Robotic Versus Open Distal Ureteral Reconstruction and Reimplantation for Benign Stricture Disease

Perioperative and functionnal outcomes of robot-assisted laparoscopic versus open ureterovesical reimplantation for benign lower ureteral pathologies: a single-center comparative study

PURPOSE

The robot-assisted laparoscopic (RALUVR) and open (OUVR) approaches have both been described for ureterovesical reimplantation to treat benign lower ureteral pathologies. Thus, we aimed to compare the perioperative and functional outcomes of RALUVR vs. OUVR.

METHODS

We performed a retrospective comparative study including all consecutive patients treated with RALUVR or OUVR for benign lower ureteral pathologies between January 2013 and December 2022 at our center. Logistic regression analyses were used to assess the predictors of complication ≥ Clavien-Dindo (CD) III within 90 days, prolonged length of stay (LOS), and 90-day overall success. The Kaplan-Meier method and Cox regression analyses were used to assess vesicoureteral reflux-free (VU-RFS) and stenosis-free (SFS) survivals.

RESULTS

Overall, 44 patients underwent RALUVR (n = 19; 43%) and OUVR (n = 25; 57%). In univariable logistic regression analyses, the use of RALUVR vs. OUVR was not significantly associated with postoperative complications ≥ CDIII (OR = 0.98; 95% CI=[0.17-5.09]; p = 0.98), and 90-day overall success (OR = 1.43; 95% CI=[0.24-11.28]; p = 0.7). Despite a shorter median LOS after RALUVR vs. OUVR (4 vs. 10 days, respectively; p < 0.001), multivariable logistic regression analysis showed no impact of the surgical approach on prolonged LOS (OR = 0.51, 95% CI=[0.03-13.86]; p = 0.65). No significant difference was observed in 2-year VU-RFS (72.9% vs. 100%, respectively; p = 0.2) and 2-year SFS between the RALUVR and OUVR groups (85.7% vs. 87.7%, respectively; p = 0.8). In Cox regression analysis, the use of RALUVR vs. OUVR was not significantly associated with VU-RFS (HR = 4.26; 95% CI=[0.38-47.84]; p = 0.24) or SFS (HR = 1.32; 95% CI=[0.22-8.01]; p = 0.76).

CONCLUSION

We observed that RALUVR provides similar perioperative and functional outcomes as compared to OUVR, except for potentially shorter LOS.

Robot-assisted repair of ureteral stricture

As robot-assisted laparoscopic techniques continue to advance, becoming increasingly complex and refined, there has been significant progress in the minimally invasive treatment of ureteral strictures. This abstract aims to provide an overview and description of various surgical techniques that utilize robots for repairing ureteral strictures. We have summarized the progression of these surgical methods and highlighted the latest advancements in the procedures. When compared to open surgery, robot-assisted reconstruction techniques demonstrate superior functional outcomes, fewer postoperative complications, and a faster recovery in the treatment of ureteral strictures. This abstract aims to provide an overview and description of various surgical techniques utilizing robots to repair ureteral strictures. Robotic ureteral stricture correction has emerged as a valuable therapeutic option, particularly when endoscopic procedures are not feasible. Compared to traditional open surgery, robotic methods exhibit superior therapeutic effectiveness, fewer postoperative complications, and accelerated recovery. Reconstructive procedures such as reimplantation, psoas hitch, Boari flap, ureter-to-ureter anastomosis, appendix graft, buccal mucosa graft (BMG), ileal transplantation, or kidney autotransplantation can be performed depending on the extent and location of the stricture. Robotic surgical techniques also offer advantages, such as an expanded field of vision and the incorporation of supplementary technologies such as FireflyTM, indocyanine green (ICG), and near-infrared fluorescence (NIRF) imaging. However, further long-term, multicenter investigations are necessary to validate the positive findings reported in existing case series. Compared with open surgery, robot-assisted reconstruction techniques yield superior functional outcomes, fewer postoperative complications, and accelerated recovery for the treatment of ureteral strictures.

Robot-Assisted Extravesical Ureteral Reimplantation (REVUR) in Pediatric Patients: A New Standard of Treatment for Patients with VUR-A Narrative Review

Robot-assisted extravesical ureteral reimplantation (REVUR) was described for the first time in 2004. Since then, the surgical approach of vesicoureteral reflux (VUR) has changed dramatically. The benefits of this technique are great when compared to the laparoscopic or traditional open approaches. A literature search of PubMed was performed to identify articles covering any aspect of REVUR in the pediatric population. A total of 108 papers published over the period 2004-2024 were collected. Of these, 40 studies were considered valuable in terms of obtaining a complete overview of the REVUR technique. This review aimed to describe the current state of the art of REVUR and define it as the new standard technique for surgical management of selected patients with VUR.

Robotic-Assisted Management of Ureteral Complications in Post-Renal Transplant Patients: A Case Series and Literature Review

Introduction: Urologic complications are thought to be the most common surgical complication of renal transplantation. Ureteral pathology, including stenosis, urine leak, and vesicoureteral reflux, predominates. Although endourologic and interventional radiological management may be utilized, failure rates remain relatively high and surgical reconstruction remains the definitive management. Robotic ureteral reconstruction has been demonstrated to provide patient benefit in nontransplant populations, but the literature on transplant reconstruction is very limited. This study reports an additional series of patients with a focus on surgical technique, as well as reviews the available evidence for robotic reconstruction for post-transplant ureteral complications. Methods: All institutional patients undergoing robotic-assisted reconstruction for post-transplant ureteral complications for the years 2019-2022 were included. Intra- and postoperative variables, patient demographics, and follow-up data were obtained retrospectively from parsing of patient records. Statistics were tabulated descriptively. Results: Eleven patients underwent ureteral reconstruction. Of the 11, 9 (81%) were male with a mean age of 51.9 years (16-70) and BMI of 33.8 (24.3-49.1). The most common (10/11) indication for reconstruction was stricture; the most common (10/11) technique used was Lich-Gregoir reimplantation. Mean operative time was 288 minutes (143-500). There were no intra- or immediate postoperative complications. Median length of stay was 2 days (1-22). There were two incidences of mortality at 2 and 5 months postoperatively unrelated to surgery. There were four readmissions within 30 days, three for urinary tract infection (UTI) and one for a pelvic abscess which required washout. The remainder of the cohort has been followed for a mean of 14.6 months (6-41) without any incidences of graft loss or recurrence of ureteral pathology. Conclusions: Robotic-assisted ureteral reconstruction is a technically challenging but highly feasible technique that may provide the benefits of minimally invasive surgery while still allowing definitive reconstruction. Centers with extensive robotic capabilities should consider the technique.

Robot-assisted ureteric reconstructive surgeries for benign diseases: Initial single-center experience with point of technique

INTRODUCTION

We present our initial experience with robot-assisted reconstructive surgeries with the Da Vinci Xi robotic system for benign ureteric pathologies.

MATERIALS AND METHODS

This is a retrospective review of prospectively collected data of patients who underwent robot-assisted reconstructive procedures for benign diseases of the ureter at our department from April 2018 to November 2022. Demographic and perioperative details were recorded. Patients were followed up and surgical success was evaluated on the basis of symptomatic, functional, and radiological improvement.

RESULTS

A total of 34 patients underwent robot-assisted reconstructions for benign ureteric pathologies by various techniques. Mean age, body mass index (BMI), hospital stay and follow-up duration were 36 years, 24.1 kg/m2, 5.29 days, and 7.08 months respectively. Procedures included pyeloplasty in eight, primary ureteroneocystostomy (UNC) in seven, Psoas hitch UNC in five, Boari flap UNC in six, Ureteroureterostomy in four, ureterocalicostomy in two and ileal ureteral transposition in two patients. Mean docking time, total operative time, and estimated blood loss were 31.5 min, 178 min, and 64.3 ml, respectively. All patients had radiologic or functional improvement on follow-up after 6 months.

CONCLUSION

Robot-assisted reconstructive surgery for benign ureteric and bladder pathologies imparted excellent short-term outcomes without major complications with all the advantages of a minimally invasive approach.

Robotic ureteral reconstruction for benign ureteral strictures: a systematic review of surgical techniques, complications and outcomes : Robotic Ureteral Reconstruction for Ureteral Strictures

INTRODUCTION

Robotic ureteral reconstruction (RUR) has been widely used to treat ureteral diseases. To summarize the surgical techniques, complications, and outcomes following RUR, as well as to compare data on RUR with open and laparoscopic ureteral reconstruction.

METHODS

Our systematic review was registered on the PROSPERO (CRD42022309364) database. The PubMed, Cochrane and Embase databases were searched for publications in English on 06-Feb-2022. Randomised-controlled trials (RCTs) or non-randomised cohort studies with sample size ≥ 10 cases were included.

RESULTS

A total of 23 studies were included involving 996 patients and 1004 ureters from 13 non-comparative, and 10 retrospective comparative studies. No RCT study of RUR was reported. The success rate was reported ≥ 90% in 15 studies. Four studies reported 85-90% success rate. Meta-analyses for comparative studies showed that RUR had significantly lower estimated blood loss (EBL) (P = 0.006) and shorter length of stay (LOS) (P < 0.001) than the open approach. RUR had shorter operative time than laparoscopic surgery (P < 0.001).

CONCLUSIONS

RUR is associated with lower EBL and shorter LOS than the open approach, and shorter operative time than the laparoscopic approach for the treatment of benign ureteral strictures. However, further studies and more evidence are needed to determine whether RUR is more superior.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study

BACKGROUND

Robot-assisted approach to UVJ is getting more and more used in pediatric patients.

METHODS

In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR).

RESULTS

Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery.

CONCLUSIONS

Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

What credentials are required for robotic-assisted surgery in reconstructive and functional urology?

Introduction

The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary.

Methods

A narrative review of all the relevant papers known to the author was conducted.

Results

Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU.

Conclusion

This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

Management for Benign Ureteral Stricture: Comparison of robot-assisted laparoscopy, conventional laparoscopy, and balloon dilation

PURPOSE

Robot-assisted laparoscopy (RALP), conventional laparoscopy (LP), and balloon dilation (BD) have all been identified as common treatments for benign ureteral stricture (BUS). The purpose of the research would be to compare the safety and efficacy differences in the three groups.

PATIENTS AND METHODS

Patients who received RALP, LP, or BD for BUS were studied retrospectively from January 2016 through December 2020. Professional and experienced surgeons performed all operations. We collect and analyze baseline characteristics, stricture details, peri-operative, and follow-up information.

RESULTS

The results showed no statistically significant differences between the three groups for baseline characteristics and stricture details. No statistical differences were also found between RALP and LP in specific surgical techniques. The average operative time was longer in the LP group than RALP and BD groups (178 min vs 150 min vs 67 min, respectively, P<0.001). BD had a lower estimated blood loss than RALP and LP (14 ml vs 40 ml vs 32 ml, p<0.001) and similar between the RALP and LP groups (p=0.238). The BD group had the shortest postoperative hospital stay compared with the RALP and LP groups (3 d vs 5 d vs 7 d, P<0.001), and no statistically significant differences existed between the RALP and LP groups (P=0.098). RALP had considerably greater hospitalization expenses than both LP (P<0.001) and BD (P<0.001). Complications and short-term success rates (6 months) were similar. The BD group had poorer long-term success (12 and 24 months) than the RALP and LP groups, whereas there was no statistically significant difference between the RALP and LP groups.

CONCLUSIONS

For the management of BUS, RALP, LP, and BD are all safe and effective, with equivalent complication rates and short-term success. In long-term success rates, BD is low than RPLP and LP.

Uretero-neocystostomy: a retrospective comparison of open, laparoscopic and robotic techniques

BACKGROUND

Uretero-neocystostomy (UNC) is the gold-standard for distal-ureter repair. Whether the surgery should be conducted minimally invasive (laparoscopic (LAP), robotic RAL)) or open remains unanswered by the literature.

METHODS

Retrospective analysis of surgical outcome of patients treated with UNC for distal ureteral stenosis (January 2012 - October 2021). Patient demographics, estimated blood loss (EBL), surgical technique, operative time, complications and length of hospital stay (LOS) were recorded. During the follow-up period, patient underwent renal ultrasound and kidney function tests. Success was defined as relieve of symptoms or no findings of obstruction needing urine drainage.

RESULTS

60 patients were included (9 RAL, 25 LAP, 26 open). The different cohorts were similar of age, gender, American Society of Anesthesiologists (ASA) score, body-mass index and history of prior treatment of the ureter. No intraoperative complications were detected in all groups. There was no conversion to open surgery in the RAL group, whereas one was found in the LAP arm. Six patients had a recurrent stricture, but with no significant difference between the cohorts. EBL was not different between the groups. LOS was significantly lower in the RAL + LAP group compared to open (7 vs. 13 days, p = 0.005) despite significantly longer operating times (186 vs. 125.5 min, p = 0.005).

CONCLUSION

Minimal invasive UNC, especially RAL, is a feasible and safe surgical method and provides similar results in terms of success rates in comparison to open approach. A shorter LOS could be detected. Further prospective studies need to be done.

Long-term Outcomes of Minimally Invasive Rendezvous Procedures to Treat Complex Ureteric Strictures and Injuries

Background

Complex ureteric strictures and injuries occurring during major abdominal and pelvic operations may cause significant morbidity and distress to patients. A rendezvous procedure is an endoscopic technique used in case of such injuries.

Objective

To evaluate perioperative and long-term outcomes of rendezvous procedures to treat complex ureteric strictures and injuries.

Design setting and participants

We retrospectively reviewed patients undergoing a rendezvous procedure for ureteric discontinuity including strictures and injuries, treated between 2003 and 2017 at our Institution and completing at least 12 mo of follow-up. We divided patients into two groups: early postsurgical obstruction, leakage, or detachment (group A) and late strictures (oncological/postsurgical; group B).

Outcome measurements and statistical analysis

If appropriate, we performed a retrograde study ± rigid ureteroscopy to assess the stricture 3 mo after the rendezvous procedure, followed by a MAG3 renogram at 6 wk, 6 mo, and 12 mo, and annually thereafter for 5 yr.

Results and limitations

Forty-three patients underwent a rendezvous procedure, 17 in group A (median age 50 yr, range 30-78) and 26 in group B (median age 60 yr, range: 28-83). Ureteric strictures and ureteric discontinuities were stented successfully in 15 out of 17 patients in group A (88.2%) and 22 out of 26 patients (84.6%) in group B. For both groups, the median follow-up was 6 yr. In group A, of 17 patients, 11 (64.7%) were stent free with no further interventions, two (11.7%) had a subsequent Memokath stent insertion (38%), and two (11.7%) required reconstruction. Of 26 patients in group B, eight (30.7%) required no further interventions and were stent free, ten (38.4%) were maintained with long-term stenting, and one was managed with a Memokath stent (3.8%). Of the 26 patients, only three (11.5%) required major reconstruction, while four patients with malignancy (15%) died during follow-up.

Conclusions

With a combined antegrade and retrograde approach, the majority of complex ureteric strictures/injuries can be bridged and stented with an overall immediate technical success rate of above 80%, avoiding major surgery in unfavourable circumstances and allowing time for stabilisation and recovery of the patient. Additionally, in case of technical success, further interventions may be unnecessary in up to 64% of patients with acute injury and about 31% of patients with late stricture.

Patient summary

The majority of complex ureteric strictures and injuries can be resolved using a rendezvous approach, avoiding major surgery in unfavourable circumstances. Moreover, this approach can help avoid further interventions in 64% of such patients.

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were 'robotic assisted', 'ureteric reimplantation', 'cystoplasty', 'ileal conduit', 'neobladder', 'sacrocolpopexy', 'colposuspension', 'artificial urinary sphincter', 'genitourinary fistula' and 'posterior urethral stenoses'. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.

Long-term outcome of non-antireflux robotic-assisted laparoscopic ureter reimplantation in ureteral obstruction

PURPOSE

Although robotic-assisted laparoscopic ureter reimplantation (RALUR) is a recognized alternative to open and laparoscopic ureter reimplantation in treating distal ureteral obstruction, there are limited data on long-term efficacy and safety outcomes of non-antireflux RALUR. We assessed patients undergoing RALUR, evaluating operative, functional and safety determinants.

MATERIALS AND METHODS

All consecutive patients undergoing non-antireflux RALUR between April 2015 and January 2020 were included in this retrospective cohort study. The primary outcome endpoint was recurrent distal ureteral obstruction.

RESULTS

Mean follow-up was 41.3 months (CI 95%, 33.3-49.2). Among the 26 included patients, none developed recurrent distal ureteral obstruction. Kidney function in terms of serum creatinine level (72.0 vs. 71.0 µmol/L, p=0.988) and glomerular filtration rate (92.0 vs. 91.0 mL/min, p=0.831) was stable between the preoperative period and the last follow-up. Renal pelvis dilatation decreased significantly postoperatively, from grade 2 to grade 0 (p<0.001). Most patients (73.1%) remained free from any clinical symptoms of reflux during the follow-up. The rate of postoperative complications (Clavien-Dindo grade ≥II) was 23.1%. All complications resolved without sequelae. No recurring urinary tract infections were reported.

CONCLUSIONS

Non-antireflux RALUR appears to be safe and effective in the management of distal ureteral obstruction. There was no recurrent ureteral obstruction after RALUR in our cohort during a mean follow-up of more than 3 years. Non-antireflux reimplantation did not seem to have any notable impact on renal function during the follow-up period.

Robotic ureteral reimplantation: systematic review and pooled analysis of comparative outcomes in adults

INTRODUCTION

The surgical treatment of ureteral strictures in adults represents a challenging procedure for the variability of location, extension, and etiology of the disease. Open ureteral reimplantation (OUR) offered high success rates even when considering complex ureteral disease. The debate for defining the role of robotic in the treatment of adult ureteral disease is still ongoing. The aim of the current systematic review is to provide an updated analysis of the comparative outcomes of robot-assisted UR (RAUR) versus OUR based on the available literature.

EVIDENCE ACQUISITION

An independent systematic review of the literature was performed from 2010 to 2021. Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle-Ottawa scale for nonrandomized controlled trials. Pooled analysis of demographics and clinical characteristics, as well as surgical and postoperative outcomes, was performed.

EVIDENCE SYNTHESIS

After an initial screening and full-text review, 5 studies published between 2002 and 2021 were identified and included in the analysis. All the studies were observational retrospective case-control studies. Among the 225 patients included in the pooled analysis, 94 (41.8%) and 131 (58.2%) were RAUR and OUR, respectively. There was no difference between groups in terms of baseline characteristics. No differences in surgical approach and operative time were reported among the groups. Estimated blood loss was lower for robotic approach (WMD: -121.71ml; p=0.0006). There were no significant differences between groups in overall (OR: 0.85; p=0.69) and major (OR:0.69; p=0.52) complication. RAUR group reported shorter length of stay (WMD: -2.39day; p<0.00001), catheter (WMD: -5.26day; p=0.004) and stent (WMD: -11.9day; p=0.001) time.

CONCLUSIONS

Available evidence shows that RAUR offers similar surgical outcomes if compared to OUR, and potential advantages in terms of lower blood loss, shorter hospital stay, catheter, and stent time. The adoption of one approach over the other is likely to be mainly dictated by the surgeon's preference and expertise.

Contemporary Analysis of Ureteral Reconstruction 30-Day Morbidity Utilizing the National Surgical Quality Improvement Program (NSQIP) Database: Comparison of Minimally Invasive Versus Open Approaches

OBJECTIVES

To characterize 30-day morbidity of upper ureteral reconstruction (UUR) and lower ureteral reconstruction (LUR) surgery by comparing open and minimally invasive surgery (MIS) approaches using a national surgical outcomes registry.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent UUR and LUR between 2007-2017. Primary endpoints included 30-day complications, transfusion, readmission, return to operating room (ROR), and prolonged postoperative length of stay (LOS). Multivariable logistic regression was performed to observe the association of MIS approach on 30-day outcomes.

RESULTS

3042 patients were identified with 2116 undergoing UUR and 926 undergoing LUR. Of 2116 patients undergoing UUR, 1733 (82%) were performed via MIS approach. On multivariable analysis, open approach for UUR was associated with increased odds of any 30-day complication (odds ratio (OR) 1.6 [1.1-2.4]; p=0.014), major complication (OR 1.8 [1.04-3.0]; p=0.034), transfusion (OR 3.7 [1.2- 11.5]; p=0.025), ROR (OR 2.0 [1.0-3.9]; p=0.047), and prolonged LOS (OR 5.4 [3.9-7.6]; p<0.001). Of the 926 patients undergoing LUR, 458 (49%) were performed via a MIS approach. On multivariable analysis, open approach for LUR was associated with increased odds of any 30-day complication (OR 1.5 [1.1-2.1]; p=0.028), minor complication (OR 1.7 [1.1-2.6]; p=0.02), transfusion (OR 8.1 [2.7-23.7]; p<0.001), and prolonged LOS (OR 4.2 [2.4-7.3]; p<0.001).

CONCLUSION

Utilization of a national surgical database revealed an open approach was associated with increased 30-day morbidity across multiple postoperative outcome measures. These findings suggest a MIS approach should be considered, when feasible, for upper and lower ureteral reconstruction.

Robot-Assisted Laparoscopic Ureteroureterostomy for Distal Benign Ureteral Strictures with Long-Term Follow Up

OBJECTIVES

To demonstrate feasibility of robot-assisted laparoscopic (RAL) ureteroureterostomy (UU) for benign distal ureteral strictures (DUS) in our robotic reconstruction series with long term follow up.

PATIENTS & METHODS

In a retrospective review of our prospectively maintained RAL ureteral reconstruction database, we followed patients between 6/2012-2/2019 who underwent a UU for DUS. In addition to patient demographics, we recorded the etiology, stricture length and recurrence rates. Recurrence was defined as findings of recurrent or persistent obstruction by postoperative mercaptoacetyltriglycine diuretic renal scan or the need for additional intervention with ureteral drainage or revisional surgery.

RESULTS

We identified 22 patients who underwent a RAL-UU for DUS of benign etiologies. Median age was 42 years old (IQR 39-57) and 20 of 22 patients (90.1%) were female. Median stricture length was 1.5 cm (IQR 1-2). Iatrogenic surgical injury was noted in 16 patients (73%). All ureteral reconstruction was performed using RAL. Post-operative imaging consisted of renal ultrasonography, diuretic renal scan or cross-sectional radiology within 3 months of the index operation. Further imaging was dependent on clinical judgment. Twenty patients (90.1%) had success with median follow-up time of 54.6 months with two recurrences necessitating RAL ureteroneocystostomy (UNC).

CONCLUSION

RAL-UU for DUS is technically viable and shows promising efficacy in properly selected patients. This technique may serve a niche for preserving the natural anatomical drainage of the bladder and ureter in addition to obviating the sequela of vesicoureteral reflux as seen in UNC.

Hospital Ownership, Geographic Region, Patient Age, Comorbidities and Insurance Status Appear to Influence Patient Selection Robotic-Assisted Ureteral Reimplantation for Benign Disease: A Population-Based Analysis

BACKGROUND

Robotic-assisted ureteral reimplantation (RAUR) is a relatively new minimally-invasive surgery. As such, research is lacking, and the largest adult cohort studies include fewer than 30 patients. Our aim was to be the first population-based study to report on national utilization trends, factors associated with patient selection, inpatient outcomes, and the relative cost of RAUR for adults with benign ureteral disease (BUD).

MATERIALS AND METHODS

The National Inpatient Sample (2010-2015) was queried to identify all elective, non-transplant related, open and robotic-assisted reimplants for adult BUD. Survey-weighted logistic regression using Akaike Information Criterion identified patient-/hospital-level factors associated with robotic surgery. Survey-weighted regression models examined the association of robotic surgery with outcomes and charges.

RESULTS

A weighted-total of 9,088 cases were included: 1,688 (18.6%) robotic-assisted and 7,400 (81.4%) open. There were significantly increased odds of RAUR across consecutive years (OR 3.0, p < 0.001) and among patients operated on at private for-profit hospitals (OR 2.1; p = 0.01), but significantly decreased odds among older patients (OR 0.98, p < 0.001), those with Medicaid (OR 0.5, p = 0.02), those with 2+ comorbidities (OR 0.6, p = 0.009) and those operated on in Western (OR 0.5; p = 0.005) states. RAUR was significantly associated with a reduced length-of-stay (IRR: 0.60; p <0.001), decreased odds of blood transfusion (OR: 0.40; p <0.001) and a lower mean ratio of total hospital charges (Ratio: 0.71; p = 0.006).

CONCLUSIONS

This is the first population-based study to report on the utilization and clinical benefits of RAUR for adult BUD. Open reimplantation remains the most common surgical technique utilized, despite the potential benefits of RAUR. Future research is needed to explore the mechanisms behind patient-/hospital-level factors and surgical selection. Work to investigate potential barriers in access to robotic surgery can help us provide equitable care across patient populations.

Robotic Repair of Ureteral Strictures: Techniques and Review

PURPOSE OF REVIEW

To provide an overview and description of the different surgical techniques for the robotic repair of ureteral strictures.

RECENT FINDINGS

The robotic repair of ureteral stenosis has emerged as a useful option for treating strictures unsuitable for endoscopic resolution with good results, lower morbidity, and faster recovery than open techniques. Depending on the stricture's length and location, the reconstructive options are reimplantation, psoas hitch, Boari flap, ureteroureterostomy, appendiceal onlay flap, buccal mucosa graft (BMG) ureteroplasty, ileal replacement, or renal autotransplantation. The robotic approach offers a magnified vision and the possibility of adding near-infrared fluorescence (NIRF) imaging, indocyanine green (ICG), and Firefly^TM to facilitate the technique. Multicenter studies with extended follow-up still have to confirm the good results obtained in published case series. Robotic reconstructive techniques are useful for repairing ureteral strictures, obtaining good functional results with less morbidity and faster recovery than open procedures.

ROBOT-ASSISTED URETERAL REIMPLANTATION: A SINGLE CENTER COMPARATIVE STUDY

BACKGROUND

To report a single-center experience with robot-assisted ureteral reimplantation (RAUR) and to compare its outcomes with those of open ureteral reimplantation (OUR).

MATERIALS AND METHODS

Patients who underwent RAUR or OUR for ureteral disease between 2016 and 2020 were identified. Data collected included baseline, pathological, perioperative and postoperative features. The RAUR outcomes were compared with those of OUR.

RESULTS

Overall, twenty-one (42.8%) patients underwent RAUR, and 28 (57.2%) underwent OUR. The two groups were similar in terms of baseline and pathological characteristics. There was a statistically significant difference in favor of RAUR for median operative time (216 vs. 317min, p=0.01) and median blood loss (35 vs. 175ml, p=0.001). No difference was observed in overall complication rate (33.3 vs. 46.4%, p=0.9), as well as major complications (Clavien-Dindo≥III grade) rate between RAUR and OUR groups. Median LOS was shorter for RAUR (2 vs. 6 days; p=0.001), as well as median catheterization time (16 vs. 28 days; p=0.005).

CONCLUSIONS

RAUR is a safe and effective minimally invasive surgical procedure for the management of mid to distal ureteral strictures. It can recapitulate the success rate of the gold standard OUR while offering a benefit in terms of lower surgical morbidity and faster postoperative recovery.

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up

OBJECTIVE

To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data.

PATIENTS AND METHODS

A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed.

RESULTS

The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m² , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature.

CONCLUSION

In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.

Robot-assisted laparoscopic ureteral reimplant: A single-center experience

Introduction:

Open ureteral reimplant has been the gold standard for management of lower ureteric strictures. With the widespread acceptance of robotic surgery, robotic-assisted laparoscopic ureteral reimplant (RALUR) is becoming the preferred choice for performing ureteral reimplant. We present our single-institution and single-surgeon experience of performing RALUR.

Materials and Methods:

We performed a retrospective analysis of 40 patients who underwent RALUR at our institute in the last 5 years. Demographic data were recorded along with presenting complaint and diagnosis. Intraoperative variables included operative and docking time, blood loss, intraoperative complications, technique, and procedure performed. Postoperative data that were analyzed included complications, hospital stay, and outcomes. Patient satisfaction score was calculated using a numerical scale of points 1–6.

Results:

The mean age of patients was 31.5 ± 9.8 years (r = 4–45). Male: female ratio was 3:5. The most common presenting symptom was flank pain, and the most common etiology was iatrogenic strictures in adults and congenital vesicoureteral reflux in children. The mean operative time and blood loss were 135.3 ± 45.1 min (r = 84–221) and 67.7 ± 31.4 ml (r = 32–118), respectively. There were no intraoperative complications and nil conversion to open surgery. The mean length of hospital stay was 4.5 ± 2.3 days (r = 3–9). Radiographic success was achieved in 41 out of 44 ureters. Eighty-five percent of the patients were completely satisfied with robotic approach and its outcomes.

Conclusion:

RALUR is a minimally invasive, safe, feasible, less morbid technique with good outcome.

The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes

Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.

Robot-assisted laparoscopic ureteroneocystostomy in adults: A single surgeon experience and literature review

OBJECTIVE

To present our experience and technique with robot-assisted ureteroneocystostomy (RAUN) procedure in adults.

METHODS

Between February 2015 and August 2018, a total of 30 (34 ureters) patients who underwent RAUN surgery under a single surgeon were retrospectively reviewed. Perioperative data such as age, sex, body mass index (BMI), American society of anesthesiologists score, estimated blood loss, surgical technique, operative time, complications, length of hospital stay, and stent removal time were recorded. During the follow-up, patients underwent renal function test, urinalysis, and renal ultrasound examination for evaluation. Success was defined as symptomatic and radiologic relieve. Lastly, a literature search was conducted to review all published articles regarding RAUN surgery in adults.

RESULTS

The patients' mean age, BMI, EBL, operative time, and follow-up period were 45.4 years, 23.1 kg/m2, 65.6 mL, 182.9 min, and 21.3 months, respectively. The two most common indications for the surgery were benign ureteral strictures and ureteric injuries secondary to a previous radical hysterectomy. Of the 34 cases, 26 (76.5%) and 8 (23.5%) patients received primary RAUN and RAUN with psoas hitch technique, respectively. Refluxing RAUN method was performed in all cases. No intraoperative complications were found. Two patients had a radiologic and symptomatic recurrence; one was managed with a repeat surgery while the other received ureteral dilatation treatment.

CONCLUSION

Both our study and the published literature showed that RAUN is a safe, less invasive, and effective surgical technique that can easily replicate the open ureteroneocystostomy for managing lower ureteral diseases.

Management of recurrent ureteral stricture: a retrospectively comparative study with robot-assisted laparoscopic surgery versus open approach

Background

Management of recurrent ureteral stricture is challenging. Consensus on the best surgical choice has not been demonstrated. In this study, we aim to report our experience in treating recurrent ureteral stricture and demonstrate whether robot-assisted procedure for redo ureteral surgery is as effective as open procedure while remaining less invasive.

Methods

We retrospectively assessed 41 patients (22 robot-assisted surgeries and 19 open surgeries) who underwent consecutive robot-assisted and open procedures for redo ureteral surgery from January 2014 to 2018 in our institution. Perioperative outcomes, including demographics, operative time, estimated blood loss, complications, pain scores, success rate and cost, were compared between two groups.

Results

There was no significant intergroup difference in terms of age, body mass index, gender composition and American Society of Anesthesiologists scores. A total of 31 patients underwent redo pyeloplasty and ten underwent redo uretero-ureterostomy. Compared with open group, robot-assisted group showed shorter operative time (124.55 min vs. 185.11 min, p < 0.0001), less estimated blood loss (100.00 mL vs. 182.60 mL, p = 0.008) and higher cost (61161.77¥ vs. 39470.79¥, p < 0.0001). Complication rate and pain scores were similar between two groups. Median follow-up periods were 30 and 48 months for robot-assisted and open group respectively. Success rate in the robot-assisted (85.71%) and the open group (82.35%) was not significantly different.

Conclusions

Robot-assisted surgery for recurrent stricture after previous ureteral reconstruction is as effective as open procedure and is associated with shorter operative time and less estimated blood loss.

Robot-assisted distal ureteral reconstruction for benign pathology: Current state

Distal ureteral reconstruction for benign pathologies such as stricture disease or iatrogenic injury has posed a challenge for urologist as endoscopic procedures have poor long-term outcomes, requiring definitive open reconstruction. Over the past decade, there has been an increasing shift towards robot-assisted laparoscopy (RAL) with multiple institutions reporting their outcomes. In this article, we reviewed the current literature on RAL distal ureteral reconstruction, focusing on benign pathologies only. We present peri-operative data and outcomes on the most common technique, ureteral reimplantation, as well as adjunct procedures such as psoas hitch and Boari flap. Additionally, we present alternative techniques reported in the literature with some technical considerations. Lastly, we describe the outcomes of the comparative studies between open, laparoscopy, and RAL. Although the body of literature in this field is limited, RAL reconstruction of the distal ureter appears to be safe, feasible, and with some advantages over the traditional open approach.

Expanding the indications of robotic surgery in urology: A systematic review of the literature

Objectives

To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities.

Methods

A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

Results

In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques.

Conclusion

Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

Contemporary management of ureteral strictures

Ureteral stricture disease is a luminal narrowing of the ureter leading to functional obstruction of the kidney. Treatment of strictures is mandatory to preserve and protect renal function. In recent times, the surgical management of ureteral strictures has evolved from open repair to include laparoscopic, robotic and interventional techniques. Prompt diagnosis and early first line intervention to limit obstructive complications remains the cornerstone of successful treatment. In this article, we discuss minimally invasive, endo-urological and open approaches to the repair of ureteral strictures. Open surgical repair and endoscopic techniques have traditionally been employed with varying degrees of success. The advent of laparoscopic and robotic approaches has reduced morbidity, improved cosmesis and shortened recovery time, with results that are beginning to mirror and in some cases surpass more traditional approaches.

Level of evidence: Not applicable for this multicentre audit.

Robot-assisted laparoscopic ureteral reconstruction: а systematic review of literature

Introduction

To review the literature, as well as to analyze and compare available data on robot-assisted laparoscopic (RAL) surgery versus open surgery, carried out in ureteral reconstructions in terms of different surgical characteristics.

Materials and methods

Eligible studies, published between 1997 and July 2016, were retrieved through MEDLINE by applying predetermined inclusion and exclusion criteria with the English language restriction. Publications on RAL surgeries, carried out in different ureteral reconstructions and of any study design, including case series and comparative studies, were included. The study was performed in accordance with the PRISMA statement.

Results

A total of 12 retrospective studies (case series and comparative studies) met the systematic review selection criteria involving 245 RAL and 76 open ureteral surgery cases. Main indications for ureter reconstruction were strictures, tumors and injuries. The individual results of comparative studies revealed that the EBL was statistically significantly lower for RAL than for open surgery. As for operation time, length of hospital stay and follow-up time, the data was contradictory. The rate of recurrent stricture in RAL and open groups was similar: -9.0%. The meta-analysis of three comparative studies confirmed that patients lose statistically significantly less blood in RAL, compared to open surgery.

Conclusions

The analysis of limited data available shows that robot-assisted laparoscopic ureteral reconstruction is a safe and effective minimally invasive technique with high cure rates similar to those of the conventional open approach and, with favorable safety profile. Future well-designed randomized controlled trials are required to strengthen our findings.

Robotic Autotransplantation and Management of Post-transplant Anastomotic Strictures: the Future Is Here

PURPOSE OF REVIEW

We set out to review the current published experience with robotic autotransplantation. Although the experience to date is limited, this surgery appears to be safe and technically feasible. We also examined the use of the robotic surgical platform for the management of post-transplant uretero-vesical anastomotic strictures.

RECENT FINDINGS

To date, only four reported cases of robotic autotransplantation have been described with two being performed completely intra-corporeally. An intra-corporeal approach is feasible for benign conditions, while malignant masses should be inspected and dissected extra-corporeally. Ureteric strictures after renal transplantation are common. To date, the experience with robotic surgical management is limited but has also been shown to be safe and feasible. While robotic autotransplantation is still in its infancy, it is feasible and appears to be safe. Renal allograft function and surgical outcomes are favorable and provide patients the option to have a historically more morbid surgery performed with a minimally invasive approach.

Robot-assisted ureteral reconstruction - current status and future directions

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

Expanding the Utilization of Robotic Procedures in Urologic Surgery

Although the word "robot" was coined in 1921, only close to 70 years later were robotic devices developed to assist during surgery. Urology has always been at the forefront of endoscopic, minimally invasive, and robotic developments in medicine. Robotic prostatectomy signaled the emerging role of robotic surgery in urology, but since then it has been applied to every urologic laparoscopic procedure.

Long Term Outcomes of Laparoscopic and Open Modified Lich-Gregoir Reimplantation in Adults: A multicentric comparative study

Background & Objective:

Obstructive ureteral pathologies in adult patients are most commonly due to ureteral strictures and secondary to surgical interventions. In this study, we aimed to compare open and laparoscopic modified Lich-Gregoir ureteral reimplantation with regards to outcomes in benign ureteral pathologies in adult patients.

Methods:

Between December 2008 and December 2014, 32 open cases and 29 laparoscopic cases were performed as per the data retrieved from surgical databases. All laparoscopic procedures were performed in Bakirkoy Dr. Sadi Konuk Training and Research Hospital(BEAH) and all open ureteral reimplantation procedures in Kartal Dr Lutfi Kirdar Training and Research Hospital(KEAH) and Okmeydani Training and Research Hospital(OEAH).

Results:

The mean operation time was significantly lower in the group of patients operated with open group (142.5 minutes versus 188.9 minutes; P< 0.0001). The mean duration of follow-up was longer in the laparoscopy group (31 versus 28 months; p< 0.0001). The mean amount of operation associated blood loss was significantly lower in patients operated laparoscopically (93.7 mL versus 214 mL; P< 0.0001). The mean VAS score obtained six hours after surgery was 6.6 ± 0.8 in open group, and 5.8 ± 0.7 in laparoscopic group (p=0.0004). The mean VAS scores measured at post-operative day 1 was 4.5 ± 0.7 in open group and 3.7 ± 0.9 in laparoscopy group. Time required to achieve the pre-operative capability of daily activities was significantly longer in open group (15 ± 1.4 days vs 11 ± 1.4 days; p< 0.0001).

Conclusion:

Despite open techniques provide shorter operation time and laparoscopic techniques require long learning curve, we think that laparoscopic techniques are superior to open ones since that they provide a better post-operative comfort and are better tolerated in terms of complications.

Laparoscopic Extravesical Lich-Gregoir Ureteroneocystostomy with Psoas Hitch for the Management of Ureterovaginal Fistula in Post-Hysterectomy Patients

Introduction: Most commonly ureterovaginal fistula occurs due to surgical injury inflicted to the distal ureter and because of gynaecological procedures. Open surgical repair is a standard procedure and commonly involves ureteroneocystostomy. Methods: We retrospectively reviewed data of 9 patients, who underwent laparoscopic extravesical Lich-Gregoir ureteroneocystostomy using the psoas hitch procedure for ureterovaginal fistulas following hysterectomy during the period December 2012-August 2014. Transperitoneal laparoscopic ureteroneocystostomy was performed in all cases. Results: The mean operative time was 212 min (range 170-310) and estimated blood loss was 108 ml (range 70-150). Average hospital stay was 5.7 days. Follow-up time was from 6 to 26 months. Postoperative intravenous urography was done after 3 months, which showed patent anastomosis in 8 patients except for 1 patient who had nonvisualization of the ipsilateral renal moiety. Voiding cystogram done at 3 months showed no leakage in all patients. In the postoperative period, 1 patient had recurrent ipsilateral pyelonephritis 2 weeks after surgery, while another patient had febrile UTI. Apart from these no major complications were observed. Conclusion: Laparoscopic ureteroneocystostomy with psoas hitch can be performed safely with a success rate compared to that of open surgery but with less morbidity and quick convalescence.

Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up

BACKGROUND AND PURPOSE

Use of the robotic platform for urinary reconstructive surgery is growing in popularity since its initial application with pyeloplasty for ureteropelvic junction (UPJ) repair. Although clinical series of adult robotic ureteral reconstruction appear in the literature, these reports tend to be limited in size and scope. We present the largest series to date of patients undergoing surgery for any obstruction distal to the UPJ along with outcomes and short-term follow up.

PATIENTS AND METHODS

A retrospective chart review was performed for patients undergoing robotic ureteral reconstructive procedures for any indication at our institution. Patients undergoing pyeloplasty, planned open procedures, and pediatric patients were excluded from the current analysis. Patient demographic data, etiology, procedure performed, and perioperative outcomes were reviewed. Postoperative follow up, imaging, and any re-interventions were also captured. The procedures performed included ureteroneocystostomy, psoas hitch, Boari flap, ureteroureterostomy, ureterolysis, ureterolithotomy, and nephropexy.

RESULTS

A total of 55 patients underwent robotic ureteral reconstructive procedures distal to the UPJ. Of these patients, 45 underwent intervention for a benign etiology and 10 for upper tract malignancy. All cases were successfully completed robotically with no open conversions and no intraoperative complications. Concurrent endoscopy was performed in 31 patients. The median operating room time was 221 minutes overall. Median blood loss was 50 ml with no intraoperative transfusions. The average hospital stay was 1.6 days, with 39 patients (71%) discharged on postoperative day 1. All surgical margins were negative for malignancy. The median follow up with imaging was 181 days. There were two serious complications (3.6%) and three failures (5.3%).

CONCLUSIONS

Robotic reconstruction of the ureter distal to the UPJ is feasible, safe, effective, and able to replicate techniques of open surgery with equivalent outcomes to large robotic pyeloplasty and smaller distal ureteral reconstruction series.

Open, laparoscopic, and robotic ureteroneocystotomy for benign and malignant ureteral lesions: a comparison of over 100 minimally invasive cases

INTRODUCTION

Laparoscopic (LAP) and robot-assisted laparoscopic (RAL) approaches have been applied to ureteroneocystostomies (UNC) although such experience has been limited to a small number of patients and limited follow-up. Herein, we detail our experience with over 100 minimally invasive UNC, the largest such series to date.

METHODS

All minimally invasive UNC performed at our institution between 1997 and 2013 and all open UNC performed between 2008 and 2013 were identified. Perioperative parameters of relevance were identified and recorded. Chi-squared and ANOVA with post hoc Tukey analysis were performed for all categorical and continuous variables, respectively.

RESULTS

A total of 130 patients met our study criteria. One hundred five underwent the minimally invasive approach (20 RAL and 85 LAP). Mean follow-up duration was 504 days. Patients in the RAL, LAP, and open cohorts were of similar age, gender and laterality distribution, American Society of Anesthesiologists (ASA) score, body-mass index, history of previous abdominal surgery, history of prior treatment for the ureteral lesion, and surgical indication ( Table 1 ). Operative time was similar across all cohorts (235-257 minutes, p=0.123). Estimated blood loss (EBL) was significantly lower in the RAL and LAP cohorts (100 and 150 mL) compared to their open counterparts (300 mL, p=0.001) although a decrease in hematocrit was similar across all groups. Only four intraoperative complications (4.7%) and two (2.4%) conversions to open were identified in the LAP group, without statistical significance. No intraoperative complications or conversions were identified in the RAL or open cohorts. Median length of stay (LOS) was significantly shorter in the minimally invasive cohorts compared to open (p<0.002). Ninety-day readmission rates (18.8-20%), major complications (10-20%), and failure rates (5.9-16%) were highest in the open cohort although without statistical significance.

CONCLUSION

RAL or LAP UNC is feasible, safe, and comparable to the open technique with some perioperative benefit in EBL, LOS, and stent duration.

Outcomes of robotic-assisted laparoscopic upper urinary tract reconstruction: 250 consecutive patients

OBJECTIVE

To evaluate the long-term outcomes of robotic-assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction performed at a tertiary referral centre.

MATERIALS AND METHODS

Data from 250 consecutive patients undergoing RAL UUT reconstruction, including pyeloplasty with or without stone extraction, ureterolysis, uretero-ureterostomy, ureterocalicostomy, ureteropyelostomy, ureteric reimplantation and buccal mucosa graft ureteroplasty, were collected at a tertiary referral centre between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months.

RESULTS

Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure, with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications, none greater than Clavien grade 3.

CONCLUSION

Robotic-assisted laparoscopic UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons.

Robotic distal ureterectomy with psoas hitch and ureteroneocystostomy: Surgical technique and outcomes

Use of the da Vinci^® surgical robotic system has expanded to numerous upper and lower urinary tract procedures. We describe our surgical technique and perioperative outcome of robotic distal ureterectomy with psoas hitch and ureteroneocystostomy for distal ureteral pathologies. Eight patients with a median age of 69.5 years old underwent robotic distal ureterectomy with psoas hitch and ureteroneocystostomy between April 2009 and August 2014. The entirety of all cases was performed robotically by a single surgeon at a tertiary academic medical center. Median operative time was 285 min (range: 210-360 min), estimated blood loss was 50 mL (range: 50-75 mL) and median length of hospital stay was 2.5 days (range: 1-6 days). There was one post-operative complication, a readmission for dehydration (Clavien I). It suggests that robotic distal ureterectomy with psoas hitch and ureteroneocystostomy is a safe and effective minimally invasive alternative for patients with distal ureteral pathology.

Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review

A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.

Laparoscopic repair of urogenital fistulae: A single centre experience

CONTEXT

Sparse literature exists on laparoscopic repair of urogenital fistulae (UGF).

AIMS

The purpose of the following study is to report our experience of laparoscopic UGF repair with emphasis on important steps for a successful laparoscopic repair.

SETTINGS AND DESIGN

Data of patients who underwent laparoscopic repair of UGF from 2003 to 2012 was retrospectively reviewed.

MATERIALS AND METHODS

Data was reviewed as to the aetiology, prior failed attempts, size, number and location of fistula, mean operative time, blood loss, post-operative storage/voiding symptoms and episodes of urinary tract infections (UTI).

RESULTS

Laparoscopic repair of 22 supratrigonal vesicovaginal fistulae (VVF) (five recurrent) and 31 ureterovaginal fistulae (UVF) was performed. VVF followed transabdominal hysterectomy (14), lower segment caesarean section (LSCS) (7) and oophrectomy (1). UVF followed laparoscopy assisted vaginal hysterectomy (18), transvaginal hysterectomy (2) and transabdominal hysterectomy (10) and LSCS (1). Mean VVF size was 14 mm. Mean operative time and blood loss for VVF and UVF were 140 min, 75 ml and 130 min, 60 ml respectively. In 20 VVF repairs tissue was interposed between non-overlapping suture lines. Vesico-psoas hitch was done in 29 patients of urterovaginal fistulae. All patients were continent following surgery. There were no urinary complaints in VVF patients and no UTI in UVF patients over a median follow-up of 3.2 years and 2.8 years respectively.

CONCLUSION

Laparoscopic repair of UGF gives easy, quick access to the pelvic cavity. Interposition of tissue during VVF repair and vesico-psoas hitch during UVF repair form important steps to ensure successful repair.