Joah Kim, Aryeh Keehn, MD, Michael Stifelman, MD, Lee Zhao, MD, & Daniel Eun, MD present a 72-year-old patient diagnosed with a left-sided distal ureteral stricture who undergoes a ureteral reimplantation.
alternative technique for your reader or re implantation for radiated ureter is using a non transaction side to side anastomosis. Post radiation induced your federal structures typically present a challenging surgical problems due to severe fibrosis and limited blood supply. Further your federal dissection and transaction may further compromise blood supply for the ureter or re implantation. We propose an alternative solution by minimizing your reader or dissection without transacting the ureter as this may minimize your reader or revascularization instead of a traditional and decide re implant, We propose that a side to side re implant may offer a better approach for radiate your eaters. We present a 72 year old male status, post chemo and radiation for rectal cancer, followed by abdominal, perennial resection and diverting colostomy. He subsequently developed an eight centimeter left the so urethral stricture a left sided stent couldn't be placed so left per cutaneous nerve. Frosty tube was placed. As you can see on my retrograde studies there is complete your literal obliteration noted at the distal ureter four. The patient was taken to the operating room for robotic left your federal re implantation. A standard six port template for public access was utilized with the patient and the thought of me and steve trend Ellensburg. During poor placement, a hostile abdomen was encountered. Therefore, a significant license of Ephesians was required with careful attention to preserve the left abdominal and colostomy due to the patient's previous surgical history. Once the pelvis was cleared of the small bowel adhesions, the dilated left sided, your order was readily apparent, coursing down towards the deep pelvis. Although complicated by significant reactive tissue, the yarder was mobilized and freed from the surrounding tissue. Taking care to maintain as much bestseller supply as possible as we approach the ureter. More distantly, you can see that the radiation fibrosis becomes progressively more noticeable in preparation for the possibility of a soulless hitch. The satisfaction was cleaned up. Unfortunately in this patient a sos tendon could not be identified before proceeding with the ureter. Three CCs of intravenous indo sign in green, followed by a quick 10 CC bolus of saline. Was the Minister Tell visual delineation of a euro. Toral vascular supply. As you can see here in your infrared telescopic camera mode, the more proximal and non disease portion of the ureter was well vascular arised with both medial and lateral contributions as we inspect the distal ureter. However, there is a clear line of demarcation with poor vascular charity suggestive of severe radiation changes here, vascular profusion is clearly demarcated. As illustrated at this point. The bladder was then dropped and fully mobilized in order to facilitate re implantation with the soas hitch We felt the platter with 200 CCs of sterile water to help visualize with the medial aspect of the ureter would closely approximate the post superior lateral bladder. Since we were dealing with radiated peri urethral tissues are aimless to minimize that section and preserve as much your federal vascular supply as possible. Therefore, we decided not to proceed with the traditional your it'll re implantation with the ureter is transected. Instead, the decision was made to perform a side to side anastomosis of a healthy well perf used your router to the bladder sidewall. Mhm. Here the more proximal and healthy ureter was sharply incised to the lumen and of 1.5 to 2 centimeter longitudinal incision was created along the Antero medial edge and prepared for side to side anastomosis. Once again, we utilized near infrared fluorescence imaging and repeated a three cc intravenous dose of indo sign in green to confirm that the ureter and blatter segments chosen for a nasty nemesis were healthy and well perf used. The bladder was then sharply incised on its lateral border adjacent to the your ettarashany to fashion the ureter of vesicles anastomosis. We used to running five oh absorbable monofilament future on a. T. F. Needle cut to six inches. Two passes of the future were taken on the initial corner stitch to ensure the a pickle anchoring stitch was secure. Uh huh. After securing our initial atypical stitch, we ran the left side of the anastomosis first while paying attention to take small bites and ensure good mucosa to mucosa approximation. Since minimizing future and tissue trauma is a priority. We prefer to use a Maryland dissecting grasshopper on the left to help handle tissue and futures since it delivers a lower grasping pressure compared to a needle driver. After completing nearly one side of the anastomosis, a fully Catheter was used as a conduit to deliver a pre placed 0.38 nightingale tips guide wire into the operative field. This frustration free technique enables quick linear passage of retrograde stance during your federal re implantation. Here we demonstrate, passing our six x 24 French, double J, stent over the guide wire into the kidney. A second separate six inch five oh absorbable monofilament future on a T. F. Needle was then run along the opposite edge to complete our watertight anastomosis. Again, careful attention is paid to the atypical stitches before we close the right side of the anastomosis. After completion of the right side anastomosis, we then finish the left side anastomosis. To complete our repair. A two oh absorbable barbed future was then used to hitch the bladder securely to the soas fascia, thereby decreasing tension on the ureter road bicycle. Anastomosis for soas hitch maneuvers are preferred technique is to use an absorbable clip on an absorbable barbs. Teacher with a unilateral direction sliding clip technique taking three separate points of fixation to the so it's pasha to ensure hitch durability. Finally, a momentum was located mobilized and secured in place to help protect our reconstruction site and promote vascular arised healing. Total operative time was 192 minutes estimated. Blood loss was 30 ml and the patient was discharged home without complications on post operative day one, with an intact and functioning and colostomy. In conclusion, a side to side and that's demotic urethral re implantation without the need for distal urethral dissection and transaction is a feasible approach in patients with radiation induced distal urethral strictures. Thank you very much for watching our video.
