Introduction: This video aims to provide a step-by-step approach for robot-assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC).
Methods: We demonstrate the feasibility and safety of robotic repair through three clinical scenarios after different forms of diversion and open primary surgery. UES repair is performed in the setting of an open RC and neobladder (NB), an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The RC/IC and Indiana pouch patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The RC/NB patient was placed in the supine position and port placement was similar to that of RC. The operation consists of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension-free and watertight anastomosis.
Results: All cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 174-273 minutes. Estimated blood loss ranged from 10-50ml. Patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in all three patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively.
Conclusions: Robot-assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension-free and watertight anastomosis. Our patients recovered quickly and without complications.