Utilizing computed tomography-based renal parenchymal volumes to calculate split renal function in patients with ureteral stricture disease.

PURPOSE: Evaluation of split renal function (SRF) is critical for guiding surgical treatment decisions for patients with ureteral stricture disease (USD). We aimed to determine whether computed tomography (CT)-based renal parenchymal volumes may be used to predict SRF in patients with USD. METHODS: We retrospectively reviewed all patients undergoing surgical management for USD at a single institution from October 2021 to January 2024. Patients who had preoperative nuclear medicine scan (NMS) and CT scan with intravenous contrast that were obtained within six weeks of each other were included. Interval between NMS and CT could be longer if the affected renal unit was drained with ureteral stent and/or percutaneous nephrostomy. Volume measurements were obtained using the 3D Region of Interest (ROI) Tool on Visage®7 Enterprise Imaging Platform (Visage Inc., San Diego, USA) by two investigators that were blinded to NMS derived SRF. Intraclass correlation coefficient (ICC) was used to assess consistency between investigators. Predictive accuracy was assessed using Pearson correlation coefficient (r) and linear regression. RESULTS: 40 of 160 patients met inclusion criteria. There was excellent reliability in calculating renal parenchymal volume between raters (ICC = 0.990). There was a strong linear correlation between estimated CT SRF and NMS SRF (r = 0.912, p < 0.00001). A linear regression model found RObservedSRF = -0.013 + 1.015(REstimatedSRF), with r2 = 0.832. CONCLUSION: CT-derived parenchymal volume analysis may be used to estimate SRF in patients with USD. This may obviate the need to obtain preoperative renal scans for SRF measurement in selected patients when assessing surgical management options.

Development of a Patient-Reported Outcome Measure for Patients with Ureteral Stricture Disease.

OBJECTIVES: To develop a patient-reported outcome measure using qualitative patient-centered methods and expert opinion to quantify the impact of ureteral stricture disease and its management. METHODS: Patients undergoing robotic ureteral reconstruction for ureteral stricture disease between 9/2021-4/2023 were enrolled. A novel patient-reported outcome was developed in four steps: 1) Semi-structured concept elicitation interviews to evaluate the physical, mental, and social effects of ureteral stricture disease; 2) Item generation based on themes identified in the interview transcripts, existing patient-reported outcomes on health-related QOL, and expert opinion; 3) Feedback on the generated items from a panel of external clinicians with high surgical volume for ureteral stricture disease; and 4) Cognitive interviews assessing patient comprehension and relevance. RESULTS: We conducted 14 semi-structured concept-elicitation interviews. After qualitative analysis of these interviews, we generated a 13-item instrument: 8 items assessed symptoms, 4 items assessed QOL, and 1 item assessed patient-perceived treatment success. Expert input supported the content of the patient-reported outcome measure and guided minor adjustments. Two rounds of cognitive interviews were conducted. The first round included 6 patients, and the patient-reported outcome measure was revised according to patient feedback. The second round included 4 patients, and no additional revisions were made based on the second round. CONCLUSIONS: We utilized qualitative patient-centered methods and expert opinion to develop a patient reported outcome measure to assess outcomes in patients undergoing surgery for ureteral stricture disease.

Preoperative Factors for Success of Robotic Ureteral Reconstruction for Distal Ureteral Strictures.

Introduction: To investigate preoperative predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for management of distal ureteral strictures. Methods: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for surgical repair of distal ureteral strictures between 04/2012 and 12/2022. Procedures included refluxing reimplant (58.5%), side to side reimplant (18.0%), ureteroureterostomy (12.7%), non-refluxing reimplant (6.3%), buccal mucosa ureteroplasty (2.8%), and appendiceal bypass ureteroplasty (1.7%). Patients were grouped according to whether they were surgically successful. Preoperative variables between both groups were compared using chi-square tests. All variables with associations of p < 0.2 underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p ≤ 0.05 considered statistically significant). Results: Overall, 284 patients met inclusion criteria. Univariate analysis showed obesity (p = 0.03), smoking history (p = 0.10), abdominopelvic radiation history (p = 0.14), immunocompromised state (p = 0.12), and ureteral rest (p = 0.01) were notable preoperative factors (p < 0.2). Binary logistic regression analysis further revealed the odds of surgical success in patients with obesity was 0.32 times (CI: 0.12-0.83, p = 0.02) the odds of success for patients without obesity. The odds of surgical success in patients who underwent preoperative ureteral rest was 4.2 times (CI: 1.51-11.77, p < 0.01) the odds of success for patients who did not undergo preoperative ureteral rest. Conclusion: Preoperative factors including obesity and ureteral rest may affect surgical success of RUR for management of distal ureteral strictures.

A review of complications after ureteral reconstruction.

Objective: This study aimed to provide a comprehensive overview of the complications unique to ureteral reconstruction in adults, emphasizing their presentation, diagnosis, and management in the treatment of ureteral structure disease. Methods: This review involves an in-depth analysis of existing literature and case studies pertaining to ureteral reconstruction, with a focus on examining the range of complications that can arise post-surgery. Special attention is given to the presentation of each complication, the diagnostic process involved, and the subsequent management strategies. Results: Ureteral reconstruction can treat ureteral stricture disease with low morbidity; however, complications, although uncommon, can have severe consequences. The most notable complications include urinary extravasation, stricture recurrence, urinary tract infections, compartment syndrome, symptomatic vesicoureteral reflux, and Boari flap necrosis. Each complication presents unique diagnostic challenges and requires specific management approaches. Conclusion: Ureteral reconstruction is a highly effective treatment for ureteral stricture disease. Having a strong understanding of the potential complications that patients may experience following ureteral reconstruction is not only critical to adequately counsel patients but also facilitate prompt diagnosis and management of complications when they arise.

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

OBJECTIVE: To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction (UPJO), proximal, and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between April 2012 and December 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 <.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (P ≤.05 was considered statistically significant). RESULTS: Overall, 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% vs 25.7%, P <.01) and a higher proportion of patients who underwent ureteral rest (74.3% vs 48.6%, P <.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 ((confidence interval) CI 1.26-7.54, P = .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 = .01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION: Surgical 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.

Leiomyoma Fistulization After Uterine Artery Embolization.

BACKGROUND: Uterine artery embolization (UAE) has been used to treat symptomatic uterine leiomyomas since 1995. This case report describes a rare complication of UAE, with delayed recognition, ultimately requiring definitive hysterectomy. CASE: A 53-year-old women with symptomatic leiomyomas underwent imaging demonstrating an enlarged (16.9×11.3×11.5 cm) uterus with multiple leiomyomas. She underwent UAE and, over the subsequent 3 months, and had five emergency department visits for abdominal pain and dysuria. Pelvic magnetic resonance imaging (MRI) 4 months postprocedure showed nodular mural enhancement of the right anterior bladder dome, and cystoscopy demonstrated irregular tissue on the right dome of the bladder. The patient ultimately underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, partial cystectomy with reconstruction, and omental flap for bladder necrosis and leiomyoma fistulization. CONCLUSION: Bladder necrosis and leiomyoma fistulization are rare complications of UAE that can present with pelvic pain, hematuria, and recurrent bladder stones. Computed tomography and MRI can be useful tools in evaluating for complications, but clinicians should have a low threshold to use cystoscopy to directly visualize potential abnormalities identified on imaging. Patients with complex cases with suspected post-UAE complications warrant referral to tertiary care centers for a multidisciplinary approach.

Blunt traumatic female urethral and bladder neck injuries: a 15-year single-institution experience.

PURPOSE: To describe our experience in the management and outcomes of female patients with urethral or bladder neck (BN) injury at a high-volume Level 1 trauma center. METHODS: A retrospective chart review of all female patients with urethral or BN injury by blunt trauma mechanism admitted to a Level 1 trauma center between 2005 and 2019 was performed. RESULTS: Ten patients met study criteria with median age 36.5 years. All had concomitant pelvic fractures. All injuries were confirmed operatively, with no delayed diagnoses. Two patients were lost to follow up. One patient was not eligible for early repair of urethral injury and had two repairs of a urethrovaginal fistula. Two of seven (29%) patients who underwent early repair of their injury had an early Clavien grade > 2 complication, with none reporting long-term complications at median follow-up of 15.2 months. CONCLUSIONS: Intraoperative evaluation is critical in the diagnosis of female urethral and BN injury. In our experience, acute surgical complications are not uncommon after the management of such injuries. However, there were no reported long-term complications in those patients who had prompt management of their injury. This aggressive diagnostic and surgical strategy is instrumental in attaining excellent surgical outcomes.

Functional outcomes of Fournier's gangrene: a multi-institutional experience.

INTRODUCTION: Fournier's gangrene (FG), is a progressive, necrotizing soft tissue infection of the external genitalia, perineum, and/or anorectal region. How treatment and recovery from FG impacts quality of life related to sexual and general health is poorly characterized. Our purpose is to evaluate the long term impact of FG on overall and sexual quality of life using standardized questionnaires through a multi-institutional observational study. MATERIALS AND METHODS: Multi-institutional retrospective data were collected by standardized questionnaires on patient-reported outcome measures including the Changes in Sexual Functioning Questionnaire (CSFQ) and the Veterans RAND 36 (VR-36) survey of general health-related quality of life. Data were collected via telephone call, email, and certified mail, with a 10% response rate. There was no incentive for patient participation. RESULTS: Thirty-five patients responded to the survey, with 9 female and 26 male patients. All patients in the study underwent surgical debridement between 2007-2018 at three tertiary care centers. Further reconstructions were performed for 57% of respondents. Values for respondents with overall lower sexual function were reduced in all component categories (pleasure, desire/ frequency, desire/interest, arousal/excitement, orgasm/ completion), and trended toward male sex, older age, longer time from initial debridement to reconstruction, and poorer self-reported general health-related quality of life metrics. CONCLUSION: FG is associated with high morbidity and significant decreases in quality of life across general and sexual functional domains.

Robotic ureteral reconstruction for recurrent strictures after prior failed management.

Objectives: To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. Materials and Methods: 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. Results: 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. Conclusions: RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

Complex Penile Surgery: Plication, Grafting, and Implants.

Surgical treatments for Peyronie's disease and erectile dysfunction are generally straightforward and associated with excellent outcomes. However, severe (>60°) and multidirectional curvature, hourglass deformity, severe penile shortening, and ossified plaque may complicate surgery in patients with Peyronie's disease. Similarly, a history of priapism, prior implant infection, and penile injury can pose challenges to successful implant surgery secondary to severe corporal fibrosis. Thus, when these pathophysiological processes cause severe fibrosis and loss of function of the tunica albuginea and deep cavernosal spaces, adjunctive reconstructive techniques are necessary. Herein, we integrate the literature regarding surgical management of complex Peyronie's disease and erectile dysfunction with emphasis on plication, grafting, and implants to achieve satisfactory outcomes across the full range of etiology and degree of surgical complexity.

Computed tomography-based volume calculations of renal ischemia predicts post-traumatic renal function after renal infarction injury.

OBJECTIVES: To describe a systematic method to quantify the severity of renal infarction injury and assess its association with post-traumatic renal function after blunt trauma. METHODS: We retrospectively reviewed all patients who suffered an AAST grade IV renal infarction injury without active bleeding secondary to blunt trauma between 1/2010 and 10/2020. Only patients with a pre-traumatic eGFR within 12 months of injury and post-traumatic eGFR within 3-12 months were included. Percentage of renal ischemia was defined as: (ischemic volume/total volume) × 100%. Two radiologists reviewed computed tomography images to determine ischemic and overall cross-sectional areas using the polygon region of interest tool. These areas were multiplied by slice thickness to obtain ischemic and total volumes. Intraclass correlation coefficient was used to assess consistency between radiologists. Linear regression analyses were used to assess the association between percentage of renal ischemia and post-traumatic renal function. RESULTS: Thirty-five of 140 (25.0%) patients met inclusion criteria. The median (IQR) pre-trauma eGFR was 107.7 ml/min/1.73m2 (90.6-121.8), percentage of renal ischemia was 8.4% (2.9-30.1), and decrease in eGFR after trauma was 12.9 ml/min/1.73m2 (0.4-32.6). There was excellent reliability in calculating ischemic volume (ICC = 0.987) and total kidney volume (ICC = 0.995) between two radiologists. When adjusting for pre-traumatic eGFR, patient age, and injury severity score, a 10% increase in ischemic volume was associated with a post-injury eGFR value that was 8.0 ml/min/1.73 m2 (95% CI - 11.2, - 4.7) lower. CONCLUSIONS: CT-based volume calculation of renal ischemia may be utilized to quantify kidney injury and be associated with post-traumatic renal function loss.

Ureteral Injuries Secondary to Blunt Abdominal Trauma: A 15-Year Review of Presentation, Management, and Outcomes at a Level 1 Trauma Center.

OBJECTIVE: To report our contemporary experience with ureteral injuries secondary to blunt trauma, with diagnostic methods and management stratified according to injury severity. MATERIALS AND METHODS: We performed a retrospective 15-year study (4/2005-4/2020) at a regional level I trauma center. Patients were categorized as having a partial or complete transection injury. Treatment success was defined as the absence of hydronephrosis or obstruction on follow-up imaging. RESULTS: Eighteen patients suffered 10 partial and 9 complete ureteral transections. All 16 patients who underwent initial evaluation with computed tomography were correctly graded as having partial or complete transections, and there were no missed injuries. Treatment of partial transections included observation (3/9), retrograde double-J stent placement (4/9), and Heineke-Mikulicz pyeloplasty (2/9). At a median follow-up of 9 (IQR 2-59) months, 8/9 (89%) partial transections were treated successfully. Treatment of complete transections included pyeloplasty (3/9), ureteroureterostomy (4/9), and ureteroneocystostomy (1/9). One patient who underwent attempted reconstruction 6 days after trauma required nephrectomy. At a median follow-up of 32 (IQR 4-82) months, 7/8 (89%) reconstructed complete transections were treated successfully. CONCLUSION: Computed tomography with delayed phase imaging is a sensitive test to detect ureteral injuries after blunt trauma, and computed tomography can distinguish between partial and complete transections. Partial transection injuries secondary to blunt trauma may be amenable to ureteral stent placement or close observation in select cases. Good intermediate-term outcomes can be achieved with early surgical intervention in the case of complete transections.

Perioperative and Functional Outcomes of Robot-assisted Ureteroenteric Reimplantation: A Multicenter Study of Seven Referral Institutions.

BACKGROUND: Open revision of ureteroenteric strictures (UESs) is associated with considerable morbidity. There is a lack of data evaluating the feasibility of robotic revisions. OBJECTIVE: To analyze the perioperative and functional outcomes of robot-assisted ureteroenteric reimplantation (RUER) for the management of UESs after radical cystectomy (RC). DESIGN SETTING AND PARTICIPANTS: A retrospective multicenter study of 61 patients, who underwent 63 RUERs at seven high-volume institutions between 2009 and 2020 for benign UESs after RC, was conducted. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data were reviewed for demographics, stricture characteristics, and perioperative outcomes. Variables associated with being stricture free after an RUER were evaluated using a multivariate Cox regression analysis. RESULTS AND LIMITATIONS: Among 63 RUERs, 22 were right sided (35%), 34 left sided (54%), and seven bilateral (11%). Twenty-seven (44%) had prior abdominal/pelvic surgery and five (8%) radiotherapy (RT). Thirty-two patients had American Society of Anesthesiologists (ASA) scores I-II (52%) and 29 ASA III (48%). Forty-two (68%) RUERs were in ileal conduits, 18 (29%) in neobladders, and two (3%) in Indiana pouch. The median time to diagnosis of a UES from cystectomy was 5 (3-11) mo. Of the UESs, 28 (44%) failed an endourological attempt (balloon dilatation/endoureterotomy). The median RUER operative time was 195 (175-269) min. No intraoperative complications or conversions to open approach were reported. Twenty-three (37%) patients had postoperative complications (20 [32%] were minor and three [5%] major). The median length of hospital stay was 3 (1-6) d and readmissions were 5%. After a median follow-up of 19 (8-43) mo, 84% of cases were stricture free. Lack of prior RT was the only variable associated with better stricture-free survival after RUER (hazard ratio 6.8, 95% confidence interval 1.10-42.00, p = 0.037). The study limitations include its retrospective nature and the small number of patients. CONCLUSIONS: RUER is a feasible procedure for the management of UESs. Prospective and larger studies are warranted to prove the safety and efficacy of this technique. PATIENT SUMMARY: In this study, we investigate the feasibility of a novel minimally invasive technique for the management of ureteroenteric strictures. We conclude that robotic reimplantation is a feasible and effective procedure.

Robot-Assisted Laparoscopic Distal Ureteroureterostomy for Distal Benign Ureteral Strictures with Long-Term Follow-Up.

Objectives: To demonstrate feasibility of robot-assisted laparoscopic (RAL) ureteroureterostomy (UU) for benign distal ureteral strictures (DUS) in our robotic reconstruction series with long-term follow-up. Patients and Methods: In a retrospective review of our prospectively maintained RAL ureteral reconstruction database, we followed patients between June 2012 and February 2019 who underwent a UU for DUS. In addition to patient demographics, we recorded the etiology, stricture length, and recurrence rates. Recurrence was defined as findings of recurrent or persistent obstruction by postoperative mercaptoacetyltriglycine diuretic renal scan or the need for additional intervention with ureteral drainage or revisional surgery. Results: We identified 22 patients who underwent a RAL-UU for DUS of benign etiologies. Median age was 42 years (interquartile range [IQR] 39-57) and 20 of 22 patients (90.1%) were women. Median stricture length was 1.5 cm (IQR 1-2). Iatrogenic surgical injury was noted in 16 patients (73%). All ureteral reconstruction was performed using RAL. Postoperative imaging consisted of renal ultrasonography, diuretic renal scan, or cross-sectional radiology within 3 months of the index operation. Further imaging was dependent on clinical judgment. Twenty patients (90.1%) had success with median follow-up time of 54.6 months with two recurrences necessitating RAL ureteroneocystostomy (UNC). Conclusion: RAL-UU for DUS is technically viable and shows promising efficacy in properly selected patients. This technique may serve a niche for preserving the natural anatomical drainage of the bladder and ureter in addition to obviating the sequela of vesicoureteral reflux as seen in UNC.

A review of technical progression in the robot-assisted radical prostatectomy.

Since the advent of the robotic surgery, its implementation in urology has been both wide and rapid. Particularly in extirpative surgery for prostate cancer, techniques in robotic-assisted radical prostatectomy have-and continue to-evolve to maximize functional and oncologic outcomes. In this review, we briefly present a historical perspective of the evolution of various robotic techniques, allowing us to contextualize contemporary robotic approaches to radical prostatectomy.

Pathological characteristics of the large renal mass: potential implication for clinical role of renal biopsy.

INTRODUCTION: To assess whether patients with a large renal mass, treated by radical nephrectomy (RN), could have benefited from preoperative renal mass biopsy (RMB). The decision to perform partial nephrectomy (PN) for an organ-confined > 4 cm renal mass can be complex. Albeit often feasible, oncologic safety of PN in this cohort is debated. Yet, a significant portion of large renal masses that undergo RN prove benign or indolent, indicating a potential role for RMB to guide nephron preservation. MATERIALS AND METHODS: We queried prospectively maintained databases from three institutions to identify patients who underwent RN for localized > 4 cm renal mass. We excluded patients with nodal or distant metastases. Multivariable analysis assessed how clinicopathologic variables, mass anatomic complexity, and patient comorbidities related to the likelihood of harboring an indolent neoplasm. RESULTS: A total of 702 patients underwent RN for localized > 4 cm renal mass (median tumor size 7.0 cm (IQR 5.5-9.2); 12.8% (n = 90) of patients were diagnosed with oncocytoma/oncocytic neoplasm (n = 27, 3.8%) or chromophobe RCC (n = 63, 9.0%). When stratified by tumor size, indolent tumors comprised 10.1% of 4-7 cm masses, 15.6% of ≥ 7-10 cm masses, and 17.3% of ≥ 10 cm tumors. Upon multivariate analysis, younger age was associated with indolent tumors (p = 0.04, OR 0.97, 95% CI 0.94-0.99). CONCLUSIONS: Approximately 1 in 8 patients with a renal mass > 4 cm harbored benign or low risk indolent potential lesions and were associated with younger age. As such, patients with large renal masses for whom risk trade-offs between PN and RN are unclear, present a unique opportunity for greater utilization of RMB.

A Multi-Institutional Experience with Robotic Vesicovaginal and Ureterovaginal Fistula Repair After Iatrogenic Injury.

Objectives: To describe our multi-institutional experience with robotic repair of iatrogenic urogynecologic fistulae (UGF), including vesicovaginal fistulae (VVF) and ureterovaginal fistulae (UVF). Methods: We performed a retrospective review identifying patients who underwent robotic repair of VVF and UVF between January 2010 and May 2019. All patients failed conservative management with Foley catheter or upper tract drainage (ureteral stent and/or nephrostomy tube), respectively. Patient demographics and perioperative outcomes were analyzed. Success was defined as no vaginal leakage of urine postoperatively, in the absence of drains, catheters, or stents. Results: Of 34 patients, 22/34 (65%) had VVF and 12/34 (35%) had UVF repair. VVF etiology included radiation (1/22, 4.5%) and surgery (21/22, 95.5%). Four of 22 (18%) had undergone prior repair attempt. Median console time was 187 minutes (interquartile range [IQR]: 151-219), estimated blood loss (EBL) was 50 mL (IQR: 50-93), and median length of stay (LOS) was 1 day (IQR: 1-2). Two of 22 (9%) patients had a postoperative complication. At mean follow-up of 28.9 months, 20/22 (91%) VVF cases were clinically effective. UVF etiology was gynecologic surgery in all cases; 8/12 (67%) were left-sided, 4/12 (33%) were right-sided. None was repeat repairs. Two of 12 (17%) underwent ureteroureterostomy, and 10/12 (83%) had reimplant. Median console time was 160 minutes (IQR: 133-196), EBL was 50 mL (IQR: 50-112), and LOS was 1 day (IQR: 1-1). No complications were encountered. At mean follow-up of 29.3 months, 100% of UVF repairs were effective. Conclusions: Robotic repair of iatrogenic UGF may be effectively performed with low complication rates by experienced urologic surgeons.

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 <.05 was considered significant. 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<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023). 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.