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Complex bladder neck reconstruction and posterior urethroplasty
Robotic reconstruction
Bladder neck reconstruction and posterior urethroplasty have posed a major challenge in surgical reconstruction for urologic surgeons. Often, these patients present with a previous history of radiotherapy or ablative interventions for other pathologies that have resulted in obstructive or damaged function of the lower tracts. These complications can be devastating to the patient’s quality of life,
Prior to the advent of laparoscopy, upper tract pathology (i.e., tumors, stricture, hydronephrosis) and bladder neck/posterior urethral disease posed a therapeutic challenge, as our treatment algorithm was limited to endourologic or largely open surgical intervention. Laparoscopy introduced a minimally invasive alternative to open reconstruction in challenging cases involving complex urinary tract reconstruction. The mainstream utilization of robotics has further advanced upper tract and bladder neck/posterior urethral reconstruction by improving physician dexterity, visualization, and comfort. While there is an increasing trend in the utilization of robotics for reconstruction, there are still only a limited number of providers who feel comfortable with this approach. This chapter aims to highlight major robotic reconstructive surgeries, the changes in techniques, and the associated outcomes. We overlay our experience with the published literature to provide a complete overview for the readers.
Overview of advantages of robotic reconstruction
Reconstruction of the urinary tract poses unique challenges, such as working in narrow spaces, limited mobility in certain areas, poor blood supply to various parts of the urinary tract, or limited reconstructive options based on the disease pathology. Robotics allows for more favorable and less commonly used procedures, such as an abdominoperineal approach to posterior urethral stricture repair, YV plasty for bladder neck contracture (BNC), uretero-ureterostomy and appendiceal only for mid and distal ureteral repair. Across urologic procedures, the use of robotics provides several important advantages: improved access, near-infrared fluorescent imaging guidance, and an array of adjunct procedures. The advent of the single port (SP) da Vinci system has led to further improvement in deep pelvic surgery ( Fig. 30.1 ).
Conditions that lead to poor visualization of the operative area, such as gunshot wounds, abdominal stoma, and recent surgery, were previously more definitive contraindications for minimally invasive procedures. However, with the increasing experience and prevalence of urologists who are comfortable with the robotic platform, there is an evolving practice of urinary reconstruction using this modality. The high dexterity provided by the robotic platform allows for more efficient clearing and identification of the area of interest. Indocyanine green (ICG) is also uniquely useful for the visualization of the ureter and the perfusion to the tissue ( Fig. 30.2 ). Prior to ICG, reconstructive urologists may have had to rely on visual inspection or the translumination from the ureteroscope light to identify the ureter and the margin of the stricture. This was especially difficult when the diseased area contained inflammation or fibrosis. Injection of ICG into either vasculature or diseased ureter is usually performed via ureteral catheter and/or percutaneous nephrostomy. Near-infrared fluorescence (NIRF) is used to visualize ICG and allows for the assessment of successful anastomosis, delineation of stricture location, and identification of otherwise unrecognizable structures. This can be utilized in lower tract reconstruction as well. Finally, robotics has made it easier to carry out adjunct procedures, such as buccal mucosa graft or omental wrap. This expands options and increases flexibility when carrying out primary procedures and overall increases the success rate of reconstructive surgeries. The adoption of robotics has also led to tremor reduction, finer control, less blood loss, and shorter hospital stays. We will focus our efforts on lower urinary tract reconstruction in this chapter.
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