Robot-assisted ureteral reconstruction combined with trans-trocar flexible ureteroscopy using a flexible and navigable suction ureteral access sheath: a case report and technical note.

Abstract

Background: Simultaneous management of upper urinary tract stricture and renal calculi remains a technical challenge in minimally invasive urology. Conventional hybrid techniques combining robotic reconstruction with standard flexible ureteroscopy often face limitations such as impaired visualization, irrigation fluid leakage, and difficulty in managing a substantial stone burden. We report a refined hybrid technique that integrates a flexible and navigable suction ureteral access sheath (FANS) directly into the robot-assisted ureteral reconstructive workflow.

Case presentation: A 49-year-old male patient presenting with a 1-cm middle-to-upper ureteral stricture and a concomitant lower-calyceal stone cluster (aggregate size: 18 × 16 × 12 mm; approximal density: 550 HU) underwent a refined hybrid procedure using the da Vinci Xi system following failed retrograde intrarenal surgery. Intraoperatively, a 12/14 Fr FANS (40 cm) was introduced through an assistant trocar and utilized for 40 min to facilitate thulium fiber laser lithotripsy (1.2 J/10 Hz; active lasing time: 15 min), enabling direct fragment evacuation. Stone-free status was initially confirmed via kidney-ureter-bladder radiography on postoperative day 2. At the 14-month follow-up, abdominal CT demonstrated significant resolution of hydronephrosis and confirmed no recurrence of stones or ureteral obstruction.

Conclusions: The trans-trocar FANS-assisted hybrid approach is a feasible and efficient single-session strategy for complex upper urinary tract pathology. The core innovation lies in the functional integration of suction-assisted endourology into robotic reconstructive surgery.