Introduction & Objectives: To describe the management of intraoperative vascular lesion of a major vessel during robot-assisted right radical nephroureterectomy and bladder cuff excision for suspicious upper tract urothelial carcinoma, which occurred to be benign pathology. Materials & Methods: This is the case of a 60-year-old woman with Brugada Syndrome who underwent abdominal ultrasound after complaining of abdominal pain and a single episode of hematuria. The ultrasound demonstrated a right 4-degree hydronephrosis of the kidney. The contrast-enhanced CT scan demonstrated a functional right renal exclusion due to a suspect middle ureteral tumor of 1.4cm. The pre-operative kidney function was normal. The patient was addressed to robot-assisted right radical nephroureterectomy with bladder cuff excision. After colon medialization, the opening of the Gerota, and right kidney exposure, the ureter was closed proximally. After that, the renal pelvis was opened, the urines were carefully suctioned to avoid spillage, and the right renal pelvis was closed with clips. The renal hilum and the right kidney artery and vein were closed with clips and dissected. The kidney was completely mobilized and the ureter was freed and progressively clipped toward the pelvis. During the ureter distal isolation, thick adhesions with the right external iliac artery involving the vessel itself were found. A careful smooth and blunt dissection was performed to avoid vascular injury. During the dissection, a rupture of the artery occurred. The bleeding was first controlled with Cadier and Maryland forceps. A prolene suture of the vessel was attempted, but it was unsuccessful. Therefore, a Bulldog was placed to close the artery proximally and distally, the Maryland was left in place keeping the artery defect closed, the other robotic arms were undocked and an open conversion was performed with vascular surgeon consultation. After bleeding control, the artery seemed to be infiltrated by the suspect neoplasm, and a Dacron prosthesis replacement was decided. Finally, the nephroureterectomy was completed. Results: The estimated blood loss was 1100cc which required intraoperative transfusion. The patient was transfused twice postoperatively. The abdominal drainage was removed three days after surgery, and the patient was put on antiaggregant therapy on post-operative day 2. The length of stay was 12 days. The final pathology report was polypoid endometriosis of the right ureter with focal involvement of the periadventitial layer of the external iliac artery segment. Conclusions: Endometriosis of the ureter can induce rare challenging scenarios that can lead to life-threatening complications. In experienced hands, robotics can still be used to manage complications immediately preparing the field for a safer and less stressful opening conversion.
Nightmare surgical scenario during robotic nephroureterectomy for unexpected ureteral endometriosis infiltrating the external iliac artery
Roggero, L.;Brancelli, C.;Corghi, G.;Cerruto, M. A.;Bertolo, R. G.;Antonelli, A.
2024-01-01
Abstract
Introduction & Objectives: To describe the management of intraoperative vascular lesion of a major vessel during robot-assisted right radical nephroureterectomy and bladder cuff excision for suspicious upper tract urothelial carcinoma, which occurred to be benign pathology. Materials & Methods: This is the case of a 60-year-old woman with Brugada Syndrome who underwent abdominal ultrasound after complaining of abdominal pain and a single episode of hematuria. The ultrasound demonstrated a right 4-degree hydronephrosis of the kidney. The contrast-enhanced CT scan demonstrated a functional right renal exclusion due to a suspect middle ureteral tumor of 1.4cm. The pre-operative kidney function was normal. The patient was addressed to robot-assisted right radical nephroureterectomy with bladder cuff excision. After colon medialization, the opening of the Gerota, and right kidney exposure, the ureter was closed proximally. After that, the renal pelvis was opened, the urines were carefully suctioned to avoid spillage, and the right renal pelvis was closed with clips. The renal hilum and the right kidney artery and vein were closed with clips and dissected. The kidney was completely mobilized and the ureter was freed and progressively clipped toward the pelvis. During the ureter distal isolation, thick adhesions with the right external iliac artery involving the vessel itself were found. A careful smooth and blunt dissection was performed to avoid vascular injury. During the dissection, a rupture of the artery occurred. The bleeding was first controlled with Cadier and Maryland forceps. A prolene suture of the vessel was attempted, but it was unsuccessful. Therefore, a Bulldog was placed to close the artery proximally and distally, the Maryland was left in place keeping the artery defect closed, the other robotic arms were undocked and an open conversion was performed with vascular surgeon consultation. After bleeding control, the artery seemed to be infiltrated by the suspect neoplasm, and a Dacron prosthesis replacement was decided. Finally, the nephroureterectomy was completed. Results: The estimated blood loss was 1100cc which required intraoperative transfusion. The patient was transfused twice postoperatively. The abdominal drainage was removed three days after surgery, and the patient was put on antiaggregant therapy on post-operative day 2. The length of stay was 12 days. The final pathology report was polypoid endometriosis of the right ureter with focal involvement of the periadventitial layer of the external iliac artery segment. Conclusions: Endometriosis of the ureter can induce rare challenging scenarios that can lead to life-threatening complications. In experienced hands, robotics can still be used to manage complications immediately preparing the field for a safer and less stressful opening conversion.
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