Experience with robot-assisted laparoscopic surgery of the lower ureteral segment in adults.

Open reconstructive surgery of the lower ureteral segments in adults requires wide exposure as the basic prerequisite for such complex procedures. Thus, open surgical reconstruction in this area is an invasive procedure for the patient. Nevertheless, during the last few years robot-assisted laparoscopic techniques have emerged and have also already been used successfully for minimally invasive complex reconstructive procedures in urology. We present the medical histories, descriptions of the surgical procedures, and the postoperative data for adult patients undergoing robot-assisted surgery of the lower ureteral segments. Between July 2009 and July 2010, three surgeons performed nine robot-assisted reconstructive operations of the lower ureteral segments including five segmental ureteral resections combined with the psoas hitch procedures in three cases and, in addition, a Boari flap in one of them, one ureteric stricture resection with end-to-end anastomosis, one extravesical ureteral reimplantation because of vesicorenal reflux, one bilateral intravesical ureteral reimplantation because of bilateral ureteral ectopia, and one ureterolysis with omental wrap in a patient with pelvic endometriosis. We observed no intraoperative complications. Postoperative complications occurred in six patients (Clavien Grad I n = 1, II n = 4, IVa n = 1). During a median follow up of five months all affected renal units remained asymptomatic and were free from hydronephrosis. Our data illustrate that robot-assisted surgery of the lower ureter is feasible and support the growing evidence from the literature that it can be successfully used for complex ureteric reconstruction.