Introduction: Patients with bilateral ureteral strictures and associated reduced bladder capacity post pelvic radiation therapy are commonly condemned to indwelling ureteral stents or nephrostomy tubes. We report the case of a woman submitted to robot-assisted bilateral ureteral substitution and augmentation cystoplasty with ileal loop for the management of bilateral pelvic ureteral strictures and impaired bladder capacity, at one-year follow up.
Methods: In January 2020, neoadjuvant chemo and radiotherapy for locally advanced squamous cell carcinomas of the cervix were administered to a 31-year-old female. In April 2020, she underwent radical hysterectomy, adnexectomy and pelvic lymphadenectomy (ypT0, ypN0), followed by adjuvant chemotherapy. 3 months after surgery, bilateral hydronephrosis due to bilateral pelvic ureteral stricture and a vesico-vaginal fistula (VVF) were detected. The patient underwent supratrigonal laparoscopic VVF repair and bilateral ureteral stenting. After stents removal, the patient developed pyelonephritis. Bilateral nephrostomies were placed. A robot-assisted substitution of bilateral pelvic ureters and augmentation cystoplasty with U-shaped ileal loop was planned. The ureters were identified above the stricture and sectioned at the level of the iliac vessels. A 20 cm ileal loop was sectioned with an engoGIA. The bladder dome was transversally opened for 10 cm, and the ileo-bladder anastomosis was completed with a continuous suture. Each ureter is spatulated and anastomosed on double-J stents to the end of each bowel chimney. Abdominal ultrasound was performed at 1 and 3 months. An abdominal CT scan at 6 and 12 months was recommended. Renal function was monitored every 3 months.
Results: The post-operative course was uneventful. The abdominal drain was removed on 5th post-operative day (POD) and the nephrostomy tubes were closed on 7th POD. A cystogram 2 weeks after surgery showed no urinary leakage. Thus, the Foley catheter and the ureteral stents were removed. At a 3-month follow-up the patient was asymptomatic with adequate bladder capacity, no post void residual urine, no hydronephrosis. The same results were confirmed at 1-year follow-up. On 1-year CT scan mild left hydroureter was detected, with regular bladder capacity and renal function.
Conclusions: The robot-assisted approach is effective for pelvic ureteral substitution and augmentation enterocystoplasty in patients presenting with side effects of previous surgery and radiotherapy.