Single-port robotic management of distal ureteral pathologies: straightforward access

BRIEF EXPLANATION

The Da Vinci Single-port (SP) system, utilizing a supine anterior retroperitoneal approach (SARA)^[1], provides direct and minimally invasive access to the ureter through a 3.5 cm Gibson incision [Figure 1A and B]. Our video [Video 1] (All physicians appearing in the video have provided their informed consent for the use of their images) demonstrates the step-by-step management of three distinct distal ureteral conditions treated between January and June 2025.

Figure 1. Straightforward access to the ureter with SP platform. (A) Docking of SP system; (B) Direct access to the ureter; (C) Hydronephrotic ureter stuck in inflammatory tissue; (D) Duplex collecting system with dilated ureters. SP: Single-port.

The first case involves a 43-year-old woman presenting with a left uretero-vaginal fistula, a complication of hysterectomy. The distal ureter was hydronephrotic and adhered to inflammatory tissue in communication with the vaginal cavity, causing continuous urine leakage [Figure 1C]. We performed direct ureteral reimplantation following meticulous dissection and closure of the fistulous tract.

The second case involves a left double ureterocutaneostomy in an 82-year-old woman with symptomatic complete left vesicoureteral reflux in a duplex collecting system [Figure 1D] and a low-compliance bladder. No space was left for reimplantation due to contractured bladder.

The third case describes a left distal ureterectomy and ipsilateral pelvic lymphadenectomy in a 76-year-old man with a 2-cm pTaG1 urothelial carcinoma. An extraperitoneal resection of the distal ureter and bladder cuff was performed, adhering strictly to oncological principles of urothelial carcinoma. Ureteral reimplantation was achieved using a small Boari flap to ensure a tension-free anastomosis. The flexibility of the SP platform facilitated the lymphadenectomy.

Detailed baseline and perioperative features for all three cases are presented in Table 1. All procedures were performed entirely within the retroperitoneum, allowing easier management of the ureter compared to extraperitoneal laparoscopic or multiport robotic approaches [Figure 1]. The SARA technique also offered anesthetic benefits, including improved pulmonary compliance for our patients, particularly those with obesity^[1]. Our findings support the advantages of the SP-SARA approach compared to traditional transperitoneal access for treating distal ureteral pathologies. Furthermore, this technique may offer advantages such as shorter hospital stays, improved pain control, and superior cosmetic outcomes^[2,3].