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.

OBJECTIVE:To validate the Martini staging system for postoperative rectourethral fistula (RUF) utilizing data from previous studies to determine whether it can accurately predict postoperative success rate. METHODS:A systematic search of peer-reviewed studies was conducted through January, 2020. The primary inclusion criteria for the studies were studies that evaluated outcomes based on the etiology of the fistula (ie, radiotherapy/ablation [RA] vs nonradiotherapy/ablation [NRA]). Martini RUF classification was utilized for the subgroup analysis. RESULTS:Out of 1948 papers, 7 studies with a total of 490 patients (251 in RA vs 239 NRA) were included in this study. Receiving RA increased the risk of permanent bowel diversion by 11.1 folds, eventual fistula recurrence by 9.1 folds, and post-op urinary incontinence (UI) by 2.6 folds. Similarly, compared to a Grade 0 fistula, a Grade I fistula increased the risk of permanent bowel diversion by 9.1 folds, fistula recurrence by 20 folds, and post-op UI by 2.7 folds. There were some valuable variables that were not captured by the Martini classification. CONCLUSION/CONCLUSIONS:Overall, the Martini classification system is efficacious in stratifying post-op complications from RUF repair based on the grade and etiology; however, it is limited in application. There is an opportunity for the development of more comprehensive staging systems in this domain.

With the widespread dissemination of robotic surgical platforms, pathology previously deemed insurmountable or challenging has been treated with reliable and replicable outcomes. The advantages of precise articulation for dissection and suturing, tremor reduction, three-dimensional magnified visualization, and minimally invasive trocar sites have allowed for the management of such diverse disease as recurrent or refractory bladder neck stenoses, and radiation-induced ureteral strictures, with excellent perioperative and functional outcomes. Intraoperative adjuncts such as near-infrared imaging aid in identification and preservation of healthy tissue. More recent developments include robotics via the single port platform, gender-affirming surgery, and multidisciplinary approaches to complex pelvic reconstruction. Here, we review the recent literature comprising developments in robotic-assisted genitourinary reconstruction, with a view towards emerging technologies and future trends in techniques.

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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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.

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.