Faculty Bibliography

OBJECTIVE:To examine the safety, feasibility and durability of robotic reimplantation of ureteroenteric stricture after radical cystectomy. MATERIAL AND METHODS/METHODS:A retrospective multi-institutional review was performed for all patients undergoing robotic repair of ureteroenteric stricture from January 2010-January 2019. Functional outcomes and complications were followed and data were analyzed with SPSS statistical software. RESULTS: CONCLUSION/CONCLUSIONS:Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates.

BACKGROUND:Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. OBJECTIVE:To demonstrate patency and continence outcomes of robotic-assisted VUAS repair. DESIGN, SETTING AND PARTICIPANTS/METHODS:Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. SURGICAL PROCEDURE/METHODS:The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MEASUREMENTS/METHODS:Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. RESULTS AND LIMITATIONS/CONCLUSIONS:A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. CONCLUSIONS:Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. PATIENT SUMMARY/RESULTS:We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.

Introduction & Objectives: The most widely accepted definition of female urethral stricture (FUS) is a symptomatic, anatomical narrowing of the urethra based on a failure of catheterization, urethral calibration, visual inspection, endoscopy or radiography. Thus it is a rare condition, its diagnostic and treatment are challenging for the reconstructive urologist.
Material(s) and Method(s): We present the case of a 47 year-old female, with a urethral stricture due to vulvar lichen sclerosus inducing incomplete bladder emptying and recurrent urinary tract infections. We decided to use lingual mucosa because the buccal mucosa was also affected by the lichen. The aim of this video was to describe the procedure of dorsal onlay lingual mucosa graft urethroplasty.
Result(s): The operating time was 70 minutes. The procedure began with the injection of adrenaline and xylocaine serum. An inverted U incision was performed anterior to the urethra. Dissection was carried out in the plane developed between the underlying urethra and overlying clitoral cavernous tissue. A dorsal urethrotomy was performed at a 12 o' clock position until healthy proximal urethra was reached. The lingual mucosa graft was harvested after having identified the Wharton's duct orifices. The graft edges were incised using a scalpel and the graft was removed using sharp scissors. The graft was maturated by removing the fat and muscular tissue of its non-mucosal side. The graft was sutured to the margins of the urethral plate. The distal part of the graft was quilted to the above periurethral flap in order to recreate the ventral aspect of the urethral meatus. A 18FR silicone catheter was placed carefully at the end of the procedure. No peri operative complication occurred. The patient was discharged two days after surgery and did not have recurrence of stricture after 6 months.
Conclusion(s): Dorsal onlay lingual mucosa graft urethroplasty is a feasible option for female urethral stricture with satisfactory postoperative outcomes.
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BACKGROUND:The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM/OBJECTIVE:We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS:Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES/RESULTS:Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS:There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS/CONCLUSIONS:A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS/UNASSIGNED:This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION/CONCLUSIONS:Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2021;XX:XXX-XXX.

The use of body mass index (BMI) to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested. While BMI thresholds are often meant to be protective, restricting patients from access to surgery can also cause harm. There is a rationale for the continued use of BMI, but the inherent problems with it must also be recognized, including how weight stigma impacts patients' access to gender-affirming surgery and influences clinical care. This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries, as well as analogous procedures, existing de facto BMI thresholds, and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss. BMI factors into surgical decision-making based on the existing literature, which demonstrates that high BMI is associated with increased surgical risk, including higher incidences of surgical site infections and poor wound healing, as well as the possibility of free flap complications, which are a component of certain genital procedures. This patient population is at higher risk for eating disorders, and it is prudent to find alternatives to requiring patient self-monitored weight management. The impacts of weight stigma should be considered when treating gender-affirming surgery patients, and further data and research are needed to augment shared decision-making and lead to practice change.

Silber and Kelly first described the successful autotransplantation of an intra-abdominal testis in 1976. Subsequent authors incorporated laparoscopy and demonstrated the viability of transplanted testes based on serial postoperative exams. We sought to extend this experience with use of the da Vinci surgical robot, thereby demonstrating a novel robotic technique for the management of cryptorchidism. The procedure was performed for an 18-year-old male with a solitary left intra-abdominal testis. Following establishment of pneumoperitoneum, the robot is docked with four trocars oriented towards the left lower quadrant. Testicular dissection is carried out as shown. The gonadal and inferior epigastric vessels are isolated and mobilized; once adequate length is achieved, the former is clipped and transected, and the testicle and inferior epigastric vessels are delivered out of the body. The robot is then undocked and exchanged for the operating microscope. Arterial and venous anastomoses are completed with interrupted and running 9-0 Nylon, respectively, and satisfactory re-anastomosis is confirmed visually and with Doppler. The transplanted testicle is then fixed inferiorly and laterally within the left hemiscrotum, and all incisions are closed. We note that intraoperative testicular biopsy was not performed, for three reasons: (1) to avoid further risk to an already tenuous, solitary organ, (2) because our primary aim was to preserve testicular endocrine function, and (3) because the presence of ITGCN would neither prompt orchiectomy nor obviate the need for ongoing surveillance via periodic self-examination and ultrasonography. The patient is maintained on bed rest for two days and discharged on postoperative day seven in good condition. Over one year since autotransplantation, his now intra-scrotal testicle remains palpable and stable in size. Serum testosterone is unchanged from preoperative measurements. Robotic-assisted testicular autotransplantation is a feasible and efficacious management option for the solitary intra-abdominal testis.

OBJECTIVE:To describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. METHODS:We reviewed 9 patients who underwent single-port robotic posterior urethroplasty with buccal mucosa graft from May-December 2019. Variables included patient demographics, diagnosis/etiology, and intraoperative parameters. Intraabdominal or extraperitoneal transvesical approaches are used for the stricture via supraumbilical access, and if necessary, perineal dissection is performed. Cystoscopy identifies the extent of stenosis. Anastomosis is completed with buccal mucosal graft and rectus abdominis, omental or gracilis flaps as needed. RESULTS:The mean age was 65.4 years. Robotic urethroplasty with buccal mucosa graft was performed for vesicourethral anastomotic strictures (n = 7), urethral strictures (n = 4), pubic fistula after robotic posterior urethroplasty (n = 1), and anastomotic distraction (n = 1). Strictures occurred after prostate cancer treatments (n = 8) and trauma (n = 1). All patients had prior failed endoscopic interventions: balloon dilatation, resection/incision of bladder neck, internal urethrotomy under direct vision, urethral stents, and posterior urethroplasty. Mean defect length was 3.9 cm. Five of 9 patients had ancillary procedures including rectus abdominis (n = 3), omental or gracilis (both n = 1) flap harvests. No intraoperative complications occurred. Median operative time was 377 minutes, blood loss was 200 mL, and length of stay was 2 days. Postoperative 30-day complications included urinary tract infection, epididymitis, anemia, recurrent stricture, and small bowel obstruction requiring surgery (all n = 1). Median follow-up was 11.7 months. CONCLUSION/CONCLUSIONS:Buccal mucosa grafts with ancillary maneuvers such as flap interposition or adjacent tissue transfer in robotic lower tract reconstruction is durable, safe, and comparable to open approaches.

The landscape for upper genitourinary tract reconstruction continues to evolve with innovations in technology and surgical techniques. While the use of flaps and grafts in reconstructive surgery is not a novel concept, the application of buccal mucosal grafts in ureteral reconstruction has only been described over the last 20 years and is now an important adjunct for approaching ureteral strictures. Alongside the increasing use of robotics in urologic surgery, the options available for reconstruction of the upper tract with decreasing patient morbidity are multiplying. Herein, we aim to highlight various patient characteristics which may favor the use of buccal mucosa for addressing ureteral strictures.

PURPOSE/OBJECTIVE:Postoperative surveillance urethroscopy has been shown to be an effective tool to predict reoperation within 1 year after urethroplasty. We aimed to evaluate early surveillance urethroscopy findings and long-term outcomes among urethroplasty patients in order to define the value of surveillance urethroscopy to predict failure. MATERIALS AND METHODS/METHODS:We evaluated 304 patients with at least 4 years of followup after urethroplasty performed at 10 institutions across the United States and Canada. All patients were surveilled using a flexible 17Fr cystoscope and were categorized into 3 groups: 1) normal lumen, 2) large-caliber stricture (≥17Fr) defined as the ability of the cystoscope to easily pass the narrowing and 3) small-caliber stricture (<17Fr) that the cystoscope could not be passed. Failure was stricture recurrence requiring a secondary intervention. RESULTS:The median followup time was 64.4 months (range 55.3-80.6) and the time to initial surveillance urethroscopy was 3.7 months (range 3.1-4.8) following urethroplasty. Secondary interventions were performed in 29 of 194 (15%) with normal lumens, 11 of 60 (18.3%) with ≥17Fr strictures and 32 of 50 (64%) with <17Fr strictures (p <0.001). The 1-, 3- and 9-year cumulative probability of intervention was 0.01, 0.06 and 0.23 for normal, 0.05, 0.17 and 0.18 for ≥17Fr, and 0.32, 0.50 and 0.73 for <17Fr lumen groups, respectively. Patient-reported outcome measures performed poorly to differentiate the 3 groups. CONCLUSIONS:Early cystoscopic visualization of scar recurrence that narrows the lumen to <17Fr following urethroplasty is a significant long-term predictor for patients who will eventually undergo a secondary intervention.