Robotic ureter reimplantation after urinary diversion

Introduction Benign ureterointestinal anastomotic stricture (UIAS) is a recognized long-term complication following radical cystectomy (RC) with urinary diversion (UD). The incidence of UIAS following robotic-assisted cystectomy (RARC) varies, with reported rates ranging from 6.5% to 25.3%1. Although endourologic treatments have been employed, their overall success rate is relatively low, ranging from 26% to 50%. In contrast, open surgical revision has demonstrated higher success rates, between 80% and 91%2,3. Given the morbidity associated with open surgery, there has been a shift towards minimally invasive approaches. The robotic approach offers a minimally invasive alternative to open surgery that is not inferior, with similar outcomes for UIAS reconstruction4. In this video, we demonstrate a robotic technique for the revision of UIAS, which aims to combine the effectiveness of open surgery with the reduced morbidity of a minimally invasive approach. Materials and methods From May 2020 to March 2023, six patients underwent surgery. The mean age was 62 years (range 49-68 years). Among these, two patients received conduits in open technique and four were provided with robotic neobladders. The strictures were located as follows: two on the left side, two on the right, and two on both sides. The average time to stricture formation in the series was 4.5 months.The case presented involves a 49-year-old man who developed a left ureteroileal anastomotic stricture (UIAS) six months following robot-assisted radical cystectomy (RARC) and neobladder creation. The obstruction was managed initially with nephrostomy tube drainage. The surgical technique employed is demonstrated in a step-by-step manner.Standard Da Vinci® surgical instruments were used. The patient was positioned in a 30° Trendelenburg position, with port placement similar to that in robotic prostatectomy. The pneumoperitoneum was established through a supraumbilical mini-laparotomy using the Hasson technique. Adhesions around the neobladder were carefully freed.Subsequently, the affected ureter and the stricture were identified and localized. This was achieved by intraluminal application of 10 ml of indocyanine green solution (2.5 mg/ml concentration) through the nephrostomy catheter. The ureter was mobilized as needed. The ureteral stricture was identified, and then fully excised. To exclude any malignancy at the ureteral margin, a frozen section analysis was conducted. The ureter was then spatulated. Reanastomosis between the ureter and neobladder was performed using a continuous 4-0 Stratafix suture. A DJ ureteral catheter was inserted to secure the anastomosis, and the anastomosis was completed over this catheter. Results The mean operative time at the robotic console was 122 minutes, ranging from 80 to 160 minutes, and the mean blood loss was 42 ml, within a range of 50 to 100 ml. Intraoperative frozen sections revealed no evidence of malignancy in all cases. No postoperative complications exceeding Clavien-Dindo grade 3 were observed. Two patients were treated for symptomatic urinary tract infections. The median length of stay (LOS) in the hospital was 4 days, with a range of 2 to 7 days. Median times for cystography with transurethral catheter removal and DJ catheter removal were 15 postoperative days (POD) (range: 12-27) and 23 POD (range: 17-37), respectively. No recurrence of the condition was observed during a mean follow-up period of 23 months (range 6 to 40 months). Conclusions The robotic approach represents a viable, minimally invasive alternative to conventional open surgery for the reconstruction of UIAS following UD. The surgical outcomes are comparable to those of open surgery, with the added benefits of a minimally invasive approach, including reduced blood loss and shorter hospital stays.