Katherine N Howard, BA, Lee C Zhao, MD, MS, Aaron Weinberg, MD, Mitchell A Bernstein, MD, FACS, FASCRS, Alexis L Grucela, MD, FACS, FASCRS. NYU Langone Medical Center
Introduction: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large amounts of graft, such as urethral stricture after gender affirming phalloplasty. Rectal mucosa is an alternative with less post-operative pain, no impairment in eating and speaking, and larger 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 demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty.
Methods and Procedures: IRB approval was obtained. Three female-to-male transgender adults (age range: 33-53 years) presenting with post-phalloplasty urethral strictures underwent robotic rectal mucosal harvest. The procedure was first rehearsed on an inanimate model using bovine colon. The surgery was performed under general anesthesia with the patient in lithotomy position. The GelPOINT Path Transanal Access Platform was used. The rectal mucosa was harvested by the robotic instruments after submucosal hydrodissection. Specimen size harvested correlated with clinical surface area needed for urethral reconstruction. Following specimen retrieval, flexible sigmoidoscopy was used to ensure hemostasis. The rectal mucosa graft was placed as an onlay for urethroplasty.
Results: There were no intraoperative or postoperative complications. Average graft size was 3x12cm (range: 8-15cm). Every case had excellent graft take for reconstruction. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on the first postoperative day. All reported significantly less postoperative pain and greater quality of life in comparison to prior BMG harvests. The procedure has been refined to increase efficiency and decrease operative time by maintaining adequate insufflation, retraction of the mucosal graft, and maintaining graft integrity.
Conclusions: To our knowledge, this is the first use of R-TAMIS for harvest of rectal mucosal graft. Our preliminary series indicates the robotic approach is feasible and safe. It constitutes a promising minimally-invasive technique to employ in urethral reconstruction. Demonstrated feasibility and avoidance of the challenging recovery associated with BMG harvest warrants further application and long-term evaluation of this procedure. Prospective studies evaluating graft success, donor site morbidity and long-term outcomes are needed.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86658
Program Number: P794
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster