Lower Urinary Tract Reconstruction Research Articles

Risk of acute kidney injury after lower urinary tract reconstruction with early NSAID therapy: A propensity matched retrospective analysis

The opioid epidemic response led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use non-steroidal anti-inflammatory drugs (NSAIDs) for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized. ptUsing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3mg/dL or increase in creatinine ≥1.5x baseline or urine output <0.5mL/kg/hr for 6h), we hypothesized there would be a difference in the incidence of postoperative AKI between patients who did and did not receive NSAIDs following surgery. Patients 2-18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine output were retrospectively reviewed. Chronic kidney disease (CKD) stage was calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 11 characteristics with patients undergoing similar surgeries who did not receive NSAIDs. The primary outcome was incidence of AKI within 48h of surgery. The unmatched cohorts included 243 patients. Propensity matching identified 166 patients in the NSAID arm and 41 in the no NSAID arm. 26 patients with CKD stage 2-3 were included. There was no significant difference in the incidence of postoperative AKI based on any KDIGO criteria (17.1% no NSAID versus 16.3% NSAID, p=0.87). Median postoperative opioids fell from 0.88mg/kg in the no NSAID arm to 0.37mg/kg morphine equivalents in the NSAID arm, although this was not statistically significant. Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p=0.32). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.7% with versus 17.9% without CKD). There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction, excluding those with advanced CKD. These results support that postoperative NSAIDs were an unlikely source of AKI. However, AKI remained a risk following these surgeries, regardless of NSAID use, likely owing to underlying disease, longer operations, and fluid shifts.

Trilayer composite scaffold for urethral reconstruction:in vitroevaluation of mechanical, biological, and angiogenic properties.

Regeneration of damaged urethral tissue remains a major challenge in the field of lower urinary tract reconstruction. To address this issue, various synthetic and natural biodegradable biomaterials are currently being explored for the fabrication of scaffolds that promote urethral regeneration and healing. In this study, we present an approach to fabricate a trilayer hybrid scaffold comprising a central layer of poly(lactic acid) (PLA) between two layers of chitosan. The chitosan/PLA/chitosan (CPC) scaffolds were fabricated by a sequential electrospinning process and their properties were evaluated for their suitability for urethral tissue engineering. The physical and biological properties of the CPC scaffolds were evaluated in comparison to electrospun PLA scaffolds and acellular dermis (Alloderm) as controls for a synthetic and a natural scaffold, respectively. Compared to the controls, the CPC scaffolds exhibited higher elastic modulus and ultimate tensile strength, while maintaining extensibility and suture retention strength appropriate for clinical use. The CPC scaffolds displayed significant hydrophilicity, which was associated with a higher water absorption capacity of the chitosan nanofibres. The degradation products of the CPC scaffolds did not exhibit cytotoxicity and promoted wound closure by fibroblastsin vitro. In addition, CPC scaffolds showed increased growth of smooth muscle cells, an essential component for functional regeneration of urethral tissue. Furthermore, in a chicken embryo-based assay, CPC scaffolds demonstrated significantly higher angiogenic potential, indicating their ability to promote vascularisation, a crucial aspect for successful urethral reconstruction. Overall, these results suggest that CPC hybrid scaffolds containing both natural and synthetic components offer significant advantages over conventional acellular or synthetic materials alone. CPC scaffolds show promise as potential candidates for further research into the reconstruction of the urethrain vivo.

BLADDER TRANSPLANTATION: THE NEW FRONTIER IN ABDOMINAL ORGAN TRANSPLANTATION.

Lower urinary tract abnormalities are directly implicated in the etiology of renal dysfunction in 6 to 24% of dialytic patients. These patients require bladder capacity and compliance readjustment before being considered viable candidates for renal transplantation. Vesical augmentation surgeries often involve the use of intestinal segments. Although these procedures can effectively restore bladder capacity and compliance, they present various issues related to maintaining mucous absorption and secretion capacity. Acidosis, recurrent urinary tract infections, and stone formation are extremely common, leading to frequent hospitalizations and graft function loss. Urinary tissue is certainly ideal for these reconstructions; however, bladder augmentation using ureter and renal pelvis are feasible only in a minority of cases. Experimental studies have been conducted to establish the groundwork for vascularized bladder transplantation. Last year, for the first time, this procedure was performed on a brain-dead patient. During this intervention, cystectomy was performed with preservation the vascular pedicle, followed by organ reimplantation. The graft remained viable for a period of 12 hours post-transplant. However, this intervention utilized a robotic platform, making it less reproducible in a multi-organ procurement setting as well as for most transplant centers. Moreover, it is debatable whether the benefits of exclusive bladder transplantation outweigh the risks associated with immunosuppression. For patients needing renal transplantation and requiring lower urinary tract reconstruction, however, utilizing the donor's bladder may offer an attractive alternative, avoiding the inherent complications of enterocystoplasty without increasing immunological risk. Combined kidney and bladder transplantation has the potential to emerge as the next frontier in abdominal organ transplants.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study

Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33% had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70%, Mitrofanoff appendicovesicostomy in 52%, Monti ileovesicostomy in 15%, and antegrade continence enema channel in 38%. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51% followed by a "lack of time, money, or clinical resources" in 36%. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

Pregnancy After Lower Urinary Tract Reconstruction: Considerations for Prenatal Management and Delivery

Pregnancy After Lower Urinary Tract Reconstruction: Considerations for Prenatal Management and Delivery

Robot-assisted reconstructive surgery of lower urinary tract in children: a narrative review on technical aspects and current literature.

Robotic approach is used widely for paediatric upper tract urinary reconstruction. This is a narrative review looking at the current status of robotic approach in lower urinary tract reconstruction. The aim of this article is to highlight the important technical aspects of commonly performed robotic lower urinary tract reconstructive surgeries and review the current literature. MEDLINE database search was conducted using MeSH terms and Boolean operators from Jan 2000 to Jun 2022. Abstracts were screened to exclude those in languages other than English as also articles pertaining to (I) upper urinary tract surgery, (II) only laparoscopic surgery (not robot-assisted) and (III) non-urological topics. Selected articles were then reviewed and search expanded to include their references with a focus on advanced lower urinary tract reconstruction. The technical aspects of robotic ureteric reimplantation, continent catheterisable channel and autoaugmentation are discussed in detail. The early outcomes are comparable to open surgery. The true advantage of robotic approach becomes apparent when performing lower urinary tract reconstruction, where space in the pelvis is limited and access is challenging. Only a few centres are currently performing bladder neck surgery and bladder augmentation. Robotic lower urinary tract reconstruction in children is feasible and safe. Robotic approach offers better access, especially in the limited space within the pelvis. It reduces blood loss and post-operative pain allowing early recovery and discharge. Long-term follow-up with increasing experience could further validate these early observations.

Percutaneous Cystolitholapaxy Is Safe and Effective in Adult Patients With Lower Urinary Tract Reconstruction Utilizing Bowel

To investigate the safety, efficacy, and surgical approach of percutaneous bladder calculi removal in adult patients with prior lower urinary tract reconstruction utilizing bowel using a single-institution database. Twenty patients with prior history of lower urinary tract reconstruction (continent cutaneous urinary reservoir, augmentation enterocystoplasty with catheterizable channel, or ileal neobladder) who underwent percutaneous cystolitholapaxy from 2014-2020 were identified from an IRB-approved database. Analysis of patient demographics, operative details, stone composition, stone-free rates, recurrence, and associated complications was performed. Percutaneous access and either ultrasonic lithotripter or laser lithotripsy was utilized to remove bladder stones. Over half of the patients also underwent concomitant renal stone removal via percutaneous removal or retrograde ureteroscopy. Postoperative CT imaging revealed complete bladder stone clearance in 90% of patients. There were no notable complications from percutaneous bladder stone removal and most patients were discharged either the same day or within twenty-four hours. Urine and stone analysis revealed infection was present in the majority of patients. Bladder stones recurred in 45% of patients after more than two years of follow-up, on average. Percutaneous cystolitholapaxy is a safe and effective approach for the removal of moderate-sized bladder calculi in adults with prior lower urinary tract reconstruction utilizing bowel. Its efficacy and minimally invasive nature make it the approach of choice at our institution.

MP53-05 RISK OF ACUTE KIDNEY INJURY AFTER LOWER URINARY TRACT RECONSTRUCTION WITH EARLY NSAID THERAPY: A PROPENSITY MATCHED RETROSPECTIVE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP53-05 RISK OF ACUTE KIDNEY INJURY AFTER LOWER URINARY TRACT RECONSTRUCTION WITH EARLY NSAID THERAPY: A PROPENSITY MATCHED RETROSPECTIVE ANALYSIS Darren Ha, Eliza D. Blanchette, Duncan T. Wilcox, Vijaya M. Vemulakonda, Daniel N. Wood, and Kyle O. Rove Darren HaDarren Ha More articles by this author , Eliza D. BlanchetteEliza D. Blanchette More articles by this author , Duncan T. WilcoxDuncan T. Wilcox More articles by this author , Vijaya M. VemulakondaVijaya M. Vemulakonda More articles by this author , Daniel N. WoodDaniel N. Wood More articles by this author , and Kyle O. RoveKyle O. Rove More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Response to the opioid epidemic led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use NSAIDs for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized. Using the Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3 mg/dL or increase in creatinine ≥1.5× baseline or urine output <0.5 mL/kg/hr for 6 hours), we hypothesized there would be a difference in incidence of postoperative AKI between patients who did and did not receive NSAIDs after these operations. METHODS: Patients 2–18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine were reviewed. CKD and stage were calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 19 characteristics in a 2:1 ratio with patients undergoing similar surgeries who did not receive NSAIDs in the operating room or in the first 6 hours postoperatively. The primary outcome was incidence of AKI during 48 hours after surgery. RESULTS: The unmatched cohorts included 260 patients. After propensity matching, there were no meaningful differences in most characteristics among 118 in the NSAID arm and 59 in the no NSAID arm. 54 CKD and 4 renal transplant patients were included. There was no difference in the incidence of postoperative AKI based on any KDIGO criteria (18.6% no NSAID vs 15.3% NSAID, p=0.71). Median postoperative opioids fell from 0.75 mg/kg in the no NSAID arm to 0.30 mg/kg morphine equivalents in the NSAID arm (p=0.02). Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p=0.38). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.6% vs 16.4%). CONCLUSIONS: There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction. These results support that postoperative NSAIDs were an unlikely source of AKI and result in lower opioid usage, but also indicate a proportion of patients undergoing these operations may be susceptible to AKI, likely owing to underlying disease, longer operations, and fluid shifts. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e713 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Darren Ha More articles by this author Eliza D. Blanchette More articles by this author Duncan T. Wilcox More articles by this author Vijaya M. Vemulakonda More articles by this author Daniel N. Wood More articles by this author Kyle O. Rove More articles by this author Expand All Advertisement PDF downloadLoading ...

Lower Urinary Tract Reconstruction for Ectopic Ureterocele: What Happens in the Long-term Follow-up?

BackgroundWe aimed to analyze the long-term clinical and lower urinary tract function outcomes in children with duplex system ectopic ureterocele who underwent ureteroneocystostomy and ureterocelectomy. MethodsFifty-one patients (28 females, 23 males) who underwent a series of surgical interventions including lower urinary tract reconstruction in childhood for duplex system ectopic ureterocele in our center between 1998 and 2019, were retrospectively reviewed. The demographic and clinical data, surgical history, and the indication for ureterocelectomy were noted. Lower urinary tract dysfunction (LUTD) status was assessed through dysfunctional voiding symptom scores (DVSS) and uroflowmetry in all patients at the last follow-up. The clinical outcomes, and LUTD were evaluated. ResultsAt the last visit at a mean follow-up of 117.18 ± 57.87 months after ureterocelectomy, ipsilateral persistent lower pole VUR was detected in 5.6% (3/54 renal units, 2 females and 1 male) of the cases, who were treated using the subureteric injection. Abnormal DVSS (median 11, range 9–15) was detected in 27.4% (14/51 pts) of the patients. Out of these, 57.1% (8/14 pts) had storage symptoms, 35.7% (5/14 pts) had voiding symptoms, and 7.1% (1/14 pts) had both storage and voiding symptoms while 71.4%(10/14 pts) had abnormal uroflowmetry findings (plateau shaped flow curve in 2, staccato shaped curve with sustained EMG activity in 3, tower shaped curve in 2, interrupted shaped curve in 3 patients). Five patients had elevated residual volume. Anticholinergics were administered to six patients who had overactive bladder symptoms. In addition, two girls required open bladder neck reconstruction due to stress incontinence caused by bladder neck insufficiency. ConclusionsOur findings showed that clinical success was achieved using the lower urinary tract reconstruction with no need for re-operation in 90.2% of patients with duplex system ectopic ureterocele. However, LUTD was present in 27.4% of our patients in the long-term follow-up. Therefore, LUTD should be carefully assessed in the long-term follow-up of these patients.

Approach to Lower Urinary Tract Reconstruction: A Survey of Adult and Pediatric Urologist Perspectives and Experiences

IntroductionRobotic adoption has rapidly increased within urology. Initial uptake in adult urology has outpaced that seen in pediatric procedures. The aim of this study was to determine adult and pediatric urologist satisfaction with specific procedural steps in lower urinary tract reconstruction (LUTR) using an open versus robotic approach and define drivers and barriers to robotics adoption to inform device development relevant to current needs.MethodsA survey was distributed to practicing urologists. Questions assessed surgeon demographics, technology adoption, satisfaction with anastomotic steps in continent neobladder (CN) and augmentation cystoplasty (AC), and drivers/barriers influencing robotic use.ResultsOf 110 respondents, 49% practiced in academic institutions; 51% reported non-academic, private, or other. Specializations were pediatrics (36%), oncology/robotics (25%), or other (39%). Sixty-eight percent completed training in the past decade. In the past year, 55% completed only open CN or AC, 36% only robotic, and 9% both. Of those that performed robotic procedures, 5% used only an intra-corporeal approach, 85% used only extra-corporeal, and 10% used both. Surgeons who performed robotic LUTR alone expressed high satisfaction with all CN and AC procedural steps evaluated. Overall, of the anastomoses evaluated, urologists found urethrovesical anastomoses more satisfactory using a robotic versus open approach. Pediatric versus adult urologists were overall less satisfied with the robotic approach. In terms of robotic adoption, major drivers for CN were adoption by neighboring institutions, improved perioperative outcomes, and equivalent oncological outcomes; barriers were cost of robotic purchase and maintenance, surgeon support for robotics, and difficult learning curve. Major drivers for AC were adoption by neighboring institutions, decreased operative time, and equivalent oncological outcomes; barriers were increased operative time, cost, and minimal perceived benefit of extracorporeal procedures.ConclusionUrologic oncologists and surgeons performing robotic LUTR alone were highly satisfied with the robotic approach. Pediatric urologists reported lower overall satisfaction with robotic steps in LUTR, potentially corresponding with limitations of current robotic platforms for pediatric application and relative training exposure. Major drivers overall were competition and outcomes; major barriers were cost, operative time, and learning curve. Based on this select surgeon cohort recruited through targeted social media platforms, maximizing surgeon experience through training and innovations to reduce complication rates is anticipated to facilitate broader adoption of robotics in LUTR. Future studies that include a broad international distribution across the specialty may further pinpoint specified needs for adult versus pediatric specialists and drive targeted robotics platform development.

Is lower urinary tract surgery without upper pole heminephrectomy safe and effective in the long-term treatment of duplex system ureterocele?

Objective: The study aimed to retrospectively evaluate postoperative results of patients with duplex system ureterocele (DSU) who underwent endoscopic ureterocele incision (UI), lower urinary tract reconstruction (LUTR) or both, and investigate the necessity of upper pole heminephrectomy (UPH) in ureterocele treatment. Patients and methods: In total, 44 patients with DSU who were operated on in December 2005 and December 2018 were evaluated for patient characteristics, ureterocele location, differential renal function (DRF), vesicoureteral reflux (VUR), postoperative incontinence, proteinuria, hypertension and urinary tract infection (UTI). Results: UI was performed in 27 of 44 cases (61.3%) as the first-line treatment. Ten of them (37%) had no urinary infection or renal function loss at a mean of 3 years (1.5–7 years). LUTR was needed in 17 patients after UI due to VUR in 14 patients and bladder outlet obstruction (BOO) in 3 patients. In total, 34 patients who underwent LUTR, proteinuria or incontinence were not detected in the mean 6 years’ follow-up. Thirty-three patients (97%) had identical renal scans and similar DRF before and after the operation. No patient underwent UPH. Conclusion: UI must be considered the first-line treatment in DSU in infancy. In older patients, especially with VUR, LUTR is effective and safe and UPH mostly is not necessary. Level of evidence: 4

Enhanced Recovery After Surgery (ERAS) for Lower Urinary Tract Reconstruction in Children

Enhanced Recovery After Surgery (ERAS) for Lower Urinary Tract Reconstruction in Children

Single-Port Robotic Posterior Urethroplasty Using Buccal Mucosa Grafts: Technique and Outcomes

ObjectiveTo describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. MethodsWe 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. ResultsThe 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. ConclusionBuccal 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.

MP53-08 A QUALITATIVE ASSESSMENT OF DRIVERS, BARRIERS, AND VALUE IN ROBOTIC-ASSISTED LOWER URINARY TRACT RECONSTRUCTION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (MP53)1 Sep 2021MP53-08 A QUALITATIVE ASSESSMENT OF DRIVERS, BARRIERS, AND VALUE IN ROBOTIC-ASSISTED LOWER URINARY TRACT RECONSTRUCTION Katerina Lembrikova, George Aninwene, Peyton Tebon, Matthew Becker, Allen Siapno, Justine Yamashiro, Erika Wood, and Renea Sturm Katerina LembrikovaKaterina Lembrikova More articles by this author , George AninweneGeorge Aninwene More articles by this author , Peyton TebonPeyton Tebon More articles by this author , Matthew BeckerMatthew Becker More articles by this author , Allen SiapnoAllen Siapno More articles by this author , Justine YamashiroJustine Yamashiro More articles by this author , Erika WoodErika Wood More articles by this author , and Renea SturmRenea Sturm More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002083.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite randomized controlled trials (RCTs) demonstrating feasibility and short-term oncologic non-inferiority of robotic radical cystectomy and urinary diversion, its superiority over the open approach has not been definitively demonstrated. The aims of this study are to identify factors influencing transition to robotic surgery and value requirements for adoption in lower urinary tract reconstruction (LUTR). METHODS: Over 300 stakeholders including physicians, administrators, and industry representatives were identified by LinkedIn, social media, references, and publications. Each was contacted with a request to participate in a structured interview including targeted questions and open-ended discussion. Interviews were conducted virtually and evaluated by a bioengineer, business professional, and urologist via a modified framework method. An initial review of interview notes identified main themes, followed by additional reviews for mapping of codes and stances across stakeholders. RESULTS: 29 urologists (17 academic, 12 non-academic), 25 device representatives, 22 administrators, 10 patients, 10 researchers, and 6 referring physicians were interviewed (n=102). Factors influencing robotic use in LUTR are illustrated (Table). Interviewees reported median procedures to achieve competence and maintain skill were 25 total (IQR 20,30) and 15 per year (10,20), respectively. Complications and readmissions were identified as the most important value requirements. When considering adoption of novel technology for LUTR, the median minimum required decrease in complications and readmissions from a patient perspective was 5% (IQR 1,5) and 1% (1,1) and for urologists was 3% (1, 15) and 8% (1,19), respectively. CONCLUSIONS: There are a range of drivers and barriers to robotics use in LUTR that may not be fully captured by RCTs. Yet, the desired end goals of decreased complications and readmissions resonated across stakeholders. Novel offerings should focus on technical aspects of the procedure that directly affect post-operative recovery beyond improvements provided by Enhanced Recovery After Surgery protocol utilization. Additionally, the perceived learning curve for robotic LUTR must be addressed to increase uptake in this space. Source of Funding: NSF Innovation Corps: #2045366 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e941-e941 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katerina Lembrikova More articles by this author George Aninwene More articles by this author Peyton Tebon More articles by this author Matthew Becker More articles by this author Allen Siapno More articles by this author Justine Yamashiro More articles by this author Erika Wood More articles by this author Renea Sturm More articles by this author Expand All Advertisement Loading ...

The emerging role of robotics in upper and lower urinary tract reconstruction.

Developments in robotic reconstructive urology have introduced novel treatments for complex upper and lower urinary tract disease. Short-term and mid-term data demonstrates excellent outcomes and minimal morbidity, suggesting the advanced instrumentation and visualization of robotics represent a new treatment paradigm in patients that are historically difficult to treat. Here we review recent developments in the robotically assisted surgical management of urethral and ureteral strictures. The minimally invasive approach, enhanced precision and reach, and near-infrared fluorescence imaging capabilities of robotic platforms have proven to be valuable additions in reconstructive urology where perfusion is often compromised, or anatomy is distorted. These benefits are leveraged heavily in recent descriptions of robotic-assisted posterior urethroplasty and ureteroplasty. Short-term to mid-term follow-up data for these procedures show excellent patency rates with low morbidity and complication rates when compared with open approaches. Long-term data for these procedures are not yet available. The role of robotics in reconstructive urology is being actively investigated. Initial findings demonstrate excellent results with low morbidity in the treatment of upper and lower urinary tract disease. Long-term data will ultimately determine the role of robotics in the reconstructive armamentarium.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature.

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR). We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies). Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section. Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Use of conditioned media (CM) and xeno-free serum substitute on human adipose-derived stem cells (ADSCs) differentiation into urothelial-like cells.

BackgroundCongenital abnormalities, cancers as well as injuries can cause irreversible damage to the urinary tract, which eventually requires tissue reconstruction. Smooth muscle cells, endothelial cells, and urothelial cells are the major cell types required for the reconstruction of lower urinary tract. Adult stem cells represent an accessible source of unlimited repertoire of untransformed cells.AimFetal bovine serum (FBS) is the most vital supplement in the culture media used for cellular proliferation and differentiation. However, due to the increasing interest in manufacturing xeno-free stem cell-based cellular products, optimizing the composition of the culture media and the serum-type used is of paramount importance. In this study, the effects of FBS and pooled human platelet (pHPL) lysate were assessed on the capacity of human adipose-derived stem cells (ADSCs) to differentiate into urothelial-like cells. Also, we aimed to compare the ability of both conditioned media (CM) and unconditioned urothelial cell media (UCM) to induce urothelial differentiation of ADCS in vitro.MethodsADSCs were isolated from human lipoaspirates and characterized by flow cytometry for their ability to express the most common mesenchymal stem cell (MSCs) markers. The differentiation potential was also assessed by differentiating them into osteogenic and adipogenic cell lineages. To evaluate the capacity of ADSCs to differentiate towards the urothelial-like lineage, cells were cultured with either CM or UCM, supplemented with either 5% pHPL, 2.5% pHPL or 10% FBS. After 14 days of induction, cells were utilized for gene expression and immunofluorescence analysis.ResultsADSCs cultured in CM and supplemented with FBS exhibited the highest upregulation levels of the urothelial cell markers; cytokeratin-18 (CK-18), cytokeratin-19 (CK-19), and Uroplakin-2 (UPK-2), with a 6.7, 4.2- and a 2-folds increase in gene expression, respectively. Meanwhile, the use of CM supplemented with either 5% pHPL or 2.5% pHPL, and UCM supplemented with either 5% pHPL or 2.5% pHPL showed low expression levels of CK-18 and CK-19 and no upregulation of UPK-2 level was observed. In contrast, the use of UCM with FBS has increased the levels of CK-18 and CK-19, however to a lesser extent compared to CM. At the cellular level, CK-18 and UPK-2 were only detected in CM/FBS supplemented group. Growth factor analysis revealed an increase in the expression levels of EGF, VEGF and PDGF in all of the differentiated groups.ConclusionEfficient ADSCs urothelial differentiation is dependent on the use of conditioned media. The presence of high concentrations of proliferation-inducing growth factors present in the pHPL reduces the efficiency of ADSCs differentiation towards the urothelial lineage. Additionally, the increase in EGF, VEGF and PDGF during the differentiation implicates them in the mechanism of urothelial cell differentiation.

Inflammatory Myofibroblastic Tumor Presenting as Gross Hematuria in a Pediatric Patient With VACTERL Syndrome Following Bladder Augmentation

Inflammatory myofibroblastic tumors (IMT) are rare and poorly understood inflammatory neoplasms. Most commonly occurring in the liver and gastrointestinal tract, cases of bladder involvement have been rarely reported. Bladder IMT generally presents with gross hematuria and can be differentiated from other bladder tumors by expression of anaplastic lymphoma kinase. We report the occurrence of an Bladder IMT detected following lower urinary tract reconstruction with bladder augmentation.

This Month in Adult Urology

This Month in Adult Urology

Design and development of the Pediatric Urology Recovery After Surgery Endeavor (PURSUE) multicentre pilot and exploratory study

IntroductionLower urinary tract reconstruction in paediatric urology represents a physiologically stressful event that is associated with high complication rates, including readmissions and emergency room visits. Enhanced recovery after surgery (ERAS)...