Female pelvic medicine and reconstructive surgery fellows' case logs remained stable during the COVID-19 pandemic.

INTRODUCTION: During the COVID-19 pandemic and subsequent staffing shortages there was concern about the case volume, and thus competency, of graduating trainees due to reduced surgical volumes. Elective procedures were particularly affected, which includes Female Pelvic Medicine and Reconstructive Surgery (FPMRS) cases. To understand whether FPMRS fellows were affected, we assessed their case logs for changes during the pandemic. METHODS: The nationally aggregated case logs of graduating FPMRS fellows, both urology and obstetrics and gynecology (OBGYN), were obtained from the Accreditation Council for Graduate Medical Education. The available academic years (AYs) included 2018-2019, 2019-2020, and 2020-2021. Standard deviation for each index category was derived from the average and 90th percentile data. One-way analysis of variance was used to compare differences in case volumes for tracked index categories between AYs. RESULTS: Graduating fellows logged an average of 517.4 (standard deviation [SD] 28.6) and 818.0 (SD 37.9) cases, for urology and OBGYN respectively, over their fellowship training during the examined period. No significant differences in total surgical procedures were found for either specialty between pre-COVID AY 2018-2019 and COVID-affected AYs 2019-2020 and 2020-2021. For urology fellows, gastrointestinal (GI) procedures was the only index case category with a significant difference, and it was a decrease between the two COVID-affected AYs: 2020-2021 compared to 2019-2020 (8.9 vs. 4.2, p = 0.04). For both urology and OBGYN fellows, there was a statistically significant decrease in graft/mesh augmentation procedures from COVID-affected AY 2019-2020 to AY 2020-2021. This may be attributed to the reclassification of mesh removal cases from graft/mesh augmentation procedures to genital procedures in 2020-2021. There was not a significant decrease in these procedures from pre-COVID AY 2018-2019 to the COVID-affected AYs. There were no other statistically significant differences between AYs for OBGYN fellows. CONCLUSIONS: Surgical case volumes for FPMRS urology and OBGYN fellows who trained during the COVID-19 pandemic were comparable to those of their pre-pandemic peers. No significant differences between pre-COVID and COVID-affected years were found for either total surgical procedures or index case categories. Despite disruptions in health care nationwide, FPMRS trainee case volumes were largely unaffected.

A narcotic free pathway for postoperative pain following urethroplasty.

INTRODUCTION: In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics. MATERIALS AND METHODS: We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs). RESULTS: Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44). CONCLUSIONS: The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.

Outcomes and Risk Factors of Revision and Replacement Artificial Urinary Sphincter Implantation in Radiated and Nonradiated Cases.

PURPOSE: Risk factors for complications after artificial urinary sphincter surgery include a history of pelvic radiation and prior artificial urinary sphincter complication. The survival of a second artificial urinary sphincter in the setting of prior device complication and radiation is not well described. We report the survival of redo artificial urinary sphincter surgery and identify risk factors for repeat complications. MATERIALS AND METHODS: A multi-institutional database was queried for redo artificial urinary sphincter surgeries. The primary outcome was median survival of a second and third artificial urinary sphincter in radiated and nonradiated cases. A Cox proportional hazards survival analysis was performed to identify additional patient and surgery risk factors. RESULTS: Median time to explantation of the initial artificial urinary sphincter in radiated (150) and nonradiated (174) cases was 26.4 and 35.6 months, respectively (p=0.043). For a second device median time to explantation was 30.1 and 38.7 months (p=0.034) and for a third device it was 28.5 and 30.6 months (p=0.020), respectively. The 5-year revision-free survival for patients undergoing a second artificial urinary sphincter surgery with no risk factors, history of radiation, history of urethroplasty, and history of radiation and urethroplasty were 83.1%, 72.6%, 63.9% and 46%, respectively. CONCLUSIONS: Patients without additional risk factors undergoing second and third artificial urinary sphincter surgeries experience revision-free rates similar to those of their initial artificial urinary sphincter devices. Patients who have been treated with pelvic radiation have earlier artificial urinary sphincter complications. When multiple risk factors exist, revision-free rates decrease significantly.

Renal Trauma Classification and Management: Validating the Revised Renal Injury Grading Scale.

PURPOSE: To better characterize traumatic renal injury a revision to the 1989 American Association for the Surgery of Trauma renal injury scale was proposed in which grade IV includes all collecting system and segmental vascular injuries and grade V includes main renal hilar injury. We sought to validate the 2009 grading scale, emphasizing reclassifications between the 1989 and 2009 versions, and subsequent management. MATERIALS AND METHODS: Patient demographics and renal injury characteristics, computerized tomography imaging, radiology reports and subsequent management were recorded in a prospective trauma database. Multivariable logistic regression models for intervention were compared using 1989 and 2009 grades to evaluate which grading scale better predicted management. RESULTS: Of 256 renal injury cases 56 (21.9%) were reclassified using the revised 2009 scale, including 50 (19.5%) which were upgraded, 6 (2.3%) which were downgraded and 200 (78.1%) which were unchanged. Of grade III or higher cases management was nonoperative in 112 (78.9%), angioembolization in 9 (6.3%), nephrectomy in 9 (6.3%) and renorrhaphy in 12 (8.5%). Management was significantly associated with original and revised grades (chi-square p=0.02 and <0.001, respectively). Further, the multivariable model using the 2009 grades significantly outperformed the 1989 model. Radiology reports rarely included renal injury scales. CONCLUSIONS: Using the revised renal injury grading scale led to more definitive classification of renal injury and a stronger association with renal trauma management. Applying the revised criteria may facilitate and improve the multidisciplinary care of renal trauma.

Prevalence and surgical management of concurrent adult acquired buried penis and urethral stricture disease.

PURPOSE: To describe the prevalence and surgical management of coexistent adult acquired buried penis (AABP) and urethral stricture disease. AABP patients often have urinary dribbling with resultant chronic local moisture, infection, and inflammation that combine to cause urethral stricture disease. To date, no screening or surgical management algorithms have been described. METHODS: A multi-institutional retrospective study was conducted of the surgical management strategies for patients with concurrent AABP and urethral stricture disease from 2010 to 2017. AABP patient demographics, physical exam findings, and comorbidities were compared between those with and without stricture disease to suggest those that would selectively benefit from screening for stricture disease. RESULTS: Of the 42 patients surgically managed for AABP, 13 had urethral stricture disease (31.0%). Stricture location was universal in the anterior urethra. Sixty-one percent (n = 8) of strictures were 6 cm or longer and managed prior to AABP repair with Kulkarni urethroplasty. Patients with urethral stricture disease were significantly more likely to have clinically diagnosed lichen sclerosus (p = 0.00019). There was no significant difference in BMI, age, or comorbidities between patients with and without urethral stricture disease. CONCLUSIONS: Extensive anterior urethral stricture is common in patients with AABP. Clinical characteristics cannot predict stricture presence except possibly the presence of lichen sclerosus. Definitive stricture surgical options include extensive Johanson Urethroplasty or Kulkarni Urethroplasty. Kulkarni Urethroplasty prior to AABP repair has the benefits of a single-stage repair, good cosmetic outcome with meatal voiding, and dorsal graft placement to allow safe degloving of the penis in the subsequent AABP repair.

Trends in renal calculus composition and 24-hour urine analyses in patients with neurologically derived musculoskeletal deficiencies.

PURPOSE: To better characterize metabolic stone risk in patients with neurologically derived musculoskeletal deficiencies (NDMD) by determining how patient characteristics relate to renal calculus composition and 24-hour urine parameters. MATERIALS AND METHODS: We performed a retrospective cohort study of adult patients with neurologically derived musculoskeletal deficiencies presenting to our multidisciplinary Kidney Stone Clinic. Patients with a diagnosis of NDMD, at least one 24-hour urine collection, and one chemical stone analysis were included in the analysis. Calculi were classified as primarily metabolic or elevated pH. We assessed in clinical factors, demographics, and urine metabolites for differences between patients who formed primarily metabolic or elevated pH stones. RESULTS: Over a 16-year period, 100 patients with NDMD and nephrolithiasis were identified and 41 met inclusion criteria. Thirty percent (12 / 41) of patients had purely metabolic calculi. Patients with metabolic calculi were significantly more likely to be obese (median body mass index 30.3kg / m2 versus 25.9kg / m2), void spontaneously (75% vs. 6.9%), and have low urine volumes (100% vs. 69%). Patients who formed elevated pH stones were more likely to have positive preoperative urine cultures with urease splitting organisms (58.6% vs. 16.7%) and be hyperoxaluric and hypocitraturic on 24-hour urine analysis (37mg / day and 265mg / day versus 29mg / day and 523mg / day). CONCLUSIONS: Among patients with NDMD, metabolic factors may play a more significant role in renal calculus formation than previously believed. There is still a high incidence of carbonate apatite calculi, which could be attributed to bacteriuria. However, obesity, low urine volumes, hypocitraturia, and hyperoxaluria suggest an underrecognized metabolic contribution to stone formation in this population.

Surgical Management of Adult Acquired Buried Penis.

PURPOSE OF REVIEW: Adult acquired buried penis is a morbid condition characterized by complete entrapment of the phallus as a result of morbid obesity, post-surgical cicatrix formation, or primary genital lymphedema. Hygienic voiding is not possible and urinary dribbling is frequent with accompanying inflammation, skin breakdown, and infection from the chronic moisture. The end result is penile skin fibrosis resulting in permanent functional loss. Herein, we describe the etiology of adult acquired buried penis, advances in its surgical management, and quality of life outcomes with treatment. RECENT FINDINGS: Adult acquired buried penis is increasing in incidence as morbid obesity becomes more prevalent. Frequently comorbid conditions affect treatment including those affecting wound healing such a diabetes mellitus. Functional and cosmetic surgical outcomes are being published in greater volume in recent years leading to more refined treatment algorithms. Patient quality of life is greatly improved by definitive surgical management. Adult acquired buried penis is a morbid condition that is increasing in incidence as obesity becomes more commonplace. Surgical management often necessitates surgical lipectomy of the suprapubic fat pad, scrotoplasty, and penile split thickness skin graft. Substantial quality of life improvements have been consistently reported after surgical treatment.

Role of cannabinoid receptor type 1 in tibial and pudendal neuromodulation of bladder overactivity in cats.

The role of cannabinoid type 1 (CB1) receptors in tibial and pudendal neuromodulation of bladder overactivity induced by intravesical infusion of 0.5% acetic acid (AA) was determined in α-chloralose anesthetized cats. AA irritation significantly (P < 0.01) reduced bladder capacity to 36.6 ± 4.8% of saline control capacity. Tibial nerve stimulation (TNS) at two or four times threshold (2T or 4T) intensity for inducing toe movement inhibited bladder overactivity and significantly (P < 0.01) increased bladder capacity to 69.2 ± 9.7 and 79.5 ± 7.2% of saline control, respectively. AM 251 (a CB1 receptor antagonist) administered intravenously at 0.03 or 0.1 mg/kg significantly (P < 0.05) reduced the inhibition induced by 2T or 4T TNS, respectively, without changing the prestimulation bladder capacity. However, intrathecal administration of AM 251 (0.03 mg) to L7 spinal segment had no effect on TNS inhibition. Pudendal nerve stimulation (PNS) also inhibited bladder overactivity induced by AA irritation, but AM 251 at 0.01-1 mg/kg iv had no effect on PNS inhibition or the prestimulation bladder capacity. These results indicate that CB1 receptors play an important role in tibial but not pudendal neuromodulation of bladder overactivity and the site of action is not within the lumbar L7 spinal cord. Identification of neurotransmitters involved in TNS or PNS inhibition of bladder overactivity is important for understanding the mechanisms of action underlying clinical application of neuromodulation therapies for bladder disorders.

Sex difference in the contribution of GABAB receptors to tibial neuromodulation of bladder overactivity in cats.

This study investigated the role of γ-aminobutyric acid subtype B (GABAB) receptors in tibial and pudendal neuromodulation of bladder overactivity induced by intravesical administration of dilute (0.5%) acetic acid (AA) in α-chloralose-anesthetized cats. To inhibit bladder overactivity, tibial or pudendal nerve stimulation (TNS or PNS) was applied at 5 Hz and two or four times threshold (T) intensity for inducing toe or anal sphincter twitch. TNS at 2T or 4T intensity significantly (P < 0.05) increased the bladder capacity to 173.8 ± 16.2 or 198.5 ± 24.1%, respectively, of control capacity. Meanwhile, PNS at 2T or 4T intensity significantly (P < 0.05) increased the bladder capacity to 217 ± 18.8 and 221.3 ± 22.3% of control capacity, respectively. CGP52432 (a GABAB receptor antagonist) at intravenous dosages of 0.1-1 mg/kg completely removed the TNS inhibition in female cats but had no effect in male cats. CGP52432 administered intravenously also had no effect on control bladder capacity or the pudendal inhibition of bladder overactivity. These results reveal a sex difference in the role of GABAB receptors in tibial neuromodulation of bladder overactivity in cats and that GABAB receptors are not involved in either pudendal neuromodulation or irritation-induced bladder overactivity.

Lumbosacral spinal segmental contributions to tibial and pudendal neuromodulation of bladder overactivity in cats.

AIMS: To determine the spinal segmental afferent contributions to tibial and pudendal inhibition of bladder overactivity. METHODS: Intravesical infusion of 0.5% acetic acid was used to irritate the bladder and induce bladder overactivity in anesthetized cats. Tibial or pudendal nerve stimulation was used to suppress the bladder overactivity and increase bladder capacity during cystometry. L5-S3 dorsal roots ipsilateral to the stimulation were exposed by a laminectomy and transected sequentially during the experiments to determine the role of individual dorsal roots in tibial or pudendal neuromodulation. RESULTS: Transection of L5 dorsal root had no effect. Transection of L6 dorsal root in four cats produced an average 18% reduction in tibial inhibition, which is not a significant change when averaged in the group of 10 cats. Transection of L7 dorsal root completely removed the tibial inhibition without changing reflex bladder activity or pudendal inhibition. Transection of S1 dorsal root reduced the pudendal inhibition, after which transection of S2 dorsal root completely removed the pudendal inhibition. Transection of S3 dorsal root had no effect. The control bladder capacity was increased only by transection of S2 dorsal root. CONCLUSIONS: This study in cats revealed that tibial and pudendal neuromodulation of reflex bladder overactivity depends on activation of primary afferent pathways that project into different spinal segments. This difference may be related to the recent observation in cats that the two types of neuromodulation have different mechanisms of action.

Contribution of GABAA, Glycine, and Opioid Receptors to Sacral Neuromodulation of Bladder Overactivity in Cats.

In α-chloralose-anesthetized cats, we examined the role of GABAA, glycine, and opioid receptors in sacral neuromodulation-induced inhibition of bladder overactivity elicited by intravesical infusion of 0.5% acetic acid (AA). AA irritation significantly (P < 0.01) reduced bladder capacity to 59.5 ± 4.8% of saline control. S1 or S2 dorsal root stimulation at threshold intensity for inducing reflex twitching of the anal sphincter or toe significantly (P < 0.01) increased bladder capacity to 105.3 ± 9.0% and 134.8 ± 8.9% of saline control, respectively. Picrotoxin, a GABAA receptor antagonist administered i.v., blocked S1 inhibition at 0.3 mg/kg and blocked S2 inhibition at 1.0 mg/kg. Picrotoxin (0.4 mg, i.t.) did not alter the inhibition induced during S1 or S2 stimulation, but unmasked a significant (P < 0.05) poststimulation inhibition that persisted after termination of stimulation. Naloxone, an opioid receptor antagonist (0.3 mg, i.t.), significantly (P < 0.05) reduced prestimulation bladder capacity and removed the poststimulation inhibition. Strychnine, a glycine receptor antagonist (0.03-0.3 mg/kg, i.v.), significantly (P < 0.05) increased prestimulation bladder capacity but did not reduce sacral S1 or S2 inhibition. After strychnine (0.3 mg/kg, i.v.), picrotoxin (0.3 mg/kg, i.v.) further (P < 0.05) increased prestimulation bladder capacity and completely blocked both S1 and S2 inhibition. These results indicate that supraspinal GABAA receptors play an important role in sacral neuromodulation of bladder overactivity, whereas glycine receptors only play a minor role to facilitate the GABAA inhibitory mechanism. The poststimulation inhibition unmasked by blocking spinal GABAA receptors was mediated by an opioid mechanism.

Renal biopsy for medical renal disease: indications and contraindications.

INTRODUCTION: Percutaneous renal biopsy (PRB) is a safe and effective modality for sampling kidney tissue. In limited circumstances, alternative methods for kidney biopsy may be indicated. Historical contraindications for PRB such as bleeding diathesis, morbid obesity and solitary kidney have been called into question in the literature. We present a review of the literature on PRB and the risks and benefits associated with alternatives. MATERIALS AND METHODS: A review of the literature was performed through MEDLINE and PubMed. A total of 726 articles exist under the query, "percutaneous renal biopsy." Large series describing indications, contraindications, procedural methods, and complications were extracted. To further investigate the risks of percutaneous renal biopsy on solitary kidneys, the literature on percutaneous nephrolithotomy (PCNL) and biopsy of transplant kidneys were queried. Summaries of the data were compiled and synthesized in the body of the text. RESULTS: Percutaneous renal biopsy is safe and effective in the majority of kidney units for the evaluation of medical renal disease. Rates of bleeding range from 0.3%-7.4%, and nephrectomy rates are exceedingly low (0.1%-0.5%). Bleeding rates in open and laparoscopic approaches are comparable and range from 0%-7.0%, with major complications ranging from 0%-6.1%. CONCLUSIONS: The successes of percutaneous methods have called into question traditional contraindications such as solitary kidney, bleeding diathesis, and morbid obesity. In limited cases, alternative methods may be appropriate. We present a review of the literature for the various approaches and their associated complication rates.

Simultaneous cuff revision and placement of an AdVance male sling for persistent post-prostatectomy urinary incontinence initially managed with AMS 800 artificial urinary sphincter.

Placement of an artificial urinary sphincter (AUS) remains the gold standard for treatment of stress urinary incontinence after radical prostatectomy. Persistent or recurrent incontinence after AUS placement can occur. Options then include cuff revision or placement of a retrourethral transobturator sling (RTS), among other alternatives. This report describes simultaneous cuff revision and placement of a RTS for management of refractory stress urinary incontinence after radical prostatectomy. This approach obviates the need for additional procedures if one approach fails. This is especially valuable for patients averse to operative intervention and those at high risk for general anesthesia.

Robotic Ureteral Reconstruction.

It is generally accepted that robotic ureteral reconstruction provides equivalent results to open and laparoscopic approaches while decreasing pain and length of stay. There is a rapid expansion of robotic ureteral reconstructive techniques, platforms, and adjunctive technologies, enabling more efficient, safer, and novel surgical approaches that could not be done in the past. For instance, indocyanine green use allows rapid, precise location of ureteral stenosis and determination of tissue perfusion. Multi-image display allows the surgeon to integrate the robotic field and ureteroscopic images. Novel robotic surgical techniques, such as buccal mucosa ureteroplasty, are changing the treatment algorithm for ureteral strictures.

Effect of COVID-19 on Graduating Urology Resident Case Logs: Analysis of the Accreditation Council of Graduate Medical Education National Data Reports.

OBJECTIVE: To assess the national case logs of the first graduating urologic resident cohorts to have trained during the COVID-19 pandemic for effects on surgical volumes. METHODS: The nationally aggregated Accreditation Council for Graduate Medical Education urology resident case logs were obtained for graduates of academic years (AYs) 2015-2016 through 2020-2021. Case volume differences for tracked index categories were compared between AYs with a 1-way analysis of variance. Data were then combined into pre-COVID and COVID-affected resident cohorts and differences in average cases logged were analyzed with 2-tailed student's t-tests. RESULTS: Graduating urology residents logged an average of 1322 (SD 24.8) cases over their residency during the examined period. Total cases had multiple statistical differences between AYs but the only index category with a statistically significant decrease for a COVID-affected AY compared to pre-COVID AY was pediatric majors: AY 2020-2021 logged fewer cases than AY 2015-2016 (53.9 vs 63.0, P = .004) and AY 2018-2019 (53.9 vs 61.2, P = .04). When aggregated into pre- and COVID-affected cohorts, both pediatric minor (123.4 vs 117.5, P = .049) and pediatric major (61.4 vs 56.8, P = .003) case averages decreased for the COVID-affected cohort of residents, but no adult index category decreased. CONCLUSION: National graduating urology resident surgical volume for adult index categories was maintained through the pandemic. Pediatric cases saw a statistical decrease in volume of questionable clinical significance. This does not eliminate concern that individuals may have experienced a detrimental impact on their resident education.

Outcomes of Initial Transcorporal Versus Standard Placement of Artificial Urinary Sphincter in Patients With Prior Radiation.

OBJECTIVE: This study aimed to evaluate both device and functional outcomes of men who underwent initial artificial urinary sphincter (AUS) placement after pelvic radiation using the transcorporal versus the standard approach. METHODS: A retrospective review of patients who underwent first-time AUS placement after pelvic irradiation for prostate cancer was conducted between January 2008 and June 2020. Patients were grouped by transcorporal versus standard device placement. The primary outcomes of interest included major complications (revision or explant surgery) and functional outcomes (pads per day, International Prostate Symptom Score {IPSS}, quality of life {QOL} score). RESULTS: We identified 45 patients who underwent first-time AUS with a history of prior pelvic irradiation for prostate cancer, 27 underwent transcorporal placement and 18 underwent standard placement. Transcorporal AUS placement resulted in a significantly lower number of major complications (p=0.01), explants (p=0.02), and revisions (p=0.04) The transcorporal artificial urinary sphincter group had better postoperative pads per day (p=0.04), IPSS (p<0.01), and IPSS QOL score (p<0.01). CONCLUSIONS: Initial transcorporal artificial urinary sphincter placement is a promising technique with lower rates of major complications in patients with a history of prior pelvic radiation and had better functional urinary outcomes.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization.

BACKGROUND: Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population. METHODS: Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results. RESULTS: A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5-5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0-5.3), no patients underwent urinary diversion. CONCLUSIONS: Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

Robotic Surgery for the Reconstruction of Transplant Ureteral Strictures.

OBJECTIVE: To demonstrate the feasibility and success of a robotic approach to reconstruction of ureterovesical anastomotic strictures in kidney transplants. MATERIALS AND METHODS: Between November 2017 and December 2019, a total of 5 patients with transplant ureteral stricture were identified and treated with robot assisted laparoscopic repair. All patients were confirmed to have ureteral stricture with a preoperative antegrade nephrostogram through their nephrostomy tube and cystogram. The patients demographics, ureteral characteristics, type of procedure, and outcomes are reported. RESULTS: All patients were diagnosed after evaluation for renal deterioration. The average age of the patients was 49 years old. The average stricture length was 2.5 cm, and the location was variable, though more commonly in the distal ureter. Three patients required a pyelo-vesicostomy, while 2 required a ureteroneocystostomy. The mean length of stay was 2.2 days. Average follow-up was 97 days, with all 5 patients having successful outcomes, no strictures or delayed leaks were identified. There were no wound infections or readmissions within 30 days. CONCLUSION: Though a complex repair, the robot-assisted approach to transplant ureter reconstruction using either an end to side neoureterocystotomy or direct pyelo-vesicotomy is technically feasible and successful. Given the many advantages inherent in comparison to an open approach, the robotic repair offers significant advantages to both the patient and the surgeon who is experienced with robotic surgery and reconstructive principles.

Robotic-assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics.

OBJECTIVE: To describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging. The robotic platform has demonstrated benefits in these characteristics in deep pelvic surgery. METHODS: We report a retrospective review of 10 patients who underwent robotic-assisted urethroplasty at a single institution by a single surgeon in a 1 year period. All patients underwent a standard perineal dissection with robotic-assisted placement of proximal sutures. Postoperative outcomes include urethroplasty leak rate as determined by voiding cystourethrograms, urethroplasty success rate, and perioperative complications. RESULTS: The mean age of this cohort was 43 years old (14-68). Average stricture length was 2.2 cm (1.5-3.0 cm) and most frequently in the bulbar urethra (5/10). Seven patients underwent nontransecting urethroplasties while 3 underwent transecting anastomotic repair. At postoperative voiding cystourethrograms, no patient had urinary extravasation. Average set-up time for the robotic portion of the surgery was 15 minutes with 30-45 minutes needed for suture placement. CONCLUSION: Robotic-assisted urethroplasty provides excellent visualization and ergonomics for posterior and proximal bulbar urethral reconstruction. This is particularly helpful in patients with narrow pelvic anatomy and long distances from the perineal skin to the proximal urethral edge. Operative and postoperative outcomes are comparable to the standard approach with improved surgeon comfort and visualization. Additional follow-up is required to assess long-term outcomes in comparison to a standard approach.