Ureteral strictures are mainly iatrogenic, due to abdominal surgery or traumatic ureteroscopy. Historically, open ureteral reimplantation, ileal ureter and autotransplantation were the most commonly used techniques to repair ureteral injuries. The rise of robotic surgery may have facilitated those procedures but has also been accompanied by the emergence of new upper urinary tract reconstruction techniques such as buccal mucosa graft ureteroplasty or side to side reimplantation. The aim of this study was to report the outcomes of an initial single –center experience of robotic upper urinary tract reconstruction (UUTRR) for ureteral strictures.

The charts of all the patients who underwent UUTRR for ureteral strictures at a single academic center between 2015 and 2022 were retrospectively reviewed. UUTRR for ureteropelvic junction obstruction, open reconstructions and ureteroileal strictures were excluded. All the remaining patients were included for analysis. The primary outcome was the absence of stricture recurrence at last follow-up defined as the need for drainage and/or surgical treatment and/or symptomatic hydronephrosis.

Twenty-seven patients were included. Patients characteristics are summarized in table 1 : most of them were women (2/3), most stenosis were as expected iatrogenic, mainly due to previous abdominal surgery, and half of them were located in the pelvic portion of the ureter. Median follow-up was 10 months, with 1 patient lost to follow-up.
The surgical technique was buccal mucosa graft ureteroplasty in five cases (18.5%), Boari flap in five cases (18.5%), psoas hitch in eight cases (26%), excision and primary anastomosis in one case (3.7%) and ureterolysis + intraperitonization in one case (3.7%). Perioperative results are summarized in table 2 : mean operative time around 200 minutes, mean hospital discharge at day 3, and  mean blood losses around 80 mL. We also reported several characteristics of interest such as ureteral rest, green firefly use, and perioperative ureteroscopy. Regarding postoperative complications, eight patients had one (29.6%), but only one major one (i.e. Clavien grade 3 or higher 3.7%). After a median follow-up of 10 months, the success rate according to the primary outcome was 85.2%.

The only two predictive factors significantly associated with failure were a history of previous radiotherapy (failure risk 66.7% vs. 8.3%; p=0.02) and stricture length (OR=2.4; p=0.009).

Robotic upper urinary reconstruction for ureteral stricture is feasible with various techniques, either reproducing some old techniques or directly developed in robotic surgery. Preliminary reports are encouraging with low morbidity and recurrence rate. Patients who underwent radiotherapy and/or with extended ureteral strictures might have a higher risk of recurrence.