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). In females, vaginal drainage commonly manifests as persistent incontinence, often misdiagnosed as neurogenic bladder, vaginal discharge, or fistula—especially in adulthood, where nearly 30% of cases are diagnosed after age 18³.

Standard treatment for poorly functioning moieties is surgical excision, with robotic-assisted laparoscopic heminephroureterectomy increasingly preferred over open or laparoscopic approaches due to enhanced precision, minimized blood loss, decreased hospitalization duration, and minimal complications^4,5. Indocyanine green (ICG) fluorescence further improves vascular identification and tissue preservation^6,7. This article is suitable for specialists who treat uncommon congenital conditions in intricate cases.

Case Presentation:

A 41-year-old female, wheelchair-dependent due to progressive relapsing-remitting multiple sclerosis (EDSS 6.5) and bilateral hip arthroplasties, presented with continuous vaginal urinary leakage, recurrent urinary tract infections (multidrug-resistant Escherichia coli), intermittent lower abdominal pain, and episodic fever (up to 38.5 °C). Symptoms were initially attributed to neurogenic bladder secondary to multiple sclerosis, leading to initiation of intermittent self-catheterization and reliance on incontinence pads. This conservative approach exacerbated social withdrawal, psychological distress, and recurrent infections. Diagnostic evaluation included contrast-enhanced CT urography demonstrating a right duplex kidney with severe hydronephrosis of a non-functioning upper pole moiety and a tortuous, dilated ectopic megaureter (30 mm) inserting into the vaginal vault (Figure 2), retrograde pyelography confirming the ectopic insertion, and MAG3 scintigraphy verifying 0% differential function of the upper pole (preserved lower pole function: 33% of the total renal function). Percutaneous nephrostomy placement achieved decompression of hydronephrosis over four weeks.

Diagnosis, Assessment, Plan:

Right-sided duplex kidney with vaginal ectopic ureter from a non-functioning upper pole moiety causing continuous incontinence and recurrent pyelonephritis. Differential diagnosis included neurogenic bladder dysfunction, vesicovaginal fistula, or single-system ectopic ureter. Multimodal imaging (CT urography, retrograde pyelography, MAG3 scintigraphy) showing obstruction, megaureter, absent upper pole function, and vaginal insertion bypassing sphincter control. Initial temporary diversion with percutaneous nephrostomy and targeted antibiotics to resolve infection and inflammation, followed by definitive robot-assisted upper pole heminephroureterectomy. The robotic approach was selected for superior visualization and precision. ICG fluorescence was planned to safeguard the lower pole vascular supply. Anticipated complications (bleeding, lower pole ischemia, infection recurrence) were minimized through fluorescence-guided dissection and an experienced robotic team.

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-weight heparin was initiated the night before surgery and continued daily for three weeks post-discharge.
3. A Foley catheter was placed in the bladder and inflated with 10 mL of saline.

2. Patient positioning

1. After the introduction of general anesthesia, the patient was then positioned in lateral decubitus to facilitate optimal exposure of both the upper abdomen and the pelvis.
2. The patient was securely fastened to the operating table to prevent shifting.

3. Trocar placement and robot docking

1. Pneumoperitoneum was established (12 mmHg) through a mini-laparotomy paraumbilically.
2. A standard transperitoneal renal robotic configuration was used: a cranial paraumbilical camera port and three additional trocars on a pararectal line, one cranial trocar for bipolar forceps, and two caudal trocars.
3. The first one, next to the camera port, was used for the monopolar scissors, and the most caudal one was used for the robotic grasping instrument. Trocars were arranged in a curved arc toward the renal pelvis and the ureter, maintaining 8 cm spacing between them.
4. The robotic system was docked from a lateral approach. Instruments included monopolar scissors, fenestrated bipolar forceps, robotic surgical forceps, and a needle holder.

4. Robotic-assisted heminephrectomy

1. The right colon was mobilized medially. Gerota’s fascia was incised to expose the duplex kidney using the robotic monopolar scissors.
2. The renal hilus was exposed, and the renal vessels were isolated.
3. Vascular Identification with Indocyanine Green (ICG): After isolating the upper pole vascular pedicle, two small arteries were clamped, and intravenous indocyanine green was administered to identify the inferior moiety’s blood supply and preserve it.
4. After planning the resection line, the upper moiety vessels (two small arteries and one vein) were clipped and transected.
5. Upper pole resection: To prevent bleeding from the resection line between the two moieties, the arteries of the lower pole moiety were closed with a clamp.
6. After delineating the resection line between the two moieties, the upper pole moiety was dissected and excised from the under moiety using the robotic monopolar scissors.
7. Then a rennoraphy was performed using a 3-0 monofilament suture in a running technique using the robotic needle holder (Figure 3).
8. The clamps were removed to allow circulation through the lower pole-moiety artery.
9. The blood supply to the preserved moiety was again checked using ICG, and it appeared normal (Figure 4).

5. Upper moiety ureteral dissection and excision

1. The ectopic ureter was traced distally to its vaginal insertion using the monopolar robotic scissors and the bipolar forceps (Figure 5).
2. The ureter was resected as low as possible to eliminate any residual stump. The vaginal orifice of the ureter was closed with a clip.

6. Control of the blood supply and closure

1. ICG was used to control the circulation of the preserved tissue under the moiety and its ureter to the ureterovesical junction. The entire unit appeared to have an adequate blood supply.
2. Hemostasis was verified. No drain was placed. Ports were removed under vision. The fascia was closed with a running suture using a 1-0 Vicryl.
3. The Foley catheter was left intact in the bladder and was removed on the first postoperative day.

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