Robotic intracorporeal bilateral ileal ureter replacement for the treatment of post-radiation complex ureteral stricture complicated by uretero-arterial fistula.

Background: Radiotherapy is a crucial treatment modality for gynecological malignancies. However, managing its long-term complications, such as ureteral strictures and uretero-arterial fistulas, is challenging. These complications often lead to recurrent hematuria, infections, and renal function impairment. Traditional ureteral stent placement has limited efficacy, particularly for complex cases involving vascular complications, which frequently necessitate surgical intervention. Objective: To summarize the management of complex cases involving bilateral ureteral strictures combined with iliac artery aneurysms and uretero-arterial fistulas following radiotherapy for cervical cancer, and to explore the feasibility and clinical efficacy of robot-assisted laparoscopic bilateral ileal ureter replacement with bladder anastomosis. Materials and methods: The patient was a 73-year-old female who presented with bilateral ureteral strictures and recurrent hematuria 9 years after undergoing postoperative radiotherapy for cervical cancer. Previous treatments, including multiple ureteral stent placements and vascular interventions, had been ineffective. Imaging studies revealed strictures in the mid-to-distal segments of both ureters and an iliac artery aneurysm. Following a multidisciplinary team discussion, a robotic total intracorporeal bilateral ileal ureter replacement with bladder anastomosis was performed. A 25-cm segment of ileum was harvested and configured in an inverted "7" shape for the anastomosis, and an anti-reflux procedure was incorporated. Detailed surgical steps are available in the accompanying video. Results: The procedure was completed successfully, with a total operative time of 245 min and an estimated blood loss of approximately 80 mL, without conversion to open surgery. The patient recovered well postoperatively, with no complications such as anastomotic leakage or infection. The ureteral stents were removed 2 months after surgery. A follow-up examination at 3 months postoperatively revealed significant improvement: hydronephrosis had markedly decreased, serum creatinine levels had dropped from a preoperative value of 256 µmol/L to 93 µmol/L, urinary function was satisfactory, and the patient's quality of life had significantly improved. Conclusion: Robotic total intracorporeal bilateral ileal ureter replacement is a safe and effective method for treating complex post-radiation ureteral strictures complicated by vascular conditions. This approach significantly improves renal function and alleviates clinical symptoms, making it a viable option for complex cases that have failed conventional treatments.