V11-07 robotic-Assited Transplanted Ureteral Stricture Management

Abstract

computed tomography scan revealed compression of the left renal vein under the superior mesenteric artery. She underwent a venogram with intravenous ultrasound, which demonstrated >90% narrowing of the left renal vein under the SMA, diagnostic for Nutcracker Syndrome.RESULTS: After positioning in Trendelenburg position and obtaining pneumoperitoneum, ports were placed similar to a robot assisted retroperitoneal lymphadenectomy procedure. The retroperitoneum was exposed by incising the posterior peritoneum and tacking this to the anterior abdominal wall. The inferior vena cava (IVC) was identified and skeletonized, with emphasis on identification and dissection of the left renal vein. Vascular control was obtained using modified Rummell tourniquets. During our dissection, we identified a dilated and prominent left gonadal vein. We anastomosed the distal aspect of the left gonadal vein to the IVC, to provide constant venous outflow from the left kidney during transposition of the left renal vein. With the left kidney draining through both the left renal and gonadal vein, the left renal vein was stapled flush with the IVC. We then performed left renal vein transposition by anastomosing the left renal vein to the IVC below the left of the previous insertion with Gore-Tex suture. Vascular clamps were removed to assess the integrity of the anastomoses, and hemostasis was excellent. Total estimated blood loss was 50mL, and total operative time was 3 hours and 19 minutes. Postoperative creatinine improved to 0.57 mg/dL from 0.75 mg/dL preoperatively. The patient was discharged on postoperative day one. At 6 weeks follow up, her flank/abdominal pain had completely resolved.CONCLUSIONS: Robot assisted renal vein transposition is a feasible and safe alternative to open transposition for Nutcracker Syndrome. Transposition of the left renal vein without venous outflow obstruction is possible when utilizing the native gonadal vein as a conduit to the IVC. Using this approach, adequate venous outflow can avoid nephron injury.