Minimizing variability: Standardized approach to retroperitoneal single‐port robot‐assisted ureteral reconstruction

Abstract

Evidence suggests that robot‐assisted ureteroplasty is a safe and feasible management option of ureteral strictures. The retroperitoneal approach to ureteral reconstruction using single‐port (SP) robot can be beneficial in challenging cases of patients with prior history of abdominopelvic surgery or radiation. Herein, we present a standardized approach to retroperitoneal SP robot‐assisted ureteral reconstruction, highlighting the advantages of this technique in selected clinical scenarios.

Graphical abstract

Keywords

clinical outcome / robotic surgery / robotic ureteroplasty / retroperitoneal ureteral reconstruction / single‐port (SP) robot

1 INTRODUCTION

The principles of ureteral reconstruction include preservation of blood supply, mucosa‐to‐mucosa apposition, and tension‐free anastomosis. However, the technique of ureteral reconstruction is dependent on stricture location, caliber, length, and available local tissue. Robotics has been applied to aid in minimally invasive reconstruction of complex ureteral pathology with excellent functional outcomes[1–3]. The single‐port (SP) allows for precise dissection in narrow spaces, which is especially useful in patients with previous surgeries, extensive abdominal adhesions, or those with radiation‐induced scarring and fibrosis. In this article, we present a standardized approach to retroperitoneal SP robot‐assisted ureteral reconstruction, highlighting the advantages of this technique in selected clinical scenarios.

2 MAKING THE CASE FOR SP RETROPERITONEAL RECONSTRUCTION

Multiport robot requires space for placement of each port. Transperitoneal access in reoperative abdomen often requires lysis of adhesions and risks bowel damage. The SP robot uniquely allows for minimal dissection for access as its single port only requires a few centimeters of working space. Urologists are familiar with both intraperitoneal and retroperitoneal anatomy, but ureteral reconstruction is more commonly performed from a transperitoneal approach. The retroperitoneal approach may be challenging due to its lack of landmarks, but adjuvant techniques such as concurrent ureteroscopy, near‐infrared fluorescent (NIRF) imaging, and indocyanine green (ICG) can assist with safe identification of the ureter.

The retroperitoneal approach also does not require flank positioning as the peritoneal contents do not need to be retracted away from the field of dissection. We use a supine position, which decreases the risk of positional injury and allows easier concurrent ureteroscopy and harvest of oral mucosa if needed. Additionally, if there is a urine leak, the fluid is isolated in the retroperitoneum away from the peritoneum which may cause ileus.

3 PREPROCEDURAL CONSIDERATIONS

We recommend removal of stents across the ureteral stricture (ureteral rest) to allow the ureteral stricture to mature before attempting reconstruction. This allows for a complete preoperative evaluation (i.e., obtaining a split function renal scan, computed tomography, or fluoroscopic imaging delineating the area of stricture), but also to improve intraoperative success[4]. Ureteral rest, defined as the absence of double‐J (J‐J) stent or nephroureteral tube across the ureter for 4–6 weeks before reconstruction allows for resolution of inflammation, stricture maturation, and selection of the most appropriate surgical reconstructive technique. Lee et al.[4] compared perioperative outcomes of patients undergoing and not undergoing ureteral rest before reconstruction. Ureteral rest was associated with higher surgical success rate, lower estimated blood loss, and decreased utilization of buccal mucosal graft ureteroplasty, making this preoperative step an important consideration.

While preoperative workup informs patient counseling prior to reconstruction, intraoperative findings may change the plan, and the surgeon should be able to perform a broad spectrum of reconstruction. Patients should be counseled on the wide spectrum of these techniques, including nephrectomy, if reconstruction cannot be accomplished.

4 PATIENT POSITION

For the retroperitoneal approach, the entire abdomen and genitals are prepped, and if oral mucosa ureteroplasty is planned, the mouth is prepped. For shorter strictures requiring oral mucosa augmentation, use of lower lip mucosa graft can be utilized, which can be easier to harvest with the robot docked. However, harvesting a graft greater than 2.5 cm can cause injury to the mental nerve. This can cause paresthesia to the anterior mandible, and thus an alternative site (buccal) is recommended.

If there is a risk of needing intraperitoneal access, such as use of appendiceal onlay or if the surgeon suspects there is a high risk of conversion to a transperitoneal approach (such as for appendiceal onlay or ileal ureter), the patient may be positioned in a flank position instead of standard supine position from the start of the case. This will allow the bowel contents to fall to the contralateral side.

5 EFFICIENCY/INSTRUMENTS

5.1 NIRF for ureteral identification

NIRF may be used to identify urinary tract structures through transillumination of the white light of the endoscope. This can be particularly useful with ureteral identification in patients with significant retroperitoneal tissue or significant scar from previous surgery or urinoma. This can be achieved through concomitant ureteroscopy for ureteral identification. An analog ureteroscope is preferred to digital modes, as more light in the infrared spectrum is emitted allowing for better visualization through tissue. In the case of long‐segment stricture, both antegrade and retrograde ureteroscopy can be used to guide dissection of the proximal and distal ureter.

5.2 NIRF and ICG

ICG becomes fluorescent green when visualized under near‐infrared light. The use of ICG is twofold. ICG may be instilled via ureteral catheterization about 30 min prior to the surgery to assist with ureteral identification. It will be fluorescent green where ICG contacts urothelium. Second, ICG may be given intravenously for assessment of tissue vascularity. This can be repeated every 30 min. However, if ICG is used for ureteral identification, it cannot be used for vascularity as the ureter will be persistently fluorescent.

6 INCISION, INITIAL DISSECTION, AND APPROACH

A 3‐cm incision is made one‐third of the distance from the anterior superior iliac spine to the umbilicus (Figure 1). Dissection is carried down to the fascia and two holding stitches are placed on the fascia with 0 polyglactin. The fascia is opened horizontally between the two holding sutures and the abdominal wall musculature is bluntly spread. The peritoneum is carefully swept medially until the retroperitoneal fat is identified. If the peritoneum is entered, it can be closed with absorbable suture. The retroperitoneal fat is swept with a digit circumferentially around the incision off the abdominal wall and transversalis musculature. A surgeon's finger is then used to bluntly dissect down to the psoas major muscle. Then, a small SP access port is placed. Unlike in transperitoneal surgery, this approach offers few landmarks that would confirm entering a proper plane once the robot is docked; therefore, performing this dissection to the retroperitoneum is critical for the success of the procedure.

An 8‐mm Airseal is used for insufflation on the side port. The robot is then docked (Figure 2). If the ureteral pathology is above the level of the iliac vessels, the robot is aimed toward the ipsilateral kidney. If the pathology is below the level of the iliac vessels, the robot is aimed toward the pelvis and bladder.

We position the camera at the 6 o'clock position. Table 1 shows the configuration of the robotic arms and camera during initial dissection. This is maintained throughout the case if possible. The initial dissection starts with lifting the retroperitoneal fat above the psoas.

For suturing, a change in configuration of the instruments is made to have two grasping instruments on the right and left side, so the scissors and the needle driver swap positions. Table 2 shows the configuration for suturing.

An assistant port is not used. Instead, a Remotely Operated Suction Irrigation System is utilized. This is positioned between the camera clutch and the left arm pedal (Figure 3). A silk suture is tied at the tip to assist with moving. This is passed through the assistant port on the SP Access Port Kit.

7 TROUBLESHOOTING ACCESS

The dissection required for the retroperitoneal approach can be challenging. This section addresses many common errors in obtaining robotic access.

• If the peritoneum is entered, it is often difficult to dissect back into the retroperitoneal space. It can also be difficult to tell between retroperitoneal fat and intraperitoneal fat. One clue is that the bowel contents/mesenteric fat often bulges out through the peritonotomy, while retroperitoneal fat does not. We recommend closure of the peritoneal opening once this is recognized, prior to any further dissection. A stay suture can be used to provide traction and to help sweep the peritoneum medially.

• If the transversus abdominus muscle is not opened and the surgeon remains superficial to this layer, lateral dissection can be directed around the abdominal cavity and posterior to the psoas. If this is not recognized early, robotic dissection can cause injury to the exiting spinal nerves.

• Given there are limited anatomic landmarks to guide the surgeon, tools such as NIRF and ureteroscopy are especially useful. For surgeons with limited experience with robotic retroperitoneal surgery, we recommend starting with short proximal ureteral strictures or ureteropelvic junction obstruction in patients with normal body mass indices.

• If a stapler is needed, in cases of bowel‐based reconstruction, a 12‐mm assist port is required. When this is not expected from the start, repositioning may be required by rotating the table and placement into the Trendelenberg position. The surgeon robotically opens the anterior lateral peritoneum to insufflate the peritoneal space. We place our assist port periumbilically. This is usually done after ureteral dissection is performed and bowel‐based ureteral reconstruction is needed.

8 REVIEW OF TECHNIQUES IN URETERAL RECONSTRUCTION

8.1 Ureteroneocystostomy (nontransecting and transecting reimplant)

Distal ureteral reconstruction for strictures below the pelvic brim is commonly accomplished by ureteroneocystostomy (ureteral reimplant). The procedure begins with identification of the psoas muscle and the ureter in the retroperitoneal space. Traditionally, distal ureteral reimplant is performed in an end‐to‐end fashion (transecting refluxing reimplant) where the ureter is circumferentially dissected, transected proximal to the area of the stricture, and anastomosed to the dome of the bladder.

In patients with a history of pelvic radiation, more scarring and ischemia of the periureteral tissue may be present, and distal ureterolysis may be difficult to perform due to significant fibrosis and obliteration of anatomic planes. Thus, a nontransecting reimplant may be used in these scenarios. During nontransecting reimplant, circumferential ureteral dissection is avoided so as not to disrupt periureteral vasculature and lead to ischemia and restenosis. Instead, the ureter is incised longitudinally in its anteromedial aspect and anastomosed to the bladder in a side‐to‐side manner (Figure 4). Since only the anterior aspect of the ureter is incised, the posterior plate can maintain its original blood supply and help prevent a stricture recurrence[5]. This technique is not advised for patients with distal ureteral fistula as the fistula could continue after reimplantation is completed.

In the initial description of this technique, Slawin et al. in 2019 reported leaving the strictured segment in situ and performing a 3–4‐cm‐long ureterotomy proximal to the stricture followed by anastomosis with a cystotomy made in the posterolateral aspect of the bladder[5]. The procedure was performed in 16 patients with a follow‐up of 12.5 months with no recurrence of stricture observed[5]. Since then, the group has applied the technique with success to challenging cases of patients who developed symptomatic ureteral stricture after radiation therapy for abdominopelvic malignancies[1,6] with the hypothesis that minimal dissection in the irradiated field lowers the risk of iatrogenic injuries to surrounding structures.

Ureterovesical junction (UVJ) preserving technique can be used in select patients with suspected poor bladder compliance. Onlay techniques using grafts such as oral mucosa graft or appendiceal flap can be used to preserve the antirefluxing mechanism of the UVJ. These techniques can avoid reflux during voiding or transmittance of high bladder pressures due to poor compliance, causing flank pain. These techniques have been shown to have high rates of success similar to reimplantation[7].

8.2 Psoas hitch and Boari flap

Psoas hitch and Boari flap are adjunctive techniques that can be used with ureteral reimplantation when the distance between the patent distal ureter and the bladder is too large. They can bridge the gap between the ureter and the bladder allowing for ureteral reimplant with less tension on anastomosis. Both techniques can be easily performed and adapted for the SP retroperitoneal approach.

Psoas hitch requires mobilization of the bladder from the anterior abdominal wall to the level of endopelvic fascia. The length is gained by partial or complete division of the contralateral bladder pedicle. The bladder is then deviated toward the site of the ureteral injury and secured to the psoas tendon with a long‐acting absorbable suture allowing for the ureter to be anastomosed to the bladder with no tension. While placing the stitch through the psoas tendon one must avoid injury to the genitofemoral nerve. This can be safely accomplished by placing the stitch parallel to the muscle fibers.

While the psoas hitch allows for a gain of extra 4–5 cm during a distal ureteroneocystostomy, it may not be adequate for longer strictures. Boari flap is a reconstructive technique using the length of the bladder wall and mucosa to repair ureteral defects up to 15 cm[8], which cannot be bridged by psoas hitch alone. During the procedure, the bladder is filled with saline to aid in flap outline creation. An anterior bladder flap is developed with a minimum width of the base of 5 cm to ensure sufficient perfusion and lower the risk of repair breakdown due to flap ischemia. Additional length may be gained by developing the anterior bladder flap in a diagonal fashion or through the creation of a “spiral” Boari flap[9]. Alternatively, a transverse bladder incision can be made and closed longitudinally in Heineke Mikulicz fashion allowing for extra bladder length in more proximal injuries[10]. It is important to remember that a generous vesical flap that is often required may compromise bladder volume in some patients[11]; therefore, careful intraoperative evaluation is needed. After the bladder is secured to the psoas muscle, a ureter is spatulated and anastomosed to the bladder with a running 4‐0 absorbable suture. A 6 Fr J‐J stent is placed across the repair for 4–6 weeks.

One of the advantages of using a retroperitoneal approach to ureteral reconstruction with psoas hitch and Boari flap is that there was no need for colon mobilization, which may be difficult in patients who underwent previous intraperitoneal procedures. The earliest report of robotic ureteral reconstruction with Boari flap comes from Schimpf and Wagner, who described a single case of a 75‐year‐old woman with persistent benign ureteral stricture who underwent robot‐assisted transecting reimplant and Boari flap with 6 months follow‐up after which no recurrence was observed[12]. The largest to date, multi‐institutional experience using Boari flap in robotic ureteral reconstruction has been published by Corse et al. as part of Collaborative of Robotic Reconstructive Urology. Among patients included in the study, 4 (8%) underwent the SP approach, 34 (68%) had undergone previous abdominal surgery, 17 (34%) had prior ureteral stricture treatment, and 9 (18%) had prior pelvic radiation. The median follow‐up was 15 months, and the reported success rate was 90%[9].

8.3 Ureteroureterostomy

Ureteroureterostomy (UU) is a reconstructive technique in which a strictured segment is excised, and the two remaining ends of the ureter are spatulated to 1–2 cm and reanastomosed over a stent (Figure 5). This technique has traditionally been used for repair of unifocal, proximal, and mid‐ureteral strictures, shorter than 3 cm in length. Previously, this was not recommended for distal strictures due to concern for higher failure rates associated with tenuous blood supply to the distal ureter. However, internal data pending publication indicate that UU may be a viable option in select patients with equal efficacy to ureteral reimplantation. Additionally, this procedure may not be well suited for reconstruction in patients who have previously undergone radiation or other retroperitoneal procedures. In a well‐selected group of patients, the retroperitoneal approach using the SP robot discussed here can be particularly useful given the need for articulation and stability required for careful dissection and suturing in a narrow space.

In 2015, Lee et al. presented the largest to date case series based on their experience with robot‐assisted UU in a pediatric population. In their study, the authors reviewed 25 patients undergoing robotic UU for benign strictures and observed no stricture recurrence after a 16.4‐month follow‐up[13]. Several years later, Maestroni et al. reported excellent outcomes after performing a robot‐assisted UU for a patient with retrocaval ureter[14].

8.4 Buccal mucosal graft ureteroplasty

Long, multifocal strictures of the proximal and mid‐ureter are challenging to repair. When the available ureteral length prohibits direct anastomosis of the ureter, substitution techniques like bowel interposition or autotransplantation may be necessary. These treatment options, however, carry significant risk of immediate and delayed complications, including ileus, metabolic acidosis, and vascular complications[15,16]. As an alternative to the more morbid techniques of bowel interposition or autotransplantation, Naude proposed, in 1999, open ureteroplasty with buccal mucosal graft (BMG)[17]. Buccal mucosa has been recognized in genitourinary reconstruction due to its resilience and excellent biological qualities that can counteract the effects of harsh environments within the urinary tract[18].

Zhao et al. pioneered the adaptation of robotic technology to BMG ureteroplasty. In 2015, the group reported a 100% success rate in four patients who underwent BMG ureteroplasty after a follow‐up of 15.5 months[19]. Three years later, the group published their experience including 19 patients with median stricture length of 4 cm treated with robotic BMG ureteroplasty. Seventy‐nine percent of patients underwent an onlay graft after incision of the stricture while the rest underwent augmented anastomotic repair. Of note, 53% of the patients had a history of previously failed ureteral reconstruction. At a median follow‐up of 26 months, the success rate was 90%[20]. An updated analysis of intermediate‐term outcomes for 54 patients who underwent a robotic BMG repair published by the group in 2020 is the largest to date multi‐institutional experience with this technique[21]. With 87% success rate during the 27.5‐month follow‐up, the group has shown that the robotic adaptation of the BMG ureteroplasty is not only safe and feasible but also has excellent, durable outcomes. In 2022, Yang et al. described their experience with robotic BMG in 29 patients and observed no stricture recurrence after 12 months[22].

There are two approaches to ureteroplasty with buccal mucosa depending on the nature of the underlying stricture: BMG onlay is used for narrowed ureteral segments and augmented anastomotic technique is used for obliterated, transected ureters, or those without adequate ureteral plate for onlay technique. In the BMG onlay technique, strictured segment of the ureter is longitudinally incised and a BMG graft of appropriate length and width of 10–15 mm is anastomosed to the defect with an absorbable running suture (Figure 6). The augmented anastomotic technique involves excision of the obliterated segment, anastomosing a plate of healthy ureter using running absorbable suture, and anastomosing a BMG over the defect. In both cases, a J‐J stent is placed after completion of the first half of anastomosis.

Although the initially described techniques were carried out using a multiport robotic platform where the arms are placed strategically based on anatomy and location of the target tissue, they can be easily adopted to a SP robot that simplifies the approach by requiring only umbilical incision and allowing access to the upper and lower ureter. With the retroperitoneal approach, we prefer to perform a posteriorly ureteral onlay and rely on the psoas muscle for the vascular bed for mucosa graft. Furthermore, for shorter segments, lower lip or lingual oral mucosa may be utilized.

8.5 Appendiceal onlay

Reconstruction of a long stricture or complete obliteration of a segment of the proximal to mid‐right ureter may be accomplished with appendiceal onlay or appendiceal interposition. Not only does the appendix come with its native blood supply and can be easily mobilized but it also has been shown to have negligible absorption of urine given its small surface area, making it a potential reconstructive option in patients with favorable anatomy. Given the requirement for appendiceal mobilization and therefore intraperitoneal access, there is no role for the retroperitoneal approach in this reconstructive technique if the surgeon knows this will be used from the start. However, if during ureteral reconstruction the surgeon determines that oral mucosa or graft bed is not ideal, appendiceal onlay or interposition technique may be easily used after retroperitoneal dissection. The peritoneum can be opened lateral to the colon from the retroperitoneum. From there, the robot can be turned to access the right colon and appendix. The appendix is transected at the base while preserving the vascular pedicle containing the appendiceal artery. Here, ICG can be used intravenously to ensure adequate perfusion after harvesting of the appendix. The distal tip of the appendix is removed. The ureter is then mobilized only on its anterior surface and incised longitudinally with the incision extending beyond the proximal and distal ends of the stricture (Figure 7). The appendix is incised longitudinally on the antimesenteric border and anastomosed in the running fashion to the ureteral plate using a long‐acting absorbable suture (Figure 8). The colon may need to be mobilized and pexed near the reconstruction if there is concern for tension on the anastomosis.

If the appendiceal interposition technique is used, we recommend calibrating the appendix with an 8 Fr catheter to ensure there are no appendiceal strictures. We also spatulate both the ureter and the appendix prior to anastomosis.

Appendiceal onlay or interposition requires careful surgical planning. The technique relies on favorable anatomy, which includes the presence of the appendix, ability to mobilize the colon, and satisfactory blood supply to the appendix after transection, as well as adequate length of the appendix to cover the ureteral defect[10]. If any of those conditions are not met, the surgeon may have to re‐evaluate the approach and use an alternate technique. On the other hand, in favorable conditions there are numerous advantages of performing an appendiceal onlay or interposition ureteroplasty. For one, there is a lower risk of ischemia of the repair given preserved, native blood supply to the appendix via mesoappendix. Additionally, circumferential dissection of the ureter is not required, which further preserves blood supply to the area of reconstruction. When compared to a BMG ureteroplasty, this technique does not require a reinforcement with an omental flap. Lastly, there is no donor site morbidity.

Although the appendiceal onlay technique was introduced by Melnikoff over a century ago[23], it has not been frequently used until recently when Reggio et al.[24] described their experience with laparoscopic appendiceal graft techniques in six patients with ureteral strictures with no recurrence at 16 months follow‐up. In 2020, Cheng et al.[25] published the first robotic experience using appendiceal onlay/graft in eight patients with proximal to mid‐ureteral stricture. During the 12.8‐month follow‐up period, the authors reported only one stricture recurrence. Updated outcomes for the same group of patients after 18 months follow‐up revealed 2 stricture recurrences[26].

8.6 Pyeloplasty

Ureteropelvic junction (UPJ) obstruction (UPJO) is commonly caused by extrinsic compression due to a crossing vessel or intrinsic obstruction secondary to aperistaltic ureteral segment. The gold standard treatment is dismembered pyeloplasty which is now performed robotically with success rates ranging between 95% and 98%[27,28]. The procedure begins with identification and dissection of the renal pelvis from peri‐renal adipose tissue. Care must be taken not to devascularize the ureter during dissection. Next the presence or absence of a crossing vessel is determined. During dismembered pyeloplasty part of the procedure, the UPJ is transected, spatulated, and if necessary, anteriorly transposed. The ureter is also spatulated and a running anastomosis is performed over a 6Fr ureteral stent.

To date, the largest case series comes from Chammas et al.[3], who in 2014 reported treating 131 patients with robotic pyeloplasty with only one recurrence after 50 months of follow‐up and Lee et al.[7], who in 2020 reported their experience with primary and secondary robotic pyeloplasty in 158 patients with similarly positive outcomes. Billah et al. reported on their early transition to SP from a multiport robotic platform for the treatment of UPJOs due to improved cosmesis and a more focused operative field[29].

The retroperitoneal approach also allows for a flap pyeloplasty. There are several techniques including Y‐V (Figure 9) or spiral flap pyeloplasty depending on the amount of redundant renal pelvis tissue. A medial ureterotomy is done at the level of obstruction just below the level of the diseased segment. This is extended proximally into the healthy renal pelvis. The surgeon's preferred renal pelvis flap is then constructed, and the anastomosis is performed over a ureteral stent.

Careful preoperative evaluation of patients requiring UPJO repair is important for the success of the procedure. The presence of anomalous anatomy or failure of previous reconstructive procedures may affect the surgeon's decision regarding the appropriate approach. The retroperitoneal approach offers outcomes similar to transperitoneal surgery with rapid identification of the UPJ and potentially shorter operative time. Additionally, it avoids bowel manipulation and mobilization, which may be difficult in patients who underwent previous abdominal surgeries and offers a contained retroperitoneal environment in the event of a urinary leak.

8.7 Ureterocalicostomy

Patients presenting with UPJO or proximal ureteral strictures who cannot undergo pyeloplasty due to a short ureter that cannot safely reach the renal pelvis or the renal pelvis that cannot be adequately dissected and mobilized due to scar may benefit from a ureterocalicostomy. This technique involves anastomosis between the segment of the ureter and the dilated lower pole calyceal system of the kidney. The procedure begins with the identification of the ureter and its transection below the level of the stricture. The proximal stump is then closed with a suture. The renal hilum is isolated, and the lower pole of the kidney is cleared of Gerota's fascia. The ultrasound probe is used to identify the lower pole calyx. The surgeon may elect to perform this with renal ischemia. The lower pole calyx is transected with endoscopic shears. Any bleeding encountered at this point is managed with suture ligation and electrocautery similar to a renorrhaphy. A flexible ureteroscope can be introduced through the trocar to evaluate the collecting system and remove any stones. The ureter is then anastomosed to the lower pole calyx in an interrupted fashion and a J‐J stent is inserted across the repair (Figure 10).

The first experience with robot‐assisted ureterocalicostomy was described by Mufarrij et al. in 2007[30]. The authors reported radiographic and symptomatic improvement after 6 months of follow‐up. Since then, additional either single patient case reports or small series reported favorable results with robotic ureterocalicostomy[31–33]. In 2022 Mittal et al. published the largest case series including 24 pediatric patients with a history of failed pyeloplasty for UPJO treated with robotic ureterocalicostomy. The authors reported improvement in symptoms and hydronephrosis in 22 (92%) patients, with two (8%) patients requiring additional endoscopic intervention at 16.1 months of follow‐up, concluding that this technique is a safe and efficacious salvage option for failed pyeloplasty or complex anatomy[34].

9 CONCLUSION

Robotic ureteral reconstruction has been on the rise over the last decade. With advancements in robotic technologies, specifically introduction of the SP robotic platform, more techniques and surgical approaches to ureteral reconstruction become possible. Selection of the optimal approach, however, remains challenging due to the paucity of data regarding the application of robotic reconstructive techniques, especially in complex cases. Here, we review a standardized approach to retroperitoneal SP robot‐assisted ureteral reconstruction with its appropriate applications and advantages while recognizing that more multi‐institutional collaborative efforts will be needed to further assess feasibility and outcomes of the proposed approach. The retroperitoneal approach avoids much of the abdominal morbidity and dissection required for transperitoneal access, especially in the reoperative abdomen. Furthermore, the supine position facilitates easier access to oral mucosa harvest and confers less risk for positional injury. Finally, this approach is consistent and the same regardless of stricture location and can allow for simplicity and efficiency with ancillary operative room support staff.

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