Faculty Bibliography

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 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.

BACKGROUND:Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved. OBJECTIVE:To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up. SURGICAL PROCEDURE/METHODS:Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex. MEASUREMENTS/METHODS:Demographics, perioperative data, and clinical outcomes were evaluated. RESULTS AND LIMITATIONS/CONCLUSIONS:A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%). CONCLUSIONS:RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches. PATIENT SUMMARY/UNASSIGNED:We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.

Background: Nontransecting urethroplasty for pelvic fracture urethral injuries (PFUI) has been shown to have equivalent patency rates to the transecting anastomotic urethroplasty while resulting in a decreased de novo erectile dysfunction rate [1-4]. A barrier to more widespread adoption of the non-transecting technique is the perception that exposure and placement of the proximal anastomotic sutures is difficult, and that specialized instruments or retractors are necessary. Herein, we share our technique to demonstrate how to perform non-transecting anastomotic urethroplasty for PFUI with minimal specialized equipment and a training method for practicing the placement of the proximal anastomotic sutures.
Material(s) and Method(s): The nontransecting urethroplasty is performed on a 31-year-old male who suffered PFUI with a subsequent urethral obliteration at the level of the membranous urethra. The patient is placed in regular lithotomy, and a Lone Star (Cooper Surgical, Trumbull, CT) retractor with a vaginal pack tied to the head of the bed is used for exposure. Dissection is carried to the point of complete obliteration. Scar tissue is fully excised from both ends of the urethra while preserving the ventral spongiosum and bulbar arteries. Ten to 12 proximal anastomotic sutures are placed from outside to inside the lumen by employing the ski needle technique. We demonstrate a simple practice model built from common items to practice this versatile technique. The right sided sutures are then passed from inside to outside on the distal urethral end. A urethral catheter is placed followed by the remaining sutures. The central tendon is cut to increase urethral mobilization. The sutures are then tied down while the assistant provides cephalad traction of the bulbar urethra.
Result(s): The Foley catheter was removed after two weeks and the suprapubic tube was clamped. The suprapubic tube was removed one week later after demonstrating a post void residual of zero ml. The patient is completely continent and has excellent erectile function.
Conclusion(s): Nontransecting anastomotic urethroplasty is an excellent technique for treating PFUI while minimizing well-known complications of traditional excision and primary anastomotic posterior urethroplasty such as de novo erectile dysfunction. Proximal urethral suturing is a challenging aspect of posterior urethroplasty but can be mastered through practice on a suturing model.
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OBJECTIVE:To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up. MATERIALS AND METHODS/METHODS:We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as <17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease. RESULTS:Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P <.001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P <.01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year. CONCLUSION/CONCLUSIONS:Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.

Gender-affirming surgery is becoming more accessible, and radiologists must be familiar with both terminology and anatomy following gender-affirming surgical procedures. This essay will review the most common gender-affirming genital surgeries, their post-operative anatomy, and common complications by providing intraoperative photographs, illustrations, and cross-sectional images. Routine radiologic imaging recommendations for transgender patients will also be reviewed.

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.

OBJECTIVES/OBJECTIVE:To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS:We retrospectively reviewed our multi-institutional, Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RP between 04/2012-09/2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; p<0.05 was considered significant. RESULTS:Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 versus 50.0 milliliters, respectively; p<0.01) and longer operative time (188.0 versus 136.0 minutes, respectively; p=0.02). There was no difference in major (Clavien>2) complications (p=0.29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% versus 92.3%, respectively; p=0.44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% versus 0.0%, respectively, p<0.01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% versus 40.8%, respectively; p<0.01) for secondary versus primary repair. CONCLUSIONS:Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.