Category: Robotic Surgery: New Techniques - Benign

Introduction & Objective :

Vesicourethral stenosis (VUS) is reported to occur in up to 10% of prostatectomies. Recalcitrant VUS often require formal reconstructive techniques such as abdominal and/or perineal dissection, use of fasciocutaneous flaps, and pubectomy. The perineal approach requires urethral mobilization with risk of injury to urethral blood supply and external sphincter; meanwhile to facilitate visualization, a pubectomy is often required for open abdominal repair. In select cases, a transabdominal robotic assisted posterior urethroplasty may enable preservation of distal urinary sphincter, and avoid extensive urethral mobilization and pubectomy. We describe our minimally invasive technique augmented by near-infrared (NIR) filter (Firefly®) combined with urethroscopy to facilitate posterior urethral dissection and urethral stricture identification.

Methods :

A 67 yo man presented with an obliterated VUS. He had previously undergone a retropubic prostatectomy for a Gleason 4+5 pT2a R1 Nx prostate cancer. Following endoscopic incision and transurethral resection, he rapidly developed an obliterated VUS. Combined cystogram and retrograde urethrogram demonstrated a 3cm posterior stricture. Flexible cystoscopy confirmed an obliterated stricture proximal to the external sphincter. Intraoperatively, the patient was placed in low lithotomy position. The cystoscope was advanced per urethra to level of stricture and secured. A sizer was placed in the rectum to avoid injury. Initially, posterior dissection was performed to level of urogenital diaphragm. The cystoscope white light was visualized with NIR to facilitate urethral stricture identification. Following anterior dissection and stricture excision, a running VU anastomosis with 2-0 barbed suture was performed.

Results :

Total operative time was 270 minutes. Estimated blood loss was 100mL. The patient was dismissed on postoperative day 1 without complication. He underwent an uncomplicated VCUG and catheter removal at 4 weeks. There has been no evidence of stricture recurrence. 

Conclusions : Robotic posterior urethroplasty augmented by NIR technology is a feasible, minimally invasive option for definitive VUS repair. Preserving external urinary sphincter and avoiding urethra mobilization and pubectomy may reduce operative morbidity.

Presenting Author(s)

• 

  David Yang

  – Urology Resident, Department of Urology, Mayo Clinic, Rochester, MN, Rochester, Minnesota

Author(s)

• RA

  Ross Avant

  – Rochester, Minnesota
• AM

  Adam Miller

  – Rochester, Minnesota
• 

  Matthew Tollefson

  – Department of Urology, Mayo Clinic, Rochester, MN, Rochester, Minnesota
• BV

  Boyd Viers

  – Department of Urology, Mayo Clinic, Rochester, MN, Rochester, Minnesota