Table 4.

Challenges and cautions/modifications.

Outcomes of concerns	Possible technical reasons	Modifications adopted
Urinary retention	Damage to nerve plexus	Precise dissection at VUJ between ureter and bladder, avoiding medial and caudal detrusor dissection (Figure 4C)
		Judicious use of electrocautery
Incomplete reflux resolution	Inadequate tunnel length	Standardized measurement of the tunnel length in the collapsed bladder (Figure 3C)
	Cephalad slippage of the ureter out of the tunnel	Including the ureter adventitia in the first few and last tunnel closure suture (“advancement stitches”). Proximal ureteral mobilization to release tension on tunnel closure
	Incomplete detrusor separation for the tunnel creation	Use of hitch stitch for adequate traction and bladder distension to facilitate dissection (Figure 3D)
Ureteral obstruction	Ureteral injury	Avoiding pre-stenting unless absolutely necessary (e.g., Duplex system), avoiding excessive traction and direct cautery usage on the ureter
	Excessive ureteral mobilization	Ureteral mobilization to the required length with frequent assessments
	Tight tunnel	“Bottom-up” approach starting at the UVJ with careful and stepwise closure of tunnel, raising adequate detrusor flaps to have a spacious tunnel
	Acute angulation of the ureter	Studying the course of the ureter and its angulation prior to hitch stitch and marking the corresponding tunnel line (Figure 3C)
Urinary leak	Cystotomy	Careful identification and repair prior to closure of detrussorotomy
	Leak from ureteral suture-line	Maximize urinary drainage with bladder catheter and/or suprapubic tube, and place ureteral stent if necessary.
	Refluxing stumps in cases of ectopic ureteral insertion	Adequate exposure, resection of residual, and closure of the stump.
Multiple post site scars	Multiple port site scars	HidES (Hidden incision for endoscopic surgery) groin ports, hide umbilical camera port within umbilical crease; only two working 5 mm ports; no assist port.
Injury to vas and vessels	Poor field of vision	Preservation of uterine vessels; Under-vision dissection distal to the vas deferens. Starting the distal ureteral dissection with good hemostasis to maintain optimum visibility (Figure 3A).