Faculty Bibliography

BACKGROUND:Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. OBJECTIVE:To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. DESIGN, SETTING, AND PARTICIPANTS/METHODS:This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. SURGICAL PROCEDURE/METHODS:RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/UNASSIGNED:Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS/CONCLUSIONS:The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. CONCLUSIONS:RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. PATIENT SUMMARY/UNASSIGNED:We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

OBJECTIVE: To evaluate the success of urethroplasty for urethral strictures arising after erosion of an artificial urinary sphincter (AUS) and rates of subsequent AUS replacement. PATIENTS AND METHODS: From 2009-2016, we identified patients from the Trauma and Urologic Reconstruction Network of Surgeons and several other centers. We included patients with urethral strictures arising from AUS erosion undergoing urethroplasty with/without subsequent AUS replacement. We retrospectively reviewed patient demographics, history, stricture characteristics, and outcomes. Variables in patients with and without complications after AUS replacement were compared using Chi-Square test, independent samples t-test, and Mann-Whitney-U test when appropriate. RESULTS: Thirty-one men were identified with the inclusion criteria. Radical prostatectomy was the etiology of incontinence in 87%, and 33% had radiation therapy. Anastomotic (28) and buccal graft substitution (3) urethroplasty were performed. Follow-up cystoscopy was done in 28 patients (median 4.5 months, interquartile range[IQR]: 3-8) showing no urethral stricture recurrences. Median overall follow-up was 22.0 months (IQR: 15-38). In 27 men (87%), AUS was replaced at median of 6.0 months (IQR: 4-7) after urethroplasty. In 25 patients with >3 months of follow-up after AUS replacement, urethral complications requiring AUS revision / removal occurred in 9 patients (36%) and included sub-cuff atrophy (3), and erosion (6). Mean length of stricture was higher in patients who developed a complication after urethroplasty and AUS replacement (2.2 vs. 1.5 cm, p=0.04). CONCLUSIONS: In patients with urethral stricture after AUS erosion, urethroplasty is successful. However, AUS replacement after urethroplasty has a high erosion rate even in the short-term.

OBJECTIVE: To describe a novel technique of robotic inguinal lymphadenectomy with near infrared fluorescence imaging (NIRF) using indocyanine green (ICG) to facilitate lymph node identification during robotic groin dissection for penile cancer. MATERIALS AND METHODS: The patient is placed in lithotomy position with access to the groin. Three robotic ports and 1 assist port are placed in a V configuration below the tip of femoral triangle. Intradermal ICG is injected at the base of the penis (0.5 mL of 2 mg/kg concentration in normal saline), and the lymphatic channels and nodes are visualized using NIRF in the robotic console approximately 15 minutes after injection. The surgical template established in the open approach is then replicated using NIRF to ensure complete resection of the affected nodes. RESULTS: A total of 10 groin dissections in 5 patients have been completed using this technique, with an average lymph node yield of 7 per groin (range 5-13 lymph nodes). Mean operative time per groin was 207 minutes (range 164-258 minutes) and estimated blood loss was 38 mL (range 25-50 mL). Mean length of hospital stay was 1.8 days (range 0-4 days). Identification of the lymphatic drainage pattern from the superficial to deep groin nodes to pelvic nodes underneath the inguinal ligament was identified in all patients. With a mean follow-up of 10 months (range 3-16 months), there have been no postoperative infections, lymphatic leaks, wound breakdown, or necrosis. Pathologically involved lymph nodes were identified using NIRF. CONCLUSION: Our novel technique of robotic inguinal lymphadenectomy with fluorescence lymphangiography allows for identification and excision of both superficial and deep groin nodes with a significant reduction in morbidity compared with the open approach. Prospective studies are required to ensure long-term efficacy and results of this procedure.

In recent years, the issues of the transgender population have become more visible in the media worldwide. Transgender patients at various stages of their transformation will present to urologic clinics requiring general or specialized urologic care. Knowledge of specifics of reconstructed anatomy and potential unique complications of the reconstruction will become important in providing urologic care to these patients. In this article, we have concentrated on describing diagnosis and treatment of the more common urologic complications after female-to-male reconstructions: urethrocutaneous fistulae, neourethral strictures, and symptomatic persistent vaginal cavities.