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

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.

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.

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.