We present an extravesical robotic ureteral re-implantation for the management of a ureterovaginal fistula. The patient is a 55-year-old female who underwent a robotic hysterectomy at an outside facility. Following catheter removal, she developed urinary incontinence three days after surgery. She was subsequently managed with a urethral catheter but had persistent incontinence. Abdominal and pelvic imaging showed a left ureteral injury and a left nephrostomy tube was subsequently placed. The patient had persistent incontinence despite this and presented to our office for further evaluation and management. At the time of our consultation, she had been having incontinence for roughly four weeks without other symptoms. She is otherwise healthy. On evaluation, the patient is well-appearing. Her abdomen is soft, non-tender, with a left nephrostomy tube in place and draining clear urine. On pelvic evaluation, she has a well-healing vaginal cuff without obvious fistulas track and clear fluid pooled in the vagina. Her evaluation showed a normal white blood cell count as well as renal function. Imaging was obtained and a CT urogram showed no evidence of contralateral ureteral injury or pelvic abscess. Cystoscopy was performed, which showed inflammation of the left ureteral orifice, however, was otherwise negative for a vesicovaginal fistula. The patient was counseled regarding management options, including a more conservative approach with either antigrade or retrograde ureteral stent placement or proceeding directly to ureteral reimplantation. An attempt was made at antigrade ureteral stent placement given the patient's indwelling left nephrostomy tube. As shown here, the guide wire passed into the vagina and stent placement was unsuccessful. The patient then opted for ureteral reimplantation. Here we present our surgical technique for extravesical robotic ureteral reimplantation. Following port placement and docking, given involvement of the left ureter, the dissection begins with mobilization of the colon. Following this, the ureter is identified where it crosses the iliac vessels, well proximal to the area of injury. Dissection is then carried out circumferentially. Once this has been obtained, a vessel loop is passed around the ureter and manipulated by the third arm to aid with retraction. Dissection is then carried further into the pelvis and down to the level of the ureterovaginal fistula. Once this has been achieved, the distal ureter is suture ligated and tied off. The ureter is then transected. As shown here, there is insufficient length to allow for primary reimplantation without tension, thus the bladder is mobilized. As shown, this provided enough additional length to allow for a tension-free anastomosis. The bladder is secured laterally for additional support with a vicral suture. This will take tension off the planned ureteral reimplantation and stabilize the bladder to aid with manipulation. A stay suture is placed through the distal end of the ureter to aid in handling the tissue in an atraumatic fashion. The site for the cystotomy is chosen and dissection carried through the detrusor muscle and into the bladder. The ureter is then spatulated to allow for a wide anastomosis. A delayed absorbable monofilament suture is placed into the bladder as well as the heel of the ureter to begin the anastomosis. The suture is tied outside the lumen. For an extravesical technique, we perform a running anastomosis with two sutures. An additional suture at the toe of the anastomosis is placed and again tied outside the lumen. The first suture is then run from the toe to the heel of the anastomosis, making sure to obtain mucosa-to-mucosa apposition with direct visualization. A closed-ended double-J ureteral stent is then placed. The remaining suture is then placed in a running fashion from the heel to the toe, thus completing the anastomosis. Additional reinforcing sutures are placed through the ureteral adventitia for additional support. The anastomosis is then tested with retrograde filling with normal saline via the indwelling Foley catheter. As shown here, there was no evidence of extravasation. The bladder is then drained, the ports removed, and the port sites closed. Postoperatively, the catheter was left in place for 10 days, followed by a cystogram to ensure adequate bladder healing. The ureteral stent was removed at six weeks postoperatively. Six weeks after stent removal, the patient underwent a repeat renal ultrasound, which showed no evidence of hydronephrosis. Important technical considerations for robotic ureteral reimplantation include adequate ureteral mobilization and exclusion of the pathologic segment, wide ureteral spatulation with good mucosal apposition and a watertight closure, ensuring that the anastomosis is tension-free, postoperative bladder drainage to allow for adequate healing, and continued follow-up to ensure ureteral patency postoperatively. Robotic ureteral reimplantation was originally reported during radical prostatectomy in 2004. Since then, this technique has been expanded to other cases necessitating ureteral reconstruction, such as ureteral stricture disease, distal ureteral malignancies, as well as fistula repairs as shown here. Notably, excellent outcomes with robotic ureteral reimplantation have been reported, though typically in case series. One recent series of 43 cases of iatrogenic pelvic urinary tract injuries with a mean follow-up of 16 months showed a 4% rate of ureteral obstruction following reimplantation. This highlights the need for patient follow-up following this procedure. Importantly, a minimally invasive approach to ureteral reimplantation has been associated with lower 30-day morbidity than an open approach.

ureterovaginal fistula

robotic hysterectomy

urinary incontinence

extravesical robotic ureteral reimplantation

minimally invasive approaches