Experience Leads to Results…

Dr. Richstone has incredible experience in reconstructing the urinary tract. His research publications include some of the largest published experiences in the world. Some folks are born with a blockage in the ureter tube, so the kidney cannot drain urine (the image on the right is such a patient of mine). Some patients had their ureter injured during gynecologic or colon surgery, or the ureter scarred from a stone or stone surgery. Dr Richstone can repair nearly any urinary obstruction using the most minimally invasive technology to optimize successful repair. Some of the urinary blockages and associated surgeries that Dr. Richstone repairs include:

  • Ureteroureterostomy

  • Ureteral reimplant/ureteroneocystostomy

  • Ureteral stricture repair with buccal graft

  • Boari flap and bladder advancement flaps

  • Ileal ureter substitution

  • Appendiceal onlay grafts

  • Ureteopelvic junction obstruction (UPJO) repair

  • Retroperitoneal fibrosis - ureterolysis

  • Cystectomy anastomotic stricture

  • Ureteral obstruction after stone procedure

BLADDER

URETER

Ureteral Strictures Near the Bladder

The image on the left is an x-ray of a patient sent to me with an injured ureter. The ureter is the long thin tube, but the bottom section of the doesn’t make it all the way down to the bladder, the round structure on the bottom left. There is a bad scar that formed - a stricture - that completely obliterated the ureter tube hollow center, so no urine could drain. This is called a "distal" stricture because it is the bottom of the ureter, closest to the bladder and furthest from the kidney. I performed a robotic ureteral reimplant with a Boari flap (image on the right) and fixed the problem. A Boari flap is a procedure where you use part of the bladder wall to make a new connection up to the ureter.

Our group submitted our data of over 300 cases - the largest single center experience in the world - demonstrating a 98% success rate of this operation. It is extremely successful, minimally invasive with most patients spending 24 hours or less in the hospital

BOARI FLAP CONNECTNG URETER BACK TO BLADDER

Proximal and Mid-Ureteral Strictures

When the narrowed or scarred section of the ureter is higher up - near the kidney or in the middle of the ureter, there are several approaches to repair. My patient below had a scar in the ureter caused by a colon surgery with another doctor. On the left, the narrow part of the ureter is in between the blue loops holding the ureter gently upward. The image on the right, during robotic surgery, shows my use of ICG (indocyanine green). The elevated part of the ureter does not light up green, but rather stays grey. This means it does not have good blood flow and needs to be removed and reconstructed. In this case I could cut out the bad piece of ureter, and connect one end of the ureter directly to the other. This is called a Robotic Ueteroureterostomy and is highly successful. In other cases, if I cannot connect one end of the ureter to the other, we can fix the problem in other ways. This includes using the appendix, a skin graft (buccal mucosa), small intestine, and other creative approaches. I have extensive experience with all available techniques and always choose the least invasive and simplest approach.

Ureteropelvic Junction Obstruction (UPJO) - Surgical Repair with Robotic Pyeloplasty

The three x-rays below are three patients of mine who all had an obstruction of the upper ureter known as a ureteropelvic junction obstruction (UPJO) - which I fixed with robotic surgery. The ureteropelvic junction is where the renal pelvis (the hollow part of the kidney that collects urine) becomes the ureter (the thin tube through which urine passes down to the bladder). At this connection - the UPJ - there is a funneling, or tapering, from the larger renal pelvis to the narrow ureter. Some people are born with this connection being too tight, and that is called a ureteropelvic junction obstruction (UPJO). Surgery to repair this small tight area is called a pyeloplasty. I perform both single port robotic pyeloplasty and multiport robotic pyeloplasty that has an incredibly high success rate - 98%.

This patient of mine had prior spine surgery. The ureter was unknowingly blocked when the surgeon was dealing with bleeding. Here, during robotic surgery, I identified the ureter and traced it down to the site of blockage….

Getting closer to the actual blockage, I found where the the ureter was sewn to a blood vessel with suture - the purple thread…..

Within the scar tissue, I found a needle left behind during the prior surgery. I performed a robotic ureteroureterostomy repair that fixed the blockage.