title: Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model.
abstract: OBJECTIVE
  To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures.
  
  
  METHODS
  Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated.
  
  
  RESULTS
  All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003).
  
  
  CONCLUSIONS
  Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA. brandao.lf@gmail.com.|Department of Urology, Paulista School of Medicine, UNIFESP, Sao Paulo, SP, Brazil. brandao.lf@gmail.com.
authors.forename: Luis Felipe
authors.initials: LF
authors.lastname: Brandao
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.|Case Western Reserve University School of Medicine, Cleveland, OH, USA.
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Oktay
authors.initials: O
authors.lastname: Akca
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.|Case Western Reserve University School of Medicine, Cleveland, OH, USA.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Homayoun
authors.initials: H
authors.lastname: Zargar
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Shubha
authors.initials: S
authors.lastname: De
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Jayram
authors.initials: J
authors.lastname: Krishnam
authors.affiliation: Pathology Department, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Patil
authors.initials: P
authors.lastname: Pallavi
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Manoj
authors.initials: M
authors.lastname: Monga
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
authors.affiliation: Pathology Department, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Cristina
authors.initials: C
authors.lastname: Magi-Galluzzi
authors.affiliation: Department of Urology, Paulista School of Medicine, UNIFESP, Sao Paulo, SP, Brazil.
authors.forename: Cassio
authors.initials: C
authors.lastname: Andreoni
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, 9500, Euclid Avenue, Q10-1, Cleveland, OH, 44195, USA.
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D000818:Animals; D002454:Cell Differentiation; D003251:Constriction, Pathologic / Q000601:surgery; D005240:Feasibility Studies; D007682:Kidney Pelvis; D008297:Male; D059630:Mesenchymal Stem Cells; D023421:Models, Animal; D058628:Myofibroblasts; D010537:Peritoneum / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D065287:Robotic Surgical Procedures / Q000379:methods; D013524:Surgical Flaps / Q000098:blood supply; D034421:Sus scrofa; D013552:Swine; D014513:Ureter / Q000293:injuries / Q000601:surgery*; D014515:Ureteral Diseases / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*; D019459:Urothelium
keywords: Mesothelium; Minimally invasive surgery; Neoureter; Peritoneum; Reconstructive surgery; Robot-assisted; Robotic surgery; Stem cells; Tissue engineering; Tubularized peritoneal flap; Ureter reconstruction