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.
References
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):387–394
Browne BM, Vanni AJ (2017) Use of alternative techniques and grafts in urethroplasty. Urol Clin North Am 44(1):127–140
Palmer DA et al (2016) Urethral reconstruction with rectal mucosa graft onlay: a novel, minimally invasive technique. J Urol 196(3):782–786
Martin-Perez B et al (2014) A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol 18(9):775–788
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Howard, K.N., Zhao, L.C., Weinberg, A.C. et al. A novel surgery: robotic transanal rectal mucosal harvest. Tech Coloproctol 23, 691 (2019). https://doi.org/10.1007/s10151-019-02008-8
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DOI: https://doi.org/10.1007/s10151-019-02008-8