Robot-Assisted Upper Pole Hemi-nephroureterectomy for Vaginal Ectopic Ureter

Summary

A robotic-assisted heminephroureterectomy was performed to address refractory vaginal incontinence resulting from an ectopic ureter in a duplex kidney in a 41-year-old woman with multiple sclerosis, preserving the lower pole and controlling its blood supply with ICG.

Abstract

A duplex kidney with vaginal ectopic ureter insertion is a rare congenital anomaly frequently presenting as refractory urinary incontinence in females and often misdiagnosed as neurogenic bladder or vesicovaginal fistula. The authors describe the case of a 41-year-old female with progressive relapsing-remitting multiple sclerosis (EDSS 6.5), wheelchair dependent, bilateral hip arthroplasties, persistent vaginal leakage, recurrent multidrug-resistant Escherichia coli urinary tract infections, and initial misattribution to neurogenic bladder leading to intermittent self-catheterization. Multimodal imaging—contrast-enhanced CT urography, retrograde pyelography, and MAG3 renal scintigraphy—revealed a right-sided duplex kidney with a non-functioning, hydronephrotic upper pole moiety (0% differential function) and a tortuous megaureter (30 mm diameter) ectopically draining into the vaginal vault. Following percutaneous nephrostomy for decompression and antibiotic treatment for infection control, robotic-assisted upper pole heminephroureterectomy was performed. Indocyanine green fluorescence guidance enabled precise upper pole resection. The ectopic ureter was traced and excised distally. The procedure lasted 90 min with 50 mL blood loss and no intraoperative complications. The postoperative course was also uneventful. The 12-month follow-up demonstrated complete resolution of incontinence with high patient satisfaction. This case illustrates the diagnostic challenges of ectopic ureters in adults with neurological impairment and demonstrates the feasibility and favorable outcome of robotic surgery for complex congenital urogenital anomalies in high-risk patients.

Introduction

Duplex collecting systems are the most common congenital renal anomaly, affecting approximately 0.8% of the population¹. Ectopic ureters are rarer (0.025–0.05%) but are associated with duplex systems in up to 80% of cases², predominantly involving the upper pole moiety according to the Weigert-Meyer rule, whereby the upper pole ureter inserts medially and inferiorly and frequently drains ectopically into the vagina, urethra, or vestibule in females. Embryological maldevelopment of the ureteric bud leads to ectopic insertion, obstruction, hydronephrosis, and continuous urinary leakage (Figure 1<....

Protocol

The patient consented in writing to all treatment steps and anonymous publication. The study complies with the Declaration of Helsinki and was approved by the ethics committees of the Westfalen-Lippe Medical Association and the University of Muenster (2023–500-f-S) for retrospective data management. All the materials used in this case report are listed in the Table of Materials.

1. Perioperative preparation

1. Antibiotic prophylaxis with a single-dose intravenous cephalosporin was administered 30 min prior to skin incision.
2. Venous thromboprophylaxis with subcutaneous low-molecular-w....

Results

The robotic heminephroureterectomy was performed successfully without any intraoperative or immediate postoperative complications. The operative duration was 90 min with an estimated blood loss of 50 mL. Renal ultrasound performed at 2 weeks post-surgery confirmed resolution of hydronephrosis and preserved function of the lower pole. A CT scan at 10 weeks postoperatively demonstrated a morphologically intact renal unit exhibiting normal contrast enhancement and unobstructed urinary flow through the ureter, which appeared.......

Discussion

The diagnostic journey in this case highlights the considerable challenges posed by congenital ureteral anomalies presenting in adulthood^1,2, particularly when superimposed on pre-existing neurological conditions. In this patient, the presence of multiple sclerosis with established neurogenic bladder dysfunction created a diagnostic trap, leading to years of conservative management with intermittent catheterization and incontinence pads before the true anatomical.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Bulldog Clamp	Cmed	399-100-799	Vessels closure clamp
da Vinci Xi robotic system	Intuitive Surgical	https://www.intuitive.com/en-in/products-and-services/da-vinci/xi	Robotic system
Indocyanine green (ICG) dye	Diagnostic Green GmbH	https://diagnosticgreen.com/row/icg-pharmaceutical-product/	25 mg vial
Monocryl 3-0	Ethicon	D9645	Absorbable suture used for renorraphy
Transurethral Foley catheter	B. Braun Melsungen AG	https://catalogs.bbraun.com/en-01/c/PRODUCTS0000000976/urinary-catheters	16 Fr, 2-way
Vicryl 1-0	Ethicon	VP2347	Absorbable suture used for Fascia Closure