This video presentation demonstrates a robot-assisted laparoscopic segmental ureterectomy, aortocaval lymph node dissection with Boari flap reconstruction using the Da Vinci Xi Surgical System in a 36-year-old male who initially presented with painless gross hematuria and intermittent flank pain. Contrast-enhanced CT urography revealed an enhancing 2.5cm mass localized to the right mid-ureter, with no evidence of further upper tract involvement. The patient was counseled regarding treatment options and opted for segmental ureteral resection for a renal preserving surgical approach.

The patient was positioned in dorsal lithotomy, followed by cystoscopy and retrograde pyelography. A four-port robotic access was used with two additional accessory ports for laparoscopic use. After mobilizing the colon, the ureter and iliac vessels were dissected. The robotic approach facilitated precise dissection of the right ureter with en bloc excision of the tumor-bearing mid-ureteral segment.The tumor was excised with a bladder cuff, ensuring vascularity and confirming a negative proximal margin via frozen section. Aortocaval lymph node dissection was performed to address the enlarged node. Following tumor removal, a tension-free Boari flap was constructed using bladder mobilization and tailored advancement to bridge the ureteral defect. Ureterovesical anastomosis was performed over a double-J stent with watertight closure and psoas hitch to prevent tension and retraction.

The procedure was completed without intraoperative complications. Total operating time was 240 minutes with an estimated blood loss of 100ml. Post-operative recovery was uneventful. Voiding cystourethrogram at 10 days postoperatively showed no leakage. Final histopathology revealed muscle-invasive high-grade urothelial carcinoma of the right mid-ureter with one positive lymph node (pT2N1), and negative surgical margins.

This case underscores the utility of robot-assisted minimally invasive surgery in the management of upper tract urothelial carcinoma, while illustrating the balance between oncological control and renal preservation.