Using a Reconstructive Ladder for Surgical Reconstruction of Transplant Ureteral Stricture Disease

Abstract

Reconstruction of transplant ureteral stricture disease (USD) is a challenging surgical problem. In this article, we review our reconstructive ladder for robotic reconstruction of transplant USD and report our outcomes. We performed a retrospective review of patients undergoing robotic transplant reimplantation for USD after kidney transplantation at our institution between 11/2021 and 3/2023. Only patients with at least 1-year follow-up were included. The first rung of our reconstructive ladder is a side-to-side nontransecting reimplant. We prefer this method whenever possible because it avoids transection of the ureter, preserving the fragile blood supply. When this technique is not possible, because of long stricture length and/or limited bladder mobility, we proceed to the second rung of our reconstructive ladder, a Boari flap reconstruction. Surgical success in our cohort was defined as being hardware-free without evidence of ureteral obstruction on imaging. There were 6 patients in our cohort: 3 underwent side-to-side reconstruction and 3 underwent Boari flap reconstruction. Median console time was 139 minutes (interquartile range [IQR] 85-175), estimated blood loss was 25 milliliters (IQR 25-81), and length of stay was 1 day (IQR 1-3). We had one major (Clavien ≥ III) complication, which was an intensive care unit transfer postoperatively for hypertension requiring a nicardipine drip. Median follow-up was 14 months (IQR 13-18) with a 100% surgical success rate. Utilization of a reconstructive ladder for management of transplant USD may allow for a systematic approach based on reconstructive principles. Our approach was associated with excellent intermediate-term outcomes.