Ureteroplasty with Buccal Mucosa Graft Guided by Fluorescence

In this video we describe our technique of ureteroplasty with buccal mucosa graft guided by fluorescence. The patient was a sixty-nine years old man who developed a left ureteral stricture after endoscopic treatment of a 9 mm stone. Preliminary ureteroscopy confirmed a tight ureteral lumbar stricture. A nephrostomy tube was placed and a combined pyelography showed a 3 cm long stricture. A robot-assisted ureteroplasty with buccal mucosa graft was planned.

Key points of our procedure were:

1) flexible ureteroscopy with application of a guidewire trough the stricture,

2) preparation of the stricture under guidance of transillumination and Firefly tool,

3) identification of the lower limit of the stricture using transillumination by ureteroscope and Firefly tool, of the upper limit of the stricture by transnephrostomic ICG injection and of ureteral tissue quality by intravenous ICG injection,

4) incision of the anterior ureteral wall preserving the posterior plate and stone removal,

5) harvest of buccal mucosa graft from a cheek,

6) graft ureteroplasty over a ureteral stent with four half sutures to prevent the curl of the graft,

7) omental wrapping to support graft revascularization.

Buccal mucosa grafting can be safely and effectively used for treatment of long and complex ureteral strictures. The use of a combined endoscopic and robotic approach with assistance of ICG fluorescence allows a better surgical planning and can optimize the surgical and functional outcomes.