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

Introduction

Ureteral stricture is characterized by luminal narrowing of the ureter, which impairs urinary drainage and may lead to upper urinary tract obstruction and hydronephrosis. This condition can result from a variety of etiologies, including congenital abnormalities, iatrogenic injury, and long-standing stone-related obstruction (1). Although endoscopic management is generally considered a first-line option for ureteral strictures <2 cm and ureteropelvic junction obstruction, the failure risk is higher in strictures >2 cm, ischemic strictures, and in patients with severe hydronephrosis or significant renal function impairment (2). Under these circumstances, ureteral reconstruction remains the gold standard treatment.

The strategy of ureteral reconstruction is primarily determined by stricture location and length, and long-segment proximal or mid-ureteral strictures are particularly challenging. In some complex cases, extensive periureteral scar tissue and the diseased ureteral segment must be excised, leaving inadequate ureteral length for a tension-free end-to-end anastomosis. Although ileal ureter replacement and kidney autotransplantation may address these situations, both procedures are technically demanding and face risks related to bowel substitution and vascular complications (3,4).

In recent years, many urologists have favored oral mucosal graft (OMG) ureteroplasty or appendiceal flap ureteroplasty for complex proximal or mid-ureteral strictures to avoid ileal ureter replacement and kidney autotransplantation. By using an onlay technique, the narrowed ureteral lumen can be augmented to restore unobstructed urinary drainage, and encouraging success rates have been reported (5-7). However, these approaches have inherent limitations. Harvesting OMGs, including buccal and lingual grafts, may be associated with donor-site morbidity such as perioral numbness, persistent trismus, speech difficulties, and difficulty protruding the tongue. Appendiceal flap reconstruction is feasible only in patients with an intact and healthy appendix and is most commonly applicable to right-sided disease.

Vesical mucosa represents a potentially ideal graft material for ureteral reconstruction. Similar to the ureter, it is covered by urothelium, which may facilitate reliable engraftment in the urinary environment. Recent studies have reported successful outcomes using vesical mucosal grafts (VMGs) for ureteral strictures (8). Building on these reports, we describe our technique and experience with robot-assisted VMG ureteroplasty. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0300/rc).

Preoperative preparations and requirements

Patient

A 36-year-old woman presented to Peking University First Hospital with a history of left flank pain for more than 9 months. Seven months earlier, ultrasound revealed left hydronephrosis. She subsequently underwent further evaluation with computed tomography urography (CTU) and magnetic resonance urography (MRU), which suggested a left ureteral stricture. Five months before presentation, a left-sided double-J (D-J) stent was placed and removed 3 months later. After stent removal, follow-up CTU demonstrated worsening left hydronephrosis (Figure 1A). One month before surgery, a left percutaneous nephrostomy was performed at our institution. Antegrade and retrograde pyelography subsequently demonstrated an approximately 5-cm mid-ureteral stricture on the left side (Figure 1B).

Figure 1 Preoperative radiographic evaluation. (A) Computed tomography urography showing left hydronephrosis; (B) antegrade and retrograde pyelography showing a left mid-ureteral stricture (arrow).

Preoperatively, the patient had preserved bladder function, without abnormalities in either the filling or voiding phase, and had a bladder capacity of more than 400 mL. Given the left-sided nature of the disease, appendiceal flap ureteroplasty was not considered an optimal option. In addition, because she was scheduled to undergo dental implantation one month later, VMG ureteroplasty was selected to avoid possible interference of OMG harvest with the planned intraoral procedure.

The patient’s demographic characteristics and perioperative outcomes were prospectively collected in our Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER) database. The harvested VMG was measured for length and width.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research ethics committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Preoperative preparation

A percutaneous nephrostomy tube was placed one month before surgery to allow adequate ureteral rest (9,10). A preoperative urine culture was obtained to guide subsequent antibiotic therapy and to minimize bacterial contamination from urinary spillage during dissection. Prophylactic antibiotics were administered with cefoperazone-sulbactam sodium (3 g intravenously, 1 hour preoperatively). A 16-Fr Foley catheter was inserted before surgery. The procedure was performed by Dr. Yang using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA).

Step-by-step description

Patient positioning and port placement

After induction of general anesthesia with nasotracheal intubation, the patient was placed in a 30° Trendelenburg position. Port placement is shown in Figure 2, using a configuration similar to our previously reported robotic pelvic procedures (11).

Figure 2 Port distribution for robot-assisted vesical mucosa graft ureteroplasty.

Identification of the ureter and longitudinal incision of the stricture segment

The surgical procedure is shown in Video S1 and Figure 3. After carefully releasing the bowel adhesions, the lateral peritoneum was incised near the left iliac vessels and the dissection was carried proximally to identify the stricture segment of the left ureter, which was densely covered by scar tissue (Figure 4A). The ventral periureteral fibrotic tissue was carefully dissected to expose the ureter (Figure 4B). To preserve ureteral blood supply, excessive dorsal mobilization was avoided; the ureteral wall appeared edematous and stiff (Figure 4C).

Figure 3 Surgical steps of robot-assisted vesical mucosa graft ureteroplasty. Illustration courtesy of Ms. Yiru Zhou. (A) Identification of the stricture segment. (B) Longitudinal incision of the stricture segment and harvesting the vesical mucosal graft. (C) Stent placement and ventral onlay anastomosis. (D) Wrapping the anastomosis with surrounding fat and closure of the bladder incision.

Figure 4 Identification of the ureter and longitudinal incision of the stricture segment. (A) The stricture segment of the left ureter was densely covered by scar tissue. (B) Carefully dissect the ventral periureteral fibrotic tissue to expose the ureter. (C) The stricture segment of the left ureter, the ureteral wall appeared edematous and stiff. (D) A longitudinal incision was made along the anterior wall of the stricture segment. (E) Peri-incisional fibrotic tissue was excised. (F) Use an 8-Fr ureteral catheter to probe the ureter to confirm luminal patency.

A longitudinal incision was then made along the anterior wall of the stricture and extended over the entire length of the diseased segment until healthy ureter was reached proximally and distally (Figure 4D). Peri-incisional fibrotic tissue was excised to facilitate subsequent graft anastomosis (Figure 4E). We then used an 8-Fr ureteral catheter to probe the proximal and distal ureter, respectively, to confirm luminal patency (Figure 4F).

Harvesting and tailoring of the VMG

We measured the length of the ureteral defect using a graduated ureteral catheter (Figure 5A). The bladder was filled with normal saline. Based on the measured length, we marked the graft length on the bladder dome with monopolar scissor (Figure 5B) and outlined the graft, with a planned size of approximately 5 cm × 1 cm. We then harvested the VMG by making a full-thickness incision in the bladder wall along the marked outline (Figure 5C,5D).

Figure 5 Harvesting and tailoring of the VMG. (A) Measure the length of the ureteral defect using a graduated ureteral catheter. (B) Mark the graft length on the bladder dome with monopolar scissor. (C,D) Harvest the VMG by making a full-thickness incision in the bladder wall along the marked outline. (E) Tailor the graft extracorporeally by removing the serosal layer, detrusor muscle and the submucosal tissue while preserving the lamina propria. (F) Prepared VMG, appearing as a pale, fusiform strip. VMG, vesical mucosal graft.

The graft was prepared extracorporeally. Using fine scissors, we first split the graft longitudinally to remove the serosal layer and detrusor muscle, thereby exposing the slightly pale pink-white submucosal tissue. Next, the submucosal tissue was gradually thinned while preserving the lamina propria as much as possible and avoiding mucosal perforation (Figure 5E). During tailoring, excess tissue debris could be irrigated away with normal saline as needed. The final VMG appeared as a pale, fusiform strip (Figure 5F).

Stent placement and ventral onlay anastomosis

A ventral onlay anastomosis was then performed. A D-J stent was inserted along a nitinol hydrophilic guide wire from the incision into the ureter (Figure 6A). We adopted our previously reported “two-point” technique by placing one 5-0 absorbable anchoring suture at each end of the VMG to minimize graft twisting or displacement during suturing (Figure 6B) (5).

Figure 6 Ventral onlay anastomosis and mesenteric fat wrapping. (A) D-J stent was inserted from the incision into the ureter. (B) Placing one anchoring stitch at each end of the VMG. (C) Using intravenous ICG to assess perfusion around the anastomotic site, well-perfused tissue appears bright green under fluorescence imaging. (D,E) The VMG was sutured to the ureteral defect in a running fashion using 5-0 absorbable suture. (F) Wrapping the anastomosis with adjacent mesenteric fat. D-J, double-J; ICG, indocyanine green; VMG, vesical mucosal graft.

Before the anastomosis, 2 mL of 2.5 mg/mL indocyanine green (ICG) was administered intravenously to assess perfusion around the anastomotic site (Figure 6C). After satisfactory perfusion had been confirmed, the VMG was sutured to the ureteral defect in a running fashion using 5-0 absorbable suture (Figure 6D,6E).

Wrapping the anastomosis with surrounding fat and closure of the bladder incision

After completion of the anastomosis, the adjacent mesenteric fat was secured and draped over the VMG using a 3-0 absorbable barbed suture (Figure 6F). The bladder incision was then closed in a running fashion with a 3-0 absorbable barbed suture. Finally, a pelvic drain was placed.

Postoperative considerations and tasks

A plain abdominal radiograph was obtained on postoperative day 1 to confirm the position of the D-J stent. The pelvic drain was removed on postoperative day 3 after the output had decreased to <50 mL. The Foley catheter was removed 1 week after surgery. The nephrostomy tube was clamped on postoperative day 14 and removed 1 month postoperatively. The D-J stent was removed 3 months after surgery. Complete success was defined as the absence of clinical symptoms and no evidence of obstruction on imaging.

The preoperative serum creatinine level was 78.8 µmol/L, and the estimated glomerular filtration rate (eGFR) was 83.487 mL/min/1.73 m². The procedure was completed successfully in 146 minutes, with an estimated blood loss of 10 mL. The patient was discharged after a postoperative hospital stay of 5 days.

During 6 months of follow-up, no donor-site morbidity or other postoperative complications were observed. The patient remained asymptomatic and required no additional surgical intervention. Computed tomography performed at postoperative month 3, one week after DJ stent removal, demonstrated marked improvement of hydronephrosis (Figure 7). Follow-up ultrasonography at postoperative month 6 showed no significant hydronephrosis. At the 6-month follow-up, the serum creatinine level was 74.0 µmol/L and the eGFR was 88.143 mL/min/1.73 m². Lower urinary tract symptoms were also assessed using the Overactive Bladder Symptom Score, and the patient scored 2 points.

Figure 7 Postoperative computed tomography urography.

Tips and pearls

First, meticulous management of the diseased ureteral segment and preservation of its blood supply are critical to reduce the risk of recurrent stricture. After longitudinal incision of the stricture segment (Figure 8A), a ureteral catheter was used to confirm luminal patency. During dissection, excessive mobilization of the ureter should be avoided whenever possible to preserve its vascularity; in our practice, only the ventral aspect of the ureter was mobilized whenever feasible, while dorsal dissection was minimized. In addition, ICG was used during reconstruction to assess ureteral perfusion at the anastomotic site. Second, extracorporeal tailoring of the VMG, including removal of the serosal layer, muscular layer, and submucosal fatty tissue while preserving the lamina propria (Figure 8B), may help promote graft survival and reduce the risk of subsequent ischemic contracture. Third, before anastomosis of the VMG to the ureteral defect, anchoring sutures were placed at both ends of the graft to stabilize it and prevent twisting (Figure 8C). Keeping the graft edges straight also facilitates continuous suturing (Figure 8D). Finally, wrapping the VMG with adjacent mesenteric fat may provide mechanical support, promote revascularization, and reduce the likelihood of adhesion formation around the anastomosis.

Figure 8 Surgical technique of robot-assisted VMG ureteroplasty. Illustration courtesy of Ms. Yiru Zhou. (A) Longitudinal incision of the stricture segment. (B) Prepare the VMG by removing the serosal layer, detrusor muscle and the submucosal tissue. (C) Place one anchoring stitch at each end of the VMG. (D) Finish the onlay anastomosis in a running fashion. VMG, vesical mucosal graft.

Discussion

For proximal or mid-ureteral strictures, a watertight, tension-free end-to-end anastomosis is generally preferred for short strictures. In some complex cases, however, the stricture is long, or excision of the periureteral scar tissue and diseased ureter results in an extensive ureteral defect, making primary anastomosis difficult to achieve. In such situations, ileal ureter replacement or kidney autotransplantation has traditionally been used. However, both procedures are technically demanding, more invasive, and associated with relatively high complication rates (12-14). With ongoing technological advances, robot-assisted surgery has demonstrated distinct advantages in upper urinary tract reconstruction. The robotic platform provides a magnified three-dimensional view and highly dexterous wristed instruments, which facilitate dissection of scar tissue and enable precise suturing and high-quality anastomosis within confined anatomical spaces. In addition, the robotic platform can be readily integrated with technologies such as three-dimensional reconstruction and ICG fluorescence imaging, thereby allowing intraoperative navigation and assessment of tissue perfusion (15). In recent years, robot-assisted ureteroplasty using autologous tissue transfer has provided a new reconstructive option for these patients. In this approach, the ventral wall of the stricture segment is longitudinally incised to create a “ureteral plate” with maximal preservation of blood supply, and the narrowed ureteral lumen is then augmented using an onlay graft or flap to restore unobstructed urinary drainage (16). In patients with severely diseased, completely obliterated, or transected ureters, an “augmented anastomosis” can be used to reconstruct the posterior ureteral wall and create a ureteral plate (6). Furthermore, when the remaining ureteral tissue is insufficient to complete a full posterior augmented anastomosis, a partial posterior augmented anastomosis can be performed using a posterior-inlay technique with an autologous graft to complete the ureteral plate (17).

Autologous tissues used for ureteroplasty include both flaps and grafts. Grafts are harvested from a donor site and transferred to the recipient site, where they establish a new blood supply (18), whereas flaps retain their native vascular pedicle and therefore preserve their original blood supply after transfer (19). The ideal autologous tissue for ureteral reconstruction should be hairless, easy to access and harvest, and viable in a urinary environment. Currently, commonly used autologous tissues include oral mucosa (buccal and lingual mucosa), appendiceal flaps, ileal mucosa, and vesical mucosa.

OMGs, including buccal mucosa grafts (BMGs) and lingual mucosa grafts (LMGs), have been widely used in ureteroplasty because they are hairless, easy to harvest, and compatible with a moist environment. In addition, they have a thick epithelium, a high content of elastic fibers, a thin lamina propria, and a rich capillary network, all of which facilitate graft take. In 1999, Naudé reported the first case of BMG ureteroplasty (20), and in 2016, Li et al. reported the first laparoscopic LMG ureteroplasty (21). Current evidence shows that OMG ureteroplasty achieves excellent success rates, exceeding 95% in some series (1). Regarding stricture length, previous reports have described BMG ureteroplasty for ureteral strictures up to 5–8 cm in length (6,22), whereas our group has shown that LMG ureteroplasty can be used to treat strictures of up to 6.5 cm (5). Although previously reported LMG length can exceed 12 cm, an excessively long LMG may impair tongue movement and function and cause donor-site numbness (23). Studies have shown that long-term donor-site morbidity after OMG harvest includes perioral numbness, persistent trismus, speech difficulties, and difficulty protruding the tongue. Wood et al. observed long-term donor-site morbidity after BMG urethroplasty and found persistent perioral numbness in 26% of patients, altered salivation in 11%, and limited mouth opening in 9% (24). Xu et al. evaluated donor-site morbidity after LMG harvest and reported mild-to-moderate impairment of fine tongue movement in 34.6% of patients, accompanied by donor-site numbness in 27.2%, taste loss in 12.3%, and slurred speech at 6 months in 13.6% (23). Whether buccal or lingual mucosa is the better graft source remains controversial. Some studies suggest that lingual mucosa may be associated with a lower rate of postoperative oral complications than buccal mucosa (25). In addition, because the tongue can be fully exteriorized, LMG harvest may be technically easier in some cases. Patients who smoke or chew betel nut or smokeless tobacco often have poor oral hygiene and unhealthy oral mucosa, which may increase the risk of postoperative complications and surgical failure (26). We also do not recommend OMG ureteroplasty in patients with oral mucosal disorders such as oral submucous fibrosis. Furthermore, the presence of a donor-site wound within the oral cavity may interfere with oral procedures scheduled in the early postoperative period.

The human appendix is a tubular structure measuring approximately 5–10 cm in length and 5–10 mm in diameter. It lies close to the right ureter, has a rich blood supply from the appendiceal artery, and is lined by mucosa, making it an attractive option for ureteral reconstruction (27). In addition, appendiceal mucosa has lower absorptive and secretory activity than ileal mucosa, which may reduce the risks of postoperative systemic acidosis and mucus retention (28). Multiple studies have confirmed the utility of appendiceal flaps in ureteral reconstruction, with satisfactory success rates ranging from 81% to 100%; in these series, the mean stricture length ranged from 2.5 to 6.5 cm (29). Nevertheless, appendiceal reconstruction also has limitations. First, patients must not have a history of appendectomy, and prior appendicitis may result in appendiceal atrophy. Second, the available appendiceal length limits the length of ureter that can be reconstructed. Finally, because of its anatomical proximity to the right ureter and the limited mobility of the mesoappendix, the appendix is generally used only for right-sided ureteral strictures.

Vesical mucosa is an appealing graft material for ureteral reconstruction because it is readily available, suitable for long-segment augmentation, richly vascularized, and highly distensible (30). Like the ureter, vesical mucosa is covered by urothelium, allowing it to tolerate exposure to urine while minimizing the risks of stone formation and metabolic complications. Compared with a Boari flap, a free VMG is more suitable for proximal and mid-ureteral strictures. In addition, harvesting a vesical mucosa graft does not disrupt the ureteral orifice and has minimal impact on bladder anatomy, which may help reduce postoperative lower urinary tract symptoms. Morra et al. reported their experience with robot-assisted ureteroplasty using a VMG in 14 patients (8). Using a totally robot-assisted approach, they harvested a VMG with preservation of part of the submucosal and muscular layers and applied it as an onlay graft over the stricture ureteral segment. With stricture lengths ranging from 3 to 6 cm and a median follow-up of 21.3 months, no stricture recurrence or donor-site complications were observed, indicating that a free VMG is a feasible option for ureteral reconstruction (Table 1).

Similar to skin grafting, restoration of blood supply to a VMG occurs through two sequential processes: plasmatic imbibition and inosculation (31,32). During the first 48 hours, graft survival depends on plasmatic imbibition, during which nutrients and metabolic waste products are exchanged between the recipient bed and the graft by passive diffusion. From approximately 48 hours to 1 week after surgery, vascular anastomoses form between the graft and the recipient bed in a process known as inosculation, in which capillaries from the host tissue grow into the graft. Optimal completion of these two steps depends on rapid activation of the recipient bed, adequate vascularity, and close apposition and fixation of the graft. Kuzaka et al. used microangiography to evaluate the blood supply of ureters reconstructed with free VMGs and found complete regeneration of the ureteral mucosa in the reconstructed segment, but no vascular reconstruction or muscular regeneration. This ultimately led to dense scarring, restenosis, and severe periureteral fibrosis (33). We believe that thorough removal of muscle tissue and fat while preserving the lamina propria is critical for successful VMG harvest and engraftment. A thinner graft may facilitate early plasmatic imbibition, whereas preservation of the highly vascular lamina propria may support later graft survival (34,35). Because the da Vinci Xi system used in our case lacks haptic feedback, excessive traction during graft handling could potentially injure the VMG. Based on our previous experience with OMG ureteroplasty, we therefore chose to prepare the VMG extracorporeally (5,36). After removal of the serosal layer and muscle with scissors, the submucosal fat was carefully trimmed while preserving the lamina propria as much as possible; the tailored graft had a slightly pinkish-white appearance. Because the processed VMG was relatively thin, we adopted our previously reported “two-point” fixation technique to prevent graft curling and displacement during anastomosis. Specifically, two 5-0 absorbable anchoring sutures were placed, one at each end of the VMG, before starting the anastomosis. During preparation of the recipient bed, we aimed to preserve ureteral blood supply as much as possible by minimizing ureteral mobilization. In this patient, only the ventral wall of the ureter was incised longitudinally, and dorsal dissection was avoided, which helped preserve ureteral vascularity. Before anastomosis, avascular scar tissue around the anastomotic edges was sharply excised, and perfusion was assessed by intravenous ICG injection.

The main causes of failure after ureteral reconstructive surgery using tissue transfer include ischemia, infection, and local adhesion. For completely free grafts, including VMG, inadequate blood supply is of particular concern. In addition, we have observed that patients with previous failed reconstruction often have marked hyperplasia, adhesions, and scar formation around the stricture segment. These pathological changes may impair ureteral peristalsis and aggravate urinary obstruction through compression, stiffening, or angulation of the ureter. Previous studies have reported that wrapping the reconstruction with omentum or perinephric fat may enhance local blood supply, prevent scar formation around the anastomosis, and reduce adhesions (37,38). Similar to omentum and perinephric fat, mesenteric fat contains abundant blood vessels, nerves, and lymphatics. In the present case, mesenteric fat adjacent to the anastomosis was fixed over the VMG to support the graft, promote early revascularization, enhance graft perfusion, and reduce adhesion formation.

In this study, we describe our initial experience with robot-assisted VMG ureteroplasty for a mid-ureteral stricture. During 6 months of follow-up, the patient became symptom-free, renal function remained stable, and hydronephrosis improved markedly. However, this report is limited by its single-case design, short follow-up, and the lack of objective postoperative bladder functional assessment. In addition, because the procedure was performed in a carefully selected patient by an experienced robotic reconstructive urologist, its reproducibility and generalizability remain uncertain. Larger studies are needed to evaluate the long-term efficacy of this technique and to identify which patients are most likely to benefit from it.

Conclusions

Robot-assisted VMG ureteroplasty may be a feasible reconstructive option for selected patients with complex proximal or mid-ureteral strictures and preserved bladder function, particularly when OMG or AF may be less suitable. However, given the single-case design and limited follow-up, these findings should be interpreted cautiously. Further studies with larger cohorts, longer follow-up, and more comprehensive functional assessment are needed.

Acknowledgments

The authors would like to thank Ms. Yiru Zhou for providing excellent medical illustrations presented in Figures 3,8.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0300/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0300/prf

Funding: This work was supported by the Beijing Research Ward Excellence Program (BRWEP) (No. BRWEP2024W054070101) and National High Level Hospital Clinical Research Funding (Youth Clinical Research Project of Peking University First Hospital) (No. 2023YC16).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0300/coif). Xuesong Li serves as an Editor-in-Chief of Translational Andrology and Urology from March 2026 to March 2029. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article, the accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Xu H, Zeng X, Xie L, et al. Ureteroplasty for the Repair of Ureteral Stricture Using Lingual Mucosa and Buccal Mucosa Grafts: A Meta-Analysis. Urol Int 2025;109:533-45. [Crossref] [PubMed]
2. Gnessin E, Yossepowitch O, Holland R, et al. Holmium laser endoureterotomy for benign ureteral stricture: a single center experience. J Urol 2009;182:2775-9. [Crossref] [PubMed]
3. Eisenberg ML, Lee KL, Zumrutbas AE, et al. Long-term outcomes and late complications of laparoscopic nephrectomy with renal autotransplantation. J Urol 2008;179:240-3. [Crossref] [PubMed]
4. Chung BI, Hamawy KJ, Zinman LN, et al. The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results. J Urol 2006;175:179-83; discussion 183-4. [Crossref] [PubMed]
5. Yang K, Fan S, Wang J, et al. Robotic-assisted Lingual Mucosal Graft Ureteroplasty for the Repair of Complex Ureteral Strictures: Technique Description and the Medium-term Outcome. Eur Urol 2022;81:533-40. [Crossref] [PubMed]
6. Zhao LC, Weinberg AC, Lee Z, et al. Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience. Eur Urol 2018;73:419-26. [Crossref] [PubMed]
7. Cho EY, Chaudry AE, Puri D, et al. Outcomes of Robot-assisted Appendiceal Ureteroplasty From a Multi-institutional Experience. Urology 2024;192:136-40. [Crossref] [PubMed]
8. Morra I, Busacca G, Ornaghi PI, et al. Vesical Mucosal Graft for the Treatment of Ureteral Strictures with a Total Robot-assisted Approach. Eur Urol 2025;88:293-300. [Crossref] [PubMed]
9. Lee Z, Lee M, Lee R, et al. Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures. Urology 2021;152:160-6. [Crossref] [PubMed]
10. Xiong S, Fan S, Huang Y, et al. Clinical efficacy and risk factors of minimally invasive surgery for failed pyeloplasty: a prospective multicenter cohort study. Int J Surg 2025; Epub ahead of print. [Crossref]
11. Xu L, Li X, Zhao F, et al. Robot-assisted redo ureteral reimplantation in adults after failed primary surgery: technique and outcomes from two centers. Minerva Urol Nephrol 2025;77:69-78. [Crossref] [PubMed]
12. Zhong W, Hong P, Ding G, et al. Technical considerations and outcomes for ileal ureter replacement: a retrospective study in China. BMC Surg 2019;19:9. [Crossref] [PubMed]
13. Armatys SA, Mellon MJ, Beck SD, et al. Use of ileum as ureteral replacement in urological reconstruction. J Urol 2009;181:177-81. [Crossref] [PubMed]
14. Cowan NG, Banerji JS, Johnston RB, et al. Renal Autotransplantation: 27-Year Experience at 2 Institutions. J Urol 2015;194:1357-61. [Crossref] [PubMed]
15. Vangeneugden J, Lavagno F, Berquin C, et al. Robot-assisted Management of Complex Ureteral Stenosis in Kidney Transplant Patients: Multicenter Case Series and Description of Surgical Techniques. Eur Urol Open Sci 2025;77:23-8. [Crossref] [PubMed]
16. Xiong S, Wang J, Zhu W, et al. Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review. Biomed Res Int 2020;2020:6178286. [Crossref] [PubMed]
17. Chen S, Yang K, Li Z, et al. Robotic buccal mucosal graft ureteroplasty using combination of posterior-inlay and anterior-onlay technique. Transl Androl Urol 2024;13:2330-7. [Crossref] [PubMed]
18. Garaffa G, Ralph DJ, Eardley I. Principles of Tissue Transfer in Urology. In: Payne S, Eardley I, O’Flynn K, editors. Imaging and Technology in Urology. London: Springer London; 2012. p. 243-8.
19. Bryk DJ, Yamaguchi Y, Zhao LC. Tissue transfer techniques in reconstructive urology. Korean J Urol 2015;56:478-86. [Crossref] [PubMed]
20. Naude JH. Buccal mucosal grafts in the treatment of ureteric lesions. BJU Int 1999;83:751-4. [Crossref] [PubMed]
21. Li B, Xu Y, Hai B, et al. Laparoscopic onlay lingual mucosal graft ureteroplasty for proximal ureteral stricture: initial experience and 9-month follow-up. Int Urol Nephrol 2016;48:1275-9. [Crossref] [PubMed]
22. Kroepfl D, Loewen H, Klevecka V, et al. Treatment of long ureteric strictures with buccal mucosal grafts. BJU Int 2010;105:1452-5. [Crossref] [PubMed]
23. Xu YM, Li C, Xie H, et al. Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts. J Urol 2017;198:401-6. [Crossref] [PubMed]
24. Wood DN, Allen SE, Andrich DE, et al. The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain. J Urol 2004;172:580-3. [Crossref] [PubMed]
25. Kumar A, Das SK, Trivedi S, et al. Substitution urethroplasty for anterior urethral strictures: buccal versus lingual mucosal graft. Urol Int 2010;84:78-83. [Crossref] [PubMed]
26. Sinha RJ, Singh V, Sankhwar SN, et al. Donor site morbidity in oral mucosa graft urethroplasty: implications of tobacco consumption. BMC Urol 2009;9:15. [Crossref] [PubMed]
27. Zhang B, Chen J, Chen X, et al. Laparoscopic ureteroplasty for the treatment of long ureteral strictures with appendiceal interposition and appendiceal onlay flap: technical description and initial experience. World J Urol 2025;43:678. [Crossref] [PubMed]
28. Wang J, Xiong S, Fan S, et al. Appendiceal Onlay Flap Ureteroplasty for the Treatment of Complex Ureteral Strictures: Initial Experience of Nine Patients. J Endourol 2020;34:874-81. [Crossref] [PubMed]
29. Bello D, Van Shufflin M, Hofer MD. Expanding the Armamentarium: Perspectives on Buccal Mucosal Grafts and Appendiceal Flaps in Ureteral Reconstructive Surgery. J Clin Med 2025;14:7681. [Crossref] [PubMed]
30. Sunagawa M, Wolf-Johnston A, Nomiya M, et al. Urinary bladder mucosal responses to ischemia. World J Urol 2015;33:275-80. [Crossref] [PubMed]
31. Adams DC, Ramsey ML. Grafts in Dermatologic Surgery: Review and Update on Full‐ and Split‐Thickness Skin Grafts, Free Cartilage Grafts, and Composite Grafts. Dermatol Surg 2005;31:1055-67. [Crossref] [PubMed]
32. Greenwood J, Amjadi M, Dearman B, et al. Real-time demonstration of split skin graft inosculation and integra dermal matrix neovascularization using confocal laser scanning microscopy. Eplasty 2009;9:e33.
33. Kuzaka B, Borkowski T, Kuzaka P, et al. Lack of usefulness of ureteral reconstruction with free bladder mucosa flap in dogs confirmed by microangiography. Med Sci Monit 2014;20:1117-20. [Crossref] [PubMed]
34. Levy ME, Elliott SP. Graft Use in Bulbar Urethroplasty. Urol Clin North Am 2017;44:39-47. [Crossref] [PubMed]
35. Campos-Juanatey F, Azueta Etxebarria A, Calleja Hermosa P, et al. Histological Comparison of Buccal and Lingual Mucosa Grafts for Urethroplasty: Do They Share Tissue Structures and Vascular Supply? J Clin Med 2022;11:2064. [Crossref] [PubMed]
36. Fan S, Yin L, Yang K, et al. Posteriorly Augmented Anastomotic Ureteroplasty with Lingual Mucosal Onlay Grafts for Long Proximal Ureteral Strictures: 10 Cases of Experience. J Endourol 2021;35:192-9. [Crossref] [PubMed]
37. Wang J, Zhang B, Fan J, et al. The application of the “omental wrapping” technique with autologous onlay flap/graft ureteroplasty for the management of long ureteral strictures. Transl Androl Urol 2021;10:2871-8. [Crossref] [PubMed]
38. Jiang Y, Yang C, Fang L, et al. The application of the “perinephric fat wrapping” technique with oral mucosal graft for the management of ureter repair and reconstruction. World J Urol 2024;42:528. [Crossref] [PubMed]