Reconstruction Articles

Articles

  • "Sandwich" mesh reconstruction of female giant urethral diverticulum: a case report.

    There is no consensus between urologists on the diagnosis and treatment of female urethral diverticula. Once the diagnosis has been established, the most common treatment approach is surgical excision and reconstruction.

    Published March 24, 2020
  • Advances in Surgical Reconstructive Techniques in the Management of Penile, Urethral, and Scrotal Cancer.

    This article reviews the most up-to-date surgical treatment options for the reconstructive management of patients with penile, urethral, and scrotal cancer. Each organ system is examined individually.

    Published October 21, 2016
  • Analysis of a 7-year national online audit of the management of open reconstructive urethral surgery in men.

    To conduct an audit of the management of urethral pathology in men presenting for reconstructive urethral surgery in the UK.

    Between 1 June 2010 and 31 May 2017, data on men presenting with urethral pathologies requiring reconstruction were entered onto a secure online data platform.

    Published December 29, 2019
  • Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review.

    To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients.

    Published February 6, 2017
  • Feasibility of Intracorporeal Robotic-Assisted Laparoscopic Appendiceal Interposition for Ureteral Structure Disease: a Case Report.

    To describe a robotic-assisted laparoscopic technique for using the appendix to repair ureteral stricture disease MATERIALS AND METHODS: A case of a patient presenting with a 5cm obliterative right ureteral stricture was reviewed, and surgical technique, complications, and outcomes were reported.

    Published September 18, 2017
  • Female Urethral Strictures: Review of Diagnosis, Etiology, and Management.

    In this review, we describe the incidence, diagnosis, and management of urethral strictures in women.

    Definitive repair of urethral strictures in women traditionally utilizes vaginal and labial flaps.

    Published November 18, 2019
  • Immediate Continence Rates in RALRP: A Comparison of Three Techniques.

    Robot-assisted laparoscopic radical prostatectomy (RALRP) is said to provide excellent long-term continence. In this study, we compared the early incontinence outcomes of our patients, who had undergone no reconstruction, posterior reconstruction only, or total anatomic restoration and posterior reconstruction.

    Published November 1, 2016
  • Impact of Renorrhaphy Techniques on Renal Functional Outcome After Partial Nephrectomy - Beyond the Abstract

    On behalf of the Young Academic Urologists (YAU) Kidney Cancer working group of the European Urological Association (EAU), a systematic review and quantitative synthesis of the impact of suture techniques during laparoscopic and robot-assisted partial nephrectomy was recently published in the British Journal of Urology International.1 Interesting findings of the study included that running suture, particularly using barbed wires, has shortened the operating and ischemia times. A further advantage could derive from avoiding a double-layer suture. It is known that the goal of partial nephrectomy is the complete tumor excision with negative margins, maximal functional preservation, and avoidance of complications. Resection and renorrhaphy techniques actually affect the amount of vascularized parenchyma preserved, which represents a major determinant of ultimate renal function.

    Renorrhaphy techniques during minimally-invasive partial nephrectomy have evolved due to several reasons. During the earlier laparoscopic series, renorrhaphy was focused on minimizing complications by accurate hemostasis and closure of the collecting system. Nowadays, the concept of “nephron-sparing renorrhaphy” aims to maximize the vascularized parenchymal volume and thus the ultimate renal function. Despite the important relationship between the suture technique and the functional outcomes of partial nephrectomy, the urological guidelines do not provide any recommendations about the optimal renorrhaphy technique, since evidence on the preferred technique remains inconclusive.

    On behalf of the YAU Kidney Cancer working group again we published on European Urology Oncology the first systematic assessment on the impact of suture technique on renal function during partial nephrectomy. With the report, we sought to pool the available literature data on the impact of suture techniques on renal function after minimally invasive partial nephrectomy.

    In our previous publication on perioperative outcomes of surgery, interrupted renorrhaphy technique resulted in higher operative time, ischemia time, and complications relative to the running suture technique. In the present report, we were able to perform a quantitative synthesis of three studies comparing interrupted versus running suture, which included data on estimated glomerular filtration rate (eGFR) for a total of 124 versus 269 patients. Postoperative eGFR was assessed between the date of discharge and 1 month postoperatively. No significant differences were found between pre- and postoperative eGFR in both patients who received an interrupted suture (Figure 1A) or those who received a running suture (Figure 1B). A similar renal functional outcome was observed despite longer ischemia times for interrupted suture, confirming the current literature showing a low impact on renal function of longer ischemia intervals. On the contrary, we believe that running sutures possibly tend to incorporate a larger amount of healthy parenchyma, thus smoothing the differences in renal function; however, further studies are needed to confirm this statement.

    sutureAB

    Single-layer techniques have reported allowing for better perioperative outcomes and a non-significantly higher rate of postoperative complications when compared to standard double-layer techniques. In the quantitative analysis comparing single- versus double-layer renorrhaphy including pre- and postoperative GFR data (321 vs 199 patients), we found a benefit in functional outcomes in favor of the single-layer technique (Figures 1C and 1D). Among the three studies included in the quantitative synthesis, the one performed by Bahler et al. was particularly underlined, which investigated the feasibility of omitting the cortical renorrhaphy during robotic partial nephrectomy. Without differences in the postoperative complications, Bahler and colleagues reported a significantly lower percentage of volume loss of the operated kidney (assessed by software-based volumetric assessment on computed tomography scans) when omitting one renorrhaphy layer. This finding was postulated to be secondary to the hypoperfusion of the parenchyma that occurs during cortical renorrhaphy. According to the available evidence as well as expert opinions, the cortical rather than the medullary layer could be omitted during single-layer renorrhaphy. On the contrary, the use of a single-layer technique has remained questionable and with limited diffusion as it prevents re-approximation of the renal cortical rims. The choice often depends on the tumor growth pattern. Moreover, the volume of perilesional healthy parenchyma excised will have an impact on the renorrhaphy.

    Bertola_Suture_C_D.pngIn our recent publication commented herein, it was acknowledged that only a limited number of studies was considered. Moreover, we did not account for tumor complexity. Furthermore, the available literature allowed for early postoperative functional data assessment only. It is known that functional recovery occurs at longer follow-up, and the clinical relevance of the benefit reported favoring single-layer suture technique remains questionable. These limitations compromised the quality of the evidence. Notwithstanding these limitations, our study represents the first pooled analysis of the literature able to reference the impact of renorrhaphy on renal function following partial nephrectomy. The analysis suggests that “less is more” for renorrhaphy, that is, single-layer renorrhaphy techniques may lead to better postoperative renal function. Future efforts are warranted for improving the literature evidence.


    Written by: Riccardo Bertolo, MD – Young Academic Urologist, Renal Cancer Working Group - San Carlo di Nancy Hospital, Rome, Italy

    References: 
    1. Bertolo et al. Perioperative, oncological and functional outcomes after robotic partial nephrectomy vs. cryoablation in the elderly: A propensity score matched analysis. BJU Int. 2019 Apr;37(4):294.e9-294.e15. doi: 10.1016/j.urolonc.2018.12.016. 

    Read the Abstract

    Published September 24, 2019
  • Long-term complications of continent catheterizable channels: a problem for transitional urologists.

    A majority of the transitional urology patient population have neurogenic bladder and many of these patients have undergone creation of continent catheterizable channels (CCCs) to facilitate bladder emptying.

    Published September 23, 2018
  • Non-Clinical Barriers to Care for Neurogenic Patients Undergoing Complex Urologic Reconstruction.

    To identify non-clinical factors affecting post-operative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction.

    Adult patients with neurogenic bladder undergoing benign GU reconstruction between 10/2010 and 11/2015 were included.

    Published November 2, 2018
  • Outcomes of adult urethroplasty with commercially available acellular matrix.

    Reconstruction for complex urethral strictures may necessitate grafting. Buccal mucosal graft (BMG) harvest involves additional morbidity, making 'off-the-shelf' options attractive. Multiple extracellular matrices (ECMs) have been used with varying degrees of success.

    Published December 2, 2018
  • Posterior, Anterior, and Periurethral Surgical Reconstruction of Urinary Continence Mechanisms in Robot-assisted Radical Prostatectomy: A Description and Video Compilation of Commonly Performed Surgical Techniques.

    Robot-assisted radical prostatectomy (RARP) is hampered by side effects that may have a serious impact on quality of life, particularly stress urinary incontinence. Continence rates may be improved by surgical reconstruction of the pelvic floor.

    Published December 16, 2018
  • Prosthetic Placement After Phalloplasty.

    Significant developments have enabled the transformation of phalloplasty to a functional organ. Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle.

    Published November 10, 2019
  • Reconstruction of the urethra with an anterior vaginal mucosal flap in female urethral stricture.

    We present our single institution experience with urethral reconstruction by using anterior U-shaped vaginal flap in female patients with urethral stricture.

    Retrospective analysis was performed from March 2014 to April 2018.

    Published August 11, 2019
  • Robotic Assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics.

    To describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging.

    Published December 2, 2018
  • Robotic Surgery as Applied to Functional and Reconstructive Urology.

    In recent years, there has been a rapid uptake in the use of laparoscopic and robotic surgery within urological oncological surgery. There is now growing interest in applying these surgical techniques to functional and reconstructive urology (FRU).

    Published July 14, 2019
  • Robotic Y-V Plasty for Recalcitrant Bladder Neck Contracture.

    To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR).

    We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in seven patients who underwent RYVBNR at our institution between March 2016 and September 2017.

    Published May 20, 2018
  • Systematic Review and Pooled Analysis of the Impact of Renorrhaphy Techniques on Renal Functional Outcome After Partial Nephrectomy.

    Despite the important relationship between renorrhaphy and functional outcomes of partial nephrectomy, the urological guidelines do not provide recommendations about the optimal renorrhaphy technique.

    Published August 27, 2019
  • The role of international partnerships in improving urethral reconstruction in low- and middle-income countries.

    To explore the impact of education and training in international surgical partnerships on outcomes of urethral stricture disease in low- and middle-income countries. To encourage data collection and outcomes assessments to promote evidence-based and safe surgical care.

    Published June 16, 2019