Robotic ileal ureter with bladder augmentation in a modified Studer fashion for a long ureteral stricture and small bladder

Abstract

Introduction and Objective: The surgical management of radiation-induced distal ureteral stricture and contracted bladder is challenging. The purpose of this video is to show the feasibility, safety, and functional outcomes of an intracorporeal robot-assisted ileal ureter and bladder augmentation in a modified Studer fashion for a long right ureteral stricture and a small bladder. Methods: A 34-year-old African woman had a history of cervical cancer that was treated with radical surgery and whole pelvis radiation in 2015. She was free of cancer recurrence 6 years after radiotherapy. She developed a long ureteral stricture and a small bladder (188 ml). She was managed with a chronic ureteral stent and complained of urinary frequency, urgency, and nocturia. The International Prostate Symptom Score (IPSS) was 22. A transperitoneal robotic approach was utilized with the Da Vinci Xi™ platform similar to radical cystectomy. The right ureter stricture above the level of the iliac vessels was identified and transected. A 17 cm gap was measured between the proximal ureter and the bladder dome. A segment of 30 cm of terminal ileum was isolated (20 cm for the cystoplasty, 10 cm for the chimney). Intestinal continuity was restored with a side-to-side anastomosis. The inferior 20 cm segment was detubularized and folded into a “U” shape in a modified Studer fashion, leaving 10 cm of superior ileum for creating the afferent chimney. The bladder dome was incised transversely. The posterior cystoplasty was performed by suturing the inferior “U” shape of the ileum patch to the posterior edge of the bladder. A tension-free uretero-ileal Bricker anastomosis was performed in an interrupted fashion using 4-0 PDS sutures. A double-J ureteral stent was placed. The anterior closure of the cystoplasty was completed using running 3-0 V-Loc sutures. Results: The patient was discharged on postoperative day 5. The Foley catheter was removed after 21 days and the ureteral stent was removed 3 months later. A CT Urogram at 6 months showed no hydronephrosis. The patient reported improved urinary symptoms of frequency, urgency, and nocturia. Postoperative urodynamics revealed improved urinary symptoms (IPSS 11), functional capacity (253 ml), low pressure and complete voiding. Conclusions: Robotic ileal ureter with bladder augmentation in a modified Studer fashion is feasible and safe. It offers an excellent functional outcome for patients with a long ureteral stricture and a contracted bladder. This reconstructive approach can be individualized by adjusting the length of chimney and size of bladder augmentation.

Keywords

• Ileal ureter
• Bladder augmentation
• Ureteral stricture
• Contracted bladder
• Robotic surgery