Advertisement

Robotic transanal minimally invasive rectal mucosa harvest

  • Katherine N. Howard
  • Lee C. Zhao
  • Aaron C. Weinberg
  • Michael Granieri
  • Mitchell A. Bernstein
  • Alexis L. GrucelaEmail author
Endoluminal Surgery
  • 13 Downloads

Abstract

Introduction

Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. 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

Six patients (ages 28–60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty.

Results

There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months.

Conclusions

To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Keywords

TAMIS Robotic surgery Transanal surgery Rectal mucosa Urethroplasty Transgender surgery 

Notes

Compliance with ethical standards

Disclosures

Drs. Zhao, Weinberg, Granieri, Bernstein, Grucela, and Ms. Howard have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Fichtner J et al (2004) Long-term outcome of ventral buccal mucosa onlay graft urethroplasty for urethral stricture repair. Urology 64(4):648–650Google Scholar
  2. 2.
    Lumen N, Oosterlinck W, Hoebeke P (2012) Urethral reconstruction using buccal mucosa or penile skin grafts: systematic review and meta-analysis. Urol Int 89(4):387–394Google Scholar
  3. 3.
    Markiewicz MR et al (2007) The oral mucosa graft: a systematic review. J Urol 178(2):387–394Google Scholar
  4. 4.
    Morey AF, McAninch JW (1996) When and how to use buccal mucosal grafts in adult bulbar urethroplasty. Urology 48(2):194–198Google Scholar
  5. 5.
    Browne BM, Vanni AJ (2017) Use of alternative techniques and grafts in urethroplasty. Urol Clin North Am 44(1):127–140Google Scholar
  6. 6.
    Chauhan S, Yadav SS, Tomar V (2016) Outcome of buccal mucosa and lingual mucosa graft urethroplasty in the management of urethral strictures: a comparative study. Urol Ann 8(1):36–41Google Scholar
  7. 7.
    Horiguchi A (2017) Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol 24(7):493–503Google Scholar
  8. 8.
    Song LJ et al (2009) Lingual mucosal grafts for anterior urethroplasty: a review. BJU Int 104(8):1052–1056Google Scholar
  9. 9.
    Palmer DA et al (2016) Urethral reconstruction with rectal mucosa graft onlay: a novel, minimally invasive technique. J Urol 196(3):782–786Google Scholar
  10. 10.
    Xu YM et al (2004) 1-stage urethral reconstruction using colonic mucosa graft for the treatment of a long complex urethral stricture. J Urol 171(1):220–223Google Scholar
  11. 11.
    Xu YM et al (2009) Urethral reconstruction using colonic mucosa graft for complex strictures. J Urol 182(3):1040–1043Google Scholar
  12. 12.
    Levy ME, Elliott SP (2017) Graft use in bulbar urethroplasty. Urol Clin North Am 44(1):39–47Google Scholar
  13. 13.
    Donkov II et al (2006) Dorsal onlay augmentation urethroplasty with small intestinal submucosa: modified Barbagli technique for strictures of the bulbar urethra. Int J Urol 13(11):1415–1417Google Scholar
  14. 14.
    Farahat YA et al (2009) Endoscopic urethroplasty using small intestinal submucosal patch in cases of recurrent urethral stricture: a preliminary study. J Endourol 23(12):2001–2005Google Scholar
  15. 15.
    Hauser S et al (2006) Small intestine submucosa in urethral stricture repair in a consecutive series. Urology 68(2):263–266Google Scholar
  16. 16.
    Liu Y et al (2017) Urethral reconstruction with autologous urine-derived stem cells seeded in three-dimensional porous small intestinal submucosa in a rabbit model. Stem Cell Res Ther 8(1):63Google Scholar
  17. 17.
    Palminteri E et al (2012) Long-term results of small intestinal submucosa graft in bulbar urethral reconstruction. Urology 79(3):695–701Google Scholar
  18. 18.
    Gallegos MA, Santucci RA (2016) Advances in urethral stricture management. F1000Res 5:2913Google Scholar
  19. 19.
    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24(9):2200–2205Google Scholar
  20. 20.
    Albert MR et al (2013) Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 56(3):301–307Google Scholar
  21. 21.
    Lim SB et al (2012) Feasibility of transanal minimally invasive surgery for mid-rectal lesions. Surg Endosc 26(11):3127–3132Google Scholar
  22. 22.
    Martin-Perez B et al (2014) A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol 18(9):775–788Google Scholar
  23. 23.
    McLemore EC et al (2014) Transanal minimally invasive surgery for benign and malignant rectal neoplasia. Am J Surg 208(3):372–381Google Scholar
  24. 24.
    Althumairi AA, Gearhart SL (2015) Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond. J Gastrointest Oncol 6(3):296–306Google Scholar
  25. 25.
    Gill S et al (2015) Transanal minimally invasive surgery (TAMIS): standardizing a reproducible procedure. J Gastrointest Surg 19(8):1528–1536Google Scholar
  26. 26.
    deBeche-Adams T et al (2017) Transanal minimally invasive surgery (TAMIS): a clinical spotlight review. Surg Endosc 31(10):3791–3800Google Scholar
  27. 27.
    Atallah S et al (2012) Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique. Tech Coloproctol 16(5):389–392Google Scholar
  28. 28.
    Vallribera Valls F et al (2014) Robotic transanal endoscopic microsurgery in benign rectal tumour. J Robot Surg 8(3):277–280Google Scholar
  29. 29.
    Erenler I et al (2017) Robotic transanal minimally invasive surgery (R-TAMIS) with the da Vinci Xi System—a video vignette. Colorectal Dis 19(4):401Google Scholar
  30. 30.
    Verheijen PM, Consten EC, Broeders IA (2014) Robotic transanal total mesorectal excision for rectal cancer: experience with a first case. Int J Med Robot 10(4):423–426Google Scholar
  31. 31.
    Nikolavsky D et al (2017) Urologic sequelae following phalloplasty in transgendered patients. Urol Clin North Am 44(1):113–125Google Scholar
  32. 32.
    Frey JD et al (2017) An update on genital reconstruction options for the female-to-male transgender patient: a review of the literature. Plast Reconstr Surg 139(3):728–737Google Scholar
  33. 33.
    Morrison SD, Chen ML, Crane CN (2017) An overview of female-to-male gender-confirming surgery. Nat Rev Urol 14(8):486Google Scholar
  34. 34.
    Salgado CJ et al (2016) Prelamination of neourethra with uterine mucosa in radial forearm osteocutaneous free flap phalloplasty in the female-to-male transgender patient. Case Rep Urol 2016:1–4Google Scholar
  35. 35.
    Gomez Ruiz M et al (2015) Robotic-assisted laparoscopic transanal total mesorectal excision for rectal cancer: a prospective pilot study. Dis Colon Rectum 58(1):145–153Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.New York University School of MedicineNew YorkUSA
  2. 2.Department of UrologyNew York University Langone Medical CenterNew YorkUSA
  3. 3.Department of Surgery, Division of Colorectal SurgeryNew York University Langone Medical CenterNew YorkUSA

Personalised recommendations