Daniel Eun, MD, Fox Chase-Temple Urologic Institute Provider, provides an overview of buccal mucosa graft ureteroplasty procedure and pointers for providers looking to learn how to perfom. Alright so I'm gonna talk on bulky mucosa grafting rhinoplasty, I'll try to stick to tech technical pointers and some lessons that we learned out of our collaborative database. Um And so you know, you guys saw me do one of these earlier today um I think that was just great discussion on it and um I was able to show kind of some some tricks that we used. Um you know the buccal mucosa graft. Uh you know, we we we credit johan today as the first openly constructivist uh South africa to have applied this concept to the order uh first in a live baboon survival model but then to apply to humans. And um it took us a little bit to get dig out that paper and it was really li who who dug that dusted that paper off and um started off at N. Y. U. And and uh they were brave, you know mike and and lee were brave enough to start down this road and uh with the goal of improving patient care. And so they reported uh this early on and after first starting this around 2013. And you know, I I kind of uh you know uh stumbled upon this at the W. C. E. And in Taipei and it literally made me like want to fall over when I started to understand the gravity of what they were doing. And then so I quickly jumped on and since then we've really published tremendously uh to try to change the paradigm of how urethral strictures are being managed in our world because it really hadn't gone anywhere in a long time. And then we won multiple awards from this. And and it's catching on. And, and so, you know, years later now we're, you know, approaching 10 years now where the first urinal buckle, your little your little plastics were done. Um and um and and so as we put our database together and we sat up in somewhere in central Jersey in a hotel room sequestered together, trying to figure out how to put this database together. We've now been able to put it together and really present. And so um you know, there are interim uh data has has slowly shifted. And as we, our latest collaborative paper which we included only people with greater than 12 month follow up. So this is a true intermediate um experience. Um you know, the numbers show that we had a little bit more failures than our early experience when we looked at just the short term outcomes. And so um if you look at our our our patients, 54 patients, four out of five were incision on on lease and uh one out of five or augmented. And a systematic buckle graphs. Um 33% of them had failed prior attempts at reconstruction. You know, this, the average structure length was three centimeters. We had a 5% major postoperative complication rate, medium length of stay was one day. And uh you know, the paper that we put, we put out like a couple of years before this gave us, I think a 94% success rate, but we just looked at people with more than 12 month follow up, that success rate dropped to about 87 88%. And so what you see here is that there are some early failures, But there was also some later failures at around 10 plus months out. And so the kind of the, the concept that, you know, if it's, if it's good after roughly about a year, that's probably gonna stay good may not necessarily be true. And that's what we're finding. And so, um, you know, first I'll just go to a video kind of showing um, you know, this is a patient that we did had a double level structure. I think in the older days before this was an option, this person would have been an illegal ureter. Right? And so um instead of going through that traditional concept, we um, we decided that we're going to do a robotic approach and essentially harvest to buckle graphs and lay them in. And so this is our, you know, poor placement and normally I just put in the top three to the right those green ports. But because there was a lower structure, I added the ports a so that I could pour hop and jump, um my access down and so my camera would move down one point and everything would shift down. And so as we do the dissection here, you can see, You know as we're approaching, you can see you know, similar to today but you know this is probably a lot worse. You know that sticky retro peritoneal fat sticking to your strictures. And you know this is a little bit hokey. We we used a I don't know, there's a 15 blade um you know, but you know it was a it's a way to open up and um the lower structure here we decided to do a mucus ectomy where we cut out the kind of very narrowed uh mucosa. But we didn't cut out the back wall. And so we then approximated the back wall mucosa together and then did an only. And so that's I guess you would kind of consider this almost like a hybridized um between a true only and a augmented and mathematic. And so here's our first draft and putting that in Using you know, similar future as I did today. 50. Try to keep respectful overtime. Here's I. C. G. So I'm using I. C. G. To understand you know the the bed of tissue that we're going to to make sure it has good blood supply and here's our upper structure that we're gonna fix as well, You're through. And then here's our momentum. So this all looks you know fairly familiar in here. I'm re interrogating the issue with buckle, I mean with I. C. G. And and looking at my momentum flap and making sure that everything is really well vascular used at the end of the case right? It's all this looks uh you know fairly familiar and some version to some degree of what we did earlier today. So from a technical standpoint, you know I would break it down to three different, you know what I do pre operatively and assessing and managing an inter operative decision making and postoperative assessment management. Um Kind of lessons that we've kind of all talked about and put together. You know one is you know it's good to get a good solid anatomical overview. Um A Ct NMR. You're a grand sometimes it's good probably retrograde um you know and a grade retrograde polygram's from outside institutions. You know you get it as a piece of information but it's not hugely reliable. I don't really trust other people's retro grades and a and a grades. Um You also want to get a nuclear medicine renal scan to see if they're salvageable function. You also want to assess if there's a loss of function and you certainly want to look at your T. One half uh and drainage times. But really you know the true assessment is what I do in the operating room with retrograde or retrograde slash and a great polygram studies. But what I'll tell you is that if the stent has just been removed on that day. So say the patient's been living with a stent for like three months and I pull that stand out, then I shoot an integrated retrograde or just retrograde. I consider that a low quality study. And the reason why is that? I think the stent in there that's been in dwelling in there has molded that your eyes are open and it's not a true picture like you know much like somebody who's doing the Urethra plasticky, you don't shoot a retrograde urethra graham right after you pull out a fully that's been in there for three months, right? So I consider that a piece of information and a low quality piece of information and I'll get my true one later on after I rest the ureter. Right? And so a lot of times what we do is a stance between the O. R. And I are. So we'll actually leave a urinary catheter up the ureter will send the patient to pack you'll they'll go straight down to interventional radiology. And with that Euro Catherine place the IR specialist, You can squirt the renal pelvis and then do one stick uh you know no frost on the tube and we just do that because we think that's better patient care and then we rest that your order for a minimum about 3-4 weeks. Um and if there's no prior stent like the one today then we can consider repair on the same day. And so we um there's one paper that we put out through our group uh talking about the your eternal rest concept, the concept that's really well known amongst reconstructionists in the Urethra and where we think that that concept is also very pertinent and very true in the ureter. And so we've shown that there is a higher success rate in patients who have had, you're under arrest versus patients who had been operated on with a stent in place. Um as far as intra operative decision making, there's a lot of points to make here, you know, So here at my high reliability assessment is the one after I've rested the order and I do a repeat retrograde or repeat a grade. We'll call it up and down a gram to determine the length of location. And the other concept that I really want to talk about is the obliteration of the ureter. If that ureter looks obliterated and we define that in our own group as the inability to pass a wire through if we cannot pass a wire through, we call that obliterated by definition and it's a nomenclature that we're trying to build up because we think that that's significant not only in the operative plan and the the complication risk, but your operative plan is going to be different. Right? And so I'd like to park the retro kath like I did today just below the structure. I think all of these guys here do it a little bit differently with similar intentions and then um you know with a buccal graft you don't have to do a crazy dissection and and a lot of cases I think that you get to the Euro to identify the structure. You don't necessarily have to completely mobilize that you're on your way. Um Because sometimes completely mobilize that you're off the iliac vessels or you know off the aorta is dangerous. Right? And um you know, and so I think less work to get the job done is better. Um And and less anxiety provoking. And so also preserves the blood supply um as well. And then you know, we like to use many of us like to use I. C. G. Um to assess tissue perfusion. You know, we uh this was a philadelphia geologic society uh S a um that Basically saying that the actual graph that you will put into the ureter and and surgery is roughly about 30-50% longer than the estimated length when you eyeball it on retrograde polygram. Right? And so another paper that we put out was about long length structures. We're looking at really long length and we look at traditional ways, you know, your local cost me you're it or you're asking me with downward foxxy, you know, although there's not a lot of patients in this group we find is that there's a significantly higher failure rate versus if you just did a buccal graft, right? Um And so if other additional uh inter operative decision making, you know. so I talked about obliterated versus non ability or inability to pass a wire or you're a catheter up the presence of illumined dictates what procedures are going to do. If there is no loom in, you're gonna have to excise a segment out and then do a back wall, repair what we call it, augmented uh anna's thematic versus if if there is a looming then typically you'll run a pair of scissors like I did through today. And then only. And so you know the great the best thing about an incision in only is that the traditional way to do a U. U. Where U. Um Transect across the ureter and then you spatula eight um and a diseased ureter. And suddenly you've increased the size of your gap that you've got to put together. And so by um you know when you spatula eight you know a centimeter or one direction centimeter another. Now you're one centimeter gap has become 2.5 3 centimeters. And to try to put that together and now you're putting more attention on the futures. So there's you know we all know that's the reason why you're you're Ostuni is more subject to failure, right? And so the great thing is that you don't have to do that, you can keep that back all together. You can keep the actual blood supply of the ureter and you can just only your buccal graft down. Now if I get asked this all the time and you know how big of a buccal graft can you do in some cases I want I think it's easier instead of doing a huge buckle like length of buccal graft, sometimes I'll just cut out and I'll actually shorten it because I think eight centimeter graft is much more likely to fail than a four centimeter graphic. And so sometimes I will do the extra work to do to to to exercise it and do a downward backpacks and make my graph smaller. I don't know if everybody here would agree with me on that but that's what I prefer to do. But if there is you know obliteration you have to excise the scar and then you have to consider doing a downward slope X. If you have a large gap. And so um we um you know looked at obliteration and what will tell you from looking at the data and obliteration is that there is more operative time and so you have to reserve more time in the O. R. If you plan, if you're pre planning procedures, you see that there's obliteration or transaction um there's gonna be more adjunctive maneuvers that you have to do. Um they're gonna have more blood loss and you're gonna have a higher complication rate and it's just inherent in the complexity of the operation. Um Additionally um mentum flap you know I've always been able to get it, I know that there's some cases where it's not going to be available. Um we talked about this a lot about securing it carefully and there's different thoughts on it, but I think the concept is the same and then um, and then um, you know, avoid small or mental windows because you, you want to be careful of an internal hernia. Um, a lot of times we'll stick a flexible system scope into the bladder at the end of the case to make sure the distal curl is of the stent is in the bladder Because I don't want to them to show up in my office six weeks later for the stent removal and go that, that stent didn't make it down into the bladder. And then the other thing is that, you know, buckle graph does not preclude the traditional option. If this fails, you can still do an illegal, your murderer, you can still do all the other things. And so and so what I would say is that you got the buckle graph gives you a free shot right? And so post operatively I moved to stand at six weeks in the office. Typically I get a renal scan at three months and then nine months and then annually thereafter. Um, and then um, when to take them back, you know, to do a retrograde and reassess if there's continual pain, this continued loss of function, recurrent infections or what looks like high grade obstruction on renal scan, I will take them back to re investigate, see what's going on. A lot of times when I find that in the past few scope up is that it's actually a peristaltic. It stopped functioning well, but it's not mechanically obstructed. Um, and so um, you know, we we manage we you know, we we have a pretty broad definition of definition of failure, which is pain, recurrent infections, um and loss of function. Mm hmm. Um, but so that that's what I want to share. We offer our fellowship for one year for any of you guys that are interested. Thank you.