Robotic reconstruction

Reconstruction higher up the urinary tract

Not every narrowing of the urinary tract is in the urethra. Strictures also occur at the bladder neck, along the ureters — the tubes carrying urine from the kidneys to the bladder — and at the pelviureteric junction (PUJ) where the kidney's drainage system meets the ureter.

These are harder to reach. Traditional treatment has been repeated endoscopic dilatation or incision, long-term ureteric stents that need changing every few months, a nephrostomy tube draining the kidney through the skin, or major open surgery. For many patients, that has meant years of repeated procedures with no end point.

What robotic reconstruction changes

The robotic platform gives magnified three-dimensional vision and instruments with a range of movement that the human wrist cannot achieve, through incisions of around a centimetre. That combination makes it possible to perform delicate reconstructive suturing deep in the pelvis or high in the abdomen — work that previously required a large open incision.

Applying the reconstructive principles used in the urethra to these locations means bringing in graft tissue to widen a narrowed segment, rather than simply cutting it out and rejoining, which is not always possible where a long segment is diseased.

Buccal mucosa outside the urethra

Buccal mucosa — the lining of the inside of the cheek — has been the workhorse graft in urethral reconstruction for decades. It takes reliably, tolerates a wet environment, carries no hair, and the donor site heals in a couple of weeks.

Using it robotically to patch a ureter, bladder neck or PUJ is a comparatively recent development, and it makes reconstruction possible in patients whose only previous option was a permanent stent, a nephrostomy, removal of the kidney, or replacing a segment of ureter with bowel. It combines a reconstructive urology skill set with a robotic one, which is why it is performed in relatively few centres.

Assessment

Planning is detailed, because the operation is tailored to the exact site and length of disease. Assessment typically includes cross-sectional imaging, antegrade or retrograde studies to map the stricture, functional imaging to establish how well the affected kidney is working, endoscopic inspection, and review of every previous operation note. Kidney function that has already been lost cannot be recovered by reconstruction, so establishing what is worth saving is part of the decision.

Your mouth is examined as part of the assessment, since it is the graft donor site.

The operation and recovery

Surgery is performed under general anaesthetic through several small incisions. Where buccal graft is needed, it is harvested from inside the cheek at the start. The narrowed segment is opened, the graft is let in to widen it, and it is covered with well-vascularised tissue to support healing. A stent is usually left across the repair, along with a catheter and sometimes a drain.

Hospital stay is typically a few days. The stent generally stays in place for several weeks and is removed endoscopically. Your mouth will be sore for one to two weeks. Most patients return to desk work within two to four weeks and avoid heavy lifting for around six.

Follow-up imaging confirms that the reconstruction is draining properly and that kidney function is preserved.

Risks

Risks include bleeding, infection, urinary leak from the repair, graft failure, recurrent narrowing, the need for further stenting or surgery, injury to adjacent structures, conversion to open surgery, and donor site problems in the mouth. Given the complexity, these are discussed in detail and with reference to your own imaging before you decide.

Our practice

I lead the Southeast London Urethral Reconstruction Team at Guy's Hospital. Together with my consultant colleague Raj Nair, a leading expert in robotic surgery, we offer buccal graft reconstruction of bladder neck strictures, ureteric strictures and PUJ strictures, with the largest experience of this type of robotic reconstruction in the UK. Guy's Urology was ranked the leading urology unit in Europe and eighth in the world in Newsweek's World's Best Specialised Hospitals for Urology 2025.