Appendiceal ureteroplasty - optimization of technique and considerations for successful ureter repair

Appendiceal ureteroplasty has re-emerged in the modern robotic era as a versatile option for complex ureteric stricture disease. This manuscript is presented as a narrative technical review, incorporating an illustrative single-centre case series, outlining patient selection, technique, perioperative management, and outcomes of robotic appendiceal ureteroplasty.

Patients undergoing robotic appendiceal onlay ureteroplasty at the authors' institution since the commencement of their robotic reconstructive programme in September 2018 were identified from a prospectively maintained database for retrospective audit of outcomes. Appendiceal reconstruction was considered where the stricture was right-sided, the appendix was healthy on intraoperative assessment, and the defect was amenable to onlay repair, with a minimum of three months' follow-up required for inclusion. Preoperative assessment includes CT urography, retrograde pyelography, ureteroscopy, and nuclear medicine renography as required. Intraoperative technique is detailed for three reconstructive strategies: appendiceal onlay, appendiceal augmented ureteroureterostomy, and appendiceal interposition, with key technical principles including preservation of ureteric blood supply, assessment of appendiceal vascularity, tension-free anastomosis, and stented reconstruction.

Five patients met inclusion criteria (median age 42 years, IQR 30-62.5). Strictures were most often mid-ureteric (60%) and secondary to stone disease (80%), with a mean length of 3.6 ± 0.6 cm. At a median follow-up of 13 months (IQR 8.5-40.5), three patients achieved complete objective and subjective success, with no hydronephrosis, stable renal function, and freedom from pain, infection, or reintervention. A fourth patient was an objective success despite mild hydronephrosis, and a subjective success aside from a single urinary tract infection. The remaining patient had stable moderate hydronephrosis but a decline in renal function (GFR 84 to 65 mL/min/1.73 m²) and recurrent urinary tract infections, representing both an objective and subjective failure, though reintervention has been declined to date. One Clavien-Dindo 3a complication occurred; no patient required reintervention.

Robotic appendiceal ureteroplasty is a technically feasible, well-vascularised reconstructive option for complex right-sided ureteric strictures. This series reports on short- to medium-term results with detailed optimal technical steps; standardised reporting and prospective collaborative data are required to define durability and optimise patient selection. Some patients develop narrowing of the tube (ureter) that drains urine from the kidney to the bladder, which can cause pain, infection, and kidney damage. This article describes the technique of how the appendix can be successfully repurposed during robotic surgery to repair these narrowed segments. Published studies show high success rates and good long-term outcomes when the appendix is suitable for reconstruction.