Introduction

Urology has been at the forefront of minimally invasive surgery since the introduction of laparoscopy and performance of the first laparoscopic nephrectomy [1]. Since that time, minimally invasive surgery has been applied to a greater range of urologic procedures, and tools have been miniaturized. Minimally invasive techniques were used for ureteral procedures as early as 1993, with the introduction of laparoscopy for correction of vesicoureteral reflux [2]. The greatest leap in improvement of urologic minimally invasive surgery came with the introduction of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). The original da Vinci robot was introduced in 1999. Three versions have been released since that time; the most recent of which, the Si-HD system, includes an upgraded surgeon console and dual console capability [3]. The robot was originally embraced by the urologic community to facilitate the performance of radical prostatectomy [4]. With its six degrees of freedom and ability to provide magnification and decrease tremor, the robot allows tasks requiring fine movements and intracorporeal suturing to be performed with greater ease than pure laparoscopic instruments. This observation prompted the use of the robot for reconstructive urologic surgery. The robot has been used for ureteral reconstruction in all parts of the ureter. In this article, we will focus on the use of the robot for distal ureteral reconstruction and emphasize new techniques and advances in this field.

Pre-operative Evaluation

In general, the same considerations that are given to patients considered for laparoscopic surgery need to be given to any potential robotic surgery patient. The patient’s comorbidities, especially those that may be limiting to the ability to insufflate the abdomen or tolerate general anesthesia, must be noted. Robotic distal ureteral reconstruction is typically performed in the Trendelenburg position, and the patient must be able to tolerate this position for several hours [5••]. The patient’s previous abdominal surgeries should be noted. Previous abdominal surgery is not an absolute contraindication to robotic surgery, especially for the experienced robotic surgeon; however, the surgeon may wish to alter the technique for achieving insufflations and be prepared to perform adhesiolysis. Similarly, obesity can make a minimally invasive procedure more difficult, and the surgeon ought to encourage weight loss when appropriate and time permits; however, robotic surgery can be performed in overweight patients. Longer trocars are available and should be used in obese patients. This population arguably has the most to gain from a minimally invasive procedure, as these patients are the most likely to have difficulty with wound healing and mobility post-operatively when they undergo large incisions.

Beyond basic considerations, the patient’s particular anatomy must be thoroughly defined pre-operatively. Cpomputed tomography (CT) urogram and retrograde pyelography can be used to determine the exact location and extent of disease. Bowel prep should be strongly considered. We have found the use of a mechanical bowel prep with magnesium citrate and/or enema to be helpful [5••]. Peri-operative antibiotics can be given according to the set guidelines and patient’s previous cultures.

Intraoperative Set Up and Patient Positioning

Appropriate patient positioning and port placement is crucial to performance of a successful robotic operation. For distal ureteral reconstruction, patients can be positioned in lithotomy position, similarly to the positioning for robotic prostatectomy. The patient is then placed in a steep Trendelenburg position. We have found it beneficial to position the patient with a slight tilt on the side of the operation for better exposure. The abdomen can be insufflated using preferred technique of surgeon, and ports place as in Fig. 1 [5••]. Robot is docked between the patient’s legs.

Fig. 1
figure 1

Port placement for distal ureteral reconstruction

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Consideration can be given to performing a cystoscopy with a retrograde placement of JJ stent prior to starting the operation. We have found it feasible to place a stent in an antegrade fashion when a stent is indicated, and for this reason we do not regularly perform cystoscopy and stent placement. After the anastamosis is started, a new moistened double-J stent is brought through an assistant port, with the floppy end of the wire emanating from the stent. The stent is advanced into the ureter until it reaches into the kidney. The wire is then removed and the lower end of J is manipulated into the bladder.

Adult Population

Indications

The robot has been used to perform distal ureteral reconstruction and reimplantion in adults for benign as well as malignant conditions. The first case was performed by Yohannes and associates, and was performed for distal ureteral stricture in 2003 [6]. The published series of procedures recently performed for benign conditions can be seen in Table 1.

Table 1 Published series of distal ureteral reconstruction and reimplantation for benign indications since 2008
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Robotic reconstruction of the distal ureter has also been described for the treatment of low-grade ureteral carcinoma of the distal ureter, though the number of cases reported is much smaller than that for benign conditions. Reconstructive techniques, such as reimplant, psoas hitch, utereoureterostomy, and Boari flap, have all been performed for cancer as well as benign disease. Indications for performing these procedures for malignancy are the same as for performing them in an open fashion. In these patients, oncologic control must be considered first and foremost, as with any other surgical procedure for cancer. The various series of robot procedures for malignancy of the distal ureter can be seen in Table 2.

Table 2 Published series of distal ureteral reconstruction and reimplantation for malignant indications since 2008
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Techniques

A complete work up must be conducted pre-operatively. In cases of malignancy, this should include cystoscopy to ensure absence of bladder tumors. If cystoscopy is performed in the same setting as the robotic procedure, a JJ stent can be placed at that time. We typically perform cystoscopic evaluation in the clinic prior to bringing the patient to the operating room (OR) and have found it safe and feasible to place JJ stents in an antegrade fashion (Fig. 2) [5••]. The technique of using a ureteroscope to help with identification of the location of the tumor/pathology intraoperatively has also been described, and this is something that can be set up during the cystoscopic part of the procedure. Yang et al. described passing a guide wire into the affected ureter in order to subsequently pass the ureteroscope over the wire and visualize the tumor while the surgeon is marking the area of the tumor robotically [9]. In our recent experience, when the patients have a previously placed nephrostomy tube, we have instilled indocyanine green dye for visualization of the precise area of obstruction in the ureter robotically.

Fig. 2
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Intra-operative picture showing ureteroneocystostomy and ureter after antegrade placement of JJ ureteral stent

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Distal ureteral reconstruction is typically performed in a transperitoneal manner. The posterior peritoneum is incised at the level of the iliac vessels. The ureter is isolated. A vessel loop can be used to isolate the ureter. Distal ureteral dissection can be performed with 200–300 cc of saline in the bladder, as this will likely aid in dissection [5••]. In cases of bladder cuff excision, the cystotomy is closed with 3-0 absorbable suture, and a new cystotomy is made for reimplantation of the ureter. Distal ureteral reconstruction appears to be more time-consuming than proximal ureteral reconstruction, likely due to the maneuvers necessary to ensure a tension free anastomosis. The bladder can be mobilized from the anterior abdominal wall by incising the peritoneum lateral to the obliterated umbilical artery. The urachus is transected. The contralateral superior bladder pedicle may be ligated to improve bladder mobilization. A psoas hitch is recommended if there is any concern about a tension-free anastomosis. Care must be taken to avoid the genitofemoral nerve in doing so, as with open procedures. The anastomosis is made with great to ensure good mucosal apposition. Prior to completion of the ureteroneocystostomy, a stent can be placed either over the wire that was placed cystoscopically or in an antegrade fashion. We leave a self-suction drain and foley catheter in place [5••]. The drain is typically removed on the first or second post-operative, or when the drainage is less than 30 cc in 12 hours. The foley catheter is removed 24–48 hours after the drain is removed. We often instruct patients to remove the foley catheter at home after discharge. In cases where the bladder is repaired, the foley catheter remains in place for 10 days and we obtain a cystogram prior to removal. The JJ stent is removed 3 weeks post-operatively, and the patient undergoes imaging 3 months post-operatively to assess the repair. Appropriate follow-up from oncologic standpoint must of course be undertaken in patients having had surgery for cancer.

Pediatric Considerations

The interest in distal ureteral reconstruction and reimplantation in children revolves around the treatment of vesicoureteral reflux in children with recurrent febrile urinary tract infections who are at risk of renal scar formation. Peters reported an early series of 24 children who underwent robotic assisted laparoscopic ureteral reimplantation in 2004 [10]. Larger series have been reported since that time, including a series of 41 patients who underwent bilateral nerve sparing robotic extravesical reimplantation [17•]. This procedure is of particular interest in the pediatric population, as urinary retention post-operatively is a major concern in the population of children undergoing extravesical reimplanation, especially when the procedure is performed bilaterally. In the series presented by Casale, none of the patients had retention post-operatively. Furthermore, all patients underwent post-operative voiding cysto-urethrogram (VCUG) and a resolution of 97.6 % was seen, which is comparable to results seen with open surgery. This is in contrast with the reported urinary retention rate of up to 20 % when bilateral extravesical ureteral reimplantation is performed in an open fashion [18]. The authors in this study hypothesize that perhaps the great visualization possible with the robot allows for careful handling of the periureteral tissues at the bladder hiatus, and allows for visualization and avoidance of the pelvic plexus around this area. More recent publications have reported on extravesical and intravesical reimplanation in children with good results [10, 11•].

Minimally invasive ureteral reimplantation in children can be challenging; however, the potential benefits are tremendous. Minimally invasive approaches are obviously desirable in children, due to improved cosmesis and decreased pain. Extravesical reimplantation also allows the child to maintain an anatomy that may be more conducive to instrumentation later in life, should the child need ureteroscopic procedures or stone disease or other indications. Furthermore, the bladder is not opened during this operation, and the child may have less bleeding post operatively and less bladder spasms. If this type of reimplantation can be performed in children without putting the child at excessive risk of retention as with open procedures, robotic extravesical reimplantation could offer great advantages to open reimplantation performed in the traditional cross-trigonal fashion. Operative time may be longer with robotic approaches and the neurovascular bundle lateral to the ureteral hiatus may not be easily identifiable. Surgeon experience and comfort level should certainly be taken into consideration when choosing the type of operation a child should undergo. Larger studies involving multiple surgeons and institutions with follow-up of the patients with VCUG are necessary in this population prior to proclaiming whether or not robotic reimplanation in children is superior to open procedures; however, the potential advantages of the robot are promising.

Conclusion

The benefits of minimally invasive surgery have been enumerated on multiple occasions, and include decreased post-operative pain, decreased length of hospitalization, and improved cosmesis. The introduction of the robot and its improvement over the years has allowed urologists to perform minimally invasive procedures with greater ease and precision. The robot has been used successfully to perform various reconstructive procedures of the distal ureter in the pediatric and adult population. The published series involving patients who have undergone robotic ureteral reconstruction have become larger over the recent years, and the results have been excellent. As surgeons become more and more comfortable with this technology, the cases undertaken robotically will likely be more and more complex and the outcomes even better.