Faculty Bibliography

PURPOSE:Robot-assisted surgical management of ureteral stricture is a relatively uncommon procedure with numerous techniques described. This literature review combined with expert opinion outlines the key surgical principles of ureteral reconstruction and proposes an algorithm for the robot-assisted treatment of ureteral strictures. METHODS:A narrative literature review was conducted using PubMed and Cochrane databases with a predefined search strategy including terms related to ureteroplasty and upper urinary tract reconstruction. The search yielded approximately 900 results. After screening, 219 relevant studies were selected for analysis. Two authors independently reviewed all included articles, and whenever evidence was inconsistent or insufficient, consensus was reached through discussion within the full author group. RESULTS:Robotic ureteral reconstruction includes several techniques, with the choice of procedure guided by multiple factors. Key principles include the use of healthy tissue, creation of a tension-free anastomosis, and ensuring adequate drainage. Outcomes may be further optimized by preoperative ureteral rest, intraoperative ureteroscopy, and the use of intravenous indocyanine green (ICG). Buccal mucosa grafting has emerged as a breakthrough in minimally invasive reconstruction. The robotic approach is adept at managing standard techniques such as ureteroureterostomy, psoas hitch, Boari flap, ureteroneocystostomy, and more recently described methods such as non-transecting ureteral reimplantation and bladder flap ureteroplasty. Ileal ureter remains a good option in cases of challenging reconstructions and patients with prior radiation therapy or extensive defects. CONCLUSION:Robot- assisted ureteral reconstruction has shifted the paradigm in stricture management, allowing complex reconstructive operations to be performed with minimally invasive techniques. This expert review summarizes key surgical approaches and presents a practical algorithm to guide urologists in the management of ureteral strictures.

OBJECTIVE:To describes our institutional experience of a case series using a novel multi-segment, chimeric free ileal flap for posterior urethral reconstruction, focusing on surgical technique, perioperative management, and functional outcomes. Complex posterior urethral defects, particularly those resulting from radiation pose a significant reconstructive challenge that is not easily approachable with standard reconstructive techniques. In this case series, we present a novel approach for this complex problem. METHODS:We retrospectively reviewed consecutive patients who underwent posterior urethral reconstruction with a chimeric free ileal flap at our institution. Data were collected via chart review. RESULTS:Six male patients (median age: 61 years range: 59-77) with radiation-associated posterior urethral stenosis and bladder neck pathology underwent reconstruction. One was an active smoker; three had prior failed reconstructions. A 20-cm ileal segment was harvested and designed into a chimeric construct in all cases. The left deep inferior epigastric vessels were used for flap anastomosis. Median operative time was 717 minutes, and median hospital stay was 9 days. Two patients experienced early postoperative complications; none had flap loss. At median follow-up of 204 days, four patients had successful functional outcomes. One had persistent leak, and one required cystectomy for newly diagnosed squamous cell carcinoma found at the bladder neck on final pathology. CONCLUSIONS:Chimeric free ileal flap reconstruction is a novel management option for radiation-associated posterior urethral defects, offering well-vascularized, versatile tissue in patients unsuitable for traditional approaches. However, this approach is complex that requires multidisciplinary collaboration and extensive surgical planning.

OBJECTIVES/OBJECTIVE:To determine the early experience with paclitaxel-drug coated balloon (DCB) for both anterior urethral stricture disease (aUSD) and posterior urethral stenoses (PUS). METHODS:A retrospective review of patients undergoing Optilume® DCB in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database was performed. Both functional (improved subjective voiding without a secondary procedure) and anatomic (open lumen on cystoscopy) success rates were determined. Kaplan Meier estimates were used to determine the risk of failure by LSE classification and LSE Stage. RESULTS:A total of 319 patients were treated with the DCB, of which 260 were for aUSD and 59 were for PUS. Median age was 64 years (Interquartile range [IQR] 48-73). Recurrence was noted in 119 patients (37.3%) at a median follow-up of 5.7 months (IQR 3-12). For aUSD, the 1-year functional recurrence-free survival was 78.4% (95% CI 71.8-85.4) and anatomical recurrence-free survival was 66.4% (95% CI 59.5-74.2). For PUS, the 1-year functional recurrence-free survival was 75.8% (95% CI 61.4-93.7) and anatomical recurrence-free survival was 59.4% (95% CI 44.1-80). Recurrences of any kind were significantly more likely in patients with strictures after hypospadias repair (HR 5.21, 95% CI 1.06-25.6, p=0.042), and use of 24 Fr, 3 cm DCB (HR 3.64, 95% 1.10-12.09, p=0.035). These were also significant predictors of anatomical recurrences. CONCLUSIONS:Multi-institutional utilization of the DCB for aUSD and PUS demonstrates a low effectiveness among high-risk strictures. Recurrence after DCB varies based on stricture characteristics and subtype, which are important for preoperative counseling and postoperative surveillance.

OBJECTIVE:The objective of this study was to determine the outcomes of robotic peritoneal flap vaginoplasty. BACKGROUND:There is a lack of long-term outcomes data for gender-affirming vaginoplasty to inform patient decision-making. METHODS:A retrospective cohort of 500 consecutive patients undergoing robotic peritoneal flap vaginoplasty from 2017-2023 were reviewed. Complications requiring procedural intervention, self-reported vaginal dimensions, and orgasm were recorded at each follow up visit and analyzed as outcomes. RESULTS:487 (97%) of patients were followed to 3 months, and 425 (85%) to 1 year or greater. Twenty patients (4%) had a complication requiring procedural intervention, and 61(12%) had elective revision surgery. Median self-reported vaginal depth and width at 1 year was 14.5 cm (14.5-14.5) and 3.8 cm (3.8-3.8 cm). There were 12 patients (4%) no longer dilating using standard dilators at this pre-scheduled 1-year appointment, and at last follow-up ≥1 year, 8% were no longer dilating. Thirty-six (8%) of patients were considered anorgasmic at last follow up. Difficulty with orgasm prior to surgery was associated with lower rates of achieving orgasm after surgery and less consistent vaginal depth at 1 year, however 80% of these patients were able to orgasm after surgery. CONCLUSIONS:Clinician-observed and patient-reported outcomes for robotic gender-affirming peritoneal flap vaginoplasty were superior to those reported in the literature for penile inversion vaginoplasty. Patients who do not achieve orgasm prior to surgery are less likely to achieve orgasm and maintain vaginal depth afterwards, however the majority of these patients have improved sexual health after surgery.

OBJECTIVES/UNASSIGNED:To compare the outcomes of open versus robotic ureteral reimplantation procedures at a single centre. MATERIAL AND METHODS/UNASSIGNED:The charts of all patients with ureteral strictures who underwent open ureteral reimplantation between 2005 and 2024, and those who underwent robotic reimplantation between 2013 and 2024, were retrospectively reviewed, and the outcomes of the two approaches were compared. RESULTS/UNASSIGNED:Eighty patients were included in the final analysis: 45 in the open surgery group and 35 in the robotic group. After a median follow-up duration of 16,5 months for the open group and 10 months for the robotic group, the stricture recurrence rate was similar in both groups (6,8% vs. 8.6%; p = 0.99). In terms of long-term complications, there were similar rates of symptomatic reflux (4.4% vs. 5.7%; p = 0.99) and flank pain (8.9% vs. 8.6%; p = 0.99) between both groups. There were more recurrent urinary tract infections in the open group (17.8% vs. 8.6%) and more de novo lower urinary tract symptoms in the robotic group (11.4% vs. 2.2%), but these differences were not statistically significant (p = 0.33 and p = 0.16, respectively). Overall, 30 patients (38%) had at least one long-term complication (35.6% vs 40%; p = 0.82). The only variable significantly associated with the risk of stricture recurrence was radiotherapy (OR = 11.2; p = 0.01). CONCLUSION/UNASSIGNED:The robotic approach appears to be non-inferior to the open approach in terms of stricture recurrence while being associated with a shorter length of hospital stay and lower estimated blood loss. More importantly, the present series raises questions regarding the long-term consequences of ureteral reimplantation and confirms the higher risk of failure in radiated patients.

PURPOSE/OBJECTIVE:To investigate outcomes of robotic ureteral reconstruction (RUR) in female patients with ureteral strictures caused by peri-ureteral endometriosis lesions. METHODS:We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for surgical management of endometriosis-induced ureteral strictures between 2017 and 2022. Indications for surgery included female patients with radiographic evidence of ureteral strictures and/or decreasing renal function on renal scan. We performed a descriptives analysis of perioperative outcomes in patients who met inclusion criteria. Surgical success was defined as freedom from additional interventions for recurrent ureteral stenosis. RESULTS:Overall, 19 patients met the inclusion criteria. Median age was 39 (IQR 30-43) years. Ureteral strictures were located in the middle ureter in 4 (21.1%) patients and in the distal ureter in 15 (78.9%) patients. Fourteen (73.6%) patients had a known preoperative diagnosis of endometriosis. RUR techniques included refluxing reimplantation (47.4%), side-to-side reimplantation (21.1%), ureteroureterostomy (21.1%), and buccal mucosa graft ureteroplasty (10.5%). There was one (5.3%) major postoperative complication (Clavien > 2) in which a patient developed an intrabdominal abscess requiring drainage by interventional radiology. Five (26.3%) patients were ultimately diagnosed postoperatively with endometriosis based on surgical pathology. At a median follow-up of 22.5 (IQR 11.7-41.5) months, 18 (94.7%) patients were surgically successful. CONCLUSION/CONCLUSIONS:Clinicians should maintain a high index of suspicion for endometriosis in premenopausal women with ureteral stricture disease. RUR techniques may be effective for the management of patients with ureteral strictures secondary to endometriosis.

Choice of vaginoplasty technique is guided by the patient's natal anatomy, patient goals, and surgeon preference. The biggest distinction among techniques is the choice of lining for the vaginal canal. This chapter provides an overview of current data on the most pertinent complications, both universal and specific to different techniques for gender-affirming vaginoplasty. Clinical pearls for the management of these complications and indications for revision will be reviewed.

The surgical approach of ureteral stricture has changed dramatically over the past 15 years with the rise of robotic upper urinary tract reconstruction. This study aimed to evaluate the outcomes of all robotic ureteral reconstructions performed at a single academic center for ureteral stricture and to assess the predictive factors of stricture recurrence. The charts of all patients who underwent robot-assisted ureteral reconstruction between 2013 and 2024 at a single academic center were retrospectively reviewed. Many different surgical techniques were used including non-refluxing reimplantation with or without psoas hitch, refluxing ureteral reimplantation (side-to-side), Boari flap, uretero-ureterostomy, ureterolysis and buccal mucosa graft (BMG) ureteroplasty. The primary outcome was the absence of stricture recurrence, defined as no need for repeat surgery, urinary drainage, or symptomatic upper urinary tract dilation at the last follow-up. Sixty patients, accounting for 63 ureteral reconstructions, were included in the final analysis. Twenty-five patients experienced early postoperative complications (40%), the majority being Clavien-Dindo grade 2. There were only three (5%) major complications (Clavien-Dindo grade 3b). Stricture recurrence occurred in six patients (10%), with a median time to recurrence of 2.5 months postoperatively. Radiotherapy was the only factor significantly associated with an increased risk of stricture recurrence. The present series confirm the overall low morbidity and low recurrence rate of robotic ureteral reconstruction using a variety of surgical techniques. Comparative studies with longer follow-up periods are necessary to evaluate outcomes in comparison to traditional surgical approaches.