Surgical Techniques in Urology Laparoendoscopic Single-site Repair of Retrocaval Ureter: First Case Report Riccardo Autorino, Rakesh Khanna, Michael A. White, Georges-Pascal Haber, Gaurang Shah, Jihad H. Kaouk, and Robert J. Stein OBJECTIVE METHODS
We describe a case of retrocaval ureter treated with laparoendoscopic single-site surgery (LESS). A 26-year-old female was referred to our institution with a history of intermittent right-sided flank pain. Radiological imaging demonstrated hydronephrosis, suggesting the presence of a retrocaval ureter. A LESS repair was planned. Retrograde pyelogram confirmed a classic appearance for retrocaval ureter. A ureteral stent was positioned. The patient was placed in modified flank position. A 2-cm, completely concealed umbilical access was created, through which a single port access platform was positioned. An in-line endoscope was used for visualization. Articulating instruments were used during initial dissection. The entire ureter was mobilized posterior to the vena cava and transected at the caudal-most point where the dilated portion of the proximal ureter ended. The distal ureter was repositioned lateral to the inferior vena cava and spatulated laterally. The proximal ureter was spatulated medially. Two 4-0 Vicryl sutures were used for the ureteroureteral anastomosis. A separate 2-mm grasper placed in the right lower quadrant was used to assist with suture reconstruction. A drain was left through the umbilicus. Blood loss was minimal. Total operative time was 3 hours. The patient was discharged on postoperative day 2. At the 3-month follow-up, diuretic radionuclide scan revealed no evidence of obstruction of the right kidney and the patient was symptom-free. Albeit challenging, LESS repair for retrocaval ureter is a feasible procedure that can be considered as a treatment option for this rare anatomic anomaly. UROLOGY 76: 1501–1505, 2010. © 2010 Elsevier Inc.
etrocaval ureter represents a rare congenital anomaly as a result of the persistence of the posterior cardinal vein caudal to the renal vein. It most commonly presents in the fourth decade of life with lumbar pain, urinary tract infection, and/or secondary urolithiasis.1 Open surgery has represented the gold standard for successful treatment of this condition.2 Nevertheless, laparoscopic surgery is being increasingly used for a variety of ablative and reconstructive urological procedures and has been associated with decreased postoperative pain and shorter convalescence, especially for upper tract and reconstructive procedures.3 Surgical correction of retrocaval ureter can be performed with a laparoscopic approach and the outcome has been successful in the small number of cases described.4 Typically, laparoscopic ureteral reconstruction involves the use of several (3-6) transcutaneous ports. In
Robert J. Stein is a speaker for Applied Medical. From the Center for Laparoscopy and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States Reprint requests: Riccardo Autorino, Center for Laparoscopy and Robotic Surgery, Glickman Urological and Kidney Institute, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: [email protected]
or [email protected]
© 2010 Elsevier Inc. All Rights Reserved
recent years, laparoendoscopic single-site surgery (LESS) techniques have been used successfully to improve the esthetic outcome and possibly further reduce morbidity for ureteral reconstruction, including cases of pyeloplasty, ureteroneocystostomy, and ileal interposition.5 LESS is emerging in an effort to duplicate standard laparoscopic procedures through a virtually scar-free approach.6 Herein we describe a case of retrocaval ureter treated with LESS. To our knowledge, this represents the first such case reported in the literature.
CASE REPORT Preoperative Work-Up A 26-year-old female (body mass index 22) with no previous surgical history was referred to our institution with complaints of intermittent right-sided flank pain. Renal ultrasound demonstrated right-sided hydronephrosis and computed tomography scan suggested the presence of a retrocaval ureter. Serum testing demonstrated preserved renal function, and LESS repair of retrocaval ureter was planned.
Surgical Procedure Retrograde pyelogram confirmed a classic appearance suggesting retrocaval ureter (Fig. 1A) and a 4.7-Fr, 26-cm double-J ureteral 0090-4295/10/$36.00 doi:10.1016/j.urology.2010.01.031
Figure 1. Intraoperative views: (A) Retrograde pyelogram demonstrating typical appearance of retrocaval ureter; (B) external intraoperative view: GelPoint single-port access device with an EndoEye in-line endoscope and articulating instruments; (C) intraoperative view: distal ureter medial to the inferior vena cava (yellow cross) and inferior vena cava (blue star); (D) intraoperative view: completed ureteroureterostomy.
stent was positioned. The patient was then placed in rightside-up modified flank position. A 2-cm intra-umbilical incision was created and a GelPoint (Applied, Rancho Santa Margarita, CA) single-port access device was placed using open Hasson technique. It includes three 5-mm ports and an insufflation cannula, through which CO2 pneumoperitoneum was achieved and set at 13 mm Hg (Fig. 1B). An EndoEYE (Olympus, Center Valley, PA) in-line endoscope was used for visualization, and articulating instruments (Cambridge Endo, Framingham, MA) were used during initial dissection. The colon was dissected medially and the proximal ureter lateral to the vena cava was identified and dissected to a point somewhat posterior to the vena cava. Then, the more distal ureteral portion medial to the vena cava was identified and the ureter was traced superiorly to the level of the vena cava as well (Fig. 1C). The entire ureter was mobilized posterior to the vena cava and transected at the caudal-most point where the dilated portion of the proximal ureter ended. The stent was brought out of the proximal ureter and the distal ureter with the stent indwelling was brought lateral to the inferior vena cava in a normal anatomic position. The distal ureter was spatulated laterally and the proximal ureter medially. Consideration was given to resecting the retrocaval portion of the ureter but it was felt that this may create excessive tension when performing the reconstruction. Two 4-0 Vicryl sutures were used to perform a running anastomosis (Fig. 1D). After initiating the anastomosis, the proximal portion of the stent was replaced within the proximal ureter and the renal pelvis. An additional 2-mm grasper placed in the right lower quadrant was used to assist with suture reconstruction. A Jackson-Pratt drain was left through the umbilicus. Total operative time was 3 hours. 1502
Postoperative Course The patient’s postoperative course was uneventful and the Foley catheter was removed on the first postoperative day. Laboratory analysis of the drainage fluid suggested no urinary extravasation, and the drain was removed and patient discharged on the second postoperative day after return of bowel function. The indwelling stent was removed 4 weeks postoperatively. At 3-month follow-up, diuretic radionuclide scan revealed no evidence of obstruction of the right kidney (Fig. 2A), and the patient also remained symptom-free (Fig. 2B).
COMMENT Retrocaval ureter represents a rare congenital anomaly, with an incidence of 1/1000 live births.1 Surgical treatment is usually required when the patient is symptomatic or develops obstruction. There have been few reported cases of minimally invasive repair of this anomaly likely because of the infrequent incidence of this condition, the perceived risk with dissection of the inferior vena cava, and the technical complexity of laparoscopic ureteroureteral anastomosis. Laparoscopic transperitoneal repair of retrocaval ureter was first described by Baba and colleagues, who noted that intracorporeal suturing represented the most challenging part of the procedure.7 Since then, both transperitoneal and retroperitoneal approaches have been reported for the laparoscopic repair of this anomaly (Table 1). Matsuda et al. reported repair UROLOGY 76 (6), 2010
Figure 2. Three-month follow-up: (A) diuretic radionuclide scan demonstrating no evidence of obstruction; (B) view of the scar. Table 1. Laparoscopic management of retrocaval ureter: literature overview Approach Transperitoneal
5 (1 ⫻ 5; 4 ⫻ 10)
15 8 11
1 1 1
NA NA 4 (1 ⫻ 5; 3 ⫻ 10/12)
6 7.5 7.5
NA NA NA
4 (3 ⫻ 5; 1 ⫻ 10)
3 (2 ⫻ 5; 1 ⫻ 12)
4 (1 ⫻ 5; 3 ⫻ 8/10)
Op. Time (Hours)
Los (Days) 9
3 (1 ⫻ 5; 2 ⫻ 12) 3 (2 ⫻ 5; 1 ⫻ 10)
4 (2 ⫻ 5; 2 ⫻ 10/12)
3 (3 ⫻ 10)
3 (1 ⫻ 5; 2 ⫻ 10/12) 4 (2 ⫻ 5; 2 ⫻ 10/12)
Technical Notes Interrupted sutures; stenting at the end of the procedure Minilaparotomy required for anastomosis — Interrupted sutures ureteral catheter replaced by ureteral stent at the end of the procedure Interrupted sutures; stenting before surgery Interrupted sutures; antegrade stent insertion No excision of retrocaval ureteral segment; two running sutures; intraop. stent insertion Robotic-assisted procedure; interrupted sutures; antegrade stent insertion Running suture with ENDO STITCH device Stay stitch; Endoski needle; interrupted sutures Interrupted sutures; ureteral catheter replaced by stent at the end of procedure Interrupted sutures; stenting before surgery Interrupted sutures; antegrade stent insertion Extracorporeal suturing Running suture with ENDO STITCH device
NA, not available; LOS, length of stay. * Mean value.
of retrocaval ureter with laparoscopic ureteroureterostomy using 5 ports.8 In the case report of Polascik and Chen, longer operative time was cited as a significant drawback of laparoscopy in this setting.9 Salomon et al. reported the first case of retroperitoneoscopic repair of retrocaval ureter in a young man.10 They reported that operative duration was shorter than that for the transperitoneal approach. Similarly, Ameda et al. used transperitoneal and retroperitoneal laparoscopy in 2 cases of retrocaval ureter, respectively, and found that retroperitoneoscopy seemed more suitable for UROLOGY 76 (6), 2010
retrocaval ureter.11 Gupta et al. used a 3-port retroperitoneoscopic approach to perform ureteroureteral anastomosis.12 They felt that retroperitoneal access seemed safer, easier, and less time-consuming, providing direct access to the ureter and inferior vena cava. Thus far, the largest retroperitoneoscopic series has been reported by Xu et al.13 By contrast, Ramalingham et al. presented their experience with the transperitoneal repair of retrocaval ureter in 2 cases.14 They believed that transperitoneal intracorporeal suturing is less time-consuming and relatively eas1503
ier than retroperitoneoscopic suturing. More recently, Simforoosh et al. reported a series comprising 6 cases of laparoscopic repair of retrocaval ureter without excision of the retrocaval segment, including one with a renal pelvic stone.1 All authors seemed to agree that the most difficult and time-consuming aspect of the surgery is suture placement. Ishitoya et al. reported laparoscopic ureterolysis in a case of retrocaval ureter.15 Because laparoscopic reanastomosis of the transected ureter proved too time-consuming, ureteroureterostomy was performed through a 5-cm minilaparotomy. Similarly, Tobias-Machado et al. reported a case of retroperitoneoscopic treatment with extracorporeal suture of the ureteral stumps.16 To overcome problems related to suturing, the use of an automated suture device was suggested in the reports by Polascik et al. and Mugiya et al.9,17 In the last few years, there has been increasing interest in performing reconstructive and extirpative urologic procedures using LESS techniques. The transumbilical single-port approach is practical and affords a virtually scar-free result. Experience is increasing and thus far we have accumulated more than 100 LESS procedures at our institution.18 In this report, we describe the first successful case of LESS repair of retrocaval ureter using the GelPoint (Applied, Rancho Santa Margarita, CA) access platform. There are several beneficial features of this platform’s design, which provide advantages for LESS procedures. It provides a larger outer working profile for greater spacing of ports and less external clashing, its wound retractor can accommodate 1.5-7– cm incisions and varied abdominal wall thickness, and the device “floats” above the incision, which maximizes the internal working space and facilitates the introduction and exchange of instrumentation. The procedure was technically successful and operative time at 3 hours was comparable to that of reported standard laparoscopic series. To this point in our experience we have tended to use an ancillary 2-mm needlescopic grasper as an instrument in the nondominant hand to aid in triangulation for delicate reconstructive suturing. This 2-mm port is introduced through a small puncture that requires no formal closure. Other approaches that can be considered, if placement of ancillary ports is not desired, include using articulating needle drivers or an ENDO STITCH device (US Surgical/Tyco, Norwalk, CT). LESS procedures remain somewhat cumbersome, and further refinement in instrumentation is needed before the technique may achieve the level of standardization that has become the case for conventional laparoscopy. The present report provides a proof of principle for LESS repair of retrocaval ureter. The cosmetic advantage is the most appealing aspect of LESS, especially for younger patients. Recovery benefits for LESS compared with standard laparoscopic procedures are debated. Comparative series for LESS nephrectomy and LESS pyeloplasty have 1504
demonstrated no significant recovery benefit when compared with the standard laparoscopic procedures.19,20 Nevertheless, a report from Canes and colleagues suggested that LESS donor nephrectomy does demonstrate several significant recovery advantages over the standard laparoscopic procedure.21 Recently, Hemal et al. commented on the ease of dissection and intracorporeal suturing as the main advantages of the application of robotic technology to laparoscopic repair of retrocaval ureter.22 Recognized benefits of the da Vinci robotic System (Intuitive Surgical, Inc., Sunnyvale, CA) over conventional laparoscopy include superior ergonomics, 3-dimensional optical magnification of the operative field within direct control of the console surgeon, enhanced surgeon dexterity within the field of view, and precision of surgical manipulation with tremor reduction. Thus, many surgeons suggest that robotic technology may help overcome many of the challenges that are inherent in LESS procedures that have until now largely used adapted laparoscopic techniques.23 With modifications to port and robotic instrument configuration, we have reported the first successful series of robotic LESS procedures in humans. A salient highlight of these procedures was the improved facility for intracorporeal dissection and suturing with easier articulation and superior ergonomics.24 Further refinements in robotic technology are also necessary because the da Vinci system is not specifically designed for this approach.
CONCLUSIONS Albeit technically challenging, LESS repair for retrocaval ureter might represent a feasible new treatment option for this rare anatomic anomaly. References 1. Simforoosh N, Nouri-Mahdavi, TA. Laparoscopic pyelopyelostomy for retrocaval ureter without excision of the retrocaval segment: first report of 6 cases. J Urol. 2006;175:2166-2169. 2. Anderson JC, Hynes W. Retrocaval ureter: a case report diagnosed pre-operatively and treated successfully by a plastic operation. Br J Urol. 1949;21:209-214. 3. Stein RJ, Turna B, Patel NS, et al. Laparoscopic assisted ileal ureter: technique, outcomes and comparison to the open procedure. J Urol. 2009;182(3):1032-1039. 4. Chung BI, Gill IS. Laparoscopic dismembered pyeloplasty of a retrocaval ureter: case report and review of the literature. Eur Urol. 2008;54:1433-1436. 5. Desai MM, Stein R, Rao P, et al. Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for advanced reconstruction: initial experience. Urology. 2009;73(1):182-187. 6. Box G, Averch T, Cadeddu J, et al. Nomenclature of natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) procedures in urology. J Endourol. 2008; 22(11):2575-2581. 7. Baba S, Oya M, Miyahara M, Deguchi N, Tazki H. Laparoscopic surgical correction of circumcaval ureter. Urology. 1994;44(1):122126. 8. Matsuda T, Yasumoto R, Tsujino T. Laparoscopic treatment of a retrocaval ureter. Eur Urol. 1996;29(1):115-118. 9. Polascik TJ, Chen RN. Laparoscopic ureteroureterostomy for retrocaval ureter. J Urol. 1998;160(1):121-122.
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10. Salomon L, Hoznek A, Balian C, Gasman D, Chopin DK, Abbou CC. Retroperitoneal laparoscopy of a retrocaval ureter. BJU Int. 1999;84(1):181-182. 11. Ameda K, Kakizaki H, Harabayashi T, Watarai Y, Nonomura K, Koyanagi T. Laparoscopic ureteroureterostomy for retrocaval ureter. Int J Urol. 2001;8(2):71-74. 12. Gupta NP, Hemal AK, Singh I, Khaitan A. Retroperitoneoscopic ureterolysis and reconstruction of retrocaval ureter. J Endourol. 2001;15(3):291-293. 13. Xu D, Yao Y, Ren J, Liu Y, Gao Y, Che J, Cui X, Chen M. Retroperitoneal laparoscopic ureteroureterostomy for retrocaval ureter: report of 7 cases. Urology [10.1016/j.urology.2009.04.097]. 14. Ramalingam M, Selvarajan K. Laparoscopic transperitoneal repair of retrocaval ureter: report of two cases. J Endourol. 2003;7:85-87. 15. Ishitoya S, Okubo K, Arai Y. Laparoscopic ureterolysis for retrocaval ureter. Br J Urol. 1996;77:162-163. 16. Tobias-Machado M, Lasmar MT, Wroclawski ER. Retroperitoneoscopic surgery with intracorporeal uretero-ureteral anastomosis for treating retrocaval ureter. Int Braz J Urol. 2005;31:147150. 17. Mugiya S, Suzuki K, Ohhira T. Un-no T, Takayama T, Fujita K. Retroperitoneoscopic treatment of a retrocaval ureter. Int J Urol. 1999;6:419-422.
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18. White WM, Haber GP, Goel RK, Crouzet S, Stein RJ, Kaouk JH. Single-port urological surgery: single-center experience with the first 100 cases. Urology. 2009;74(4):801-804. 19. Raman JD, Bagrodia A, Cadeddu JA. Single-incision, umbilical laparoscopic versus conventional laparoscopic nephrectomy: A comparison of perioperative outcomes and short-term measures of convalescence. Eur Urol. 2009;55:1198-1204. 20. Tracy CR, Raman JD, Bagrodia A, Cadeddu JA. Perioperative outcomes in patients undergoing conventional laparoscopic versus laparoendoscopic single-site pyeloplasty. Urology. 2009; 74(5):1029-1034. 21. Canes D, Berger A, Aron M, et al. Laparo-endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol. 2010;57:95-101. 22. Hemal AK, Rao R, Sharma S, Clement RGE. Pure robotic retrocaval ureter repair. Int Braz J Urol. 2008;34:734-738. 23. Rané A, Tan GY, Tewari AK. Laparo-endoscopic single-site surgery in urology: is robotics the missing link? BJU Int. 2009;104(8): 1041-1043. 24. Kaouk JH, Goel RK, Haber GP, Crouzet S, Stein RJ. Robotic single-port transumbilical surgery in humans: initial report. BJU Int. 2009;103:366-369.