Faculty Bibliography

PURPOSE:Robot-assisted surgical management of ureteral stricture is a relatively uncommon procedure with numerous techniques described. This literature review combined with expert opinion outlines the key surgical principles of ureteral reconstruction and proposes an algorithm for the robot-assisted treatment of ureteral strictures. METHODS:A narrative literature review was conducted using PubMed and Cochrane databases with a predefined search strategy including terms related to ureteroplasty and upper urinary tract reconstruction. The search yielded approximately 900 results. After screening, 219 relevant studies were selected for analysis. Two authors independently reviewed all included articles, and whenever evidence was inconsistent or insufficient, consensus was reached through discussion within the full author group. RESULTS:Robotic ureteral reconstruction includes several techniques, with the choice of procedure guided by multiple factors. Key principles include the use of healthy tissue, creation of a tension-free anastomosis, and ensuring adequate drainage. Outcomes may be further optimized by preoperative ureteral rest, intraoperative ureteroscopy, and the use of intravenous indocyanine green (ICG). Buccal mucosa grafting has emerged as a breakthrough in minimally invasive reconstruction. The robotic approach is adept at managing standard techniques such as ureteroureterostomy, psoas hitch, Boari flap, ureteroneocystostomy, and more recently described methods such as non-transecting ureteral reimplantation and bladder flap ureteroplasty. Ileal ureter remains a good option in cases of challenging reconstructions and patients with prior radiation therapy or extensive defects. CONCLUSION:Robot- assisted ureteral reconstruction has shifted the paradigm in stricture management, allowing complex reconstructive operations to be performed with minimally invasive techniques. This expert review summarizes key surgical approaches and presents a practical algorithm to guide urologists in the management of ureteral strictures.

BACKGROUND AND OBJECTIVE/UNASSIGNED:Robot-assisted buccal mucosa graft (BMG) ureteroplasty was introduced a decade ago and has since gained wide adoption within the urology community. However, available data on the outcomes of robot-assisted BMG ureteroplasty remain limited, and no large European series has been published to date. This study aims to report the outcomes of a multicenter European experience with robot-assisted BMG ureteroplasty (RBMGU) for the management of ureteral strictures. METHODS/UNASSIGNED:Medical records of all the patients who underwent RBMGU for ureteral strictures at four European centers between 2018 and 2024 were reviewed retrospectively. The primary outcome was the absence of stricture recurrence at the last follow-up, defined as the lack of need for urinary drainage or repeat surgery, or the presence of symptomatic hydronephrosis. KEY FINDINGS AND LIMITATIONS/UNASSIGNED:A total of 39 patients were included. The median stricture length was 3 cm, with 36% involving the pelvic ureter. A period of ureteral rest was implemented in 85% of patients. Early postoperative complications occurred in eight patients (21%), with only one major event (3%). After a median follow-up of 12 mo, the overall success rate was 87%. No predictive factors for recurrence were identified. CONCLUSIONS AND CLINICAL IMPLICATIONS/UNASSIGNED:RBMGU for ureteral stricture appears to be a feasible and reproducible technique across multiple surgeons and institutions. The outcomes demonstrate a promising trend, with preliminary results indicating low morbidity and recurrence rates. Further studies with larger cohorts are warranted to identify the risk factors for recurrence and to better define the optimal indications for this procedure. PATIENT SUMMARY/UNASSIGNED:In this report, we present the outcomes of robotic ureteral stricture reconstruction using buccal mucosa grafts across four European centers. The results are encouraging, demonstrating low rates of stricture recurrence and postoperative complications. We emphasize the key advantages of robotic-assisted reconstruction and the broad spectrum of ureteral strictures that may benefit from this approach.

OBJECTIVE:To generate surgeon consensus on metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) outcomes statements using a modified Delphi method. MATERIALS AND METHODS/METHODS:We invited MaPGAS surgeons to anonymously participate in a two-round web-based Delphi survey to generate consensus on patient centered outcome statements generated from surgeon practice patterns, literature review, and patient input. Consensus was predefined as at least 70% agreement. Surgeons were asked to provide open ended feedback on statements which were thematically analyzed and used to revise statements not reaching consensus for a second-round survey. RESULTS:Twenty-one metoidioplasty and phalloplasty surgeons were invited and 16 (76%) reviewed 39 statements in round one and 17/20 (85%) reviewed 10 statements in round two. Following round two, nearly all statements reached consensus: 14/15 (93%) of statements on metoidioplasty, 11/12 (92%) of radial forearm phalloplasty statements and 12/12 (100%) of anterolateral thigh phalloplasty statements. We found that 12/12 (100%) statements on sexual health, 8/8 (100%) statements on non-urinary complications, and 16/18 (89%) statements on urinary outcomes met consensus. CONCLUSIONS:In a modified web-based Delphi survey, surgeons reached consensus on nearly all outcome statements. Variations in surgeon experience, length of follow up, and reporting of outcomes contribute to different definitions of urinary complications. Results from this study will help create decision making tools for individuals considering metoidioplasty and phalloplasty.

OBJECTIVES/UNASSIGNED:To compare the outcomes of open versus robotic ureteral reimplantation procedures at a single centre. MATERIAL AND METHODS/UNASSIGNED:The charts of all patients with ureteral strictures who underwent open ureteral reimplantation between 2005 and 2024, and those who underwent robotic reimplantation between 2013 and 2024, were retrospectively reviewed, and the outcomes of the two approaches were compared. RESULTS/UNASSIGNED:Eighty patients were included in the final analysis: 45 in the open surgery group and 35 in the robotic group. After a median follow-up duration of 16,5 months for the open group and 10 months for the robotic group, the stricture recurrence rate was similar in both groups (6,8% vs. 8.6%; p = 0.99). In terms of long-term complications, there were similar rates of symptomatic reflux (4.4% vs. 5.7%; p = 0.99) and flank pain (8.9% vs. 8.6%; p = 0.99) between both groups. There were more recurrent urinary tract infections in the open group (17.8% vs. 8.6%) and more de novo lower urinary tract symptoms in the robotic group (11.4% vs. 2.2%), but these differences were not statistically significant (p = 0.33 and p = 0.16, respectively). Overall, 30 patients (38%) had at least one long-term complication (35.6% vs 40%; p = 0.82). The only variable significantly associated with the risk of stricture recurrence was radiotherapy (OR = 11.2; p = 0.01). CONCLUSION/UNASSIGNED:The robotic approach appears to be non-inferior to the open approach in terms of stricture recurrence while being associated with a shorter length of hospital stay and lower estimated blood loss. More importantly, the present series raises questions regarding the long-term consequences of ureteral reimplantation and confirms the higher risk of failure in radiated patients.

OBJECTIVES/OBJECTIVE:To determine the early experience with paclitaxel-drug coated balloon (DCB) for both anterior urethral stricture disease (aUSD) and posterior urethral stenoses (PUS). METHODS:A retrospective review of patients undergoing Optilume® DCB in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) database was performed. Both functional (improved subjective voiding without a secondary procedure) and anatomic (open lumen on cystoscopy) success rates were determined. Kaplan Meier estimates were used to determine the risk of failure by LSE classification and LSE Stage. RESULTS:A total of 319 patients were treated with the DCB, of which 260 were for aUSD and 59 were for PUS. Median age was 64 years (Interquartile range [IQR] 48-73). Recurrence was noted in 119 patients (37.3%) at a median follow-up of 5.7 months (IQR 3-12). For aUSD, the 1-year functional recurrence-free survival was 78.4% (95% CI 71.8-85.4) and anatomical recurrence-free survival was 66.4% (95% CI 59.5-74.2). For PUS, the 1-year functional recurrence-free survival was 75.8% (95% CI 61.4-93.7) and anatomical recurrence-free survival was 59.4% (95% CI 44.1-80). Recurrences of any kind were significantly more likely in patients with strictures after hypospadias repair (HR 5.21, 95% CI 1.06-25.6, p=0.042), and use of 24 Fr, 3 cm DCB (HR 3.64, 95% 1.10-12.09, p=0.035). These were also significant predictors of anatomical recurrences. CONCLUSIONS:Multi-institutional utilization of the DCB for aUSD and PUS demonstrates a low effectiveness among high-risk strictures. Recurrence after DCB varies based on stricture characteristics and subtype, which are important for preoperative counseling and postoperative surveillance.

OBJECTIVE:To describes our institutional experience of a case series using a novel multi-segment, chimeric free ileal flap for posterior urethral reconstruction, focusing on surgical technique, perioperative management, and functional outcomes. Complex posterior urethral defects, particularly those resulting from radiation pose a significant reconstructive challenge that is not easily approachable with standard reconstructive techniques. In this case series, we present a novel approach for this complex problem. METHODS:We retrospectively reviewed consecutive patients who underwent posterior urethral reconstruction with a chimeric free ileal flap at our institution. Data were collected via chart review. RESULTS:Six male patients (median age: 61 years range: 59-77) with radiation-associated posterior urethral stenosis and bladder neck pathology underwent reconstruction. One was an active smoker; three had prior failed reconstructions. A 20-cm ileal segment was harvested and designed into a chimeric construct in all cases. The left deep inferior epigastric vessels were used for flap anastomosis. Median operative time was 717 minutes, and median hospital stay was 9 days. Two patients experienced early postoperative complications; none had flap loss. At median follow-up of 204 days, four patients had successful functional outcomes. One had persistent leak, and one required cystectomy for newly diagnosed squamous cell carcinoma found at the bladder neck on final pathology. CONCLUSIONS:Chimeric free ileal flap reconstruction is a novel management option for radiation-associated posterior urethral defects, offering well-vascularized, versatile tissue in patients unsuitable for traditional approaches. However, this approach is complex that requires multidisciplinary collaboration and extensive surgical planning.

PURPOSE/OBJECTIVE:To investigate outcomes of robotic ureteral reconstruction (RUR) in female patients with ureteral strictures caused by peri-ureteral endometriosis lesions. METHODS:We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for surgical management of endometriosis-induced ureteral strictures between 2017 and 2022. Indications for surgery included female patients with radiographic evidence of ureteral strictures and/or decreasing renal function on renal scan. We performed a descriptives analysis of perioperative outcomes in patients who met inclusion criteria. Surgical success was defined as freedom from additional interventions for recurrent ureteral stenosis. RESULTS:Overall, 19 patients met the inclusion criteria. Median age was 39 (IQR 30-43) years. Ureteral strictures were located in the middle ureter in 4 (21.1%) patients and in the distal ureter in 15 (78.9%) patients. Fourteen (73.6%) patients had a known preoperative diagnosis of endometriosis. RUR techniques included refluxing reimplantation (47.4%), side-to-side reimplantation (21.1%), ureteroureterostomy (21.1%), and buccal mucosa graft ureteroplasty (10.5%). There was one (5.3%) major postoperative complication (Clavien > 2) in which a patient developed an intrabdominal abscess requiring drainage by interventional radiology. Five (26.3%) patients were ultimately diagnosed postoperatively with endometriosis based on surgical pathology. At a median follow-up of 22.5 (IQR 11.7-41.5) months, 18 (94.7%) patients were surgically successful. CONCLUSION/CONCLUSIONS:Clinicians should maintain a high index of suspicion for endometriosis in premenopausal women with ureteral stricture disease. RUR techniques may be effective for the management of patients with ureteral strictures secondary to endometriosis.

Choice of vaginoplasty technique is guided by the patient's natal anatomy, patient goals, and surgeon preference. The biggest distinction among techniques is the choice of lining for the vaginal canal. This chapter provides an overview of current data on the most pertinent complications, both universal and specific to different techniques for gender-affirming vaginoplasty. Clinical pearls for the management of these complications and indications for revision will be reviewed.