The evolution of reconstructive urology, with Daniel Eun, MD

Over the past 2 decades, reconstructive urology has undergone a dramatic transformation, driven by advances in surgical technology, refined operative techniques, and growing multidisciplinary collaboration. Among the surgeons helping drive this evolution forward is Daniel D. Eun, MD, of Jefferson Health, whose work has spanned some of the field’s most significant advances. From the early adoption of robotic surgery in urologic reconstruction to the incorporation of buccal mucosa graft techniques and near-infrared fluorescence imaging, Eun has been at the forefront of efforts to expand what is surgically possible for patients with complex urologic conditions.

In this Q&A, Eun reflects on how reconstructive urology has evolved from a field once dominated by open surgery to one increasingly defined by minimally invasive and robotic approaches. He explains how technological innovation has improved visualization, tissue preservation, and overall surgical outcomes. Eun also highlights the importance of tailoring surgical training and adoption to global systems.

Beyond the technical advances, Eun emphasizes a growing need within the specialty: training the next generation of reconstructive urologists. As the field continues to evolve, he underscores the importance of mentorship, institutional support, and surgical experience in ensuring these highly specialized procedures remain accessible to patients who need them most.

Urology Times: How has reconstructive urology changed over the past decade, particularly with the integration of robotic platforms?

Eun: Since the FDA clearance of the da Vinci robotic surgical platform to perform intra-abdominal surgery in 2000, the use of the robot to perform urologic cancer surgery became widely adopted. Initially, the surgical robot was used to perform basic reconstructive surgery such as pyeloplasty and ureteral reimplantation. However, the techniques and principles were adopted from open surgery techniques. Many patients with more complex reconstruction needs were managed with drains and stent and were not being offered a definitive repair option due to high failure rates using traditional open surgery.

I was one of the few surgeons in the world to start pushing the envelope with the surgical robot to address various reconstructive conditions that were not being addressed. Due to the difficulty and complexity of these cases, I realized that the fellowship training and high-volume experience with cancer was a huge benefit. Since I wasn’t formally trained to do reconstructive surgery, there was much I needed to learn as I started to tackle more complex cases over the years. Due to the unique nature of each individual case, I began to study established techniques in pediatric and reconstructive surgery.

One of the technological breakthroughs came around 2010, when the da Vinci robot came with a new optical system called Firefly that could enable surgeons to see real-time blood flow using near-infrared fluorescence technology. Another breakthrough innovation was to use buccal mucosa graft, the tissue lining the inside of the mouth to patch the ureter in the setting of an injury or blockage. Using this knowledge, evolving technology, and guidance from colleagues, I began to innovate new techniques and repurpose old concepts to come up with unique solutions at a high success rate. I developed a motto of “fix it, don’t manage it.” Over the years, I built a multi-institutional database to track outcomes, helped edit the first textbook on robotic reconstructive techniques, and published the backbone of peer-reviewed literature of this newly burgeoning subfield of urology.

As one of the founders of this subfield, I have been approached by hundreds of urologists and urology trainees from all over the world who have thanked me for my contributions and the impact that I have made to improve the field of urology.

Urology Times: From a training standpoint, how should residency and fellowship programs evolve to ensure adequate exposure and competency in robotic reconstruction?

Eun: Since robotic urologic reconstruction is still a relatively new field, there is a large gap between a few leading robotic reconstructive centers and other more traditional centers, including many well-known academic medical centers. Due to the difficult nature of these cases, many centers are embracing the new concepts but are just not able to provide the services for the more complex cases. That gap also translates to training residents and fellows since there are few surgeons out there in academic programs that can performing many of these complex cases.

In order to train in surgical techniques, you need talent, experience, and volume. One of the reasons why I am looking to train fellows who are interested in an academic career is because I want to help close this gap. We need to place more surgeons out there who will transfer this knowledge and ability to others.

Urology Times: You’ve trained surgeons in more than 20 countries. How do you adapt your teaching approach to different health care systems, resource environments, and baseline levels of robotic experience?

Eun: That’s a great question. Each country has its own paradigm of health care delivery that can hugely vary from one country to another. Factors such as payor model, financial incentives, availability of technology, openness to new technology by patients, health care literacy, quality of training, how restrictive surgical indications are governed, and financial resources within the population must be taken into consideration as no two systems are the same. A certain surgical procedure that makes logical sense in one country may not make any sense in another country.

That being said, we are now in the era of multiple competing robotic surgical systems on the global market and as a result, access to robotic surgical care is improving across all continents. Countries that I never thought would have robotic surgical systems now have multiple surgical systems in competing hospitals. Each of these countries that adopt robotics have surgeons that are at the beginning of the learning curve, similar to what US surgeons went through 15 to 20 years ago. Different countries may also have different needs based on what they see more frequently in their patient population and what they might be restricted to offering based on rules or reimbursement allowances.

As I visit different countries, I try to understand how their health care paradigm operates and what their needs might be. I also try to open their eyes as to what other countries are doing and how they may evolve over time. I remember introducing novel uses of near-infrared fluorescence technology and innovative reconstructive procedures to South Korea and China about 10 years ago, and they are now rapidly embracing the technology in the past few years.

Urology Times: What are the key barriers to adopting robotic reconstructive techniques globally, and which strategies have you found most effective in overcoming them?

Eun: Robotic reconstructive procedures are technically complex and often more difficult to execute than traditional oncologic procedures. Therefore, you need the most experienced surgeons who have an interest in developing these demanding skills. In some places in the world, the surgeons have matured to the level that they can perform these tasks and in other places, they are not there yet. For example, I have been in and out of the Gulf region in the last few years. There are well trained and experienced surgeons in Saudi Arabia and Kuwait that are now offering complex robotic reconstructive surgery for their patients. It is so exciting to see this happen in real time on a global scale.