Reconstructive Surgery for Ureteral Strictures: Boari Flap, Psoas Hitch, Buccal Mucosa, and Other Techniques

The robotic approach for ureteral reconstruction has been widely popularized due to patient advantages that come with minimally invasive surgery, surgeon ergonomics, and reproducibility with outcomes comparable to that of open or laparoscopic surgery. While well-established reconstructive procedures such as pyeloplasty, ureteral reimplantation, and primary ureteroureterostomy are feasible for straightforward stricture disease, newer robotic techniques have been proven to be safe and effective to treat ureteral strictures that are more complex due to location, length, etiology, or a combination of those reasons. Deciding which technique to utilize first depends on the location of the stricture—proximal and mid-ureteral disease may be treated with ureteroureterostomy, buccal mucosal graft ureteroplasty, or, if amenable, Boari flap ureteroneocystostomy, while mid- and distal ureteral disease can be treated with ureteroureterostomy, ureteroneocystostomy with or without adjunctive mobility maneuvers, or appendiceal ureteroplasty. The principles of ureteral reconstruction include preservation of the ureteral blood supply within the adventitia; mucosa-to-mucosa apposition for any anastomosis, including buccal mucosal grafts; and tension-free anastomoses. Creating a tension-free anastomosis is usually the determining factor for harvesting buccal mucosa graft (in strictures too long for excision and ureteroureterostomy) or utilizing adjunctive mobility maneuvers in ureteroneocystostomy such as psoas hitch or Boari flap. In this book chapter, we discuss key considerations for preoperative, intraoperative, and postoperative decision-making to address ureteral reconstruction through robotic surgery.