Robotic Ureteral Reconstruction for Iatrogenic Ureteral Injury in Situs Inversus Totalis

N. Behtash, K. Nguyen, B. Hartwyk, V. Vilchez, Z. Sadeghi

Situs inversus totalis; Ureteral injury; Robotic reconstruction

Iatrogenic ureteral injuries can be particularly diAicult to manage in the setting of altered anatomy, prior surgery, and dense fibrosis. Reconstruction requires careful assessment of

the location and extent of injury, the quality of the remaining ureter, and the feasibility of bladder-based repair. This video presents the robotic management of a 65-year-old woman with situs inversus totalis, recurrent urinary tract infections, and nephrostomy dependence following a missed ureteral injury during prior bowel surgery. Intraoperatively, we identified a severely dilated ureter ending at the pelvic brim and encased in dense fibrosis and adhesions. Robotic ureterolysis was performed around this segment of the ureter, and flexible ureteroscopy with ICG dye was used to assess the patency of the proximal ureteral lumen. Next, we mobilized the bladder by developing the space of Retzius on both sides and dissecting the bladder away from the abdominal wall. There was moderate scarring around the bladder, likely due to recurrent infections or inflammation.

Once the bladder was adequately mobilized, a transverse incision approximately 10 cm in length was made in the anterior bladder wall to prepare for hitching and Boari flap creation.

Ureteral reimplantation was then performed. Next, the perivesical fat and posterior peritoneal flap were approximated over the Boari flap anastomosis to separate it from the

bowel. Given the situs inversus and the presence of the appendix on the left side, the bowel was evaluated, an appendectomy was performed, and an omental flap was created for

interposition.

This case highlights the challenges of ureteral reconstruction when situs inversus totalis, prior abdominal surgery, and severe fibrosis coexist. Careful identification of the urinary tract and assessment of the remaining viable ureter are essential when selecting a reconstructive strategy. Robotic visualization, ureteroscopy, and fluorescence guidance can provide valuable anatomic information and support surgical decision-making in complex ureteral injuries.

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