Prostatic Urethral Lift: Does Age Matter?
Mohannad A. Awad, MD, Richard D. Hartnett, MD, Erin Hunt, MS4, Andrew C. Mahoney, MD.
University of Vermont Medical Center, Burlington, VT.
BACKGROUND: Complex ureteral reconstruction for stricture disease with buccal mucosa graft (BMG) is reported in the urologic literature with a number of case series touting its success for long-segment ureteral strictures that would otherwise require an ileal ureter or autotransplant. To date, there are approximately 34 reported human cases of robotic-assisted buccal ureteroplasty. However, the prior reports have varying definitions of operative success. We sought to review our single-institution experience with robotic-assisted BMG ureteroplasties to complement the existing literature.
METHODS: An institutional review board approved observational retrospective review of all robotic ureteroplasties performed with a BMG at our institution by two surgeons was undertaken. Patient demographics, operative characteristics, and post-surgical outcomes were recorded. Clinical failure of the ureteroplasty was defined as the need to perform any additional intervention on the ipsilateral collecting system secondary to refractory ureteral obstruction.
RESULTS: A total of nine robotic BMG ureteroplasties were performed at our institution from 2015-2019. The stricture etiologies were iatrogenic endoscopic calculus treatment sequelae (n=3), failed pyeloplasty (n=3), idiopathic (n=1), sequelae of nephrolithiasis (n=1), and iatrogenic ureteral injury during colorectal surgery (n=1). All ureteroplasties were performed robotically, with six using an anterior onlay technique and three using an augmented anastomotic technique. Four of the patients had previously undergone a failed prior procedure for their stricture. The average ureteral stricture length in the cohort was 5.4cm (4-7cm). The stricture location was proximal for five cases while four cases were mid-ureteral. In seven cases the onlay graft was wrapped with an omental flap and in two cases the reconstruction was wrapped with only Gerota's fascia. With an average follow up of 15.6 months (1-23 months), three (33%) of the BMG ureteroplasties required an additional intervention secondary to clinical failure of the reconstruction. Two of these cases had previous open ureteral reconstruction attempts. Of the failed reconstructions (cases 4-6), one required short term placement of a nephrostomy tube, one has required a chronic ureteral stent, and one underwent an autotransplant.
CONCLUSIONS: The BMG ureteroplasty is an important addition to the armamentarium of surgical approaches for the management of ureteral stricture disease and is a viable treatment option for long segment ureteral strictures that would otherwise require an ileal ureter or autotransplant. Our small experience adds almost 25% case volume to the existing literature. Our success rate of 67% is notable lower than a previously reported multi-institutional review of 19 patients showing a 90% success rate published by Zhao et al (Eur Urol. 2017), but comparison is hindered by our limited case volume. We hope our experience encourages continued evaluation of this method as an efficacious option moving forward.
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