Laparoscopic urinary tract reconstruction for iatrogenic ureteral injuries: a retrospective observational study from a single high-volume referral center

Introduction

Ureteral reconstruction is indispensable in urological surgery. Among the various etiologies requiring upper urinary tract repair, iatrogenic ureteral injury accounts for the majority. More than half of these injuries are associated with gynecological procedures, followed by colorectal and ureteroscopic surgeries (1). Importantly, delayed recognition of ureteral injury is more likely during minimally invasive procedures than open surgery, reflecting the inherent difficulty of intraoperative identification under laparoscopy. With the ongoing expansion of laparoscopic and robotic techniques in gynecological and general surgery, the incidence of unrecognized intraoperative ureteral injuries is expected to increase (2).

The ability to perform ureteral repair laparoscopically, via conventional laparoscopy or robotic assistance, represents a substantial advancement. This approach is particularly relevant in women and younger patients, who constitute a large proportion of gynecological cases, where cosmesis is an important consideration. Even when injuries occur during open procedures, avoiding repeat laparotomies may reduce the risk of postoperative ileus, surgical site infection, and incisional hernia, highlighting the value of minimally invasive reconstruction.

At our institution, laparoscopic ureteral reconstruction has been routinely performed since 2015, with tailoring of the surgical technique to the location of the injury. In this report, we present our systematic, single-institution experience with laparoscopic ureteral reconstruction, with a focus on the operative strategies employed according to the site of ureteral injury. Furthermore, we statistically analyzed the differences in perioperative characteristics and outcomes among the various reconstruction techniques. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0581/rc).

Methods

Patient characteristics

This retrospective study was conducted at Kameda Medical Center, Japan, and included patients who underwent laparoscopic ureteral reconstruction for iatrogenic ureteral injuries between January 2012 and December 2024. Patients who underwent reconstruction for non-iatrogenic ureteral injuries or open surgery were excluded. The reconstructive techniques included ureteroneocystostomy, ureteroneocystostomy with a Boari flap, and ileal interposition. Two experienced urological surgeons (H.A., and M.N.) performed all procedures. The surgical approach was selected based on the anatomical location of the ureteral injury, as shown in Figure 1. The ureter was categorized into three regions: distal (from the ureteral orifice to approximately 4 cm cranially), middle (from the upper boundary of the distal ureter to 2–3 cm cranially to the level of the iliac vessel crossing), and proximal (above this level). Specifically, ureteroneocystostomy was employed for distal ureteral injuries, ureteroneocystostomy with a Boari flap for middle lesions, and ileal interposition for proximal ureteral injuries. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Kameda Medical Hospital Research Ethics Committee (No. 23-080). Written informed consent was waived because the data were anonymized (opt-out approach).

Figure 1 Therapeutic algorithm for the management of ureteral injuries. Selection of laparoscopic reconstruction techniques according to the anatomical location of the injury. The ureter was categorized into three regions: distal (from the ureteral orifice to approximately 4 cm cranially), middle (from the upper boundary of the distal ureter to 2–3 cm cranial to the level of the iliac vessel crossing), and proximal (above this level).

Surgical procedures

Ureteroneocystostomy

Ureteroneocystostomy was indicated for distal ureteral injuries and was the most commonly applied technique. A camera port was placed at the umbilicus, surgical ports were established at the lower midline and left lower abdomen, and an assistant port was placed in the right lower abdomen. The procedure was performed with the patient in the Trendelenburg position (Figure 2A). Following bladder mobilization, a high bladder incision was made, and circumferential anastomosis of the spatulated distal ureter to the bladder mucosa performed using a running 4-0 absorbable suture (Figure 2B). A key technical point was to expose the bladder mucosal area to approximately three times the longitudinal diameter of the spatulated ureteral end (Figure 2B). After placement of a double-J (DJ) stent, the distal ureter was anastomosed to the bladder mucosa (Figure 2C,2D). Subsequently, the detrusor muscle was closed over the ureter using interrupted 3-0 absorbable sutures to create a submucosal tunnel (Figure 2E).

Figure 2 Optimal surgical view during laparoscopic ureteroneocystostomy. The port placement and patient positioning are shown (A). Spatulation of the distal ureter, exposure of the bladder mucosa, and ureterovesical anastomosis were observed (B-E).

Ureteroneocystostomy with Boari flap

This procedure was reserved for mid-ureteral injuries near the level of the vascular crossing, particularly in cases where a psoas hitch alone could not achieve a tension-free anastomosis. The port placement was identical to that used for ureteroneocystostomy (Figure 2A). After mobilization of the bladder, the distance between the distal ureteral stump and bladder was measured using a tape. A Boari flap was then created on the anterior bladder wall, ensuring a base width of approximately 4 cm and a sufficient length to bridge the ureteral defect, with a flap apex two- to four-fold the ureteral diameter (Figure 3A). The bladder incision was closed in two layers: the mucosa with 4-0 absorbable suture and the muscularis/serosa with 3-0 absorbable suture until the flap length matched the spatulated ureteral end (Figure 3B). Following the DJ stent placement, ureteral-to-flap anastomosis was performed using a continuous 4-0 absorbable suture (Figure 3C). When necessary, the apex of the flap was secured to the psoas tendon to ensure a tension-free configuration.

Figure 3 Optimal surgical view during laparoscopic ureteroneocystostomy with a Boari flap. The flap creation, bladder closure, and ureteral-to-flap anastomosis are illustrated (A-D).

Ileal interposition

Ileal interposition is indicated for proximal ureteral injuries with extensive defects that cannot be repaired using a Boari flap. Port placement for the lower ureter and bladder portions was identical to that used in the previous two techniques. The camera port at the umbilicus was maintained for the renal pelvis and upper ureter, and additional surgeon ports were created in the upper abdomen and flank with the patient in the lateral decubitus position (Figure 4A). A 4-cm extension of the camera port incision was used to mobilize the ileum extracorporeally. An ileal segment was isolated 15–20 cm proximal to the ileocecal valve and the segment length was determined based on the ureteral defect. The harvesting technique followed the standard steps for ileal conduit formation. Intracorporeally, the distal ileal segment was anastomosed to the anterior wall of the bladder, tailored to match the ileal diameter, using a 3-0 absorbable suture (Figure 4B,4C). The proximal segment was similarly anastomosed to the ureter or renal pelvis (Figure 4D,4E). A DJ or single-J (SJ) stent was routinely placed within the ileal segment before anastomosis.

Figure 4 Optimal surgical view during laparoscopic ileal interposition. The port placement and patient positioning are shown (A). Extracorporeal isolation of the ileal segment and intracorporeal anastomosis of the bladder and proximal ureter or renal pelvis are shown (B-E).

Patient outcomes

Perioperative outcomes, including operative time, estimated blood loss, postoperative complications, and length of hospital stay, were also assessed. Long-term outcomes were evaluated with respect to surgical success, defined as the absence of recurrent obstruction, or the need for secondary interventions. Clinical data were retrospectively extracted from standardized electronic medical records using predefined variables. Consecutive patient inclusion and standardized data collection were adopted to minimize potential selection and information bias. As this was a retrospective observational study, all consecutive eligible patients treated during the study period were included, and no formal sample size calculation was performed.

Statistical analysis

Continuous parametric variables are presented as medians with interquartile ranges (IQRs). Associations between categorical and continuous variables were assessed using the Chi-squared and Kruskal-Wallis tests, respectively. Statistical significance was set at P <0.05. All statistical analyses were performed the using Stata software (version 13.1; StataCorp LP, College Station, TX, USA). No imputation was performed for missing data because the variables included in the statistical analyses were complete. No patients were lost to follow-up before postoperative ureteral patency was confirmed.

Results

Patients’ characteristics

Twenty-five patients were included in this study and in the final analysis. No prophylactic DJ stents were placed in any of the patients. The median age of the patients was 51 (IQR, 49–66) years, and 23 patients (92.0%) were female. The most common cause of ureteral injury requiring repair was gynecological surgery (n=20), with hysterectomy being the most common procedure (n=14). Regarding the type of reconstruction, ureteroneocystostomy was performed in 14 patients (56.0%), ureteroneocystostomy with a Boari flap in seven patients (28.0%), and ileal interposition in five patients (20.0%). The median interval between injury and repair was 261 (IQR, 111–469) days. The detailed patient characteristics are summarized in Table 1. No significant differences in baseline characteristics were observed among patients undergoing different surgical procedures.

Patients’ outcomes and surgical procedures

The median operative time was 291 (IQR, 199–405) min, and the median estimated blood loss was 20 (IQR, 10–100) mL. None of the procedures required conversion to an open surgery. Postoperative complications of Clavien-Dindo grade ≥III were observed in five patients. Most patients experienced a smooth postoperative course, with 24 being able to ambulate on postoperative day (POD) 1 and the remaining patient on POD 3. Similarly, oral intake resumed on POD 1 in 23 patients, while it restarted on POD 3 and 5 in the other two patients.

Reoperation was necessary in three cases: two following ileal interposition and one after Boari flap reconstruction. Both patients with ileal interposition who required reintervention had a history of abdominal radiation therapy, and one patient also received chemotherapy, resulting in dense adhesions that complicated the surgical course. The patient who required reoperation after Boari flap placement developed recurrent ureteral stricture, necessitating secondary reconstruction with ileal interposition. Despite these challenges, all three patients ultimately achieved successful reconstruction.

The overall postoperative outcomes are summarized in Table 2, while the detailed characteristics of patients undergoing ureteroneocystostomy (n=14), ureteroneocystostomy with a Boari flap (n=7), and ileal interposition (n=4) are provided in Table S1. As expected, ileal interposition was associated with the longest operative time, with a median of 380 (IQR, 352–489) min, reflecting the additional complexity of ileal segment mobilization (P=0.008). The frequency of Clavien-Dindo grade ≥III complications and the length of hospital stay were also greatest in patients who underwent ileal interposition (P=0.003 and P=0.001, respectively) (Table 2).

Discussion

Iatrogenic ureteral injuries account for >80% of all ureteral injuries, and various repair techniques have been described. Here, we present our institutional experience with laparoscopic ureteral reconstruction, focusing on ureteroneocystostomy, ureteroneocystostomy with a Boari flap, and ileal interposition (3). In Japan, only a limited number of centers routinely perform such procedures, and our experience as a high-volume referral institution may offer valuable insights into clinical practice. By comparing the indications and outcomes of these three reconstructive strategies in parallel, we aimed to clarify their practical applications and highlight their nuances in surgical decision-making. Several previous studies have reported larger series of laparoscopic reconstruction for iatrogenic ureteral injuries (4). Although our cohort is relatively small compared with these reports, our study provides detailed clinical and surgical experience from a single high-volume referral center, including patients referred after initial management at other institutions. Our findings therefore provide complementary real-world evidence regarding the practical application and outcomes of laparoscopic ureteral reconstruction in a specialized referral setting.

Historically, most reports of ureteral reconstruction have focused on outcomes following open surgery, with a laparoscopic series emerging in the early 1990s, and robot-assisted reconstructions being increasingly reported in the past decade (5,6). The adoption of robotic assistance has further transformed this field. In 2007, de Naeyer et al. described a robotic psoas hitch with ureteral reimplantation for distal ureteral stricture (7), followed the next year by Schimpf et al., who reported the first robotic Boari flap reimplantation (8). Although open approaches remain effective, they are associated with greater morbidity, including increased postoperative pain, ileus, surgical site infections, and incisional hernias (9). In contrast, despite longer operative times compared to open repair, laparoscopic approaches provide clear advantages in terms of reduced invasiveness, faster recovery, and superior cosmetic outcomes. These benefits are particularly meaningful for younger female patients, who represent a large proportion of iatrogenic ureteral injury cases. Our experience reinforces the feasibility of laparoscopic reconstruction and supports its role as a safe and effective alternative to open repair in appropriately selected patients.

Each reconstruction method involves distinct technical considerations. Proficiency in intracorporeal suturing is essential; however, ureteroneocystostomy and Boari flap procedures are generally straightforward, associated with low complication rates and reliable outcomes, and often allow the early removal of nephrostomy tubes when present preoperatively. A critical consideration shared by both procedures is the potential for tension at the anastomotic site, which may compromise the blood supply. Intraoperatively, adjunctive maneuvers such as a psoas hitch should be considered to avoid undue tension in the anastomosis. In contrast, ileal interposition entails greater technical complexity due to the incorporation of the bowel. Consistent with this, patients who underwent ileal interposition in our series demonstrated the longest operative time, highest rates of postoperative complications, and longest hospital stay. Furthermore, specific postoperative issues such as obstruction of the DJ stent by bowel effluent may occur. Therefore, early tube removal should be avoided in patients with pre-existing nephrostomy tubes. In patients without nephrostomy tubes, placement of a SJ stent is preferred because it allows for irrigation in the event of stent occlusion.

A common challenge with all of these approaches is the difficulty of operating in previously operated or irradiated fields. Many iatrogenic ureteral injuries have been recognized postoperatively in patients who have undergone prior pelvic surgery or radiotherapy. Dense intra-abdominal adhesions can obscure the surgical field and account for a prolonged operative time, with adhesiolysis necessary in a substantial proportion of the procedures. Therefore, careful dissection is essential to minimize the risk of enteric or visceral injury and to establish an optimal operative view. Furthermore, intraoperative findings may reveal limitations that are not anticipated during preoperative assessment. For example, a more proximal ureteral segment than expected may be required for reconstruction because of adhesions or impaired vascularity. In these situations, the planned technique may need to be altered, such as conversion from ureteroneocystostomy to a Boari flap or ileal interposition, or from a Boari flap to ileal interposition. Consequently, while preoperative imaging and localization of strictures or obstructions provide important guidance, they cannot always determine the definitive surgical approach. Therefore, surgeons must remain flexible and adapt intraoperatively to achieve safe and tension-free repair.

The median interval between ureteral injury and reconstructive surgery in our series was 261 days, which was longer than that reported in some previous studies (10). This relatively long interval was mainly attributable to delayed referral to our institution. In many cases, a nephrostomy or DJ stent was initially placed at the referring institution to manage urinary obstruction or leakage, followed by referral to our institution for definitive reconstructive surgery. Therefore, the most critical factor in managing iatrogenic ureteral injury is intraoperative recognition of the injury. When identified during the index surgery, immediate repair significantly reduces complication rates compared with delayed recognition (2,11). However, the intraoperative detection rate remains low, and delayed diagnosis can result in renal dysfunction, cortical thinning, and, in some cases, necessitates nephrectomy (12). Limited visualization during minimally invasive surgery contributes to this low recognition rate. Given the continued expansion of laparoscopic and robotic procedures, this challenge is expected to persist (13,14).

This study has some limitations. First, the cohort was relatively small compared with several previously published series of laparoscopic ureteral reconstruction. Second, as this research reflects the experience of a single, high-volume center with substantial laparoscopic expertise, the generalizability of these outcomes to lower-volume institutions remains uncertain. Future multicenter studies incorporating robotic approaches are warranted to establish the best practices and optimize the outcomes of ureteral reconstruction.

Conclusions

We summarized the institutional outcomes of laparoscopic urinary tract reconstruction and demonstrated that minimally invasive repair can be achieved successfully in most cases. By disseminating these results, we hope to refine reconstructive strategies and improve the management of iatrogenic ureteral injuries, ultimately benefiting patients with these challenging complications.

Acknowledgments

We would like to thank Editage (www.editage.jp) for English language editing. We also appreciate the artwork provided by MEDICAL FIG., a service of Medical Education, Inc.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0581/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0581/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0581/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0581/coif). The 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. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Kameda Medical Hospital Research Ethics Committee (No. 23-080). Written informed consent was waived because the data were anonymized (opt-out approach).

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/.

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