Robotic Local Fat Extirpation and Ureteric Reimplantation for Pelvic Lipomatosis with Ureteric Obstruction: Technical Considerations.

BACKGROUND: Ureteric reimplantation is the treatment of choice for pelvic lipomatosis with ureteric obstruction. Pelvic adherent fat poses a technical challenge during this surgery. DESCRIPTION OF TECHNIQUE: We describe the robotic approach to facilitate the precise dissection of the ureter and bladder in adherent fat. After creating pneumoperitoneum and port placement, the ureter is exposed at the iliac crossing and dissected distally. Perivesical fat at the intended site of ureteric reimplantation is excised and cystotomy is done. Ureterovesical anastomosis is performed over a stent. PATIENTS AND METHODS: Two patients with pelvic lipomatosis causing ureteric obstruction and renal function impairment underwent robotic ureteric reimplantation at our institute. Technical aspects and outcomes are discussed here. RESULTS: Blood loss was minimal. No intra-operative or post-operative complication was noted. Renal function improved for both patients. CONCLUSION: Robotic approach helps to overcome the technical difficulties posed by adherent fat during ureteric reimplantation in pelvic lipomatosis.

Role of Retrograde Intrarenal Surgery in the Management of Diabetic Renal Papillary Necrosis.

Introduction: It is challenging to diagnose diabetic renal papillary necrosis (RPN) radiologically due to the limitation in performing a contrast study in patients with compromised renal function. Endoscopic management by Double 'J' (DJ) stenting or percutaneous nephrostomy is the preferred treatment. The aim of our study was to analyze the role of retrograde intrarenal surgery (RIRS) in the management of RPN by retrieving necrosed papillae. Methods: This retrospective study included diabetic patients who presented with acute pyelonephritis or urosepsis at our institute. After evaluating with appropriate laboratory and radiological investigations, retrograde pyelography (RGP) and DJ stenting were performed in those who did not respond to intravenous antibiotic therapy. The RIRS was performed in patients who had filling defects in the pelvicaliceal system (PCS) on RGP after 3 weeks at the time of DJ stent removal. Patients with a minimum follow-up period of 6 months were included. Results: A total of 187 patients (81 female, 106 male) with diabetes with a mean age of 58.3 years were enrolled in this study. The mean serum creatinine was 2.7 mg/dL and mean estimated glomerular filtration rate was 32.8 mL/min/1.73 m2. One hundred twenty-six patients (67.3%) had hydroureteronephrosis (HUN), out of whom 74 (58.7%) had necrosed papillae in the PCS. In 61 (32.6%) patients, there was no HUN; however, 25 (41%) of these patients had necrosed papillae in PCS. Necrosed renal papillae were retrieved in 83 patients (46.1%) by RIRS. All the patients were followed up for a minimum period of 6 months; seven patients (3.8%) had recurrent pyelonephritis. Conclusions: The RIRS plays a significant role in the management of diabetic RPN. Retrieving necrosed papillae from the PCS after confirming their presence by RGP prevents ureteric obstruction, which leads to urosepsis, and presumptively prevents or delays future episodes of pyelonephritis.

Upper Ureteric Stricture Secondary to Celiac Plexus Block Managed by Robotic Ureterocalicostomy.

Introduction: Ureterocalicostomy is a well-established procedure of choice for recurrent pelviureteric junction (PUJ) obstruction refractory to endoscopic management, failed pyeloplasty, completely intrarenal pelvis, and iatrogenic upper ureteral stricture with significant peripelvic fibrosis. Robotic ureterocalicostomy is the procedure of choice in such scenarios where meticulous dissection and accurate anastomotic suturing is required. Case Presentation: We report the case of an 18-year-old male, who underwent celiac plexus block for pain management of chronic calcific pancreatitis and presented with pain in the epigastric region and the right flank. A CT and subsequent nephrostogram revealed an upper ureteral defect (corrosive stricture) of ∼4 cm at the level of PUJ. Robotic ureterocalicostomy was performed. We discuss the clinical presentation, evaluation, and management along with literature review. Conclusion: Iatrogenic ureteral strictures are not uncommon in urological practice, but an upper ureteral stricture secondary to celiac plexus block is a rarity. Adequate evaluation and timely intervention by reconstructive surgery, robotic ureterocalicostomy in this case, yield satisfactory results.