Faculty Bibliography

Introduction & Objective: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction; however, rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger attainable graft dimension. Laparoscopic transanal minimally invasive surgery (TAMIS) has been described by our group. Due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the Intuitive da Vinci Xi system. We present a video which fully demonstrates our technique in the novel procedure of Robotic TAMIS (R-TAMIS) rectal mucosal harvest, for the purpose of onlay graft urethroplasty.
Method(s): A 53-year-old transgender male presented with postphalloplasty urethral stricture and underwent robotic rectal mucosal harvest. His past surgical history included vaginectomy and metoidioplasty usingBMGin 2008, followed by right forearmfree flap phalloplasty five months prior to presentation. The procedure was first demonstrated in an animal model using bovine colon. IRB approval was obtained. The surgery was performed under general anesthesia with the patient in lithotomy position. The GelPOINTTM Path Transanal Access Platform was used. As demonstrated, the rectal mucosa was dissected using robotic instruments after submucosal hydrodissection. Following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. The rectal mucosa graft was placed as an onlay for urethroplasty.
Result(s): Harvested graft size was 3.5 x 10cm, correlating well with surface area needed for urethral reconstruction as determined by the urologist. There were no intraoperative or postoperative complications, and the patient recovered well, without morbidity or mortality. He regained bowel function on the first postoperative day, and reported significantly less postoperative pain in comparison to his prior BMG harvest.
Conclusion(s): To our knowledge, this is the first use of R-TAMIS for harvest of rectal mucosal graft. The robotic approach is safe and feasible. This is a promising minimally-invasive technique to harvest rectal mucosa, which can be used for urethral or vaginal reconstruction. Demonstrated feasibility and potential avoidance of the challenging recovery associated withBMGharvest warrants further application and long-term evaluation of this procedure

Introduction & Objective: To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR).
Method(s): We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in seven patients who underwent RYVBNR at our institution between March 2016 and September 2017. Indication for the procedure was incomplete emptying, recurrent urinary tract infections and dysuria. On follow-up, patients were assessed for clinical success by absence of infections, symptoms and cystoscopic evaluation. Robotic assisted dissection is performed to open the space of Retzius and mobilize the bladder. The cystoscope is passed to the level of the BNC, and FireflyTM technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion (figure 1). We place a perioperative closed suction drain, which is removed before discharge, and a catheter which will be removed in the office at approximately two weeks.
Result(s): Six men with recalcitrant BNCs and one with recalcitrant vesicourethral anastomotic stenosis underwent treatment (figure 2). All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to RABNR was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240min, estimated blood loss was 67 ml, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only two patients had persistent urinary incontinence at 1 pad per day.
Conclusion(s): RYVBNR with a Y-V plasty is a feasible and effective technique for managing a difficult reconstructive problem. (Table Presented)

INTRODUCTION/BACKGROUND:Nutritional status has been increasingly recognized as an important predictor of prognosis and surgical outcomes for cancer patients. We evaluated the effect of preoperative malnutrition on the development of surgical complications and mortality after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS/METHODS:Using data from the American College of Surgeons National Surgical Quality Improvement Program, we evaluated the association of poor nutritional status with 30-day postoperative complications and overall mortality after RNU from 2005 to 2015. The preoperative variables suggestive of poor nutritional status included hypoalbuminemia (< 3.5 g/dL), weight loss within 6 months before surgery (> 10%), and a low body mass index. RESULTS:A total of 1200 patients were identified who had undergone RNU for UTUC. The overall complication rate was 20.5% (n = 246), and mortality rate was 1.75% (n = 21). On univariate analysis, patients who experienced a postoperative complication were more likely to have hypoalbuminemia (25.0% vs. 11.4%; P < .001) and weight loss (3.7% vs. 1.0%; P = .003). After controlling for baseline characteristics and comorbidities, hypoalbuminemia was found to be a significant independent predictor of postoperative complications (odds ratio, 2.09; 95% confidence interval, 1.29-3.38; P = .003). Hypoalbuminemia was also a significant independent predictor of mortality (odds ratio, 4.31; 95% confidence interval, 1.45-12.79; P = .008) on multivariable regression analysis. CONCLUSION/CONCLUSIONS:Our results have shown that hypoalbuminemia is a significant predictor of surgical complications and mortality after RNU for UTUC. This finding supports the importance of patients' preoperative nutritional status in this population and suggests that effective nutritional interventions in the preoperative setting could improve patient outcomes.

OBJECTIVE:To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates. MATERIALS AND METHODS/METHODS:Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence. RESULTS:Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement. CONCLUSION/CONCLUSIONS:RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.

Minimally invasive surgery has made a profound impact on how urologists approach the challenges in reconstruction of the urinary tract. The advent of laparoscopic approaches to reconstructive urology have demonstrated comparable outcomes to open surgery with improved morbidity. The recent adoption of robotic surgery has seen further advancements such as improved visibility and, freedom of movement, and an easier technical learning curve. With these advantages, more reconstructive urology procedures are being performed robotically. Herein, we review reconstructive urology procedures for which robotics have been applied.

OBJECTIVE:To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR). METHODS:technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion. We place a perioperative closed suction drain, which is removed before discharge, and a 22 Fr catheter which will be removed in the office at approximately two weeks. RESULTS:Six men developed recalcitrant BNCs and one developed a recalcitrant vesicourethral anastomotic stenosis. All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to RABNR was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240min, estimated blood loss was 67 ml, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only two patients had persistent urinary incontinence at 1 pad per day. CONCLUSIONS:RYVBNR with a Y-V plasty is a feasible, and effective technique for managing a difficult reconstructive problem.

In the past decade, issues facing transgender individuals have come to the forefront of popular culture, political discourse, and medical study. The evaluating physician should have knowledge of the reconstructed anatomy, as well as potential postoperative complications. This knowledge will aid in providing appropriate care and recognizing issues that may require specialized urologic care. Transgender anatomic definitions and a synopsis of common urologic complications specific to transmen, including urethrocutaneous fistulae, neourethral strictures, and persistent vaginal cavities are discussed.

INTRODUCTION/BACKGROUND:Iatrogenic ureteral injuries represent a common surgical problem encountered by practicing urologists. With the rapidly expanding applications of robotic-assisted laparoscopic surgery, ureteral reconstruction has been an important field of recent advancement. This collaborative review sought to provide an evidence-based analysis of the latest surgical techniques and outcomes for robotic-assisted repair of ureteral injury. EVIDENCE ACQUISITION/METHODS:A systematic review of the literature up to December 2017 using PubMed/Medline was performed to identify relevant articles. Those studies included in the systematic review were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Additionally, expert opinions were included from study authors in order to critique outcomes and elaborate on surgical techniques. A cumulative outcome analysis was conducted analyzing comparative studies on robotic versus open ureteral repair. EVIDENCE SYNTHESIS/RESULTS:Thirteen case series have demonstrated the feasibility, safety, and success of robotic ureteral reconstruction. The surgical planning, timing of intervention, and various robotic reconstructive techniques need to be tailored to the specific case, depending on the location and length of the injury. Fluorescence imaging can represent a useful tool in this setting. Recently, three studies have shown the feasibility and technical success of robotic buccal mucosa grafting for ureteral repair. Soon, additional novel and experimental robotic reconstructive approaches might become available. The cumulative analysis of the three available comparative studies on robotic versus open ureteral repair showed no difference in operative time or complication rate, with a decreased blood loss and hospital length of stay favoring the robotic approach. CONCLUSIONS:Current evidence suggests that the robotic surgical platform facilitates complex ureteral reconstruction in a minimally invasive fashion. High success rates of ureteral repair using the robotic approach mirror those of open surgery, with the additional advantage of faster recovery. Novel techniques in development and surgical adjuncts show promise as the role of robotic surgery evolves.