Buccal Mucosa Grafting Plus Robot-Assisted Reconstruction Opens Ureteric Strictures with Minimal Invasion

MUSC Health is one of the few centers in the Southeast and the only one in South Carolina using buccal mucosa in robot-assisted upper urinary tract reconstruction.

Lindsey Cox, M.D., an associate professor of urology at MUSChas performed the two-step surgical procedure on patients since 2018 to remove or open strictures resulting from scar tissue, traumatic injury, congenital abnormalities and complications from prior surgeries such as kidney stone removal.

While buccal mucosa has become a well-established graft choice for reconstructive surgery in other parts of the body because of its pliability, thickness, smooth texture and tolerance of contact with urine, it is less commonly used in the ureter. And the combination of buccal mucosa grafting and robot-assisted ureteroplasty is still rare.

First reported in 2015, the procedure is complex and takes several hours because of the combination of surgeries and the complexity of the patient’s condition, Cox says. The first step is to identify the stricture and mobilize the surrounding ureter. The surgery team uses a combination of intraoperative ureteroscopic guidance and the near-infrared (NIR)fluorescence technique to determine where the scar ends and the healthy tissue begins to form a basis for the reconstruction. 

Cox says, “The use of the robot plus the NIR fluorescence technique makes it easier to identify the scar tissue and get the graft precisely where we want it.”

The scarred area is measured, and the team harvests a graft of the appropriate length from the inner cheek. Once the graft is harvested, it is placed within the abdominal cavity and the robotic system is used to complete the repair and secure the graft so that it survives in its new environment. A ureteral stent is placed to allow the area to remain open and the urine to drain into the bladder while the repair heals.

Due to the minimally invasive nature of the reconstruction, the surgery is typically less painful than one with an open incision in the abdomen or flank; however, the additional incision in the mouth can cause some discomfort initially and requires a soft diet for a few days.  The surgery replaces the open approach and often can be a last resort before a ureteral stricture can cause enough problems to necessitate removal of a kidney because it cannot be reconstructed.

Cox says the surgery has several advantages for patients. “The incision is smaller. Patients are able to leave the hospital the next day, and there is less need for opioids.”  

Recovery time is several weeks while the graft heals in place, and the ureteral stent comes out four to six weeks after the surgery in an office-based procedure. 

Most of Cox’s patients come from the Carolinas, Georgia and Florida and have had prior surgeries and/or a lengthy course of prior treatment. The numbers of men and women she treats are about equal, she says, and patients of any age can suffer from this condition. 

“We are very encouraged by our patient outcomes,” Cox says. “We have not observed any further ureteral obstruction in our patients who have undergone buccal mucosa grafting with robot-assisted surgery.”

The procedure is one of several she performs to relieve obstructions or blockages in the urinary tract caused by prior surgeries that have caused scarring, such as hysterectomy or bowel surgeries, or by congenital abnormalities, such as ureteropelvic junction obstruction. 

“At MUSC,” she says, “we’re doing more minimally invasive urinary reconstruction, including pyeloplasty for ureteropelvic obstruction, than any center in the state. For providers who have patients who feel that they’re at the end of the road, we offer options that providers or patients might not have considered. When we evaluate these conditions, we have a whole host of other treatments, including open surgery and more conservative treatments.”