Robot-Assisted Lingual Mucosa Graft Onlay Reconstruction for Ureteric Strictures Refractory to Endoscopic Treatment

Summary

Ureteric strictures often follow urological disease or therapy, with endoscopy as first-line treatment. For refractory cases, we report robot-assisted lingual mucosa graft onlay reconstruction, with detailed technique and initial outcomes. This approach aims to restore upper urinary tract patency and reduce surgical trauma and complexity.

Abstract

This study describes the detailed technique and initial experience with robot-assisted lingual mucosal graft onlay ureteric reconstruction (RLUR) in patients with ureteric strictures refractory to endoscopic treatment. Preoperative evaluation included contrast-enhanced CT with excretory phase, ureteroscopy, and ureterography. History taking, clinical examination, renal function measurement, and urinary tract echographic evaluation were used for postoperative follow-up. Recurrence of stricture was defined as the presence of ureteric narrowing, as proven by imaging with outflow obstruction above the site of reconstruction. Since 2017, fifteen patients underwent RLUR, with a median age of 53 years and a median stricture length of 3.0 cm. Strictures were located in the upper third (n = 7), mid third (n = 7), and lower third (n = 1) of the ureter, with a median of 3 prior interventions. Seven patients underwent graft-augmented anastomosis, while 8 received "classic" graft onlay. Median operative time was 215 min, with no intraoperative complications and 2 postoperative grade 3a complications (13%). At a median follow-up of 21 months, surgical success was achieved in 13 patients (87%), and the estimated two-year recurrence-free survival rate was 83%. These findings support RLUR as a safe and effective option for refractory ureteric strictures.

Introduction

Ureteric strictures are characterized by abnormal narrowing of a ureteric segment causing obstruction of the outflow of the upper urinary tract above this segment. The strictures may arise from diverse etiologies, including open or endoscopic surgical procedures, stones, trauma, radiotherapy, and so on¹. The clinical presentation and symptoms may vary, but left untreated, it may lead to progressive hydronephrosis and eventually functional loss of the ipsilateral kidney^2,3. The urinary outflow of the upper urinary tract can be temporarily restored by urinary drainage through a nephrostom....

Protocol

Starting from 2017, this technique was decided to be offered to adult (≥18 years) patients with a ureteric stricture that failed at least one endoscopic treatment. Strictures in the lower third of the ureter amenable to psoas hitch repair (as determined by the surgeon) were excluded, as well as strictures longer than 8 cm, in which case unilateral lingual mucosa graft (LMG) harvest would not be possible. Patients with a condition in the oral cavity precluding the harvest of a healthy LMG and patients with an afunctional kidney at the affected side were also excluded. Patients provided written informed consent, and the study was approved by the ethics committee o....

Results

From 2017 to 2025, 15 patients were included (Table 1). Median age was 53 (IQR 39-62) years. The location was at the upper, mid, and lower third of the ureter in resp. 7 (47%), 7 (47%), and 1 (7%) patients. The median stricture length was 3 (IQR 2-3.2) cm, and the maximum length was 8 cm. Urolithiasis treated by ureteroscopy was the main etiology, affecting 10 (67%) patients.Other etiologies encompassed failed pyeloplasty, tuberculosis, and idiopathic in resp. 3 (20%), 1 .......

Discussion

For proximal and mid ureteric strictures, common reconstruction procedures include ureteroureterostomy, ileal ureteric replacement, appendiceal flap ureteroplasty, etc. Despite the variety of options available, these techniques present their own unavoidable shortcomings^1,15. Ureteroureterostomy is indicated for short-segment strictures with limited applicability (max 4cm). It requires adequate mobilization of the ureter to achieve a tension-free anastomosis, ofte.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Doyen Tongue Spatula	Tontarra Extranet	114-463-16	tongue retractor
AirSeal iFS Insufflator trocar	ConMed	iAS8-120LP	insufflation management system
Denhard mouth gag	Integra	3734151	mouth retractor
Dentio 0.12%	I. D. Phar	2416352	0.12% chlorhexidine mouthwash
Gaviscon Advance Mint 10 mL	Reckitt Benckiser	PL 00063/0748	sodium alginate and potassium bicarbonate
Monocryl	Ethicon	Y496G	poliglecaprone suture (absorbable, synthetic, monofilament)
Silkam	B. Braun	L153	silk suture (non-absorbable, natural, braided)
Vicryl	Ethicon	VCP250H	polyglactin suture (absorbable, synthetic, braided)
Vicryl rapide	Ethicon	V2930G	polyglactin suture (absorbable, synthetic, braided)
Xylocaine	Aspen Pharmacare	284106	xylocaine 2% and epinephrine 1:200000