Faculty Bibliography

OBJECTIVE:To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction, proximal and middle ureteral stricture disease. METHODS:We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between 04/2012-12/2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of p<0.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p≤0.05 was considered statistically significant). RESULTS:Overall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% versus 25.7%, p<0.01) and a higher proportion of patients who underwent ureteral rest (74.3% versus 48.6%, p<0.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times (CI 1.26-7.54, p=0.01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, p=0.01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION/CONCLUSIONS:Surgical success of RUR for management of UPJO, proximal and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

PURPOSE/OBJECTIVE:We sought to determine whether preoperative stricture length measurement affected the choice of procedure performed, its correlation to intraoperative stricture length, and postoperative outcomes. METHODS:The Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients undergoing robotic ureteral reconstructive surgery from 2013 to 2021 who had surgical stricture length measurement. From this cohort, we identified patients with and without preoperative stricture length measurement via retrograde pyelogram or antegrade nephrostogram. Outcomes evaluated included intraoperative complications, 30-day complications greater than Clavien-Dindo grade II, hardware-free status, and need for additional procedures. RESULTS:Of 153 patients with surgical stricture length measurements, 102 (66.7%) had preoperative radiographic measurement. No repair type was more likely to have preoperative measurement. The Pearson correlation coefficient between surgical and radiographic stricture length measurements was + 0.79. The average surgical measurement was 0.71 cm (± 1.52) longer than radiographic assessment. Those with preoperative imaging waited on average 5.0 months longer for surgery, but this finding was not statistically significant (p = 0.18). There was no statistically significant difference in intraoperative complications, 30-day complication rates, hardware-free status at last follow-up, or need for additional procedures between patients with and without preoperative measurement. The only significant predictive factor was preoperative stricture length on 30-day postoperative complications. CONCLUSIONS:Despite relatively high prevalence of preoperative radiographic stricture length measurement, there are few measures where it offers clinically meaningful diagnostic information towards the definitive surgical management of ureteral stricture disease.

Objectives: To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. Materials and Methods: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Results: Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1"“3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0"“30.4) months, 94 (89.5%) cases were surgically successful. Conclusions: RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

OBJECTIVES/OBJECTIVE:To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. METHODS:We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012-03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P <.05 was considered significant. RESULTS:Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023). CONCLUSIONS:Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

OBJECTIVES/OBJECTIVE:To report our multi-institutional, comprehensive experience with robotic ureteral reconstruction (RUR) in patients with radiation-induced ureteral stricture (RIUS). PATIENTS & METHODS/METHODS:In a retrospective review of our multi-institutional robotic reconstruction database between January 2013 to January 2020, we identified patients with RIUS. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e. psoas hitch) and improved vascularity (i.e. omental wrap). Outcomes of surgery were determined by absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). RESULTS:Total of 32 patients with 35 ureteral units underwent RUR with median stricture length of 2.5cm (IQR 2-5.5). End-to-end and side-to-side reimplantation were performed in 21 (60.0%) and 8 (22.9%) of RUR's, respectively; while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required a buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow up calculations. At a median follow up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically successful. CONCLUSION/CONCLUSIONS:RUR can be performed in patients with RIUS with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Caution must be taken in such reconstructive surgeries, especially with repeat procedures due to the risk of necrosis and failure.

PURPOSE/OBJECTIVE:To report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures. MATERIALS AND METHODS/METHODS:We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain. RESULTS:Of 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4-4; maximum, 5), 6 centimeters (IQR, 5-7; maximum, 8), and 5 centimeters (IQR, 4-5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14-51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months. CONCLUSIONS:Long-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.

OBJECTIVES/OBJECTIVE:To update our prior multi-institutional experience with robotic ureteroplasty with buccal mucosa graft and analyze our intermediate-term outcomes. Although our previous multi-institutional report provided significant insight into the safety and efficacy associated with robotic ureteroplasty with buccal mucosa graft, it was limited by small patient numbers. METHODS:We retrospectively reviewed our multi-institutional database to identify all patients who underwent robotic ureteroplasty with buccal mucosa graft between 10/2013-03/2019 with ≥12 months follow up. Indication for surgery was a complex proximal and/or middle ureteral stricture not amenable to primary excision and anastomosis secondary to stricture length or peri-ureteral fibrosis. Surgical success was defined as the absence of obstructive flank pain and ureteral obstruction on functional imaging. RESULTS:Of 54 patients, 43 (79.6 %) patients underwent an onlay, and 11 (20.4%) patients underwent an augmented anastomotic robotic ureteroplasty with buccal mucosa graft. Eighteen/54 (33.3%) patients previously failed a ureteral reconstruction. The median stricture length was 3.0 (IQR 2.0-4.0, range 1-8) centimeters. There were 3/54 (5.6%) major postoperative complications. The median length of stay was 1.0 (IQR 1.0-3.0) day. At a median follow-up of 27.5 (IQR 21.3-38.0) months, 47/54 (87.0%) cases were surgically successful. Stricture recurrences were diagnosed ≤2 months postoperatively in 3/7 (42.9%) patients, and ≥10 months postoperatively in 4/7 (57.1%) patients. CONCLUSIONS:Robotic ureteroplasty with buccal mucosa graft is associated with low peri-operative morbidity and excellent intermediate-term outcomes.

OBJECTIVES/OBJECTIVE:To report a multi-institutional experience with robotic appendiceal ureteroplasty. METHODS:This is a retrospective review of 13 patients undergoing right appendiceal flap ureteroplasty at two institutions between April 2016 and October 2019. The primary endpoint was surgical success defined by the absence of flank pain and radiographic evidence of ureteral patency. RESULTS:8/13 (62%) underwent appendiceal onlay while 5/13 (38%) underwent appendiceal interposition Mean length of stricture was 6.5 cm (range 1.5-15 cm) affecting anywhere along the right ureter. Mean operative time was 337 minutes (range 206-583), mean estimated blood loss was 116 mL (range 50-600), and median length of stay was 2.5 days (range 1-9). Balloon dilation was required in 1/12 (8%). One patient died on post-operative day 0 due to a sudden cardiovascular event. Otherwise, there were no complications (Clavien-Dindo > 2) within 30 days from surgery. At a mean follow up of 14.6 months, 11/12 (92%) were successful. CONCLUSION/CONCLUSIONS:Robotic appendiceal ureteroplasty for right ureteral strictures is a versatile technique with high success rates across institutions.