Uretero-peritoneal Fistula after Robot-Assisted Ipsilateral Lower-to-Upper pole Uretero-ureterostomy
Mitali Kini, MD, Edward Gong, MD.
Northwestern Memorial Hospital, Chicago, IL, USA.
BACKGROUND: Ipsilateral uretero-ureterostomy (IUU) has been used to treat lower pole vesicoureteral reflux (VUR), minimizing the risk posed by hilum dissection. The robot platform enables optimum visualization of the distal ureteral stump. Here, we depict a complication of uretero-peritoneal fistula following a robot-assisted laparoscopic lower-to-upper pole IUU (RAL IUU) that was subsequently repaired with ureteral stump ligation and closure of the peritoneum.
Methods: The patient was a 22-month-old boy who had presented with antenatal hydronephrosis, with voiding cystourethrogram (VCUG) demonstrating Grade 5 VUR to the lower pole of a duplicated left collecting system. The patient underwent lower-to-upper RAL IUU in 2020. Cystoscopy with retrograde pyelogram (RPG) of the left lower pole revealed severe lower pole hydronephrosis. An 8 mm robotic camera port was placed with left and right lower quadrant 8 mm working ports. The left upper pole ureter was identified. Distal dissection was performed. The lower pole ureter was transected where it narrowed and suture ligated with a 4-0 Vicryl suture. The remaining ureter was cut obliquely and the upper pole ureter was opened longitudinally. Ureteroureterostomy was then performed with two running 5-0 Monocryl sutures.
The patient returned 2 weeks after stent removal with fevers and low urine output. VCUG revealed a urine leak from the lower pole ureteral stump and the patient was taken back to the operating room.
Cystoscopy and RPG of the left upper pole orifice demonstrated a normal caliber and a fully patent anastomosis. RPG demonstrated extravasation from the lower pole ureteral stump. A ureteral stent was placed and attention was then paid to the robotic portion of the surgery. The stent was traced to the pelvis, identifying an uretero-peritoneal fistula. This was circumscribed and dissected distally to the hiatus of the bladder. The ureter was hitched proximally, suture ligated twice and free tied once with a 4-0 Vicryl suture. The excess ureter was excised. The ureter was passed deep into the pelvis and the peritoneum was closed with a running 4-0 Vicryl suture.
Results: The patient’s postoperative course was uncomplicated. At his most recent follow up at 3 years of age, his hydronephrosis had improved and he had had no urinary tract infections.
Conclusions: We present our experience with lower-to-upper pole RAL IUU, with a proposed technique to manage a rare complication of uretero-peritoneal fistula.
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