Treatment algorithm for robotic transplant ureteral stricture repair

Abstract

Objective

Surgical repair of transplant ureteral stricture disease can be complex. Patient anatomy and stricture severity can vary widely, thus reconstructive techniques should be catered to individual cases with careful consideration of patient anatomy and stricture characteristics. Here, we describe our treatment algorithm for robotic reconstruction of transplant ureteral strictures.

Patients and surgical procedure

In patients with favorable anatomy, where the bladder can be mobilized to healthy ureter or the renal pelvis, our preference is to perform a nontransecting side-to-side anastomosis. Theoretically, a longitudinal ureterotomy should better preserve the fragile ureteral blood supply compared to ureteral transection. This is particularly important in the transplant ureter, where ischemia is often the underlying cause of stricture formation. However, some patients may have a small capacity bladder or fibrosis that prevents sufficient bladder mobilization. In such cases, ureteral transection may be necessary to facilitate additional ureteral mobilization. If the ureteral defect is short, an end-to-end ureterovesical reimplant can be performed. In patients with a longer defect not amenable to a direct reimplant, we perform a Boari flap. In patients where a Boari flap is not advisable, such as in patients with a small bladder capacity or a prior history of pelvic radiation, a transplant to native ureteroureterostomy is another alternative in patients with viable native ureter.

Results

From 2021–2024, eight total patients underwent robotic transplant ureteral stricture repair at our institution. Two underwent nontransecting side-to-side neoureterocystostomy, 1 pyelovesicostomy, 1 excision and end-to-end neoureterocystostomy, and 4 Boari flap. Median console time was 139 mins (IQR 109–188), estimated blood loss was 25 ml (IQR 25–100), and length of stay was 1 day (IQR 1–3). There was one major (Clavien ≥ III) complication that was an intensive care unit transfer for hypertensive urgency. At a median follow-up of 13 months (IQR 8.5–17), 100 % of patients were surgically successful.

Conclusion

Robotic transplant ureteral stricture repair is a challenging operation. Tailoring reconstructive techniques to patient stricture characteristics in a stepwise fashion allows for a systematic approach that has been associated with excellent outcomes at a median follow-up of 13 months.