Robotic ureteral reconstruction of non-absorbable clip erosion into the ureter: a case series.

Background: Delayed migration of non-absorbable surgical clips into the urinary tract is a rare but potentially morbid complication that may lead to pain, infection, stone formation, and urinary obstruction. The literature on clip erosion into the upper tracts are limited to a handful of case reports of case reports. The purpose of our study was to review outcomes of robotic ureteral reconstruction (RUR) of non-absorbable clip erosion into the ureter.

Case Description: We retrospectively reviewed all patients who underwent RUR for management of clip erosion into the ureter between September 2022-April 2024 at our tertiary academic center. Indication for surgery was ureteral obstruction. Six patients underwent RUR for clip erosion into the ureter. All patients had non-absorbable clip erosion from a prior urologic surgery. The median length of time between placement of non-absorbable clip and diagnosis of erosion was 90.5 months (IQR, 48.4-219.1). When clip erosion involved ≥80% of the circumference of the ureter, we utilized a transecting technique. As such, two patients underwent ureteral reimplantation with adjunctive maneuvers such as a psoas hitch or Boari flap. When clip erosion involved <80% of the circumference of the ureter, we utilized a non-transecting technique utilizing buccal mucosa graft for four patients. The median operative time was 157 minutes (IQR, 132-318), estimated blood loss was 50 cc (IQR, 31.25-318) and length of stay was 1 day (IQR, 1-1). There were no major (Clavien >2) postoperative complications. At a median follow up of 14.8 months (IQR, 10.1-18.7), all patients achieved surgical success, defined as the absence of obstructive flank pain and ureteral obstruction on functional imaging.

Conclusions: Diagnosis of clip erosion into the ureter is generally delayed. RUR for non-absorbable clip erosion into the ureter is associated with low morbidity and excellent outcomes. When possible, we recommend utilization of interposing a fat flap to minimize the risk of erosion into the upper tracts.