a patient with a solitary kidney , cysteine stones , and recurrent ureteral strictures underwent robot - assisted laparoscopic ureterectomy with ileal ureter formation .
using a transperitoneal , 4-port robotic approach , we removed the strictured ureter and created an ileal ureter .
the ileal - pyelo and ileal - vesical anastomoses were performed using the robotic system .
operative time was 9 hours with negligible blood loss , and the patient was discharged after 5 days .
a cystogram at 10 days demonstrated patent anastomoses without extravasation . the patient continues to do well 48 months later .
robot - assisted laparoscopic ileal ureter replacement is feasible with excellent long - term outcome .
in patients who require complex ureteral reconstruction , one surgical option is the creation of an ileal ureter substitution , in which a segment of diseased ureter is removed and substituted with an isoperistaltic segment of ileum . in the appropriate patient , outcomes from this procedure are good .
based on the long - term robotic and advanced laparoscopic experience at our institution in both urologic and colorectal surgery , we felt that use of the da vinci robotic system ( intuitive surgical , inc , sunnyvale , ca ) in this procedure may show benefit over the conventional laparoscopic or open technique .
a search of the english language medical literature since 1950 did not find any reports of a robotic - assisted laparoscopic ileal ureter creation . here , we describe our technique and 48-month follow - up .
a 39-year - old man with a solitary left kidney and cysteine stones had undergone 27 procedures including stents , ureteroscopies , and percutaneous nephrolithotomies over 18 months .
he was on maximal medical therapy to prevent stone formation and was otherwise healthy with a serum creatinine of 1.3mg / dl .
the patient opted for a  stone chute  with ileal ureter replacement and chose the robotic - assisted approach after an extensive preoperative discussion of the surgical options , risks , and benefits .
the patient was secured to the table in a 45-degree , left - flank - up position .
a hasson trocar was placed periumbilically and used for the robotic camera port , specimen removal , and the bowel anastomosis .
three 8-mm da vinci robotic trocars were placed ; ports 1 and 2 were used for the superior dissection and anastomosis while ports 1 and 3 were used for the inferior dissection and anastomosis ( figure 1 ) .
port placement for robotic ileal ureter creation : a 12-mm trocar was placed at the umbilicus with a hasson technique ( h ) .
though significant peri - ureteral inflammation was present , the ureter was identified crossing the iliac vessels .
after dissecting the ureter as far superiorly as possible , the robot was repositioned to perform the remaining superior dissection .
a 5-mm , 0-degree lens was placed through port 2 , and the specimen was removed with a retrieval bag inserted through the hasson trocar . using standard laparoscopic instruments and a harmonic scalpel , an appropriate length of ileum was selected and transected using a laparoscopic stapling device .
the mesentery was incised with a harmonic scalpel to allow adequate mobilization , and the ileum was swung laterally .
two long 0 silk sutures were placed on each end of the bowel and clipped together to allow for easier identification for the bowel anastomosis .
a dyed and undyed 20 monocryl on an sh needle ( ethicon , cincinnati , oh ) were tied together , and a running ileal - pyelo anastomosis was performed as described for urethral - vesical anastomosis after radical prostatectomy . after completing the posterior portion of the anastomosis , a 0.038 guidewire was passed through the ileal segment , over which an 8fr , 26-cm double jj stent was passed .
a cystotomy was performed in the superior - lateral bladder , and the mucosa was everted with interrupted 30 vicryl on an rb needle ( ethicon , cincinnati , oh ) .
a jackson - pratt drain was placed near each anastomosis and brought out through ports 1 and 3 ( figure 2 ) .
the 5-mm , 0-degree lens was again passed into port 2 and the previously placed ileal sutures were grasped through the hasson trocar .
the bowel was brought out through this site , and bowel continuity was restored using stapling devices .
two 10-mm jackson - pratt drains are placed through the 8-mm robotic ports 1 and 3 .
he has not had any episodes of obstruction or renal colic and continues to do well 48 months after surgery .
the primary indication for ileal ureter replacement is lengthy ureteral injury precluding simple reimplantation or a boari flap .
the only alternatives for most patients requiring ileal ureter are a permanent nephrostomy tube , autotransplantation , and nephrectomy . given his solitary kidney and history of cysteine stones ,
laparoscopic techniques are being increasingly utilized for reconstructive procedures , such as radical prostatectomy and cystectomy . with experience
, this technology is being applied to an expanding number of procedures . to our knowledge ,
robotic - assisted laparoscopic surgery offers several advantages over conventional laparoscopic surgery and is ideally suited for longer , complex reconstructive procedures .
the robotic system offers a 3-dimensional visualization with magnification for the surgeon , who can control camera position .
the surgical instruments have increased degrees of freedom that facilitate the surgeon 's ability to perform complex maneuvers in a tight space without tremor or fatigue .
these factors also decrease estimated blood loss , incision length , hospital length of stay , postoperative pain , and complication rate compared with open or laparoscopic surgery .
although the large surgical field required for this procedure may seem to preclude the robotic approach , our technique demonstrates that the same ports can be used with changes in the robotic position to safely complete the surgery .
this surgery was done prior to the introduction of the newer da vinci - s system , but either system could be used today . despite the advantages of robotics , the procedure was lengthy for several reasons .
identification of the ureter was difficult due to severe retroperitoneal inflammation , which was not unexpected given the patient 's stone history and would have also complicated open surgery .
lastly , surgeons and nurses were performing a new procedure , and the learning curve for laparoscopic procedures has been demonstrated to be significant .
times for this case were similar to times for reported laparoscopic cases . with advancing robotic experience , some of these drawbacks can be expected to improve .
the robot - assisted approach achieved the goals of traditional ileal ureter replacement , with maintenance of renal function and decreased stone formation , along with the usual benefits of a minimally invasive approach .
because ileal ureter replacement is not a commonly performed procedure , it is unlikely a prospective comparison of the open and laparoscopic approach will be forthcoming . however , robot - assisted laparoscopic ileal ureter replacement appears to be a reasonable alternative to the open approach in the appropriate patient .
 background and objectives : a patient with a solitary kidney , cysteine stones , and recurrent ureteral strictures underwent robot - assisted laparoscopic ureterectomy with ileal ureter formation.methods:using a transperitoneal , 4-port robotic approach , we removed the strictured ureter and created an ileal ureter . 
 the ileal - pyelo and ileal - vesical anastomoses were performed using the robotic system . 
 an extracorporeal bowel anastomosis was performed using stapling devices . 
 operative time was 9 hours with negligible blood loss , and the patient was discharged after 5 days.results:a cystogram at 10 days demonstrated patent anastomoses without extravasation . the patient continues to do well 48 months later.conclusion:robot-assisted laparoscopic ileal ureter replacement is feasible with excellent long - term outcome . 
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INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION