Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience

Background: Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. Objective: To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. Design, setting, and participants: This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. Surgical procedure: RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. Outcome measurements and statistical analysis: Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. Results and limitations: The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0 cm (range 2.0–8.0), operative time was 200 min (range 136–397), estimated blood loss was 95 ml (range 25–420), and length of stay was 2 d (range 1–15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. Conclusions: RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. Patient summary: We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction. The management of long ureteral strictures can be challenging. We describe a reproducible effective robotic technique for the management of this condition that uses a buccal mucosa graft. At median follow-up of 26 mo, the overall success rate was 89%.