Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction [1]. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. If rectal mucosa is used, there is less postoperative pain, no oral impairment, and grafts can be larger [2, 3]. Laparoscopic transanal minimally invasive surgery (TAMIS) has been described for many applications [4]. Due to technical challenges of harvesting a sizable graft within the lumen, we adopted a new robotic approach, which has been shown to be safe and feasible. To our knowledge, this is the first use of robotic TAMIS (R-TAMIS) for rectal mucosa harvest.

This procedure is performed in the lithotomy position with a 30° scope, two instrumented robotic arms, and an assistant port. Key features of the technique include: (1) consistent insufflation of the rectum and colon to 12–15 mmHg to avoid luminal collapse; (2) distal-to-proximal measurement of the desired length of mucosa and scoring of the area prior to dissection; (3) interval injection of lidocaine with epinephrine solution to raise and hydrodissect the mucosal plane and minimize bleeding; (4) dissection to submucosal plane and elevation of the flap with gentle blunt dissection and cautery; (5) retraction of the flap by suture placement for unobstructed view; (6) resulting mucosal defect left to heal by secondary intent to avoid stricture; and (7) post-surgical sigmoidoscopy to inspect for injury and complete hemostasis.

The attached video demonstrates our technique of R-TAMIS in the harvest of rectal mucosa. None of the six patients on whom we have performed this procedure have had intra- or postoperative rectal complications. In all cases, graft size and quality were sufficient for the intended subsequent onlay graft urethroplasty.