Resident Physician Rutgers Robert Wood Johnson Medical School
Introduction: Ureterocalicostomy is a repair option for proximal ureteral strictures indicated in the setting of prior failed pyeloplasty, intrarenal pelvis, or significant lower pole caliectasis. In this video, we demonstrate a case of proximal ureteral stricture and recurrent nephrolithiasis, refractory to shock wave lithotripsy, treated with robotic-assisted laparoscopic ureterocalicostomy.
Methods: This procedure was performed using the da Vinci Xi robotic platform. The patient was prepped in the right lateral decubitus position and ports were placed. To begin, the bowel was mobilized, the ureter was identified, and the renal hilum was skeletonized. Next, the proximal stricture, intrarenal pelvis, and its high insertion were verified. Once the lower pole of the kidney was defatted, intraoperative ultrasonography was used to identify the location of the partial nephrectomy. After clamping the renal artery, a wedge resection of the lower pole parenchyma was performed. The parenchyma was then oversewn and the clamps were removed. At this point, a 16-French flexible cystoscope was placed through the assistant port and into the pyelotomy for stone basket extraction. The ureter was incised at the ureteropelvic junction and spatulated at the posterior aspect for 3cm. The kidney was then mobilized completely and affixed to the left psoas muscle. Next, the ureter was anastomosed to the lower calyx in a tension-free fashion and a ureteral stent was placed. The bladder was backfilled using methylene blue dyed saline and watertight seal of the anastomosis was confirmed. Finally, the anastomosis was wrapped with a Gerota’s flap.
Results: The procedure lasted approximately 4.5 hours without any complications. Estimated blood loss was 70cc. On postoperative day one, the drain was removed and the patient was discharged home. Postoperative computed tomography imaging revealed decreased stone burden. Six-week ureteroscopy revealed a wide-open lumen at the anastomotic site and retrograde pyelography showed no evidence of obstruction. At six months, a Lasix renogram once again demonstrated no evidence of obstruction.
Conclusions: Robotic-assisted laparoscopic ureterocalicostomy is a safe and effective repair option that should be considered for proximal ureteral strictures with intrarenal pelvis and dependent lower pole calyx.