Today’s operation was a laparoscopic uretero–ileal conduit re-anastomosis.

The patient had previously undergone robot-assisted radical cystectomy with ileal conduit diversion, but later developed a ureteral stricture, requiring long-term nephrostomy management.

He came from a distant region with a strong wish:

“Is there any way to unify my nephrostomy and stoma into one?”

Cancer control was excellent with no recurrence, yet every institution he visited told him that reconstructive revision surgery would be too difficult. He had been searching for a solution for a long time.

🔧 Key Steps of Today’s Surgery

The procedure began with lysis of intra-abdominal adhesions.

Adhesions after robotic surgery can be extremely dense, but fortunately, today’s case allowed a smoother dissection than expected.

Next, the stenotic ureteral segment was excised and re-anastomosed to the ileal conduit.

At the same time, we repaired an associated abdominal wall incisional hernia.

Managing two urinary outlets—nephrostomy and stoma—is physically and psychologically exhausting.

Now that they have been unified, the patient’s quality of life will likely improve dramatically.

🤖 Why perform the “cleanup” of robotic surgery using laparoscopy?

This is the main message I wanted to share today.

Patients often ask:

“If robotic surgery is so advanced, why isn’t the revision also done robotically?”

The answer is simple:

Robotic surgery is excellent, but it is not omnipotent.

Robotic technology has allowed many surgeons to perform procedures that used to be considered highly difficult—

and that is unquestionably a great benefit for modern surgical care.

However, when it comes to troubleshooting reconstructive complications,

there are limitations that no machine can overcome.

Reconstructive revision requires:

the extent and character of adhesions the degree of tissue fibrosis the vascularity of the ureter the condition of the previous reconstruction real-time decision-making

These factors rely heavily on

what the surgeon sees, feels, and judges in the moment—not only on instrument dexterity.

This is why, in many revision cases,

laparoscopy is more advantageous than robotic surgery.

And importantly:

Ureteral reconstruction is not inherently difficult.

Laparoscopic pyeloplasty, for example, was widely performed before the robotic era, achieving outcomes comparable to open surgery.

I am not saying every revision must be laparoscopic.

Robotic suturing is undeniably comfortable, and performing only the anastomotic portion robotically can be a reasonable hybrid approach.

But—

“It cannot be repaired.”

This is the statement that never sits right with me.

⚠️ A growing concern in the robotic era

Robotics has democratized surgery.

Operations once limited to highly skilled surgeons can now be performed by many, with stable quality.

But this progress brings a new risk:

The number of surgeons capable of solving complications is decreasing.

Surgery is not only “performing standard procedures.”

It is the ability to reconstruct, revise, and rescue—

to combine techniques to achieve a solution.

This is where a surgeon’s true value is tested.

Robots are not the enemy.

If anything, the robotic era demands even greater commitment to surgical education in:

judgement experience anatomical intuition reconstructive craftsmanship

Completing today’s surgery reinforced this belief.