V01-02: Three-dimensional augmented reality robot-assisted segmental ureterectomy with buccal mucosa graft for the repair of upper complex ureteral strictures
Introduction: Ureteral stenosis constitutes a very complex surgical scenario with a high rate of post-operative failure. For 2-3 cm upper stenosis, a robotic-assisted segmental ureteral resection with subsequent uretero-ureteral anastomosis using a buccal mucosa graft is a fesible option. For the intraoperative identification of the stenosis, a concomitant ureteroscopy is usually performed. However, the addition of the endoscopy increases the intraoperative complexity and costs of the surgery. In order to increase the precision in locating the stricture during the surgical dissection of the ureter, we tested 3D augmented reality (AR) surgical navigation during the intervention. Methods: AR intraoperative navigation is performed using a dedicated ICON rack connected to the DaVinci® surgical console. A 3D mouse is used by an assistant to manually overlap the 3D virtual model on the operative field. The surgeon can visualize the superimposed images in real time via Tile Pro technology. Three cases of different level ureteral strictures caused by stones embedded into the ureteral wall and located above the iliac vessels cross are shown in the video. AR is used to superimpose the 3D virtual model of the ureter together with its stone over the operative field, leading to a precise location and resection of the stricture. In the reconstructive phase, the mucosal graft is put into the abdominal cavity once the posterior plate of the anastomosis is realized with a termino-terminal suture, minimizing the tension on the defect repair. Results: In all the three cases, AR allowed a proper identification of the endoluminal stricture. All the surgeries were successful without significative intra and post-operative complications. Postoperative examinations confirmed the success of the procedures. Conclusions: AR intraoperative guidance showed to be a useful and precise technological tool able to correctly identify the ureteral stricture even when not visible on the ureteral wall surface, leading to maximize the preservation of ureteral peri-strictural healthy tissue. SOURCE OF Funding: none