Distal Ureteral iatrogenic injuries, though relatively rare, present a challenging complication arising from various ginecological, urological and general surgeries procedures. Effectively managing such injuries requires a thorough understanding of the available surgical approaches and their associated risks. Several strategies exist for correcting distal ureteral injuries. These include ureteroureterostomy, ureteroneocystostomy with or without psoas-hitch or Boari flap, transureteroureterostomy, and kidney autotransplantation, between others. Each approach can be performed immediately or deferred, using open, laparoscopic, or robotic-assisted techniques. Robotic-assisted procedures offer precision and enhanced visualization, which can be particularly advantageous in complex cases. However, performing robotic surgery after previous operations can present additional challenges, including altered anatomy, scar tissue, and an increased risk of further complications.
We aim to present a clinical case of a 38-year-old female patient that underwent a laparoscopic anterior resection of the rectum and endometriosis foci complicated with distal left iatrogenic ureteral injury managed with left nefrostomy. Postop complicated by partial rectal anastomotic dehiscence, necessitating open surgery with anastomosis disassembly and a left sided terminal colostomy. 
We aim to discuss the various surgical approaches to correct the distal ureteral injury and the challenges faced by the urologist. Additionally, to describe the feasibility, safety, and efficacy of robotic-assisted ureteroneocystostomy with psoas-hitch and lich-gregoir technique.

This video was created using both the patient's clinical records and surgery video recordings. Additionally, relevant literature on surgical techniques for correcting ureteral injuries was reviewed.

The robotic-assisted ureteroneocystostomy with psoas-hitch was successfully completed without intraoperative complications, despite the procedure's difficulty due to extensive peritoneal adhesions. The total operative time was 210 minutes, with minimal blood loss of less than 50 ml. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day with a bladder catheter

The decision to employ robotic-assisted ureteroneocystostomy with psoas-hitch was influenced by the need to preserve the left- sided terminal colostomy and to avoid compromising conditions for future intestinal reconstruction. Given the challenges of the situation, a second open approach to address the ureteral injury could have severely jeopardized the potential for future intestinal reconstruction. Ureteral and bowel reconstruction during same approach could be too risky, in addition to being extremely difficult too. A robotic-assisted approach aimed to minimize additional trauma and preserve abdominal integrity, which is crucial for any subsequent reconstructive procedures. The success of this procedure, despite the challenging operative conditions, underscores that robotics might still has a space in the managment of complications of previous open and laparoscopic procedures, given its benefits in enhancing surgical precision and visualization. On the other hand, although the outcome was very positive in this case, the benefits and risks should always be weighed before making any surgical decision. A precise, individualized, multidisciplinary decision is essential in such complex cases. In conclusion, the robotic-assisted approach in this case not only provided a successful outcome but also highlights the potential of robotic techniques in addressing complex ureteral injuries, even after previous complicated open surgeries. This experience supports the continued individualized use of robotic-assisted surgery in the management of challenging ureteral injuries, provided that the specific anatomical and procedural complexities are carefully considered.

Carlo De Cicco, Maria Lorena Ret Dávalos, Ben Van Cleynenbreugel, Jasper Verguts, Philippe Robert Koninckx, Iatrogenic ureteral lesions and repair: A review for gynecologists, Journal of Minimally Invasive Gynecology, Volume 14, Issue 4, 2007, Pages 428-435, ISSN 1553-4650, https://doi.org/10.1016/j.jmig.2007.01.003.