A novel tattooing technique for ureteric strictures in robotic ureteroureterostomy: a non‐inferiority analysis

摘要

A ureteric stricture can be treated either endoscopically or with ureteric reconstruction. The developments in robotic ureteric repair have led to similar success rates to open techniques, with the addition of decreased hospitalization duration and blood loss [1-7]. Recognition of the stricture during robotic ureteric reconstruction, however, can be challenging. In this study, we introduce the novel technique of ureteroscopic ‘tattooing’ of the ureteric lumen on the level of the stricture to subsequently recognize it during robotic ureteroureterostomy. We also compare our technique with others used for ureteric stricture identification. Our preliminary data show that this technique is easy to use and can reduce the operating time and the complication rate postoperatively. A total of four patients with benign ureteric strictures underwent robot-assisted ureteroureterostomy in a single tertiary hospital. All patients underwent preoperative MAG3 renograms and CT urograms, which showed obstruction on the side of the stricture and provided a measure of its length (<3 cm). Patients were followed up for 1 year after their procedures with MAG3 renograms at 3 and 12 months. Three patients were male and one female. All the male patients had left ureteric strictures, while the female patient had a right stricture. Long standing obstruction from impacted ureteric stones caused the stricture in two patients and multiple ureteroscopies caused it in the other two. In all the cases a retrograde ureteroscopy with a semirigid 7-Fr ureteroscope preceded the robotic ureterectomy. A retrograde study confirmed the length of the stricture in all cases. The patients were placed in a Lloyd-Davies position. The distal end of the ureteric stricture was marked with black dye with the use of a fine endoscopic injection needle (EndoTNeedle™; GI Supply, Specialty Endoscopic Products, Mechanicsburg, PA, USA) through the working channel. Initially, the needle was pushed through the mucosa. It is of utmost importance to approach the mucosa tangentially to avoid the injection of the dye outside the ureter, which can cause inflammation or the injury of surrounding organs and vessels. After insertion of the needle, the catheter was withdrawn slightly and pulled towards the lumen to ensure that the needle was directly under the mucosa. We inserted 0.5 mL of black dye on the anterior wall of the ureteric lumen (12 o’ clock position) at the distal end of the stricture. We used a permanent carbon black dye, commercially available as Spot® Ex, ready for injection with the endoscopic injection needle. In all the cases we used the needle without the sheath to be able to pass it through the working channel of the ureteroscope. Subsequently the patient was placed in the supine position with the corresponding side of the operation elevated with a wedge. The Da Vinci Xi Robotic System was used with three robotic ports. The port configuration was similar to that used in robotic pyeloplasty. The colon was mobilized and the marked ‘tattooed’ ureter was identified and mobilized extensively above and below the mark (Fig. 1). It was then incised just under the mark, opened, and 2–3 cm of ureteric segment above the mark were removed depending on the measured length of the stricture. The proximal and distal ends are spatulated. A 3–0 double ended Quill-type suture was used for end-to-end anastomosis over a 6-Ch/26-cm JJ ureteric stent. Subsequently, an omental wrap was created and a 20-Fr Robinson's drain was placed next to the anastomosis. All four patients in our study were discharged on the next day and no complications or readmissions occurred. The mean (range) operating time was 128.75 (110–150) min. The mean (range) blood loss was 45 (20–110) mL. The stent was removed 4 weeks later and a MAG3 renogram, performed at 3 months postoperatively, showed no obstruction, with improvement of the function of the kidney in three of the patients and unchanged function in the fourth patie