NARUS 2018: Low Ureter Strictures, Reimplant, Boari Flap

Las Vegas, NV (UroToday.com) Dr. Ronney Abaza provided a discussion regarding utilization of the robotic platform for treating lower ureter strictures. As Dr. Abaza is apt to point out, stricture localization is not always visible on preoperative imaging in that we can see the transition point, but not necessarily the stricture length. Furthermore, if the ureter is stented for obstruction it may be even harder to delineate. As Dr. Abaza notes, if the stricture is low, one can cut up to healthy ureteral tissue, but if this technique is taken we must be prepared for anything based on an unknown preoperative stricture length.

Several years ago, Dr. Abaza published a case series highlighting three unique methods for identifying a ureteral stricture length and location: (i) using a ureteral occlusion balloon catheter to identify a stricture by distending the collecting system proximal to the obstruction and cinching the balloon against the stricture; (ii) using a flexible ureteroscope introduced through a 5-mm port and into the incised ureter to guide excision of extensive polyposis; (iii) using retrograde ureteroscopy with "cutting to the light" laparoscopically/robotically [1]. General principles for identifying location of the pathology include (i) having access to the urethra, (ii) having all types of scopes available, (iii) scoping transurethrally or through a port, (iv) using the Tilepro platform.

For a robotic ureteral reimplantation, Dr. Abaza will position the patient and ports like a radical prostatectomy. Additionally, he will fill the bladder with CO2 rather than saline to prevent operating in a saline filled abdomen. He notes that the reimplantation can be either refluxing or non-refluxing; he does not use a drain, removes the Foley the following morning, and occasionally performs the procedure on an outpatient basis.

For instances where there is long distance from the ureter to the bladder, he will mobilize the bladder, lower the pneumoperitoneum to take tension off of the ureter, and perform either a psoas hitch or Boari flap. If a psoas hitch or Boari flap are likely, Dr. Abaza notes that preoperative planning is critical in that a preoperative ureteroscopy or retrograde pyelogram/cystogram will help in gauging the gap between the bladder and ureter, as well as assess bladder size. Even in these instances, he will still position the patient similarly to a robotic prostatectomy, unless the lesion is very proximal.

Additional tips and tricks for a robotic Boari flap include (i) filling the bladder with CO2, not saline, (ii) keeping a wide base (almost triangular), (iii) remembering that bleeding is good (ie. healthy tissue), and (iv) use of indocyanine green (ICG) to test for ischemic edges. To test the bladder closure, Dr. Abaza will fill the bladder to capacity (should be no leak), and if he is unsure, adding ICG to the irrigation can help identify potential leaks.

Speaker: Ronney Abaza, OhioHealth Dublin Medical Center, Dublin, OH

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

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