion to be endometriosis. Conclusions: Robot-assisted Boari flap ureteral reimplantation can be regarded as a technically challenging though safe and feasible treatment option in selected patients with a wide distal ureteric defect. Surgical experience is key to avoid intra- and peri-operative complications and to obtain a good surgical outcome.
Eur Urol Suppl 2017; 16(6);e2395