| Summary: | Introduction: Reconstructive techniques for ureteric strictures can compromise the blood supply of an anomalous ureter with distorted vasculature. Current approach of dismembering the vesicoureteric junction (VUJ) and re-implantation of ureter may compromise the vasculature of the remnant distal ureter and consequently the anastomosis. The need to fully mobilise distal ureteric segment by dissection may lead to complications such as ureteric aperistalsis, anastomotic stricture and pelvic hematoma requiring re-operation. In this report we aim to present a novel modified technique to the side-to-side VU anastomosis with emphasis on maximum vasculature-preserving dissection of the distal ureter and the incorporation of ureteric tapering. Patient and Surgical Procedure: A 57 year-old female patient has a history of congenital left mega-ureter who presented with progressive left flank pain of about 6-month duration. Pre-operative retrograde pyelogram showed a short segment VUJ stricture. The robotic-assisted laparoscopic side-to-side VU anastomosis technique is as follows: (1) five-port configuration triangulating to the left pelvis (2) Dissection limited to the anterior aspect of the mid-distal ureter with the strictured distal ureter and the VUJ left intact (3) Side-to-side anastomosis between the medial ureteric wall proximal to the strictured segment and the left lateral bladder wall (4) Tapering of the dilated ureter. Results: The operative time was 3 hours with blood loss of less than 100 mls. The patient was discharged uneventful on post-operative day-2 (POD-2) and urinary catheter was removed on POD-7. Retrograde pyelogram and ureteroscopy at 6 weeks post-operatively confirmed patency of the neoureterocystostomy and tapered ureter, with marked improvement of pelvicalyceal dilatation and prompt drainage of contrast. There was no complications reported and the patient had resolution of symptoms post-operatively. Conclusion: In this report, a novel robotic-assisted laparoscopic side-to-side VU anastomosis technique with ureteric tapering was illustrated in the management of a patient with a congenital obstructed mega-ureter. The technique emphasises maximum preservation of ureteric vasculature by minimising ureteric dissection, with tapering of the grossly redundant dilated mega-ureter which improves urinary drainage while minimising urinary stasis.
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