Robot-assisted ureteric reimplantation: Indications, techniques, and outcomes of an effective robotic platform adaptation

Study concept and design : Sarah Lorger, Bishoy Hanna, Scott Leslie. Data acquisition : Sarah Lorger, Bishoy Hanna, Ahmed Goolam, Matthew Winter, Nariman Ahmadi, Philip Dundee, Scott Leslie. Data analysis : Sarah Lorger. Drafting of the manuscript : Sarah Lorger. Critical revision of manuscript : Mark Broe, George McClintock, Darshan Sitharthan, Ahmed Goolam, Matthew Winter, Nariman Ahmadi, Patrick-Julien Treacy, Nicola Jeffery, Michael Cooper, Alan Lam, Philip Dundee, Scott Leslie.

The study consisted of 34 patients who were operated on by six surgeons at 12 different institutions throughout Australia. Most of these surgeons underwent fellowships in robotic and minimally invasive surgery and had over 10 years of experience as consultant urologists. The demographics of the patients are shown in Table 1 . Female patients represented 59% of the cohort and the mean age of the cohort was 55 years. The most common ureteric pathology requiring reimplantation was iatrogenic injury, representing 15 (44%) cases, followed by 13 (38%) cases of stricture disease, five (15%) cases of other benign pathologies, and one (2.9%) case of malignancy ( Table 1 ). Of the gynaecological iatrogenic injuries, five cases were secondary to hysterectomies, four cases were secondary to endometriosis surgery, and one case was secondary to an ovarian cystectomy. The urological iatrogenic injuries included one case secondary to robot-assisted radical prostatectomy and bladder diverticulectomy, one case for transurethral resection of bladder tumour, and one case due to diverticulectomy. The one general surgical case was due to a laparotomy secondary to small bowel obstruction. There was one iatrogenic case of unknown aetiology. Aetiologies of iatrogenic injuries are detailed in Table 2 . Stricture disease is also a common aetiology, which is detailed in Table 1 . Table 1 Preoperative patient demographics and aetiological data. Table 1 Characteristic Value ( n =34) Age, year 55 (30–87) Sex  Female 20 (59)  Male 14 (41) Iatrogenic injury 15 (44)  Gynaecological  Hysterectomy 5  Endometriosis surgery 4  Ovarian cystectomy 1  Urological  RARP and bladder diverticulectomy 1  TURBT 1  Diverticulectomy 1  General surgery  Laparotomy for small bowel obstruction 1  Unknown 1 Stricture disease 13 (38)  Endometriosis 4  Radiation stricture 2  Distal ureteric stricture post renal transplant 2  Stricture post cystectomy and neobladder 2  Stricture post cystectomy 1  Distal ureteric stricture 1  Bilateral ureteric stricture a 1 Other benign conditions 5 (15)  Amyloid 1  Retroperitoneal fibrosis 1  Megaureter with functional obstruction 1  Robotic diverticulectomy arising near the ureteric orifice 1  Unknown 1 Malignancy 1 (2.9)  Urothelial carcinoma involving distal ureter 1 RARP, robot-assisted radical prostatectomy; TURBT, transurethral resection of bladder tumour. Note: values are presented as mean (range), n , or n (%), and total percentages may not be 100% due to rounding. a Previous reimplantation as a child. Table 2 Details of iatrogenic injuries. Table 2 Patient No. Category Procedure Presentation timing Presentation type 1 Gynaecological Hysterectomy Delayed Ureterovaginal fistula 2 Gynaecological Hysterectomy Delayed Unknown 3 Gynaecological Hysterectomy Delayed Ureteric obstruction 4 Gynaecological Hysterectomy Delayed Ureterovaginal fistula 5 Gynaecological Hysterectomy Delayed Ureteric leak 6 Gynaecological Endometriosis surgery Delayed Ureteric leak 7 Gynaecological Endometriosis surgery Intraoperative NA 8 Gynaecological Endometriosis surgery Intraoperative NA 9 Gynaecological Endometriosis surgery Intraoperative NA 10 Gynaecological Ovarian cystectomy Delayed Unknown 11 Urological RARP and bladder diverticulectomy Intraoperative NA 12 Gynaecological TURBT Delayed Ureteric obstruction 13 Gynaecological Diverticulectomy Intraoperative NA 14 General surgery Laparotomy for small bowel obstruction Delayed Ureteric leak 15 Unknown Unknown Delayed Unknown RARP, robot-assisted radical prostatectomy; TURBT, transurethral resection of bladder tumour; NA, not applicable. Preoperative patient demographics and aetiological data. RARP, robot-assisted radical prostatectomy; TURBT, transurethral resection of bladder tumour. Note: values are presented as mean (range), n , or n (%), and total percentages may not be 100% due to rounding. Previous reimplantation as a child. Details of iatrogenic injuries. RARP, robot-assisted radical prostatectomy; TURBT, transurethral resection of bladder tumour; NA, not applicable. For those with iatrogenic injuries, 10 (67%) were delayed presentations and five (33%) were identified intraoperatively. In the delayed presentations, three cases presented as a ureteric leak, two presented as ureteric obstruction, and two presented with ureterovaginal fistulas. It was unknown how three of the cases presented, as detailed in Table 2 . Of the patients with strictures, four were secondary to cystectomy and urinary diversion, with two patients undergoing reimplantation into a neobladder and two into an ileal conduit. Surgical details including site and side of ureteric pathology are detailed in Table 3 . A psoas hitch was documented in 20 (59%) of the cases, and a Boari flap was used in eight (24%) of the cases. Table 3 Perioperative data. Table 3 Variable Value ( n =34) Site and side of ureteric pathology  Left 16 (47)  Right 15 (44)  Transplant ureter 2 (5.9)  Bilateral 1 (2.9) Use of psoas hitch 20 (59) Use of Boari flap 8 (24) Conversion to open 1 (2.9) EBL, mL 53 (2–300) EBL, estimated blood loss. Note: values are presented as mean (range) or n (%), and total percentages may not be 100% due to rounding. Perioperative data. EBL, estimated blood loss. Note: values are presented as mean (range) or n (%), and total percentages may not be 100% due to rounding. The mean hospital length of stay was 5.7 (range 1.0–25.0) days. The mean length of time until the ureteric stent was removed was 44 days, as detailed in Table 4 . Table 4 Postoperative data. Table 4 Variable Value ( n =34) Length of stay, day 5.7 (1.0–25.0) a Stent duration, day 44 (10–85) b Radiological resolution  Resolved 29/31 c (94)  Failure 2/31 c (6.5) Ultrasound PVR, mL 30 (0–79) Creatinine, μmol/L 83 eGFR, mL/min/1.73 m 2 74 Major complication (Clavien–Dindo grade ≥III) 4 (12) d Patients with LUTS  Onset after stent removal 13/22 e (59)  With psoas hitch 11/20 (55)  With Boari flap 5/8 (62)  Overall LUTS 13/22 e (59)  Outcomes at 12 months  With complete resolution 17/22 e (77)  Requiring pharmacological management 5/22 e (23) PVR, post-void residual; eGFR, estimated glomerular filtration rate; LUTS, lower urinary tract symptoms. Note: values are presented as mean (range), mean, n (%), or n / N (%), and total percentages may not be 100% due to rounding. a Data available for 29 patients. b Data available for 26 patients. c Data available for 31 patients. d All Clavien–Dindo grade IIIb (under a general anaesthetic): reinsertion of ureteric stent due to malposition, clot retention requiring washout in theatres, sepsis and bacteraemia requiring nephrostomy insertion, and hydroureteronephrosis requiring nephrostomy insertion. e For LUTS-related endpoints, four patients with a history of cystectomy were excluded from the analysis; data were available for 22 of the remaining 30 patients. Postoperative data. PVR, post-void residual; eGFR, estimated glomerular filtration rate; LUTS, lower urinary tract symptoms. Note: values are presented as mean (range), mean, n (%), or n / N (%), and total percentages may not be 100% due to rounding. Data available for 29 patients. Data available for 26 patients. Data available for 31 patients. All Clavien–Dindo grade IIIb (under a general anaesthetic): reinsertion of ureteric stent due to malposition, clot retention requiring washout in theatres, sepsis and bacteraemia requiring nephrostomy insertion, and hydroureteronephrosis requiring nephrostomy insertion. For LUTS-related endpoints, four patients with a history of cystectomy were excluded from the analysis; data were available for 22 of the remaining 30 patients. Radiological resolution was defined as the successful reconstruction of the ureter with resolution of the initial pathology and occurred in 94% of patients in this cohort. Of the 15 iatrogenic injuries, five (33%) were identified intraoperatively, and the other 10 (67%) had delayed presentation, of which seven cases presented with ureteric leak, obstruction, or fistula secondary to surgical misadventure (the remaining three cases had unknown presentation type). Resolution of these injuries was achieved with robotic reimplantation for all but one patient. This patient had a failed reimplantation with obstruction requiring nephrostomy and antegrade stent insertion. This patient underwent a robotic reimplantation following a ureteric leak caused during adhesiolysis for a small bowel obstruction on a background of a cystectomy and ileal conduit formation. Unfortunately, this patient was lost to follow-up as they moved overseas. Nineteen patients presented with a stricture of the ureter or malignancy and following robotic reimplantation, postoperative imaging confirmed resolution of the ureteric obstruction in all but one patient. This patient had a ureteric stricture post-renal transplant, although on postoperative renal tract ultrasound they had a reduction in ureteric dilatation; unfortunately, they did not have any improvement in renal function. Four patients underwent ureteric reimplantation for ureteroileal anastomotic stricture following cystectomy and urinary diversion. Three of these patients presented with ureteric strictures with onset ranging from 3 months to 2 years after initial surgery. The other patient had a urinary leak after laparotomy for small bowel obstruction. The long-term follow-up for patients varied between surgeons. Patients without postoperative LUTS who achieved radiological resolution often had annual follow-up for a few years and then were discharged back to their primary physicians. In contrast, other patients were still seen annually by their urologists. The mean follow-up time for the patients with postoperative LUTS was 6.6 (range 3–16) months. Thirteen patients had some degree of postoperative LUTS; nine patients did not have any postoperative LUTS; four patients were excluded due to a history of cystectomy (with ileal conduit or neobladder formation). There were no data available for the remaining eight patients regarding postoperative LUTS, as detailed in Table 4 . Eleven of the 20 (55%) patients with a psoas hitch experienced some degree of postoperative LUTS. Five of the eight (63%) patients with a Boari flap experienced some degree of postoperative LUTS. Of the 13 patients reporting postoperative LUTS, six had minor symptoms and did not require pharmacological management; two had obstructive symptoms that resolved after transurethral resection of the prostate; one had partial resolution following ovarian cystectomy; the remaining five patients were treated pharmacologically. Of note, one patient received both pharmacological management and transurethral resection of the prostate. Ten out of the 13 (77%) patients had complete resolution of their LUTS. The remaining three (23%) had some degree of ongoing LUTS and still required pharmacological management at 12 months after surgery. The use of the beta-3 receptor agonist (mirabegron), the muscarinic receptor antagonist (solifenacin), the anticholinergic (oxybutynin), or the alpha blocker (tamsulosin) is detailed in Table 5 . Table 5 Details of postoperative LUTS, treatment, and resolution for each patient with postoperative LUTS. Table 5 Patient No. Type of LUTS Medications Taking at 12 mo Surgery Resolution Timeframe, mo 1 Irritative symptoms Mirabegron and oxybutynin No NA Resolved NA 2 Irritative symptoms (minor) No No NA Resolved 4 3 Voiding and irritative symptoms Tamsulosin No TURP Resolved post-TURP 10 4 Irritative symptoms Mirabegron Yes Ovarian cystectomy Improved but ongoing NA 5 Irritative symptoms Solifenacin, mirabegron, and oxybutynin Yes NA Ongoing NA 6 Irritative symptoms Mirabegron No NA Resolved 5 7 Irritative symptoms (minor) No No NA Resolved 3 8 Irritative symptoms (minor) No No NA Resolved 3 9 Urinary retention No No TURP Resolved post-TURP 4 10 Irritative symptoms Mirabegron and solifenacin Yes NA Ongoing NA 11 Irritative symptoms (minor) No No NA Resolved 3 12 Irritative symptoms (minor) No No NA Resolved 3 13 Irritative symptoms NA No NA Resolved NA LUTS, lower urinary tract symptoms; TURP, transurethral resection of the prostate; NA, not available; mo, months. Note: the mean timeframe for symptom resolution was 4 mo, with a range of 3–10 mo. Details of postoperative LUTS, treatment, and resolution for each patient with postoperative LUTS. LUTS, lower urinary tract symptoms; TURP, transurethral resection of the prostate; NA, not available; mo, months. Note: the mean timeframe for symptom resolution was 4 mo, with a range of 3–10 mo. Renal tract ultrasound is often completed 6 weeks after the ureteric stent is removed. Thirteen patients had records of their ultrasound at this point. The mean post-void residual was 30 mL, with a range from 0 mL to 79 mL. Biochemical evaluation was also performed at this time and showed a mean creatinine level of 83 μmol/L and the mean estimated glomerular filtration rate of 74 mL/min/1.73 m 2 ( Table 4 ). Four (12%) cases reported a major complication (Clavien–Dindo grade ≥III), which is detailed in Table 4 . One case was converted to open due to dense adhesions from previous abdominal surgery, and it was deemed unsafe to enter the abdomen with laparoscopic ports. Five (33%) of the 15 iatrogenic injuries were repaired at the time of injury. The remaining injuries were repaired in a delayed fashion.

Ethics approval was obtained for this study in addition to a separate video atlas which has already been published [ 13 ]. The ethics approval number was 2020/ ETH00958 , granted by Nepean Blue Mountains Local Health District Human Research Ethics Committee. This multi-institutional, retrospective cohort study examined the outcomes of 34 patients who underwent robot-assisted ureteric reimplantation across 12 Australian institutions (Chris O'Brien Lifehouse, Camperdown, NSW; Epworth Healthcare, Richmond, VIC; John Flynn Private Hospital, Tugun, QLD; Mater Hospital, Wollstonecraft, NSW; Royal North Shore Hospital, St Leonards, NSW; The Royal Melbourne Hospital, Parkville, VIC; Royal Prince Alfred Hospital, Camperdown, NSW; Sydney Adventist Hospital, Wahroonga, NSW; St Luke's Care, Potts Point, NSW; St George Private Hospital, Kogarah, NSW; Strathfield Private Hospital, Strathfield, NSW; and St Vincent's Hospital, Fitzroy, VIC). The rarity of this procedure performed robotically necessitated a multi-institutional approach to gather an appropriate sample size. Demographic data, as well as the aetiology of ureteric pathology, side, and site of surgery, were collected. Patients with an elective or delayed repair were ideally preoperatively assessed with CT imaging including a urographic phase, in addition to cystoscopy and, when indicated, retrograde imaging studies. These assessments were crucial to exclude concurrent contralateral ureteric or bladder injuries or pathologies and to evaluate bladder capacity, particularly before undertaking a Boari flap procedure. Postoperative data were collected and analysed for length of stay, duration of ureteric stents, complications, radiological resolution, and presence of postoperative LUTS. Data were managed and analysed using Microsoft Excel (2024) with descriptive statistics for data analysis. Inclusion criteria were all patients undergoing successful or attempted robot-assisted ureteric reimplantation over a 9-year period between 15 September 2015 and 12 September 2024. These patients included those who underwent primary or staged repair for iatrogenic injury in addition to elective reimplantation for other pathologies. Patients were placed in the lithotomy position with a 25-degree Trendelenburg position. Surgeons used the da Vinci Xi platform (Intuitive Surgical, Sunnyvale, CA, USA), and robotic port configuration was similar to that of a robot-assisted radical prostatectomy. However, the camera port and three 8-mm robotic working ports were positioned three fingerbreadths higher than the standard port placement for prostatectomy ( Fig. 1 ) as this optimises the working space of the robotic instruments for the most complex part of the procedure, which is the ureteric anastomosis often performed at the level of the pelvic brim. For patients undergoing ureteral reimplantation to an ileal conduit, the ports were placed obliquely across the abdomen, with the right-sided ports higher than the left-sided ports in order to avoid the ileal conduit. A 12-mm or 8-mm AirSeal port (CONMED, Utica, NY, USA) was placed in the left upper quadrant for the assistant. After adhesiolysis and medial reflection of the sigmoid colon, if it was a left-sided procedure, the ureter was identified and elevated with a vessel loop ( Fig. 2 A). It was mobilised down to the level of pathology with careful preservation of peri-ureteric tissue to achieve the maximum length of the ureter. The ureter was clipped at the site of pathology and transected proximally. The bladder was fully mobilised anteriorly and laterally on the contralateral side to the pathology, and extra care was taken not to injure the contralateral ureter during this process. To maximise bladder mobility, it was important to divide the medial umbilical ligaments on both sides as well as the urachus ( Fig. 2 B). This allowed development of the space of Retzius, separating the bladder from the anterior abdominal wall and thereby promoting a tension-free psoas hitch. The bladder was filled via the urethral catheter and a psoas hitch was performed using 2/0 Vicryl (Ethicon, Inc., Somerville, NJ, USA). A small neocystotomy was performed anteriorly near the dome ( Fig. 2 C). Following spatulation of the ureter ( Fig. 2 D), the uretero-vesical anastomosis was performed with a 2×15 cm 4/0 Vicryl RB-1 needle, with the mucosa-to-mucosa closure under direct vision ( Fig. 2 E and F). Alternatively, a reverse cutting P-3 needle could be used, which allows the needle to pass through tissues with less resistance, compared with the tapered RB-1 needle. The anastomosis was performed in a watertight, continuous fashion with a 6 Fr ureteric stent inserted before completion of the anastomosis ( Fig. 2 G–I). If a psoas hitch alone did not allow the bladder to reach the healthy ureter, then a Boari flap was created. The dimensions of the flap were marked out such that the ureteric anastomosis was not under tension. The ureter was tunnelled inside the flap and spatulated, and the anastomosis was carried out with 4-0 Vicryl as described above. The cystotomy was then closed in a continuous fashion with 3-0 V-Loc sutures (Medtronic, Galway, Ireland), typically in a single layer with incorporation of the bladder mucosa, detrusor fibres, and serosa in single, full-thickness bites. A small abdominal drain was placed, and an 18 Fr urethral catheter was left in situ on free drainage for 7–10 days. A cystogram was performed prior to urethral catheter removal to ensure the ureteric anastomosis and cystotomy were well healed with no evidence of a leak. The timing of ureteric stent removal varied between surgeons and varied depending on patient factors; however, the mean time for stent removal was 6 weeks. Figure 1 Robotic ureteric reimplantation port placement (the robotic ports were placed three fingerbreadths above the level of the umbilicus; the assistant port was placed in the left upper quadrant and was either an 8 mm or a 12 mm AirSeal port). U, umbilicus. Blue dot: camera port; green dot: robotic port; white dot: assistant port. Figure 1 Figure 2 Intraoperative images of a robotic ureteric reimplantation. (A) Identification and elevation of the ureter with a vessel loop; (B) Division of bilateral medial umbilical ligaments and the urachus; (C) Performance of a small anterior neocystotomy near the dome; (D) Spatulation of the ureter; (E) Commencing performance of uretero-vesical anastomosis with the mucosa-to-mucosa closure under direct vision; (F) Continuation of the uretero-vesical anastomosis; (G) Insertion of a 6 Fr ureteric stent before completion of the anastomosis; (H) A ureteric stent in the correct position before closing the anastomosis; (I) Closure of the anastomosis. Figure 2 Robotic ureteric reimplantation port placement (the robotic ports were placed three fingerbreadths above the level of the umbilicus; the assistant port was placed in the left upper quadrant and was either an 8 mm or a 12 mm AirSeal port). U, umbilicus. Blue dot: camera port; green dot: robotic port; white dot: assistant port. Intraoperative images of a robotic ureteric reimplantation. (A) Identification and elevation of the ureter with a vessel loop; (B) Division of bilateral medial umbilical ligaments and the urachus; (C) Performance of a small anterior neocystotomy near the dome; (D) Spatulation of the ureter; (E) Commencing performance of uretero-vesical anastomosis with the mucosa-to-mucosa closure under direct vision; (F) Continuation of the uretero-vesical anastomosis; (G) Insertion of a 6 Fr ureteric stent before completion of the anastomosis; (H) A ureteric stent in the correct position before closing the anastomosis; (I) Closure of the anastomosis.

Within the limits of a non-randomised study and compared with current literature, this study confirms that robot-assisted ureteric reimplantation is a viable option in terms of outcomes and complication rates.

The robotic platform has demonstrated advantages in pelvic surgery, including enhanced camera stability, three-dimensional vision of the operative field, and greater dexterity especially within the confined space of the pelvis [ 14 ]. A systematic review by Kawka et al. [ 15 ] comparing laparoscopic to robotic pelvic surgery found no significant difference in mortality, complication rates, or length of stay across most studies. Robotic ureteric reimplantation surgery is a less commonly performed pelvic operation, with prostatectomy being the most common robotic urological procedure [ 16 ]. Reimplantation is often performed emergently due to iatrogenic injuries, which account for 44% of cases in this cohort study. The emergent and relatively infrequent nature of these surgeries poses challenges for conducting randomised controlled trials, thus limiting the availability of high-quality evidence. Currently, the best available evidence predominantly stems from case–control and cohort studies. Since the first documented case of robotic ureteric reimplantation in 2007 [ 17 ], its use has primarily been reported through small, single-institution case series. Fifer et al. [ 18 ] presented one of the largest single-institution reviews of robot-assisted ureteric reimplantation involving 55 patients, in which 45 cases had benign pathologies and 10 were malignant. The authors reported an average length of stay of 1.6 days and an overall success rate of 94.7% based on symptom resolution and radiographic outcomes. Kozinn et al. [ 1 ] conducted a retrospective comparison of 10 robot-assisted ureteric reimplantations with 10 age-matched controls undergoing an open procedure. Estimated blood loss was significantly reduced in the robotic group (30.6 mL vs . 327.5 mL, p =0.001) and the average length of stay was also significantly reduced (2.4 days vs . 5.1 days, p =0.01). All patients had complete clinical and radiological resolution. This indicates that the robotic approach can achieve comparable clinical outcomes to open surgery while offering substantial reductions in blood loss and hospitalisation time. Carbonara et al. [ 19 ] performed a systematic review comparing the outcomes of robotic and open ureteric reimplantations. The authors included five studies and found statistically significant reductions in estimated blood loss in the robotic groups, with no significant differences in clinical outcomes or complication rates. Comparative studies encompassing all three modalities—open, laparoscopic-assisted, and robot-assisted—remain scarce. Elsamra et al. [ 20 ] compared 20 robot-assisted, 85 laparoscopic-assisted, and 25 open ureteric reimplantations and demonstrated significantly lower estimated blood loss and length of stay for both robot-assisted and laparoscopic-assisted approaches compared with open ureteric reimplantation. There was no statistical difference between complications, readmission, or failure rates. Ramesmayer et al. [ 21 ] compared 60 patients who underwent ureteric reimplantation: nine robot-assisted, 25 laparoscopic-assisted, and 26 open. Statistical analysis was performed by grouping the two minimally invasive modalities and compared them with the open group. Length of stay was significantly reduced in the minimally invasive group (9 days vs . 13 days, p =0.005). Operating time was significantly less in the open group. In this study, there was a significant difference in both major complications and 90-day readmission rates, both of which were higher for the open group. While this cohort study, which included 34 cases, is smaller than Fifer et al.'s study [ 18 ], it is, to our knowledge, the largest cohort study assessing outcomes for robotic ureteric reimplantations in Australia. The involvement of six surgeons with high case volumes in robotic surgery demonstrates that well-trained surgeons can effectively and safely conduct robotic ureteric reimplantation with a 94% success rate. Following robotic ureteric reimplantation, as the bladder is invariably reconstructed with either a psoas hitch or a Boari flap, patients commonly describe storage-type LUTS following catheter removal. These irritative symptoms, which include frequency, urgency, and nocturia may be further exacerbated by the presence of the stent. The inclusion of LUTS assessment is a strength of this study. The high rate of successful radiological outcomes in this cohort was observed across patients with diverse aetiologies of ureteric pathology and various types of reconstruction or reimplantation. Of note, three patients did not have available data for radiological resolution, and eight patients did not have available data for postoperative LUTS. The mean hospital stay was 5.7 days, which aligns with the reported literature (1.6 days [ 18 ] to 7.6 days [ 8 ]). Major complications (Clavien–Dindo grade ≥III) were observed in four (12%) patients and included: one patient requiring operative repositioning of their ureteric stent, one patient with clot retention requiring operative bladder washout, one patient with persistent hydroureteronephrosis requiring nephrostomy and antegrade ureteric stent insertion, and one patient with sepsis and bacteraemia requiring nephrostomy insertion. This complication rate, while on the higher end, remains within the reported literature from 3.6% [ 18 ] to 15.4% [ 22 ] and is potentially reflective of the complex patient profiles encountered in this study, including diverse pathologies and patient comorbidities. This cohort also included two cases of ureteric reimplantation in patients who had previously undergone ureteric reimplantation during renal transplantation. Ureterovesical anastomosis stricture is a known complication following renal transplantation with an incidence of 1.9%–3.7% [ 23 ]. Late ureteric stricture, as in the two cases in this series, is often due to devascularisation of the transplant ureter [ 23 ]. One patient achieved complete radiological and clinical resolution after reimplantation. In contrast, another patient exhibited reduced ureteric dilatation without an improvement in renal function, likely due to a multifactorial decline in a 40-year-old transplant kidney. This patient returned to haemodialysis and has been relisted on the transplant list. Kim et al. [ 23 ] described five patients with transplant ureteral strictures; three of these patients underwent a robot-assisted pyelovesicostomy and the other two had robot-assisted ureteroneocystostomy. Four out of the five patients had improved creatinine levels following surgery; however, the other patient had persistently elevated creatinine levels above baseline despite resolution of hydronephrosis and normal cystoscopy, which was eventually attributed to T-cell-mediated rejection seen on biopsy. All the cases in this study and the comparison to the literature are for multi-port robotic ureteral reimplantation. The use of a single-port robotic platform is an emerging and evolving technology within this space. Research by Heo et al. [ 24 ] using a single-port system for 21 patients requiring ureteral reimplantation demonstrated 97.4% radiographic improvement and 100% symptomatic improvement. All new technologies come with a learning curve for surgeons, and larger comparative research is needed to further assess perioperative and long-term outcomes and the overall viability of the single-port robotic platform [ 25 ]. This study has limitations due to the small size and the retrospective nature. There are some data unavailable for radiological resolution, postoperative LUTS, and length of stay, which need to be considered when interpreting the results of this study. The heterogeneous aetiology can also make it harder to interpret outcomes. The small size, heterogeneous aetiology, and incomplete data may limit the generalisability of this study's results to external patient groups. However, as discussed above, this is a relatively uncommon procedure and this study provides useful information on the practicality and the benefits of a robot-assisted minimally invasive approach. This study has demonstrated that robot-assisted ureteric reimplantation is a feasible and successful surgical option for a wide range of patients and pathologies. This cohort study has demonstrated radiological success after robot-assisted ureteric reimplantation from both iatrogenic causes and primary pathologies. Furthermore, this cohort study has demonstrated the appropriateness of robotic ureteric reimplantation for patients with previous abdominopelvic surgeries, including patients who have had a kidney transplant, ileal conduit, and neobladder formation. This is important given the expansion of robotic pelvic surgery throughout urology and other specialties, demonstrating that if an injury occurs and is identified during the primary operation, a competent robotically-trained urologist can safely and efficiently perform this operation, resulting in patients receiving the best practice which is primary ureteric reimplantation at the time of injury.

Iatrogenic ureteric injury is the most common aetiology requiring reimplantation of the ureter, although multiple other conditions, including stricture disease, malignancy, endometriosis, external trauma, infection, and radiation therapy can lead to ureteric complications that require reimplantation [ 1 ]. The distal third of the ureter is most often damaged in iatrogenic injury due to its proximity to pelvic organs [ 2 , 3 ]. Iatrogenic injuries should ideally be identified during the initial operation with consideration of primary repair, though many are detected in the postoperative period [ 2 , 4 , 5 ]. The approach to ureteric injury repair is complex and depends on the timing of the diagnosis, location, and severity of injury [ [1] , [2] , [3] , [4] , 6 ]. Treatment options can include endoscopic techniques, reconstructive procedures, or even renal autotransplantation [ 7 ]. A psoas hitch or Boari flap may be needed for repair of ureteral injuries between 5 cm and 15 cm away from the ureteral orifice [ 4 ]. Traditionally, open surgery has been the method of choice for complex ureteral reimplantation due to the intricate nature of the ureteric reconstruction within the pelvis [ [10] , [11] , [12] , [7] , [8] , [9] ]. Laparoscopic reimplantation offers a less invasive alternative with evidence of shorter hospital length of stay, reduced blood loss, and reduced postoperative analgesia requirements compared with open surgery [ 10 ]. However, laparoscopic ureteric reimplantation, especially in a recent post-surgical pelvis, demands a high level of laparoscopic and technical skills for safe dissection and reconstruction, limiting its widespread adoption [ 1 ]. The robot-assisted approach for ureteric reimplantation has become increasingly popular for complex reconstructive repair as it provides improved dexterity, fine movements of the instruments within the confines of the pelvis, and three-dimensional visualisation [ 1 ]. Given the prevalence of ureteric injuries during pelvic surgeries, the choice of repair often depends on the type of pelvic surgery performed, the timing of the diagnosis, the location of the injury, and the severity of injury, and the expertise available. The primary objective of our study was to evaluate the radiological outcomes of robot-assisted ureteric reimplantation. The secondary objectives were to assess demographics, the aetiology of ureteric pathology, length of stay, presence of postoperative lower urinary tract symptoms (LUTS), and complication rates in comparison to outcomes in the current literature.

The authors declare no conflict of interest.