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Transvaginal Ureteral Reimplantation (Single-Port Robotic vNOTES)

Single-port robotic-assisted transvaginal retroperitoneal ureteral reimplantation is an early-experience approach that combines three innovations: single-port robotic surgery (da Vinci SP), transvaginal natural-orifice access (vNOTES) through a posterior colpotomy, and retroperitoneal ureteral reimplantation without a transperitoneal route.[1][2][3]

For the gynecologic foundations of robotic vNOTES (platforms, docking, learning curve, indications, outcomes), see vNOTES & Robotic vNOTES.

For standard robotic ureteral reimplantation, see Ureteral Reimplantation.

What This Procedure Combines​

ComponentEstablished evidence
Single-port robotic ureteral reimplantation (transabdominal)Kaouk 2019 — first step-by-step description with da Vinci SP in 3 patients (benign distal ureteral strictures); OR 150–180 min, EBL 50 mL, discharge POD 1–2, no complications. One case completed pure single-site without an assistant port.[1] Hebert 2019 — first true single-port ureteroneocystostomy with da Vinci SP without an assistant port; 127 min, 20 mL EBL. Innovations: flexible nasotracheal suction tubing alongside the cannula and percutaneous JJ stent placement via angiocatheter.[2]
Robotic transvaginal retroperitoneal accessLaydner 2013 — robotic retroperitoneal transvaginal NOTES nephrectomy in a cadaver model. Lithotomy transperitoneal failed because of robotic-arm collision; prone jackknife retroperitoneal approach succeeded (238 min). Established that retroperitoneal positioning is what makes vaginal robotic access to the upper tract feasible.[3]
Retroperitoneal single-port robotic surgery (transabdominal SARA)Crivellaro group — 18 upper-tract procedures (partial nephrectomy, pyeloplasty, nephroureterectomy) entirely in the retroperitoneum via Supine Anterior Retroperitoneal Access. Same-day discharge in 83% of partial-nephrectomy patients, median OR 160 min, no narcotic at 7 d.[4]

Rationale for the Combined Approach​

  • Direct retroperitoneal access to the distal ureter and bladder without bowel mobilization or peritoneal violation — potentially fewer ileus and adhesion-related sequelae.
  • Anatomic proximity of the posterior vaginal fornix to the distal ureter — the fornix sits close to the retroperitoneal space containing the distal ureter and ureterovesical junction, making it a logical access corridor.
  • No abdominal incisions — true scarless surgery with cosmetic and pain advantages.
  • Single-port robotic articulation — wristed instruments and a flexible camera offset the limited working space inherent to both transvaginal and retroperitoneal approaches.[1][4]

Technical Challenges​

  • Working space. The retroperitoneum accessed transvaginally is a very confined operative 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 — direct reimplantation is feasible. Psoas hitch or Boari-flap modifications, however, are technically challenging through this corridor.
  • Orientation. As with all vNOTES procedures, the field is viewed "upside down" relative to standard transabdominal approaches; significant spatial adaptation is required.
  • Stent placement. Percutaneous JJ stenting techniques (per Hebert 2019) may be necessary, since standard antegrade stenting through the vaginal port is difficult.[2]
  • Colpotomy closure. Secure closure of the vaginal incision is critical to prevent vesicovaginal or rectovaginal fistula.

Outcomes Benchmarks From Standard Robotic Ureteral Reimplantation​

The transvaginal retroperitoneal SP variant should be benchmarked against the established robotic ureteral-reimplantation literature:

  • Multicenter robotic vs open (n = 51 robotic, n = 79 open): robotic was an independent predictor of shorter OR time, lower blood loss, shorter hospital stay, and shorter catheterization time (all p <0.05).[5]
  • Single-center comparative: robotic median OR 216 vs 317 min (open), EBL 35 vs 175 mL, LOS 2 vs 6 d (all p ≤ 0.01) with equivalent complication rates.[6]
  • Success rates for robotic ureteral reimplantation consistently exceed 94–96% across multiple series.[6][7][8]

Current Status and Open Questions​

The combined transvaginal retroperitoneal SP reimplantation is at the frontier of MIS urologic reconstruction — even standard robotic vNOTES for gynecologic indications is still evolving, and robotic transvaginal retroperitoneal nephrectomy has only been demonstrated in cadavers.[3] Questions that early-experience series should address:

  • Standardization of the transvaginal retroperitoneal access technique.
  • Colpotomy-related complications: infection, fistula, sexual function.
  • Comparison with established transabdominal single-port SP reimplantation.
  • Long-term stricture-recurrence rates.

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