Faculty Bibliography

Urologists in the United States may see a greater number of transgender or gender-variant patients in their practices due to changing legislation, insurance coverage, and greater social acceptance of transgender individuals. While gender-confirming surgeries should only be attempted by experienced reconstructive surgeons, patients may seek care from general urologists for orchiectomy and management of voiding dysfunction or other concerns that may be complicated by prior reconstructions

Introduction & Objective: The management of concurrent ipsilateral ureteral strictures is challenging as the ureter cannot be transected in two places. The mainstays of reconstruction in this clinical scenario include renal autotransplant or ileal ureter, both of which are associated with morbid short and long-term complications. The concept of an onlay graft or flap to increase the size of the lumen is a well-established technique for urethral reconstruction. We demonstrate the feasibility of this concept to the ureter by placing an onlay of bladder and appendix to manage concurrent ureteral strictures. Materials and Methods: A 66-year-old man with bilateral proximal ureteral stones who developed a 3 cm right distal ureteral stricture, and a 6 cm right proximal ureteral after undergoing ureteroscopy and laser lithotripsy at an outside institution. These strictures were refractory to endoscopic management. The patient had an elevated creatinine. Robotic reconstruction was performed. Simultaneous intraoperative ureteroscopy was performed to delineate the stricture. As the ureteroscope was passed retrograde, the 3 cm distal and 6 cm proximal ureteral strictures were incised using the robot along the anterior aspect of the ureter. The patient's appendix was mobilized, detubularized, and placed as an onlay flap onto the proximal stricture. The distal ureteral stricture was repaired by marsupializing a flap of bladder onto the ureter for a non-transecting reimplant. Results: The patient had an uneventful postoperative course and went home on postoperative day 4. Nephrostogramperformed at 6 weeks post op demonstrated prompt drainage of contrast after stent removal. Patient did not have flank pain after stent removal, and ultrasound at 4 months post op demonstrated no hydronephrosis. Conclusions: For the appropriate patient, ureteral reconstruction using onlay of appendix and bladder is a feasible option for multiple ureteral strictures. Long-term outcomes need to be elucidated

OBJECTIVE: To evaluate our long-term outcomes of robotic assisted laparoscopic (RAL) upper urinary tract (UUT) reconstruction. MATERIALS AND METHODS: Data from 250 consecutive patients undergoing RAL UUT reconstruction including pyeloplasty with or without stone extraction, ureterolysis, ureteroureterostomy, ureterocalicostomy, ureteropyelostomy, ureteral reimplantation and buccal mucosa graft ureteroplasty was collected at a tertiary referral center between March 2003 and December 2013. The primary outcomes were symptomatic and radiographic improvement of obstruction and complication rate. The mean follow-up was 17.1 months. RESULTS: Radiographic and symptomatic success rates ranged from 85% to 100% for each procedure with a 98% radiographic success rate and 97% symptomatic success rate for the entire series. There were a total of 34 complications; none greater than Clavien grade 3. CONCLUSION: RAL UUT can be performed with few complications, with durable long-term success, and is a reasonable alternative to the open procedure in experienced robotic surgeons

OBJECTIVE: To describe the technique of robotic buccal mucosa graft ureteroplasty as a minimally invasive alternative method of ureteral reconstruction for proximal or multifocal ureteral strictures not amenable to primary anastomosis. METHODS: Between October 2013 and May 2014, we performed robotic assisted ureteral reconstruction using buccal mucosa grafts in four patients (mean age 41.5, range 23-67). The indication for surgery was a proximal or multifocal stricture not amenable to ureteroureterostomy or ureteropyelostomy. Buccal mucosa grafts were harvested to be the length of the strictured segment and 1cm in width and placed in the ureter as an anterior or posterior onlay. Follow up was performed with diuretic renogram at least 3 months post operatively and renal ultrasound as well as clinical assessment of symptoms. RESULTS: All four patients underwent successful robotic assisted reconstruction of the ureter using buccal mucosa graft. There were no intraoperative complications. At a median follow up of 15.5 months (range 10.7 to 18.6), there has been 100% success. CONCLUSIONS: Robotic buccal mucosa graft ureteroplasty is a feasible option for reconstruction of proximal or multifocal ureteral strictures that are not amenable to primary anastomosis, and it avoids the morbidity of alternative procedures.

Tissue transfer techniques are an essential part of the reconstructive urologist's armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

OBJECTIVE: To determine a nationwide contemporary description of surgical Fournier gangrene (FG) and necrotizing fasciitis of the genitalia (NFG) outcomes because historically reported mortality rates for FG and NFG are based on small single-institution studies from the 1980s and the 1990s. METHODS: The National Surgical Quality Improvement Program is a risk-adjusted surgical database used by nearly 400 hospitals nationwide, which tracks preoperative, intraoperative, and 30-day postoperative clinical variables. Data are extracted from patient charts by an independent surgical clinical reviewer at each hospital. Using the National Surgical Quality Improvement Program data from 2005 to 2009, we calculated 30-day mortality rates and identified preoperative factors associated with increased mortality. RESULTS: A total of 650 patients were identified with surgery for FG or NFG. Fourteen patients with do not resuscitate orders placed preoperatively were excluded from analyses. For the remaining 636 patients, the overall 30-day mortality was 10.1% (64 of 636). Fifty-seven percent of patients (360 of 636) were men, 70% (446 of 636) were white, and 13% (81 of 636) were African American. Multivariate logistic regression indicated that increased age (odds ratio [OR], 1.041; P = .004), body mass index (OR, 1.045; P <.001), and preoperative white blood cell count (OR, 1.061; P = .001), and decreased platelet count (OR, 0.993; P <.001) were all associated with increased risk of death. CONCLUSION: We determined a surgical mortality rate for FG-NFG of 10.1%. This rate is about half of historically published estimates and similar to recent studies. The lower rate may indicate improvements in therapy. Increased age, body mass index, and white blood cell count, and decreased platelet count were all associated with an increased risk of 30-day mortality.