Objective: Secondary pyeloplasty for recurrent ureteropelvic junction obstruction may be a safe and feasible surgical option for patients. This study aimed to demonstrate outcomes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty. Methods: We performed a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery database for all consecutive patients who underwent buccal mucosa graft ureteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvic junction obstruction after prior failed pyeloplasty. Primary outcome included surgical success which was defined as the absence of flank pain and obstruction on imaging. Results: Overall, ten patients were included in our analysis. The median stricture length was 2.5 (interquartile range IQR 1.8–4.0) cm. Median operative time was 230.5 (IQR 199.5–287.0) min and median estimated blood loss was 50 (IQR 28.8–102.5) mL. At a median follow-up of 10.3 (IQR 6.2–14.8) months, 80% of patients were surgically successful and there were no major (Clavien-Dindo grade>2) complications. Conclusion: Buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option for patients with recurrent UPJO who failed prior pyeloplasty and has comparable outcomes to the literature regarding standard transecting techniques.Lewis Katz School of MedicineUrolog

Eun, Daniel

Eun|

Lee, Matthew

Loecher, Matthew

Nagoda, Elizabeth

Stifelman, Michael

Strauss, David

Zhao, Lee

Asian Journal of Urology

English

TUScholarShare (Temple University)

Q1Q3Q2+ MODELAJUR608_proof ■ 20 November 2023 ■ 1/5Asian Journal of Urology xxx (xxxx) xxx123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960Available online at www.sciencedirect.comScienceDirectjournal homepage: www.elsevier .com/locate/a jur6162636465666768697071Original Article727374757677787980818283Role of buccal mucosa graft ureteroplasty inthe surgical management of pyeloplastyfailureMatthew Lee a,*, Elizabeth Nagoda a, David Strauss a,Matthew Loecher a, Michael Stifelman b, Lee Zhao c,Daniel Eun a84858687888990a Department of Urology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USAb Department of Urology, Hackensack Meridian School of Medicine, Hackensack University MedicalCenter, Hackensack, NJ, USAc Department of Urology, New York University Grossman School of Medicine, New York UniversityLangone Health System, New York, NY, USA919293Received 3 July 2023; accepted 28 September 2023949596979899100101102103KEYWORDSUreteral obstruction;Buccal mucosa graft;Pyeloplasty;Robotics;Stricture* Corresponding author.E-mail address: matthewlee019@gPeer review under responsibility oPlease cite this article as: M. Lee, E.pyeloplasty failure, Asian Journal ofhttps://doi.org/10.1016/j.ajur.2023.02214-3882/ª 2023 Editorial Office of Athe CC BY-NC-ND license (http://crea104105106107108109110Abstract Objective: Secondary pyeloplasty for recurrent ureteropelvic junction obstructionmay be a safe and feasible surgical option for patients. This study aimed to demonstrate out-comes of utilizing a non-transecting buccal mucosa graft ureteroplasty for management ofrecurrent ureteropelvic junction obstruction after prior failed pyeloplasty.Methods: We performed a retrospective review of our Collaborative of Reconstructive RoboticUreteral Surgery database for all consecutive patients who underwent buccal mucosa graft ur-eteroplasty between April 2012 and June 2022 for management of recurrent ureteropelvicjunction obstruction after prior failed pyeloplasty. Primary outcome included surgical successwhich was defined as the absence of flank pain and obstruction on imaging.Results: Overall, ten patients were included in our analysis. The median stricture length was2.5 (interquartile range IQR 1.8e4.0) cm. Median operative time was 230.5 (IQR 199.5e287.0)min and median estimated blood loss was 50 (IQR 28.8e102.5) mL. At a median follow-up of10.3 (IQR 6.2e14.8) months, 80% of patients were surgically successful and there were no ma-jor (Clavien-Dindo grade>2) complications.mail.com (M. Lee).f Tongji University.Nagoda, D. Strauss et al., Role of buccal mucosa graft ureteroplasty in the surgical management ofUrology, https://doi.org/10.1016/j.ajur.2023.09.0019.001sian Journal of Urology. Production and hosting by Elsevier B.V. This is an open access article undertivecommons.org/licenses/by-nc-nd/4.0/).111112113114115116117118119120121122M. Lee, E. Nagoda, D. Strauss et al.+ MODELAJUR608_proof ■ 20 November 2023 ■ 2/5123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869Conclusion: buccal mucosa graft ureteroplasty is a valuable non-transecting surgical option forpatients with recurrent UPJO who failed prior pyeloplasty and has comparable outcomes to theliterature regarding standard transecting techniques.ª 2023 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. Thisis an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).7071727374757677787980818283848586878889909192939495969798991001011021031041051061071081091101111121131141151161171181191201211221231241. IntroductionThe gold standard technique for definitive management ofa ureteropelvic junction obstruction (UPJO) is a pyelo-plasty. Primary robotic pyeloplasty has been associatedwith a greater than 90% success rate [1e3]. Although failureoccurs infrequently in this setting, when it does occur,management of recurrent UPJO after prior failed pyelo-plasty can be challenging due to increased periureteralscarring and fibrosis in the previous surgical area. This canoften make re-operative ureteral dissection and identifi-cation technically difficult and can risk further devascula-rization to the ureter.Secondary pyeloplasty for recurrent UPJO may be a safeand feasible surgical option. A dismembered (transecting)pyeloplasty is most often performed for these patients.With recent advancements in robotic ureteral reconstruc-tive surgery, various additional non-transecting techniquesmay also be utilized in this setting [4]. Non-transectingtechniques may be considered a good option for redocases due to preservation of the ureteral blood supply. Abuccal mucosa graft ureteroplasty (BMGU) is one type ofnon-transecting pyeloplasty technique which has gainedfavor in the recent literature for management of proximaland middle ureteral strictures [5,6]. However, publisheddata regarding its use in management of recurrent UPJO arelimited. Herein, we report our surgical technique andperioperative outcomes with BMGU for management ofrecurrent UPJO.2. Materials and methodsWe performed an Institutional Review Board approvedretrospective review of our Collaborative of ReconstructiveRobotic Ureteral Surgery (CORRUS) database for allconsecutive patients undergoing BMGU between April 2012and June 2022 for management of recurrent UPJO afterprior failed pyeloplasty (open, laparoscopic and/or robotictechniques). BMGU was performed across three institutions(Temple University, Philadelphia, PA, USA; HackensackUniversity Medical Center, Hackensack, NJ, USA; New YorkUniversity Langone Health, New York, NY, USA) using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA,USA). Surgery was indicated in patients with radiographicevidence (i.e. computed tomography, retrograde pyelo-gram, antegrade pyelogram) of a UPJO and clinical symp-toms (i.e. flank pain, recurrent urinary tract infections) ordecreasing renal function on preoperative renal scan. Notall patients had preoperative renal scans prior to theirsurgery; however, all patients did have one of the afore-mentioned radiographic imaging studies for diagnosis of2their UPJO. Surgical success was assessed at each post-operative visit and was defined as the resolution of radio-graphic obstruction on a 6-month postoperative renal scanand resolution of obstructive symptoms. Preoperatively, allpatients underwent percutaneous nephrostomy drainagefor at least 4 weeks to facilitate ureteral rest. All patientswith positive preoperative urine cultures were treated withantibiotics (based on culture sensitivities) for 5e7 daysprior to arriving for surgery and all patients received peri-operative antibiotics on the day of surgery.As described previously in the literature, we utilized aBMGU for recurrent UPJO in patients with nonobliterative(narrowed) long-segment (greater than 2 cm) UPJO and/orsignificant fibrosis around the UPJO [4]. For patients whoonly had a stricture identified on preoperative computedtomography, we performed a retrograde and antegradepyelogram on the day of surgery to evaluate the ureteralstricture. We began by performing a ureterolysis to exposethe anterior surface of the UPJO and made a longitudinalincision over the strictured segment. The length of thegraft was determined by intracorporeally measuring theureteral defect. Intraureteral or intravenous indocyaninegreen (ICG) may be utilized under near infrared fluores-cence for aid in ureteral and stricture identification.Injecting 2 mL ICG intravenously allowed for assessment ofureteral perfusion under near infrared fluorescence.Intraureteral ICG aided in localizing the ureter and deter-mining stricture margins by injecting 5 mL ICG into theureteral lumen via a ureteral catheter and/or percutaneousnephrostomy tube [7]. Hypointense signals under nearinfrared fluorescence signified poorly perfused tissue whichindicates stricture location and its margins (Fig. 1). Abuccal mucosa graft (BMG) was then harvested by hydro-dissecting the buccal mucosa with lidocaine with epineph-rine and excising it off the buccinator muscle. The BMGonlay was then anastomosed to the remaining defect with5e0 absorbable monofilament suture (Fig. 1). A broad-based pedicle of greater omentum was mobilized andwrapped around the reconstructed ureter and pexed inplace to supplement healing. No intrabdominal drains wereplaced during these cases. A double-J ureteral stent isplaced across the anastomosis and removed at approxi-mately 6 weeks postoperatively. A foley was placed at theend of the case, but this was removed on postoperative Day0 or 1 prior to discharge.3. ResultsPatient demographics and preoperative variables aresummarized in Table 1. Ten patients were included in ouranalysis. Etiology of strictures included 40% congenital andFigure 1 Buccal mucosa graft ureteroplasty. (A) Intravenous indocyanine was utilized for stricture identification and the stric-tured segment of the ureteropelvic junction appeared hypointense when visualized under near infrared fluorescence; (B) A lon-gitudinal incision was made along the ventral aspect of the ureteropelvic junction across the strictured segment and a ruler wasutilized to measure the stricture length; (C) A buccal mucosa graft was anastomosed to the ventral defect in a running fashion using5e0 absorbable monofilament suture.Table 1 Patient demographics and preoperativevariables.Variable ValueAge, year 39.5 (29.5e52.5)Body mass index, kg/m2 25.7 (24.3e30.7)SexMale 5 (50)Female 5 (50)Etiology of strictureCongenital 4 (40)Iatrogenic 6 (60)LateralityLeft 8 (80)Right 2 (20)Note: values are presented as median (interquartile range), or n(%).Table 2 Intraoperative details and follow-up results.Variable Patient (nZ10)#1 #2 #3 #4 #Length of stricture, cm 2 2 4 3 7Operative time, min 146 201 265 225 2Estimated blood loss, mL 150 60 30 50 2Intraoperative complications No No No No NIndocyanine green usage Yes Yes Yes Yes YLength of stay, day 1 1 0 0 1Follow-up, months 22.4 47.1 11.4 11.6 9Major (Clavien-Dindo grade>2)complicationsNo No No No NSurgical success Yes Yes No Yes Na Values are presented as median (interquartile range).Asian Journal of Urology xxx (xxxx) xxx+ MODELAJUR608_proof ■ 20 November 2023 ■ 3/5312345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182838485868788899091929394959697989910010110210310410560% iatrogenic (prior ureteroscopy, prior UPJO surgery).Intraoperative and postoperative outcomes are summa-rized in Table 2. The median intraoperative stricturelength was 2.5 (interquartile range IQR 1.8e4.0) cm. Me-dian operative time was 230.5 (IQR 199.5e287.0) min andmedian estimated blood loss was 50 (IQR 28.8e102.5) mL.There were no intraoperative complications. ICG undernear infrared fluorescence was utilized in 60% of cases toaid in visualization of the ureter (intraureteral ICG in83.3% of cases).At a median follow-up of 10.3 (IQR 6.2e14.8) months,80% of patients were surgically successful and there wereno major (Clavien-Dindo grade>2) complications. The twopatients who failed secondary pyeloplasty have beenmanaged with chronic ureteral stent exchanges. Both pa-tients had decreasing split function on the affected side ontheir postoperative renal scans with prolonged half timesand had recurrence of flank pain.Value5 #6 #7 #8 #9 #104 1 1 3 2 2.5 (1.8e4.0)a80 236 308 206 195 318 230.5 (199.5e287.0)a5 25 100 50 110 50 50 (28.8e102.5)ao No No No No No 0%es Yes No No No No 60%1 0 0 1 1 1 (0e1)a.2 12.3 8.5 6.0 6.3 6.0 10.3 (6.2e14.8)ao No No No No No 0%o Yes Yes Yes Yes Yes 80%106107108109110111112113114115116117118119120121122123124M. Lee, E. Nagoda, D. Strauss et al.+ MODELAJUR608_proof ■ 20 November 2023 ■ 4/51234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859606162636465666768697071727374757677787980818283848586878889909192939495969798991001011021031041051061071081091101111121131141151161171181194. DiscussionRecurrent UPJO after prior failed pyeloplasty may betechnically difficult to perform. There is typically signifi-cant fibrosis and scarring at the re-operative site whichmakes it difficult to perform ureterolysis and increases therisk of devascularization to the ureter during dissection.Nevertheless, surgical pyeloplasty in the re-operativesetting has shown better outcomes as compared to endo-scopic management in this setting [4,8e10].Most studies in the literature describe utilization of adismembered (transecting) pyeloplasty in the recurrentsetting [8e10]. Sundaram et al. performed a retrospectiveanalysis reporting outcomes of patients undergoing sec-ondary laparoscopic pyeloplasty after prior failed endo-scopic (91.7%) or surgical (8.3%) intervention for a UPJO. Ata mean follow up of 10 months, 30 (83.3%) patients weresuccessful [9]. Hammady et al. [10] performed a retro-spective study comparing primary and secondary laparo-scopic pyeloplasty. There were 32 patients in the secondaryUPJO group who underwent prior failed open pyeloplasty.At a mean follow up of 32.4 months, 90.6% of patients weresurgically successful. In their comparison, the authorsfound that there was a significantly longer operative timeassociated with the secondary group [10].In our study, we describe outcomes of ten adult patientswho underwent robotic BMGU for management of recurrentUPJO after a prior failed pyeloplasty. At a median follow-upof 10.3 months, there was an 80% success rate. The riskfactors contributing to the failed reconstructive repair inthe two patients involved in our study may be multifacto-rial. These patients had longer strictures that extendeddown into the proximal ureter which makes reconstructionmore complex. Furthermore, these patients had multipleprior endoscopic and open ureteral reconstruction attemptswhich could increase the amount of periureteral scarringand inflammation in this area.We presume there are benefits of utilizing a non-transecting technique for management of UPJO in the re-operative setting. This technique avoids complete tran-section of the ureter which may help avoid devasculariza-tion of the ureteral blood supply and reduces the need forsignificant ureterolysis. By solely making a longitudinalincision along the strictured segment, the ureteral bloodsupply may be preserved. Also, when performing a BMGU,the ureter remains in continuity which may facilitate for-mation of an anastomosis that is tension-free. This tech-nique may be limited in patients with a crossing vessel orother forms of extrinsic compression as only a transectingpyeloplasty is indicated in these cases.This study certainly has its limitations. It is a retro-spective in design and includes a small sample size. Also,the benefits of utilizing a non-transecting technique forpreservation of the ureteral blood supply is only theoreticalas we did not have a way to measure ureteral vasculatureduring these cases. Furthermore, the safety and efficacy ofBMGU for management of ureteral strictures has only been4evaluated in smaller cohorts with intermediate-termfollow-up [6]. As such, larger series with longer termfollow-up are necessary to analyze outcomes of recurrentUPJO.5. ConclusionBMGU is a valuable non-transecting surgical option for pa-tients with recurrent UPJO who failed prior pyeloplasty andhas comparable outcomes to the literature regardingstandard transecting techniques. Future robust studies areneeded to validate this procedure for the management ofrecurrent UPJO.Author contributionsStudy concept and design: Matthew Lee, Daniel Eun.Data acquisition: Matthew Lee, David Strauss, MatthewLoecher, Elizabeth Nagoda.Data analysis: Matthew Lee.Drafting of manuscript: Matthew Lee, Daniel Eun.Critical revision of the manuscript: Daniel Eun, MichaelStifelman, Lee Zhao.Conflicts of interestMatthew Lee, David Strauss, Matthew Loecher, ElizabethNagoda, and Lee Zhao declare no conflict of interest.Michael Stifelman is on the Scientific Advisory Board forIntuitive (Sunnyvale, CA, USA), a consultant for VTI Medical(Waltham, MA, USA), and performs educational activitiesfor Ethicon (Somerville, NJ, USA). Daniel Eun is a paidspeaker, consultant, and proctor for Intuitive Surgical(Sunnyvale, CA, USA), a consultant for Medtronic (Minne-apolis, MN, USA), and a shareholder of Melzi Corp (LosAltos, CA, USA). Daniel Eun receives trainee funding sup-port from Hitachi Medical (Tokyo, Japan).References[1] Sundaram C, Hopf H, Bahler C. Long-term outcomes of robot-assisted laparoscopic pyeloplasty for ureteropelvic junctionobstruction. Urology 2016;90:106e11.[2] Etafy M, Pick D, Said S, Hsueh T, Kerbl D, Mucksavage P, et al.Robotic pyeloplasty: the university of California-irvine expe-rience. J Urol 2011;185:2196e200.[3] Gupta N, Nayyar R, Hemal A, Mukherjee S, Kumar R, Dogra P.Outcome analysis of robotic pyeloplasty: a large single-centreexperience. BJUI 2010;105:980e3.[4] Lee M, Lee Z, Strauss D, Jun MS, Koster H, Asghar A, et al.Multi-institutional experience comparing outcomes of adultpatients undergoing secondary versus primary robotic pyelo-plasty. Urology 2020;145:275e80.[5] Zhao LC, Weinberg AC, Lee Z, Ferretti MJ, Koo HP, Metro MJ,et al. Robotic ureteral reconstruction using buccal mucosagrafts: a multi-institutional experience. Eur Urol 2018;73:419e26.120121122123124Asian Journal of Urology xxx (xxxx) xxx+ MODELAJUR608_proof ■ 20 November 2023 ■ 5/5123456789101112131415161718[6] Lee Z, Lee M, Koster H, Lee R, Cheng N, Jun M, et al. A multi-institutional experience with robotic ureteroplasty withbuccal mucosa graft: an updated analysis of intermediate-term outcomes. Urology 2021;147:306e10.[7] Lee Z, Moore B, Giusto L, Eun D. Use of indocyanine greenduring robot-assisted ureteral reconstructions. Eur Urol 2015;67:291e8.[8] Atug F, Burgess SV, Castle E, Thomas J. Role of robotics in themanagement of secondary ureteropelvic junction obstruction.Int J Clin Pract 2006;60:9e11.5[9] Sundaram CP, Grubb R, Rehman J, Nan Y, Chen C, Landman J,et al. Laparoscopic pyeloplasty for secondary ureteropelvicjunction obstruction. J Urol 2003;169:2037e40.[10] Hammady A, Elbadry MS, Rashed E, Moussa A, Gamal W,Dawood W, et al. Laparoscopic repyeloplasty after failedopen repair of ureteropelvic junction obstruction: a case-matched multi-institutional study. Scand J Urol 2017;51:402e6.

Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure

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Role of buccal mucosa graft ureteroplasty in the surgical management of pyeloplasty failure

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