Laparoscopic and Robot-Assisted Ureteral Reimplantation (RALUR)

In laparoscopic reimplantation, the surgeon works through a few small openings in the abdominal wall using a camera and slender instruments; in robot-assisted laparoscopic ureteral reimplantation (RALUR), the same instruments are attached to robotic arms controlled by the surgeon from a console. The robot does not operate on its own; it translates the surgeon's hand movements into tremor-free, scaled motion under three-dimensional vision.

The most visible gain of the minimally invasive method is the incision: instead of a 4–6 cm horizontal incision in the lower abdomen, only a few 5–8 mm puncture scars remain. Postoperative pain is generally less, the need for pain relievers is shorter, and the hospital stay is around 1 day in most series.

The success of minimally invasive reimplantation is reported in the literature at roughly 88–97%; although this approaches the 95–98% rate of open surgery, it has remained lower and more variable, especially in early-series reports. Results are closely tied to the surgeon's and the center's experience; the learning curve is significant.

The best candidate for minimally invasive reimplantation is an older child or adolescent with primary VUR (no bladder problem), a ureter that is not excessively wide, and no additional anatomical anomaly; unilateral cases give the most predictable results. A previously unsuccessful endoscopic injection does not rule out the minimally invasive approach.

• Young infants and low-weight children (limited working space)
• A markedly dilated ureter (megaureter) requiring narrowing
• Anatomy requiring additional repair, such as ureterocele, duplex collecting system, or paraureteral diverticulum
• Secondary reflux due to neurogenic bladder or posterior urethral valves
• The possibility of extensive adhesions in children who have previously had bladder or intra-abdominal surgery

• In the following situations, open reimplantation is usually found to be more suitable; however, this list is not an absolute restriction — it is a framework that experienced centers evaluate on a case-by-case basis.

The good results reported for minimally invasive reimplantation come from centers that perform this operation many times a year; it is inherent to this method that results vary by center. For this reason, the question of 'how much experience does this team have with each method' comes before the question of 'robotic or open.' The family should be told about the success rates and risks of the open, endoscopic, and minimally invasive options based on that specific center's own experience.

• In our practice, reimplantation is performed by the two pediatric urologists operating together; the choice of method is determined through joint assessment, taking into account the child's age, ureteral diameter, any accompanying anomaly, and the family's priorities. In children considered suitable for the minimally invasive approach, this option is discussed openly with the family, together with its advantages and limits; the goal is not the size of the incision but the lasting correction of reflux and the protection of the kidney.