Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery

Objectives: Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. Patients and Methods: In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e., psoas hitch) and improved vascularity (i.e., omental wrap). Outcomes of surgery were determined by the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). Results: A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100 mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow-up calculations. At a median follow-up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically effective. Conclusion: RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.