Ureteral Triplication- Laparoscopic Partial Nephrectomy With Highly Selective Arterial Dissection: Description of Surgical Technique

BACKGROUND/OBJECTIVE: Ureteral triplication is a rare congenital malformation with a wide spectrum of presentation that requires a high index of suspicion in order to diagnose. To date, only about 100 cases have been published in medical literature. Smith et al¹ proposed a classification for ureteral triplication that describes it as three separate ureters and three separate ureteral orifices with no interconnection between ureters. In this video, we present a surgical approach for laparoscopic partial nephrectomy of both upper moieties in the context of ureteral triplication. MATERIALS AND METHODS: The procedure is initiated with cystoscopy and retrograde pyelogram to better determine the pertinent anatomy. A ureteral catheter is inserted into the healthy ureter to facilitate its identification and reduce the risk of inadvertent injury. The patient is placed in the modified flank position. A 5 mm camera port is inserted using the Hasson technique and two additional ports are inserted under vision. The colon is deflected medially, and the kidney, ureters and blood supply are identified. Both upper pole ureters are transected. Variance of the blood supply can be encountered; therefore, highly selective dissection of the vessels is performed, and care is taken to preserve the main renal vessels. Upper pole partial nephrectomy is carried out using a harmonic scalpel at the demarcation line. RESULTS: Operative time was 182 minutes. Discharge was on post-operative day 2 without intra or postoperative complications. Follow-up ultrasound 3 months postoperation demonstrated a normal lower pole moiety without hydronephrosis or hydroureter. CONCLUSIONS: Laparoscopic partial nephrectomy with highly selective dissection of vessels in the context of a ureteral triplication anomaly is feasible and safe. Abnormal blood supply should be considered and addressed accordingly.