Category: Robotic Surgery: New Techniques - Benign
Introduction & Objective :
Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction; however, rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger attainable graft dimension. Laparoscopic transanal minimally invasive surgery (TAMIS) has been described by our group. Due to the technical challenges of harvesting a sizable graft within a confined space, we adopted a new approach using the Intuitive da Vinci Xi® system. We present a video which fully demonstrates our technique in the novel procedure of Robotic TAMIS (R-TAMIS) rectal mucosal harvest, for the purpose of onlay graft urethroplasty.
A 53-year-old transgender male presented with post-phalloplasty urethral stricture and underwent robotic rectal mucosal harvest. His past surgical history included vaginectomy and metoidioplasty using BMG in 2008, followed by right forearm free flap phalloplasty five months prior to presentation. The procedure was first demonstrated in an animal model using bovine colon. IRB approval was obtained. The surgery was performed under general anesthesia with the patient in lithotomy position. The GelPOINTTM Path Transanal Access Platform was used. As demonstrated, the rectal mucosa was dissected using robotic instruments after submucosal hydrodissection. Following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. The rectal mucosa graft was placed as an onlay for urethroplasty.
Harvested graft size was 3.5x10cm, correlating well with surface area needed for urethral reconstruction as determined by the urologist. There were no intraoperative or postoperative complications, and the patient recovered well, without morbidity or mortality. He regained bowel function on the first postoperative day, and reported significantly less postoperative pain in comparison to his prior BMG harvest.
To our knowledge, this is the first use of R-TAMIS for harvest of rectal mucosal graft. The robotic approach is safe and feasible. This is a promising minimally-invasive technique to harvest rectal mucosa, which can be used for urethral or vaginal reconstruction. Demonstrated feasibility and potential avoidance of the challenging recovery associated with BMG harvest warrants further application and long-term evaluation of this procedure.
Lee Zhao– Assistant Professor, NYU Langone Health, New York, New York
Katherine Howard– Medical Student, New York University School of Medicine, New York, New York
Aaron Weinberg– Chesapeake Urology Associates, LLC, Baltimore, Maryland
Mitchell Bernstein– Associate Professor of Surgery; Director, Division of Colon & Rectal Surgery, NYU Langone Health, New York, New York
Alexis Grucela– Assistant Professor, Department of Surgery, NYU Langone Health, New York, New York
New York University School of Medicine
New York, New York
Associate Professor of Surgery; Director, Division of Colon & Rectal Surgery
NYU Langone Health
New York, New York