New England Section of the American Urological Association

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Characteristics and Clinical Outcomes of a Multi-Institutional Observational Patient Cohort Who Underwent Anastomotic Posterior Urethroplasty by a Combined Robotic Transabdominal and Open Transperineal Approach
Jaime A. Cavallo, MD, MPHS1, Alex J. Vanni, MD1, Geolani Dy, MD2, Sabrina Stair, MD2, David Canes, MD1, Lee Zhao, MD, MS2
1Lahey Hospital and Medical Center, Burlington, MA, 2New York University Langone Medical Center, New York, NY

Background:
Urethral strictures occurring between the bladder neck and the bulbar urethra present a uniquely challenging reconstruction, especially when complicated by a prior history of radiation therapy. These patients are frequently managed a suprapubic tube or urinary diversion due to the complexity of reconstruction. Our objective is to review patency and incontinence outcomes of posterior urethral reconstruction treated by a combined robotic transabdominal and open transperineal approach.
Methods:
A multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic transabdominal and open transperineal surgical approach between 1/2012 and 12/2018 was performed. We reviewed patient demographics, medical history, etiology, and previous endoscopic treatment. Urethroplasty success was anatomic and based upon atraumatic passage of a 17 Fr flexible cystoscope. Incontinence was defined as the use of >1 pad per day or procedures for incontinence.
Results:
Between 1/2012 and 12/2018, a total of 15 patients underwent anastomotic posterior urethroplasty by a combined robotic transabdominal and open transperineal approach at 2 institutions. Mean follow-up was 388 (range 10-1487) days. Mean age was 58.2 (SD 19.1) years, median Charlson Comorbidity Index was 4 (range 0-6) for these men. 40.0% of the cohort (n=6) had a tobacco smoking history. 66.7% of the cohort (n=10) had a history of prostate cancer, and 6.7% of the cohort (n=1) had a history of urothelial cancer. All patients with a history of prostate cancer were treated with radiation therapy: 20% (n=2) brachytherapy, 60% (n=6) eternal beam radiation therapy (EBRT), and 20% (n=2) combination brachytherapy and EBRT. Of the patients with prostate cancer, 20% (n=2) underwent salvage prostatectomy. Mean time from radiation therapy to diagnosis of posterior urethral stricture was 8.2 (SD 5.6) years. 86.7% (n=13), 13.3% (n=2), and 6.7% (n=1) of the cohort underwent previous procedures for urethral stricture, bladder outlet obstruction, and other urologic disease, respectively. Obstructive voiding management at presentation was with a suprapubic catheter for 53.3% (n=8) and intermittent catheterization for 13.3% (n=2) of the cohort. Reconstruction required prostatectomy and corporal splitting in 40.0% (n=6) and 6.7% (n=1) of the cohort, respectively. Gracilis muscle flaps were used in 26.7% (n=4) of the cohort. Postoperative hematoma, wound abscess, urinary leak, and PE/DVT each occurred in 6.7% (n=1) of the cohort. Stricture recurrence occurred in 13.3% (n=2) of the cohort. 26.7% (n=4) of the cohort reported de novo erectile dysfunction at a mean of 104 (range 79-137) postoperative days after the index procedure. 46.7% (n=7) of the cohort had pre-existing stress urinary incontinence (SUI); an additional 33.3% (n=5) developed de novo SUI after the index procedure. 40.0% (n=6) of the cohort underwent placement of an artificial urinary sphincter at a mean interval of 411 (range 105-1487) days after the index procedure.
Conclusions:
Complex posterior urethroplasty by a combined robotic transabdominal and open transperineal approach is associated with a low rate of stricture recurrence. Urinary incontinence is expected following this operation, and short-term results of AUS placement following reconstruction are encouraging. Further follow-up is needed to determine the long-term risk of urethral erosion in these high-risk patients.


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