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ROBOTICS Robotic-Assisted Upper Urinary Tract Reconstruction: Tips and Tricks

By: Kian Ahmadieh, MD, University of California, San Diego; Dhruv Puri, BA, University of California, San Diego; Jill C. Buckley, MD, University of California, San Diego | Posted on: 01 Mar 2024

Upper urinary tract reconstruction was traditionally performed through an open approach. The integration of robotics in urology has revolutionized the field of upper urinary tract reconstruction, providing improved visualization, dexterity, as well as use of near-infrared fluorescence to aid in ureteral identification and assess tissue perfusion.

The key to successful upper urinary tract reconstruction is an extensive preoperative workup to understand the location and length of the ureteral defect (eg, cystogram, antegrade nephrostogram, retrograde pyelogram). The surgical approach is guided by the location, length, and etiology of disease as well as various patient factors including surgical history and prior radiation therapy. We outline common surgical options in the management of upper tract stricture disease (Figure). Despite thorough preoperative workup, surgeons may encounter unforeseen intraoperative findings, necessitating multiple techniques in their armamentarium to adapt to the variety of possible presentations.


Figure. Decision-tree model outlining common management options for upper urinary tract stricture disease.

In many cases of upper urinary tract reconstruction, patients exhibit significant periureteral and retroperitoneal tissue reaction, increasing the difficulty of ureteral identification. Here we outline techniques that can be utilized intraoperatively to identify the ureter in such complex cases.

The patient positioning and port placement are largely dependent on the location and size of the stricture. The patient should be positioned to allow access to the urethra and the nephrostomy tube site, when applicable. Indocyanine green (ICG) is a fluorescent tracer that can be administered intraluminally in a retrograde or antegrade fashion to aid in ureteral identification. When coupled with the near-infrared fluorescence (NIRF) imaging properties of the Firefly system, ICG can assist in the identification of the ureter when placed intraluminally and can help delineate the proximal and distal portions of the stricture.1,2 The benefits of ICG include its high signal to noise ratio, safety profile, and tissue penetration.3

In cases of dense scar surrounding the ureter, the ICG fluorescence may be difficult to visualize. Alternatively, the surgical assistant can perform retrograde ureteroscopy or antegrade pyeloscopy (through an existing nephrostomy tube tract) to assist with identification of the ureter. The Firefly system can be utilized to identify the light from the ureteroscope. If the surgeon is unable to visualize the light from the ureteroscope, the surgical assistant can gently deflect the ureteroscope back and forth to aid in ureteral identification. The TilePro feature of the da Vinci surgical system can also be used to allow the surgeon on the console to simultaneously visualize the live images from the ureteroscope as well as the robotic camera.4

A crucial factor in a successful reconstruction is ensuring the entire diseased portion of the ureter is identified and treated. Prior to completing the repair, the proximal and distal portions of the ureter should be evaluated. A ureteroscope can be placed through the assistant trocar to evaluate the proximal and distal portions of the ureteral defect. Alternatively, each end can be cannulated to ensure there is no narrowing of the repaired segments of the ureter (eg, 10F red rubber catheter).

Common principles for any urologic reconstructive procedure include a tension-free anastomosis with well-perfused tissue. The previously described near-infrared fluorescence properties of the robotic system can also be used to evaluate tissue perfusion.5 Anastomotic tissue perfusion can be evaluated after intravenous administration of indocyanine green coupled with the NIRF properties of the Firefly system to help ensure healthy vascularized tissue is utilized (signified by a fluorescent color) to better prevent surgical complication/failure. In cases where there is concern of the viability of the tissue, adjunct maneuvers can be performed such as an omental/peritoneal flap wrap to improve vascularity.6

Numerous techniques have been described in the field of upper urinary tract reconstruction including ureteroneocystostomy, ureteroureterostomy, appendiceal interposition, Boari flap, ileal interposition, etc. Novel techniques include the utilization of buccal mucosal graft in the reconstruction of complex ureteral strictures.7 Our technique using buccal mucosal graft in upper urinary tract reconstruction, which is currently under review, has yielded favorable outcomes. A total of 21 patients underwent upper urinary tract reconstruction with buccal mucosal graft. Nine patients (42.9%) had prior abdominal/pelvic surgeries, and 6 patients (29.6%) with prior abdominal/pelvic radiation. Only 2 patients (9.5%) required subsequent procedures (percutaneous nephrostomy tube and revisional surgery).

The field of upper urinary tract reconstruction is constantly evolving. Minimally invasive technology allows the utilization of NIRF to help identify ureteral strictures and assess tissue perfusion. Surgical techniques largely depend on the stricture location and length. Novel techniques have been described including the use of buccal mucosal graft in the repair of complex ureteral strictures. Continued research is needed to understand how to incorporate new technological advancements in the field of upper urinary tract reconstruction.

  1. Elbakry AA, Pan MM, Buckley JC. Frontiers in post-radiation urologic reconstruction; robotic surgery and near-infrared fluorescence imaging. AME Med J. 2022;10.21037/amj-21-3.
  2. Lee Z, Moore B, Giusto L, Eun DD. Use of indocyanine green during robot-assisted ureteral reconstructions. Eur Urol. 2015;67(2):291-298.
  3. Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green fluorescent imaging in surgery. Int J Biomed Imaging. 2012;2012:940585.