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Transvaginal Ureteral Reimplantation

Transvaginal ureteral reimplantation has been attempted with the da Vinci SP through an anterolateral vaginal-fornix incision into the pelvic retroperitoneum. In a six-patient 2026 video abstract, three attempts required conversion because of dense scarring or an injury too proximal for this corridor; mean follow-up across the series was 6.5 months.[10] Published clinical outcomes exist for transabdominal single-port reimplantation. Robotic transvaginal retroperitoneal access to the upper tract has been described in a cadaver nephrectomy model, while a separate nonrobotic transvaginal ureteroneocystostomy case reported healing without sequelae through six months.[1][2][3][9]

For established operative principles and patient selection, see Ureteral Reimplantation. For access technology, see vNOTES & Robotic vNOTES.

What the Published Sources Show​

SourceActual procedure and evidence
Kaouk 2019Three consecutive transabdominal SP reimplantations for distal benign strictures (post-hysterectomy injury, diverticulum compressing the ureter, bilateral ureteroenteric strictures after neobladder); the diverticulum case also included diverticulectomy and litholapaxy. Operative times for the three cases were 165, 150 and 180 min; Table 1 lists blood loss as 30, 50 and 50 mL, respectively. There were no intraoperative complications, and discharge was on postoperative day 1, 1 and 2. The bilateral case used an assistant port through the shared GelSeal cap without a separate assistant incision.[1]
Hebert 2019A single refluxing ureteroneocystostomy in a woman with an obliterative distal stricture after hysterectomy, through a 25-mm infraumbilical incision, without an assistant port: 127 min, blood loss 20 mL, no complications. Flexible nasotracheal suction tubing was passed alongside the cannula and the stent was placed percutaneously through a 14-gauge angiocatheter.[2]
Laydner 2013Robotic transvaginal nephrectomy was attempted in three female cadavers using a three-arm da Vinci Si and a multichannel port in the posterior vaginal fornix; this was not a da Vinci SP case. The lithotomy transperitoneal approach was not possible because the robotic arms collided with the legs and bowel retraction was limited. A retroperitoneal approach in the prone jackknife position was completed in one cadaver (238 min, no retroperitoneal organ or vessel injury). In another cadaver a rectal injury occurred during access and the procedure could not be completed.[3]
Pellegrino 2023Supine anterior retroperitoneal access (SARA) with the da Vinci SP through a 3-cm incision at the McBurney point, in 18 patients (12 partial nephrectomies, 2 pyeloplasties, 2 nephroureterectomies, 2 radical nephrectomies). Of the partial nephrectomy patients, 83% were discharged the same day, and no patient reported narcotic use at 7 days.[4]

The retroperitoneal prone jackknife position was described as instrumental in providing robotic access to the kidney through the vagina in the cadaver model.[3]

Proposed Rationale​

The following advantages of the combined approach are proposed, not demonstrated:

  • Retroperitoneal access. The distal ureter and bladder could be reached without bowel mobilization or peritoneal entry, which might reduce ileus and adhesion-related sequelae.
  • Pelvic access. A nonrobotic transvaginal reimplantation case exposed the distal ureter through anterior vaginal dissection.[9]
  • No abdominal incision when completed through the vaginal route.
  • Single-port robotic articulation. Wristed instruments and a flexible camera may offset the limited working space of transvaginal and retroperitoneal approaches.[1][4]

Technical Challenges​

  • Working space. The retroperitoneum reached transvaginally is a confined field. Balloon dilation or CO₂ insufflation is needed to deploy robotic instruments.
  • Instrument reach. The distal ureter and bladder dome lie close to the vaginal access point, so direct reimplantation is feasible in principle. Psoas hitch or Boari flap modifications are technically challenging through this corridor.
  • Orientation. As in other vNOTES procedures, the field is viewed inverted relative to transabdominal approaches, and the surgeon must adapt spatially.
  • Stent placement. Plan guidewire and stent access before completing the anastomosis. The nonrobotic transvaginal case passed a guidewire through the urethra and placed a 6-Fr double-pigtail stent over it; the transabdominal SP Hebert case used a percutaneous angiocatheter.[9][2]
  • Colpotomy closure. Secure closure of the vaginal incision is needed to prevent vesicovaginal or rectovaginal fistula.

Outcome Benchmarks From Transabdominal Robotic Reimplantation​

Transvaginal series would be compared with the established robotic reimplantation literature, which is retrospective:

  • Multicenter robotic versus open: 51 robotic, 79 open; robotic approach was an independent predictor of shorter operative time, lower blood loss, shorter hospital stay and shorter catheterization.[5]
  • Single-center comparison: 21 robotic, 28 open; median operative time 216 versus 317 min, blood loss 35 versus 175 mL, hospital stay 2 versus 6 days, catheterization 16 versus 28 days. Overall complication rates did not differ (33.3% versus 46.4%).[6]
  • Success. In a retrospective comparison of laparoscopic (19) and robotic (47) reimplantation, the authors reported success rates of 94.7% and 95.5%, respectively (symptomatic improvement, decreased hydronephrosis and improved drainage).[7] A four-center series of 183 robotic reconstructions included 145 pyeloplasties, 17 ureteroureterostomies, and 21 distal reimplantations. At a median cohort follow-up of 24 months, pyeloplasty and ureteroureterostomy success exceeded 90%.[8] Among 21 transperitoneal distal reimplantations for mixed pathology, one recurred (estimated two-year recurrence-free rate 93.3%, 95% CI 61.3–99.0), and two had grade III postoperative complications requiring intervention.[8]

Evidence and Safety Limits​

Access anatomy, rectal and bladder protection, vascular reach, tension-free reimplantation, stenting, and secure vaginal closure must be demonstrated for the exact technique.

Procedure-specific reports should document access complications, conversion, infection or fistula, vaginal healing, patient-reported outcomes, renal drainage, and durable freedom from reintervention before those advantages are claimed.

Open questions for early-experience series: standardization of the access technique, colpotomy-related complications (infection, fistula, sexual function), comparison with transabdominal single-port reimplantation, and long-term stricture recurrence.

See Also​

Videos​

Single-Port Robotic Transvaginal Ureteral Reimplantation
Operative video — early experience

References​

1. Kaouk JH, Garisto J, Eltemamy M, Bertolo R. Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP surgical system. BJU Int. 2019;123(4):733–739. doi:10.1111/bju.14635

2. Hebert KJ, Joseph J, Gettman M, et al. Technical considerations of single-port ureteroneocystostomy utilizing the da Vinci SP platform. Urology. 2019;129:236. doi:10.1016/j.urology.2019.03.020

3. Laydner H, Autorino R, Isac W, et al. Robotic retroperitoneal transvaginal natural orifice translumenal endoscopic surgery (NOTES) nephrectomy: feasibility study in a cadaver model. Urology. 2013;81(6):1232–1237. doi:10.1016/j.urology.2012.11.083

4. Pellegrino AA, Chen G, Morgantini L, Calvo RS, Crivellaro S. Simplifying retroperitoneal robotic single-port surgery: novel Supine Anterior Retroperitoneal Access. Eur Urol. 2023;84(2):223–228. doi:10.1016/j.eururo.2023.05.006

5. Ziewers S, Dotzauer R, Thomas A, et al. Robotic-assisted vs. open ureteral reimplantation: a multicentre comparison. World J Urol. 2024;42(1):194. doi:10.1007/s00345-024-04875-9

6. Carbonara U, Branche B, Cisu T, et al. Robot-assisted ureteral reimplantation: a single-center comparative study. J Endourol. 2021;35(10):1504–1511. doi:10.1089/end.2021.0083

7. Batra R, Agrawal A, Singh A, et al. Laparoscopic ureteric reimplantation versus robotic-assisted laparoscopic ureteric reimplantation for lower ureter pathology: single-institutional comparative study. Int J Urol. 2022;29(11):1362–1367. doi:10.1111/iju.14998

8. Buffi NM, Lughezzani G, Hurle R, et al. Robot-assisted surgery for benign ureteral strictures: experience and outcomes from four tertiary care institutions. Eur Urol. 2017;71(6):945–951. doi:10.1016/j.eururo.2016.07.022

9. Berry LK, McKenzie CM, Lentz SS. "Transvaginal ureteroneocystostomy." Urol Case Rep. 2023;51:102558. doi:10.1016/j.eucr.2023.102558

10. Walasek A, Ratanapornsompong W, Sarawong S, Elbakry A, Zhao L. "V01-05 Single-port robotic-assisted transvaginal retroperitoneal ureteral reimplantation: early experience." J Urol. 2026;215(5S):e19. doi:10.1097/01.JU.0001191264.83903.71.05