NARUS 2019: Primary Ureteral Reimplantation
Before undertaking the reconstruction of the upper urinary tract, the length and location of the ureteral stricture need to be delineated. This should be done using CT scans, cystoscopy and retrograde pyelogram, and antegrade nephrostogram. A renal scan should be performed as well, as it is the gold standard functional study. The renal scan provides the split function of the kidney. If it above 20, reconstructive surgery must be performed, if it is 10-20 (indeterminate), the option of inserting a stent is possible with a repeat of the renal scan. Lastly, if it is less than 10, no intervention is required, unless the patient is symptomatic. The excretion data of the renal scan is also important, with and without Lasix.
In the planning stage of the reconstructive procedure, the mechanism causing the obstruction must be understood. This can be due to trauma (avulsion, instrumentation, iatrogenic), foreign body (impacted stone, clip/suture), disease (cancer, retroperitoneal fibrosis, tuberculosis, endometriosis), and radiotherapy. It is also important to consider the length and density of the stricture, whether the patient has had prior surgery and the blood supply. The ureter receives most of its blood supply laterally in the lower third, and medially in the upper third.
The top 5 specialties that cause ureteral strictures include the urologist, gynecologist, general surgeon, colorectal surgeon, and vascular surgeon. The most important point is the prevention of ureteral injuries. This can be achieved using safe ureteroscopy techniques, ureteral stenting before laparoscopic and robotic surgeries, and high index for suspicion for a gynecologist and colorectal surgeons, if their procedures are close to the ureter.
It is best if the problem was fixed using minimally invasive methods (robotic). The available treatment options include an end to end ureteroureterostomy, ureteroneocystostomy, Boari-flap creation, and reverse nephropexy if there is tension in the upper ureter. When the injury is done intraoperatively and is recognized immediately, it is recommended to manage it using minimally invasive techniques. Converting to an open procedure usually compounds the situation. At first step, it is important to perform cystoscopy and retrograde pyelogram, and pass a guidewire and stent if possible.
In conclusion, the robotic reconstruction of the upper urinary tract should be performed in exactly the same manner as the open procedure. This has shown comparable results, with a shorter hospital stay, less use of narcotics, quicker return to normal activities, less risk of hernias and abdominal and incisional hernias.
Presented by: Raju Thomas, MD, FACS, FRCS, MHA, Chair of the Department of Urology at Tulane University Medical Center, New Orleans, Louisiana
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at 2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States