Buccal mucosa graft ureteroplasty is a procedure for reconstruction of long-segment ureteral strictures that are not amenable for routine procedures. During a live urologic reconstruction surgery, Dr. Eun demonstrates how ureteral strictures can be successfully treated using a robotic approach.
mhm, mm hmm, mm hmm. Good morning everybody. This is Alex Dasani. We are getting started with another day of live surgeries. I'm here with the world famous doctor dan um from temple. Uh and our team consists of two of our other great first assists Annelise and Nathalie who are going to showcase their talent. Today, we're also joined by dr craig Hunter here. He's a fellowship trained reconstructive urologist. He's gonna help us do a buckle graft. Harvest the anesthesiologist. Like it's like they're glad soccer, Excellent anesthesiologist who also helped us yesterday. So today's case we have a 54 year old female essentially healthy who presented with 11 to 12 millimeter proximal urethral stone that was impacted. She had to um Euro Doris copies to clear her of her stone. A month or two later she developed a proximal ureter stricture and was symptomatic. She has good renal function. Split function is 45 55 45 being the affected kidney. Uh I uh when she came to me, she already came to me symptomatic. I did a retro grades on her found that she has about a centimeter two centimeter half proximal ureter stricture. I did a balloon dilation and put a stent in for a couple of weeks. The stent was removed and she was still symptomatic. So our plan is today to do a robotic curator of plastic with a buccal mucosal graph. And I'm gonna hand it over here to dr daniel. So we see a a proximal um you know urethral stricture. It's not very long. And you know, fortunately, you know, for me today, this patient doesn't have an extensive history of of indwelling um hardware and you know I mean although she's been scoped twice, balloon dilated once and a short stand trial, you know I don't anticipate that we're gonna have a ton of inflammation in this ureter. Um which is kind of nice to showcase our technique today. So I feel very fortunate I wanted to go over to the abdomen just to show you our poor placements. We have a five millimeter umbilical assistant ports for suctioning and we hide the incision into the umbilicus we have 38 millimeter ports along the para median line. Hand breath apart. The first the superior most report is about a finger breath off the costal margin. And that's where you see that blue line going up and down and just along that para median line and straight line, just four finger breaths apart. We place our ports apart and I usually just go with three. Um And a lot of these patients at our institution, home institution would be sent home on the same day. And so you know smaller ports less sports obviously better if somebody's really worried about cosmetics. I mean you know sometimes we could just assistant list. It's not a big deal. Um And so you know we have a pressure running. I'm not as low as as Ronnie um We have a pressure of like 12 to 15 going on right now. And so let's uh what I've done so far is just mobilized the colon just so that we can get to the case. And so that's where we're all jump into the one point that Alex and I were discussing um prior to the cases were doing the retrograde was that I told him that over the over the years as I've done more and more of these, the way I do my retrograde is also kind of important because as I'm planning for the study, what I what I found valuable is um doing a low pressure retrograde polygram and a high pressure retrograde polygram so that under distention and under pressure, I can see what it stretches out to and really kind of define the structure point. But I also want to see under low pressure how it collapses. And those things give me quality of information um on the anatomy I'm about to operate on. And so there's all sorts of like little tricks tips and tricks that we can gather from each other, you know when I talk to um people and you know, I'm always kind of open to understanding and learning a little bit more. Um and so as much information that we can gather before the case to anticipate what we're about to run into. It's always very helpful. There was a short stent trial for two weeks where she had improvement of her pain and then it came out luckily for us, this patient has not had an indwelling stand for a while. Um And so uh you know that's the most ideal situation because Um you know we always prefer your eternal rest for you know 34 weeks um minimally and so to to be able to um you know get to this case and not have to deal with a perk tube and um a stent. The patient had some some symptoms but it was livable. So she was willing to go to surgery without any hardware in. So that was nice. So here we have mobilized the colon. Um I was actually a little bit tempted to do a trans music colic approach because um she she's um she's not obese and she had very thin colon colon mesen terry. So this is her Girardi's fashion. You could see the edge right along here, right? And as I've opened up and drop the coal and you can see the ureter already wiggling in there. So you know the the anatomy is very favorable. Um Yes I use a hook as you guys always point out um it's just my preferred dissection instruments. Um And so here what we're doing is just getting too into the location and I try not to overly dissect the ureter, you know from down below. Um If if I don't need to I think that minimizing your literal dissection, minimizing disruption of blood supply is always you know good for what we're trying to accomplish. Can you just talk briefly as to your choice of procedure as to what goes through your mind or your algorithm and deciding what you do photograph or Other options that one can consider. Yeah. So I think the first thing is you know it's obvious to all of us, you know its location and you know the length of the structure um And those are the primary considerations but secondary considering that they are also very important is also um is also understanding whether the the it's just narrowed or whether it's obliterated. We think that that's a very important kind of key point um to understanding because if it's obliterated then um and there's no loom in there then I don't think that just a simple only um you know it's a good option in most of these cases and so then we have to cut out the scar and we have to um um do what we call like an excision with a back wall um you know approximation will call an augmented repair um And as thematic repair and so that that those are the big kind of things in my mind as we're doing our retro grades and preoperative evaluation is because you know if if it's an augmented repair it takes more time you have to maybe you know in your day preserve a little bit more time to be able to do the case um In this in this particular case I think our options um the options were um we could we could do a buccal or we could do a you you and you know in this kind of case I'm not entirely dogmatic that um that buckles the only option. I mean I think that um that hey you you could be done in this case and so if you ask me why I would do a, you buckle over you you in this case, you know, I would say um one that's obviously good for teaching today but to this operation is a is a is a is a stone former and this patient is going to end up with um more stones in the future. And um when I when I think about a you you um you know, I I think that that that that area of repair is potentially just a little bit tight even though it's, you know, it's open and it could also present another place for a stone to get caught. And so in her case I'm more readily thinking, you know, a buccal graft is probably going to be better so that um if she passes more stones um she may not get, you know, another impacted stone or a point of obstruction dan. Are you gonna do concurrent? You're dangerous copy. No. So um I think I I will use your horoscope if I really I'm struggling to find but in the vast majority of cases, I don't feel like I need your horoscope in there. Usually you can find it and if you have any questions you can distended the collecting system with your horoscope. So I generally like to park the ureter scope a little just below the area of the structure. So that's that's the tip of your horoscope. Very intentionally parked there any comments or suggestions on creating exposure with with the three arms. I see that you're kind of going back and forth as a, you know, using just one instrument versus both at the same time. Would you ever think of putting like a keith needle in? I'm getting there. Yeah, I've already kind of told the back table that that's what we're gonna do, but I don't want to put it in too early because then I'll set it and then I'll need it and I'll dissect further. And so I think I'm just looking for kind of a key point where I feel like I'm there and then I'll put the retraction sutures in. So I think retracting features are great. Um it's a great way to um to minimize your poor placements, especially for these type of reconstructive procedures. Um you know, so I'm just trying to get to the point where where I want to put the future in and I think I'm just about there. It's very characteristic to get this kind of this, this is very kind of sticky retro peritoneal fat that sticks right to the urinary um system. In these kind of cases. It's just very, it's what we would almost expect to find as we encounter the ureter. And so I'm just trying to be very considerate about this tissue because you know, I think blood supplies important. So we're using the eight millimeter report as the entry for our our B and T. F. Needles because the five millimeter ports is just a little bit small. And if we're not careful, it would just blunt the needle tips. And so um instead of putting in a 12 ports, we just are gonna decide to use a robotic eight millimeter ports as the conduit to get, you know, graft material and suture in and out. The reason why pan back is I want to see which way I want procedures to pull back and um and so I think this is very important because it's the ergonomics of what we do um that really allow this case to be more painful or less painful. And so there's there's several tricks that I've developed along the way. Um and so I don't have to stick 1/4 arm in here to do this. But I love these 6" 30 barbed sutures because I think that they're super versatile. You can customize your approach. You can reset it as you go along through the case. I do what I call the fishhook which allows you to kind of set it and reset it if you want to throw out the case. And so see what I've done is just kind of set a broad area that I can retract back, not just one point and then that fish hooking of the needle allows me to reset it or tighten it up. Um you know, and so these are like little fun little tricks that you can do that are easy. You know, there are other options I've seen out there as far as far as product goes. You know, I think to me, cheap and simple is is good. So this because of this retraction now I'm able to get in there deeply. You know, this is one of those cases where because there's not a huge inflammatory um you know, response That on on initial inspection and early dissection, it's not 100% obvious where the structure is. And so one of the reasons why I park this down here is um um I don't know if you guys just saw it, but are we ready to do it again when, when we're going to inject under pressure. Um and so what I sometimes do is to help us to make this decision. So they will inject water up the uh up the retrograde catheter. And as they just end up the system will look for the wasting or the narrowing. And so I think that we just saw, you know, this is where you can see There's a little Kateri mark here. This is where kind of the harshest of the fat was inflamed and so that usually clues me in that that's probably where the stricture site is. But that's not always 100%. So you guys want to go ahead and inject. Okay we're injecting up. You can see kind of just a little bit of wasting right there, right. And it's not very impressive but you know there's been many times where I've I've been tempted on just the urinal license. I think we fixed the problem and then the few times I've gone back and actually stopped the case re drape the patient and then shot retrograde and flatten the patient out. I have always found that the structure is still there and so I still have to go back and fix it. And so um you know these in these type of scenarios even though it kinda looks okay from the outside. I've learned over time that it's better to just still open it up and just put a buckle graph down. Okay, so here that's my decision point that we just did here. That's kind of the little trick I use here is that sometimes it's very obvious where the structure is sometimes you know you you want more confirmation and so this this injection and installation from from the urethral catheter is very helpful you know? And so I'm thinking I'm gonna I'm gonna open this up here. The other thing that I'll use and I don't I don't feel strongly that I actually I actually have to do this but I think it's a great teaching opportunities that we're gonna shoot some I. C. G. Here. And what I'll say is that although I don't think you have to do it at this is you know I could do the case without it. I'll tell you that sometimes it's um it's it's very interesting to see in the very early arterial phase of the iceberg in the near infrared. You see where the arterial supply goes Because after after the initial period everything will turn green and everything will kind of like um equilibrium. But in the very early phases when you see what lights up first that's where your where your your arterial blood supply is. And I use that as an important piece of information you know to be honest in this case probably not a huge deal but there are some cases where that is important to understand where the arteries are. Okay so um so for the purposes of this surgery we'll we'll shoot the I. C. G. Kind of the show intravascular. So she's small lady. Right And so let's just do um like let's do 1.5 one CC. So you can see immediately the art artery the blood supply came in from this direction. Right And then everything turned green. And I think that that's that's um that's I think an important thing to learn off of these irritable cases because it's not just any of the blood supply but it's where the arteries are coming in from. And so we'll look at that and say the major blood supply is coming from this direction from this group right here, then it broke out into here and then it went down the ureter and so there's a strong um axl blood supply coming down this way and you can see branches coming off this way. And so I'm gonna open up my urethra to me this way and try not to get into these big arteries uh in the blood supply so that that's the main teaching point I wanted to make here dan, talk to us while you're cutting the ureter in this direction, what you're looking for, you're not using any Kateri. Yeah I'm trying not to use any Kateri, I'm trying to just get a precise decision and you know there's scar here. So it's the scissors are bouncing off of it, I'm putting I'm putting tension on it without trying to grab you know it's like a I don't want to handle my ureter directly as much as possible. So if the sucker could come in here and just pull a little bit in here to just give me some traction. So I'm just trying to get some traction so that I can get an incision into the lumen alright so I'd like to calibrate, you know it's not uncommon on these type of cases to find stone fragments that that extruded and got embedded from the uterus coptic procedure, you know the saying this free flow tells me that we at least approximately we're really open. Um but I like to kind of run my scissors and open and that's that's wide open there. I think one tip two when opening up these, you know we clearly saw that it was super scarred. You know the buckle graph, you know you can pretty much customize its length and you if you make it a little bit the incision a little bit longer, that's fine. So I usually start where there's normal ureter where there's no scarring and I bring the incision once you have this hole in the order you can just write it up or write it down. Which um can sometimes be a little easier. Can you suck right here? I mean so externally it looked okay but certainly you could see right there. I mean there's a bed of scar, there's definitely kind of hypertrophy and narrowing in this area. That definitely is the cause. And I would say probably one of the most common reasons why these things fail is that we don't open it low enough into where it's open. And so I agree with video. Um It's good it's you know if if you have any doubts cut down until you know where it's where you feel confident that it is open. And so a lot of times we can do guys is take that ruler Um cut it to about three or maybe four cm and then also cut the ruler in half. So it's super skinny and then put put it down, you know using the scissor when I spread in there. I mean it's just I guess after doing a bunch of these, you just, you know when you're in there and it's open, it's wide open, you know, so when I get in there and it's very freely spreads and you kind of calibrate that ureter diameter um if there's any question, especially on the lower part that you're not there, it's just it's important that you get that sense. And so when you do these and you start, you know, getting these maneuvers. I mean that's we're definitely open. And also if you if you, you know, if you suck and look very carefully here, you can see, I mean this this is our stricture bed right there, right? And you can see clearly, you know, this is not a long stricture. And so here, you know, I made a little extra half snip here to make sure we're down lower, we're certainly above it, you know? And so I feel very comfortable that a two centimeter graft here is gonna be what, you know, perfect size and I dont oversize these, I think it's important to make it fit. Kind of like an Armani suit. Can you also show uh the position of the person harvey that's the buckle because that actually is a little tricky. Okay so you can see we have kind of a wall above the drape set up. He's got his own little field, he's nasally intubated just to give him a little bit more room and then I'm still able to work right. And so you know if if if it gets in the way or your your harvest surgeon is bothered and they want to kind of you know you two D. Dock and take maybe that left arm out that's fine. You know sometimes go grab lunch but in this case you know he's not bothered, he's still working. And so what I'm going to do is I'm gonna start looking for momentum um You know so that we don't waste time. The reason dan's grabbing the momentum is you need when the, when the graph comes in, if you so your graph then you turn on, you know, you inject I. B. I. C. G. And U. Turn on the near infrared fluorescence graft is black. You know there's no blood flow there and so you need a blood supply to kind of support the graft. Um Can you just comment on momentum versus perino frick fat. Um What your thoughts are versus yeah so I've never I've never sewed it post yearly onto the soas muscle you're opening up the sohus bed, you're so featuring your graft onto the bed of Soas which is a good blood supply and then you got to lay your heart on top. And so you know you're kind of working upside down. I always prefer momentum and I have to say every single case I've been able to even on re operative cases I've been able to find momentum. It's very close to you know where you're working especially on the proximal ureter. There really shouldn't be a big struggle to get it in most of these cases. And you can see we have more than enough. And the only thing that really bothers me, you know the things that I worry about on momentum is to make sure that you don't you know you try to minimize if you have to mobilize and start cutting on the momentum that's fine. But make big windows because you're trying to avoid the worst complication from a mental flap which is an internal hernia. Right? And what kind of with did you ask for on the graft? And I said um like one centimeter at the at the widest point um you know the tolerances between one centimeter to like 10.8 is kind of what I I always would prefer I always like to kind of give an oval shaped graph so that I'm not dealing with hard corners. Um You know if you're going to ah um have a little bit of of uh tapering. You know I'd have my one centimeter on this side and a 10.8 centimeter down on this side. Um and then this uh long dimension, you know exactly what you want, which is two centimeters in this case, right? If they give you something a little longer, you know, then you have to decide you want to snip it off and trim it on the field or um or do you want to just make another snip down? And a lot of times I'll just make an extra snip down to match the length of the graft. But from a technical standpoint, Um one I always prefer to measure and then go harvest. You know, I've talked to some people who um from a workflow standpoint, they go get the harvest early. And and I I always get uncomfortable with that because you don't really know before you open it up, how far you're gonna cut up And you know, I, you know, that's not an ideal situation when you cut a two centimeter graphed out and you actually have a three centimeter, you know stricture that you've opened up, right? Um and so I always like to measure and then go harvest and then as far as sewing this thing in, I always like to put more five oh here in a five oh here and that way I don't have to worry about as I'm sewing. You know, sometimes if you're so too much on the graph side versus the other side. Sometimes it doesn't end up exactly in this corner that you want. And so I feel like if you pin down the edges and then do one side and then do the other side it always is you know you're you're at least lined up um you know properly the graft is ready guys so you guys can take out my right arm and um and then we what we do is we put the great, we already put a stitch in on the upper corner With a 50 monochrome on a T. F. Thomas frank needle Cut to 6". And we slipped the graft into the finger of a glove that we cut off so that it kind of protects it as we bring it in through the ports. And so that's what they're about to give me because I think this is a fantastic move sometimes you know you can injure or kind of tear the graft while it's going through the ports, especially if you don't have a experienced bedside er um So I think this move you know by putting it in the in the glove of the finger of the glove. And putting it through is a great little trick. The other little thing I like to always you know teach the residences, you know in the beginning I used a Maryland needle driver combination um because of cost savings and what I realized also um you know as I did more and more of these um that's that looks like a nice graph. Thank you. That looks like a very nice craft. So the other thing is that these needle drivers have a stronger crush force then um then um then um than Maryland. And so what I like to do is actually like this tandem choice of instruments too. So because um I try not to as much as I can try not to grab the five oman a krill with a needle driver because you'll see you know it will chew it up and then it might cause the future to fail. It's one of the reasons why I actually don't like braided suture. Especially when using at like a 50. Gauge because um it will just chew right through the fibers. And so I I started off early on in the day using a braided uh suture. I went to pds next. That's way too much memory. And um if you ever try to break a 50 monocle in your hand, I suggest you try it. It's a very very tough future. There's much less memory on it. And so to me the uh you know, however after having tried it a bunch of different ways. Um I feel like the the monocle is an ideal ideal future. It's very tough. Um It doesn't have a lot of memory. You know I've asked them to be rounded off if there's a little bit of a fatter side of the graph that's on the upper side. But for the most part, I mean it looks, it looks like like it's, you know, reasonably wide. Um you know, certainly more than, you know, perfect for what we need here. I always like to um really kind of use a short tail, you know, when we're, when we're suturing in this area. The last thing you want is a tale that's just getting in your way. And so I always kind of preach, you know, uh long tail as a sloppy surgeon. I think one thing to um taking care not to make the graft to wide, especially when you have kind of a not that severe of this picture. Um sometimes on like if you're getting renal scans after surgery, um sometimes, you know, there'll be a little bit of stasis because the order Paracelsus and this segment is going to be, you know, it's not going to paris styles as well. So I've definitely had cases where um you know, the renal scan may not look like it's draining, but you drive a you scope up and it's, you know, very patiently wide. Um and I suspect sometimes you get a little bit of of urinary stasis, especially if the graph is too wide or you're doing kind of a long reconstruction. So what I'm doing right now is I have two sutures in the one side that I'm not going to start going on, I'm gonna tension it. So I use this pulley system to to just give a little bit of back traction. And I'm careful how I fish hook my needle because I want to be able to bend it back and use this needle later on. But it's just a little trick to just make the case go a little bit more nicely. Um I always was impressed by our pediatric surgeons when I was a resident and how like nice they made their field with little retraction futures. And so I am using this police system. Two kind of duplicate what I learned from my pediatric urology mentors. Um And so you can see how that that tensions this out pulls us out. And so um it makes it maybe a little bit easier to sew too. And I think what I'm going to do is I'm gonna so this part first and then so this part later. So I'll close this and then I'll push the the the wire up and um and then place a stent. How are you going to suture the momentum onto this. Um Are you gonna put over and do like some interrupted into the graft? Or I'm actually gonna probably put 1 1 lower ledge over here and then take the upper lip and then and then packs it down hard. I don't quilt it like you guys do. I I think it's actually very intrigued watching you guys when you do it that way. And I think it's great. But you know my thought is is that that's the way I've been doing it and not have problems with it and so I'm, you know, that's what I've I've kind of stuck to doing, I'm a little bit worried sometimes about tutoring directly onto the ground because of the momentum pulls hard, I don't want it to like, you know, pull on the suture line. One of the reasons why I decided to do this side later, but actually we need to put the stand up in it, is that I like to finish off by sewing towards myself. Um you guys uh can you pass the guide wire up? Um so push the, you can push the euro cath up or just give me the guy passed a guide wire up through the years ago catheter and I'll catch it up here. Alright, I'll hold it so I'll give you, give me some back tension on the wire and go ahead and pass, We're Gonna put a six x 24 French up. She's 54, Okay, stent should be coming up now, Okay, you can go ahead and burn the wire, yep, tell us what your what the rest of the steps are that you're gonna do, you're gonna, so the backseat your line, so this up and then I'm gonna bring this momentum up and I'm gonna make a tongue that's going to, you know, I'm going to pull the tongue up to here, so I won't work on the tip of the tongue. I'll work on the base of the tongue and I'll suit you that back here and then I'll wrap that tongue over here and then I'll shoot your over here that way it's hugging the graft and then I'll fix it to also the barracudas to make sure that, um, if there's some tension on the graph, on the flat on the mental flap, it won't, it won't just easily pull out. I really want to make sure it's secure your final product here. Money shot. But to just shy of 2.4, maybe a centimeter to just shy of 2.5. It looks like you've got plenty of well vascular sized fat within the, you know, within the road is there that's covering the rap. But but so, but the momentum you think still is necessary. You know, I don't like parametric fat because I think parametric fat has a lot of inflammatory potential. I see that all the time in kidney surgery. So, to me that's like, you know, that's not, that's not the kind of fat I want to use, you know, you know, momentum even after an inflammatory response a lot of times we can see it's still very supple, you know, so there's some kind of inflammatory quality to retro peritoneal fat that I don't like. And that's one of one of the reasons why I'm very opposed to using it. Um, you know, in this type of scenario, okay, you want to just give me one of those absorbable clips? It's nice dan, great job. Okay. Mhm, mm hmm, mm hmm. Yeah.