With the advent of minimally invasive surgical techniques, buccal mucosal graft ureteroplasty (BMGU) has been adapted for laparoscopic and robotic approaches, offering patients reduced morbidity, shorter hospital stay, and faster recovery time.  Here we report the first laparoscopic BMGU in the Philippines, highlighting the feasibilty and technical considerations of this minimally invasive approach in the local setting. 

In this report, we show our surgical technique for retroperitoneoscopic BMGU for a 2.61 cm proximal ureteral stricture. The patient was positioned in a modified flank position. A 1.5cm incision was made between the lateral edge of the latissimus dorsi and external oblique muscle to access the retroperitoneal space. Secondary trocars were placed under direct palpation: a 10mm trocar below the 12th rib, a 5mm trocar 2cm above the iliac crest, and an additional 5mm trocar between them. Insufflation was maintained at 10-12mmHg. Dissection was performed to locate and visualize the proximal third ureter, revealing dense adhesions in the area. The posterior ureter was carefully exposed, and an incision was made. A 3.5cm ureterotomy was created and extended proximally and distally until healthy tissue was identified. A guidewire was then inserted through the ureterotomy site, followed by antegrade placement of a double-J stent.  Buccal mucosa, measuring 4.5 x 1 cm was harvested via a standard technique. With the mucosal layer facing inwards, the graft was sutured to the ureterotomy as a dorsal onlay patch using continuous V-loc 3-0 suture. Perinephric fat was mobilized and was quilted to the graft and the ureteral wall to ensure fixation. Further closure of Gerota's fascia was done.

Total operative time was 5 hours 50 minutes with 100ml blood loss. Dense adhesions were found on the area of the stricture; posterior segment was exposed. However, no further adhesiolysis was performed. The patient was sent home on the 3rd post-operative day. Initial followup was at 1 week to assess wound healing.

Retroperitoneoscopic BMGU is a reproducible technique for proximal ureteral strictures with good and promising results and low morbidity.