Robotic Breakthrough for Near-Obliterative Ureteric Strictures, Case Report Finds
Surgeons have successfully adapted a specialized non-transecting surgical technique, originally utilized for complex urethral repair, to treat near-obliterative ureteric blockages through robotic-assisted reconstruction. This innovative approach, known as the Joshi step, integrates mucosa-to-mucosa suturing with Buccal Mucosa Graft (BMG) augmentation to effectively expand the diameter of the ureter while meticulously protecting its vital vascular network.
These findings of the case series are published in the Urology Video Journal in August, 2025, by Dr. Sanjay Kulkarni and his research team.
The procedure represents a significant advancement in clinical urology because it specifically targets the high risk of treatment failure in patients whose ureters are nearly completely obstructed following previous endoscopic procedures or chronic inflammatory conditions. By maintaining the continuity of the ureter instead of performing a full transection, the technique ensures better tissue healing and provides a more robust anatomical foundation for long-term surgical success.
A 38-year-old male presented with chronic, dull right flank pain two years after he underwent ureteroscopy with laser lithotripsy for stone management. Clinical investigations, including Computerized Tomography (CT) and Retrograde Pyelogram (RGP), revealed a short-segment stricture located in the right upper ureter. The surgical team performed a Robotic Buccal Mucosa Graft Ureteroplasty (RBMGU), which involved harvesting a graft from the patient’s oral cavity and utilizing robotic assistance for the precise placement of the tissue. They employed the Joshi step to widen the ureteral plate, and following a six-week period with an internal stent, postoperative ultrasonography confirmed the complete resolution of hydronephrosis.
Mechanistic Insights
The mechanistic advantage of the Joshi step lies in its non-transecting nature, which involves performing a precise mucosa-to-mucosa suture at the narrowest point of the stricture before augmenting the opposite wall with the harvested BMG. This specific method preserves the essential longitudinal blood supply of the ureter that traditional transecting repairs often sever, thereby significantly improving the viability of the graft and the physiological integrity of the reconstruction.
Potential Clinical Implementation
For practitioners, this technique offers a superior strategy for managing complex ureteric obstructions, as evidenced by a study of eleven patients treated between January 2023 and January 2025 with no major postoperative complications. The data, which showed a mean stricture length of 5.3 centimeters and successful outcomes over an eleven-month follow-up period, indicates that this approach reduces morbidity and enhances surgical precision compared to traditional open or laparoscopic methods. Future clinical investigations will likely focus on the long-term durability of these functional outcomes, potentially leading to the wider adoption of this method for patients who do not respond to conventional treatments.
Reference
Kulkarni S, Hosamani A, Chandankhede U, Joshi P. Non-transecting anastomotic augmentation (Joshi step) BMG ureteroplasty in near obliterative ureteric stricture using robot. Urology Video Journal. 2025;27:100359.
