Robotic distal ureterectomy and reimplantation

Robotic surgery that removes the lower part of a ureter, the tube from the kidney to the bladder, along with a tumor and a small cuff of bladder, and then reconnects the healthy ureter to the bladder so you keep your kidney.

Also called Distal ureterectomy, Segmental ureterectomy, Robotic distal ureterectomy, Ureteral reimplantation, Ureteroneocystostomy, Psoas hitch, Boari flap, Kidney-sparing surgery for ureter cancer

Where: Hospital operating room
Anesthesia: General anesthesia (fully asleep)
Time in the room: About 3 to 5 hours
Hospital stay: Usually 1 to 3 nights
Going home with: A stent inside the ureter for about 4 to 6 weeks; a bladder catheter for about 7 to 14 days; sometimes a drain for a day or two
Back to normal: About 3 to 6 weeks
Back to work: Desk work in about 2 to 3 weeks; heavy physical work in about 6 weeks

See the steps

Left kidneyLeft ureterBladderTumor

Where it happens. The highlighted part is what this procedure treats.

Overview

The ureters are two thin tubes that carry urine from the kidneys down to the bladder. They are lined by the same kind of cells as the bladder, called urothelium, and cancer can start in that lining. This is called upper tract urothelial carcinoma. When it grows in the lowest part of the ureter, near the bladder, the kidney above it is often healthy.

The traditional operation for ureter cancer removes the kidney, the whole ureter and a small cuff of bladder (nephroureterectomy). For tumors in the lower ureter, a distal ureterectomy removes only the lower ureter with the tumor and a cuff of bladder around its opening, and keeps the kidney. The AUA and EAU guidelines support kidney-sparing treatment for low-risk tumors, usually starting with laser treatment through a scope, and support distal ureterectomy for lower ureter tumors that a scope cannot fully treat and for selected higher-risk tumors there. Studies, mostly comparing groups of patients rather than randomized trials, suggest cancer control similar to removing the kidney for well-chosen lower ureter tumors.

Once the diseased segment is removed, the healthy ureter must be joined back to the bladder. If the gap is short, the ureter is sewn straight into the bladder. If it is longer, the bladder is stretched up and stitched to a muscle in the back of the pelvis (a psoas hitch). If it is longer still, a strip of bladder wall is rolled into a tube to bridge the gap (a Boari flap). A thin stent inside the ureter protects the new join for several weeks.

Urothelial cancer can come back in other parts of the lining, most often in the bladder. Regular checks of the bladder with a scope, and of the kidney and remaining ureter with scans or a scope, continue for years. Keeping the kidney also keeps more kidney function, which matters if chemotherapy such as cisplatin is ever needed.

The parts of your body involved

Each kidney drains into a renal pelvis, which narrows into the ureter. The ureter runs down along the back of the belly, crosses the large iliac blood vessels at the edge of the pelvis, and enters the bladder at an angle through its wall, opening on the inside at a small slit called the ureteral orifice. The lowest few centimeters, inside the pelvis, are the distal ureter. Beside the bladder runs the psoas muscle, whose tendon can serve as an anchor for the bladder.

Kidney
Makes urine. In this operation it stays in place and keeps working.
Ureter
The thin tube from the kidney to the bladder, about 25 to 30 centimeters (10 to 12 inches) long.
Distal ureter
The lowest part of the ureter, in the pelvis, where the tumor sits. This part is removed.
Ureteral orifice and bladder cuff
The opening where the ureter enters the bladder. A small cuff of bladder wall around it is removed with the ureter, because tumor cells can sit in this tunnel.
Bladder
The bladder is stretchy and mobile, which lets the surgeon move it up to meet a shortened ureter.
Psoas muscle
A large muscle along the back of the pelvis. In a psoas hitch, the bladder is stitched to its tendon to hold it up.

Why it’s done

Your urologist recommends this operation when a tumor in the lower ureter needs to be removed and the kidney above it is worth keeping.

To remove the tumor completely
Large, numerous or deep tumors can be hard to treat fully with a laser through a scope. Surgery removes them with the surrounding wall.
To keep the kidney
Keeping both kidneys protects long-term kidney function. This matters most if you have one kidney, weak kidney function, diabetes or high blood pressure.
To keep treatment options open
Good kidney function makes it more likely that cisplatin chemotherapy, the most effective chemotherapy for urothelial cancer, can be given if ever needed.
To learn the exact grade and stage
The pathologist examines the whole tumor and the ureter wall, and any lymph nodes, which guides whether more treatment is needed.
To relieve a blockage
A tumor can block urine flow and swell the kidney. Removing it and reconnecting the ureter lets the kidney drain again.

Other options

Laser treatment through a scope
For small low-grade tumors, a thin scope passed up the ureter can burn or remove the tumor without any cuts. It often needs repeating, with regular scope checks.
Nephroureterectomy
Removing the kidney, the whole ureter and a bladder cuff. It is the standard for many high-risk tumors and for tumors higher up, or when the other kidney is healthy and the tumor is aggressive.
Mitomycin gel
A chemotherapy gel placed into the kidney's drainage system for low-grade tumors. It is designed mainly for tumors inside the kidney and can cause narrowing when used in the ureter.
Chemotherapy before surgery
For larger or invasive high-grade tumors, some teams give chemotherapy first. It is being studied more for upper tract cancer.
Chemotherapy after surgery
In the POUT trial, chemotherapy after surgery for cancer that had grown deeper into the wall or into nodes lowered the chance of it coming back.

In the operating room, step by step

Press play or pick a step. Each drawing shows what your surgeon is doing at that moment. Your team may do some steps differently.

YouOperating tableAnesthesia team

1 / 10

1. Going to sleep and positioning

The anesthesiologist puts you fully to sleep and places a breathing tube. You lie on your back with your legs slightly apart in soft supports, so the bladder can be reached from below with a scope, and the table is tilted head-down to let the bowel slide away from the pelvis.

More detail

The tilt is usually less steep than for prostate surgery. Your arms are padded and tucked, and your eyes are protected.

The anesthesiologist puts you fully to sleep and places a breathing tube. You lie on your back with your legs slightly apart in soft supports, so the bladder can be reached from below with a scope, and the table is tilted head-down to let the bowel slide away from the pelvis.
More detail
The tilt is usually less steep than for prostate surgery. Your arms are padded and tucked, and your eyes are protected.
Many surgeons start with a cystoscopy, passing a thin scope through the urethra to check the bladder lining for other tumors and to see the opening of the ureter. A catheter is then placed in the bladder.
More detail
Some surgeons also place a thin wire or stent up the ureter at this point, or take more biopsies. Any small bladder tumors found are treated now.
Your surgeon makes about five or six small cuts across the belly. Ports go through each cut, and carbon dioxide gas lifts the belly wall to give room to work. Surgeons call this gas-filled space a pneumoperitoneum. It is kept at a gentle pressure, usually 12 to 15 mmHg, and it is what gives the camera and instruments room to move.
More detail
The port layout is similar to robotic bladder or prostate surgery, sometimes shifted toward the side of the tumor.
The robotic cart is rolled up and its arms attached to the ports. Your surgeon sits at the console in the same room, sees a magnified 3D view, and controls every movement. The robot never moves on its own. A bedside assistant and nurse stay beside you.
More detail
Most centers use the da Vinci Xi or da Vinci 5. The fine wristed instruments are well suited to the delicate stitching of the ureter.
Your surgeon finds the ureter where it crosses the iliac blood vessels at the edge of the pelvis and follows it down toward the bladder. A clip is placed across the ureter above the tumor early, so tumor cells cannot spill down or out while the surgeon works.
More detail
The ureter's blood supply runs in a thin sheath along it, so the surgeon handles the healthy part gently and keeps that sheath intact. This helps the new join heal. For higher-grade tumors, the surgeon also removes the lymph nodes along the iliac vessels on that side, where ureter cancer can spread first, keeping the obturator nerve and large vessels intact. For low-grade tumors this is often not needed.
Your surgeon frees the lower ureter down to where it enters the bladder and removes it together with a small cuff of bladder wall around its opening. The ureter is cut above the tumor, and the piece is placed in a bag.
More detail
The upper cut edge of the ureter is often checked under the microscope during surgery (a frozen section). If cancer is still present at that edge, more ureter is removed, and very rarely the plan changes to removing the kidney.
Your surgeon checks whether the healthy ureter reaches the bladder without tension. If the gap is short, the ureter goes straight into the bladder. If not, the bladder is freed and stretched up toward the ureter and stitched to the tendon of the psoas muscle (a psoas hitch). For a longer gap, a flap of bladder wall is cut and rolled into a tube to reach the ureter (a Boari flap).
More detail
A join without tension heals best. A psoas hitch can bridge a gap of several centimeters, and a Boari flap can reach farther, sometimes up toward the middle of the ureter.
The end of the ureter is trimmed, opened slightly, and sewn into a new opening in the bladder with fine dissolving stitches. Before the join is finished, a thin, soft stent is placed with one coil in the kidney and the other in the bladder, to hold the join open while it heals.
More detail
This join is called a ureteroneocystostomy. In adults, many surgeons sew the ureter straight in; others make a short tunnel in the bladder wall to reduce urine flowing back up toward the kidney.
The opening in the bladder is closed in layers, and the bladder is filled with salt water through the catheter to make sure every join is watertight. A thin drain may be left beside the bladder.
More detail
Your team may give a single dose of chemotherapy into the bladder around the time of surgery to lower the chance of new bladder tumors. The timing depends on when the bladder is sealed.
The robot is undocked. The bag with the ureter is removed through one of the port cuts, which may be widened slightly. The cuts are closed with dissolving stitches and skin glue. You wake with a catheter, and the stent stays inside you, out of sight.
More detail
The ureter, bladder cuff and any lymph nodes go to the pathology lab, and the report usually takes about 1 to 2 weeks.

Your surgeon is in control the whole time

The surgeon sits at a console a few steps from you and moves every instrument with hand controls and foot pedals. The robot cannot move on its own or make decisions.

A magnified 3D view

A camera on one arm gives the surgeon a bright, three-dimensional picture magnified about ten times, which helps them see small nerves and vessels.

Wristed instruments through keyholes

The instruments are about the width of a pencil and bend like a wrist inside your body, so the surgeon can stitch and dissect through small openings.

A team at your side

A bedside assistant and a scrub nurse stay at the table, and the anesthesia team watches your breathing and blood pressure throughout. Most U.S. hospitals use the da Vinci system made by Intuitive.

After the operation

In the hospital

Waking up
You wake in the recovery room with a bladder catheter and sometimes a drain. Bladder spasms are common because of the bladder repair.
Walking and eating
You walk the evening of surgery or the next morning, and usually eat light food the next day.
Pain control
Scheduled acetaminophen, few opioid pills, and medicine for bladder spasms if needed.
The drain
If you have a drain, it usually comes out before you go home, once tests show the fluid is not urine.
Catheter teaching
A nurse shows you how to use the leg bag and night bag.
Going home
Most people go home after 1 to 3 nights with the catheter in place.

At home

Pain
Soreness at the cuts and in the lower belly for 1 to 2 weeks. Acetaminophen on schedule usually helps.
Catheter care
Keep the bag below the bladder and the tube secured. The catheter protects the bladder repair and usually stays for about 7 to 14 days. Some teams check the bladder with an X-ray dye test before removing it.
Stent symptoms
After the catheter is out, the stent can cause a need to go often, urgency, blood in the urine, and an ache in the side when you pee, because urine can flow back up the stent. These ease when the stent is removed.
Wounds and showering
Shower after 24 to 48 hours. Avoid baths and swimming until the cuts are healed and the catheter is out.
Diet and fluids
Eat normally and drink enough to keep your urine pale.
Bowels
Take a stool softener while using opioid pills, and avoid straining, which presses on the bladder repair.
Activity and lifting
Walk daily. Avoid lifting more than about 10 to 15 pounds and hard exercise for about 4 to 6 weeks.
Driving
Do not drive while the catheter is in or while taking opioid pills.
Work
Desk work in about 2 to 3 weeks; heavier work in about 6 weeks.
Sex
Usually fine once the catheter is out and you feel comfortable.

Recovery timeline

Day 0
Surgery day
Surgery takes about 3 to 5 hours. You wake with a catheter.
Days 1 to 3
Going home
Most people go home with the catheter, and with the stent inside.
Weeks 1 to 2
Catheter out and pathology
The catheter comes out, sometimes after a dye test of the bladder. Your surgeon reviews the grade, stage and margins.
Weeks 4 to 6
Stent out
The stent is removed in the office with a quick cystoscopy. Stent symptoms fade within a day or two.
About 3 months
First checks
A cystoscopy of the bladder and a scan or ultrasound to make sure the kidney drains well through the new join.
Year 1
Regular surveillance
Bladder checks every 3 months or so, plus scans and sometimes a scope look up the ureter.
Years 2 to 5 and beyond
Ongoing checks
Checks become less frequent if all stays clear, but continue for years.

What it feels like

Most people say recovery from the surgery itself was easier than they expected. The catheter and especially the stent are the parts they remember, along with the regular checks that follow.

Deciding to keep the kidney
Many people wonder whether keeping the kidney means taking a chance with the cancer.
What helpsAsk your surgeon how your tumor's grade and size affect that balance, and what the follow-up would be. For well-chosen lower ureter tumors, studies suggest cancer control similar to removing the kidney.
Waking up
Grogginess, soreness, and strong bladder spasms from the repair.
What helpsAsk early for spasm medicine. Spasms usually ease over a few days.
The catheter days
The catheter tugs and the bladder can cramp, with urine leaking around the tube.
What helpsSecure the tube to your thigh, check for kinks, avoid constipation, and use the spasm medicine.
Living with the stent
Many people find the stent more bothersome than the surgery: needing to pee often, a pulling ache in the side when they go, and pink urine after activity.
What helpsAsk about medicines that relax the bladder or the ureter. Drink steadily through the day. Remember that it is temporary and the date it comes out.
Stent removal day
Many people worry it will hurt. Most say it takes seconds and is mildly uncomfortable, with relief within a day.
What helpsNumbing gel is used. Drink well afterward. A short ache in the side that day is common.
The pathology results
Waiting to hear whether the cancer was low grade and fully removed can be hard.
What helpsAsk when you will hear and what each result would mean for the plan, including any chemotherapy.
The first bladder check
Many people feel anxious before each cystoscopy, knowing new bladder tumors can appear.
What helpsAsk for results right after the scope, which is usually possible. Regular checks catch new tumors early, when they are easy to treat.

How well it works

Success means the tumor is fully removed with clear margins, the kidney drains well through the new join, and follow-up checks of the bladder and upper urinary tract stay clear.

Clear margins
The pathology report says whether the cut edges of the ureter and bladder cuff are free of cancer.
Grade and stage
Low-grade tumors confined to the lining have an excellent outlook. Tumors that have grown into the wall or nodes may lead to chemotherapy, which in the POUT trial lowered the chance of return.
A working kidney
An ultrasound or scan a few months after surgery checks that the kidney is not swollen and drains well. A kidney scan may measure its function.
Bladder surveillance
Because new bladder tumors are common after upper tract cancer, cystoscopies continue regularly for years.
Upper tract surveillance
Scans, and sometimes a scope up the ureter, check the kidney and remaining ureter for new tumors.

Risks

Every operation has risks. These are the ones people ask about most, with honest odds where good numbers exist. Your surgeon’s own results matter more than averages.

Common

Stent symptomsMost people

Frequent and urgent urination, an ache in the side, and blood in the urine while the stent is in.

Bladder spasms

Common while the catheter is in, because of the bladder repair.

Blood in the urine

Pink urine on and off for a few weeks, especially with activity.

A new tumor in the bladder laterAbout 1 in 4 to 1 in 2 people

This is a feature of the disease rather than a surgical complication, and the reason bladder checks continue for years.

Pain and tiredness

Soreness and low energy for 1 to 3 weeks.

Less common

Urine leak from a join

Urine can leak from the bladder repair or the new ureter join. Most leaks heal with the catheter left in longer.

Scar narrowing of the new join

Scar can narrow the join months later and block the kidney. It may be treated with a stent, a balloon, or repeat surgery.

Urine infection or kidney infection

More likely while the stent is in. Treated with antibiotics.

Urine flowing back to the kidney (reflux)

Usually causes no problems in adults, but can make kidney infections more likely.

Cancer in the remaining ureter or kidney

New tumors can appear higher up and may need scope treatment or, sometimes, removal of the kidney later.

Blood clots or lymph fluid collection

Uncommon. Walking and sometimes blood thinner shots lower clot risk.

Rare

Injury to bowel, blood vessels or nerves

Rare, and usually repaired at once.

Loss of the kidney

Very rarely, if the join fails badly or cancer is more extensive than expected, the kidney may need to be removed.

Tumor spillage

Cancer cells spilling into the belly is rare, which is why the ureter is clipped early and the specimen bagged.

Change to open surgery

Rarely needed.

Call your care team or go to the emergency room if

Fever of 101°F (38.3°C) or higher, or shaking chills.
No urine draining into the catheter bag for more than 1 to 2 hours, especially with lower belly pain. Check for kinks first, then call.
Severe pain in the side or back that does not settle with your medicine.
Thick blood or clots in the urine that do not clear with more fluids, or that block the catheter.
Clear fluid leaking steadily from a cut or the drain site.
Swelling or pain in one calf, or sudden shortness of breath (call 911).
Vomiting that will not stop, a swollen belly, or no gas or bowel movement for 3 days.
After the catheter is out: you cannot pass urine.

Questions to ask your surgeon

Why do you recommend removing only the lower ureter rather than the kidney in my case?
What are the grade and stage of my tumor, and how sure are we from the biopsy?
Do you expect a direct reimplant, a psoas hitch or a Boari flap?
Will you remove lymph nodes?
Will I get a dose of chemotherapy in the bladder around the time of surgery?
How long will I have the catheter and the stent?
How many of these operations have you done?
What will my follow-up schedule be for my bladder, ureter and kidney?
What is the chance I will need my kidney removed later?
Would chemotherapy before or after surgery help me?

Words you may hear

Pneumoperitoneum: The gas-filled belly that makes keyhole surgery possible. Carbon dioxide is pumped in through a thin needle or the first port until the belly wall lifts like a tent (usually at a pressure of 12 to 15 mmHg), giving the camera and instruments room to work. The gas is let out at the end, and the little that remains is absorbed and breathed out over a day or two; it can cause shoulder-tip ache in the meantime.
Urothelium: The lining of the kidney's drainage system, ureters and bladder.
Upper tract urothelial carcinoma: Cancer of the lining of the kidney's drainage system or the ureter.
Ureter: The thin tube carrying urine from the kidney to the bladder.
Distal ureterectomy: Removing the lowest part of the ureter, near the bladder.
Bladder cuff: A small ring of bladder wall around the ureter opening, removed with the ureter.
Ureteroneocystostomy: Sewing the ureter into a new opening in the bladder; also called ureteral reimplantation.
Psoas hitch: Stretching the bladder up and stitching it to the psoas muscle tendon to reach a shortened ureter.
Boari flap: A strip of bladder wall rolled into a tube to bridge a longer gap to the ureter.
Double-J stent: A thin soft tube with a coil at each end, running from the kidney to the bladder, that holds the ureter open while it heals.
Frozen section: A quick microscope check of tissue during surgery, such as the cut edge of the ureter.
CT urogram: A CT scan with dye that outlines the kidneys, ureters and bladder.
Ureteroscopy: Looking up the ureter with a thin scope passed through the urethra and bladder.
Urine cytology: A urine test that looks for cancer cells under the microscope.
Nephroureterectomy: Removing the kidney, the whole ureter and a bladder cuff.

Common questions

Will I keep my kidney?

Yes. That is the purpose of this operation. The kidney stays and keeps working, and urine drains through the reconnected ureter.

Is it as safe for the cancer as removing the kidney?

For well-chosen tumors in the lower ureter, studies suggest similar cancer control, though most of the evidence comes from comparing groups of patients rather than randomized trials. Your surgeon will weigh your tumor's grade, size and stage.

Why do I need bladder checks if the tumor was in the ureter?

Urothelial cancer often appears again in the bladder lining. Regular cystoscopies find new tumors early, when they are small and easy to treat.

What does the stent feel like?

Many people feel the need to pee often, a pulling ache in the side when they go, and see some blood in the urine. It is temporary and usually comes out in 4 to 6 weeks.

Will urine flow back up to my kidney?

Sometimes, depending on how the ureter was joined. In adults this usually causes no problems, though it can make kidney infections a little more likely.

Could the cancer come back higher up?

Yes, new tumors can appear in the remaining ureter or the kidney. That is why scans and sometimes scope checks of the upper tract continue for years.

Sources this page draws on

American Urological Association and Society of Urologic Oncology, Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline (2023)
European Association of Urology, EAU Guidelines on Upper Urinary Tract Urothelial Carcinoma
The Lancet, Adjuvant chemotherapy in upper tract urothelial carcinoma (the POUT trial): a phase 3, open-label, randomised controlled trial (2020)
European Urology, ODMIT-C trial: a single postoperative intravesical dose of mitomycin C to prevent bladder tumours after nephroureterectomy (2011)

Written November 2026. This page explains what usually happens. It is not medical advice and does not replace a conversation with your own surgeon, whose plan for you comes first.

Robotic distal ureterectomy and reimplantation

Overview

The parts of your body involved

Why it’s done

Other options

Getting ready

Weeks before

The week before

The day before

The morning of surgery

In the operating room, step by step

1. Going to sleep and positioning

After the operation

In the hospital

At home

Recovery timeline

What it feels like

Deciding to keep the kidney

Waking up

The catheter days

Living with the stent

Stent removal day

The pathology results

The first bladder check