Ureteral stricture: current treatment algorithm and key surgical principles in the robotic upper urinary tract reconstruction era

Abstract

Robot-assisted surgical management of ureteral stricture is a relatively uncommon procedure with numerous techniques described. This literature review combined with expert opinion outlines the key surgical principles of ureteral reconstruction and proposes an algorithm for the robot-assisted treatment of ureteral strictures. A narrative literature review was conducted using PubMed and Cochrane databases with a predefined search strategy including terms related to ureteroplasty and upper urinary tract reconstruction. The search yielded approximately 900 results. After screening, 219 relevant studies were selected for analysis. Two authors independently reviewed all included articles, and whenever evidence was inconsistent or insufficient, consensus was reached through discussion within the full author group. Robotic ureteral reconstruction includes several techniques, with the choice of procedure guided by multiple factors. Key principles include the use of healthy tissue, creation of a tension-free anastomosis, and ensuring adequate drainage. Outcomes may be further optimized by preoperative ureteral rest, intraoperative ureteroscopy, and the use of intravenous indocyanine green (ICG). Buccal mucosa grafting has emerged as a breakthrough in minimally invasive reconstruction. The robotic approach is adept at managing standard techniques such as ureteroureterostomy, psoas hitch, Boari flap, ureteroneocystostomy, and more recently described methods such as non-transecting ureteral reimplantation and bladder flap ureteroplasty. Ileal ureter remains a good option in cases of challenging reconstructions and patients with prior radiation therapy or extensive defects. Robot- assisted ureteral reconstruction has shifted the paradigm in stricture management, allowing complex reconstructive operations to be performed with minimally invasive techniques. This expert review summarizes key surgical approaches and presents a practical algorithm to guide urologists in the management of ureteral strictures.