Robotic Lower Urinary Tract Reconstruction Sunchin Kim, MDa, Jill C. Buckley, MDb,* KEYWORDS Robotic lower urinary tract reconstruction Bladder neck contracture Proximal urethral stricture Genitourinary fistula Rectourethral fistula KEY POINTS Robotic reconstruction for the lower urinary tract is novel and currently rare but is promising as a new technique to approach complicated repairs. Bladder neck contractures and vesicourethral anastomotic strictures have been successfully re- paired robotically with good patency rates and improved rates of urinary incontinence versus tradi- tional approaches. Robotic-assisted surgery versus traditional approaches enable better visualization and greater control of anastomotic sutures during proximal and posterior urethral stricture repair. Although reports and case series are promising more studies, and higher-level evidence are needed to conclusively support robotic reconstruction of the lower urinary tract. INTRODUCTION processes in the LUT that are appropriate for ro- botic repair, including bladder neck contractures Reconstruction of the urinary tract was first 1 (BNCs), proximal urethral strictures, and genitouri- described in 1851 with a ureterosigmoidostomy, nary fistulas. Given the rare occurrence of these followed by the ileal conduit described by Bricker pathologies and the relatively new robotic tech- in the 1950s as the primary form of urinary diver- 2 niques that have been described, most of the sion from the lower urinary tract (LUT). Over the data presented are case series and reports that last several decades, there has been development speak to the technical feasibility of the robotic of numerous novel techniques to facilitate the approach rather than comparative effectiveness reconstruction of the LUT instead of urinary diver- with traditional open techniques. sion. The advent of laparoscopy and subsequent robotic techniques have allowed even further inno- BLADDER NECK CONTRACTURES AND vation to allow complex LUT issues to be managed VESICOURETHRAL ANASTOMOTIC as orthotopically as possible with the addition of STRICTURES numerous benefits offered by laparoscopic tech- niques. Reconstructive urologists have increas- BNCs and vesicourethral anastomotic strictures ingly adopted the robotic platform to address a (VUAS) are well-known complications that occur wide variety of upper and LUT pathologies. after prostate procedures for both benign and ma- The LUT anatomy includes the bladder, bladder lignant conditions. These 2 complications are dis- neck, prostate, urinary sphincter, and the urethra. cussed together given their similar locations and Not all disease processes in this anatomic region general approaches to successful reconstruction. require laparoscopic surgery to repair. This article Although the precise pathophysiology of BNC re- instead focuses on the anatomy and disease mains unclear, scar hypertrophy is considered to a Department of Urology, University of California San Diego, San Diego, CA, USA; b Department of Urology, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA * Corresponding author. E-mail address: [email protected] Urol Clin N Am 48 (2021) 103–112 https://doi.org/10.1016/j.ucl.2020.09.006 Descargado0094-0143/21/ para BINASSSÓ 2020 Circulaci Elsevier ([email protected]) Inc. All rights reserved. en National Library of Health and Social Security de ClinicalKey.es por Elsevier en febrero 15, urologic.theclinics.com 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. 104 Kim & Buckley be the basis for recurrence due to a prolonged in- right side, and 2 robotic ports on the left side flammatory phase and/or ischemia.3 BNC has a (Fig. 1A). reported incidence after transurethral resection of prostate between 0% and 9.6%,4,5 although Patients with a history of outlet deobstruction rates have varied between different techniques procedure used to treat benign conditions such as outlet Patients who have had a transurethral procedure obstruction. After a radical prostatectomy, VUAS of the prostate or a simple prostatectomy can be rates have historically been reported to be as approached anteriorly by developing the space high 16%6–8; however, the advent of robotic sur- of Retzius and dropping the bladder off the ante- gery and improved visualization enables better rior surface of the abdominal wall. This dissection mucosal apposition and watertight anastomosis, is carried inferiorly underneath the pubic symphy- and rates have decreased to 2.2%.9 sis to the junction between the prostate and Initial treatment of BNC is highly variable, bladder neck. Given most patients have under- ranging from a simple dilation to endoscopic pro- gone several transurethral procedures prior for cedures using cold knife, electrocautery, lasers, recurrent BNC, there may be a dense desmoplas- and loop resection. These procedures can also tic reaction that may require careful dissection to be augmented with the addition of a steroid or a separate the bladder and prostate from the ante- cytotoxic agent such as mitomycin C. Treatment rior pelvis (Fig. 1B). After dissection of the desmo- success has ranged from 58% to 89% after these plastic reaction off of the bladder neck junction techniques.10–12 However, when conservative or (Fig. 1C), a flexible cystoscope is passed retro- endoscopic treatment fails, a more invasive option grade through the urethra to identify the location is considered. Open reconstruction of BNC has and extent of BNC. Firefly technology can be historically been performed in patients with highly used to help delineate the location of the contrac- recalcitrant BNC. Because of the rare nature of ture (Fig. 1D). these procedures, most published series are The bladder is then opened anteriorly just prox- limited by a small sample size and may vary signif- imal to the bladder neck and continued distally to icantly in techniques, ranging from abdominoperi- determine the proximal extent of the contracture neal, perineal, and transpubic approaches.13–15 (Fig. 1E). Using sharp dissection and electrocau- Although the reported patency rates have been tery, the scar tissue is completely excised. The as high as 93.3%, dissection through the external mucosal edges are then brought together to urinary sphincter is associated with significant risk create a posterior plate using interrupted 4-0 Vicryl for urinary incontinence.16 sutures (Fig. 1F). A Y-V plasty is then performed Robotic reconstruction of BNC is becoming a (Fig. 1G). The long arm of the Y is a longitudinal more widely adopted technique that has been incision of the bladder neck scar on the anterior described as advantageous in regard to lower esti- aspect. An inverted V incision is made on the ante- mated blood loss, reduced postoperative pain, rior aspect of the bladder neck. A 16-Fr Foley cath- shorter hospitalization, and improved continence eter is brought through as the final catheter. The rates, as the dissection is above the level of the apex of the V bladder flap is then advanced to sphincter, and avoids the morbidity of a pubec- the distal aspect of the anterior longitudinal inci- tomy described in open procedures. There is sion through the scar, which is then closed with also the potential advantage of improved durability a running V-loc suture. After anastomosis, a leak in placing a future artificial urinary sphincter due to test is performed by flushing the catheter with sa- the lack of prior perineal dissection. line (Fig. 1H). Patients with a history of prostatectomy Procedural Approach The procedure is approached similarly to The surgical principles for a successful anasto- described earlier, although the dissection is usu- mosis for urethral strictures are applicable to ally more difficult due to the more distal location BNC repairs. A tension-free, watertight, mucosa and severe adherence to the pubic symphysis. to mucosa apposition, well-vascularized, and The bladder neck is approached anteriorly by catheterized anastomosis using resorbable su- developing the space of Retzius and dropping tures is crucial. the bladder off the anterior surface of the abdom- The patient is placed in a steep Trendelenburg inal wall. This dissection is carried inferiorly under- position, and the abdomen is entered using a neath the pubic symphysis to the area of the similar approach to robotic prostatectomy. Port vesicourethral anastomosis, which is notably very placement includes a supraumbilical midline cam- distal. A flexible cystoscope is then passed era port, a robotic port and assistant port on the through the urethra to identify the location and Descargado para BINASSS Circulaci ([email protected]) en National Library of Health and Social Security de ClinicalKey.es por Elsevier en febrero 15, 2021. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados. Robotic Lower Urinary Tract Reconstruction 105 Fig. 1. (A) Robotic port placement for bladder neck reconstruction. (B) Desmoplastic reaction from prior transure- thral procedures for bladder neck contractures. (C) Bladder neck junction after dissection of desmoplastic reac- tion. (D) Determination of location of bladder neck contracture using Firefly technology and TilePro. (E) Longitudinal incision from bladder through bladder neck contracture. (F) After excision of bladder neck contrac- ture, the posterior plate is brought