Robot-assisted vesical mucosal graft ureteroplasty: a novel technique using an autologous tissue substitute for ureteral reconstruction

Ureteroplasty using autologous grafts or flaps has emerged as an important reconstructive option for complex proximal or mid-ureteral strictures. Among available tissues, vesical mucosa may be a promising graft material because it is covered by urothelium, readily available, and well adapted to the urinary environment. This study aimed to present our surgical technique and perioperative outcomes of robot-assisted vesical mucosal graft (VMG) ureteroplasty for a mid-ureteral stricture. A 36-year-old woman with progressive left hydronephrosis was admitted to our hospital after failed prior endourological management. Preoperative antegrade and retrograde pyelography demonstrated an approximately 5-cm stricture in the left mid-ureter. In addition, the patient was scheduled to undergo dental implantation, making oral mucosal graft harvest less desirable. Robot-assisted VMG ureteroplasty was therefore performed. The procedure consisted of four main steps: identification of the ureter and longitudinal incision of the stricture segment; harvesting and ex vivo tailoring of the VMG; double-J stent placement and ventral onlay anastomosis; and mesenteric fat wrapping of the graft with closure of the bladder incision. During graft preparation, the serosal and muscular layers were removed, and the submucosal tissue was carefully thinned while preserving the lamina propria as much as possible. A previously reported “two-point” fixation technique was used to stabilize the VMG during anastomosis, and indocyanine green was administered intravenously to confirm satisfactory perfusion before suturing. The procedure was completed successfully in 146 minutes, with an estimated blood loss of 10 mL. Postoperative hospital stay was 5 days, and no perioperative complications occurred. During 6 months of follow-up, the patient remained asymptomatic, renal function was stable, and computed tomography showed improvement of hydronephrosis. In conclusion, robot-assisted VMG ureteroplasty appears to be a safe and feasible option for selected patients with mid-ureteral stricture. Larger series and longer follow-up are needed to further validate this technique.