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The patient was a 64 year old man with previous history of left radical nephrectomy due to renal cell carcinoma presented with gross hematuria since3 three months ago. Urine cytology was negative for malignancy. Ultrasonography revealed mild to moderate hydroureteronephrosis in the right side and intravenous pyelography showed filling defect in the distal part of right ureter. Ureteroscopy was performed and confirmed the papillary tumor in distal part of ureter and the other segments were free of tumor. Cold cup biopsy of this mass was positive for low grade urothelial carcinoma.
The patient underwent laparoscopic distal ureterectomy and Boari flap reimplantation. In the supine position, one 12 mm, one 10 mm and two 5mm trocars were inserted. The ureter was freed from surrounding tissues from up to down and with safe margin from tumor, ureter was ligated using clips. The ureter freed intramurally from the bladder and the specimen extracted using Endobag. Flap with suitable diameter and blood supply separated from bladder and then the ureteral stump anastomosed to the flap on 8 Fr stent using 4-0 vicryl sutures. Finally, the bladder closed using 0 vicryl sutures and urethral catheter was fixed.
Urethral catheter was removed 15 days after operation and cystogram revealed no leakage. Final pathology was compatible with low grade papillary urothelial carcinoma and all of the margins were free of tumor.
Allaparthi and their colleagues reported robotic distal ureterectomy with boari flap reconstruction for low grade distal ureteral urothelial cancers in two cases with good results and 6 months tumor free period. Likewise, Uberoi revealed the feasibility of Robot-assisted laparoscopic distal ureterectomy and ureteral reimplantation with psoas hitch or Boari flap in patients with midureteral and distal-ureteral tumors not amenable to endoscopic resection.