Robotic buccal graft placement feasible, reproducible

An initial assessment of robotic ureteral reconstruction using buccal mucosa graft indicates that it is a feasible and reproducible approach for reconstruction of complex ureteral strictures, reconstructive urologists reported at the AUA annual meeting in New Orleans.

Lee C. Zhao, MDNew Orleans-An initial assessment of robotic ureteral reconstruction using buccal mucosa graft indicates that it is a feasible and reproducible approach for reconstruction of complex ureteral strictures, reconstructive urologists reported at the AUA annual meeting in New Orleans.

Now, larger and longer experience is needed to optimize the technique and to understand the durability of the outcome, said first author Lee C. Zhao, MD, assistant professor of urology, New York University Langone Medical Center, New York.

“Our goal is to develop a minimally invasive alternative to current techniques for treating long proximal or multifocal ureteral strictures,” he said.

“As these are rare cases, we hope to enlist other centers to join in our multi-institutional study and establish a registry of how the cases are being performed and the outcomes. With that information, we can hone in on the best technique and factors for recurrence.”

Dr. Zhao presented data from 12 patients operated on over an 18-month period (October 2013 to April 2015) at his institution, Tulane University School of Medicine in New Orleans, and Temple University School of Medicine in Philadelphia. The indications for ureteral reconstruction were a proximal or multifocal stricture not amenable to ureteroureterostomy or pyeloplasty. Stricture length for the cohort ranged from 1.5 to 6 cm (mean, 3.5 cm).

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All of the surgeries were completed without any complications. The mean operative time was just over 4 hours, with a range from about 3 to 6 hours. Mean estimated blood loss was 87.5 mL (range, 25 to 200 mL), and mean length of hospitalization was 2 days (maximum, 3 days).

“The longer operative times were at institutions where patient repositioning was done for the graft harvest. At NYU, we do the entire procedure with the patient in the flank position,” Dr. Zhao said.

Pyelograms performed at 6-7 weeks at the time of stent removal confirmed patency of all anastomoses. Of eight patients who had sufficiently long follow-up to be evaluated with a diuretic renal scan (3 to 4 months), six were obstruction-free.

Dr. Zhao said, however, he would not classify the outcome as a failure in the other two cases. He explained that one patient had narrowing of the ureterovesical junction due to a new stricture distant from the anastomosis that was managed successfully with balloon dilation. In the second case, although diuretic T1/2 was 22 minutes, there was drainage on retrograde pyelogram, and the patient was asymptomatic.

The only surgery-related postoperative complication was stent migration requiring replacement, which occurred in one patient.

Dr. Zhao told Urology Times that the procedure is not technically out of the reach of any surgeon who is proficient in performing upper-tract robotic procedures. He noted, however, that it is nice to work with a team because ureteroscopy and buccal mucosal harvesting can be done simultaneously.

NEXT: How the procedure is performed

How the procedure is performed

To perform the procedure, the patient is positioned in a modified lateral decubitus lithotomy position that will enable bladder access, while the mouth is draped separately for harvesting the buccal mucosa graft. Port placement sites are similar to those used for pyeloplasty. Ureterolysis is performed followed by an ureterotomy through the segment of the stricture and suturing of the buccal mucosa graft. The graft can be placed ventrally or dorsally. Omentum is usually used as backing to help perfuse the graft.

Dr. Zhao emphasized the benefit for nephrostomy tube placement and ureteral stent removal preoperatively, which enables accurate delineation of the beginning and end of the stricture. In addition, it is very helpful to be able to place an ureteroscope during the procedure to visualize the stricture, which is why patients are positioned in a modified lithotomy position at NYU.

Dr. Zhao told Urology Times he considers robotic ureteral reconstruction using buccal mucosal graft to be a great option for patients with strictures due to nephrolithiasis, prior pyeloplasty, ureteroscopic injury, and trauma.

“A nice thing about the operation is that it doesn’t burn any bridges. Afterwards, patients remain candidates for other reconstruction options,” he said.

“If we think of where this procedure might fit on the ladder of reconstructive options, robotic ureteral reconstruction using buccal mucosal graft is a nice middle rung for fixing an otherwise difficult problem.”