Robotic ureteral reimplantation for endometriosis: the Lich-Gregoir technique. A step-by-step approach

BACKGROUND: Urinary tract endometriosis affects fewer than 6% of patients with endometriosis, with ureteral involvement representing the second most common site of disease (9-23%). The condition is often asymptomatic, which may result in silent loss of renal function. Surgical intervention is required in cases of ureteral obstruction. Ureteroneocystostomy is indicated for distal ureteral disease, particularly when ureterolysis is insufficient or vascular compromise is present. The Lich-Gregoir technique is an extravesical approach to ureteral reimplantation into the bladder. OBJECTIVES: To present a step-by-step demonstration of robot-assisted ureteral reimplantation using the Lich-Gregoir technique following excision of a parametrial and vaginal endometriosis nodule. PARTICIPANT: A 47-year-old nulliparous woman presented with dysuria, deep dyspareunia, and dyschezia. Imaging revealed a left parametrial endometriosis nodule extending to the vagina, causing distal ureteral obstruction and grade III hydronephrosis. INTERVENTION: This narrated video demonstrates the surgical management of severe ureteral endometriosis, including ureterolysis, safe nodule excision, and ureteral reimplantation using the Lich-Gregoir technique. Reimplantation was preferred to segmental resection or ureterolysis due to distal stenosis, proximity to the bladder, and the depth of disease infiltration. The patient remained asymptomatic at follow-up visits at 1 and 6 months. Retrograde cystography performed 3 weeks postoperatively showed no leakage. CONCLUSIONS: Robot-assisted Lich-Gregoir ureteral reimplantation represents a feasible and reproducible option for distal ureteral endometriosis. The robotic platform may facilitate precise and complex reconstructive procedures. WHAT IS NEW?: The case illustrates the role of robotic surgery in complex pelvic endometriosis, demonstrates the feasibility of integrating ureteroneocystostomy with simultaneous excision of parametrial and vaginal endometriosis.