the delayed setting , there is often significant scarring , and traditionally these injuries have been repaired through a standard open surgical approach .
however , the expansion of laparoscopic and robotic pelvic surgery suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries .
we present , to our knowledge , the first case of delayed robotic - assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy .
a 57-year - old female underwent a seemingly uncomplicated robotic - assisted total hysterectomy and bilateral oophorectomy for symptomatic fibroids .
on postoperative day number 8 , she presented for her postoperative follow - up appointment with a complaint of persistent low back discomfort and right flank pain .
the same day , a ct scan with iv contrast was obtained that demonstrated severe right - sided hydroureteronephrosis consistent with a high - grade obstruction ( figure 1 ) .
she was admitted , and the following day ( postoperative day 9 ) , she was taken back to the operating room for further evaluation and management .
a retrograde uretero - pyelogram demonstrated an abrupt cutoff of the right distal ureter consistent with suture ligation ( figure 2 ) .
a ureteral stent was successfully placed , but the ureter remained severely medially deviated , and it was elected to definitively relieve the obstruction .
the patient was explored , and the ureteral obstruction repaired via a less - invasive approach using robotic assistance .
ct with iv contrast showing severe right - sided hydroureteronephrosis consistent with a high - grade obstruction .
retrograde uretero - pyelogram demonstrating an abrupt cutoff of the right distal ureter consistent with suture ligation .
a 4-port format was used with a 12-mm supraumbilical camera port , two 8-mm robotic ports each placed lateral to the medial umbilical ligaments and 19 cm from the pubic symphysis , and a 12-mm right lower quadrant assistant port .
a penrose drain was placed encircling the ureter , and the ureter was dissected sharply towards the bladder . during this dissection , it became apparent that the right ureter had been incorporated into the running suture used to close the vaginal cuff .
the suture was cut and the vaginal closure taken down in its entirety . after releasing the suture , the ureter appeared healthy but encased in inflammatory tissue that was excised .
the vaginal cuff was re - closed with a running 30 vicryl secured with lapraty clips ( ethicon , cincinnati , oh ) .
her ureteral stent was removed 3 weeks later . a follow - up lasix renal scan 3-months postoperatively demonstrated normal renal function bilaterally without evidence of obstruction .
a 4-port format was used with a 12-mm supraumbilical camera port , two 8-mm robotic ports each placed lateral to the medial umbilical ligaments and 19 cm from the pubic symphysis , and a 12-mm right lower quadrant assistant port .
a penrose drain was placed encircling the ureter , and the ureter was dissected sharply towards the bladder . during this dissection
, it became apparent that the right ureter had been incorporated into the running suture used to close the vaginal cuff .
the suture was cut and the vaginal closure taken down in its entirety . after releasing the suture , the ureter appeared healthy but encased in inflammatory tissue that was excised .
the vaginal cuff was re - closed with a running 30 vicryl secured with lapraty clips ( ethicon , cincinnati , oh ) .
her ureteral stent was removed 3 weeks later . a follow - up lasix renal scan 3-months postoperatively demonstrated normal renal function bilaterally without evidence of obstruction .
in females , the ureter courses medially at the base of the broad ligament , traversing just below the uterine vessels and then enters the bladder posterolaterally approximately 2.3 cm from the lateral edge of the cervix .
half of all ureteral injuries involve suture ligation , and the majority of ureteral injuries are not identified intraoperatively .
the typical management of iatrogenic obstruction of the ureter that is recognized postoperatively involves initial stenting followed by delayed open ureterolysis , repair , ureteral reimplantation , or both .
the role of robotic hysterectomy has been expanding rapidly , and iatrogenic ureteral ligation during robotic and laparoscopic gynecologic surgery has been reported . because these complications are rarely found intraoperatively , there is usually great reluctance on the part of the surgeon or patient , or both , to manage these complications robotically . despite this
, there is a potential role for robotic surgery in the delayed management of iatrogenic ureteral obstruction . as the role of robotic - assisted surgery continues to expand ,
complications from minimally invasive urologic and gynecologic surgery can now be managed robotically as well .
recent reports have shown that with robotic - assisted techniques , it is feasible to perform upper and lower urinary tract reconstruction with such procedures as ureteral reimplantation and ureteroureterostomy .
it is logical that these same techniques can be used for the management of ureteral complications .
our experience supports a role for robotic repair of iatrogenic ureteral obstruction due to suture ligation .
this role can potentially be expanded to include the repair of other iatrogenic ureteral injuries .
this can potentially preserve the advantages to the patient of the initial minimally invasive surgery .
 background and objectives : ureteral injuries , while rare , do occur during gynecologic procedures . 
 the expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries . 
 we present , to our knowledge , the first case of delayed robotic - assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.methods:we present a case report and review of the literature.results:a 57-year - old female underwent a seemingly uncomplicated robotic - assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids . on postoperative day 8 , she presented with persistent right flank pain . 
 imaging studies revealed high - grade ureteral obstruction consistent with suture ligation of the right ureter . 
 she underwent successful robotic - assisted ureteral deligation and ureterolysis . 
 her postoperative course was unremarkable , and she was discharged home on postoperative day 1 from the deligation.conclusion:robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible . 
 this can potentially preserve the advantages to the patient that are being seen from the initial less - invasive surgery . 
INTRODUCTION
CASE REPORT
Description of Robotic Surgical Procedure
DISCUSSION
CONCLUSION