Arora Sohrab, Campbell Logan, Tourojman Mouafak, Pucheril Daniel, Jones Lamont R, Rogers Craig
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI.
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI.
Urology. 2017 Dec;110:257-258. doi: 10.1016/j.urology.2017.06.037. Epub 2017 Jul 6.
To demonstrate robot-assisted ureterolysis and buccal mucosal graft (BMG) ureteroplasty for the management of a complex, long recurrent ureteral stricture developing after ureterolysis, and also to demonstrate the use of near-infrared fluorescence (NIRF) imaging and intraoperative ureteroscopy during this procedure.
A 58-year-old man with a history of cabergoline treatment and a cardiac catheterization through the left groin presented with left flank pain and hydronephrosis. A computed tomography scan showed extensive fibrosis around the ureter and a ureteral stricture close to a tortuous left external iliac artery. A computed tomography-guided biopsy showed a benign fibrous tissue around the stricture with no increase in IgG4-expressing plasma cells. A robot-assisted ureterolysis with an omental wrap was performed. One year after the ureterolysis, the patient developed a recurrent ureteral stricture. Retrograde ureterogram showed a long, 6-cm stricture in the upper ureter. For the robotic ureteroplasty, the patient was placed in modified lateral position with port placement similar to the left pyeloplasty. Intraoperative flexible ureteroscopy and NIRF were used to define the distal extent of the stricture. For this, the ureteroscope was advanced until the stricture, and transilluminance of light from the ureteroscope was seen from the robotic camera using Firefly. Ureteral stricture was incised along its length over the ureteroscope. Two BMGs were harvested and sown together to obtain a longer graft. The graft was minimally defatted and brought in the abdomen through one of the ports. The composite graft was then sutured with 4-0 PDS as an onlay graft with the mucosal side facing toward the lumen of the ureter. Ureteroscopy was used to confirm patency, followed by stent placement. NIRF was used to confirm the viability of the ureter and the surrounding tissue. The omental flap was then harvested using a vessel sealer, fixed to the psoas fascia beneath the ureter, and then wrapped over the reconstructed ureter. The omental flap was also tacked to the side of the BMG with a suture to promote blood supply.
The procedure was uncomplicated with an operative time of 280 minutes, an estimated blood loss of 75 mL, and an uneventful hospital stay. MAG3 Renal scan after 3 and 6 months of surgery showed no recurrence or obstruction.
Despite the limitation of being a single case with only a 6-month follow-up, our report shows that robot-assisted BMG is a safe option for the reconstruction of long upper ureteral strictures. This procedure may be a less morbid alternative to an autotransplant and ileal ureter in these patients. However, outcomes need to be studied in a larger series with a longer follow-up.
展示机器人辅助下输尿管松解术及颊黏膜移植（BMG）输尿管成形术用于处理输尿管松解术后发生的复杂、长段复发性输尿管狭窄，并展示在此手术过程中近红外荧光（NIRF）成像及术中输尿管镜检查的应用。
一名58岁男性，有卡麦角林治疗史且曾通过左腹股沟进行心导管检查，出现左侧腰痛及肾积水。计算机断层扫描显示输尿管周围广泛纤维化，输尿管狭窄靠近迂曲的左髂外动脉。计算机断层扫描引导下的活检显示狭窄周围为良性纤维组织，表达IgG4的浆细胞无增多。进行了带网膜包裹的机器人辅助输尿管松解术。输尿管松解术后1年，患者出现复发性输尿管狭窄。逆行输尿管造影显示上段输尿管有一段6厘米长的狭窄。对于机器人输尿管成形术，患者取改良侧卧位，端口放置类似于左肾盂成形术。术中使用可弯曲输尿管镜及NIRF来确定狭窄的远端范围。为此，将输尿管镜推进至狭窄处，通过Firefly系统从机器人摄像头观察到输尿管镜发出的透光。沿输尿管镜纵向切开输尿管狭窄处。采集两片BMG并缝合在一起以获得更长的移植物。移植物进行最小程度的脱脂处理，通过一个端口引入腹腔。然后用4-0 PDS将复合移植物作为覆盖移植物缝合，黏膜面朝输尿管腔。使用输尿管镜确认通畅，随后放置支架。使用NIRF确认输尿管及周围组织的活力。然后使用血管闭合器采集网膜瓣，固定于输尿管下方的腰大肌筋膜，再包裹于重建的输尿管上。网膜瓣也用缝线固定于BMG一侧以促进血供。
手术过程顺利，手术时间280分钟，估计失血量75毫升，住院过程平稳。术后3个月和6个月的MAG3肾扫描显示无复发或梗阻。
尽管本报告仅为单例且随访仅6个月存在局限性，但我们的报告表明机器人辅助BMG是重建上段长段输尿管狭窄的一种安全选择。对于这些患者，此手术可能是自体肾移植和回肠代输尿管的一种创伤较小的替代方法。然而，需要在更大系列且随访时间更长的研究中观察结果。
