Refining Robotic Extravesical Ureteral Reimplantation: Impact of Ureteral Adventitia Inclusion and Distal-First Detrusorraphy

<b>Background</b>: Robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV) is an established minimally invasive option for vesicoureteral reflux (VUR); however, surgical success remains variable, and detrusorraphy technique is a key determinant of reflux resolution. This study evaluated whether a refined detrusorraphy technique is associated with improved surgical outcomes following RALUR-EV. <b>Methods</b>: We retrospectively reviewed patients who underwent RALUR-EV performed by a single surgeon between August 2013 and February 2023. A technique modification introduced in November 2021 incorporated ureteral adventitia inclusion during detrusorraphy and a distal-first detrusorraphy suture. Patients were divided into two groups according to the surgical period. Surgical success was defined as radiographic resolution of VUR on postoperative voiding cystourethrography without ureteral obstruction. <b>Results</b>: A total of 62 patients (96 ureters) were included. The modified technique group demonstrated significantly higher surgical success rates than the conventional group at both the ureter level (97.8% vs. 76.5%, <i>p</i> = 0.002) and the patient level (96.6% vs. 69.7%, <i>p</i> = 0.006). On patient-level multivariable analysis, the modified detrusorraphy technique was independently associated with a reduced risk of surgical failure. <b>Conclusions</b>: A refined detrusorraphy technique is associated with improved early radiographic success after RALUR-EV without increasing perioperative morbidity.