Ileal ureter replacement versus kidney autotransplantation for complex ureteral strictures in the robotic era: a systematic review and meta-analysis.

Purpose: To systematically evaluate and compare the perioperative metrics, renal functional preservation, and surgical success rates of ileal ureter replacement (IU) versus kidney autotransplantation (KAT) for complex ureteral strictures, with a specific focus on the emerging role of robotic-assisted techniques.

Methods

A systematic literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library up to February 2026, following PRISMA 2020 guidelines. Thirty-two studies involving 1,044 patients (1,003 IU; 41 KAT) were included. The primary outcome was surgical success rate. Secondary outcomes included changes in estimated glomerular filtration rate (ΔeGFR), major complications (Clavien-Dindo ≥ III), and perioperative efficiency.

Results

The KAT group exhibited better baseline renal function compared to the IU group. Despite this selection bias, meta-analysis revealed no statistically significant difference in surgical success rates between IU (93.0%) and KAT (87.8%) (OR 1.85, 95% CI: 0.69–4.95, P = 0.22; I^2 = 0%). Similarly, both techniques demonstrated comparable renal functional preservation (ΔeGFR MD -0.93 mL/min, P = 0.86) and major complication rates (3.6% vs. 2.4%, P = 1.00). However, IU was associated with significantly shorter operative time (MD -139 min, P < 0.001) but a longer hospital stay (MD + 5.7 days, P = 0.02). Notably, the robotic IU subgroup achieved a success rate of 90.7%, confirming the high efficacy of minimally invasive reconstruction.

Conclusion

Based on current low-certainty evidence, both IU and KAT are effective salvage procedures for complex ureteral strictures. While KAT offers shorter hospitalization, IU provides a significant advantage in operative efficiency. Given the inherent selection bias, IU represents a pragmatic and robust reconstruction strategy, with robotic-assisted techniques further enhancing its clinical feasibility for the majority of patients with complex ureteral defects.