Reconstructive Urologic Surgery Research Articles

Narrative review of flaps and grafts in robotic reconstructive urologic surgery

Narrative review of flaps and grafts in robotic reconstructive urologic surgery

Insights into cellular behavior and micromolecular communication in urothelial micrografts

Autologous micrografting is a technique currently applied within skin wound healing, however, the potential use for surgical correction of other organs with epithelial lining, including the urinary bladder, remains largely unexplored. Currently, little is known about the micrograft expansion potential and the micromolecular events that occur in micrografted urothelial cells. In this study, we aimed to evaluate the proliferative potential of different porcine urothelial micrograft sizes in vitro, and, furthermore, to explore how urothelial micrografts communicate and which microcellular events are triggered. We demonstrated that increased tissue fragmentation subsequently potentiated the yield of proliferative cells and the cellular expansion potential, which confirms, that the micrografting principles of skin epithelium also apply to uroepithelium. Furthermore, we targeted the expression of the extracellular signal-regulated kinase (ERK) pathway and demonstrated that ERK activation occurred predominately at the micrograft borders and that ERK inhibition led to decreased urothelial migration and proliferation. Finally, we successfully isolated extracellular vesicles from the micrograft culture medium and evaluated their contents and relevance within various enriched biological processes. Our findings substantiate the potential of applying urothelial micrografting in future tissue-engineering models for reconstructive urological surgery, and, furthermore, highlights certain mechanisms as potential targets for future wound healing treatments.

(283) Managing Patient Pain Expectations in Buried Penis Repair: An Opportunity for Quality Improvement

Abstract Introduction Buried penis repairs are complex cases often requiring collaboration between urology and plastic surgery. These surgeries are often extensive, can require split thickness skin grafting (STSG) of the penile shaft, negative pressure wound vac, and have high incidence of wound complications. There are no studies that evaluate perioperative pain in patients undergoing buried penis repair. Objective In the ongoing opioid epidemic, we aim to evaluate patient risk factors and peri-operative elements that can minimize opioid use in buried penis repair. Methods A retrospective chart review of patients who underwent buried penis repair from 7/2012 to 7/2021 was performed. Patient demographics, comorbidities and perioperative data were collected, including history of chronic pain, indications, intraoperative findings, perioperative pain control, and 30-day post-operative encounters. The state’s prescription monitoring program was used to verify use of prescription pain medications prior to surgery, at discharge, and refills, collected as Morphine Equivalent Dose (MED). Results A total of 63 patients were included in analysis. Mean age was 55.9 ± 14.4 with a mean pre-op BMI of 41.99 ± 9.17. 75% required a STSG on the penile shaft. The median discharge MED (dMED) was 150, ranging from 0 to 450 MED. 36.5% required opioid refills within 30 days of surgery. This cohort was further separated into two groups: patients who were discharged with < 150 MED (A) vs ≥ 150 MED (B), based on the median dMED. Three patients were excluded: two were on home opioids, one discharged on benzodiazepines. There were no differences in age, pre-op BMI, medical comorbidities (CAD, PVD, HTN, DM, psychiatric history) or history of chronic pain between the cohorts. Surgery for improvement of hygiene was more likely to have higher dMED, 40.7% (A) vs 69.7% (B), p=0.017. Other surgical indications (sexual health, voiding) showed no difference. Prior surgeries (urethral procedures, circumcision) were statistically more likely to require higher dMED, 48.1% (A) vs 72.7% (B), p=0.033. If a penile skin graft was required, there was no difference in graft size and dMED. Twenty-six patients had a hospital managed wound vac, while 19 patients had home wound vacs, but there was no difference in dMED. Although there was no standardized hospital pain regimen, patients on scheduled acetaminophen were more likely to have a lower dMED, 70.3%(A) vs 42.4% (B), p=0.021. 40.7% (A) vs 36.4% (B) of patients required opioid refills within 30 days of surgery, showing no statistical significance. Conclusions For patients who are embarking on buried penis repair, providers can pre-operatively set pain control expectations, especially for those who require repair for hygiene purposes or have had prior urologic reconstructive surgery. In the perioperative setting, this data supports the use of non-opioids, specifically scheduled acetaminophen, to minimize opioid prescribing at discharge. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

Is endourological intervention a suitable treatment option in the management of iatrogenic thermal ureteral injury? A contemporary case series

BackgroundIatrogenic ureteral injury (IUI) is relatively rare, however, can cause sepsis, kidney failure, and death. Most cases of IUI are not recognized until the patient presents with symptoms following pelvic surgery or radiotherapy. Recently, minimally invasive approaches have been used more frequently in the treatment of IUI. This study evaluates urological intervention success rates and long-term clinical outcomes according to the type of IUI following hysterectomy.MethodsTwenty-seven patients who underwent surgery due to IUI in our clinic following hysterectomy were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis of IUI. The IUI cases diagnosed within the first 24 h following hysterectomy were designated as "immediate" IUI, while that diagnosed late period was considered 'delayed' IUI. The type of IUI was categorized as "cold transection" if it was due to surgical dissection or ligation without any thermal energy, and "thermal injury" if it was related to any energy-based surgical device. Patient information, laboratory and perioperative data, imaging studies, and complications were assessed retrospectively.ResultsAll cases of delayed diagnosis IUI were secondary to laparoscopic hysterectomy (P = 0.041). Patients with thermal injury to the ureter were mostly diagnosed late (delayed) (P = 0.029). While 31% of the patients who underwent endourological intervention were diagnosed immediately, 69% of them were diagnosed as delayed. These rates were roughly reversed for open reconstructive surgery: 73% and 27% (P = 0.041), respectively. We detected eight ureteral complications in our patient cohort following the urological intervention. In all these failed cases, the cause of IUI was a thermal injury (P = 0.046) and the patients had received endourological treatment (P = 0.005). No complications were detected in patients who undergo open urological reconstructive surgery. While one of the patients who developed urological complications had an immediate diagnosis, seven were in the delayed group (P = 0.016).ConclusionEndourological intervention is performed more frequently in delayed diagnosed IUI following hysterectomy, however, the treatment success rate is low if thermal damage has developed in the ureter. Surgical reconstruction is should be preferred in these thermal injury cases to avoid further ureter-related complications.

The impact of COVID-19 pandemic on reconstructive urologic surgery and andrology Spanish units’ practice during the state of alarm in 2020: National survey

IntroductionIn Spain the state of alarm secondary to COVID-19 dramatically changed the medical and surgical assistance activity of other pathologies. Regarding urological pathologies, those considered as “non-urgent” (andrology and reconstructive surgery) were postponed or even unattended. Material and methodsIn May 2020, once the first COVID-19 wave was almost over and still in the state of alarm, a 24-item survey was sent to 120 urologists from the Andrology Group and the Urologic Reconstructive Surgery Group of the Spanish Urological Association (AEU). Its aim was to determine the impact on clinical and surgical practice in both subspecialties. ResultsWe observed a response rate of 75.8% with 91 answered surveys. Before the state of alarm, 49.5% of urologists had 1–2 weekly surgical sessions available, surgical waiting list was 3–12 months for the 71.4%, and 39.6% attended between 20–40 patients weekly in office. During the state of alarm, 95.6% were given any kind of surgical guidelines, prioritizing emergency and oncologic pathologies. In the 85.7% of the hospitals neither andrology nor reconstructive surgeries were performed. In office, around 50% of patients were attended not on-site, most of them through telemedicine (phone calls and e-mails). ConclusionsThe negative pandemic implications in relation to the andrology and reconstructive surgery pathologies were truly important. After almost 2 years from the start of the pandemic, the true final impact on our health system has yet to be determined.

Impacto de la pandemia en la actividad de las unidades de cirugía reconstructiva urológica y de andrología en España durante el estado de alarma (COVID-19) en 2020: resultados de una encuesta nacional

IntroductionIn Spain the state of alarm secondary to COVID-19 dramatically changed the medical and surgical assistance activity of other pathologies. Regarding urological pathologies, those considered as «non-urgent» (andrology and reconstructive surgery) were postponed or even unattended. Material and methodsIn May 2020, once the first COVID-19 wave was almost over and still in the state of alarm, a 24-item survey was sent to 120 urologists from the Andrology Group and the Urologic Reconstructive Surgery Group of the Spanish Urological Association (AEU). Its aim was to determine the impact on clinical and surgical practice in both subspecialties. ResultsWe observed a response rate of 75.8% with 91 answered surveys. Before the state of alarm, 49.5% of urologists had 1-2 weekly surgical sessions available, surgical waiting list was 3-12 months for the 71.4%, and 39.6% attended between 20-40 patients weekly in office. During the state of alarm, 95.6% were given any kind of surgical guidelines, prioritizing emergency and oncologic pathologies. In the 85.7% of the hospitals neither andrology nor reconstructive surgeries were performed. In office, around 50% of patients were attended not on-site, most of them through telemedicine (phone calls and e-mails). ConclusionsThe negative pandemic implications in relation to the andrology and reconstructive surgery pathologies were truly important. After almost 2 years from the start of the pandemic, the true final impact on our health system has yet to be determined.

Challenges in the management of caudal duplication syndrome

Caudal duplication syndrome (CDS) is a rare developmental anomaly in which embryonic cloaca and notochord structures are duplicated [1]. Due to the diverse clinical manifestation and rarity of CDS, it is crucial to report every case and to share experience and outcomes of individually adjusted management plans. We report here the case of a 2-year-old girl born with duplication of the urogenital (bladder, urethra, uterus, vagina, vulva) and gastrointestinal (gallbladder, appendix vermiformis) systems. Additionally, coccygeal agenesis, lipomyelomeningocele and vertical talus were present. A thorough examination and urological reconstructive surgery were performed. While there may be a desire from patients, parents and healthcare specialists to modify all malformations to an anatomically correct state, the current opinion is that only anatomical variants that influence function should be modified. Consent from patients should be sought for decisions regarding more sensitive matters such as vulva surgery for cosmetic reasons or correction of anatomical variants without functional consequences.

The reporting quality of randomized controlled trials and experimental animal studies for urethroplasty.

To assess the reporting quality of randomized controlled trials and experimental animal studies examining urethroplasty in reconstructive urological surgery literature. We performed a comprehensive literature search to identify all urethroplasty-related RCTs examining humans as well as animal models. We used the Consolidated Standards ofReportingTrials (CONSORT) and the Animals in Research: Reportingin vivoExperiments (ARRIVE) guidelines to assess reporting quality. Two reviewers performed data abstraction independently and in duplicate. We then generated descriptive statistics including CONSORT (0-25) and ARRIVE (0-20) summary scores using the median and interquartile range. Twenty studies were ultimately included; 14 randomized controlled trials and 6 experimental animal studies. All studies were two-armed, parallel group studies. Median sample sizes (and interquartile range) of the human and animal studies were 48.5 (31.8-53.8) and 18 (15.3-27.5), respectively. The median CONSORT and ARRIVE scores were 10.0 (8.75-12.63) and 7.97 (6.79-8.64), respectively. Human randomized controlled trials did not consistently report the method of allocation concealment (6/14; 42.9%), blinding (2/14; 14.3%), or discuss the generalizability of the results (6/14; 42.9%). Animal studies infrequently reported why a given animal model was used (1/6; 16.7%), how they were allocated to groups (0/6; 0%) or what the experimental primary and secondary outcomes were (0/6; 0%). Urethroplasty literature is marked by a paucity of both randomized controlled trials and experimental design animal studies. The existing studies are inconsistently reported and are therefore of uncertain methodological quality.

Enhanced recovery after surgery and anesthetic outcomes in pediatric reconstructive urologic surgery.

Enhanced recovery after surgery (ERAS) is a perioperative management strategy to hasten postoperative recovery. We examined the effects of a pilot implementation of ERAS for pediatric patients on anesthetic outcomes. We performed a prospective case-control study utilizing an ERAS protocol in patients aged < 18years undergoing urologic reconstruction that included a bowel anastomosis. Protocol elements included: multimodal analgesia, opioid minimization, and routine nausea/vomiting prophylaxis. ERAS patients were propensity-matched with historical controls. Outcomes of interest included maximum PACU pain score, time to first opioid, opioid-free days, and need for opioids on day of discharge. A total of 13 ERAS patients and 26 historical controls were included, with median ages 9.9years (IQR 9.1-11) and 10.4years (IQR 8.0-12.4), respectively. ERAS increased the percentage of patients who did not receive any intraoperative or postoperative opioids (0% vs 15%, p = 0.046 for both) and reduced maximum PACU pain score (3 vs 0, p < 0.001). The use of postoperative supplemental oxygen was decreased in the ERAS group (85% vs 38%, p = 0.013). The implementation of an ERAS protocol appears to decrease postoperative pain, opioid usage, and positively impact other anesthetic outcomes in children undergoing urologic reconstructive surgery utilizing a bowel anastomosis.

Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction

With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear. This study aims to assess the impact of an ERAS protocol on outpatient opioid prescription patterns after pediatric lower urinary tract reconstructive surgery. We hypothesize that implementation of an ERAS protocol leads to fewer outpatient opioid prescriptions as measured by number and total quantity of oral morphine milligram equivalents by body weight per patient. All patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility between 2011 and 2017 were reviewed. Patients were divided into pre-ERAS and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Prescription Drug Monitoring Program was used to track filling of postoperative opioid prescriptions for patients covered by the database. A total of 167 urologic reconstructive surgeries were analyzed, including 83 before ERAS and 84 after ERAS implementation. Patients in the ERAS cohort received and filled more outpatient opioid prescriptions at time of discharge (82.6% historical vs 93.9% ERAS, p=0.015; 76.1% vs 57.9%, p=0.012). There were no differences in prescription total morphine milligram equivalents normalized to body mass, total days supplied, or 90-day opioid prescription refill rates. We found an unexpected increase in postoperative outpatient opioid prescriptions following implementation of an ERAS protocol for lower urinary tract reconstructive surgery. Possible reasons include worry about pain crisis at home in the setting of decreased hospital length of stay in the ERAS cohort or generalized upward drift in opioid prescribing patterns over time. ERAS protocols in other subspecialties reveal mixed findings but consistently suggest standardization of outpatient opioid prescribing patterns leads to a decrease in opioid prescriptions. Patients received more, not fewer, outpatient opioid prescriptions following major urologic reconstructive surgery after implementation of an ERAS protocol. Purposeful efforts should be made to standardize opioid prescriptions at discharge based on meaningful clinical criteria.

Electrospinning: Application and Prospects for Urologic Tissue Engineering.

Functional disorders and injuries of urinary bladder, urethra, and ureter may necessitate the application of urologic reconstructive surgeries to recover normal urine passage, prevent progressive damages of these organs and upstream structures, and improve the quality of life of patients. Reconstructive surgeries are generally very invasive procedures that utilize autologous tissues. In addition to imperfect functional outcomes, these procedures are associated with significant complications owing to long-term contact of urine with unspecific tissues, donor site morbidity, and lack of sufficient tissue for vast reconstructions. Thanks to the extensive advancements in tissue engineering strategies, reconstruction of the diseased urologic organs through tissue engineering have provided promising vistas during the last two decades. Several biomaterials and fabrication methods have been utilized for reconstruction of the urinary tract in animal models and human subjects; however, limited success has been reported, which inspires the application of new methods and biomaterials. Electrospinning is the primary method for the production of nanofibers from a broad array of natural and synthetic biomaterials. The biomimetic structure of electrospun scaffolds provides an ECM-like matrix that can modulate cells’ function. In addition, electrospinning is a versatile technique for the incorporation of drugs, biomolecules, and living cells into the constructed scaffolds. This method can also be integrated with other fabrication procedures to achieve hybrid smart constructs with improved performance. Herein, we reviewed the application and outcomes of electrospun scaffolds in tissue engineering of bladder, urethra, and ureter. First, we presented the current status of tissue engineering in each organ, then reviewed electrospun scaffolds from the simplest to the most intricate designs, and summarized the outcomes of preclinical (animal) studies in this area.

Neurogenic Bladder: Epidemiology, Diagnosis, and Management.

Lower urinary tract dysfunction is a common sequel of neurological disease resulting in symptoms that significantly impacts quality of life. The site of the neurological lesion and its nature influence the pattern of dysfunction. The risk for developing upper urinary tract damage and renal failure is considerably lower in patients with slowly progressive nontraumatic neurological disorders, compared with those with spinal cord injury or spina bifida. This acknowledged difference in morbidity is considered when developing appropriate management algorithms. The preliminary evaluation consists of history taking, and a bladder diary and may be supplemented by tests such as uroflowmetry, post-void residual measurement, renal ultrasound, (video-)urodynamics, neurophysiology, and urethrocystoscopy, depending on the clinical indications. Incomplete bladder emptying is most often managed by intermittent catheterization, and storage dysfunction is managed by antimuscarinic medications. Intra-detrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity. Neuromodulation offers promise for managing both storage and voiding dysfunction. In select patients, reconstructive urological surgery may become necessary. An individualized, patient-tailored approach is required for the management of lower urinary tract dysfunction in this special population.

Long-term urological assessment and management of cloaca patients: A single tertiary institution experience

PurposePreserving renal function and achieving urinary continence are the most important urological goals in the management of cloaca patients. Many prognostic factors have been described, such as the length of the common channel (CC) and urethra, the presence of spinal dysraphism, and associated urological anomalies. The aim of this study was to analyze urinary continence status and need for reconstructive procedures and their correlation with urological risk factors in a series with a long-term follow-up. Material and methodsThe institutional database of patients with anorectal malformations was reviewed. Patients with cloaca who underwent cloacal reconstructive surgery at our institution between January 1995 and May 2015 and who had a minimum postoperative follow-up of 5 years with complete urological care were included.Urologic and spinal anomalies, length of the CC, renal function, urodynamic study patterns, continence status, and urologic reconstructive surgeries were assessed. A CC was defined as long CC when its measure was longer than 3 cm in the cloacogram and then confirmed by cystoscopy. Descriptive statistical analysis was performed. ResultsFifty-five cloaca patients with a mean follow-up of 12 years (5–20) were included. A long CC was documented in 38 patients (69%). The sacral ratio (SR) was <0.4 in the AP projection in 30 (54.5%). Urodynamic evaluation revealed an inadequate detrusor contraction pattern in 65.4% of the cases. A CC >3 cm and SR <0.4 were significantly correlated with this urodynamic finding. A total of 50 patients (91%) achieved urinary continence, but only 30.9% had volitional voiding and 56% needed major urological reconstructive surgeries. Eighteen patients (32.7%) were in stage 2 or more of chronic kidney disease (<90 ml/min/1.73 m2) at the last follow-up visit. ConclusionCloacal management requires a multidisciplinary and long-term follow-up. Early assessment of prognostic urological factors and accurate stratification of each patient are essential to avoid renal impairment and achieve urinary continence in the future. The length of the common channel and the presence of spinal dysraphism were correlated with the presence of neurovesical dysfunction specifically an abnormal bladder contraction efficiency. A significant number of these patients will need catheterization and reconstructive urinary tract surgeries to attain urinary continence. Type of studyRetrospective study. Level of evidenceLevel 3. Retrospective comparative study.

Urethroplasty performed with an autologous urothelium-vegetated collagen fleece to treat urethral stricture in the minipig model.

Tissue-engineered materials in urethral reconstructive surgeries are a promising field for innovative therapy. Collagen matrices increase stability of cell-based implants and can promote viability and proliferation of urothelial cells. In this study, a collagen type I-based cell carrier (CCC) with stratified multi-layer autologous urothelium was used for urethroplasty after induction of urethral stricture in eight minipigs. Minipigs underwent surgical procedures to induce urethral stricture by thermocoagulation. Simultaneously, bladder tissue was harvested. Urothelial cells were expanded, labeled with PKH26 and seeded onto CCC in high density. 3weeks after strictures were induced and verified by urethrography, minipigs underwent urethroplasty using the seeded CCC. Two animals were euthanized after 1, 2, 4, and 24weeks. Urethras were histologically examined for integration and survival of seeded CCC. In vivo phenotype of multi-layered urothelium matrix constructs was characterized via immunofluorescence staining with pancytokeratin, CK20, p63, E-cadherin and ZO-1. Seeded CCCs showed excellent stability and suturability after manipulation and application. Transplanted cells were detected using positive PKH26 fluorescence up to 6months after labeling. Urothelium matrix implants integrated well into the host tissue without sign of inflammation. Animals showed no sign of rejection or stricture recurrence (urethrography) at any time during experimental period. Immunofluorescence analysis confirmed epithelial phenotype, junction formation and differentiation after 2weeks. CCC can be suitable for urologic reconstructive surgeries and represents a promising option for clinical application. Longer follow-up results are required to exclude re-occurrence of stricture reformation.

Follow up of Patients with Eagle-Barett (Prune Belly) Syndrome Treated with Single-Stage Abdominoplasty and Total Genitourinary Tract Reconstruction

Abstract Introduction The Prune Belly Syndrome (PBS) is the deficiency or congenital hypoplasia of the abdominal muscles accompanied with disorders of the urinary tract. The surgical treatment for the uropathy of the PBS seeks to correct the anatomical defects that induce damage to the urinary tract, including the improvement of the bladder emptying. The correction of the abdominal wall defect must be considered as an important part of the treatment. Objective To describe of the most relevant clinic characteristics and outcomes of a group of eight patients with PBS managed with abdominoplasty and reconstructive urologic surgery. Methods Retrospective review of the medical charts of patients with PBS at Hospital Universitario San Ignacio, Hospital Militar Central of Bogotá, Clinica Infantil Colsubsidio and Fundación Oftalmológica Ardila Lulle of Bucaramanga, (Colombia) that were managed with reconstructive surgery of the urinary tract and Monfort technique abdominoplasty (between 2006 and 2016) by one of the authors (JPN). The evaluated variables included: phenotypic appearance, renal function, bowel movements, and urinary tract infection (UTI) episodes. These variables as well as the abdominal wall aspect, were evaluated postoperatively. Results There were 11 patients identified with PBS between 2006 and 2016. Eight (8) of them underwent reconstructive urologic surgery, orchidopexy and Monfort technique abdominoplasty. After the procedures, none of the patients presented deterioration of the renal function, and they reported a better quality of the stools according to the Bristol scale; there were also less episodes of UTI. The phenotypic aspect of the abdominal wall was qualified as satisfactory in all cases. Conclusions Reconstructive urologic surgery and abdominoplasty in patients with PBS is an excellent choice of management that reduces the number of UTIs, improves bowel movements according to the Bristol scale, and preserves the renal function. This management approach also improves the phenotypic aspect of the abdominal wall. All of this leads to higher survival rate and better quality of life.

Outcomes of reconstructive urinary tract surgery after pelvic radiotherapy

Background: Pelvic radiotherapy causes tissue atrophy and fibrosis, leading to urinary tract dysfunction. Tissue ischaemia poses a significant surgical challenge. This study examined the urological sequelae of radiotherapy, types of reconstructive urological surgery (RUS) required and functional outcomes.Methods: A retrospective review was performed of all radiotherapy patients who underwent RUS at a tertiary centre between 2007–2017. Details including time from radiotherapy, pre-operative assessments, type of surgery performed and functional outcome were analysed.Results: Fifty-four patients were identified. The primary malignancy was cervical (32), colorectal (9) and other urogenital/metastatic origins in the remaining cases. Mean time between radiation and RUS was 13 years. Sixty-nine reconstructive surgeries were performed. Twenty-two patients had fistulae, but only 27% were closed and 73% ended with urinary diversion. Eighteen had ureteric strictures, with 56% having associated bladder dysfunction. Twelve (67%) patients had RUS, of whom 83% required bowel interposition, and 33% primary diversion. Nine of 24 patients with contracted bladders were reconstructed and eight remain functionally continent. Renal function stabilised or improved in 87%. Nine patients (17%) had Clavien 3 or 4 complications.Conclusions: A variety of complex, major RUS were required. In 61%, urinary diversion was necessary, with radiotherapy fistulae being a particular challenge and closed in only a third. In total, 37% of patients were reconstructed achieving functional continence and restoration of upper-tract drainage with renal function preservation. This surgery was at a cost of a re-intervention rate of 28% and significant morbidity in 17%. RUS in the radiotherapy field should be performed in centres with experience.

Robotics and urologic reconstructive surgery.

Minimally invasive surgery has made a profound impact on how urologists approach the challenges in reconstruction of the urinary tract. The advent of laparoscopic approaches to reconstructive urology have demonstrated comparable outcomes to open surgery with improved morbidity. The recent adoption of robotic surgery has seen further advancements such as improved visibility and, freedom of movement, and an easier technical learning curve. With these advantages, more reconstructive urology procedures are being performed robotically. Herein, we review reconstructive urology procedures for which robotics have been applied.

Outcomes of reconstructive urological surgery in radiotherapy patients

Outcomes of reconstructive urological surgery in radiotherapy patients

Autologous Gastrointestinal Reconstruction (AGR) for Patients with Enterocutaneous Fistula - associated intestinal failure

Background: An enterocutaneous fistula (ECF) remains a challenging surgical problem. Recent advances in the fields of critical care, interventional radiology, wound care and, nutritional support have significantly decreased the mortality rate from 40% to 10%. Fewer than 25% of ECFs will close spontaneously with the remainder requiring surgical repair. A small number of patients with ECFs have associated short gut syndrome (SGS). We describe herein our recent experience on the surgical management of complex ECFs in patient with short gut syndrome (<200cm). Methods: We retrospectively reviewed 341 adult patients who were referred to our Center between January 2013 and December 2016. Results: Fifty-three patients with complex ECFs were evaluated and underwent surgical intervention in our center. Forty of them (75%) had SGS. Three of these patients are currently waiting for a definitive surgical procedure (most recent surgery < 6 months). The mean patient age at the time of operation was 55 years (range 24 to 79). ECFs were related to surgical complications (68%), Crohn’s disease (12%), and others causes (12%). All patients had high output fistulas (>500 cc/day) and were on TPN at the time of operation. Mean residual bowel length was 105 cm (range 0 cm to 200 cm). Thirteen patients (35%) had definitive end ostomy and eight patients (22%) had ultra-short gut syndrome (<50 cm). Three patients had combined ECFs and complex urinary fistulas requiring urologic reconstructive surgery (8%). Patients were weaned off TPN according to their postoperative GI tract anatomy and remaining small bowel length. After 3, 6 and 12 months 62%, 43% and 19% are still on TPN. There were no intraoperative or perioperative deaths (<28 days). Two patients underwent an uneventful isolated small bowel transplant and another three are listed for isolated intestinal transplantation. After 20 months median follow-up (range 2 to 47 months), thirty three patients are alive (89%). Conclusion: In summary, patients with short bowel syndrome and complex ECFs can achieve full nutritional autonomy after autologous gastrointestinal reconstruction (AGR). Early referral to intestinal rehabilitation/transplant centers can expedite the adequate treatment for patients with ECF-associated intestinal failure and minimize postoperative morbidity and mortality. Intestinal transplantation should be reserved for patients who failed AGR.

Future Prospects for Human Tissue Engineered Urethra Transplantation: Decellularization and Recellularization-Based Urethra Regeneration.

To evaluate the histological characteristics of decellularized human urethra after transplantation into the rat omentum and compare in vivo cell seeding with perfusion-based and cell sheet urethral regeneration. Eight adult human male urethras accompanied with the surrounding corpus spongiosum were obtained. The tissues were decellularized with detergent-based method. The efficacy of decellularization and extracellular matrix preservation was evaluated by several techniques. Decellularized scaffolds were transplanted into the omentum of 12 male rats and located into the scrotum. Biopsies were taken 1, 3, and 6months postoperatively to assess the natural recellularization. Mesenchymal stem cells obtained from preputial tissue were seeded with perfusion-based and cell sheet techniques as well. Immunohistochemical staining with α-actin, cytokeratin AE1/AE3, synaptophysin, and CD31 antibodies were performed. Removal of nuclear components and preservation of biomechanical properties was confirmed. In-vivo recellularization revealed promising results in progressive angiogenesis and cell seeding of epithelium-like cells in the lining of the urethra as well as smooth muscle cells in the wall structure. In-vitro urethral regeneration revealed that cell sheet engineering was the technique of choice compared to perfusion-based technique. This study may paw the road for clinical application of acellular urethral matrix with the surrounding corpus spongiosum in urological reconstructive surgery.