Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Current Urology Reports

22-03-2024 | REVIEW

Flaps and Grafts in Robotic Reconstructive Surgery

Authors: Karen M. Doersch, Kathleen A. Li, Divya Ajay

Published in: Current Urology Reports

Login to get access

Abstract

Purpose of Review

The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques.

Recent Findings

Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site.

Summary

Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.
Literature
1.
Yee DS, Ornstein DK. Repair of rectal injury during robotic-assisted laparoscopic prostatectomy. Urology. 2008;72(2):428–31.CrossRefPubMed
2.
Roberts WB, Tseng K, Walsh PC, Han M. Critical appraisal of management of rectal injury during radical prostatectomy. Urology. 2010;76(5):1088–91.CrossRefPubMed
3.
Sotelo R, de Andrade R, Carmona O, Astigueta J, Velasquez A, Trujillo G, et al. Robotic repair of rectovesical fistula resulting from open radical prostatectomy. Urology. 2008;72(6):1344–6.CrossRefPubMed
4.
Bragayrac LA, Azhar RA, Fernandez G, Cabrera M, Saenz E, Machuca V, et al. Robotic repair of vesicovaginal fistulae with the transperitoneal-transvaginal approach: a case series. Int Braz J Urol. 2014;40(6):810–5.CrossRefPubMed
5.
Medina LG, Cacciamani GE, Hernandez A, Landsberger H, Doumanian L, Ashrafi AN, et al. Robotic management of rectourethral fistulas after focal treatment for prostate cancer. Urology. 2018;118:241.CrossRefPubMed
6.
Antonelli A, Veccia A, Morena T, Furlan M, Peroni A, Simeone C. Robot-assisted vesico-vaginal fistula repair: technical nuances. Int Braz J Urol. 2021;47(2):684–5.CrossRefPubMed
7.
Sayegh AS, La Riva A, Perez LC, Medina LG, Poncel J, Ortega DG, et al. Robotic simultaneous repair of rectovesical fistula with vesicourethral anastomotic stricture after radical prostatectomy: step-by-step technique and outcomes. Urology. 2023;175:107–13.CrossRefPubMed
8.
Agrawal V, Kucherov V, Bendana E, Joseph J, Rashid H, Wu G. Robot-assisted laparoscopic repair of vesicovaginal fistula: a single-center experience. Urology. 2015;86(2):276–81.CrossRefPubMed
9.
Melamud O, Eichel L, Turbow B, Shanberg A. Laparoscopic vesicovaginal fistula repair with robotic reconstruction. Urology. 2005;65(1):163–6.CrossRefPubMed
10.
Jacoby A, Maliha S, Granieri MA, Cohen O, Dy GW, Bluebond-Langner R, et al. Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J Urol. 2019;201(6):1171–6.CrossRefPubMed
11.
Lundy SD, Hauser N, Wood H, Fergany A, Angermeier K. Management of prostatosymphyseal fistula following photoselective vaporization of the prostate: Case series and systematic review of the literature. Curr Urol. 2022;16(2):88–93.CrossRefPubMedPubMedCentral
12.
Gloger S, Ubrig B, Boy A, Leyh-Bannurah SR, Siemer S, Arndt M, et al. Bilateral peritoneal flaps reduce incidence and complications of lymphoceles after robotic radical prostatectomy with pelvic lymph node dissection-results of the prospective randomized multicenter trial ProLy. J Urol. 2022;208(2):333–40.CrossRefPubMedPubMedCentral
13.
• Student V Jr, Tudos Z, Studentova Z, Cesak O, Studentova H, Repa V, et al. Effect of peritoneal fixation (PerFix) on lymphocele formation in robot-assisted radical prostatectomy with pelvic lymphadenectomy: results of a randomized prospective trial. Eur Urol. 2023;83(2):154–62. Results of prospectve randomized study regarding the use of peritoneal flap fixation to prevent lymphoceles, which has resulted in broad adoption of this tehcniques.
14.
Wagner J, McLaughlin T, Pinto K, Tortora J, Gangakhedkar A, Staff I. The effect of a peritoneal iliac flap on lymphocele formation after robotic radical prostatectomy: results from the PLUS trial. Urology. 2023;173:104–10.CrossRefPubMed
15.
Deutsch S, Hadaschik B, Lebentrau S, Ubrig B, Burger M, May M. Clinical importance of a peritoneal interposition flap to prevent symptomatic lymphoceles after robot-assisted radical prostatectomy and pelvic lymph node dissection: a systematic review and meta-analysis. Urol Int. 2022;106(1):28–34.CrossRefPubMed
16.
Jun MS, Gonzalez E, Zhao LC, Bluebond-Langner R. Penile inversion vaginoplasty with robotically assisted peritoneal flaps. Plast Reconstr Surg. 2021;148(2):439–42.CrossRefPubMedPubMedCentral
17.
Salibian AA, Schechter LS, Kuzon WM, Bouman MB, van der Sluis WB, Zhao LC, et al. Vaginal canal reconstruction in penile inversion vaginoplasty with flaps, peritoneum, or skin grafts: where is the evidence? Plast Reconstr Surg. 2021;147(4):634e-e643.CrossRefPubMed
18.
Pedersen J, Song DH, Selber JC. Robotic, intraperitoneal harvest of the rectus abdominis muscle. Plast Reconstr Surg. 2014;134(5):1057–63.CrossRefPubMed
19.
Tasdemir N, Abali R, Celik C, Yazici CM, Akkus D. The use of an anterior abdominal wall peritoneal flap in the laparoscopic repair of vesicouterine fistula. Int Surg. 2014;99(5):673–6.CrossRefPubMedPubMedCentral
20.
•• Davila AA, Goldman J, Kleban S, Lyons M, Brosious J, Bardakcioglu O, et al. Reducing complications and expanding use of robotic rectus abdominis muscle harvest for pelvic reconstruction. Plast Reconstr Surg. 2022;150(1):190–5. This study discusses the technique for isolating and using a VRAM flap for perineal reconstruction and compares it to subjects manage with gracilis flaps, demonstrating similar outcomes for both techniques.
21.
Eseme EA, Scampa M, Viscardi JA, Ebai M, Kalbermatten DF, Oranges CM. Surgical outcomes of VRAM vs. gracilis flaps in vulvo-perineal reconstruction following oncologic resection: a proportional meta-analysis. Cancers (Basel). 2022;14(17):4300.CrossRefPubMed
22.
Sanderson DJ, Rutkowski J, Attuwaybi B, Eddib A. Robotic Repair of Supratrigonal Vesicovaginal Fistula with Sigmoid Epiploica Interposition. Journal of the Society of Laparoscopic and Robotic Surgeons. 2018;22(4):e2018.00055.
23.
Takeda T, Shonaka T, Tani C, Hayashi T, Kakizaki H, Sumi Y. Gracilis muscle flap combined with a laparoscopic transabdominal approach is effective in the treatment of post-prostatectomy rectourethral fistula: a case report. Int J Surg Case Rep. 2022;92: 106856.CrossRefPubMedPubMedCentral
24.
Roth T, Rodney MG, Blythe J, McGehee RP. Suprapubic approach for repair of a massive vesicovaginal fistula utilizing a myocutaneous gracilis muscle flap. Journal of Pelvic Medicine and Surgery. 2003;9(1):19–22.CrossRef
25.
Cohen O, Stranix JT, Zhao L, Levine J, Bluebond-Langner R. Use of a split pedicled gracilis muscle flap in robotically assisted vaginectomy and urethral lengthening for phalloplasty: a novel technique for female-to-male genital reconstruction. Plast Reconstr Surg. 2020;145(6):1512–5.CrossRefPubMed
26.
Jun MS, Shakir NA, Blasdel G, Cohen O, Levine JP, Bluebond-Langner R, et al. Robotic-assisted vaginectomy during staged gender-affirming penile reconstruction surgery: technique and outcomes. Urology. 2021;152:74–8.CrossRefPubMed
27.
Burks RT, Crim J, Fink BP, Boylan DN, Greis PE. The effects of semitendinosus and gracilis harvest in anterior cruciate ligament reconstruction. Arthroscopy. 2005;21(10):1177–85.CrossRefPubMed
28.
• Hebert KJ, Naik N, Allawi A, Kelley SR, Behm KT, Viers BR. Rectourethral fistula repair using robotic transanal minimally invasive surgery (TAMIS) approach. Urology. 2021;154:338. This is a 2 patient series describing the TAMIS approach for fistula repair, including an instructional video with no significant complications reported at 5 months post-operatively.
29.
• Parker A, Brydges H, Blasdel G, Bluebond-Langner R, Zhao LC. Mending the gap: AlloDerm as a safe and effective option for vaginal canal lining in revision robotic assisted gender affirming peritoneal flap vaginoplasty. Urology. 2023;173:204–8. This study describes the use of Alloderm, an acellular tissue matrix, to provide extra tissue in the setting of revision vaginoplasty.
30.
31.
Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016–24.CrossRefPubMedPubMedCentral
32.
•• Patel S, Chaus FM, Funk JT, Twiss CO. Total autologous fascia lata sacrocolpopexy for treatment of pelvic organ prolapse: experience in thirty-four patients. Urology. 2022;170:73–7. This study is a case series of subjects undergoing a fascia lata sacroculpopexy for pelvic organ prolapse, demonstrating a high degree of success with few complications.
33.
Tate SB, Blackwell L, Lorenz DJ, Steptoe MM, Culligan PJ. Randomized trial of fascia lata and polypropylene mesh for abdominal sacrocolpopexy: 5-year follow-up. Int Urogynecol J. 2011;22(2):137–43.CrossRefPubMed
34.
Damiani GR, Villa M, Falcicchio G, Cesana C, Malvasi A, Picardi N, et al. Robotic sacrocolpopexy with autologous fascia lata: a case series. Gynecol Minim Invasive Ther. 2023;12(1):10–4.CrossRefPubMedPubMedCentral
35.
•• Shoureshi PS, Dubinskaya A, Magner D, Eilber KS. Robotic sacrohysteropexy with concurrent rectopexy using fascia lata graft. Urology. 2023;173:228. This study demonstrates the use of a fascia lata graft for sacrohysteropexy for subjects desiring to retain their uterus with a video and demonstrates a single successful repair of prolapse.
Metadata
Title
Flaps and Grafts in Robotic Reconstructive Surgery
Authors
Karen M. Doersch
Kathleen A. Li
Divya Ajay
Publication date
22-03-2024
Publisher
Springer US
Published in
Current Urology Reports
Print ISSN: 1527-2737
Electronic ISSN: 1534-6285
DOI
https://doi.org/10.1007/s11934-024-01201-z