What's known on the subject? and What does the study add?
Open reconstructive surgery of the lower ureteric segment in adults often requires large incisions, as the basic prerequisite for such complex procedures is wide exposure. Published experience on minimally invasive techniques in this challenging surgical field, e.g. conventional laparoscopy or robot-assisted laparoscopy, still remains limited.
We report our experience from one of the largest single institution series on robot-assisted reconstructive surgery of the distal ureter in adults, with a special focus on technical aspects of the different surgical procedures.
To describe the feasibility of and operative techniques used during different daVinci® robot-assisted laparoscopic reconstructive procedures of the distal ureter, and to report the short-term outcome of such procedures.
Patients and Methods
Between June 2009 and October 2011, 16 patients underwent robot-assisted operations of the distal ureter because of various underlying pathological conditions.
We present a description of each procedure, the incidence of perioperative complications and the results of follow-up examination.
The data were collected retrospectively using the patients’ records and questionnaires sent to the patients and the referring urologists. The follow-up examinations were done at the discretion of the referring urologists.
The surgical indications and operative techniques were as follows: seven distal ureteric resections [DUR] with psoas hitch procedures (+/– Boari flap; four), extravesical reimplantation (two) or end-to-end anastomosis (one) because of benign distal ureteric stricture; four DUR with psoas hitch procedure (+/– Boari flap) and pelvic lymphadenectomy for urothelial carcinoma of the ureter; one DUR with psoas hitch procedure and Boari flap because of unexpected locally recurrent prostate cancer; one extravesical reimplantation because of vesico-ureteric reflux; one bilateral intravesical reimplantation of ectopic ureters (as part of a radical prostatectomy); one resection of a non-functioning upper kidney pole with associated megaureter and ureterocele and intravesical reimplantation of lower pole ureter; one resection of pelvic endometriosis and ureterolysis with omental wrap.
The median operative duration (including docking/undocking of the robot) was 260 min.
There were no intraoperative complications but there was one conversion to open surgery. Complications according to the Clavien-Dindo classification occurred in 12 patients (75%) ≤ 90 days of surgery: 10 (62%) minor (grade I–II) and two (12%) major complications (grades IIIb and IVa, respectively).
The median hospital stay after surgery was 7.5 days. At a median follow-up of 10.2 months, 15 patients (94%) remained without signs of urinary tract obstruction and 13 (81%) were asymptomatic.
Robot-assisted reconstructive surgery of the distal ureter is feasible and can be used without compromising the generally accepted principles of open surgical procedures.
The functional outcome was good in short-term follow-up and severe postoperative complications were rare.
In case of distal ureteric lesions in adults, surgical repair and reconstruction with primary ureteroureterostomy is seldom possible. Thus, excision of the diseased segment followed by reimplantation of the distal ureter is often necessary. Depending on the length of the distal ureteric defect, various reconstructive options are available, including direct ureteroneocystostomy, and psoas hitch either alone or combined with Boari flap. This allows bridging of ureteric defects of 4–5, 6–10 and 12–15 cm, respectively . However, in this context open reconstructive surgery of the lower ureteric segment in adults often requires large incisions, as the basic prerequisite for such complex procedures is wide exposure.
On the other hand, published experience on minimally invasive techniques in this challenging surgical field, e.g. conventional laparoscopy or robot-assisted laparoscopy, still remains limited [2-23]. Nevertheless, in contrast to conventional laparoscopy the daVinci® robot seems to be especially useful in this field, as all its advantages, e.g. minimal invasiveness of a laparoscopic approach, plus the accurate dexterity of the robotic surgical instruments combined with three-dimensional depth perception, make it possible to mimic open surgical techniques.
Based on this rationale, surgeons experienced in open urological reconstruction should also be able to adopt reconstructive procedures of the distal ureter early in a robotic programme. Against this background, we began to use the daVinci® robot for all reconstructive procedures involving the distal ureter in July 2009. Previously, however, initial proficiency with robotic radical prostatectomy (RP) had been achieved, and marked the first milestone since implementation of robotics in our institution in April 2009. In the present study, we present one of the largest single institution series on robot-assisted reconstructive surgery of the distal ureter in adults.
Patients and Methods
Between June 2009 and October 2011 three surgeons performed 16 robot-assisted reconstructive operations of the distal ureter (14 by K.D.; one by L.H. and one by D.Y.) in nine women and seven men because of various underlying pathological conditions. In the beginning the standard four-arm daVinci® surgical system (Intuitive Surgical Inc., Mountain View, CA, USA) was used, and from January 2011 on the daVinci Si HD surgical system, each in eight cases. The principles of ureteric reconstruction and reimplantation that were applied are summarised in Table 1. These principles are generally accepted, and described in detail in Campbell-Walsh Urology in the chapter ‘Management of Upper Urinary Tract Obstruction’ by Nakada and Hsu . We present a description of each reconstructive procedure, the patient characteristics, the perioperative data, the incidence of 90-day postoperative complications and the results of follow-up examinations. Each procedure was electronically recorded and could be analysed for the purpose of this article. All data were collected retrospectively using the patients’ records and standardised questionnaires sent to the patients and their referring urologists. The follow-up examinations were done at the discretion of the referring urologists. Descriptive statistics comprise median and range for continuous variables and frequencies and percentages for categorical variables.
Table 1. Principles of distal ureteric reconstruction and reimplantation used in the present series.
Adequate mobilisation of the distal ureter without traumatic tissue manipulation to preserve its blood supply.
Gentle handling of the bladder to reduce postoperative haematuria and bladder spasms.
Generous mobilisation of the bladder with preservation of its blood supply (dissection of the contralateral bladder pedicle only if necessary).
Fixation of the bladder on the psoas muscle carefully avoiding injuries to the genitofemoral or femoral nerves (Fig. 5).
Choosing the position of the neo-hiatus (entry point of the ureter into the bladder) and the direction of the submucosal tunnel to correspond well with the anatomical course of the ureter (Figs 6 and 10).
Creation of a submucosal tunnel of adequate width and length, and with sufficient muscular backing.
Spatulation of the ureter.
Anchoring sutures of the ureter.
Meticulous suturing when creating the neo-orifice.
Complete covering of the ureter with bladder mucosa to avoid fibrosis (Fig. 7).
Tension-free vesico-ureteric anastomosis.
Meticulous watertight closure of the bladder.
Adequate postoperative drainage is obligatory.
Omentum majus wrap, if impaired blood supply is suspected.
Patient Characteristics, Underlying Ureteric Pathologies and Surgical Procedures
The patients (nine women and seven men) had a median (range) age of 63.5 (39–80) years, a body mass index of 26.0 (19.5–33.9) kg/m2, and a Charlson score of 2 (0–3). The patient characteristics, underlying ureteric pathologies and operative techniques are listed in detail in Table 2 (The patient numbers used in Tables 2 and 3 are also referred to in the article).
Table 2. Data on all 16 patients showing patient characteristics, underlying ureteric pathology, surgical procedure, operating time and length of postoperative hospital stay.
Underlying ureteric pathology
OP duration, min
Hospital stay, days
BMI, body mass index; DUR, distal ureteric resection; OP, operation; PLND, pelvic lymphadenectomy.
Urothelial carcinoma of distal ureter, pTa pN0 (0/10) G1 R0
DUR with reimplantation and PLND (psoas hitch)
Urothelial carcinoma of distal ureter, pT2 pN0 (0/20) G2–3 R0
DUR with reimplantation and PLND (psoas hitch + Boari flap)
Urothelial carcinoma of distal ureter, pT1 pN0 (0/10) G1 R0
Ureterolysis, endometriosis resection and omentum wrap of the ureter
Renal unit free of hydronephrosis
Bowel preparation was accomplished using a sodium phosphate-bisacodyl regimen the evening before surgery. In each case general anaesthesia combined with high peridural anaesthesia was used. Single ‘shot’ antibiotic prophylaxis was given at anaesthetic induction. In the postoperative course patients were mobilised starting the day of surgery. Routinely, a polyethylene glycol macrogel was administered twice a day, and a bisacodyl suppository on the second day after surgery to prevent postoperative ileus. Thromboembolic prophylaxis with s.c. low-molecular-weight heparin into the upper arm was given for at least 1 week in patients with benign disease and 4–5 weeks in patients with malignant disease.
General Surgical Procedure
The patients were put in a steep Trendelenburg position with the legs spread at 50–60 ° and slightly flexed at the knee (Fig. 1). An 18-F Foley urethral catheter was always inserted. The robot was positioned at the foot of the table between the patient's legs. All operations were performed using a four-arm robotic setting, with the fourth arm placed contralaterally to the diseased ureter, when possible (Fig. 2). Trocar positioning was as follows: a 12-mm robotic camera port 5 cm above the umbilicus in the median line; two 8-mm robotic ports bilaterally along the midclavicular line at the level of the umbilicus; a fourth 8-mm robotic port on the contralateral side of the diseased ureter ≈10 cm lateral to the other ipsilateral 8-mm robotic port, a 5-mm assistant port between the camera port and the 8-mm robotic port, and a 12-mm assistant port in the flank area ≈3 cm above the iliac crest on the contralateral side of the fourth arm. After insertion of the camera port using a mini laparotomy the pneumoperitoneum was created with a pressure of 12 mmHg, and the robot was docked. During surgery a 6-F JJ stent was placed using a guidewire via one of the assistant ports in all patients in whom no ureteric stent was placed preoperatively or in whom the pre-existing ureteric stent had to be removed intraoperatively (only the patient with the VUR did not need ureteric stenting at all). At the end of the surgical procedure an easy flow drain was inserted near the reconstructed site and the robot was undocked. The postoperative dwelling time for the urethral catheter and the JJ stent depended on the particular surgical procedure and on the cystographic follow-up after surgery.
Description of Each Reconstructive Surgical Procedure
1. Distal ureteric resection and reimplantation in psoas hitch technique with (patients no. 2,4,5,7,8) or without Boari flap procedure (patients no. 1,3,6,9)
After mobilisation of either the sigmoid colon or the caecum the ureter was identified as it crossed the iliac vessels. Then the ureter was undermined, held in proper position using a vessel loop and the fourth robotic arm for traction, and followed caudally to the strictured or tumour-bearing segment (Fig. 3). In the case of a distal ureteric stricture the affected segment was transected above the stricture and just before its insertion into the bladder. In the case of a distal ureteric tumour the following steps were performed: (i) The affected segment was isolated, clipped proximally and distally with Hem-o-lok® clips and transected proximally (Fig. 4). (ii) After transection of the ureter a pre-existing JJ stent was additionally double-clipped with Hem-o-lok clips and divided proximally. (iii) A frozen section of the distal edge of the remaining ureter was always performed. (iv) After filling of the bladder with distilled water a bladder cuff was resected along with the distal ureter. (v) Then closure of the bladder was completed in two layers, and an ipsilateral pelvic lymphadenectomy performed. (vi) Both the ureter/bladder cuff specimen and the lymphadenectomy specimen were collected in retrieval bags directly after resection.
After resection of the diseased distal ureter the bladder was mobilised as far as possible. Care was taken not to harm the vascular pedicles of the bladder. Then the bladder was filled with physiological saline until maximal capacity was reached. Thereafter, the decision was made as to whether the psoas hitch procedure should be combined with creation of a Boari flap. In the case of only a psoas hitch procedure two 2-0 polyglactin sutures were used to fix the posterior bladder wall to the psoas muscle on the side of the affected ureter (Fig. 5), carefully avoiding the genitofemoral and the femoral nerves. The bladder was filled again with physiological saline and a classical longitudinal incision was made at the bladder dome in the direction of the two fixing sutures to ensure an appropriate anatomic course of the ureter (Fig. 6). Then the ureter was spatulated, brought through a 3–4 cm long submucosal tunnel into the bladder, and anchored in the bladder with three 3-0 polyglactin sutures. Using interrupted 5-0 polyglactin sutures a further mucosal coaptation of the neo-orifice was achieved (Fig. 7). Then a 6-F JJ stent was passed into the reimplanted ureter via a guidewire through one of the assistance ports. If a Boari flap was necessary, it was fashioned from the anterior wall of the bladder with a length : width ratio of 2:1 (e.g. 8 cm in length and 4 cm in width). Implantation of the ureter in the flap was performed with the same technique as described previously for the psoas hitch procedure. Thereafter the Boari flap was tubularised with 4-0 poliglecaprone sutures in two layers. Closure of the bladder with 3-0 poliglecaprone running sutures in two layers was completed identically in both psoas hitch with and without Boari flap. The vesico-ureteric anastomosis was additionally reinforced with several 5-0 poliglecaprone sutures between the serosa of the bladder and the adventitia of the ureter. At the end of reconstruction the bladder was filled with 200 mL physiological saline to exclude leakage.
2. Extravesical anti-refluxing ureteric reimplantation (four ureters in three patients; patients no. 11–13)
The ureter was identified at its crossing with the iliac vessels and followed caudally to its insertion into the bladder. In two patients (patients no. 11 and 12) bilateral and unilateral intramural ureteric strictures, respectively, were resected and in another patient (patient no. 13) with a history of persistent symptomatic VUR after endoscopic injection therapy a residual bulge of a bulking agent near the ureteric orifice was removed. Based on the ureteric insertion, the musculature of the bladder wall was incised along a distance of ≈4 cm in the direction of the bladder dome to expose the mucosa, which was left intact. Then the ureter was placed in this extravesical submucosal channel, its distal end was spatulated, and after insertion of a 6-F JJ stent anastomosis with the bladder mucosa was accomplished using 4-0 polyglactin sutures. Subsequently, the bladder wall was closed over the ureter with a 3-0 poliglecaprone running suture to form a submucosal tunnel.
3. Intravesical refluxing and anti-refluxing ureteric reimplantation (three ureters in two patients; patients no. 14 and 15)
In a patient with prostate cancer undergoing robot-assisted RP (patient no. 15) unrecognised bilateral ectopic ureters coming from the upper poles of the kidneys were inadvertently transected during bladder neck dissection. The diagnosis of bilateral prostatic ureteric ectopia, however, did not become clear until ureteric catheters had been inserted in both the natural ureteric orifices and the proximal and distal parts of the transected ectopic ureters showing the ureteric orifices of the upper pole ureters in the prostatic urethra. Thereafter, both upper pole ureters were reimplanted supratrigonally in the bladder without creation of a submucosal tunnel (Fig. 8). J stents were inserted into the reimplanted ureters via a guidewire through the 5-mm assistance port and percutaneously channelled. Then the RP was completed as usual. In another patient with a ureteric duplication (patient no. 14) an intravesical anti-refluxing reimplantation of the lower pole ureter was performed after resection of the dysplastic upper pole kidney together with its appendant megaureter and ectopic ureterocele. In this case, the submucosal anti-refluxing tunnel was created intravesically through longitudinal incision of the mucosa, followed by preparation of mucosal flaps on both sides of the incision and their coaptation above the ureter along its intravesical course. Again a JJ stent was placed via an assistance trocar.
4. Ureteric stricture resection and end-to-end anastomosis (patient no. 10)
The patient developed a left-sided distal ureteric stricture subsequent to laparoscopic endometriosis surgery with concomitant iatrogenic injury to the left ureter. Only after 90 min tedious release of extensive pelvic adhesions was the left ureter identified as it crossed the iliac vessels and followed caudally taking care not to harm its blood supply. Directly prevesically the short ureteric stricture was isolated and resected. The proximal and distal ends of the ureter were spatulated using EndoWrist® Potts scissors. Because of a well preserved blood supply of both ureteric ends it was decided to perform an oval shaped tension-free end-to-end anastomosis. The surrounding scarred tissue was partially left in situ to be used as an anchor point for approximation sutures of the ureteric ends (Fig. 9). Thus, it was possible to remove tension from the ureteric end-to-end anastomosis, which was made using 5-0 polydioxanone running sutures. The preoperatively implanted 6-F JJ stent was left in place.
5. Endometriosis resection, ureterolysis and omentum wrap of the ureter (patient no. 16)
The left ureter was identified as it crossed the iliac vessels, and followed caudally to its insertion into the bladder. In its distal course the ureter was completely released from an encircling endometriosis focus. At the same time the left-sided adnexa was resected, and hysterectomy was performed. After retrieval of the specimens through the vagina, the left ureter was covered with a mobilised omentum majus wrap. The preoperatively implanted 6-F JJ stent was left in place.
Perioperative data, 90-day postoperative complications and follow-up results
Operative durations (including docking and undocking of the robot) and length of postoperative hospital stay for each procedure are given in Table 2. The median (range) hospital stay after surgery was 7.5 (5–35) days. The operative durations for the most frequent reconstructive procedures were as follows:
Distal ureteric resection and reimplantation with or without psoas hitch technique +/– Boari flap due to benign lesions; the median (range) duration was 250 (153–320) min.
Distal ureteric resection and reimplantation with psoas hitch +/– Boari flap combined with pelvic lymphadenectomy due to urothelial carcinoma; the median (range) duration was 320 (218–320) min.
There were no intraoperative complications, but there was one conversion to open surgery in a patient with massive peritoneal adhesions after former pancreatectomy (patient no. 3). Complications according to the Clavien-Dindo classification occurred in 12 (75%) patients ≤ 90 days of surgery (Table 3), 10 (62%) patients presenting minor (grade I–II), and two (12%) major complications (grade IIIb and IVa, respectively). Follow-up examinations were done at the discretion of the referring urologists and comprised renal ultrasonography (US) in 14 patients (patient no. 3–16) and excretory urography in two (patient no. 1: IVU; patient no. 2: CT urography). Patient no. 7 additionally underwent diuretic 99mTc-mercaptoacetyltriglycine (MAG3) renography and MRI after the diagnosis of hydroneprosis was made on renal US. At a median (range) follow up of 10.2 (0–30.5) months, 15 (94%) patients remained without signs of urinary tract obstruction and 13 (81%) were asymptomatic (Table 3). In one case, an asymptomatic hydronephrosis due to a short filiform anastomotic stricture occurred 13 months after surgery and was treated endoscopically via laser incision. Furthermore, in one case an overactive bladder developed, and in a further case mild leg weakness due to intraoperative femoral nerve lesion persisted. One of the four patients with underlying upper tract urothelial carcinoma had a recurrence and underwent radical cystectomy and right-sided nephroureterectomy because of urothelial carcinoma of the bladder, the ureter and the renal pelvis. There were no cases of extraureteric or extravesical tumour recurrence, i.e. no recurrences due to intraoperative tumour cell spillage.
It has been reported that suturing and tissue handling in the limited space of the pelvis can be more easily performed with the robot compared with conventional laparoscopy . These factors are even more relevant in complex surgical procedures such as ureteric reconstruction. Successful robot-assisted distal ureterectomy with psoas hitch and Boari flap reconstruction in patients with urothelial cancers has already been described [6, 9, 16-20]. In this context, recently published studies suggest that a minimally invasive laparoscopic approach to upper tract urothelial carcinoma provides good oncological outcomes and does not result in a clinically significant increased risk of tumour spillage, provided that principles of oncological surgery are obeyed [25-29]. These principles include thorough preoperative staging, intraoperative frozen sections of the distal edge of the remaining proximal ureter, minimising urinary flow, and en bloc dissection of the diseased ureteric segment and the bladder cuff to avoid spillage of tumour cells. We feel that our approach to urothelial carcinoma of the distal ureter with a double clip technique, rinsing of the bladder with distilled water, and use of a retrieval bag for extraction of the tumour specimen and the lymph nodes, minimised the risk of tumour spillage, so that it should be no higher than during open surgery. Indeed, none of the present four patients with upper tract urothelial carcinoma developed extraureteric tumour recurrence during follow-up. However, in this context it has to be considered that the present results might be limited due to the fact that only one patient was followed using CT, while the rest underwent either IVU or renal US so far since follow-up in these patients was still rather short (0–10 months).
As with urothelial carcinoma of the distal ureter the use of robotics for surgery of benign distal ureteric defects or strictures is also still limited, probably due to the relative rarity of these conditions [2-5, 16-19, 23]. Furthermore, in almost all of these series a refluxive ureteric reimplantation was performed [2, 4, 5, 16, 18, 19, 23]. Only De Naeyer et al.  reported a robot-assisted anti-refluxive psoas hitch reimplantation in an early case report in 2007. Both in this case report  and the one of Hemal et al.  very short operative durations of 120 and 130 min, respectively, were reported. In contrast, the present median operative duration of 250 min is consistent with most other studies (median 172 min ; mean 208 min ; case report 210 min ; median 239.5 min ; mean 306.6 min ) and it should be keep in mind that in contrast to the present anti-refluxing reimplantation, all these other studies used a more easily performed refluxing technique. We feel that an anti-refluxing reimplantation of the ureter regardless of whether performed extra- or intravesically, by open surgery or robot-assisted laparoscopy, has some advantages. If the position of the ureteric neo-hiatus (entry point of the ureter into the bladder wall) and the direction of the submucosal tunnel are in line with the anatomical course of the ureter, angulation of the ureter in different filling states of the bladder should be more easily avoided (Fig. 10). Furthermore, such a tunnel of adequate calibre should also allow uncomplicated ureteric catheterisation or ureterorenoscopy (Fig. 11). Additionally, avoidance of VUR itself may preserve renal function and prevent pyelonephritis, although in a retrospective review by Stefanovic et al.  preservation of renal function could not be demonstrated. In the context of ureteric reimplantation it is also important to mention that we avoided long-term ureteric stenting before surgery whenever possible, in order to prevent alterations like ureteric wall thickening complicating surgical reconstruction .
In patients with extrinsic endometriosis, ureterolysis alone may be sufficient to correct ureteric obstruction . Following the surgical technique in retroperitoneal fibrosis, we additionally placed an omental wrap around the diseased ureter to prevent entrapment of the ureter in forming scars .
An incidentally encountered ectopic ureter in a man undergoing RP is a rare condition that has only been reported in a few case reports [32, 33]. To our knowledge the present description of bilateral robot-assited intravesical reimplantation of bilateral upper pole ectopic ureters inserting into the prostatic urethra in a patient undergoing RP is the only one published to date.
Extravesical robot-assisted ureteric reimplantation due to VUR is in its infancy, even in children [10, 12-15]. Nevertheless, initial retrospective comparative studies have reported similar success rates to open surgery [14, 15]. Our single adult patient undergoing robot-assisted extravesical ureteric re-implantation due to VUR was likewise treated successfully.
Simultaneous robot-assisted resection of an upper pole kidney with an associated megaureter and an ectopic ureterocele together with intravesical reimplantation of an ipsilateral lower pole ureter was feasible and successful in our hands, and, to our knowledge, has not been described to date.
End-to-end anastomosis of the distal ureter after stricture resection should certainly not be regarded as routine. However, in the case presented here it was considered because of, both a well preserved blood supply of the generously spatulated ureteric ends and the possibility of an absolutely tension-free anastomosis between them. In addition, to prevent any kind of tension postoperatively the surrounding scar tissue was partially left in situ and used as an anchor point.
A potential drawback of robot-assisted reconstructions is the use of a transperitoneal approach, with its accompanying risk for postoperative ileus and peritoneal urinary leakage, both observed in one patient each in our series.
Our experience with robotics in ureteric reconstruction for defects of the distal ureter is largely concordant with the still limited worldwide experience. The present study has shown that robot-assisted reconstructive surgery of the distal ureter is feasible, and can be used without compromising the generally accepted principles of open surgical procedures. The functional outcome was good in short-term follow-up. The incidence of minor complications was high but the number of severe complications was low, and thus not discouraging. It is the personal opinion of the senior author, that in the future robotics will replace conventional laparoscopy in reconstructive surgery of the distal ureter, and even come to challenge open surgery.
We would like to thank Ms H. Coleman for revision of the English manuscript and Mrs M. Vanberg for her help with the data processing.
Conflict of Interest
D. Kroepfl and Y. Davoudi are official proctors for Intuitive Surgical Inc.