Robotic Ureteral Reconstruction Research Articles

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures

OBJECTIVETo investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction, proximal and middle ureteral stricture disease. METHODSWe retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between 04/2012-12/2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of p<0.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p≤0.05 was considered statistically significant). RESULTSOverall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% versus 25.7%, p<0.01) and a higher proportion of patients who underwent ureteral rest (74.3% versus 48.6%, p<0.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times (CI 1.26-7.54, p=0.01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, p=0.01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSIONSurgical success of RUR for management of UPJO, proximal and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

Robotic ureteral reconstruction for benign ureteral strictures: a systematic review of surgical techniques, complications and outcomes

IntroductionRobotic ureteral reconstruction (RUR) has been widely used to treat ureteral diseases. To summarize the surgical techniques, complications, and outcomes following RUR, as well as to compare data on RUR with open and laparoscopic ureteral reconstruction.MethodsOur systematic review was registered on the PROSPERO (CRD42022309364) database. The PubMed, Cochrane and Embase databases were searched for publications in English on 06-Feb-2022. Randomised-controlled trials (RCTs) or non-randomised cohort studies with sample size ≥ 10 cases were included.ResultsA total of 23 studies were included involving 996 patients and 1004 ureters from 13 non-comparative, and 10 retrospective comparative studies. No RCT study of RUR was reported. The success rate was reported ≥ 90% in 15 studies. Four studies reported 85–90% success rate. Meta-analyses for comparative studies showed that RUR had significantly lower estimated blood loss (EBL) (P = 0.006) and shorter length of stay (LOS) (P < 0.001) than the open approach. RUR had shorter operative time than laparoscopic surgery (P < 0.001).ConclusionsRUR is associated with lower EBL and shorter LOS than the open approach, and shorter operative time than the laparoscopic approach for the treatment of benign ureteral strictures. However, further studies and more evidence are needed to determine whether RUR is more superior.

Outcomes and treatment failure after open or robotic ureteral reconstruction for iatrogenic injuries.

The aim of this study is to assess the aetiology, perioperative outcomes and treatment failure of contemporary patients undergoing open or robot-assisted ureteral reconstruction for iatrogenic injuries. We retrospectively analysed consecutive patients who underwent ureteral reconstruction for iatrogenic injuries at two academic centres 07/2013 and 06/2022. A variety of open or robot-assisted procedures were performed, including uretero-cystoneostomy, Boari bladder flap, uretero-ureterostomy, ileal replacement and pyelo-ureteroplasty. All procedures were performed by a single surgeon with extensive experience in open and robot-assisted surgery and preference-based management. Outcome measures were aetiology, estimated blood loss, length of stay, postoperative complications and treatment failure, defined as upper tract obstruction requiring permanent urinary drainage. We also planned a subgroup analysis comparing the outcomes between open and robot-assisted procedures. Fifty-nine patients were included. Most injuries were consequent to endourological procedures (44%). The most frequently performed procedures were uretero-cystoneostomy (49.2%) and Boari bladder flap (32.2%). Forty (67.8%) were open, and 19 (32.2%) were robot-assisted procedures. Major postoperative complications were recorded in seven (11.9%) patients. After a median follow-up of 42 months (interquartile range 12-24), treatment failure was observed in seven (11.9%) cases. Robot-assisted versus open procedures were associated with decreased estimated blood loss (p =0.01), length of stay (p < 0.001) and treatment failure (0/19 vs. 7/36, p =0.04). In our series of iatrogenic ureteral lesions requiring reconstructive surgery, endourological procedures were the most frequent cause. Major postoperative complications were infrequent, and treatment failure rate was low. The robot-assisted approach was associated with improved perioperative outcomes and lower failure rate compared with open.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-06 ASSESSING THE ACCURACY OF PREOPERATIVE RADIOGRAPHIC IMAGING IN DETERMINING URETERAL STRICTURE LENGTH AT TIME OF ROBOTIC URETERAL RECONSTRUCTION Labeeqa Khizir, Alain Kaldany, Hiren V. Patel, and Sammy E. Elsamra Labeeqa KhizirLabeeqa Khizir More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Hiren V. PatelHiren V. Patel More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: During robotic ureteral reconstruction, accurate measurement of ureteral stricture length is important for surgical planning. We aimed to determine the accuracy of using conventional fluoroscopic imaging compared to ureteroscopy and direct measurement with measuring tape during intra-operative robotic repair. METHODS: A retrospective review was conducted for 15 patients with ureteral stricture disease at a single institution treated with robotic repair. Data was collected regarding etiology of ureteral stricture disease, measured preoperative radiographic stricture length on fluoroscopy, and measured intraoperative robotic stricture length. A Wilcoxon matched-pairs rank test was performed to compare ureteral length measurements. RESULTS: The most common etiologies of ureteral stricture were prior medical history of stone disease (n=10), prior ureteropelvic junction obstruction repair (n=3), and other iatrogenic causes (n=2) (Table 1). A majority of patients had ureteral stricture repair using buccal mucosa (n=7) or appendiceal onlay (n=6) grafts (Table 1). A total of 11 patients (73%) had >1 cm difference in stricture length between radiographic and robotic measurement (Figure 1). Of these patients, 73% (n=8) had prior medical history of stone disease (Table 1). The intraoperative robotic length was significantly longer compared to preoperative radiographic length (Median difference 1.2 cm, 98% CI 0.15-2.3, p<0.05) (Figure 1). CONCLUSIONS: Conventional preoperative radiographic measurement significantly underestimates the ureteral stricture length compared to intraoperative measurement. This may have clinical significance in influencing operative planning, technique, and the length of graft that is harvested. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e568 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Labeeqa Khizir More articles by this author Alain Kaldany More articles by this author Hiren V. Patel More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

Redo Robotic Ureteroplasty After Prior Failed Ureterocalicostomy

Clinical History: Surgical management of patients with recurrent strictures after prior ureterocalicostomy for complex ureteropelvic junction obstruction is challenging because of extensive periureteral fibrosis and scarring that is present in this setting. Physical Examination: The patient presented with left flank pain. Diagnosis: We report the case of a 37-year-old male patient with a recurrent symptomatic stricture after undergoing a laparoscopic converted to open left ureterocalicostomy 12 years prior. Retrograde pyelogram showed a small filling defect and 1 cm narrowed segment at the ureter's insertion point into the lower pole calix. Intervention: We describe our approach for robotic ureteral reconstruction for patients with recurrent strictures after prior ureterocalicostomy. We highlight the utilization of intravenous indocyanine green (ICG) to facilitate identification of the strictured aspect of the ureter. A longitudinal incision was made along the strictured segment and a buccal mucosa graft was anastomosed to the defect in onlay manner. Follow-Up/Outcomes: Intraoperatively, operative time was 213 minutes and estimated blood loss was 100 mL. There were no intraoperative complications and the patient was discharged on the same day. At follow-up of 20 months, the patient had no flank pain and his postoperative renal scan showed normal split function and half washout time of 12 minutes bilaterally. Robotic ureteral reconstruction may be utilized for management of patients with recurrent ureteral strictures after prior ureterocalicostomy. Near infrared fluorescence with ICG may assist with identification of the strictured ureter in these complex settings. This surgical approach may reduce damage to the fragile periureteral blood supply and minimize the risk of stricture recurrence. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The study was approved by the institutional review board at Temple University (protocol number 20793). M.L. and J.J. have no conflicts of interest to disclose. D.E. is founder of Melzi corp and a consultant for Intuitive Surgical and Johnson and Johnson. Runtime of video: 4 mins 45 secs

MP42-03 ASSESSMENT OF PATIENT-REPORTED OUTCOMES OF URETERAL STRICTURE DISEASE AND ROBOTIC URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-03 ASSESSMENT OF PATIENT-REPORTED OUTCOMES OF URETERAL STRICTURE DISEASE AND ROBOTIC URETERAL RECONSTRUCTION Devin Boehm, Kyle Nolla, Jonathan Rosenfeld, Emily Ji, James Griffith, and Ziho Lee Devin BoehmDevin Boehm More articles by this author , Kyle NollaKyle Nolla More articles by this author , Jonathan RosenfeldJonathan Rosenfeld More articles by this author , Emily JiEmily Ji More articles by this author , James GriffithJames Griffith More articles by this author , and Ziho LeeZiho Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patient perspectives regarding clinical conditions and the influence of treatments are essential to patient-centered care. We aimed to evaluate patient-reported outcomes regarding experiences, symptoms, and impacts of ureteral stricture disease (USD) and robotic ureteral reconstruction (RUR). METHODS: Patients undergoing RUR for USD between 9/2021 and 9/2022 were eligible for enrollment. Semi-structured concept elicitation interviews were conducted to evaluate the physical, mental, and social effects of USD at three stages: 1. Preoperative, 2. Postoperative recovery (with ureteral stent), 3. Postoperative recovery (after stent removal). Concerning symptoms related to USD, patients rated symptom bother from 0 (none) to 10 (extreme). We conducted interviews until concept saturation was achieved and no new information was gained. Interviews were transcribed, coded, and qualitatively analyzed. RESULTS: Concept saturation was reached after 14 interviews. In the preoperative phase, flank pain (10/14 [71%]) and urinary urgency (6/14 [42%]) were the most common symptoms. All patients with urinary urgency had a ureteral stent during the preoperative phase. The median (IQR) preoperative bother scores of flank pain and urinary urgency were 8.5 (6.6-10) and 9.0 (5.8-10), respectively. The most common themes were emotional distress to symptoms (10/14 [71]%) and social/occupational impairment (9/14 [64]%). The most common factors that influenced a patient’s decision to undergo RUR were renal function preservation (8/14 [57]%), and the desire to remove hardware (i.e., nephrostomy tubes and ureteral stents) (8/8 [100]% who had presurgical hardware). During postoperative recovery, urinary urgency (8/14 [57%]) and flank pain (5/14 [35%]) were the most common symptoms. The median (IQR) postoperative recovery phase bother scores of flank pain and urinary urgency were 8.0 (4.0-8.0) and 6.0 (5.8-9.0), respectively. In the postoperative recovery phase, 1/14 (7%) reported intermittent flank pain (bother=4). All patients reported a “successful surgery.” Patients most commonly described surgical success as complete symptom relief (8/14 [57%]). CONCLUSIONS: Flank pain and urinary urgency (related to ureteral stent) were the most bothersome symptoms in the preoperative phase. Renal function preservation and the desire to remove hardware were the most common factors that influenced patients to undergo RUR. Symptom relief was the most commonly described determinant of patient-perceived surgical success. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e567 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Devin Boehm More articles by this author Kyle Nolla More articles by this author Jonathan Rosenfeld More articles by this author Emily Ji More articles by this author James Griffith More articles by this author Ziho Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-13 ROBOTIC NON-TRANSECTING URETERAL REIMPLANTATION: A MULTI-INSTITUTIONAL EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023MP42-13 ROBOTIC NON-TRANSECTING URETERAL REIMPLANTATION: A MULTI-INSTITUTIONAL EXPERIENCE Brian Chao, David Strauss, Matthew Lee, Teona Iarajuli, Jennifer Nguyen, Ashley Alford, Michael Stifelman, Daniel Eun, and Lee Zhao Brian ChaoBrian Chao More articles by this author , David StraussDavid Strauss More articles by this author , Matthew LeeMatthew Lee More articles by this author , Teona IarajuliTeona Iarajuli More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Ashley AlfordAshley Alford More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Daniel EunDaniel Eun More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic non-transecting ureteroneocystostomy (reimplantation) is an efficacious alternative to conventional reimplantation for mid- to distal ureteral strictures. We sought to update our multi-institutional experience with this technique and analyze intermediate-term outcomes. METHODS: We retrospectively reviewed a multi-institutional database of robotic ureteral reconstruction (CORRUS, or Collaborative of Reconstructive Robotic Ureteral Surgery) for patients undergoing robotic non-transecting reimplantation. Demographic, perioperative, and postoperative data were captured and reported using descriptive statistics. The primary outcome of interest was freedom from recurrent ureteral stenosis, defined as the absence of obstructive findings on follow-up imaging. Minimum follow-up duration for inclusion was three months. RESULTS: We identified 50 patients (comprising 55 ureters) who underwent robotic non-transecting ureteroneocystostomy between 2016 and 2022. Demographic, perioperative, and postoperative data are shown in the accompanying Table 1. Median stricture length was 2.8 cm (IQR 1–4). 17 patients (34%) had a history of radiation and 28 (56%) had prior abdominal or pelvic surgeries. 15 patients (30%) failed endoscopic stricture management; three (6%) failed prior reconstructive attempts. There was one intraoperative complication, a gastric injury repaired primarily by general surgery without subsequent sequelae. There were no immediate (≤30 days) postoperative complications. Over a median follow-up of 17.1 months (7.2–32.0), 47 patients (94%) comprising 52 ureters (95%) remained free from recurrent stricture disease. CONCLUSIONS: Our updated experience reaffirms the safety and efficacy of robotic non-transecting ureteral reimplantation. Despite a high proportion of patients with complex stricture disease, reimplantation was accomplished with minimal morbidity, satisfactory patency rates, and durable outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e572 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Chao More articles by this author David Strauss More articles by this author Matthew Lee More articles by this author Teona Iarajuli More articles by this author Jennifer Nguyen More articles by this author Ashley Alford More articles by this author Michael Stifelman More articles by this author Daniel Eun More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic ureteral reconstruction for recurrent strictures after prior failed management.

To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1-3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 94 (89.5%) cases were surgically successful. RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Outcomes of single-port robotic ureteral reconstruction using the da Vinci SP® system.

The da Vinci SP® robotic system enables three double-jointed wristed instruments and a fully wristed three-dimensional camera to be placed through a single port. This study presents our experience with robot-assisted ureteral reconstruction using the SP system and reports its outcomes. Between December 2018 and April 2022, a single surgeon performed robotic ureteral reconstruction using the SP system in 39 patients: 18 underwent pyeloplasty and 21 received ureteral reimplantation. Demographic and perioperative patient data were collected and analyzed. Radiographic and symptomatic improvements were assessed 3 months after surgery. In pyeloplasty group, 12 patients (66.7%) were female and two patients (11.1%) had undergone previous surgery for ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 8 mL, and the median length of stay in hospital was 3 days. There was one case of a complication involving postoperative percutaneous nephrostomy (PCN). In ureteral reimplantation group, 19 patients (90.5%) were female and ten patients (47.6%) had undergone gynecological surgery that caused ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 10 mL, and the median length of stay in hospital was 4 days. We observed one case of open conversion and two cases of complications (colonic serosal tearing and postoperative PCN after ileal ureter replacement). The radiographic results and symptoms successfully improved following both surgeries. Despite adhesion-related complications, the SP system appears to be safe and effective for use in robot-assisted ureteral reconstruction.

MP25-11 PREDICTORS OF SURGICAL SUCCESS FOR ROBOTIC URETERAL RECONSTRUCTION OF PROXIMAL AND MIDDLE URETERAL STRICTURES

You have accessJournal of UrologyCME1 May 2022MP25-11 PREDICTORS OF SURGICAL SUCCESS FOR ROBOTIC URETERAL RECONSTRUCTION OF PROXIMAL AND MIDDLE URETERAL STRICTURES Matthew Lee, Ziho Lee, Randall Lee, David Strauss, Rohit Reddy, Lee C. Zhao, Michael D. Stifelman, and Daniel Eun Matthew LeeMatthew Lee More articles by this author , Ziho LeeZiho Lee More articles by this author , Randall LeeRandall Lee More articles by this author , David StraussDavid Strauss More articles by this author , Rohit ReddyRohit Reddy More articles by this author , Lee C. ZhaoLee C. Zhao More articles by this author , Michael D. StifelmanMichael D. Stifelman More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for proximal and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for proximal and/or middle ureteral stricture disease between 04/2012-01/2019. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether or not they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of p<0.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p≤0.05 was considered statistically significant). RESULTS: Overall, 228 patients met inclusion criteria. Univariate analysis (Table 1) showed that there were a lower proportion of patients with diabetes (8.5% versus 29.6%, p<0.01) and a higher proportion of patients who underwent ureteral rest (84.5% versus 63.0%, p=0.01) in the surgical success group. Multivariate logistic regression analysis (Table 2) further revealed that patients with diabetes were 3.74 times more at risk (p=0.01, CI: 1.35-10.37) of failing to achieve surgical success compared to those without diabetes. Patients undergoing ureteral rest prior to RUR were 2.68 times more likely (p=0.04, CI: 1.05-6.82) to achieve surgical success compared to those who did not undergo ureteral rest. CONCLUSIONS: In patients undergoing RUR for management of proximal and middle ureteral strictures, preoperative factors such as the absence of diabetes and the implementation of ureteral rest may optimize surgical outcomes. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e432 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Ziho Lee More articles by this author Randall Lee More articles by this author David Strauss More articles by this author Rohit Reddy More articles by this author Lee C. Zhao More articles by this author Michael D. Stifelman More articles by this author Daniel Eun More articles by this author Expand All Advertisement PDF DownloadLoading ...

Indocyanine green (ICG) assessment of ureteral perfusion during pediatric robotic surgery

Vascular preservation is a tenet of successful ureteral reconstruction. Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) provides real-time identification of tissue perfusion during robotic surgery. Here, we present our utilization of NIRF with ICG to ensure adequate ureteral perfusion during robotic reconstruction in 3 pediatric patients. Between July 2019 and May 2020, we utilized NIRF with ICG during 3 consecutive robotic ureteral reconstructive cases in an academic pediatric urology practice. Patients were 3-, 14-, and 17-years-old and presented with congenital ureteral stricture, mid-ureteral polyp disease, and distal-ureteral polyp disease, respectively. Following surgical reconstruction of each patient's underlying pathology, ICG doses of 0.039–0.086 mg/kg IV were used to elucidate blood supply to the affected segment of ureter prior to closing. In all 3 cases, NIRF with da Vinci Xi endoscope's Firefly® technology confirmed perfusion proximal and distal to target anatomy within 60 seconds of administration. Use of ICG appears to be low-cost, safe, and useful during pediatric urologic robotic surgery. This technology may be helpful to confirm satisfactory blood supply to the ureter following robotic ureteral reconstruction, as demonstrated in our case series of 3 pediatric patients.

Robotic Ureteral Reimplantation: Nonrefluxing Intravesical and Extravesical Techniques

Introduction: Nonrefluxing ureteral reimplantation is the gold standard surgical management of patients with symptomatic vesicoureteral reflux (VUR).1,2 Intravesical and extravesical ureteral reimplantation were traditionally performed with an open approach through the Cohen, Lich-Gregoir, Glen-Anderson, and Politano-Leadbetter techniques.3 However, there has been recent adoption of minimally invasive approaches including the use of robotic assistance.1 Moreover, these nonrefluxing ureteral reimplantation techniques have been primarily described in the pediatric population rather than in adults.2 We demonstrate our techniques and describe outcomes of adult patients undergoing nonrefluxing intravesical and extravesical robotic ureteral reimplantation (RUR). Materials and Methods: We reviewed our institution's own robotic ureteral reconstruction database to identify consecutive adult patients with a history of VUR who underwent nonrefluxing intravesical or extravesical RUR between September 2016 and November 2020. Indications for surgery included patients with symptoms of flank pain and/or recurrent infections secondary to VUR. Our primary outcome was surgical success, which we defined as the absence of postoperative flank pain and radiographic absence of VUR on voiding cystourethrogram or obstruction on diuretic renal scan. Before beginning the procedure, all patients underwent cystoscopy, cystogram, and/or retrograde pyelogram. Robotic ports are placed similarly for both techniques through the standard prostatectomy configuration without a fourth robotic port or the right lateral 12 mm assistant port. A 5 or 12 mm assistant port is placed between the camera and the right robotic port. Meticulous dissection of the distal ureter to preserve its fragile blood supply is performed for both techniques. In the robotic intravesical technique, adapted from the Politano-Leadbetter technique, the ureter is redirected through a new supratrigonal hiatus and submucosal tunnel created in a 5:1 ratio.4 The neoureteral orifice (UO) is relocated distally (subtrigonometry) and medial to the orthotopic UO. In the robotic extravesical technique, adapted from the Lich-Gregoir technique, a mucosa sparing extravesical tunnel is created according to the Paquin guidelines with a 5:1 length to diameter ratio.5,6 In patients who have a previous ureteroneocystostomy complicated by reflux symptoms, the existing reimplant site can be left intact and revised with an extravesical tunnel to prevent reflux. Results: Three patients met inclusion criteria. Two patients underwent nonrefluxing extravesical RUR and one patient underwent intravesical RUR. The patient who underwent an extravesical RUR had a history of reimplantation that was complicated by severe reflux-related symptoms. Intraoperatively, the mean estimated blood loss was 50 mL and mean robotic console time was 162 minutes. Postoperatively, none of the patients experienced major (Clavien >2) complications. With regard to surgical success, at a mean follow-up of 20.5 months, all patients were free of urinary tract infections and obstructive flank pain symptoms. In addition, all patients achieved complete resolution of VUR on postoperative voiding cystourethrogram or renal scan. Conclusions: Nonrefluxing intravesical and extravesical RUR may be safely and effectively utilized for surgical management of adult patients with symptomatic VUR. Moreover, the nonrefluxing extravesical RUR can be used to revise select patients with prior reimplantation complicated by symptomatic reflux. S.K., C.O., and M.L. have no competing financial interests. D.D.E. reports a relationship with Intuitive Surgical that includes consulting or advisory and speaking and lecture fees. D.D.E. reports a relationship with Melzi Corp that includes board membership. D.D.E. reports a relationship with Johnson and Johnson that includes consulting or advisory. Accepted for presentation at Mid-Atlantic AUA 2021. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: Music (Gentle Wave by Ketsa) is not copyrighted material and was obtained from a royalty-free source. Runtime of video: 7 mins 14 secs

PD35-02 MULTI-INSTITUTIONAL EXPERIENCE WITH ROBOTIC URETERAL RECONSTRUCTION FOR RECURRENT STRICTURES AFTER PRIOR FAILED MANAGEMENT

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I (PD35)1 Sep 2021PD35-02 MULTI-INSTITUTIONAL EXPERIENCE WITH ROBOTIC URETERAL RECONSTRUCTION FOR RECURRENT STRICTURES AFTER PRIOR FAILED MANAGEMENT Matthew Lee, Ziho Lee, Chinonyerem Okoro, Aeen Asghar, Randall Lee, David Strauss, Rohit Reddy, Michael Metro, Michael Stifelman, Lee C Zhao, and Daniel Eun Matthew LeeMatthew Lee More articles by this author , Ziho LeeZiho Lee More articles by this author , Chinonyerem OkoroChinonyerem Okoro More articles by this author , Aeen AsgharAeen Asghar More articles by this author , Randall LeeRandall Lee More articles by this author , David StraussDavid Strauss More articles by this author , Rohit ReddyRohit Reddy More articles by this author , Michael MetroMichael Metro More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Lee C ZhaoLee C Zhao More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002039.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical repair of recurrent ureteral strictures after prior failed intervention is technically challenging. We described our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. METHODS: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012—01/2020 for a recurrent ureteral stricture after having undergone a prior failed endoscopic and/or surgical repair. The method for repair was determined by the primary surgeon based on clinical history and intraoperative findings. Postoperatively, patients were assessed for surgical success defined as the absence of flank pain and obstruction on imaging. RESULTS: Overall, 105 patients met inclusion criteria (Table 1). Median stricture length was 2 (IQR 1-3) centimeters. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were 9 (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). Overall median operative time was 187.5 (IQR 143.8-279.3) minutes and estimated blood loss was 50 (IQR 40-100) milliliters. RUR techniques included ureteroureterostomy (3.4%), ureterocalycostomy (5.2%), pyeloplasty (69.0%) or buccal mucosa graft ureteroplasty (22.4%) for UPJ and proximal strictures; ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) for middle strictures; ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) for distal strictures. Adjunctive techniques such as a downward nephropexy, psoas hitch or Boari flap were utilized in 7 (6.7%), 10 (9.5%) and 8 (7.6%) cases, respectively. Major (Clavien>2) postoperative complications occurred in 2 (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 95 (90.5%) cases were surgically successful. CONCLUSIONS: RUR may be performed with excellent intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e588-e588 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Lee More articles by this author Ziho Lee More articles by this author Chinonyerem Okoro More articles by this author Aeen Asghar More articles by this author Randall Lee More articles by this author David Strauss More articles by this author Rohit Reddy More articles by this author Michael Metro More articles by this author Michael Stifelman More articles by this author Lee C Zhao More articles by this author Daniel Eun More articles by this author Expand All Advertisement Loading ...

Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures

To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012-03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P <.05 was considered significant. Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023). Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

Intermediate-term outcomes after robotic ureteral reconstruction for long-segment (≥4 centimeters) strictures in the proximal ureter: A multi-institutional experience.

PurposeTo report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures.Materials and MethodsWe 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.ResultsOf 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.ConclusionsLong-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.

Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery.

Objectives: Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. Patients and Methods: In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. 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 the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). Results: A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required 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 100 mL (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 effective. Conclusion: RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.

PD41-08 URETERAL REST IS ASSOCIATED WITH IMPROVED OUTCOMES IN PATIENTS UNDERGOING ROBOTIC URETERAL RECONSTRUCTION OF PROXIMAL AND MIDDLE URETERAL STRICTURES

Objectives To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction. Methods We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012—03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P Results Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p Conclusions Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.

Laparoscopic and Robotic Management of Ureteral Stricture in Adults.

The aim of this review was to provide an update on the status of minimal invasive treatment of ureteral stricture either with a laparoscopic or robotic surgery. Eligible studies, published until November 2019 were retrieved through Medline, Cochrane and Pubmed databases. Predetermined inclusion and exclusion criteria were used as selection method for data synthesis and acquisition. The study was performed in accordance with the PRISMA statement. A total of 19 retrospective studies met the inclusion criteria. All of them demonstrated the safety, feasibility and success of both laparoscopic and robotic ureteral reconstruction. Individual case series or cumulative comparison analysis of the available studies showed at least equivalent success rates and a trend favoring laparoscopic and robotic groups in terms of estimated blood loss and length of hospital stay to the detriment of longer operative times and possibly higher cost. Current evidence suggests the effectiveness, safety and increasing incorporation of minimally invasive techniques for complex stricture repair and reconstruction.

Best practices in near-infrared fluorescence imaging with indocyanine green (NIRF/ICG)-guided robotic urologic surgery: a systematic review-based expert consensus.

The aim of the present study is to investigate the impact of the near-infrared (NIRF) technology with indocyanine green (ICG) in robotic urologic surgery by performing a systematic literature review and to provide evidence-based expert recommendations on best practices in this field. All English language publications on NIRF/ICG-guided robotic urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus® and Web of Science™ databases (up to April 2019). Experts in the field provided detailed pictures and intraoperative video-clips of different NIRF/ICG-guided robotic surgeries with recommendations for each procedure. A unique QRcode was generated and linked to each underlying video-clip. This new exclusive feature makes the present the first "dynamic paper" that merges text and figure description with their own video providing readers an innovative, immersive, high-quality and user-friendly experience. Our electronic search identified a total of 576 papers. Of these, 36 studies included in the present systematic review reporting the use of NIRF/ICG in robotic partial nephrectomy (n = 13), robotic radical prostatectomy and lymphadenectomy (n = 7), robotic ureteral re-implantation and reconstruction (n = 5), robotic adrenalectomy (n = 4), robotic radical cystectomy (n = 3), penectomy and robotic inguinal lymphadenectomy (n = 2), robotic simple prostatectomy (n = 1), robotic kidney transplantation (n = 1) and robotic sacrocolpopexy (n = 1). NIRF/ICG technology has now emerged as a safe, feasible and useful tool that may facilitate urologic robotic surgery. It has been shown to improve the identification of key anatomical landmarks and pathological structures for oncological and non-oncological procedures. Level of evidence is predominantly low. Larger series with longer follow-up are needed, especially in assessing the quality of the nodal dissection and the feasibility of the identification of sentinel nodes and the impact of these novel technologies on long-term oncological and functional outcomes.