Faculty Bibliography

OBJECTIVES/OBJECTIVE:To report our multi-institutional, comprehensive experience with robotic ureteral reconstruction (RUR) in patients with radiation-induced ureteral stricture (RIUS). PATIENTS & METHODS/METHODS:In a retrospective review of our multi-institutional robotic reconstruction database between January 2013 to January 2020, we identified patients with RIUS. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e. psoas hitch) and improved vascularity (i.e. omental wrap). Outcomes of surgery were determined by absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). RESULTS:Total of 32 patients with 35 ureteral units underwent RUR with median stricture length of 2.5cm (IQR 2-5.5). End-to-end and side-to-side reimplantation were performed in 21 (60.0%) and 8 (22.9%) of RUR's, respectively; while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required a buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow up calculations. At a median follow up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically successful. CONCLUSION/CONCLUSIONS:RUR can be performed in patients with RIUS with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Caution must be taken in such reconstructive surgeries, especially with repeat procedures due to the risk of necrosis and failure.

OBJECTIVE:To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS:Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS:With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION/CONCLUSIONS:For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

Robotically assisted laparoscopic techniques may be used for proximal and distal ureteral strictures. Distal strictures may be approached with ureteroneocystotomy, psoas hitch, and Boari flap. Ureteroureterostomy, buccal mucosa graft ureteroplasty, and appendiceal flap ureteroplasty are viable techniques for strictures anywhere along the ureter. Ileal ureteral substitution is reserved for more extensive disease, and autotransplantation is reserved for salvage situations.

BACKGROUND:Gender-affirming surgery is becoming increasingly more common. Procedures including chest masculinization, breast augmentation, vaginoplasty, metoidioplasty, and phalloplasty routinely generate discarded tissue. The incidence of finding an occult malignancy or premalignant lesion in specimens from gender-affirming surgery is unknown. The authors therefore conducted a retrospective review of all transgender patients at their institution who underwent gender-affirming surgery to determine the incidence of precancerous and malignant lesions found incidentally. METHODS:A retrospective review of transgender patients who underwent gender-affirming surgery at the authors' institution between 2017 and 2018 performed by a single plastic surgeon and a single reconstructive urologic surgeon was conducted. Only transgender patients who underwent gender-affirming surgery that led to routine pathologic review of discarded tissue (mastectomy, vaginoplasty, vaginectomy as part of phalloplasty) were included. Charts were reviewed and patient demographics, duration of hormonal therapy, medical comorbidities, genetic risk factors for cancer, medications (including steroids or other immunosuppressants), pathology reports, and cancer management were recorded. RESULTS:Between 2017 and 2018, 295 transgender patients underwent gender-affirming surgery that generated discarded tissue sent for pathologic evaluation. During this period, 193 bilateral mastectomies, 94 vaginoplasties with orchiectomies, and eight vaginectomies were performed; 6.4 percent of all patients had an atypical lesion found on routine pathologic evaluation. CONCLUSIONS:Gender-affirming surgery is increasingly more common given the increase in access to care. The authors' review of routine pathologic specimens generated from gender-affirming surgery yielded a 6.4 percent rate of finding atypical lesions requiring further evaluation. The authors advocate that all specimens be sent for pathologic evaluation.

PURPOSE/OBJECTIVE:To report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures. MATERIALS AND METHODS/METHODS:We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain. RESULTS:Of 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4-4; maximum, 5), 6 centimeters (IQR, 5-7; maximum, 8), and 5 centimeters (IQR, 4-5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14-51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months. CONCLUSIONS:Long-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.

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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