a closer look
Lifesaving Urological Repair, With the Help of A Robot BY AMANDA CASTLEMAN
Evan Kovac, MD
6
PULSE • SPRING 2025
T
hirteen years of complications ended with a three-centimeter robotic incision for “Bob,” now 51 years old, thanks to NJMS urologists. In 2011, a gunshot to his abdomen required major surgery at another institution. The bullet sliced his ureter, which transports urine from the kidney to the bladder. To help it heal properly, doctors inserted a stent: a plastic device typically deployed for three to six months. Forgotten, it grew encrusted, which required more invasive procedures, culminating in a 10-centimeter-long stricture enveloping threequarters of Bob’s ureter. With such a challenging scar, doctors contemplated removing the affected kidney or leaving a tube inside him permanently, which could lead to infections and discomfort. Neither choice appealed. Enter associate professors Amjad Alwaal, MD, director of urologic reconstruction and men’s health, and Evan Kovac, MD, director of urologic oncology and robotic surgeon at NJMS and University Hospital. Together, they hoped to save the kidney, which still had good function. “But the last thing we wanted to do was go into his abdomen again,” Kovac explains. “It was a hostile environment with a lot of scar tissue, and risk of injuring other structures and organs.” The team turned to a single-port surgical robot. This minimally invasive procedure—introduced in 2018—relies on one small keyhole incision into the patient’s navel or abdomen, versus the usual three to five. All instruments enter the body through this channel, then fan open. Bonus: this technique can lead to less pain and quicker recoveries. “We did this retroperitoneally, making an incision in the patient’s side to stay away from the complex and scarred abdominal cavity,” Kovac says. The surgical team then reconstructed the ureter with smooth, wet mucosal tissue from inside Bob’s cheek. Alwaal harvested this buccal sample, then halved it lengthwise, tying the pieces end-to-end. Then Kovac planted it on the psoas, a significant hip flexor muscle, which has the strong blood supply a graft needs to survive. “To our knowledge, this was one of the longest single-port, retroperitoneal, buccal KEITH B. BRATCHER, JR.