Management of Renal Transplant Ureteral Strictures: Versatility of a Robotic-Assisted Approach

<b><i>Introduction:</i></b> Ureteral stricture after renal transplantation has a reported incidence of 1.4%-4.7%. This is classically repaired using an open surgical approach. The objective of this case series is to demonstrate the feasibility and effectiveness of robot-assisted repair for ureteral stricture following kidney transplantation. <b><i>Methods:</i></b> Between November 2021 and May 2024, 10 patients underwent robot-assisted repair. Nephrostomy tubes were placed in all patients prior to the robotic repair. Patients were positioned supine with Trendelenburg tilt, and robotic ports were arranged in a W configuration. Indocyanine green was administered through the nephrostomy tube. If necessary, the pre-stented native ureter was identified and dissected. The reconstructive technique was tailored to the location and length of the stricture. Ureteral stents were placed for 4-6 weeks. <b><i>Results:</i></b> Patient demographics transplant characteristics, and details of stricture repair techniques along with associated outcomes were analyzed. Strictures were located at the ureterovesical anastomosis in eight patients, at the ureteropelvic junction in one patient, and at multiple sites in one patient. Repair techniques included ureteroneocystostomy (five patients) and Boari flap reconstruction (two patients). The native ureter was used in three patients (two ureteroureterostomies and one ureteropyelostomy). A bladder hitch was performed in two patients. Median operative time was 255.5 minutes, blood loss was 62 mL, and the hospital stay was 2 days. Postoperative complications occurred in two patients, and five patients required readmission within 30 days. At 3-month follow-up, all patients had excellent renal allograft function (median serum creatinine = 1.63 mg/dL) and were nephrostomy tube- and stent-free. <b><i>Conclusions:</i></b> Robotic repair of ureteral stricture following kidney transplantation is a safe, minimally invasive approach with reduced postoperative pain and shorter hospital stays. This approach should be considered the primary treatment option for renal transplant ureteral strictures and included within the renal transplant surgeons' repertoire of procedures.