Robotic Surgery - How to do Lower Ureteric Mass Excision by Dr Rajesh Taneja, Apollo Hospital
http://www.drrajeshtaneja.com/
Lower Ureteric Mass Excision (Robotic Surgery) by Dr Rajesh, Urologist, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi.
We are presenting a case of robotic excision of lower ureteric mass.
A 14-year-old male patient presented with left flank pain for one week which was non radiating, moderate in severity with no aggravating or relieving factors
Ultrasonography of abdomen revealed left hydroureteronephrosis with a possibility of stone in left lower ureter.
Non contrast computed tomography of KUB, region revealed no stone with a possibility of mass in lower ureter causing hydroureteronephrosis.
patient was posted for ureteroscopic biopsy
Ureteroscopic findings noted were tight distorted lumen of left lower ureter with smooth urothelial surface.
random biopsy taken which was unremarkable
Patient was posted for magnetic resonance urography which revealed irregular 3into2into1.2 centimetre mass. with moderate post contrast enhancement arising from left lower ureter reaching upto ureterovesical junction. with moderate hydroureteronephrosis and delayed contrast excretion from left kidney.
These are the t-2 weighted M.R. pictures depicting the cut off at lower ureter with a mass lesion indenting the posterior bladder wall on left side
Working diagnosis was soft tissue tumor of left lower ureter causing hydroureteronephrosis
Patient was posted for surgery and robotic assisted excision of left lower ureteric mass with en block left pelvic lymphadenectomy with ureteric reimplantation. after contralateral mobilisation of bladder with double J stenting was done
Surgical Videos Demonstration
This is the video depicting the surgical procedure.
Left side pelvic lymphadenectomy being done with external iliac vessels, medial umbilical ligament and obturator nerve being exposed.
Excision of lower ureteric mass with cuff of bladder being carried out.
Cut end of ureter being examined for any gross visible lesion.
Cut section from ureter which was sent for frozen section biopsy for any evidence of malignancy.
Bladder being mobilized from opposite side to facilitate tension free ureteroneocyststomy.
Closure of excision site using 3 o barbed absorbable suture.
Anchoring suture being applied to reduce tension on anastomosis.
ureteroneocystostomy being carried out.
Double J stent being positioned, and finally anastamosis completed.
Operative findings were irregular 3into2into2 centimetre mass arising from lower ureter adherent to peri ureteric tissue
Post operatively patient recovered well, pelvic drain was removed on 3rd postoperative day and foleys catheter on the 5th post operative day.
Histopathology report of the excised mass revealed chronic ureteritis. with mass lesion composed of spindle cells mixed with variable amounts of extracellular collagen, lymphocytes, plasma cells with adventitial fibrosis with no evidence of malignancy
Final diagnosis made was inflammatory myofibroblastic tumor, an inflammatory pseudotumor which is a rare condition of unknown cause. characterized by the presence of a mass that may simulate malignancy. composed of spindle cells mixed with variable amounts of extracellular collagen, lymphocytes, and plasma cells.
Originally found in the lungs, but has been identified at various extrapulmonary sites. in the urogenital tract, inflammatory pseudotumor preferentially involves the bladder.
On follow up postoperatively double J stent was removed after 6 weeks. D T P A scan done after 3 and 12 months revealed bilateral non obstructed normally functioning kidneys
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