robot - assisted laparoscopic radical prostatectomy ( ralrp ) combines the advantages of minimal invasive surgery and quicker learning compared with conventional laparoscopic radical prostatectomy .
as more patients seek ralrp , more anatomic variants will be encountered by surgeons performing this procedure .
successful open radical retropubic prostatectomy has been described in patients with abnormalities of wolffian duct derivatives , including ectopic ureteral insertion into the seminal vesicle .
we describe successful performance of ralrp on a patient with localized prostate cancer and complete left ureteral duplication with ectopic insertion into the prostatic urethra .
a 52-year - old man presented with psa of 5.1  ng  ml and was found to have gleason 3  +  3 adenocarcinoma of the prostate with clinical stage t1c .
his baseline creatinine was 0.9  mg  dl ; no prior urological history or childhood illness existed .
the right ureteral orifice was in the orthotopic position and the left ureteral orifice was not initially seen .
closer inspection revealed a ureteral orifice on the left , draining into the prostatic urethra with urine effluxing from this position .
a double pigtail ureteral stent was then placed with the flexible cystoscope . to completely excise the prostate ,
we proceeded with a transperitoneal approach to ralrp using the four - armed da vinci surgical system ( intuitive surgical , sunnyvale , ca , usa ) , with six trocars , as previously reported . before releasing the bladder from the anterior abdominal wall we elected to identify the left ureter by incising the peritoneum anterior to the common iliac artery .
we localized the ureter with our stent seen within ; an additional second ureter running parallel was appreciated , thus confirming ureteral duplication .
both ureters were traced down to the posterior detrusor using robotic instruments while leaving adequate surrounding adventitia .
we proceeded with radical prostatectomy , including bladder mobilization from the abdominal wall , followed by incision of endopelvic fascia and ligation of the dorsal venous complex .
the anterior portion of the prostatovesicular junction was incised , exposing the urothelial surface and trigone .
the previously placed stent was emanating from the ectopic insertion in the prostatic urethra ( fig .  1 ) .
given the finding of the second ureter , we closely observed for a second left ureteral orifice and this was appreciated very close to the bladder neck within the confines of the bladder
. the patient therefore had complete left ureteral duplication with ectopic insertion of one ureter within the prostatic urethra . 

1incision of posterior prostatovesicular junction ( single arrow - head ) with prostate above and bladder neck below .
note the foley catheter ( double arrow - head ) providing upward traction and the ureteral stent ( arrow ) located in the ectopic ureter inserting into the prostatic urethra incision of posterior prostatovesicular junction ( single arrow - head ) with prostate above and bladder neck below .
note the foley catheter ( double arrow - head ) providing upward traction and the ureteral stent ( arrow ) located in the ectopic ureter inserting into the prostatic urethra the posterior portion of the prostatovesicular junction was then incised . in performing this maneuver , we purposefully transected the left distal ectopic ureter as it entered the prostate .
the dome of the bladder was lifted up with forceps using the fourth robotic arm .
both left ureters were traced down along the posterior detrusor muscle to maximize ureteral length .
the duplicated ureters were then transected by use of the robotic curved scissors at the level of the bladder hiatus where the lower pole moiety ureter entered the bladder .
this defect in the posterior bladder was closed with running 2 - 0 vicryl in two layers .
the remainder of the prostatectomy was completed including dissection of both vas deferens and seminal vesicles , incision of denonvilliers fascia , and control of the vascular pedicles with preservation of the bilateral neurovascular bundles .
the urethrovesical anastomosis was completed using our modified running suture technique , which utilizes a single lapra - ty to secure approximation of the posterior plate .
the ectopic ureter was previously stented and the second left ureter was cannulated with a 0.38 glidewire inserted through the assistant s
a stay suture of 3 - 0 vicryl was placed in the lateral and medial adventitia surrounding the duplicated ureters .
next , each ureter was spatulated by incising a short segment of their adjoining walls .
a y - type conjoined ureteral anastomosis was then configured by bringing the respective posterior walls together using interrupted 5 - 0  pds followed by suturing the respective anterior walls together in the same fashion ( fig . 
a double pigtail ureteral stent was exchanged for the ureteral catheter leaving two stents emanating , one from each left ureter . 

after spatulation , an anterior and a posterior suture line provide for a common opening for both left ureters before ureteroneocystotomy y - type conjoined ureteral anastomosis for duplicated ureters .
after spatulation , an anterior and a posterior suture line provide for a common opening for both left ureters before ureteroneocystotomy the bladder was filled with saline and a cystotomy was made in the left posterior bladder .
this procedure was successfully completed in approximately 420  min without open conversion and the estimated blood loss was 200  ml .
the patient had the pelvic drain removed on pod # 3 and was discharged on pod # 4 .
a cystogram performed on pod # 14 revealed left - sided reflux to both moieties but no extravasation .
final pathology demonstrated a 26  g gland with organ confined gleason 3  +  3 adenocarcinoma and negative surgical margins .
the incidence of partial and complete ureteral duplication , on the basis of autopsy studies , is 1 in 125 or 0.8% .
although 80% of ectopic ureters are associated with duplication , many ectopic ureters in males are associated with a single system .
the most common sites of termination of ectopic ureters in males are the posterior urethra ( 47% ) and the seminal vesicles ( 33% ) .
ideal cases for applying robotic assistance in laparoscopy involve a reconstructive component in a relatively confined working space .
robot - assisted procedures are well described in the urological literature and include radical prostatectomy , radical cystoprostatectomy [ 9 , 10 ] dismembered pyeloplasty , and vaso - vasostomy .
the authors describe incidental right distal ureteral transection at the level of the seminal vesical , which was identified intraoperatively with indigo carmine .
a stent was placed , the distal ureter was spatulated , and ureteroneocystotomy was performed .
our case is similar but more complex , because of complete ureteral duplication and the elective nature of proceeding despite a potentially troublesome anatomic variant .
we performed three reconstructive maneuvers during one case including vesicourethral anastomosis , a y - type conjoined ureteral anastomosis , and ureteroneocystotomy .
although this complex procedure could have been performed with conventional laparoscopic techniques , we feel robotic assistance was extremely useful in saving time and minimizing operator fatigue .
the reconstructive technique used for this duplicated system was a wallace anastomotic variant in which both ureters were brought together in a y - typed conjoined anastomosis before ureteroneocystotomy .
this is a known refluxing type anastomosis classically described as a ureteral - intestinal anastomotic technique used during cystectomy and creation of urinary diversion .
advantages of this technique include low occurrence of stricture and the ability to keep duplicated ureters together in a common sheath to be mobilized as a unit without risk of compromising a shared blood supply .
the theoretical disadvantage is that obstruction of one ureter may lend to obstruction of the other , which is in immediately close proximity .
accordingly , the wallace technique is not recommended during radical cystectomy when great concern for ureteral recurrence exists .
other options for reconstruction were considered , for example ureteroureterostomy with the upper pole ureter joining the lower pole ureter proximal to the bladder hiatus .
this course of action would have been difficult in this case given the extreme close proximity of the lower pole ureteral orifice to the bladder neck .
consideration was also given to separately implanting each ureter into the bladder at separate locations .
we felt this option was suboptimum because of theoretical concern for a shared blood supply between the duplicated ureters which if compromised could lead to stricture formation .
this case demonstrates the possible utility of preoperative flexible cystoscopy in prostatectomy patients . at our institution flexible cystoscopy is routinely performed either in the office or in the operating room immediately before prostatectomy .
this is not a practice uniformly accepted by all who perform radical prostatectomy but we agree with others who advocate performing flexible cystoscopy that it provides information about bladder pathology , preexisting urethral abnormalities , and the location and status of the ureteral orifices . in our teaching institution , we have also found that excision of the prostatovesicular junction is a relatively challenging step in teaching and learning this procedure and that immediate cystoscopy facilitates the learning process . in conclusion , ureteral anomalies , although uncommonly encountered , are detectable and do not preclude safe and effective performance of ralrp without the need for open conversion .
in this case , robotic assistance enabled timely performance of three laparoscopic reconstructive maneuvers in one setting and improved surgeon ergonomics compared with conventional laparoscopic prostatectomy .
 robotically assisted laparoscopic radical prostatectomy ( ralrp ) has become an alternative surgical treatment option for patients with localized prostate cancer . 
 rare anatomic variations result in modification of established techniques . 
 we describe the first successful completion of ralrp for localized prostate cancer in a patient with coexisting complete left ureteral duplication and ectopic insertion of the upper pole moiety ureter into the prostatic urethra . after standard radical prostate excision and vesicourethral anastomosis , 
 the unique anatomy in this case required additional reconstructive maneuvers including construction of a y - type conjoined ureteral anastomosis and ureteroneocystotomy . 
 the procedure was safely completed without open conversion . 
 operative time was 420  min and ebl was 200  ml . 
 ureteral stents were removed in six weeks and ivp showed no evidence of obstruction . when faced with a ureteral anomaly , ralrp can be safely completed . 
 robotic technology is helpful in performing additional delicate reconstructive maneuvers . 
Introduction
Materials and methods
Results
Discussion