Retrocaval ureter (RCU) is a rare congenital anomaly resulting from dysplasia of the inferior vena cava (IVC). It can induce hydronephrosis and progressive obstruction and renal dysfunction. The surgical repair involves complete transection of the compressed retrocaval ureter segment, anterior transposition of both ends of the ureter followed by a watertight uretero-ureteral or ureteropelvic anastomosis. This reconstructive operation has been traditionally performed with an open surgical approach. We performed a laparoscopic repair to help the patient overcome the disadvantages of the open technique which includes an unsightly lengthy surgical incision, more pronounced pain experience and prolonged hospital stay. We report here a rare congenital anomaly of the ureter. Further, we present the important features of this minimally invasive surgical repair, focusing on important anatomical landmarks and some surgical tips and tricks to help increase the success rate of the repair.

A 32-year-old female was admitted at a local hospital in Hongkong last December 2022 for right flank pain, fever and chills. She was managed as a case of acute pyelonephritis and discharged in good condition. Two months later, the patient noted recurrence of the symptoms which prompted readmission for more antibiotic therapy. She sought consult with a urologist last February 2023 wherein a CT Urogram was done. There was no evident hydronephrosis or hydroureter. The contralateral left kidney and urinary bladder had no pathology. Patient was advised surgery but was lost to follow up. Last March 2024, patient noted recurrence of right flank pain with no other associated symptoms. She consulted a private urologist was advised for surgery. She underwent laparoscopic repair of the retrocaval ureter. The operative time was 120 minutes with minimal blood loss. A JP drain was placed in the retroperitoneum. She tolerated the procedure well without any intraoperative complications. She was discharged on postoperative day 4 after removal of the JP drain and urethral catheter on postoperative days 3 and 4, respectively. The indwelling ureteral stent was removed after a month. At six month follow-up she was doing well with no recurrence of infection.

The first reported laparoscopic repair of a retrocaval ureter in the Philippines was published by the same author of this report. There are several caveats in facilitating the conduct of this minimally invasive procedure. First and foremost is the preoperative retrograde insertion of a ureteral stent which is done under fluoroscopic control. Once the ureteral stent is in place, this can serve as a guide for facile identification of the ureter during laparoscopy.

The advancement in technology and availability of equipment in laparoscopic surgery will eventually replace open surgery over the time in dealing with these types of complex urologic cases. It has been shown that minimally invasive approach can be done safely and effectively with minimal complication.