複雜輸尿管狹窄藉達文西手術重建:個案報告及文獻回顧

廖凡霆、李宗融、侯鎮邦、陳建綸、林友翔、蔡翰宇、陳昱廷、鄧子麒

林口長庚紀念醫院外科部泌尿科

Reconstruction of Complex Ureteral Stricture Using Robot-Assisted Surgery: A Case Report and Literature Review

Fan-Ting Liao, Tsung-Jung Lee, Chen-Pang Hou, Chien-Lun Chen, Yu-Hsiang Lin, Han-Yu Tsai, Yu‑Ting Chen, Tzu Chi Teng

Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan

*The authors Fan-Ting Liao and Tsung-Jung Lee contributed equally

Purpose:

Ureteral strictures can arise from various causes, such as iatrogenic factors, urolithiasis, trauma, or infections. Surgical reconstruction is a last resort after endoscopic intervention failure. Robotic-assisted surgery may improve outcomes of urological reconstructive surgeries with substantial benefits. Indocyanine green may be integrated with robotic surgery with Firefly fluorescence imaging for assistance. We present a case of robotic ureteral reconstruction with Boari flap after multiple surgeries for distal ureteral stricture.

Presentation of Case:

This is a 66-year-old male with a history of type 2 diabetes mellitus, hypertension, psoriasis, hyperlipidemia, and chronic hepatitis C. Initial presented with worsening renal function of creatinine level increasing from 1.13 to 2.29 mg/dL within six months. Echography reported moderate right hydronephrosis and a right renal stone measuring 0.63 cm. Subsequent CT imaging confirmed a 1.5 cm stone in the right upper ureter with obstructive uropathy.

Right ureterorenoscopy for stone manipulation was tried at first; however, identification of the stone was unsuccessful due to the intraoperative discovery of low ureteral stricture. As a result, right percutaneous nephrostomy was inserted for urinary diversion. Due to endoscopic failure, surgical removal of ureter stone was discussed and scheduled. During second admission, preoperative evaluation disclosed a creatinine level of 2.44 mg/dL and pyuria. Right ureterolithotomy was performed and indocyanine green (ICG) was used to identify stone location, where a 1.8 x 1.0 cm stone was found and removed successfully. However, post-operative KUB revealed abnormal double-J stent location with distal loop dislodged in middle ureter. Ureterorenoscopy was arranged for intend of adjusting double-J stent location; instead revealing stenotic ureteral orifice and severe low ureteral strictures, suggesting a double stricture. Due to high complexity of middle and low ureteral strictures with previous faulted surgical attempt, ureteral reconstruction was indicated. The patient underwent a second reconstructive surgery with Boari flap due to extensive defect secondary to long ureteral stricture length. Percutaneous nephrostomy was removed, and patient discharged smoothly.

Double-J catheter was removed without complications, and the patient exhibited no objective recurrence of symptoms or deterioration in renal function. Further OPD follow up shown stable creatinine with resolution of hydronephrosis.

Discussion

 Ureteral strictures could develop as complications of endourology surgeries, with reported incidences following ureterorenoscopy or retrograde intrarenal surgery ranging from 0.2% to 1.4%. These strictures can lead to irreversible renal dysfunction, severe flank pain significantly affecting patients' quality of life and subsequent infectious complications. Recent studies have highlighted the efficacy of robotic-assisted techniques for ureteral reconstruction. Indocyanine green (ICG) have been utilized in contemporary literature for real time evaluation of tissue perfusion and aid in identifying strictures which are typically ischemic; reports also shown PCN injection displaying fluorescent stones from ICG coating.

It may be challenging to confirm the position of antegrade double-J stent (DJ) insertion. We propose utilizing the Galdakao-modified supine Valdivia (GMSV) positioning, which is commonly utilized in Endoscopic Combined Intrarenal Surgery (ECIRS), during robotic surgery to perform cystoscopy for validation of distal loop of DJ

Conclusion: