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Videosurgery
Robotic management of a duplicated ureter during intracoporeal urinary diversion following robotic cystectomy
Abdullah Erdem Canda1, Erem Asil2, Erdem Koc2, Mustafa Aldemir2, Arslan Ardicoglu3, Ali Fuat Atmaca3
1Yildirim Beyazit University School of Medicine, Ankara, Turkey
2Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
3Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, Turkey
Citation: Canda A E, Asil E, Koc E, et al. Robotic management of a duplicated ureter during intracoporeal urinary diversion following robotic cystectomy. www.ceju.online/journal/10000/robotic-cystectomy-urteric-duplication-management-1421.php
Key Words: management • robotic cystectomy • urteric duplication

Robotic radical cystectomy with intracorporeal urinary diversion is increasingly being performed in the minimally invasive surgical management of invasive bladder cancer. We published our surgical technique before (1). One of the important steps of this procedure is preparation of the ureters for Wallace type anastomosis to be performed between ureters and the chimney of the Studer pouch. For this purpose, left ureter is passed to the right side under the sigmoid colon and two ureters are lifted up by using the 4th arm at their tips. Thereafter, both ureters are spatulated by monopolar curved scissors. One of the ureters might be identified to have a duplication at this stage. Although preoperative radiologic evaluation might show the presence of a duplicated ureter, as an example in this particular case, radiology might not show it and thus it might be a surprise for the operating console surgeon to come across a duplicated ureter during the surgery. This particular video explains the surgical technique used in order to perform a uretero-ureteral anastomosis (Wallace type anastomosis) in the presence of a duplicated ureter. Initially, the right ureter is spatulated and then the left ureter is spatulated. Thereafter, the console surgeon realizes that right ureter is duplicated. Therefore, a further spatulation of the duplicated right ureter is also performed. A 4/0 monocryl suture with 20 mm, ½ circle atraumatic needle is used in order to make an anastomosis between the left ureter and left side of the duplicated right ureter. Thereafter, the same suture is used in order to join the plane between duplicated right ureters. In this way, a single lumen is formed at the ends of the 3 ureters to be anastomosed to the chimney of the Studer pouch. Thereafter, 3 single J stents, 70 cm in length are inserted one by one through the abdomen and passed through the chimney of the Studer pouch and are introduced into the 3 ureters. Lastly, a double armed 3/0 barbed suture (Stratafix, 17 mm, ½ circle taper point 16x16 cm, Ethicon) is used in order to perform the anastomosis between the ureters and the chimney of the Studer pouch. Before completing this anastomosis the tips of the ureters are cut and sent for pathologic evaluation. We think that advantages of robotic surgery including three-dimensional optical magnification, dexterity in motion, and the ability to perform tremor-free and delicate movements with three independent robotic arms in addition to the camera arm for the console surgeon significantly facilitates performing this procedure.

References
  1. Canda AE, Atmaca AF, Altinova S, Akbulut Z, Balbay MD. Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int. 2012 Aug;110(3):434-44.
Article history
Submitted: 12 May, 2017
Accepted: 2 August, 2017
Published online: 3 August, 2017
doi: 10.5173/ceju.2017.1421
Corresponding author
Abdullah Erdem Canda
email: erdemcanda@yahoo.com
Conflicts of interest:  The authors declare no conflicts of interest.
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