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NARUS 2018: Proximal and Mid Ureteral Strictures

Las Vegas, NV (UroToday.com) Dr. Hemal from Wake Forest Baptist Medical Center provided a discussion of proximal and mid ureteral strictures. He started his discussion by highlighting the etiology of ureteral strictures, which may include surgical trauma (endoscopy or open, laparoscopic, robotic, pelvic ablative or reconstructive surgery), thermal injuries (delayed presence after cautery, harmonic scalpel, LigaSure, etc), radiation induced ischemia, malignancy, tuberculosis, endometriosis, radiofrequency ablation or cryoablation. What’s needed for a diagnosis is a history and clinical evaluation, as well as imaging. This may include a CT urogram, retrograde/antegrade nephrostogram, MAG-3 diuretic renogram, or MR urogram. Additionally, endoscopic evaluation with ureteroscopy may be warranted. 

There are several options for treatment when considering a ureteral stricture. This may include anatomical reconstruction without excising the ureteral segment, substitution reconstruction (segmental or total) or autotransplantation. Furthermore, one must take into account the time of the reconstruction in the setting of a ureteral injury. According to Dr. Hemal, if the lesion is found open then fix it open, whereas if found during a minimally invasive approach we should assess the lesion either laparoscopically or robotically. However, Dr. Hemal cautions that if an injury is found during an endourologic procedure, converting to an open approach only compounds the problem and a percutaneous nephrostomy should be placed and the lesion reconstructed at a later date.

Port-placement and docking for a pan-ureteral stricture operation is key. For the Si system, Dr. Hemal recommends docking the robot perpendicular to the OR table to allow distal ureteral access. While moving from proximal to distal, if necessary, the robot may be undocked and the table may be tilted to move the patient into more of a supine position. The area of interested should be triangulated with the robotic ports. For the Xi system, moving the camera port as needed can be helpful according to Dr. Hemal. If one is operating proximally to distally, the camera may be moved one port caudally, and the robotic instruments can be exchanged as desired without undocking. The retargeting feature may also be utilized to improve triangulation and ergonomics. 

According to Dr. Hemal, there are several technical concepts that need to be practiced:

  •  Excise the obstructing segment
  • Mobilize the two ends of the ureter. This may include ureterolysis with maintenance of the blood supply and/or mobilization of the kidney or bladder
  • Perform a tension-free anastomosis
  • Ensure adequate blood supply to the anastamotic area
Dr. Hemal also notes several tips for identifying the disease segment of the ureter intraoperatively:

  • Remove the ureteral stent for at least two weeks
  • Large intraluminal and extraluminal lesions can usually be found under direct visualization alone
  • Small intraluminal lesions can be identified with the aid of an end-hold catheter or via prior placement of percutaneous nephrostomy tube with instillation of indocyanine green (ICG)
  • Simultaneous ureteroscopy during the robotic portion of the procedure
Dr. Hemal is a huge proponent of ICG during ureteral surgery. There are several advantages, including (i) it may be administered antegrade, retrograde, or even paraureterally, (ii) vascular injection confirms the presence of crossing vessels, (iii) ICG pyelogram allows identification of intrinsic lesions, (iv) the disease segment is hypofluorescent, (v) the healthy ureter is fluorescent, and (vi) allows assessment of vascularity after reconstruction. There are several techniques that may be employed for benign ureteral reconstruction, including uretero-calcostomy, segmental excision and ureteroureterostomy, buccal mucosa graft, and reconstruction of a retrocaval ureter. Dr. Hemal also highlighted the use of bowel for management of ureteral strictures, including a small intestine patch, use of the appendix, a Monti’s procedure, or a complete ileal replacement.

As follows is Dr. Hemal’s approach to ureteral strictures:
Dr. Ashok Hemal concluded with several take-home, including that (i) most ureteral pathologies include complex upper ureteric reconstruction that can be handled via a robotic approach, (ii) the robotic platform can be used for diverse etiologies, including intraoperative ureteric injuries at any level of the ureter with minimal perioperative morbidity, and (iii) the experience of the entire team is key to success.

Speaker: Ashok Hemal, Wake Forest Baptist Medical Center, Winston-Salem, NC

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV