title: Robot-assisted reconstructive surgery of the distal ureter: single institution experience in 16 patients.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Urology, Pediatric Urology and Urologic Oncology, Kliniken Essen-Mitte, Essen, Germany. m-musch@web.de
authors.forename: Michael
authors.initials: M
authors.lastname: Musch
authors.forename: Lukas
authors.initials: L
authors.lastname: Hohenhorst
authors.forename: Anne
authors.initials: A
authors.lastname: Pailliart
authors.forename: Heinrich
authors.initials: H
authors.lastname: Loewen
authors.forename: Yadollah
authors.initials: Y
authors.lastname: Davoudi
authors.forename: Darko
authors.initials: D
authors.lastname: Kroepfl
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods*; D013524:Surgical Flaps; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014517:Ureteral Obstruction / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*