Category: Robotic Surgery: Lower Tract - Malignant
Introduction & Objective :
Primary perineal anastomotic urethroplasty is the gold standard in management for posterior urethral strictures. Repair of these injuries typically requires deep perineal dissection, making accurate placement of anastomotic sutures quite challenging. The robotic platform has demonstrated benefits to anastomotic suture placement in prostatectomy and has been employed by colorectal surgeons in deep pelvic surgery. To date, the robotic platform has not been employed for urethral reconstructive cases from a perineal approach. We aim to demonstrate that utilization of the robotic platform is safe and practical, yielding improved visualization and ergonomics and allowing for more accurate and confident suture placement for mucosal apposition.
We present a retrospective analysis of five patients who underwent robotic-assisted posterior urethroplasty at a single institution, University of California San Diego by a single board certified reconstructive surgeon from July – September 2017. Preoperative data was obtained such as age, mechanism of injury, and prior treatments. Post-operative measurements were obtained including voiding cystourethrograms (VCUG), flow rate, post void residual, and perioperative complications. All patients underwent a standard perineal dissection with robotic-assisted placement of anastomotic sutures. Da Vinci Si and Xi platforms were used in the study utilizing two robotic arms with needle drivers and a zero degree camera. Average set-up time was 15 minutes.
The median age of this cohort was 50 years old (14-68). The most common defect was membranous urethral stricture (3/5). One patient had prior pelvic radiation for prostate cancer. The average length of stricture was 2.2cm (1.5-3cm). 3 patients underwent non-transecting urethroplasties while 2 underwent a transecting primary anastomotic repair. No perioperative complications were noted. All patients underwent VCUG at 3 weeks prior to catheter removal, and none demonstrated contrast extravasation.
Robotic-assisted posterior urethroplasty improves visualization, ergonomics and anastomotic suturing of the urethra. This is particularly helpful in patients with narrow pelvic anatomy and high posterior urethral injuries. Opertaive and post-operative outcomes are comparable to the standard approach. Additional follow up is required to assess long term outcomes and differences in success rates between the standard and robotic approach.