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Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model

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Abstract

Objective

To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures.

Materials and methods

Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6–9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated.

Results

All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162–360). Flap tubularization suture took 31 min (19–47), and proximal anastomosis took 20 min (15–38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7–12) and 23 min (13–46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003).

Conclusions

Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

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Acknowledgments

L. F. B. received a grant support from Urology department and Research Program Committee from Cleveland Clinic. L. F. B. was sponsored by Brazilian CAPES (Coordenação de aperfeiçoamento pessoal de nível superior) as a PhD project with the School of medicine of Federal University of São Paulo (EPM-UNIFESP, Brazil).

Author’s contribution

Dr. Brandao involved in project development, data collection, data analysis and manuscript writing; Dr. Laydner involved in project development, data analysis and manuscript writing; Dr. Akca involved in project development, and data collection and analysis; Dr. Autorino involved in data analysis and manuscript editing; Dr. Zargar involved in manuscript editing; Dr. De involved in data collection and analysis; Dr. Krishnan involved in manuscript editing; Dr. Pallavi involved in pathological data analysis; Dr. Monga involved in data collection and analysis, and manuscript editing; Dr. Stein: involved in data analysis; Dr. Magi-Galluzzi involved in pathological data analysis; Dr. Andreoni involved in final review and manuscript editing; Dr. Kaouk involved in final review and manuscript editing.

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Authors and Affiliations

  1. Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA

    Luis Felipe Brandao, Humberto Laydner, Oktay Akca, Riccardo Autorino, Homayoun Zargar, Shubha De, Jayram Krishnam, Manoj Monga, Robert J. Stein & Jihad H. Kaouk

  2. Pathology Department, Cleveland Clinic, Cleveland, OH, USA

    Patil Pallavi & Cristina Magi-Galluzzi

  3. Department of Urology, Paulista School of Medicine, UNIFESP, Sao Paulo, SP, Brazil

    Luis Felipe Brandao & Cassio Andreoni

  4. Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Humberto Laydner & Riccardo Autorino

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  1. Luis Felipe Brandao
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Correspondence to Luis Felipe Brandao.

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The authors declare that they have no conflict of interest.

Ethical approval

All applicable international, national and/or institutional guidelines for the care and use of animals were followed. All procedures performed in studies involving animals were in accordance with the ethical standards of the institution or practice at which the studies were conducted.

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Informed consent was obtained from all individual participants included in the study.

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Brandao, L.F., Laydner, H., Akca, O. et al. Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model. World J Urol 35, 89–96 (2017). https://doi.org/10.1007/s00345-016-1840-4

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  • DOI: https://doi.org/10.1007/s00345-016-1840-4

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