- Email: [email protected]
V10-08 TOTAL LAPAROSCOPIC URETERAL SUBSTITUTION USING APPENDIX
THE JOURNAL OF UROLOGYâ
e1200
devascularization, fibrosis with renal fixation, and dense stricture formation. A high rate of recurrence leads to progressively complex repairs. Herein, we present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty in the management of recurrent UPJ obstruction. METHODS: We present two patients with recurrent left UPJ obstruction. Both previously underwent multiple failed open or robotic pyleoplasties, attempted endoscopic treatment and subsequent management with ureteral stent exchanges. At the time of surgery patients were placed in left lateral flank position and a Foley catheter inserted. Transperitoneal access was obtained with a Veress needle. Extensive adhesiolysis was required. The colon was reflected medially, the kidney, ureter and renal pelvis were exposed and the UPJ identified. The area surrounding the UPJ and proximal ureter were circumferentially dissected. The UPJ was entered and the ureter incised longitudinally from the renal pelvis until healthy, normal caliber ureter was demonstrated distally, with spatulation for at least 1 cm on either end. The defects were measured and found to be 3.5 and 4 cm. 8 Fr double J ureteral stents were placed. Single buccal grafts were harvested from the right inner cheek and measured for the length of the stricture and 1.5-2cm wide. A stay suture was placed to maintain orientation and minimize handling of the ureteral tissue. The graft was delivered to the abdomen and placed as an anterior onlay, over the ureteral and UPJ defect, with two 4-0 running Vicryl sutures. The tension free repair and surgical field was wrapped in omentum after confirming a water tight anastomosis. A JP drain was placed. RESULTS: Operative times were 280 and 411 minutes. Estimated blood loss was 25-50 mls. The hospital stay was 2 days. Foley catheters and JP drains were removed in the immediate post-operative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency. Both patients have been asymptomatic since stent removal and anticipate follow-up functional renal scans with Lasix in 6 months. CONCLUSIONS: Robotic salvage pyeloplasty with BMG is an attractive alternative technique in the management of recurrent UPJ obstruction demonstrating a tension free, water tight and patent repair. Short term follow up has demonstrated that it is an effective and feasible approach when compared to more extensive and invasive surgical procedures. Source of Funding: none
V10-06 ROBOTIC-ASSISTED LAPAROSCOPIC CALYCEAL DIVERTICULECTOMY
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
CONCLUSIONS: Robotic-assisted laparoscopic calyceal diverticulectomy is a feasible and safe option in the management of large persistent calyceal diverticulum. Source of Funding: None
V10-07 ROBOTIC REPAIR OF RIGHT URETERO-ILEAL ANASTOMOTIC STRICTURE FOLLOWING PRIOR ROBOTIC RADICAL CYSTECTOMY AND INTRACORPOREAL CONDUIT DIVERSION Mehrdad Alemozaffar*, Atlanta, GA INTRODUCTION AND OBJECTIVES: Uretero-ileal anastomotic stricture is a well-known complication following radical cystectomy and urinary diversion with a rate of 8-12% in open and robotic series. Some strictures can be managed endoscopically but many require revision of the uretero-ileal anastomosis. With increased utilization of robotic radical cystectomy we have started revising these strictures with a robotic approach as well. METHODS: From September 2014 - October 2016 we have performed 75 robotic radical cystectomies with 60 undergoing robotic intracorporeal ileal conduit urinary diversion. We found 6 patients that developed a uretero-ileal stricture. In the following video we highlight the technique for robotic revision of a right-sided uretero-ileal anastomotic stricuture in a patient following prior robotic radical cystectomy and intracorporeal ileal conduit urinary diversion. RESULTS: Our uretero-ileal anastomotic stricture rate following robotic radical cystectomy with intracorporeal conduit urinary diversion was 10%. Of these four were involving the left and two were involving the right ureter. Three patients were able to be managed with endoscopic dilation and three patients required revision of their uretero-ileal anastamotic stricture. All 3 patients were able to be managed with robotic uretero-ileal anastomotic revision. Mean time to diagnosis of stricture was 182 days. For the patient in the video operative time was 62 minutes, EBL was 100cc, and length of stay was 1 day. The other two patients had other concomitant operations (parastomal hernia repair in one and takedown of pre-existing colon conduit in another) that significantly impacted operative time and length of stay and were not including in analysis of perioperative outcomes. CONCLUSIONS: Uretero-ileal anastomotic strictures following robotic radical cystectomy and intracorporeal conduit urinary diversion can safely and effectively be managed with a robotic approach. Source of Funding: none
Hugh Smith*, Nathan Jung, Juan Class, Amar Singh, Darryl Turner, Dana Butler, Chris Keel, Chattanooga, TN
V10-08 INTRODUCTION AND OBJECTIVES: A calyceal diverticulum is a cystic cavity within the kidney that is lined by transitional epithelium and communicates with a calyx, or less commonly, with the renal pelvis. A calyceal diverticulum forms as a result of the failure of the degeneration of the ureteric bud. 0.2 e 0.5% are congenital; 40% are associated with calculi. This is a video demonstrating a robot assisted laparoscopic calyceal diverticulectomy. METHODS: This video demonstrates two cases of robotic calyceal diverticulectomy the first patient is a 19 year-old caucasian female and the second patient is a 25 year-old caucasian female. Who both had sudden onset of flank pain and abdominal pain. Initial work up was consistent with infection; however on repeat imaging, both patients were found to have a calyceal diverticulum. Both patients underwent a robot assisted laparoscopic diverticulectomy. Initial dissection was similar to a partial nephrectomy with mobilization of the large bowel and exposure of the renal hilum. The diverticulum is then incised, drained, and excised to the infundibulum to prevent recurrence. Any remaining urothelium was fulgurated. RESULTS: Both patients who underwent a robot assisted laparoscopic calyceal diverticulectomy are complication and re-admission free to date.
TOTAL LAPAROSCOPIC URETERAL SUBSTITUTION USING APPENDIX nior, Paulo Medeiros*, Cesar Britto, Daniel Ferreira, Maurício Ju Rodolfo Alves, Ronnie Lima, Thiago Grossi, Carla Santos, ~o, Natal RN, Brazil John Heyder Galva INTRODUCTION AND OBJECTIVES: Complex ureteral injuries have challenging repair, involving renal autotransplantation or ureteral substitution, which was first described in 1911, using bowel segments (Shoemaker), and in 1912, using the appendix (Melkianof). We report a post-pyeloplasty complex ureteral injury that was laparoscopically repaired by an appendix interposition. METHODS: A 17 year-old boy with right ureteropelvic junction (UPJ) obstruction was scheduled for pyeloplasty. During surgery, an obstruction on the ureterovesical junction was discovered, making impossible the use of a double-J stent, causing local trauma. So, Anderson-Hynes pyeloplasty was performed and he was left only with a nephrostomy tube. Twenty days later, an anterograde pyelogram demonstrated a stricture on the UPJ level. A cystoscopy showed a scar on right ureteral meatus. It was impossible to identify the right ureteral
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
meatus, during cystoscopy. Then an exploratory laparoscopy was scheduled on the fortieth postoperative day, and as the renal drainage was not possible by two points of obstruction, ureteral substitution was decided. Because of an intraoperative favorable anatomy, the appendix was chose and it was made laparoscopically. RESULTS: The operation lasted about 350 minutes and the estimated blood loss was 200ml, so the patient received no blood transfusion. Postoperatively, the patient developed urinary tract infection and was discharged in the tenth postoperative day. Double-J stent was removed on the sixtieth postoperative day. Follow-up 6 months after surgery showed a satisfied patient, with no limitations on quality of life, asymptomatic, but with a residual hydronephrosis on image studies. CONCLUSIONS: We support the use of the appendix for ureteral substitution (as a ureteral substitute) on selected cases, and we advice for the possibility of laparoscopic approach of complex injuries. We believe this is the first video of a total laparoscopic ureteral substitution using appendix. Source of Funding: None
V10-09 TIPS FOR SURGICAL TECHNIQUE DURING ROBOTIC URETERAL RECONSTRUCTION FOR VARIOUS SEGMENTS OF URETER
e1201
ureteropelvic junction obstruction (UPJO) with horseshoe kidney is uncommon. We reported that a 19 year-old man with horseshoe kidney and UPJO was underwent laparoscopic pyeloplasty and the horseshoe kidney was cut using Endo-GIA in its isthmus. METHODS: The patient presented with symptom of left flank pain with severe hydronephrosis. The diuretic renal dynamic imaging showed the complete mechanical obstruction for the upper urinary tract. The glomerular filtration rates were 34 ml/min for the left side and 40 ml/min for the right side. The computerize tomography showed the horseshoe kidney with the right-side UPJO. The ureteropelvic junction was compressed upwardly by the isthmus of horseshoe kidney. For the complete relief of the obstruction, the isthmus of the horseshoe kidney was cut using Endo-GIA combining with the laparoscopic pyeloplasty. RESULTS: The surgery was done with expected post-operative results. The operative time was 125 minutes. The post-operative hospitalization was 3 days and the double-J stent was removed 3 months after surgery. The patient is asymptomatic with complete relief of obstruction. CONCLUSIONS: When UPJO complicated with horseshoe kidney which may be the potential reason to cause hydronephrosis, cutting the horseshoe kidney using Endo-GIA combining with the laparoscopic pyeloplasty may be a feasible alternative. Source of Funding: None
Manish Patel*, Ashok Hemal, Winston Salem, NC INTRODUCTION AND OBJECTIVES: Ureteral reconstruction for different segments of ureter can be extremely challenging. There are many methods for reconstruction, most of which are typically performed using an open approach. Standard techniques such as boari flap and psoas hitch have been around for many years and are traditionally not performed using a minimally invasive approach. In this video we present multiple advanced techniques and alternatives during robotic ureteral reconstruction for various segments of ureter. METHODS: We present techniques for distal ureterectomy with reimplantation, segmental ureterectomy with end to end anastomosis, buccal mucosal patch and ileal patch for midureteral stricture, and ileal ureteral replacement for panureteral stricture. We demonstrate these techniques as well as the use of indocyanine green injection to help with identification of the level of obstruction. RESULTS: To date, 24 cases of ureteral reconstruction have been performed. Robotic console times have ranged form 60 minutes to 194 minutes. Estimated blood loss has ranged from 10-150ccs. Length of stay has ranged from 1-4 days. Follow up has ranged from 2-60 months. To date, there is no evidence of recurrent obstruction in any patient. CONCLUSIONS: Robotic ureteral reconstruction can be successfully performed on any segment of ureter and is a feasible option to more invasive open surgery. The use of indocyanine green can help delineate segments of ureter for excision. Ileal and buccal patches are good alternatives to segmental ureterectomy or more complicated flaps for midureteral strictures. Source of Funding: None
V10-10 COMBINATION OF ENDO-GIA WITH LAPAROSCOPIC PYELOPLASTY FOR THE TREATMENT OF A 19 YEAR-OLD MAN OF HORSESHOE KIDNEY WITH URETEROPELVIC JUNCTION OBSTRUCTION Xuesong Li*, Kunlin Yang, Liqun Zhou, Beijing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: The horseshoe kidney is a renal fusion anomalies which occurs in 0.25% of the population. The
V10-11 INTRACORPOREAL ROBOTIC-ASSISTED LAPAROSCOPIC APPENDICEAL INTERPOSITION FOR URETERAL STRICTURE DISEASE Vidhush K Yarlagadda*, Jeffrey W Nix, J Patrick Selph, Birmingham, AL INTRODUCTION AND OBJECTIVES: Management of complex ureteral strictures greater than 1 cm in length are traditionally treated with open or laparoscopic ureteral reconstruction. In the setting of long segment strictures not amenable to simple ureteroureterostomy, ureteral replacement with ileum classically has been described as a suitable option. Aside from ileum, a buccal mucosa graft and the appendix have been described as alternative replacement tissues. To date, there are no reports in the literature of a robotic-assisted laparoscopic (RAL) ureteral reconstruction utilizing the appendix. We report, to our knowledge, the first case of a completely intracorporeal RAL appendiceal interposition for ureteral stricture disease in a 33 year old Caucasian male with a 5 cm obliterative right-sided ureteral stricture secondary to recurrent urolithiasis. METHODS: The DaVinci Xi was docked to the patient in a fashion comparable to right nephroureterectomy. Extensive renal descensus was performed and it was determined that tension-free primary ureteroureterostomy was not feasible. Given the ideal position, length and orientation of the appendix, along with the added morbidity of bowel harvest, we elected to perform an appendiceal interposition. The appendix with its mesentery was isolated and interposed between the remaining healthy proximal and distal ends of the ureter. The ureteroappendiceal anastomoses were performed in an end-to-end fashion. A ureteral stent was left in place to allow for postoperative healing. The entire case was done intracorporeally. RESULTS: The ureteral stent was removed two weeks postoperatively. Antegrade nephrostogram showed patency of the ureter down to the bladder one month postoperatively. Lasix renal scan confirmed preservation of renal function and no obstruction three months postoperatively. CONCLUSIONS: In carefully selected patients with longsegment right-sided ureteral strictures and favorable anatomy, appendiceal interposition is a good option for ureteral reconstruction. This procedure can be done safely and effectively with robotic-assistance. Source of Funding: None
e1200
devascularization, fibrosis with renal fixation, and dense stricture formation. A high rate of recurrence leads to progressively complex repairs. Herein, we present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty in the management of recurrent UPJ obstruction. METHODS: We present two patients with recurrent left UPJ obstruction. Both previously underwent multiple failed open or robotic pyleoplasties, attempted endoscopic treatment and subsequent management with ureteral stent exchanges. At the time of surgery patients were placed in left lateral flank position and a Foley catheter inserted. Transperitoneal access was obtained with a Veress needle. Extensive adhesiolysis was required. The colon was reflected medially, the kidney, ureter and renal pelvis were exposed and the UPJ identified. The area surrounding the UPJ and proximal ureter were circumferentially dissected. The UPJ was entered and the ureter incised longitudinally from the renal pelvis until healthy, normal caliber ureter was demonstrated distally, with spatulation for at least 1 cm on either end. The defects were measured and found to be 3.5 and 4 cm. 8 Fr double J ureteral stents were placed. Single buccal grafts were harvested from the right inner cheek and measured for the length of the stricture and 1.5-2cm wide. A stay suture was placed to maintain orientation and minimize handling of the ureteral tissue. The graft was delivered to the abdomen and placed as an anterior onlay, over the ureteral and UPJ defect, with two 4-0 running Vicryl sutures. The tension free repair and surgical field was wrapped in omentum after confirming a water tight anastomosis. A JP drain was placed. RESULTS: Operative times were 280 and 411 minutes. Estimated blood loss was 25-50 mls. The hospital stay was 2 days. Foley catheters and JP drains were removed in the immediate post-operative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency. Both patients have been asymptomatic since stent removal and anticipate follow-up functional renal scans with Lasix in 6 months. CONCLUSIONS: Robotic salvage pyeloplasty with BMG is an attractive alternative technique in the management of recurrent UPJ obstruction demonstrating a tension free, water tight and patent repair. Short term follow up has demonstrated that it is an effective and feasible approach when compared to more extensive and invasive surgical procedures. Source of Funding: none
V10-06 ROBOTIC-ASSISTED LAPAROSCOPIC CALYCEAL DIVERTICULECTOMY
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
CONCLUSIONS: Robotic-assisted laparoscopic calyceal diverticulectomy is a feasible and safe option in the management of large persistent calyceal diverticulum. Source of Funding: None
V10-07 ROBOTIC REPAIR OF RIGHT URETERO-ILEAL ANASTOMOTIC STRICTURE FOLLOWING PRIOR ROBOTIC RADICAL CYSTECTOMY AND INTRACORPOREAL CONDUIT DIVERSION Mehrdad Alemozaffar*, Atlanta, GA INTRODUCTION AND OBJECTIVES: Uretero-ileal anastomotic stricture is a well-known complication following radical cystectomy and urinary diversion with a rate of 8-12% in open and robotic series. Some strictures can be managed endoscopically but many require revision of the uretero-ileal anastomosis. With increased utilization of robotic radical cystectomy we have started revising these strictures with a robotic approach as well. METHODS: From September 2014 - October 2016 we have performed 75 robotic radical cystectomies with 60 undergoing robotic intracorporeal ileal conduit urinary diversion. We found 6 patients that developed a uretero-ileal stricture. In the following video we highlight the technique for robotic revision of a right-sided uretero-ileal anastomotic stricuture in a patient following prior robotic radical cystectomy and intracorporeal ileal conduit urinary diversion. RESULTS: Our uretero-ileal anastomotic stricture rate following robotic radical cystectomy with intracorporeal conduit urinary diversion was 10%. Of these four were involving the left and two were involving the right ureter. Three patients were able to be managed with endoscopic dilation and three patients required revision of their uretero-ileal anastamotic stricture. All 3 patients were able to be managed with robotic uretero-ileal anastomotic revision. Mean time to diagnosis of stricture was 182 days. For the patient in the video operative time was 62 minutes, EBL was 100cc, and length of stay was 1 day. The other two patients had other concomitant operations (parastomal hernia repair in one and takedown of pre-existing colon conduit in another) that significantly impacted operative time and length of stay and were not including in analysis of perioperative outcomes. CONCLUSIONS: Uretero-ileal anastomotic strictures following robotic radical cystectomy and intracorporeal conduit urinary diversion can safely and effectively be managed with a robotic approach. Source of Funding: none
Hugh Smith*, Nathan Jung, Juan Class, Amar Singh, Darryl Turner, Dana Butler, Chris Keel, Chattanooga, TN
V10-08 INTRODUCTION AND OBJECTIVES: A calyceal diverticulum is a cystic cavity within the kidney that is lined by transitional epithelium and communicates with a calyx, or less commonly, with the renal pelvis. A calyceal diverticulum forms as a result of the failure of the degeneration of the ureteric bud. 0.2 e 0.5% are congenital; 40% are associated with calculi. This is a video demonstrating a robot assisted laparoscopic calyceal diverticulectomy. METHODS: This video demonstrates two cases of robotic calyceal diverticulectomy the first patient is a 19 year-old caucasian female and the second patient is a 25 year-old caucasian female. Who both had sudden onset of flank pain and abdominal pain. Initial work up was consistent with infection; however on repeat imaging, both patients were found to have a calyceal diverticulum. Both patients underwent a robot assisted laparoscopic diverticulectomy. Initial dissection was similar to a partial nephrectomy with mobilization of the large bowel and exposure of the renal hilum. The diverticulum is then incised, drained, and excised to the infundibulum to prevent recurrence. Any remaining urothelium was fulgurated. RESULTS: Both patients who underwent a robot assisted laparoscopic calyceal diverticulectomy are complication and re-admission free to date.
TOTAL LAPAROSCOPIC URETERAL SUBSTITUTION USING APPENDIX nior, Paulo Medeiros*, Cesar Britto, Daniel Ferreira, Maurício Ju Rodolfo Alves, Ronnie Lima, Thiago Grossi, Carla Santos, ~o, Natal RN, Brazil John Heyder Galva INTRODUCTION AND OBJECTIVES: Complex ureteral injuries have challenging repair, involving renal autotransplantation or ureteral substitution, which was first described in 1911, using bowel segments (Shoemaker), and in 1912, using the appendix (Melkianof). We report a post-pyeloplasty complex ureteral injury that was laparoscopically repaired by an appendix interposition. METHODS: A 17 year-old boy with right ureteropelvic junction (UPJ) obstruction was scheduled for pyeloplasty. During surgery, an obstruction on the ureterovesical junction was discovered, making impossible the use of a double-J stent, causing local trauma. So, Anderson-Hynes pyeloplasty was performed and he was left only with a nephrostomy tube. Twenty days later, an anterograde pyelogram demonstrated a stricture on the UPJ level. A cystoscopy showed a scar on right ureteral meatus. It was impossible to identify the right ureteral
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Monday, May 15, 2017
meatus, during cystoscopy. Then an exploratory laparoscopy was scheduled on the fortieth postoperative day, and as the renal drainage was not possible by two points of obstruction, ureteral substitution was decided. Because of an intraoperative favorable anatomy, the appendix was chose and it was made laparoscopically. RESULTS: The operation lasted about 350 minutes and the estimated blood loss was 200ml, so the patient received no blood transfusion. Postoperatively, the patient developed urinary tract infection and was discharged in the tenth postoperative day. Double-J stent was removed on the sixtieth postoperative day. Follow-up 6 months after surgery showed a satisfied patient, with no limitations on quality of life, asymptomatic, but with a residual hydronephrosis on image studies. CONCLUSIONS: We support the use of the appendix for ureteral substitution (as a ureteral substitute) on selected cases, and we advice for the possibility of laparoscopic approach of complex injuries. We believe this is the first video of a total laparoscopic ureteral substitution using appendix. Source of Funding: None
V10-09 TIPS FOR SURGICAL TECHNIQUE DURING ROBOTIC URETERAL RECONSTRUCTION FOR VARIOUS SEGMENTS OF URETER
e1201
ureteropelvic junction obstruction (UPJO) with horseshoe kidney is uncommon. We reported that a 19 year-old man with horseshoe kidney and UPJO was underwent laparoscopic pyeloplasty and the horseshoe kidney was cut using Endo-GIA in its isthmus. METHODS: The patient presented with symptom of left flank pain with severe hydronephrosis. The diuretic renal dynamic imaging showed the complete mechanical obstruction for the upper urinary tract. The glomerular filtration rates were 34 ml/min for the left side and 40 ml/min for the right side. The computerize tomography showed the horseshoe kidney with the right-side UPJO. The ureteropelvic junction was compressed upwardly by the isthmus of horseshoe kidney. For the complete relief of the obstruction, the isthmus of the horseshoe kidney was cut using Endo-GIA combining with the laparoscopic pyeloplasty. RESULTS: The surgery was done with expected post-operative results. The operative time was 125 minutes. The post-operative hospitalization was 3 days and the double-J stent was removed 3 months after surgery. The patient is asymptomatic with complete relief of obstruction. CONCLUSIONS: When UPJO complicated with horseshoe kidney which may be the potential reason to cause hydronephrosis, cutting the horseshoe kidney using Endo-GIA combining with the laparoscopic pyeloplasty may be a feasible alternative. Source of Funding: None
Manish Patel*, Ashok Hemal, Winston Salem, NC INTRODUCTION AND OBJECTIVES: Ureteral reconstruction for different segments of ureter can be extremely challenging. There are many methods for reconstruction, most of which are typically performed using an open approach. Standard techniques such as boari flap and psoas hitch have been around for many years and are traditionally not performed using a minimally invasive approach. In this video we present multiple advanced techniques and alternatives during robotic ureteral reconstruction for various segments of ureter. METHODS: We present techniques for distal ureterectomy with reimplantation, segmental ureterectomy with end to end anastomosis, buccal mucosal patch and ileal patch for midureteral stricture, and ileal ureteral replacement for panureteral stricture. We demonstrate these techniques as well as the use of indocyanine green injection to help with identification of the level of obstruction. RESULTS: To date, 24 cases of ureteral reconstruction have been performed. Robotic console times have ranged form 60 minutes to 194 minutes. Estimated blood loss has ranged from 10-150ccs. Length of stay has ranged from 1-4 days. Follow up has ranged from 2-60 months. To date, there is no evidence of recurrent obstruction in any patient. CONCLUSIONS: Robotic ureteral reconstruction can be successfully performed on any segment of ureter and is a feasible option to more invasive open surgery. The use of indocyanine green can help delineate segments of ureter for excision. Ileal and buccal patches are good alternatives to segmental ureterectomy or more complicated flaps for midureteral strictures. Source of Funding: None
V10-10 COMBINATION OF ENDO-GIA WITH LAPAROSCOPIC PYELOPLASTY FOR THE TREATMENT OF A 19 YEAR-OLD MAN OF HORSESHOE KIDNEY WITH URETEROPELVIC JUNCTION OBSTRUCTION Xuesong Li*, Kunlin Yang, Liqun Zhou, Beijing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: The horseshoe kidney is a renal fusion anomalies which occurs in 0.25% of the population. The
V10-11 INTRACORPOREAL ROBOTIC-ASSISTED LAPAROSCOPIC APPENDICEAL INTERPOSITION FOR URETERAL STRICTURE DISEASE Vidhush K Yarlagadda*, Jeffrey W Nix, J Patrick Selph, Birmingham, AL INTRODUCTION AND OBJECTIVES: Management of complex ureteral strictures greater than 1 cm in length are traditionally treated with open or laparoscopic ureteral reconstruction. In the setting of long segment strictures not amenable to simple ureteroureterostomy, ureteral replacement with ileum classically has been described as a suitable option. Aside from ileum, a buccal mucosa graft and the appendix have been described as alternative replacement tissues. To date, there are no reports in the literature of a robotic-assisted laparoscopic (RAL) ureteral reconstruction utilizing the appendix. We report, to our knowledge, the first case of a completely intracorporeal RAL appendiceal interposition for ureteral stricture disease in a 33 year old Caucasian male with a 5 cm obliterative right-sided ureteral stricture secondary to recurrent urolithiasis. METHODS: The DaVinci Xi was docked to the patient in a fashion comparable to right nephroureterectomy. Extensive renal descensus was performed and it was determined that tension-free primary ureteroureterostomy was not feasible. Given the ideal position, length and orientation of the appendix, along with the added morbidity of bowel harvest, we elected to perform an appendiceal interposition. The appendix with its mesentery was isolated and interposed between the remaining healthy proximal and distal ends of the ureter. The ureteroappendiceal anastomoses were performed in an end-to-end fashion. A ureteral stent was left in place to allow for postoperative healing. The entire case was done intracorporeally. RESULTS: The ureteral stent was removed two weeks postoperatively. Antegrade nephrostogram showed patency of the ureter down to the bladder one month postoperatively. Lasix renal scan confirmed preservation of renal function and no obstruction three months postoperatively. CONCLUSIONS: In carefully selected patients with longsegment right-sided ureteral strictures and favorable anatomy, appendiceal interposition is a good option for ureteral reconstruction. This procedure can be done safely and effectively with robotic-assistance. Source of Funding: None