David M. Strauss, MD presents a 53-year-old patient diagnosed with bilateral ureteral strictures from tuberculosis who undergoes a bilateral ureteral reconstruction.
robotic assisted laparoscopic left illegal ureter in her position for long segment urethral stricture the illegal ureter is a valuable reconstructive urologic tool in the setting of long segment or penury. Toral structure disease and adds to the arsenal of urethral reconstruction options for strictures. Here we present a demonstrative case of robotic assisted elio your creation. Our patient is a 53 year old female who was diagnosed with bilateral urethral strictures from tuberculosis. She was scheduled for a bilateral urethral reconstruction and at the time underwent a concurrent right Eureka Eureka Rostami. For the purpose of the video. We will focus on the left illegal ureter. The techniques shown is also applicable to a right sided procedure, proper assessment of structure, location and length, as well as placement of open ended Your epidural catheter and urethra foley should be performed prior to dissection. The integrated and retrograde pilot grams shown reveal a left 4 to 5 centimeter mid urethral dense structure at the L four l five vertebral level port positioning is outlined by the shown schematic. A super umbilical can report with eight millimeter working right and left. Robotic arms are triangulated to the target anatomy. A 12 millimeter robotic staple report is used as the fourth arm coming from the right. As for patient positioning, The patient was placed in a modified left flank up position At approximately 30°,, supported with gel bumps upon entering the abdomen. The bow was inspected to identify the distal ilium as well as to note the Elias eagle junction, A segment of distal ilium was marked with 20 Silk suture to aid identification of the distal William later in the case. Mhm. Okay. The descending colon was mobilized immediately exposed the left ureter. The left ureter was carefully circum frontally dissected their left ureter analysis. Mhm. The your orders relationship to the iliac vessels and pelvic brim is noted. Mhm. When the ureter was isolated, 4-5 cm of dense scar was noted And the approximate distance from the left side of the bladder to the healthy, approximately ureter was 10cm necessitating a large segment. Your general repair? Yeah, the proximal healthy left dilated. Ureter was first transacted sharply with scissors and then spatula hated. Uh huh. At this point we felt that we were still below the level of obstruction and that additional your order would still need to be taken. Yeah, dissection of the future. Tunnel through the sigmoid. Mesen terry is started on the left side of the abdomen. The marked a little segment was taken out of bowel continuity using two robotic 45 millimeter articulated staple loads via the fourth arm position in the right most port. The mezzanine area was additionally in size to provide mobility. Balle continuity is reestablished with an elio Elias To me, accomplished with two staple loads across the anti Mesen Terek border. The integrity of this anastomosis is then checked mm mm. A tunnel large enough to pass the harvested illegal segment from the right to the left side of the abdomen was created in the sigmoid mesen terry underneath the inferior Mesen terek artery. Mhm mm. Mhm. And overlay here displays the anatomy of the tunnel. Okay mm. The distal portion of the illegal segment can be structured to the end of a lap pad to allow for easier translocation across the abdomen. Mhm. Yeah, mm. Yeah. Once on the left side of the abdomen without tension, the distal stump of the illegal segment was opened sharply with scissors and inverted you sista. To me at the left bladder dome was utilized to create a bladder flap, which allowed for the intro vesicles anastomosis using a running three oh barbs future skin. After the posterior plate of the intro vesicles anastomosis was completed. The open ended, five French irritable Catheter was passed up. The illegal segment. The illegal segment reached the healthy dilated, your federal proximal margin without issue or attention. At this point, approximately three cm more of proximal ureter was dissected and re spatula waited. The Euro and Terek anastomosis was completed approximately with two running 5 monochrome futures. Before the end of the anastomosis. The urethral catheter was exchanged for a six by 24 centimeter double J. Urethral stent mm The patients. The frosting the tube was removed before the end of surgery. She had an uneventful hospital stay. I was discharged on post op day number five at two years. Her furosemide renal skin shows no evidence of obstruction with stable split renal function. Mhm. Illegal. Your orders have been well described with open approaches for long segment urethral strictures. In this case, we demonstrate the technique and long term viability of a robotic assisted left illegal ureter in her position and highlight the technical maneuvers of dissection, mobilization and anastomosis with a minimally invasive platform.
