Robotic Urethral Reconstruction Outcomes in Men With Posterior Urethral Stenosis

Bearrick, Elizabeth; Findlay, Bridget L.; Hebert, Kevin; Maciejko, Laura A; Theisen, Katherine M.; Viers, Boyd R.

doi:10.1016/j.urology.2021.11.035

Cited by 15 publications

(8 citation statements)

References 28 publications

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“…In the only assessment to date assessing feasibility of robotic VUAS repair in radiation patients, an honest accounting of results revealed concerningly poor outcomes including longer operative times, higher rates of incontinence, low success rates, and a high rate of reintervention, compared to nonradiated counterparts. 28 The procedure described in this report could be technically difficult in patients where the bladder neck is not funneled and advanced anteriorly toward the membranous urethra. It could be perceived especially challenging to place the 3 apical anchoring sutures of the graft in an already narrow field due to all patients having a prior history of scarred planes due to radiation.…”

Section: Discussionmentioning

confidence: 91%

“…Though this series demonstrates acceptable functional outcomes following perineal repair, some have demonstrated the robotic approach to have equally promising results in VUAS patients. 28,29 Further, some have suggested the robotic approach may confer greater visualization and dexterity in an already narrow space around the bladder neck. Importantly, however, many of these prior investigations have been limited due to the exclusion of patients with a history of radiation.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Sterling,

Simhan,

Flynn

et al. 2024

Journal of Urology

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Study Need and Importance: Radiation and surgery remain the primary treatments for intermediate-and high-risk localized prostate cancer. Anastomotic stenosis is a known sequela of these treatments with varying incidence rates depending on surgical approach and type of radiation. Endoscopic attempts to manage these patients are universally ineffective, and excisional urethroplasty techniques for the repair of postradiation anastomotic stenosis have substantial rates of new stress urinary incontinence (SUI), ranging from 18% to 71%, likely due to tissue excision in proximity of the external sphincter. Treatment of anastomotic stenosis after both prostatectomy and radiotherapy is understudied. We analyzed a multi-institutional series of radiated postprostatectomy men who underwent dorsal onlay buccal mucosal graft urethroplasty (D-BMGU) for posterior anastomotic stenosis and hypothesize that D-BMGU is technically feasible in this population with durable patency while minimizing new SUI. What We Found: In our cohort of 45 patients, 38 were patent at a median follow-up of 21 months (IQR 12-24), and there were no incidents of de novo SUI. Of the 7 recurrences only 2 occurred after 12 months. We found no evidence of differences in recurrence rate based on stricture location (P [ .65) or timing of prostatectomy (P [ .13). Postoperatively patients reported significant improvement in International Prostate Symptom Score, International Prostate Symptom Score qualityof-life domain, and postvoid dribble (P < .0001), and median postvoid residual and maximum urine flow rate significantly improved (P < .0001) Limitations: This technique cannot be used for obliterative stenosis or anastomotic disruption. The retrospective nature of this study along with variations between institutions in preoperative and postoperative protocols potentially introduces selection bias (Figure). Interpretation for Patient Care: D-BMGU is safe, feasible, and a durable reconstructive technique in patients with posterior urethral stenosis after both prostatectomy and radiotherapy. Zero patients experienced new SUI, and those with continued urinary incontinence were still able to undergo antiincontinence procedures if desired.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

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Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Sterling,

Simhan,

Flynn

et al. 2024

Journal of Urology

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“…A total of 30-day complications were observed in both the prostatectomy-alone group and radiotherapy group were 20% and 40%, respectively, these complications include anastomotic dehiscence, fluid collection and uro-symphyseal fistula formation. 75 …”

Section: Posterior Urethral Stenosesmentioning

confidence: 99%

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

Tsoi,

Elnasharty,

Culha

et al. 2023

Therapeutic Advances in Urology

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The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were ‘robotic assisted’, ‘ureteric reimplantation’, ‘cystoplasty’, ‘ileal conduit’, ‘neobladder’, ‘sacrocolpopexy’, ‘colposuspension’, ‘artificial urinary sphincter’, ‘genitourinary fistula’ and ‘posterior urethral stenoses’. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.

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“…This is inconsistent with previously reported surgical reconstruction outcomes in this patient population using a combined robotic and perineal approach; the results are humbling (including our own) and did not reflect the outcomes of this multi-institutional series. 4 This appears to be a step in the right direction and reflects a calculated “less invasive” approach with an emphasis on restoration of urethral patency over aggressive excision of scar and excessive urethral and pelvic floor dissection. Time will tell if graft take in an irradiated field can provide durable resolution of obstructive symptoms.…”

mentioning

confidence: 99%

Letter: Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Pinkhasov,

Viers

2024

Journal of Urology

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contributing factor to the overall complications. The concerns about our very inclusive composite complication rates can be overcome by selecting one's favorite components from Table 3 in the manuscript, which lists all confirmed and suspected infectious complications. The importance of understanding the definition of an infection is exemplified by the study referenced by the authors as having low infection rates, 5 which reported only the rate of prostatitis. It seems implausible that no patient experienced any postbiopsy fever, voiding symptoms, dysuria, other UTIs, or hospital visit.The location of prostate biopsy procedure, ie, in office or in the operating room, is more reflective of local practice patterns and resources. It is unlikely to play a role in reducing infectious complications because the act of inserting needles into the genitourinary tract is an inherently contaminated procedure. Regardless, nearly 3 decades of worldwide experience with the inoffice prostate biopsy would suggest that performing this procedure under sterile conditions is unnecessary and costly.The concern about sepsis rates and sample size of our study is misplaced as our RCT was not designed to study the effect on sepsis rates, but rather on all major and minor infections. Investigators who wish to study sepsis outcomes will need to conduct such a trial, with sepsis as the prespecified outcome. The systematic review by Bennett et al is seductive due to its large population (>165,000 patients). 6 This and other studies are often used by proponents as an example of low sepsis rates after transperineal prostate biopsy while selectively omitting the 4-fold increase in urinary retention or hospital admissions reported in the same studies. 7 A closer examination of that study reveals that the tremendous heterogeneity in the pooled data (technique, prophylaxis, and definitions of outcomes) was such that none of the reported differences in outcomes were statistically significant. Thus, retrospective, heterogenous, observational cohort studies cannot supplant the results of randomized controlled trials.

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Robotic Urethral Reconstruction Outcomes in Men With Posterior Urethral Stenosis

Cited by 15 publications

References 28 publications

Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

Letter: Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis

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