New York University School of Medicine, New York, NY, 10016, USA.
Department of Urology, New York University Langone Medical Center, New York, NY, 10016, USA.
Surg Endosc. 2019 Oct;33(10):3478-3483. doi: 10.1007/s00464-019-06893-w. Epub 2019 Jun 11.
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.
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 GelPOINT 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.
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.
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.
颊黏膜移植物（BMG）传统上用于尿道重建。对于需要大移植物的应用，如性别肯定性阴茎成形术后的尿道狭窄，可能会出现 BMG 不足的情况。替代 BMG 的直肠黏膜避免了口腔损伤，同时可能减少术后疼痛和更大的移植物尺寸。使用腹腔镜器械的经肛门微创外科（TAMIS）已有描述。由于在直肠腔内采集大量移植物的技术挑战，我们采用了一种新的机器人方法。我们展示了一种新的机器人经肛门微创外科（R-TAMIS）技术在采集直肠黏膜用于尿道成形术的可行性和安全性。
六名（年龄 28-60 岁）患有尿道狭窄和一名阴道狭窄的患者接受了机器人直肠黏膜采集。该程序首先在无生命的牛结肠模型上进行研究，在全身麻醉下采用 GelPOINT Path Transanal Access 截石位进行。在黏膜下水力分离后，使用机器人采集黏膜。采集的移植物大小与尿道或阴道重建所需的表面积相关。标本取出后，行软性乙状结肠镜检查以确认止血。将移植物作为尿道成形术的覆盖物放置。
无术中或术后并发症。平均移植物大小为 11.4×3.0cm。所有重建均有良好的移植物接受。所有患者均无发病或死亡。他们报告术后疼痛轻微，所有患者均在术后第一天恢复肠道功能。有 BMG 采集史的患者主观上报告术后疼痛减轻，生活质量提高。在中位随访 17 个月时，没有长期并发症。
据我们所知，这是首次使用 R-TAMIS 进行直肠黏膜采集。我们的初步系列表明，这种方法是可行和安全的，是一种有前途的微创尿道重建技术。需要进行前瞻性研究，评估移植物结果和供体部位发病率，并进行更长时间的随访。
