Ureteric stricture develops in approximately 5-10% recipients. Managing ureteric strictures in a transplanted kidney presents considerable challenges. While endoscopic approaches may yield short-term success, achieving definitive treatment necessitates surgical intervention. While open surgery is still the most common approach, robotic reconstruction has emerged as a solution to these complex surgical scenarios. In this video, we have demonstrated the points of technique and the nuances of robot-assisted management of different ureteric strictures in renal transplant grafts. We have also shared our overall experience and the final outcome.

Twelve patients underwent robot-assisted management of transplant ureteric strictures at our institution from July 2015 to June 2024. The surgical management of stricture was planned based on the location and length of the stricture. Upper ureteric strictures were managed by anastomosing the graft kidney pelvis with the native kidney ureter in an end-to-side or side-to-side manner. Short-segment lower ureteric strictures were treated with ureteric reimplantation and graft-to-native ureteroureterostomy. One long segment lower ureteric stricture was treated with Boari flap reconstruction. The demographic data, perioperative parameters and final outcomes were evaluated.

Of these 12 patients with graft ureteric strictures, seven were males, and five were females with a mean age of 31.6 ± 14.7 years and 34.2 ± 7.3 years, respectively. The median time interval for surgical intervention post renal transplant was 12.5 months (Range 6-96 months). While five patients underwent ureteric reimplantation, four patients were managed with anastomosis between the native kidney ureter and graft kidney ureter (three end-to-side and one side-to-side), one patient underwent reconstruction with Boari flap, two patients were managed with graft-to-native ureteroureterostomy. The mean console time was 156 ± 49 minutes and the mean postoperative hemoglobin-drop was 1.5 ± 0.6 g/dl. None of the patients required any blood transfusion. There was no conversion to open surgery or any other significant intraoperative complication. The mean hospital stay was 5.5 ± 2.5 days. The mean catheter and stent indwelling time were 7.5 ± 1.5 Days (except the Boari flap reconstruction, where it was 14 days) and 45.7 ± 6.6 days, respectively. The mean serum creatinine levels prior to surgery and one-month post-surgery were 2.4+/-1.02 mg/dl and 1.44+/- 0.33 mg/dl, respectively. One patient developed Clavien-Dindo grade 4a complication as he returned to hemodialysis due to recurrent graft pyelonephritis. None of the patients developed any recurrent ureteric strictures after at least one year of follow-up.

The choice of procedure for robot-assisted management of transplant ureteric strictures varies in different patients based on multiple factors. Though it is technically challenging, it is feasible and is associated with good renal function outcomes.