Introduction: This video presents the surgical technique of robot-assisted ureteral re-implantation for distal ureteral fibrosis after open cystectomy and reconstruction with Studer orthotopic neobladder. A 59-year-old patient underwent open radical cystectomy and orthotopic urinary diversion for muscle-invasive bladder cancer. Postoperatively, left hydronephrosis and pyelonephritis occurred. Antegrade attempts to place an ureteral stent were unsuccessful. A nephrostomy drain was placed in the left side. The patient was then referred for laparoscopic robotic reconstruction. Methods: The ports were placed in analogy to robot-assisted cystectomy. First an extended adhesiolysis was necessary. The intestinal loops were dissected guided by concomitant cystoscopy which revealed the borders between intestine and bladder wall. Finally, right ureter was identified in the proximity of the afferent loop of the Studer neobladder. After preparing and freeing, the right ureter was intubated with a Ch.8 mono-J catheter. The search for the left ureter continued. The left ureter was localised using Methylene blue applied antegrade by the nephrostomy tube. Several attempts to intubate the left ureter Ch.8 mono-J were frustrane due to the considerable long stricture. Further dissection into the retroperitoneal space was necessary. The ureter seemed totally fibrotic over several centimetres. Finally antegrade left ureteral catheterization and retrograde insertion of a Ch.8 mono-J catheter was successful. Accidental lesions of the afferent loop were closed with a 4-0 PDS suture. The ureters were re-implanted end-to-side with 4-0 Stratafix® running sutures. Results: The patient was discharged on the 7th postoperative day after testing the uretero-neobladder anastomosis through a pouchography and a retrograde ureteropyelography and after removal of both mono-J stents. No perioperative complications were observed. Furthermore, the left renal function showed an increasing function 1 year postoperatively in the renal scintigraphy. Conclusions: This demanding robotic reconstructive ureteral re-implantation so far shows the feasibility and the clinical value of robotic minimal invasive approaches even in complex reconstructive surgeries after open urinary diversion. SOURCE OF Funding: none
