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.
Bladder neck contracture
BNC poses a significant challenge in urologic reconstruction ( Fig. 30.3 ). Some of the common morbidity associated with BNC includes infection, urinary retention, incontinence, poor quality of life, and the need for subsequent procedures. These patients often present to a urologist after undergoing prostatectomy for prostate cancer or endoscopic treatment for BPH. Historical studies have cited the rate of BNC post-radical prostatectomy to be as high as 8.4% or 16%. , Although improving robotic techniques have seen a significant reduction in the incidence of BNC after radical prostatectomy, it remains a challenge when it does occur. Many of the patients present with symptoms within 6 to 24 months after their index operation. Often these patients are managed with an initial endoscopic intervention such as dilation or incision of the vesicourethral anastomosis (VUA). However, these interventions are often short-lived and may be entirely inapplicable in cases of complete urethral obliteration. Furthermore, they may exacerbate the dense stricture and lead to recalcitrant situations that require a more involved surgical procedure to salvage urethral voiding and maintain quality of life. These patients need to be counseled appropriately about the complex nature of their pathology and that multiple procedures may be needed to de-obstruct the urethra and then to establish continence via adjunct procedures such as artificial urinary sphincter or slings. Ultimately, if reconstructive efforts fail, then a cystectomy with urinary diversion may be the only option to salvage any degree of urinary continence in the patient.
In a robotic bladder neck reconstruction, we start by first performing a cystoscopy to visualize the obstructed urethra and passing a wire into the bladder. If a wire cannot be passed, then the scope is left in the urethra at the point of obstruction and secured to the draping. The ports are placed similarly to a robotic prostatectomy on the Xi system. With the SP robotic system, the port is docked in the midline, immediately above the umbilicus. The bladder is dropped from the anterior abdominal wall and mobilized. It is crucial to liberate the bladder on the anterior side to reach the distal-most segment. The proximal urethra is dissected and mobilized as distally as possible. At this point, the surrounding tissue and any sphincteric muscle is carefully dissected off the urethra. A Y incision is then made on the anterior side of the urethra and bladder. A longitudinal incision is made on the anterior urethra using scissors and carried past the point of obstruction. The Y limbs are made on the bladder, paying careful attention to the ureteral orifices ( Fig. 30.4 ). Next the Y limbs are advanced to the apex of the urethral spatulation in a routine fashion. We typically utilize a 3-0 Stratafix suture for this advancement to complete a watertight closure. A Foley catheter is placed at the end of the procedure, and a drain is left in place. A 2018 study by Granieri et al. demonstrated well-preserved urinary function in a small series of patients with recalcitrant BNC, and this operation has been well-adapted by multiple other institutions for this pathology.