# Refining Robotic Extravesical Ureteral Reimplantation: Impact of Ureteral Adventitia Inclusion and Distal-First Detrusorraphy

## TL;DR

A new robotic surgery technique for treating urine reflux shows better success rates without more complications.

## Contribution

A refined detrusorraphy technique with ureteral adventitia inclusion and distal-first suturing improves surgical outcomes in RALUR-EV.

## Key findings

- Modified technique group had higher success rates at both ureter and patient levels.
- Multivariable analysis showed the modified technique reduces surgical failure risk.
- Improved success was achieved without increased perioperative morbidity.

## Abstract

Background: Robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV) is an established minimally invasive option for vesicoureteral reflux (VUR); however, surgical success remains variable, and detrusorraphy technique is a key determinant of reflux resolution. This study evaluated whether a refined detrusorraphy technique is associated with improved surgical outcomes following RALUR-EV. Methods: We retrospectively reviewed patients who underwent RALUR-EV performed by a single surgeon between August 2013 and February 2023. A technique modification introduced in November 2021 incorporated ureteral adventitia inclusion during detrusorraphy and a distal-first detrusorraphy suture. Patients were divided into two groups according to the surgical period. Surgical success was defined as radiographic resolution of VUR on postoperative voiding cystourethrography without ureteral obstruction. Results: A total of 62 patients (96 ureters) were included. The modified technique group demonstrated significantly higher surgical success rates than the conventional group at both the ureter level (97.8% vs. 76.5%, p = 0.002) and the patient level (96.6% vs. 69.7%, p = 0.006). On patient-level multivariable analysis, the modified detrusorraphy technique was independently associated with a reduced risk of surgical failure. Conclusions: A refined detrusorraphy technique is associated with improved early radiographic success after RALUR-EV without increasing perioperative morbidity.