Re: Ureteral Reimplantation Via Robotic Non-Transecting Side-to-Side Anastomosis for Distal Ureteral Stricture by Slawin et al.

Dear Editor:

We have read an interesting article by Slawin et al. entitled “Ureteral Reimplantation via Robotic Non-Transecting Side-to-Side Anastomosis for Distal Ureteral Stricture.” ¹ The authors described a novel technique of ureteral reimplantation for distal ureteral stricture by robotic nontransecting side-to-side anastomosis. They retrospectively reviewed 16 cases from three institutions.

After reading this article, we still had some concerns about the technique. First, as we know, ureteroneocystostomy is the gold standard for management of distal ureteral strictures, and it has high success rate. ² In this article, the authors thought that the traditional method needed ureteral transection and mobilization of the distal ureter, which might destroy the vascularity of the anastomosis and contribute to recurrent strictures. We believe that there is still a lack of comparative study between traditional ureteroneocystostomy and this side-to-side anastomosis technique regarding recurrent stricture rate. It is a bit early to conclude that this new technique is better than the traditional method with respect to recurrent stricture rate. The recurrence of strictures after ureteral reimplantation or side-to-side anastomosis may be related to the causes, location, length, surrounding tissue, or the appropriate treatment of the strictures.

Second, we noted that the same study had already been shown in the video section of the American Urological Association 2019 before this article was published. ³ One of 16 cases had a “clinical failure” caused by persistent bothersome flank pain during urination consistent with reflux pain. Reflux is a problem that should not be ignored, whether in children ⁴ or adults. How should the reflux pain of this patient be solved? Does this patient need antireflux surgery or should they wait for conservative observation? Does the degree of the lower urinary tract obstruction need to be evaluated before this kind of refluxing ureteral reimplantation in male patients?

Third, Slawin et al. wrote, “If needed, a psoas hitch or Boari flap can be performed in the usual fashion” in the Technique Section. The psoas hitch may be performed “in the usual fashion” when it is needed, but how can the Boari flap be performed “in the usual fashion”? Should the bladder flap be tubular in side-to-side anastomosis?

Fourth, for some female patients, it may be difficult to achieve a complete tension-free side-to-side anastomosis because of the influence of the uterus and ovary.

Fifth, the authors highlighted that this technique had advantages in postradiation cases. However, we only found two cases (2/16) caused by pelvic radiation in this article. Thus, we think it is still too early to claim such advantages in postradiation patients. In another similar study, eight patients with radiation-induced ureteral strictures received this type of side-to-side anastomosis surgery. One patient (1/8) is still managed with a percutaneous nephrostomy. ⁴

Sixth, we believe that keeping the ureteral orifice plays a limited role. If the endourologic treatment could achieve a satisfactory result, why did they prefer to perform ureteral reconstructive surgery rather than first choosing an endourologic approach? We also think that the original ureteral stricture will limit usage of the endourologic treatment.

We think that this technique has three significant advantages: it avoids retraction of the end of the ureter, decreases some tension with nontransecting anastomosis, and keeps the correct anastomotic direction. Nonetheless, we would like to congratulate the authors. We hope more and longer follow-up results regarding this technique are published.