Ureteral injury during robot-assisted radical prostatectomy: management of a rare and challenging postoperative complication
Abstract
This video shows the robot-assisted distal ureteral reimplantation performed for an ureteral injury occurred during a robot assisted radical prostatectomy of a 64 years old man in good general condition, with diagnosis of high risk PCa.
No intraoperative complication was noticed, catheter has been removed after 7 days with negative cystography. 10 days after surgery the patient harboured nausea and abdominal pain, serum creatinine was 3,7 mg/dl and eGFR 16,6 ml/min. A first CT scan without and with contrast showed a big abdominal mass of 20 cm maximum, suspected of right lymphocele. Thus, abdominal drain was positioned and creatinine from it was 43,7 mg/dl. The recorded RARP video was analysed showing a left ureteral injury. A third CT scan with cystography established a urine leakage from the left distal ureter at 5 cm from the bladder. Firstly, conservative management using retrograde ureteral stenting was tried with decrease of serum creatinine at 0.9 mg/dl but without improvement of symptoms. Therefore, the decision was to surgically drain the abdominal urinoma and performed a robot-assisted distal ureteral reimplantation. The urinoma created important inflammation and after difficult identification of the left ureter and its isolation, ureteroneocystostomy was performed.
Drain and catheter were removed in post-operative day 3 and day 8, respectively. No major complications were recorded during hospital stay (10 days). Ureteral stent was removed after 6 weeks. At 3-month follow-up, blood creatinine was 0.88 mg/dl and eGFR was >90 ml/min, with no referred pain and other complains. US showed limited residual minimum pyelectasis but no hydronephrosis.