text:
Abstracts: 2017 Annual Meeting Boston, MA
Awarded Best Poster or Video
|Abstract Title
|Track 1
|Track 2
Reconstruction of Two Concurrent Ipsilateral Ureteral Strictures with Appendiceal Onlay and Non-Transecting Ureteral Reimplant
|Reconstruction Upper Tract
Abstract: V10-01
Sources of Funding: none
The management of concurrent ipsilateral ureteral strictures is challenging as the ureter cannot be transected in two places. The mainstays of reconstruction in this clinical scenario include renal autotransplant or ileal ureter, both of which are associated with morbid short and long-term complications. The concept of an onlay graft or flap to increase the size of the lumen is a well-established technique for urethral reconstruction. We demonstrate the feasibility of this concept to the ureter by placing an onlay of bladder and appendix to manage concurrent ureteral strictures.
A 66-year-old man with bilateral proximal ureteral stones developed a 3cm right distal ureteral stricture and a 6cm right proximal ureteral after undergoing ureteroscopy and laser lithotripsy at an outside institution. These strictures were refractory to endoscopic management. The patient had an elevated creatinine. Robotic reconstruction was performed with simultaneous intraoperative ureteroscopy to delineate the stricture. As the ureteroscope was passed retrograde, the 3cm distal and 6cm proximal ureteral strictures were incised using the robot along the anterior aspect of the ureter. The patient's appendix was mobilized, detubularized, and placed as an onlay flap onto the proximal stricture. The distal ureteral stricture was repaired by marsupializing a flap of bladder onto the ureter for a non-transecting reimplant.
The patient had an uneventful postoperative course and went home on postoperative day 4. Nephrostogram performed at 6 weeks post op demonstrated prompt drainage of contrast after stent removal. At 6 months post op, he had no urinary infections or flank pain. Ureteroscopy at this time demonstrated patency throughout the entire course of the right ureter.
For the appropriate patient, ureteral reconstruction using onlay of appendix and bladder is a feasible option for multiple ureteral strictures. Six-month outcomes are favorable, but long-term outcomes need to be elucidated.
Dmitry Volkin
Kiranpreet Khurana
Aaron Weinberg
Mark Ferretti
Marc Bjurlin
Michael D. Stifelman
Lee C. Zhao
Robotic buccal mucosal ureteroplasty for ureteral stricture after robotic ureterolysis
|Reconstruction Upper Tract
Abstract: V10-02
Sources of Funding: none
Long strictures involving the proximal ureter pose a reconstructive challenge. Recently, robot-assisted ureteroplasty with buccal mucosa graft (BMG) has been described. We present a patient who received both robotic ureterolysis followed by a robotic ureteroplasty the following year, in order to describe both robotic techniques on video.
A 58 year-old male on medication for a pituitary tumor presented with left ureteral obstruction and underwent a robotic ureterolysis/omental wrap procedure for presumed retroperitoneal fibrosis after failed medical management. Fibrosis was isolated to the region of a tortuous left iliac artery, which was likely due to trauma from a prior femoral artery catheterization during a cardiac procedure. The ureter was freed of fibrotic attachments and covered with an omental wrap. The patient did well for 1 year, but eventually developed recurrent ureteral obstruction with a 6cm mid/upper ureteral stricture requiring nephrostomy drainage and stent. He elected to undergo BMG ureteroplasty._x000D_ _x000D_ For both robotic procedures, the patient was positioned in modified lateral decubitus lithotomy position with ports similar to a pyeloplasty. For the ureteroplasty, the mouth was prepped separately for BMG harvest. Ureteroscopy and near-infrared fluorescence were used to define the proximal and distal extent of the stricture. The stricture was measured and the BMG was harvested accordingly. A ureterotomy was made along the length of the stricture over the ureteroscopy. The BMG was sewn to the ureteral edges as an onlay patch. Ureteroscopy was used to confirm patency and a stent was placed. An omental wrap was sutured over the ureter and BMG for blood supply._x000D_ _x000D_
The patient underwent an uncomplicated ureterolysis procedure with an EBL of 75cc, OR time of 280 minutes, and a hospital stay of 3 days. He is doing well with followup <1 year with no complications or evidence of obstruction.
We describe a case of robotic ureterolysis followed by robotic BMG ureteroplasty in the same patient. Robotic BMG ureteroplasty is an option for patients with long ureteral strictures with proximal extent, and is an alternative to autotransplantation or ileal ureter.
Chase Heilbronn
Logan Campbell
Mouafak Tourjman
Dan Pucheril
Lamont Jones
Craig Rogers
Robot Assisted Bilateral Ureteral Reimplantation on Studer Neobladder with Exposure of Iliac Artery Prosthesis
|Reconstruction Upper Tract
Abstract: V10-03
Sources of Funding: None
The Studer type neobladder is an orthotopic vesical substitution alternative that provides a continent reservoir that works at low pressure and is easy to void. One possible complication of this diversion is the uretero-intestinal stenosis. The presence of vascular prosthesis can cause an inflammatory reaction that might affect the ureters. The standard treatment for the stenosis is the surgical repair. This ureteral reconstruction is a demanding surgery in the open approach._x000D_ Robotic sugery enhaces vision of the surgical field while maintaining a high freedom of movement and facilitates a successful repair.
We present the case of a 72-year-old male, with a history of hypertension, diabetes and hyperuricemia, who's urological history began in April 2015 with a Transurethral Resection of Bladder (TURB) that showed a High Grade cT1 bladder tumor and Carcinoma in situ (Cis) with an early recurrence. In November 2015, he underwent a Robotic Assisted Laparoscopic Radical Cystoprostatectomy with bilateral lymphadenectomy and Studer type Neobladder. After removing ureteral catheters (1 week after surgery) the patient present urinary leaks at the level of uretero-neovesical anastomosis. Bilateral Nephrostomy catheters where placed. After conservative treatment with ureteral catheters, an antegrade pyelography showed resolution of the urinary leaks but presence of bilateral distal ureteral stenosis _x000D_ In March 2016 the patient presented in the emergency room with severe bleeding due to a fistula between the left common iliac artery and the Studer neobladder, requiring percutaneous placement of two arterial prostheses. _x000D_ _x000D_ In April 2016, a Robotic Assisted Laparoscopic Bilateral ureteral reimplantation on Studer Neobladder was performed. _x000D_ Local Bioglue was used to cover the area of exposure of vascular prosthesis.
The surgical time was 210 minutes. The preoperative hemoglobin was 120 mg/dL and the postoperative one was 100 mg/dL. No blood transfusions were necessary. There were no postoperative complications. The patient was discharged at the 8th day after surgery. Nephrostomies were removed 15 days after surgery.
Robot assisted surgery is a good approach for the treatment of ureterointestinal stenosis, even in cases of concomitant vascular disease.
Joan Palou
LluÃs Gausa
Ivan Schwartzmann
Laura González Pérez
Juan Antonio Peña
Enver Moncada
Pablo Juárez del Dago
Humberto Villavicencio
Early Robotic Repair of Multifocal Ureteral Perforation After Ureteroscopy
|Reconstruction Upper Tract
Abstract: V10-04
Sources of Funding: none
As urologists become more comfortable with robotic surgery, new techniques surface. Minimally invasive approaches for management of iatrogenic ureteral injuries, mostly secondary to gynecologic procedures, have been described previously. Traditional conservative management of ureteral injury, including stent placement, nephrostomy tube, or delayed repair can be morbid and require significant patience on behalf of both the patient and surgeon with potential for a prolonged course to definitive repair. We present a case which demonstrates the feasibility of early robotic repair of a multifocal ureteral injury within 24 hours of ureteroscopic insult, expediting resolution of the patient's injury.
A 73-year-old male was transferred to our institution with a reported ureteral avlusion with subsequent failure to place a stent or nephrostomy tube. We performed our own retrograde pyelogram and identified what appeared to be a devastating injury to the mid ureter. We were fortunate to pass a wire across the injuries, and a stent was placed to aid with intraoperative identification. A 4-port laparoscopic robotic approach was taken to identify the left kidney and subsequently the left ureter. Gentle dissection around the ureter in the area concerning for injury identified two separate full thickness injuries. The ureter was repaired using running absorbable suture in a tension free, watertight fashion. A drain was placed in the vicinity of the repair bed._x000D_
The patient's discharge was delayed due to postoperative fevers. Workup was negative. He was ultimately discharged with a stent and Foley catheter in place on postoperative day 3. The Foley catheter was removed on postoperative day 7. He underwent cystoscopy with stent removal and retrograde pyelogram 4 weeks after surgery, which revealed a patent ureter. Renal ultrasound at 6 weeks demonstrated no hydronephrosis, and the patient is asymptomatic._x000D_
Based on our initial experience, early robotic repair is a safe and effective modality for management of iatrogenic ureteral injury. The approach and principles of reconstruction are similar to already established techniques. In this case, it also allowed for simultaneous management of the patient's ureteral stone disease. The initial increased risk of proceeding to a more invasive treatment modality is likely offset by the shortened timeline to stent or nephrostomy tube free status. Further investigation of this approach as well as evaluation of long term outcomes will be critical to establishing this as a standard option for management of iatrogenic ureteral injuries._x000D_
Andrew Radtke
Kenneth Jacobsohn
Robotic Salvage Pyeloplasty with Buccal Mucosal Onlay Graft – A Simplified Technique
|Reconstruction Upper Tract
Abstract: V10-05
Sources of Funding: none
Surgical management of recurrent ureteral pelvic junction (UPJ) obstruction is limited by our ability to create a tension free anastomosis due to ureteral devascularization, fibrosis with renal fixation, and dense stricture formation. A high rate of recurrence leads to progressively complex repairs. Herein, we present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty in the management of recurrent UPJ obstruction.
We present two patients with recurrent left UPJ obstruction. Both previously underwent multiple failed open or robotic pyleoplasties, attempted endoscopic treatment and subsequent management with ureteral stent exchanges. At the time of surgery patients were placed in left lateral flank position and a Foley catheter inserted. Transperitoneal access was obtained with a Veress needle. Extensive adhesiolysis was required. The colon was reflected medially, the kidney, ureter and renal pelvis were exposed and the UPJ identified. The area surrounding the UPJ and proximal ureter were circumferentially dissected. The UPJ was entered and the ureter incised longitudinally from the renal pelvis until healthy, normal caliber ureter was demonstrated distally, with spatulation for at least 1 cm on either end. The defects were measured and found to be 3.5 and 4 cm. 8 Fr double J ureteral stents were placed. Single buccal grafts were harvested from the right inner cheek and measured for the length of the stricture and 1.5-2cm wide. A stay suture was placed to maintain orientation and minimize handling of the ureteral tissue. The graft was delivered to the abdomen and placed as an anterior onlay, over the ureteral and UPJ defect, with two 4-0 running Vicryl sutures. The tension free repair and surgical field was wrapped in omentum after confirming a water tight anastomosis. A JP drain was placed.
Operative times were 280 and 411 minutes. Estimated blood loss was 25-50 mls. The hospital stay was 2 days. Foley catheters and JP drains were removed in the immediate post-operative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency. Both patients have been asymptomatic since stent removal and anticipate follow-up functional renal scans with Lasix in 6 months.
Robotic salvage pyeloplasty with BMG is an attractive alternative technique in the management of recurrent UPJ obstruction demonstrating a tension free, water tight and patent repair. Short term follow up has demonstrated that it is an effective and feasible approach when compared to more extensive and invasive surgical procedures.
Ryan J. Nelson
Anna Zampini
Jeremy Reece
Kenneth Angermeier
Georges-Pascal Haber
Robotic-assisted Laparoscopic Calyceal Diverticulectomy
|Reconstruction Upper Tract
Abstract: V10-06
Sources of Funding: None
A calyceal diverticulum is a cystic cavity within the kidney that is lined by transitional epithelium and communicates with a calyx, or less commonly, with the renal pelvis. A calyceal diverticulum forms as a result of the failure of the degeneration of the ureteric bud. 0.2 – 0.5% are congenital; 40% are associated with calculi. This is a video demonstrating a robot assisted laparoscopic calyceal diverticulectomy._x000D_
This video demonstrates two cases of robotic calyceal diverticulectomy the first patient is a 19 year-old caucasian female and the second patient is a 25 year-old caucasian female. Who both had sudden onset of flank pain and abdominal pain. Initial work up was consistent with infection; however on repeat imaging, both patients were found to have a calyceal diverticulum. Both patients underwent a robot assisted laparoscopic diverticulectomy. Initial dissection was similar to a partial nephrectomy with mobilization of the large bowel and exposure of the renal hilum. The diverticulum is then incised, drained, and excised to the infundibulum to prevent recurrence. Any remaining urothelium was fulgurated.
Both patients who underwent a robot assisted laparoscopic calyceal diverticulectomy are complication and re-admission free to date.
Robotic-assisted laparoscopic calyceal diverticulectomy is a feasible and safe option in the management of large persistent calyceal diverticulum.
Hugh Smith
Nathan Jung
Juan Class
Amar Singh
Darryl Turner
Dana Butler
Chris Keel
Robotic repair of right uretero-ileal anastomotic stricture following prior robotic radical cystectomy and intracorporeal conduit diversion
|Reconstruction Upper Tract
Abstract: V10-07
Sources of Funding: none
Uretero-ileal anastomotic stricture is a well-known complication following radical cystectomy and urinary diversion with a rate of 8-12% in open and robotic series. Some strictures can be managed endoscopically but many require revision of the uretero-ileal anastomosis. With increased utilization of robotic radical cystectomy we have started revising these strictures with a robotic approach as well.
From September 2014 - October 2016 we have performed 75 robotic radical cystectomies with 60 undergoing robotic intracorporeal ileal conduit urinary diversion._x000D_ We found 6 patients that developed a uretero-ileal stricture. In the following video we highlight the technique for robotic revision of a right-sided uretero-ileal anastomotic stricuture in a patient following prior robotic radical cystectomy and intracorporeal ileal conduit urinary diversion.
Our uretero-ileal anastomotic stricture rate following robotic radical cystectomy with intracorporeal conduit urinary diversion was 10%. _x000D_ Of these four were involving the left and two were involving the right ureter. Three patients were able to be managed with endoscopic dilation_x000D_ and three patients required revision of their uretero-ileal anastamotic stricture. All 3 patients were able to be managed with robotic uretero-ileal anastomotic revision._x000D_ Mean time to diagnosis of stricture was 182 days. For the patient in the video operative time was 62 minutes, EBL was 100cc, and length of stay was 1 day. The other two patients had other concomitant operations (parastomal hernia repair in one and takedown of pre-existing colon conduit in another) that significantly impacted operative time and length of stay and were not including in analysis of perioperative outcomes.
Uretero-ileal anastomotic strictures following robotic radical cystectomy and intracorporeal conduit urinary diversion can safely and effectively be managed with a robotic approach.
Mehrdad Alemozaffar
Total laparoscopic ureteral substitution using appendix
|Reconstruction Upper Tract
Abstract: V10-08
Sources of Funding: None
Complex ureteral injuries have challenging repair, involving renal autotransplantation or ureteral substitution, which was first described in 1911, using bowel segments (Shoemaker), and in 1912, using the appendix (Melkianof). We report a post-pyeloplasty complex ureteral injury that was laparoscopically repaired by an appendix interposition.
A 17 year-old boy with right ureteropelvic junction (UPJ) obstruction was scheduled for pyeloplasty. During surgery, an obstruction on the ureterovesical junction was discovered, making impossible the use of a double-J stent, causing local trauma. So, Anderson-Hynes pyeloplasty was performed and he was left only with a nephrostomy tube. Twenty days later, an anterograde pyelogram demonstrated a stricture on the UPJ level. A cystoscopy showed a scar on right ureteral meatus. It was impossible to identify the right ureteral meatus, during cystoscopy. Then an exploratory laparoscopy was scheduled on the fortieth postoperative day, and as the renal drainage was not possible by two points of obstruction, ureteral substitution was decided. Because of an intraoperative favorable anatomy, the appendix was chose and it was made laparoscopically.
The operation lasted about 350 minutes and the estimated blood loss was 200ml, so the patient received no blood transfusion. Postoperatively, the patient developed urinary tract infection and was discharged in the tenth postoperative day. Double-J stent was removed on the sixtieth postoperative day. Follow-up 6 months after surgery showed a satisfied patient, with no limitations on quality of life, asymptomatic, but with a residual hydronephrosis on image studies.
We support the use of the appendix for ureteral substitution (as a ureteral substitute) on selected cases, and we advice for the possibility of laparoscopic approach of complex injuries. We believe this is the first video of a total laparoscopic ureteral substitution using appendix.
Paulo Medeiros
Cesar Britto
Daniel Ferreira
MaurÃcio Júnior
Rodolfo Alves
Ronnie Lima
Thiago Grossi
Carla Santos
John Heyder Galvão
Tips for Surgical Technique During Robotic Ureteral Reconstruction for Various Segments of Ureter
|Reconstruction Upper Tract
Abstract: V10-09
Sources of Funding: None
Ureteral reconstruction for different segments of ureter can be extremely challenging. There are many methods for reconstruction, most of which are typically performed using an open approach. Standard techniques such as boari flap and psoas hitch have been around for many years and are traditionally not performed using a minimally invasive approach. In this video we present multiple advanced techniques and alternatives during robotic ureteral reconstruction for various segments of ureter.
We present techniques for distal ureterectomy with reimplantation, segmental ureterectomy with end to end anastomosis, buccal mucosal patch and ileal patch for midureteral stricture, and ileal ureteral replacement for panureteral stricture. We demonstrate these techniques as well as the use of indocyanine green injection to help with identification of the level of obstruction.
To date, 24 cases of ureteral reconstruction have been performed. Robotic console times have ranged form 60 minutes to 194 minutes. Estimated blood loss has ranged from 10-150ccs. Length of stay has ranged from 1-4 days. Follow up has ranged from 2-60 months. To date, there is no evidence of recurrent obstruction in any patient.
Robotic ureteral reconstruction can be successfully performed on any segment of ureter and is a feasible option to more invasive open surgery. The use of indocyanine green can help delineate segments of ureter for excision. Ileal and buccal patches are good alternatives to segmental ureterectomy or more complicated flaps for midureteral strictures.
Manish Patel
Ashok Hemal
Radial Forearm Free Flap Substitution Urethroplasty for the Treatment of a Long Urethral Defect
|Reconstruction Lower Tract (I)
Abstract: V1-01
Sources of Funding: None
We describe the surgical steps for performing a radial forearm free flap (RFFF) substitution urethroplasty in a patient with an obliterated urethral defect after failing an excision and primary anastomotic (EPA) urethroplasty for a pelvic fracture urethral injury (PFUI).
A 9-year old male involved in an all-terrain vehicle accident was initially treated at an outside hospital for non-operative pelvic fractures and a urethral disruption. He was managed with a suprapubic catheter. The patient was referred 5 months after the injury with a 3 cm obliterated bulbar urethral defect. We performed a posterior EPA urethroplasty with corporal splitting and partial inferior pubectomy. One month after surgery, an anastomotic leak was identified on retrograde urethrogram (RUG) imaging. The urethral catheter was removed and the patient was managed with a SPT. Two months after surgery, repeat imaging was performed and an obliterated urethral defect was identified. Due to the early failure of the repair, suggesting vascular compromise and/or technical failure, we proceeded with RFFF substitution urethroplasty.
The patient underwent RFFF urethroplasty under the coordinated care of the urology and microvascular plastic surgery team. Major steps included the following: 1) dissecting the urethra and measuring the length of the urethral defect, 2) harvesting the radial forearm free flap, 3) tubularizing the flap over a catheter, 4) preparing the recipient femoral vessels in the inguinal region, 5) performing the urethral-flap anastomoses, and 6) performing the microvascular anastomoses. Following excision of scar, the urethral defect measured 10 cm. The flap was harvested from the left forearm which was closed primarily. The operation was 8:45 with 180 cc of blood loss. During the microvascular anastomoses, an acoustic microvascular coupler was placed to audibly monitor the vascular flow of the flap during the post-operative period. The patient was kept on bed rest for 48 hours, and the patient was discharged home on post-operative day 4. After 3 weeks, the urethral catheter was removed and the SPT was kept to drainage since a small leak was visualized at the proximal anastomosis on RUG imaging. The SPT was removed 3 weeks later following no visual evidence of leak on imaging. The patient continues to void without obstructive symptoms 3 months after surgery.
Radial forearm free flap urethroplasty is a treatment option for long, obliterated urethral defects and should be performed in a multidisciplinary manner with the assistance of a microvascular plastic surgeon.
Paul H Chung
Jonathan T Wingate
Jeffrey B Friedrich
Bryan B Voelzke
Combination of Endo-GIA with laparoscopic pyeloplasty for the treatment of a 19 year-old man of horseshoe kidney with ureteropelvic junction obstruction
|Reconstruction Upper Tract
Abstract: V10-10
Sources of Funding: None
The horseshoe kidney is a renal fusion anomalies which occurs in 0.25% of the population. The ureteropelvic junction obstruction (UPJO) with horseshoe kidney is uncommon. We reported that a 19 year-old man with horseshoe kidney and UPJO was underwent laparoscopic pyeloplasty and the horseshoe kidney was cut using Endo-GIA in its isthmus.
The patient presented with symptom of left flank pain with severe hydronephrosis. The diuretic renal dynamic imaging showed the complete mechanical obstruction for the upper urinary tract. The glomerular filtration rates were 34 ml/min for the left side and 40 ml/min for the right side. The computerize tomography showed the horseshoe kidney with the right-side UPJO. The ureteropelvic junction was compressed upwardly by the isthmus of horseshoe kidney. For the complete relief of the obstruction, the isthmus of the horseshoe kidney was cut using Endo-GIA combining with the laparoscopic pyeloplasty.
The surgery was done with expected post-operative results. The operative time was 125 minutes. The post-operative hospitalization was 3 days and the double-J stent was removed 3 months after surgery. The patient is asymptomatic with complete relief of obstruction.
When UPJO complicated with horseshoe kidney which may be the potential reason to cause hydronephrosis, cutting the horseshoe kidney using Endo-GIA combining with the laparoscopic pyeloplasty may be a feasible alternative.
Xuesong Li
Kunlin Yang
Liqun Zhou
Intracorporeal Robotic-Assisted Laparoscopic Appendiceal Interposition for Ureteral Stricture Disease
|Reconstruction Upper Tract
Abstract: V10-11
Sources of Funding: None
Management of complex ureteral strictures greater than 1 cm in length are traditionally treated with open or laparoscopic ureteral reconstruction. In the setting of long segment strictures not amenable to simple ureteroureterostomy, ureteral replacement with ileum classically has been described as a suitable option. Aside from ileum, a buccal mucosa graft and the appendix have been described as alternative replacement tissues. To date, there are no reports in the literature of a robotic-assisted laparoscopic (RAL) ureteral reconstruction utilizing the appendix. We report, to our knowledge, the first case of a completely intracorporeal RAL appendiceal interposition for ureteral stricture disease in a 33 year old Caucasian male with a 5 cm obliterative right-sided ureteral stricture secondary to recurrent urolithiasis.
The DaVinci Xi was docked to the patient in a fashion comparable to right nephroureterectomy. Extensive renal descensus was performed and it was determined that tension-free primary ureteroureterostomy was not feasible. Given the ideal position, length and orientation of the appendix, along with the added morbidity of bowel harvest, we elected to perform an appendiceal interposition. The appendix with its mesentery was isolated and interposed between the remaining healthy proximal and distal ends of the ureter. The ureteroappendiceal anastomoses were performed in an end-to-end fashion. A ureteral stent was left in place to allow for postoperative healing. The entire case was done intracorporeally.
The ureteral stent was removed two weeks postoperatively. Antegrade nephrostogram showed patency of the ureter down to the bladder one month postoperatively. Lasix renal scan confirmed preservation of renal function and no obstruction three months postoperatively.
In carefully selected patients with long-segment right-sided ureteral strictures and favorable anatomy, appendiceal interposition is a good option for ureteral reconstruction. This procedure can be done safely and effectively with robotic-assistance._x000D_
Vidhush K Yarlagadda
Jeffrey W Nix
J Patrick Selph
Robotic (Da Vinci Xi) ureteral reimplant with Boari flap
|Reconstruction Upper Tract
Abstract: V10-12
Sources of Funding: none
Ureteral reimplant is most commonly performed due to trauma and oncologic disease affecting the distal ureter necessitating removal and reconstruction. The most commonly utilized procedures to aid in ureteral reimplant are the psoas hitch and the Boari bladder flap repair (BFR). Both maneuvers allow more proximal lesions to be treated with implantation instead of nephrectomy. Psoas hitch involves mobilizing the contralateral bladder attachments and securing the bladder dome to the psoas tendon of the affected side. BFR, most commonly performed in conjunction with a psoas hitch, involves incising a section of bladder, rotating it toward the affected ureter and tubularizing it for anastomosis with the remaining healthy ureter. With the open BFR first performed on humans in 1947, minimally invasive techniques have been described in recent years with similar outcomes. Recent advances in robotic technology may increase the feasibility and safety of robotic assisted laparoscopic BFR in selected patients.
We present our experience utilizing the Da Vinci Xi robotic system to perform a robotic assisted BFR.
Our patient is a 64 year-old white male with history of high grade T1 bladder cancer who was found to have blood emanating from the left ureteral orifice on surveillance cystoscopy as well as two filling defects at the junction of the mid and distal ureter on retrograde pyelogram. Due to his baseline history of hypertension, diabetes, and marginal baseline renal function; he elected to undergo robotic left distal ureterectomy with left pelvic lymph node dissection, psoas hitch, BFR and stent placement. Intraoperative cystoscopy and ureteroscopy aided the robotic procedures, and the operation went without complication with an EBL of 200mL. At follow up visit 2 weeks post-operatively, our patient was recovering well, however, cystogram revealed a small leak. At post-operative week 3, CT-Urogram and repeat cystogram revealed leak resolution, and the foley catheter was removed. Ureteral stent was removed at post-operative week 6.
Robotic Boari bladder flap repair is safe and effective in carefully selected patients. Due to the ability to side dock the robot, the Da Vinci Xi robotic system enabled concurrent intraoperative cystoscopy and ureteroscopy. This allows for more accurate identification of the lesion and precise division of the ureter.
John DiBianco
Christopher Bayne
Dan Su
Ami Kilchevsky
Jeffery Sparenborg
Les Folio
Piyush Agarwal
Robot Assisted Laparoscopic Placement of Bladder Neck Artificial Urinary Sphincter.
|Reconstruction Lower Tract (I)
Abstract: V1-02
Sources of Funding: None
We present our technique of robot assisted laparoscopic placement of bladder neck artificial urethral sphincter (Robot-AUS). Compared to the open approach, the robot assisted laparoscopic technique allows for excellent visualization of the posterior dissection.
Our patient is a 49-year-old male with history of L1 spinal cord injury with stress urinary incontinence between intermittent catheterizations. Using the Da Vinci Xi surgical system, the bladder neck was circumferentially dissected. A 9cm AMS 800 AUS cuff was placed around the bladder neck after confirming appropriate sizing with simultaneous cystourethroscopy. The pressure-regulating balloon was placed in the recreated space of Retzius. Tubing connections were created extracorporeally at the right lower quadrant port site; the pump was passed subcutaneously from this port site to the right hemi-scrotum.
The patient was discharged home on post-operative day #1, performing intermittent catheterization through a deactivated cuff. His stress urinary incontinence persisted until his device was activated at post-op week 4. Six months post-operatively, he is dry without the use of pads and is able to easily pass his catheter after cycling the AUS.
Bladder neck artificial urinary sphincter is effectively placed in a minimally invasive fashion with a robot assisted laparoscopic approach; the approach provides excellent visualization of the posterior dissection. _x000D_
John Schomburg
Mya Levy
Sean Elliott
Membranous urethroplasty using dorsal onlay buccal mucosal graft for strictures associated with TURP or radiation therapy
|Reconstruction Lower Tract (I)
Abstract: V1-03
Sources of Funding: none_x000D_
To present the application of buccal mucosa graft dorsal onlay urethroplasty for membranous urethral stricture caused by TURP or radiation therapy.
All patients were confirmed to have membranous involvement using radiographic and endoscopic evaluation. Dorsal onlay urethroplasty via a one-sided urethral dissection as described by Kulkarni and Barbagli was performed in all patients. This technique was modified by carrying dorsal urethrotomy proximally through the membranous urethra and sharply excising a wedge of intracrural tissue beyond stricture area to make adequate room for buccal mucosa grafting. _x000D_ All patients were followed at 4, 8, 12 months and then yearly for assessment of functional and patient-reported outcomes.
Fifteen consecutive men with a mean age 68 years (47-72) post membranous urethral stricture repair were included. Seven patients had prior TURP, 6 had prior radiation therapy with prostate in situ, and 2 patients had radical prostatectomy followed by adjuvant radiation therapy. At a mean of 17 months (4-37) follow up, one patient required an additional procedure for stricture recurrence. No patient developed de novo incontinence. Improvement was seen with respect to mean maximum flow rate (4 to 21 cc/sec), PVR (90 to 50 cc), and International Prostate Symptom Scores (23 to 9).
Membranous urethral strictures can be effectively treated using this buccal mucosa graft dorsal onlay technique which avoids extensive urethral mobilization, urethral transection, and perirectal dissection. The described technique did not compromise continence in this group of patients. Additionally, in this series dorsal buccal mucosal graft take is demonstrated in patients with prior history of radiation therapy. _x000D_ _x000D_
Stephen Blakely
Daniela Kaefer
Michael Daugherty
Dmitriy Nikolavsky
|Reconstruction Lower Tract (I)
Abstract: V1-04
Sources of Funding: none
Bulbo-membranous urethral stenosis after surgery for benign prostate hyperplasia (BPH) are challenging because the internal sphincter has been removed and continence depends on the function of the external sphincter, which is located just at the site of the stenosis; any attempt for reconstruction may jeopardize continence. Anatomical studies have shown that the rhabdosphincter is separated from the membranous urethra by a sheath of connective tissue. We developed a novel technique performing a meticulous dissection of this sheath to separate the muscle from the urethral wall, thus performing an intra-sphincteric anastomosis without disturbing the sphincteric function
A 67 year old patient underwent a transvesical simple prostatectomy for BPH. He developed an early bulbo-membranous stenosis managed initially with repeated dilation until he went into complete retention needing a suprapubic tube. _x000D_ The bulbar urethra is exposed through a vertical perineal incision with splitting of the bulbo-spongiosum muscle and then separated from the corpus cavernosum. Opening of the perineal membrane and splitting of the intercrural space in the midline, provides access to the dorsal aspect of the bulbo-membranous junction. The bulb is then mobilized to the left side, without detachment from the perineal body and the bulbar vessels are retracted. The sheath of the membranous urethra is now opened circumferentially at the bulbo-membranous junction, carefully reflecting the circular muscle fibers of the external sphincter until exposure of the urethral wall is obtained and the connecting tissue plane is identified. Gentle blunt proximal dissection along this plane allows separating the muscle away from the urethra towards the prostatic apex until healthy urethra is found to perform the bulbo-prostatic anastomosis, which is completed with a standard parachute technique. Finally the sphincteric muscle ring is anchored to the anastomosis with interrupted absorbable stitches_x000D_
The patient was discharged on PO day 3 and the urethral catheter was removed at 3 weeks. He recovered normal continent micturition and is voiding symptoms free at 3 months of follow-up
Excision and bulbo-prostatic anastomosis with sphincter sparing for bulbo-membranous stenosis after BPH surgery is feasible and safe. Our technique allows repairing the urethra preserving continence and to our knowledge it has not been described before. A larger series and reproduction in other centers are needed to validate this technique
Cristina Baeza
Reynaldo Gomez
Rodrigo Campos
Laura Velarde
Redo bulbo-prostatic anastomotic (BPA) urethroplasty for recurrent pelvic fracture-related urethral strictures
|Reconstruction Lower Tract (I)
Abstract: V1-05
Sources of Funding: None
Surgical reconstruction of bulbomembranous urethral strictures following traumatic disruption of the pelvic ring requires careful assessment of both urethral edges, incision/excision of scar tissue and a tension-free anastomosis. Revision surgery is complicated by further loss of urethral length and often requires certain maneuvers to straighten the course of the proximal urethra and bridge longer defects. These techniques, achieved via a transperineal approach, are demonstrated in this video. The outcomes of redo-BPA are presented.
A 35 year old man developed stenosis of the bulbomembranous urethra associated with a pelvic fracture sustained during a fall from height. This recurred after anastomotic urethroplasty. During revision surgery the midline perineal incision was re-opened.The bulbar urethra was mobilised proximally off the central tendon up the point of obliteration and transected at this level. The proximal end was identified by means of a sound introduced suprapubically and spatulated. The scar tissue was excised until healthy mucosa was exposed. The distal end was mobilised and spatulated. The intercrural plane was developed, inferior wedge pubectomy performed and the urethra rerouted around the left crus of the penis to facilitate fashioning a tension-free anastomosis. _x000D_ _x000D_ Between January 2006 and December 2014, 117 patients with pelvic fracture-related urethral injuries were treated in our unit. 29 patients (24.8%) had previous attempts at repair (one attempt n=24; two attempts n=1; more than two previous repairs n=4)._x000D_
The procedures performed (in a stepwise fashion) were: anastomotic urethroplasty n=10; corporal separation n=4; wedge pubectomy n=3; rerouting of the urethra n=6. Abdomino-perineal exposure was necessary in 6 patients in order to carry out entero-urethroplasty or repair associated bladder neck injuries or fistulae. _x000D_ A successful outcome (unobstructed voiding with no evidence of radiological recurrence and no need for further surgery or instrumentation) was achieved in 22 patients (75.9%) compared to 85% in those having a primary procedure. _x000D_
The best outcome after BPA is seen in previously un-operated patients and recurrences are more difficult to salvage. Revision surgery is technically challenging but is nonetheless feasible and associated with favourable outcomes in a specialised high-volume centre.
Enrique Fes Ascanio
Simon Bugeja
Stella Ivaz
Felix Campos Juanatey
Anastasia Frost
Daniela Andrich
Anthony Mundy
The Urethral Pull-Through: Reconstructing the Devastated Posterior Urethra and Bladder Neck After Radiation
|Reconstruction Lower Tract (I)
Abstract: V1-06
Sources of Funding: None
Recurrent posterior urethral stenosis secondary to radiation-induced damage poses a significant challenge to the reconstructive surgeon. Reconstructive options are limited. Using an IRB-approved database, we present our contemporary experience of 20 patients with radiation-induced proximal urethra/bladder beck stenosis who underwent urethral pull-through urethroplasty and staged artificial urinary sphincter (AUS) placement from 2007-2016.
With the patient in lithotomy position, a midline incision is made from the penoscrotal junction to the posterior perineum. The bulbospongiosus muscle is identified and reflected off of the urethra. The urethra is mobilized posteriorly until the point of obstruction where it is then transected. With the proximal urethra and bladder neck visible, the stenosis is incised and the lumen dilated to size 14 Hegar. The urethra is trimmed and spatulated until healthy tissue is encountered. A Lowsley retractor is used to place a 22-Fr Foley as a suprapubic tube (SP) and a 22-Fr Red Robinson as the pull-through catheter. The pull-through catheter is then advanced into the urethra a length that is dependent on the length needed to span the area of stenosis into the bladder neck. The pull-through catheter is secured to the urethra with chromic suture and is then used to bring the urethra up through the proximal urethra which is allowed to heal by secondary intention. The bulb muscle is then split and placed around the urethra to serve as a vascularized layer around the repair. A large AUS cuff is placed to facilitate subsequent AUS placement. After 4 weeks the SP and pull-through catheters are removed. 12 weeks after urethroplasty, an AUS is placed. We initially use a low pressure 51-60 reservoir and the system is activated 12 weeks after placement.
No high-grade intraoperative complications were observed. 16 patients maintained urethral patency with no further dilation and 17 patients were socially continent at a median follow-up of 22 months (6.6-105 months). A median of 1 sphincter revision surgery was required to establish social continence. 4 patients had recurrent stenosis. There were 4 AUS complications (2 infections and 2 erosions). Two of these patients subsequently had new devices placed and are continent at last follow-up. Two are pending AUS reimplantation.
The urethral pull-through combined with placement of an AUS offers patients urinary continence and durable urethral patency. Our technique can be highly beneficial in the patient that traditionally would have limited desirable options.
Jeffrey Loh-Doyle
Mukul Patil
Stuart Boyd
Clampo-Tractor. A novel self retaining clamp retractor for penile urethral reconstruction: Improving surgeon ergonomics
|Reconstruction Lower Tract (I)
Abstract: V1-07
Sources of Funding: None
Constant, steady retraction and exposure are important for penile surgery - including hypospadias repair, urethral reconstruction, and correction of penile curvature. We set out to develop a retractor that would improve surgeon and assistant ergonomics and provide compression at the base of the penis to reduce blood loss. We describe this novel self-retaining penile retractor and our initial experience in its use.
This retractor is made of medical grade stainless steel. It has three components – a fixed hemostatic clamp attached to a scale, with also houses an artery forceps. This forceps moves along the scale to adjust the traction on the penis. The clamp is flat and compressive. The arms are non-traumatic and do not cause circumferential constriction. A stay suture taken through the glans is engaged by the artery forceps, and the height adjusted according to the penile length. The retractor has been used by reconstructive urologists in India, Turkey, Australia, Kuwait, Indonesia, and the United States of America.
A total of 37 reconstructive cases were performed using this penile retractor (23 redo hypospadias repairs, 7 complex penile urethroplasties, 4 penile urethrocutaneous fistula repairs, and 3 surgeries for correction of Peyronie's disease). For each case, surgeons were asked to score the retractor on a 4 point scale: 1. Extremely Non satisfactory, 2. Not Satisfactory, 3. Satisfactory, 4. Extremely Satisfactory. The average score was 3.65._x000D_ Advantages noted were ease of application, reduction of assistant fatigue, stable operative exposure and non-traumatic tissue compression conferring a bloodless field. There were no complications attributable to the device. The main limitation is that it cannot be used for hypospadias proximal to the penoscrotal junction. _x000D_ This retractor is inexpensive, durable and easy to sterilize and can be used on adult and pediatric patients alike._x000D_
In our experience this retractor has high utility in reconstruction of the penis and penile urethra. It affords improved ergonomics for the surgeon and assistant, which results in shorter operative times and reduced blood loss while avoiding tissue damage.
Pankaj Joshi
Sanjay Kulkarni
Surgical Correction of Urorectal Fistula (URF) following Radical Prostatectomy for the Treatment of Prostate Cancer.
|Reconstruction Lower Tract (I)
Abstract: V1-08
Sources of Funding: None
Urorectal fistula is the least common, but probably the most incapacitating complication associated with the surgical treatment of localised prostate cancer. There has been a considerable rise in the reported incidence of URF after the treatment of prostate cancer, presumably due to new and evolving multimodal treatments. The majority of patients with URF present with urine leakage through the rectum as the flow gradient is predominantly from the urinary to the intestinal tract.
This video describes a transperineal approach for surgical correction of URF following radical prostatectomy for the treatment of prostate cancer. We explain in detail the surgical technique and emphasise the key steps. The essential anatomical landmarks are identified including access via an inverted U-shaped, peri-anal incision, exposure of the perineal body, fistula exposure and division with independent closure of both sides of the fistula.
Over the past 10 years we have repaired URF transperineally in 62 patients with a minimum of 1 year follow-up (these exclude abdomino-perineal repairs). 44 (71%) were purely post-surgical fistulae while the remaining 18 (29%) had adjuvant radiotherapy. There were 10 failures (5 in each group), 8 of which were salvaged by an abdomino-perineal repair, giving an overall fistula closure rate of 96.8%._x000D_ _x000D_ Via a transperineal approach the rectum can be accessed easily, and the rectal defect closed in two layers, with relatively few problems. The bladder defect is more difficult to close because there is less mobility and flexibility of the tissues, and is therefore usually closed in one layer. Preservation of the levator ani muscles allows them to be interposed between the urinary and rectal suture lines longitudinally, closing the space between them and doing away with the need for a gracilis interposition flap._x000D_
URF at the level of the anastomosis or bladder base can be managed via a transerineal approach without the need for a trans-anorectal sphincter-splitting approach, a covering colostomy or an interposition flap when the circumstances are appropriate, and the surgeon is sufficiently experienced.
Enrique Fes Ascanio
Simon Bugeja
Stella Ivaz
Felix Campos Juanatey
Anastasia Frost
Daniela Andrich
Anthony Mundy
Repair of Adult Buried Penis with Removal of Suprapubic Fat Pad and Split Thickness Skin Graft: Emphasis on Patient Body Habitus
|Reconstruction Lower Tract (I)
Abstract: V1-09
Sources of Funding: None
Repair of adult acquired buried penis is a challenging surgical problem with potential for substantial morbidity when complications occur. Just a few of the post-operative problems can include: recurrence of buried penis, damage to genitourinary structures, wound breakdown / infection, and loss of split thickness skin graft. We present a technique for buried penis repair with removal of suprapubic fat pad, penile split thickness skin graft, emphasizing the importance of patient body habitus._x000D_
We reviewed records of patients undergoing a consistent technique for adult buried penis repair from 2014-2016. Information was gathered on patient demographics, past medical history, concomitant problems (such as urethral stricture, and lymphedema), and outcomes. Important aspects of surgical technique involve complete resection of the suprapubic fat pad, removal of scarred penile skin, reconstruction of the peno-abdominal and peno-scrotal junction, and split thickness skin graft of the penis._x000D_
Seven men were identified. Mean age and BMI were 40 (range 21-65 years) and 48 kg/m2 (range 39-65 kg/m2). Four patients had distal urethral stricture and required 1st stage urethroplasty of the meatus and fossa navicularis. Two patients had concomitant scrotal lymphedema and required scrotectomy with reconstruction with local flaps. Some graft loss occurred in 57%. Graft loss ranged from 20% to 50%. All patients were managed conservatively and no patients required re-grafting or additional peri-operative procedures. No patients had recurrence of buried penis or required further intervention. _x000D_
Anatomic attachment of the abdominal pannus above the supra pubic fat pad is variable among patients and an important pre-operative consideration potentially mitigating the risk of recurrence of buried penis. Wound complications are common, but generally heal with conservative measures.
Jeremy B. Myers
Bradley A. Erickson
Sorena Keihani
Is continence possible in patients with double block at bladder neck -prostate and membrano -bulbar urethra after pelvic fracture urethral injury?
|Reconstruction Lower Tract (I)
Abstract: V1-10
Sources of Funding: none
Rarely, pelvic fracture urethral injury can cause simultaneous transection of bladder neck and membrano-bulbar junction. Mundy reported sequestration of prostate. In another report, they found 85% of patients of PFUI have functioning external urethral sphincter mechanism after successful anastomotic repair. This information helped in our development of a new technique for repair in such cases to preserve continence.
We present a retrospective review of 8 patients .Preoperative evaluation requires MCU and RGU. Urethroscopy evaluates the membrano-bulbar obliteration. Antegrade cystoscopy confirms the bladder neck obliteration. Pelvic MRI is also obtained to check for the prostate. Perineal incision- bulbar urethra is mobilized and transected proximally. Suprapubic incision- posterior pubectomy is performed. An endoscope passed through SPC tract and blocked bladder neck area is opened from outside. Semen collected in the sequestrated prostatic urethra is aspirated with needle over which prostatic urethra is opened .A 6Fr endoscope is passed through the prostatic urethra distally to visualize the membranous urethra. The membranous urethra is opened perfectly under vision as distally as possible. Excision of the scar at the apex of membranous urethra is kept to minimum to preserve continence. Bulbo-Membranous Anastomosis (BMA) and bladder neck–prostatic anastomosis is performed .
Mean age 14 (5 to 36) yrs ,mean follow up 26 (14 to 72) months .Initial 2 adults are 100% incontinent . We then modified our technique of identifying membranous urethra through intraprostatic scopy and bulbo membranous anastomosis. The video is of an adult who underwent transpubic urethroplasty at age 7 for double block. As prostatic urethra was rudimentary bulbo vesical anastomosis was performed. He presented at age 18 years with pain after ejaculation. He was reoperated using our modified technique.1 adult and all 5 children were approached through the above improved technique. 2 (40%) children required redo surgery with for revision of the bladder neck anastomosis. as we had tried narrow anastomosis to help continence. All children are continent and have good flow, 2 have occasional nocturnal dribbling.
Double transection with injury at membrano-bulbar and prostate bladder neck junction requires two separate anastomoses to be performed. Postoperative continence is possible .Our step wise technique improved continence rates to ensure proper preservation of the external sphincter.
Pankaj Joshi
Devang Desai
Sandesh Surana
Hazem Orabi
Craig Hunter
Sanjay Kulkarni
Complications of Percutaneous Access during Percutaneous Nephrolithotomy
Abstract: V11-01
Sources of Funding: None.
The rate of access-related complications for percutaneous nephrolithotomy (PCNL) has been estimated to be approximately 12.5% . Often, complications are the result of inadequate pre-operative preparation for PCNL or incorrect operative methods. In this video, we discuss several important risk factors as well as several tips to address access-related complications of PCNL.
Intraoperative risk factors for access-related complications are discussed at length. These include pre-operative considerations and anatomic considerations that would necessitate alternative forms of access, including CT-guided or laparoscopically-guided access. Next, techniques to avoid problems at the time of establishing access are demonstrated and discussed in detail.
Access-related complications are often encountered in patients who require pre-operative anticoagulation or in whom a urinary tract infection may be identified pre-operatively. Addressing these issues preemptively is imperative to patient safety. Further, several risk factors for bowel injury may be addressed with meticulous knowledge of the patient&[prime]s anatomy pre-operatively. In certain cases, anatomic abnormalities necessitate laparoscopic or CT-guided access. Finally, the main difficulties at the time of obtaining access for PCNL are discussed at length, including inadvertent vascular access, extravasation of contrast, guidewire kinking, obstruction of the access tract by a staghorn calculus, bowel injury, and pleural injury. Inadvertent vascular access is often addressed by redirecting the guidewire into the collecting system. In rare cases, use of the access sheath, or balloon, to tamponade bleeding, may be required. Extravasation often necessitates re-puncture, while guidewire kinking may be rectified with the assistance of a rigid, open-ended catheter. Access for staghorn calculi may be achieved with the assistance of retrograde ureteroscopy, or maneuvering past the stone edge with a grasping forceps. Bowel injury should be addressed with drainage of the urinary tract separate from the bowel and broad spectrum antibiotics. Finally, pleural injury necessitates rapid identification to ensure expedient placement of a chest tube.
Access-related complications can introduce significant morbidity to an otherwise successful PCNL. We demonstrated some crucial skills to avoid the difficulties that are often encountered at the time of obtaining access, as well as several techniques that can be used in a timely fashion to address access-related injuries.
Vinaya Vasudevan
Zeph Okeke
Arthur Smith
Avicenna Roboflex, For Robotic Assisted Retrograde Intrarenal Laser Lithotripsy of The Kidney Stones, Larger Than 2 Cm.
Abstract: V11-02
Sources of Funding: none
Robotic assisted retrograde intra-renal surgery (RA-RIRS) with the Avicenna Roboflex allows safe, comfortable, and remote control, of all commercially available flexible ureteroscopes functions. Continuous development of Avicenna Roboflex's ergonomics and surgeon user friendliness, and precise large intra-renal stone laser fragmentation, has increased flexible endoscope durability. _x000D_ The impact of these incremental improvements on fragmentation efficiency of different stone volumes, density and compositions are unknown._x000D_
The Avicenna Roboflex allows user adjustable deflection scaling for greater tip control precision than is possible with manual flexible ureteroscope operation, where every 5 degrees of deflection movement deflects the tip 30 degrees. For optimal ergonomics, a central wheel for deflection mechanism control was eliminated, assigning this function to a new grooved thumb-wheel incorporated into the bulb of the right hand control._x000D_ Moreover, a new universal remote pedal control unit allows remote laser and fluoroscopic activation control, while laser fiber advancement and retraction from the endoscope tip, irrigation flow rate with pulsed flush options, and the ability to influence renal respiratory excursion by adjusting an inflatable compression belt balloon, which are all possible from the Master Control Console, give the operator greater control of many different aspects of the surgical procedure. In this video, these capabilities of RA-RIRS treatment are demonstrated with the Avicenna Roboflex coupled to a Storz digital flexible ureteroscope, for upper tract stones of different volumes, densities and compositions, and for the first time, in an upper tract urothelial tumor._x000D_
Of sixty-eight consecutively treated patients, 62 met stone volume eligibility criteria (<4400mm3 ) for possible single session treatment, with 24% pre-stented. Stones had HU <1500, and were treated in <2 hours without complications. Non-contrast 3 months CT showed only one significant (4mm) stone residual needing a 2nd intervention in a triple phosphate infection stone, giving an overall 98% stone free rate.
The incremental improvements incorporated into the Avicenna Roboflex Master control console have increased operator control of key surgical procedural aspects, resulting in excellent single stage treatment outcomes for a wide range of stone compos?t?ons, while releasing precious operating room resources and avoiding endoscope breakage for additional cost savings.
Anup Patel
Jan Klein
Yasser Farahat
Nida Zafer Tokatli
Ahmet Sinan Kabakci
Remzi Saglam
Applying Urolithiasis Techniques to Biliary Stones: Percutaneous Transhepatic Lithotripsy
Abstract: V11-03
Sources of Funding: None
Choledocolithiasis is a significant problem that can lead to severe cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is firstÂline treatment. However, this is not always possible when the patient has surgically altered anatomy or very large stone burden. Urologists can use our skills and technology to assist in these situations. We report our technique and outcomes from our 15 years of experience with percutaneous transhepatic endoscopic biliary lithotripsy.
Patients are selected by our gastroenterology colleagues who approach us for assistance when ERCP is not possible. We utilize a percutaneous transhepatic endoscopic approach in a combined procedure with interventional radiology. Most patient have a transhepatic biliary drain already in place. A wire is then placed through the tube into the biliary system and into the common bile duct. A 14-French ureteral access sheath is placed under fluoroscopic guidance into the common bile duct. A flexible ureteroscope is then guided through the access sheath into the biliary system. A holmium laser is used to fragment the stones. The stones can be subsequently retrieved or flushed into the intestinal tract.
Over the 16-year time period, a total of 26 procedures were performed on 18 patients (mean age 55.8 years). The indications were surgically altered anatomy in the majority of the cases that did not allow access via ERCP. Two of the patients had a large biliary stone burden which was too large to be managed by ERCP. Stone clearance was achieved in 16 of the 18 (89%) patients after a mean of 1.1 procedures. Most of these patients (61%) required only one procedure to become stone free. There were no Clavian grade III or higher complications. One patient developed cholangitis that resolved with administration of intravenous fluids and antibiotics. There were no instances of injury to the biliary system, pancreatitis, or need for urgent re-intervention at our institution.
With a multidisciplinary approach and the correctly selected patient, percutaneous transhepatic biliary endoscopic lithotripsy is a safe and effective intervention for complex biliary stones. Endourologic urolithiasis techniques can play a role in the treatment of patients with choledocolithiasis not amenable to ERCP. This improves patient care by decreasing the need for invasive surgery when ERCP is ineffective.
Brett Johnson
John Roger Bell
Prasad Dalvie
John McDermott
Stephen Nakada
Dusting Utilizing Suction Technique (DUST) for Percutaneous Nephrolithotomy: Dedicated Laser Handpiece to Treat a Staghorn Stone
Abstract: V11-04
Sources of Funding: None
Dusting, use of high frequency and low pulse energy holmium laser settings, is performed during ureteroscopy but reports on this method to treat complex renal calculi via percutaneous nephrolithotomy (PCNL) are limited. We report the first clinical feasibility of a dusting technique during PCNL with the assistance of a specially designed laser suction handpiece (LSHP).
We performed PCNL on a patient with spinal cord injury, urinary tract infection and a computed tomography scan demonstrating a left complete staghorn stone (5x3.5x2.5 cm; 1000 Hounsfield units). Prone PCNL was performed via a 30 Fr Amplatz sheath with access in the lower pole. A 120-Watt holmium laser (P120H, Lumenis) was used as the lithotripsy source to perform Dusting Utilizing a Suction Technique (DUST) for PCNL. A 550um laser fiber was inserted into the LSHP (Lumenis, Israel) which was connected to a suction pump in the P120H. The LSHP weighs 135 grams, and has a stainless steel cannula with an inner lumen diameter of 3.25 mm. Laser fiber length is controlled via a manipulation wheel, with the fiber positioned in a working channel on top of the cannula. Suction is activated on the LSHP, and fragments are sucked into a collection container. We used &[Prime]automatic&[Prime] mode where suction occurred only during laser activation.
We successfully performed DUST-PCNL using settings of 0.6 J x 70 Hz, and 1.0 J x 60 Hz, both on long pulse mode. PCNL took 110 minutes to complete; total lasing time was 21.29 mins, and laser energy usage was 47.68 kJ. The fiber tip was easily visible at the tip of the LSHP, with no failure of the device. We did not encounter any difficulty with fragment aspiration or clogging of the steel cannula or suction tubing. Ancillary devices included a basket to retrieve large fragments, and flexible nephroscopy was performed to dust an upper pole branch of the staghorn. At the end, a 22F Malecot re-entry tube was placed. A nephrostogram on post-operative day (POD) 1 demonstrated a 4 mm residual fragment. Patient was discharged on POD 2. There were no complications; stone analysis demonstrated a struvite stone.
Utilizing a 120-Watt holmium system, we confirmed initial clinical feasibility and safety of DUST-PCNL to perform simultaneous lithotripsy and aspiration for effective stone clearance. An advantage of this method is versatility in treating a stone with both rigid and flexible endoscopy using a lightweight energy source. Further clinical evaluation is needed to understand the efficacy of this technique in comparison to alternate lithotripsy sources.
Khurshid Ghani
William Roberts
Abstract: V11-05
Sources of Funding: None
In this video, we demonstrate single-stage percutaneous approach to a calyceal diverticulum (CD) with stones.
Video of surgical technique accompanied by slides and voiceover explanation of the steps
A hemostat and then an 18G diamond-tipped needle are used to line up to the target stone. If the stone is visible on KUB, a ureteral catheter is not required. An infracostal puncture is preferred to reduce the risk of lung injury even if the CD is located in the upper pole. The needle is advanced into the CD. A 0.035-inch J-tipped movable core wire is advanced through the needle and carefully coiled, avoiding back wall perforation with the stiffer portion of the wire. Guidewire control is essential - utmost attention must be paid to keeping the guidewire secure when passing dilators to prevent loss of access. An 8/10 French coaxial dilator is passed over the J-wire and a second J wire is coiled inside the diverticulum as a safety wire. The tract is balloon dilated over the working wire. Advancing the dilator too far into the diverticulum can cause posterior wall perforation and bleeding and should be avoided. A 30F Amplatz sheath is passed over the balloon dilator. In a small diverticulum, we only place the tip of the balloon dilator into the diverticular cavity with the access sheath remaining just outside._x000D_ _x000D_ A rigid nephroscope is advanced and 11F alligator forceps are used to manually dilate the remaining tract until the diverticular cavity is visualized. Grasping forceps or a lithotripter are used to remove the stone. After removal of all stone material, the cavity is inspected for presence of a flattened renal papilla. Papilla presence would indicate an obstructed hydrocalyx rather than a calyceal diverticulum. The diverticular cavity is fulgurated with a resectoscope and a rollerball electrode using 1.5% glycine irrigant. Low energy electrocautery settings are used - 20 W coagulation and 0W cut. An 18F red rubber catheter is placed in the cavity with position confirmed on fluoroscopy. The catheter is removed on post-operative day 1 if drainage is minimal. _x000D_
This single-stage technique allows quick and effective treatment of calyceal diverticulum stones.
Nadya E. York
Hazem M. Elmansy
Marcelino E. Rivera
James E. Lingeman
Step by Step Ultrasound-guided Percutaneous Nephrolithotomy: A Single Hospital Experience
Abstract: V11-06
Sources of Funding: none
Percutaneous nephrolithotomy is effective for patient who has large renal stone > 2cm in size. Ultrasound-guided percutaneous nephrolithotomy can be performed safely without radiation exposure. We describe how we performed ultrasound-guided percutaneous nephrolithotomy step by step according to our experience.
We conducted a retrospective study of patients received percutaneous nephrolithotomy from January 2012 to October 2016. In total, 205 patients were enrolled. One-hundred and thirty-six patients received ultrasonic-guide operation and 69 received fluroscopic-guided operation. Patients' clinical characteristics, operation time, hospital stay, complication, hematocrit and renal function data were recored and analyzed. We performed ultrasound-guided by following steps:(1) Double-J catheter insertion (2) Three-way Foley insertion (3) Normal saline instillation and Foley clumping (4) Needle puncture (5) Incision and Dilatation (6) Balloon dilatation and insert sheath.
Among two groups, the patient clinical characteristics do not have significant difference. There were also no difference during hospital stay, hematocrit and renal function change. However, shorter operation time (62mins vs. 87mins, p< 0.05), was noted in ultrasound-guided group maybe due to shortened puncture time. In the other hand, complete stag-horn stone patients had higher stone free rate (75% vs 90%, p< 0.05) in fluroscopic group. Complication rate is similar in two groups but one patient in ultrasound-guided group had developed bladder rupture while normal saline instillation by pressure pump.
ultrasound-guided percutaneous lithotomy is feasible for patient who has large renal stones. The outcome is similar compared to traditional fluroscopic-guided procedure. In our experience, ultrasound-guide may shorten puncture time and decrease the radiation exposure to patients and staffs. Double-J catheter insertion before puncture to create dilated calyces may help puncture easier.
Yite Chiang
Kaiyi Tzou
ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position
Abstract: V11-07
Sources of Funding: None
ECIRS (Endoscopic Combined IntraRenal Surgery) is a combined rigid and flexible antegrade and retrograde approach for the treatment of large and/or complex urolithiasis, usually performed in the Galdakao-modified supine Valdivia (GMSV) position. The aim of the present video is to describe the main distinctive and standardized steps of this surgical procedure, and to highlight the relatedadvantages in terms of safety and efficacy.
From 2004 until 2016 more 750 ECIRS have been performed in our Department. Year after yearall the procedure has been standardized step-by-step, starting from patient positioning in the GMSV position (part 1 of the video). Since ECIRS involves manypeople and a number of devices the operating room is very crowded, and a meticulous organization is needed (part 2 of the video). Being a suitable percutaneous access key to the success of any percutaneous nephrolithotomy (PNL), a combined and reproducible guidancemethod for the renal puncture has been developed, performing an ultrasound-assisted, fluoroscopy-guided and endoscopy-checked percutaneous access (part 3 of the video). Retrograde semirigid and flexible ureteroscopy before and during PNL has both a diagnostic and active role, contributing to improve safety and efficacy of ECIRS (part 4 of the video).
All the team in the operating room (urologists, anaesthetist, nurses) shares the responsability of positioning the patient correctly in the GMSV position, combining the supine Valdivia position with a modified arrangement of the lower limbs. This position presents a variety of anaesthesiological, urological and management advantages, optimally supporting ECIRS. The diagnostic role of retrograde ureteroscopy includes the preliminary evaluation of the dynamic anatomy of both lower and upper urinary tract, for a tailoringof the intraoperative choices (calyx of access, tract size, dilation method) on the single clinical case. Endovision control of each step of the renal access reduces radiation exposure and the risk of complications due to the insufficient introduction of the devices or to their overadvancement. Retrograde ureteroscopy allows treatment of stones in calyces parallel to the access tract. Final flexible nephroscopy and ureteroscopy optimize stone-free rates.
ECIRS represents a safe, effective and comprehensive approach to PNL, allowing a versatile personalized stone management, and a perfect tailoring of all the intraoperative choices on the real-time situation of the patient._x000D_ _x000D_
Cesare Marco Scoffone
Manuela Ingrosso
Cecilia Cracco
Complete Supine Percutaneous Nephrolithotomy from the Surgeon&[prime]s Point of View with a GoPro®. Ten Steps for Success.
Abstract: V11-08
Sources of Funding: None
To show a video of a complete supine Percutaneous Nephrolithotomy (csPNL) performed for the treatment of a kidney stone, from the surgeon&[prime]s point of view. The procedure was recorded with a GoPro® camera placed on the surgeon&[prime]s forehead, didactically demonstrating the 10 essential steps for a successful procedure.
The patient was a 38 years-old female patient with 2.4 cm of left kidney lower pole stone burden who presented with 3 months of lumbar pain and recurrent urinary tract infections. She had a previous diagnosis of polycystic kidney disease and chronic renal failure stage 2. CT scan showed two 1.2 cm stones in the lower pole (Guy&[prime]s Stone Score 2). She had a previous ipsilateral double J insertion due to an obstructive pyelonephritis. The surgeon had a Full HD GoPro Hero 4 Session® camera mounted on his forehead, controlled by the surgical team with a remote control. All of the mains steps were recorded, as well the cystoscopic, nephroscopic and fluoroscopic images. Informed consent was obtained prior to the procedure.
The csPCNL was uneventful with a single access in the lower pole. The surgical time was 90 minutes. Hemoglobin drop was 0.5g/dL and creatinine levels rose from 1.8mg/dL to 1.9mg/dL. A post-operative CT scan was stone-free. The patient was discharged 36 hours after surgery. The camera worked properly and didn&[prime]t cause pain or muscle discomfort to the surgeon. The quality of the recorded movie was excellent
GoPro 4 Session® camera proved to be a very interesting tool to document surgeries without interfering with the procedure and with great educational potential. More studies should be conducted to evaluate the role of this equipment in the operative room.
Fabio Vicentini
Hugo Santos
Evaristo Oliveira Neto
Carlos Batagello
Julia Amundson
Miguel Srougi
Eduardo Mazzucchi
The parallel guidewire rapid release percutaneous tract dilation
Abstract: V11-09
Sources of Funding: none
The parallel rapid release ureteral access sheath is a good way to transform the working wire into a safety wire. The guide is passed in the first 4 cm of the dilator which has a lateral slit. When the dilator is retrieved, the wire is released from the dilator through the lateral slit, and stays outside the access sheath. _x000D_ We present a video of percutaneous tract dilation parallel to the guidewire, using the same principle. The working guidewire becomes safety guidewire outside the Amplatz sheath, at the end of the dilation.
Between February 2016 and October 2016, 15 PCNL have been performed with dilation of the tract beside the guidewire._x000D_ Technique: A stiff 8 Fr ureteral catheter or JJ-stent pusher is used. The Amplatz catheter can also be used. Its tip is held with a forceps. With a &[Prime]lancet&[Prime] blade scalpel, beginning from the tip, a 4-5 cm longitudinal slit is performed in one side of the catheter. At the end of the slit, the scalpel is turned on its self to perform a small hole to accommodate the guidewire. It will be the egress point of the guidewire. After calyx puncture, a guidewire is inserted down the ureter or it is coiled in an opposite calyx. A pre-dilation to 12 Fr is performed. The catheter is bent just after the slit. Thus, the small hole will be in the apex of the bend. The tail of the guidewire is inserted into the slit tip of the catheter. After transiting in the 4 cm of the catheter with the slit, the guidewire will egress through the hole, in the summit of the bend. The catheter is advanced over the guidewire until reaching the calyceal cavity. &[Prime]One shot&[Prime] dilation is performed over the catheter with a 24 Fr Amplatz dilator and sheath. The long part of the catheter, Amplatz dilator and sheath are beside the working guidewire. When the Amplatz sheath reaches the calyx, the catheter is attracted and the guidwire is released from the first part of the catheter through the slit. Thus, the working guidewire become safety guidewire outside the Amplatz sheath._x000D_
15 patients had PCNL with dilation with this technique, 9 males and 6 females. The mean age was 39 (56-23). 8 right kidneys and 7 left. The main stone burden was 43 mm (32-56). The dilation beside the guidewire was possible in all cases. Operative time was 70 min (45-95). The tract dilation time was 4.5 min (3.5- 7). The hemoglobin drop was 0.89 (0.5-1.8). There was no complication noted during this dilation.
The dilation beside the guidewire is safe and feasible in this small series. It allows the economy of a guidewire. However, the catheter has to be very stiff to allow having a straight path to guide the dilator into the calyx. More studies are necessary to develop the technique.
Mohammed Lezrek
Hicham Tazi
adil slimani
khalil bazine
Amoqurane Beddouch
abdeghani ammani
mohammed alami
Staged Urethroplasty for Penile Urethral Strictures after Hypospadias Repair and Lichen Sclerosus
|Reconstruction Lower Tract (I)
Abstract: V1-11
Sources of Funding: None
Staged urethroplasty with oral mucosa graft is a versatile and reliable technique that allows patients with severe penile urethral strictures from lichen sclerosus, repeated failed urethroplasties and trauma to resume standing physiologic voiding. We present our technique for staged urethroplasty in this patient population.
From 2013-2016, staged urethroplasty was performed by a single surgeon (BF) on 20 men. During first-stage surgery, the urethra is divided in the midline and lateralized. Oral mucosa graft is applied to the exposed corpora cavernosa. A bolster dressing and urethral catheter are left in place for 5-7 days. Second-stage urethroplasty is performed 6-9 months later. The urethra is tubularized over a urethral stent, which remains in place for 10 days.
Stricture etiology was lichen sclerosus (9, 45%), failed hypospadias surgery (8, 40%), trauma (2, 10%), and penile calciphylaxis (1, 5%). Twelve men (60%) underwent second stage urethroplasty at a median of 277 days (range 167-738). No patient required additional grafting after first stage. Complications after second stage surgery included wound dehiscence (2, 17%), fistula (1,8%), and stricture (1, 8%).
Staged urethroplasty is an effective treatment for patients with severe penile urethral strictures from lichen sclerosus, repeated failed urethroplasties and trauma.
Andrew Gomella
Logan Hubbard
Hong Truong
Bradley Figler
Mini-percutaneous nephrolithotomy using an integrated ultrasonic and mechanical lithotripter (Olympus ShockPulse-SE Lithotripter)
Abstract: V11-10
Sources of Funding: none
Mini-percutaneous nephrolithotomy (mini-PCNL) was initially described in the late 1990s. Many variations on the technique have been described since that time focusing on differing access sizes. Lithotripsy through a mini-PCNL tract has traditionally been accomplished through laser or electro-hydraulic/pneumatic energy. We sought to explore the feasibility of lithotripsy through a mini-PCNL tract with the Olympus ShockPulse-SE Lithotripter which combines both ultrasonic and mechanical energy to optimize lithotripsy.
A 58 year male patient with a 2.5 cm left lower pole stone was identified as the initial candidate for our technique. He was positioned in the standard prone position and access was obtained into his lower pole with an 18-gauge Cook LS access needle. We proceeded to dilate a 16-French tract using a one-step dilator with the Storz Modular Minimally Invasive PCNL (MIP) System. With the Storz MIP M nephroscope and a 1.5 mm Olympus ShockPulse-SE probe, we then broke the stone into minute fragments which were initially suctioned and collected with the StoneCatcher (Boston Scientific) system. Remaining fragments were removed with an endoscopic grasper and a nitinol stone basket. The procedure was performed tubeless with a stent. After five days, a follow-up plain film was obtained and the stent removed.
The dual modality lithotripter was efficient with stone fragmentation and extraction through suction. The total operative time was 110 minutes. The patient was discharged on post-operative day one after an uncomplicated stay of 30 hours total duration. Post-operatively, his hemoglobin declined 2.3 g/dl and his creatinine rose 0.2 mg/dl. On return, his large 2.5 cm stone showed good clearance on KUB though dust like fragments (< 2 mm) remained in his lower pole.
This is the first report of using integrated ultrasonic and mechanical energy lithotripsy in a mini-PCNL. The combination of the Olympus ShockPulse-SE Lithotripter with the Storz MIP system proved efficient in terms of operative duration and stone breakdown. It was also effective at clearing a large stone burden through a small 16-French tract. This method is feasible and provides an alternative to laser or pneumatic lithotripsy and offers the benefits of suction.
Joshua Ebel
Nathaly François
Bodo Knudsen
Thulium lithotripsy: from experiment to clinical practice
Abstract: V11-11
Sources of Funding: none
To date Holmium (Ho) laser is one of the most popular and effective tools_x000D_ for lithotripsy. It emits very short pulses (0.1 – 1 ms) with high peak power (0.5-10 kW) that allows to efficiently fragment any type of urinary stones. Series of articles show Ho laser wavelength of 2.1 µm is significantly off the peak of water absorption, and so can negatively affect efficiency of stone fragmentation._x000D_ They also stressed that the thulium (Tm) fiber laser with diode laser pumping can improve stone fragmentation, because emission of Tm laser with wavelength 1.94 µm is 4.5 times stronger absorbed by water than that of Ho laser._x000D_ _x000D_ There is a lot of data on feasibility and efficacy of Tm laser application for stone fragmentation in vitro. _x000D_ _x000D_ Nevertheless, Thulium laser lithotripsy hasn't been widely utilized in the clinical settings._x000D_ _x000D_ A prototype Tm fiber laser with a peak power up to 500 W were developed by NTO «IRE – Polus»
We have evaluated in vitro performance of a prototype Tm fiber laser with a peak power up to 500 W as a potentially alternative for modern Ho laser system._x000D_ The in vitro experimental setup for measuring the stone fragmentation rate (ablation rate) included a specially designed cuvette with several levels of meshes allowing for precise quantification of size distribution of stone fragments (for the modes of fragmentation and dusting). Post – surgery human stones and BegoStone phantoms were used. The laser parameters (pulse energy and average power) were identical._x000D_ Also retropulsion effect caused by a single pulse has been evaluated. Lateral shift of a stone after a single pulse of laser energy was measured._x000D_
¥ Proposed experimental technique offers relatively simple and reliable method of comparing performance of laser lithotripters under controlled ex vivo conditions_x000D_ ¥ The Tm system, at identical laser parameters, produced about 2.3 and 1.3 times greater average ablation rate than the Ho system does in dusting and fragmentation modes, respectively_x000D_ ¥ The ratio of ablation rates on BegoStone phantoms correlated well with human stone data and varied between 1.6 and 2.3_x000D_ ¥ The effect of retropulsion of the Tm laser (at 500 W) was 75%, 60%, and 29% of that of the Ho laser for equal pulse energies of 1, 2, and 3 J, respectively. The retropulsion onset threshold was significantly higher for Tm laser_x000D_
Supported by this experimental data we assessed the clinical effectiveness of Tm fiber Urolase system with peak power of 120 W for lithotripsy. Several bladder stones with the average size about 1.9 cm were successfully destroyed. _x000D_ Further investigation in to the clinical applicability of Thulium lithotripsy is required._x000D_
Alim Dymov
Petr Glybochko
Yuri Alyaev
Andrey Vinarov
Gregory Altshuler
Viktoria Zamyatina
Nikolay Sorokin
Dmitri Enikeev
Vladimir Lekarev
Alexandra Proskura
Alexey Koshkarev
Abstract: V11-12
Sources of Funding: None
Currently, holmium laser is the most versatile energy source for the treatment of intrarenal stones by intracorporeal lithotripsy since it may be used with both flexible and rigid endoscopes, permitting access to all parts of the kidney. High-power laser enables the destruction of all kinds of stones, but the settings most suitable for the treatment of individual types remain to be defined.
In the operation theatre we used a pelvic trainer into which we introduced six different types of urinary stones from our stone library: uric acid, cystine, struvite, brushite, calcium oxalate monohydrate, and calcium oxalate dihydrate._x000D_ Ex vivo lithotripsy was performed by means of continuous serum irrigation with the Lumenis VersaPulse 120 W high-power laser, with a 550-micron fibre. Power, frequency, and potency parameters, as well as the short-pulse/long-pulse variable, were varied among the six different types of stones.
In all cases lithotripsy was commenced using low power and frequency: 0.2 J and 10 Hz. Power and frequency were raised up to a maximum of 3 J and 40 Hz, according to the type of stone, and until maximum potencies close to 120 W were obtained._x000D_ The difference in hardness of the investigated types of stones required differing power settings according to whether fragmentation into large pieces or pulverisation was desired. The different power settings used for the various types of stones are described, and the fragmentation ability and speed of the holmium laser are appraised.
High-power laser is useful for destruction of any type of urinary stone. The harder the stone, the greater is the potency needed; however, the frequency is not so important. Low power is able to yield good results on soft stones, and excellent pulverisation can be obtained by increasing the pulse frequency. The long pulse is very useful for lowering the stone retropulsion and increasing pulverisation, particularly in the case of softer stones.
Oriol Angerri
Juan Manuel López
Pavel Gavrilov
Francisco Sánchez-MartÃn
Félix Millán
Humberto Villavicencio
Surgical Management of Adult Acquired Buried Penis (AABP)
|Reconstruction Lower Tract (I)
Abstract: V1-12
Sources of Funding: none
Adult acquired buried penis as a result of obesity is a morbid condition. Affected patients have poor sexual function, urinary dribbling, mood disturbance, and poor quality of life (QoL). Weight loss is ineffective due to chronic skin changes and suprapubic fat pad (termed the escutcheon) lymphedema. Previous efforts have described limited repairs including isolated resection of the escutcheon which unfortunately often leads to reburying. We present a surgical repair including escutcheonectomy, scrotoplasty, and penile degloving with split-thickness skin graft (STSG) to provide definitive repair and halt the progression of the disease process.
A retrospective chart review was conducted of patients managed surgically for adult acquired buried penis in 2015-2016. Twelve patients were identified that underwent escutcheonectomy, scrotoplasty, penile degloving and STSG repair. All patients had morbid obesity as a sole etiology or significant contributing factor. Outcomes evaluated were surgical complications, reburying of the penis, graft take rate, and urinary symptoms.
Twelve patients underwent repair of adult acquired buried penis. All patients had good cosmetic results and durable unburying at intermediate term follow-up. Mean patient body mass index (BMI) was 45.4 ± 3.7. Fifty percent of the patients in the series were diabetics and 50% had hypertension and hyperlipidemia (Table 1). Mean operative time, length of stay (LOS), and estimated blood loss (EBL) were 312 ± 59 min, 5.3 ± 1.1 days, and 304 ± 133 cc respectively. STSG take rate was 80-100% (mean 92%) (Table 2).
Adult acquired buried penis is a challenging condition to treat. Limited surgical repairs can lead to reburying of the penis, need for further procedures, and the progression of urethral disease with voiding dysfunction. Escutcheonectomy, scrotoplasty, and STSG has encouraging intermediate term outcomes with durable unburying of the penis and good STSG take rates. Further follow-up in larger series is needed but results are thus far encouraging.
Thomas Fuller
Katherine Theisen
Paul Rusilko
Multimodal Enhanced Cystoscopy for Improved Bladder Tumor Resections
|Bladder Oncology and Diversion
Abstract: V12-01
Sources of Funding: none
Conventional transurethral resection of bladder tumor (TURBT) with white light cystoscopy (WLC) has recognized shortcomings including missed small tumors, inadequate assessment of resection margins and depth, and difficulty in differentiating cancerous from benign lesions. These limitations contribute to cancer recurrences and compel the need for repeat TURBT to ensure adequate cancer staging. Adjunctive optical imaging technologies including photodynamic diagnosis (PDD), narrow band imaging (NBI), and confocal laser endomicroscopy (CLE) improve tumor identification and characterization. Given their respective strengths and complementary characteristics, we postulate that combining wide-field (PDD and NBI) with microscopic (CLE) imaging technologies will further enhance TURBT. Towards that goal, we report our preliminary experience with multimodal enhanced cystoscopy.
The study received IRB approval. PDD was performed using hexaminolevulinate (Photocure) in combination with blue light cystoscope (Storz). NBI (Olympus) was performed with an NBI-enabled camera head attached to the standard resectoscope. Probe-based CLE was performed with fluorescein as the contrast agent along with 2.6 or 0.85 mm endomicroscopes (Cellvizio, Mauna Kea Technologies). Following TURBT with PDD or NBI, the resection bed was imaged with CLE. Imaging features of the resection bed were characterized by 3 urologists and achieved consensus. _x000D_
To date, 10 subjects have undergone multimodal imaging. No adverse events were noted due to the combination of instruments or imaging agents used. Confocal imaging features of the resection bed including elastin fibers (network of thin, interwoven strands), muscle fibers (sheets of straight, connected columns) and perivesical fat (collection of dark, round globules) were observed. Muscularis propria was present in the resected tissue on pathology assessment, confirming adequate resection. Patients are currently undergoing follow-up for cancer recurrence._x000D_
We report real-time microscopic inspection of the resection bed to assess for adequate depth of resection with CLE in combination with the macroscopic imaging technologies PDD and NBI. Further studies are needed to determine if multimodal enhanced cystoscopy results in improved TURBT with adequate depth and margins of resection and decreased recurrence rate, which may eventually translate to a decreased need for repeat TURBT._x000D_
Timothy Chang
Dharati Trivedi
Mario Sofer
Joseph Liao
Confocal Laser Endomicroscopy for bladder cancer diagnosis: how to do it & our preliminary results
|Bladder Oncology and Diversion
Abstract: V12-02
Sources of Funding: This study was supported by the Cure for Cancer foundation (http://www.cureforcancer.nl).
Cystoscopy is the cornerstone in bladder cancer diagnosis and monitoring. Although very effective, conventional white light cystoscopy has its limitations. New techniques have been developed to improve visualisation of tumours and suspicious lesions. However, no information can be given on grade of the disease during cystoscopy or per-operatively as no histopathologic information can be obtained real time. Confocal Laser Endomicroscopy (CLE) is a unique new imaging technique. It allows in vivo optical sectioning of tissue and provides real time microscopic images with high resolution. The objective of this study is to assess if we can take &[prime]optical biopsies&[prime] of the bladder using CLE.
We performed CLE in 19 patients with a bladder tumour, during transurethral resection of the bladder tumour (TURB). At the beginning of the procedure, after initial evaluation of the bladder, 360 ml of 0.1% Fluorescein, a fluorescent contrast agent, was administered intravesical via an indwelling catheter. After 5 minutes CLE was performed using the Cystoflex UHD R (Cellvizio, Mauna Kea, Paris, France), which has a resolution of 1 μm, a field of view of 240 μm, and an imaging depth of 50-65 μm. The CLE probe was introduced via the working channel of the cystoscope (Olympus or Storz 0 - 12°). CLE images were obtained of healthy tissue and tumours, and correlated with histopathology and analysed afterwards. After obtaining CLE images, the tumour was resected en-bloc. Tumour grade was assessed according to the WHO 2004 classification.
We were able to obtain good CLE images when the probe was correctly positioned. The probe has to be in good contact with the tissue, and perpendicular to the surface. Of the 19 patients; 2 had a benign lesion, 12 low-grade urothelial carcinoma, and 5 high-grade carcinoma. Differences in CLE images could be seen between healthy tissue and tumour (figure 1).
During TURB it was possible to take &[prime]optical biopsies&[prime] of the bladder. The obtained CLE images could give real time histopathologic information, and has the potential to differentiate in tumour grade during cystoscopy. These &[prime]optical biopsies&[prime] may assist urologist in future clinical practice in bladder cancer diagnosis and follow-up.
This study was supported by the Cure for Cancer foundation (http://www.cureforcancer.nl).
Esmée Liem
Jan Erik Freund
Theo de Reijke
Joyce Baard
Guido Kamphuis
Pilar Laguna Pes
Martijn de Bruin
Jean de la Rosette
robotic uteretal reimplantation for uretero-enteric anastomotic strictures
|Bladder Oncology and Diversion
Abstract: V12-03
Sources of Funding: none
Uretero-enteric anastomotic strictures occur in about 2-10% of patients treated with radical cystectomy and urinary diversion (UD). In this study we report the outcomes of robotic ureteral reimplantation for ureteroenteric anastomotic strictures in patients previously treated with robot assisted radical cystectomy (RARC) and UDs.
From April 2013 to July 2016 12 patients underwent robotic ureteral reimplantation in three tertiary referral centers. Out of 12 patients, 7 had orthotopic neobladder, 4 ileal conduit and 1 Indiana pouch. All patients had prior RARC and all but one had intracorporeal UD. _x000D_ Surgical steps include a careful ureteral dissection on the surface of the ureter/s to avoid injuring the iliac vessels, spatulation of the ureters, JJ stent insertion and finally uretero-ileal anastomosis._x000D_ Baseline, perioperative and early functional outcomes data are reported._x000D_
Mean time from RARC to uretero-anastomotic stricture diagnosis was 174 days (33-674). Mean stricture length was 2 cm (range 0.5-3), median operative time was 201 minutes (83-310) and median length of stay was 2 days (2-12)._x000D_ All cases were completed robotically. Intraoperative blood loss was negligible. Four patients experienced a Clavien grade II complication (urinary tract infection requiring antibiotics). At a median follow-up of 320 days (55-907) no recurrences occurred._x000D_
Robotic ureteral reimplantation for uretero-enteric strictures is a safe and highly effective procedure. Given the suboptimal success rate of endoscopic treatment, robotic repair has become a first treatment option in our centers.
Carlos Fay
Daniel Melecchi Freitas
Sameer Chopra
Nariman Ahmadi
Andre Berger
Mihir Desai
Inderbir Gill
Alvin Goh
Leonardo Misuraca
Salvatore Guaglianone
Mariaconsiglia Ferriero
Gabriele Tuderti
Michele Gallucci
Giuseppe Simone
Monish Aron
Robot assisted orthotopic modified Studer neobladder
|Bladder Oncology and Diversion
Abstract: V12-04
Sources of Funding: None
Robotic intracorporeal orthotopic neobladder after radical cystectomy and extended lymphadenectomy is a technically challenging procedure. So far, only a few centers worldwide have taken this procedure into routine. After over 1000 procedures and routinely performed intracorporeal Bricker urinary deviation, the swiss team started with the intracorporeal neobladder technique carefully. The video presents our standardized technique in 10 patients after one first proctored surgery by a mentoring team (AH/PW).
A daVinci SI-system with 4 arms and 6-port access was used. The left ureter is drawn unter the mesorectum to the right side. 50cm are needed for the pouch. The urethro-ileal anastomosis with a 3-0 barbed suture is performed after an approximation of rectoprostatic fascia and the ileal sling. A 60mm/45mm stapler ileo-ileostomy is established. Two holding sutures are placed 10cm proximal from the urethroileal anastomosis, marking the deepest point of the pouch. The ileum is opened at the antimesenteric side over 40cm and the posterior wall is closed using 3-0 barbed running suture. Than, the distal ventral pouch is closed. The distal ureters were incised and a Wallace plate was formed. The ureters are stented through the abdominal wall and the chimney with Ch8 mono-J catheters. The ileo-ureteral anastomosis is performed with a 3-0 double arm running suture. The last anterior segment of the pouch is closed and than proved for water tightness.
Operative time (skin-skin) was 575(420-725) minutes, bleeding 600(200-1000)ml. 1 patient required invasive ventilaton more than 24h. Time to flatus was 2(1-5) days, to bowel movement 4(3-10) days. The in-hospital stay was 15(9-27) days. There were no reoperations within 30days and no 30d- mortality. There were no positive margins nor positive lymph nodes in 22(15-43) removed nodes. The indwelling catheters remained 26(17-40) days, all pouches voided subsequently without residual urine.
Robotic intracorporeal urinary diversion with a modified orthotopic Studer neobladder is a technically demanding procedure. With a standardized setting, the procedure is feasable in experienced robotic teams with promising intraoperativ and early postoperative results.Still, long termin pouch function, metabolism and oncological follow-up have to be observed critically.
Hubert John
Christian Padevit
Kevin Horton
Abolfazl Hosseini
Peter Wiklund
Revisiting the Abdomen after Robot-Assisted Radical Cystectomy: Tips and Tricks for Robot-Assisted Repair
|Bladder Oncology and Diversion
Abstract: V12-05
Sources of Funding: Roswell Park Alliance Foundation
Reoperations following robot-assisted radical cystectomy (RARC) are challenging owing to technical complexity (abdominal adhesions and altered anatomy after cystectomy). We sought to describe our experience in robot-assisted (RA) reoperations following RARC.
We retrospectively review 406 RARCs performed by a single surgeon between 2005 and 2015. Data were reviewed for demographics, preoperative disease, and operative and perioperative outcomes. Surgical interventions for RARC-specific complications were identified and RA technique described.
For ureteroileal complications: 12 RA versus 7 open. Both had comparable perioperative outcomes. Fistula repair: 5 RA versus 6 open. Although patients in the RA group had longer operative times, they had shorter hospital stay (4 versus 10 days) and none of them required further intervention (4 in the open group did). Bowel obstruction that failed conservative treatment: 4 RA versus 7 open. Further intervention was required in 2 patients in the RA. Parastomal hernia repair: 4 RA and 2 open (one failed).
Our initial experience with RA management of RARC complications appears safe and feasible, although the decision to proceed is determined primarily by surgeon experience.
Roswell Park Alliance Foundation
Ahmed Hussein
Justen Kozlowski
Youssef Ahmed
Khurshid Guru
Utilization of Indocyanine Green Fluorescence Angiography During Intracorporeal Uretero-ileal Anastomosis Following Robotic Radical Cystectomy
|Bladder Oncology and Diversion
Abstract: V12-06
Sources of Funding: none
Indocyanine-green (ICG) is an exogenous tracer approved by he FDA and is currently used in several urological procedures such as partial nephrectomies to reveal vascular anatomy and tissue perfusion.
In this video we report our initial experience and proof-of-concept in 10 patients who underwent robotic-assisted radical cystectomy with intracorporeal diversion where ICG was utilized prior to perform uretero-ileal anastomosis to assess ureteric vascularity. _x000D_ _x000D_ _x000D_
In our cohort of 10 patients, 7 patients required resection of distal ureter in at least one ureter. Three patients required bilateral distal ureteral resection, three patients required left and one patient required right distal ureter resection._x000D_ The median resected ureteral lenght was 2cm. The median operation time 510 minutes. Complications were found in 3 patients, fever in two and ileus in one (Clavien II). The median length of stay was 5.5 days and the median follow-up was 81 days._x000D_
Intravenous injection of ICG before ureteroileal anastomosis is useful to evaluate distal ureteral vascularity. It helps to identify and excise the non-vascularized ureteral segment. Long term follow-up will be necessary to evaluate the benefits of ICG-use to prevent ureteroileal strictures.
Daniel Melecchi Freitas
Carlos Fay
Nariman Ahmadi
Andre Abreu
Toshitaka Shin
Inderbir Gill
Andre Berger
Mihir Desai
Monish Aron
Robotic intracorporeal "Padua Ileal Bladder": Surgical technique, perioperative, oncologic and functional outcomes
|Bladder Oncology and Diversion
Abstract: V12-07
Sources of Funding: none
Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and long operative times have led to concern about its reproducibility. The aim of this video is to illustrate our technique for RARC and totally intracorporeal orthotopic "Padua Ileal Bladder�.
From August 2012 to February 2014, 45 patients underwent RARC, extended pelvic lymph node dissection and intracorporeal partly stapled neobladder at a single tertiary referral centre. Surgical steps are demonstrated in the accompanying video. Demographics, clinical and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported.
Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305 minutes (IQR 282-345). Median estimated blood loss was 210 ml (IQR 50-250). Median hospital stay was 9 days (IQR7–12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8% and 77.8%, respectively, while severe complications occurred in 17.8%, 17.8% and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival and overall survival rates were 72.5%, 82.3% and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results.
Our experience supports the feasibility of totally intracorporeal neobladder following ?RARC. Operative times and perioperative complication rate are likely to be reduced with increasing experience.
Giuseppe Simone
Rocco Papalia
Leonardo Misuraca
Gabriele Tuderti
Francesco Minisola
Mariaconsiglia Ferriero
Giulio Vallati
Salvatore Guaglianone
Michele Gallucci
Ureteroileal bypass: a new robotic technic to treat ureteroentereric strictures in urinary diversion
|Bladder Oncology and Diversion
Abstract: V12-08
Sources of Funding: none
Bladder cancer is the ninth most frequently cancer diagnosed worldwide. The standard definitive treatment for MIBC is radical cystectomy (RC) and urinary reconstruction._x000D_ Complications of RC and diversion can appear after months or years of surgical treatment. Ureteroentereric strictures are a late complication after cystectomy and diversion that occur in 2% to 15% of patients.4-6 Multiple treatment alternatives have been proposed to those strictures with variable success rates, ureteral reimplantation is still considered the gold standard surgical treatment7. However, the surgical approach to the ureteroenteric anastomosis can be challenging due to fibrosis and adhesions. We propose herein a technical modification aiming to minimize ureteral dissection; the technique involves a latero-lateral anastomosis of the dilated ureter with the ileal conduit without detaching de ureter from the intestinal segment. Our experience with this technical modification is described._x000D_
We reported a patient submitted to uretero-ieal bypass to treat uretero-enteric stricture in Bricker implant._x000D_ The technique was made robot-assisted, and it is shown in the figure.
The case reported is a 70 years-old man, without any comorbities, diagnosed with muscle invasive bladder cancer after transuretral ressection. _x000D_ He was subbmited to Robot-Assisted RC with intracorporeal Bricker diversion, without any major complications._x000D_ The pathologic report of cistectomy was high grade urothelial carcinoma pT2 N0._x000D_ With 3 months of follow-up, patient refered left flank pain, without any report of urinary infecction._x000D_ Serum Creatinine before cistetomy was 0.8 mg/dL, and 3 months after surgery it increased to 1.33 mg/dL._x000D_ The CT scan showed the right kidney without any change, there was no limphnode or visceral metastasis, the left kidney had adequate contrast enhancement, and there was ureteral hydronephrosis till the implant in the Bricker, without patency for contrast. There was no sign of metastasis in the implant._x000D_ With a follow-up of one year after the uretero-ileal bypass, patient is assimptomatic, serum creatinine decreased to 0,92 mg/dL, and image control shows total resolution of hydronephrosis._x000D_
Latero-lateral ureteroenteric anastomosis is a feasible treatment option for benign anastomotic strictures. It can be performed either by open or minimally invasive approaches with good perioperative outcomes
Guilherme Padovani
Rubens Park
Marcos Mello
Rafael Coelho
Leonardo Borges
Adriano Nessralah
Miguel Srougi
William Nahas
Anatomic robot assisted radical cystectomy in female: step by step technique
|Bladder Oncology and Diversion
Abstract: V12-09
Sources of Funding: none
Robot assisted radical cystectomy in female for bladder cancer is a challenging urologic surgical procedure. We describe step by step surgical technique and present perioperative outcomes of a single patient who underwent a robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladder (iON).
A 66 yr-old female patient with a cT1/N0/M0 high grade BCG refractory recurrent bladder cancer, underwent RARC and iON.?Key steps of surgery include: the ligation of gonadic pedicles, meticulous dissection of the umbilical and uterine artery and the ureter, dissection of the bladder pedicle, opening of the vagina and creation of the plane between vagina and bladder. Cut of the urethra and securing the Foley catheter with the entire specimen placed into an Endocatch bag to minimize any urine spillage. Removal of the specimen into an endocatch bag through the vagina. Extended pelvic lymph node dissection. Suture of the vagina and creation of a peritoneal flap as posterior neobladder support.
The procedure was successfully completed. Operative time was 295 minutes, EBL was 250 mL, time to flatus was 3 days, time to bowel was 7 days. Hemoglobin and creatinine at discharge were 10.3 g/dL and 0.76 mg/dL, respectively. The hospital stay was 8 days. The pathologic stage was pT0 pN0. The number of nodes removed was 26. Postoperative course was uneventful. The patient recovered daytime continence 45 days after surgery.
A meticulous dissection of vascular suppliers of the bladder, a natural orifice specimen retrieval and the ease of posterior neobladder support thanks to a perfect vision of the small pelvis anatomic structures may contribute to minimize invasiveness and to improve perioperative outcomes of radical cystectomy in female patients.
Giuseppe Simone
Salvatore Guaglianone
Leonardo Misuraca
Francesco Minisola
Gabriele Tuderti
Mariaconsiglia Ferriero
Giuseppe Romeo
Michele Gallucci
Robot-assisted Laparoscopic Radical Cystectomy and Intracorporeal Neobladder Utilizing a Vaginal-Sparing and Staple-Free Approach
|Bladder Oncology and Diversion
Abstract: V12-10
Sources of Funding: None
At our institution robot assisted laparoscopy with intracorporeal neobladder has become standard of care for our treatment of patients with muscle invasive bladder cancer. When indicated and feasible we perform a vaginal sparing and staple-free approach for our female patients in order to optimize continence and sexual function.
Using a high definition recording system and iMovie software with narrative and annotative editing we created a video illustrating our vaginal-sparing and staple-free approach to the robot assisted laparoscopic radical cystectomy and neobladder. Our Patient is a 66 year old female with high grade bulky urothelial carcinoma of the bladder.
We have performed vaginal-sparing and staple-free robot-assisted laparoscopic radical cystectomy and intracorporeal neobladder in 12 patients. Patients age range of 41-72 years old. 70% of these patients underwent neoadjuvant chemotherapy. Total operative times range from 4.25 – 5.85 hours. The majority of patients have self-reported good satisfaction with neobladder after surgery.
In our experience, the robotic staple-free, vaginal-sparing intracorporeal neobladder is a safe and effective method of treatment for muscle invasive bladder cancer. Long term cancer control not yet proven with the robotic approach; however short term control is comparable to other methods. Further study will be needed to demonstrate the long term safely and cancer control with this technique.
Christine White
Mark Ferretti
Gregory Lovallo
Mutahar Ahmed
Laparoscopic repair of ileal conduit parastomal hernia using the modified Sugarbaker technique
|Bladder Oncology and Diversion
Abstract: V12-11
Sources of Funding: none
Parastomal hernia is a common complication of stoma formation, The reported incidence is variable depending on the degree, the duration of follow-up and the type of stoma. The incidence for ileal conduits ranges from 2% to 6.5%. Modified laparoscopy Sugarbaker technique is a possible method to repair ileal conduit parastomal hernia.
We present a case of the laparoscopic modified Sugarbaker technique applied to repair a ileal conduit parastomal hernia in a 67 years-old patient with a history of radical cystoprostatectomy and Bricker uretero-ileostomy for a bladder cancer seven years ago. The procedure is described in detail in this video.
The patient was positioned supine with both arms tucked. The abdomen was accessed using a 10-mm trocar in the axillary line, in front of the ileostomy , a 10-mm trocar by subxiphoid approach and a 5-mm trocar in the left lower quadrant._x000D_ A tedious lysis of adhesions was performed with minimal use of bipolar energy. Liberation of omental adhesions in the foramen of parastomal hernia and extraction of 40 cm. of small bowel located in parastomal hernia were performed.The parastomal hernia defect were identified and measured. We used a 15 cm x 20 cm physiomesh® mesh. The fine filament design and its macroporous structure flexible, facilitate the scar tissue formation and adaptation to the abdominal wall. The mesh was tacked in position to the abdominal wall in its periphery using the 5-mm tacking device. When we place the takers should make an external pressure on the abdominal wall. Several takers are placed in the abdominal wall, circumferentially around the ileal loop. The patient was discharged after a 2-day stay. After 20 months of follow up, the patient is free of recurrence of parstomal hernia.
The introduction of prosthetic meshes significantly decreases the recurrence rates of parastomal hernia. Laparoscopic surgery reduces_x000D_ postoperative pain, recovery time and minimize many of the morbidities associated with open procedures. Laparoscopic parastomal hernia repair has a viable option to overcome the challenges that face the hernia surgeon.
Dario Garcia-Rojo
Xavier Serra-Aracil
Angel Prera
Carlos Abad
Jesus Muñoz
Leticia De Verdonces
Marta Capdevila
Eduardo Vicente
Naim Hannaoui
Younes Fadil
Jose Luis Gonzalez-Sala
Arturo Dominguez
Clara Centeno
Victor Parejo
Mario Rosado
Paula Planelles
Juan Prats
Robotic Cystoprostatectomy with Pubectomy and Ileal Conduit for Patients with Osteomyelitis Pubis
|Bladder Oncology and Diversion
Abstract: V12-12
Sources of Funding: Nne
Osteomyelitis pubis is a rare complication of pelvic radiation and prostate surgery. This chronic condition has substantial impact on quality of life. Medical therapy has limited role and surgical resection is usually needed. Open prostatectomy or cystoprostatectomy with pubectomy is associated with difficult post-operative recovery. We report our early experience in robotic cystoprostatectomy with pubis symphysis debridement
We present an instructional video of a 77 y.o. male with history of prostate cancer. s/p open radical prostatectomy 19 years prior to his surgery, complicated with multiple Bladder neck contractures over the years. He underwent salvage radiation therapy for biochemical failure. Developed urinary incontinence. Later he underwent an attempted bladder sling placement, followed by AUS and Urolume urethral stent. Due to AUS pump erosion and eventual explanation few months later. Every 6 months thereafter he was repeatedly treated for stones encrusting. He then developed OM of the pelvic bone for the last 4 years, complicated by bacteremia and extended IV antibiotics.
Up to 2016 four patients with chronic post radiation osteomyelitis pubis underwent robotic cystectomy with pubic symphysis debridement and ileal conduit urinary diversion. One patient needed a temporary loop colostomy. Average robotic operative time: 175 minutes. Average hospital Stay 5.3 days. Median EBL 75 ± 40 ml. Antibiotics were stopped within 4 weeks. One had high grade complication and none had recurrence of the osteomyelitis.
Robotic cystectomy with pubic symphysis debridement is a feasible alternative to open cystectomy with open resection of pubis symphysis. It may provide faster recovery.
Ahmad Shabsigh
Repair of a complex vaginal J-pouch fistula utilizing a gracilis muscle interposition flap
|Female Pelvic Medicine
Abstract: V2-01
Sources of Funding: none
Rectovaginal and J-pouch vaginal fistulae are abnormal epithelialized connections between the rectum or J-pouch to the vagina. Symptoms, such as fecal incontinence, can be distressing to patients. These fistulae can be a challenge to repair and multiple repair methods have been described in the literature including transvaginal, transrectal, and flap interposition repairs. Success rates in the literature range from 10-100% and with each subsequent repair the success rate of closure decreases.
We present the case of a 35 year-old woman with a history of ulcerative colitis who developed a fistula following a total proctocolectomy and ileal-anal pouch anastomosis. When she presented she had already undergone more than ten attempts at repair. Prior to our fisula repair she had a fecal diversion with a loop ileostomy. We performed a transvaginal repair utilizing a gracilis muscle interposition flap. Indocyanine green was given intravenously and the SPY Elite imaging system was used to enable the visualization of microvascular blood flow and perfusion to the gracilis flap and to the bed of the fistula repair intraoperatively.
Our patient did well after the procedure. She was discharged home with the foley in place on post-operative day 1. At her one month follow-up the repair was intact and she was healing well.
In cases of complex rectovaginal and vaginal J-pouch fistulae, especially those that are reoperative cases, fistula repair with a gracilis interposition flap is a viable repair option. Success from this repair can be aided by assuring complete excision of non-viable tissue and a healthy flap. In our case these steps were aided by the use of the SPY Elite imaging system.
Gillian Wolff
Jack Christian Winters
Ralph Chesson
|Female Pelvic Medicine
Abstract: V2-02
Sources of Funding: None
The reclassification of vaginal mesh to a high risk device for treatment of pelvic organ prolapse prompted our group to consider alternative graft materials. Based on the similar success rates and durability of mesh and autologous fascia in the treatment of female stress urinary incontinence (SUI), our objective was to develop a transvaginal repair for anterior and apical vaginal prolapse with the use of only autologous fascia lata graft thereby avoiding synthetic mesh, allograft and xenograft. _x000D_
The video demonstrates our technique for Autologous Anterior and Apical Pelvic Organ Prolapse (AAA-POP) repair. Autologous fascia lata of suitable size (4 X 12 cm up to 5 X 14 cm) is harvested through a minimally invasive, lateral upper thigh incision. The graft is then cut into 3 strips (1cm X 12cm up to 1.3 cm X 14cm) and reassembled with one strip affixed to the bladder neck and sutured to the obturator internus fascia with 0-vicryl. The other 2 strips are sutured to the strip at the bladder neck with CV-2 Gore-Tex suture, crossed at the level of the vaginal apex, and sutured to the sacrospinous ligaments with 0-PDS. Patients were followed with subjective SEAPI scores, visual analog pain (VAP) scores (range 0-10), pelvic examination (Baden-Walker grading), and examination of the thigh harvest site._x000D_ _x000D_
The AAA-POP procedure has been performed on 5 patients with a mean age of 61 and a mean follow-up of 2 months. Apical uterine suspension was performed in 3/5 patients and the other 2/5 patients were status post hysterectomy. Symptoms of pelvic organ prolapse resolved in all 5 patients, but 1 patient had an asymptomatic grade 1 cystocele without apical prolapse at 3 months follow-up. No patients complained of SUI or urge incontinence on SEAPI scoring. 1 patient required lysis of a concurrent pubovaginal sling 2 weeks postoperatively with resolution of urinary retention, and 1 patient had mild obstructive symptoms on SEAPI scoring. 2 patients developed thigh hernias postoperatively, and the mean VAP score at the harvest site was 1.8 for all patients._x000D_
Autologous Anterior and Apical Pelvic Organ Prolapse (AAA-POP) repair with fascia lata is a feasible option in the post-mesh era and appears to be safe and efficacious with short-term follow-up. Longer follow-up is needed to determine long term success and possible complications of the procedure. Although self-reported pain scores were low, patients should be aware of the risk of residual pain at the harvest site and possible development of a thigh hernia._x000D_
Christian Twiss
Miguel Craig
Frank Lin
Joel Funk
Robot-assisted Repair of Supratrigonal Vesicovaginal Fistulae using a Peritoneal Flap Inlay
|Female Pelvic Medicine
Abstract: V2-03
Sources of Funding: none
Vesicovaginal fistulae (VVF) represent a major health-care problem in low- resourced countries, where most VVF derive from obstetric complications. In the western world, most VVF occur after difficult hysterectomies. A transvaginal approach can be used successfully in low and simple fistulae, while supratrigonal and more complex cases may require a transabdominal approach. To minimize operation trauma laparoscopic or robot-assisted techniques are being used. Though fistulae closure with tension-free, multilayer closure is feasible, the use of tissue interposition can achieve higher closure rates in larger fistulae or where the surrounding tissue is devitalized. Different materials have been described for fistula closure, including peritoneal tissue and gluteal muscle as well as artificial materials._x000D_
Our video presents a robot-assisted technique using a peritoneal flap patch for reconstruction of the VVF. A daVinci SI-system with 4 arms and 6-port access was used. Preoperatively a Fogarthy catheter is placed through the fistula to mark the fistula channel , and the ureters are also stented. After initial adhesiolysis and preparation of the vesicovaginal space, the vagina is incised. Then, the fistula is identified and excised with the surrounding tissue both on the vaginal and bladder side. Following the closure of the vagina, a pedicle peritoneal flap is harvested and interposed between vagina and dorsal bladder wall. Finally, the bladder closure is performed with double-layer sutures. The analysis was performed retrospectively including operative parameters, perioperative complications and functional outcome for all patients._x000D_
Median operative time (skin to skin) was 219 (181-331) minutes without relevant blood loss. Median length of hospital stay was 8 (4-13) days. The indwelling catheter was removed after 10 days and a normal cystogram. Postoperatively all patients (n=10) showed a recurrence-free total continence (0 pad/day). The highest postoperative complication was fever requiring antibiotic treatment (Clavien grade II). _x000D_
Robotic vesicovaginal repair of high vesicovaginal fistulae and peritoneal flap inlay is a safe minimal invasive approach with a high satisfaction rate and no recurrences in this pilot series to date. _x000D_
Christoph Schregel
Beatrice Breu
Kevin Horton
Hubert John
A Novel Robotic-Assisted Laparoscopic Repair of Posterior Compartment Prolapse: Treating Women with Defecation Dysfunction
|Female Pelvic Medicine
Abstract: V2-04
Sources of Funding: none
Symptoms associated with posterior compartment prolapse greatly impact a woman&[prime]s quality of life. These symptoms include straining or splinting to defecate, incomplete emptying, and incontinence of feces or gas. Current surgical repair options aim to repair the rectocele, but do not routinely address the size and laxity of the rectum, which may also contribute to defecation symptoms.
We present a demonstrative video of a robotic-assisted laparoscopic sacrocolpopexy and laparoscopic posterior colporrhaphy in a woman with a prior supracervical hysterectomy and subsequent robotic sacrocolpopexy with perineorrhaphy. Due to persistent defecation dysfunction combined with physical exam findings consistent with posterior compartment prolapse, the decision was made to proceed with surgical repair after the risks and benefits were discussed. The accompanying video demonstrates a plication using perirectal connective tissue and lightweight polypropylene &[Prime]Y&[Prime] mesh that is ultimately secured to the posterior colporrhaphy for additional support.
In the short-term, this novel procedure has proven effective in treating a small series of women with posterior compartment prolapse and defecation dysfunction. Those women included within our limited series report subjective improvement with regards to their original ailments of bowel dysfunction. No serious adverse events related to this surgical procedure occurred in the peri-operative period or during short-term follow up.
While longer follow-up is needed, the robotic-assisted laparoscopic sacrocolpopexy with laparoscopic posterior colporrhaphy represents a technically safe and feasible approach to treating women with posterior compartment prolapse and defecation dysfunction.
Ron Golan
Brian Dinerman
Adrien Bernstein
Kiersten Craig
Patrick Culligan
The novel technique of post-hysterectomy vaginal vault prolapse repair: apical sling and &[laquo]neocervix&[raquo] formation
|Female Pelvic Medicine
Abstract: V2-05
Sources of Funding: None
Frequency of vaginal vault prolapse (VVP) requiring surgical repair is up to 6-8% and 11.6% in patients with prior hysterectomy for uterine prolapse. Sacrocolpopexy is considered the gold standard procedure for VVP correction. Nevertheless, it is associated with long operation time, pneumoperitoneum, Trendelenburg position, and a number of well-known complications. The objective of this study was to evaluate effectiveness of novel technique: bilateral sacrospinous fixation by monofilament polypropylene apical sling (UroSling-1, Lintex) combined with neocervix formation (purse-string suture on the internal surface of the cervical fascia fixed to the tape) in surgical treatment of post - hysterectomy vaginal vault prolapse. Secondary aim was to estimate the impact of the surgery on urinary function and patient&[prime]s quality of life.
This prospective study involved 54 women suffering from post-hysterectomy prolapse. Patients underwent hybrid reconstruction of the pelvic floor in accordance with the proposed method. To evaluate the results of surgical treatment, data of a vaginal examination (POP-Q), uroflowmetry, ultrasound measurement of post-voiding residual volume were used, determined before the surgery and at control examinations after treatment. Changes in quality of life were evaluated by comparing the scores according to PFDI-20, PFIQ-7, PISQ-12, ICIQ-SF questionnaires.
Mean operation time was 35 ± 13 minutes. There were no cases of intraoperative damage to the bladder or rectum, as well as clinically significant bleeding. Median follow-up time was 12 (min-8, max-18) months. There was noted statistically significant improvement in POP-Q points, especially, Ba and C (p<0,001) in all patients. Also statistically significant improvement was found in peak and average flow rate according to uroflowmetry (p<0,05). Recurrent prolapse was noted in anterior compartment in 3.7% (2/54). After 6 months of follow-up stress urinary incontinence de novo was noted in 7.4% (4/54). Most of the patients reported a significant improvement in quality of life after treatment.
The novel technique: combination of the apical sling and purse-string &[laquo]neocervix&[raquo] formation appears to be effective and safe method for treatment patients with post-hysterectomy prolapse. This technique also provides high functional results and improves quality of life.
Dmitry Shkarupa
Alexey Pisarev
Ekaterina Shapovalova
Anastasia Zaytseva
Nikita Kubin
Female Dorsal Onlay Buccal Mucosa Graft Urethroplasty
|Female Pelvic Medicine
Abstract: V2-06
Sources of Funding: None
Female urethral strictures can present significant challenge which can be further complicated from challenging location or length of stricture. The objective of this video is to demonstrate the use of a buccal mucosa graft in the treatment of female urethral strictures.
This video demonstrates the use of a dorsal onlay buccal mucosal graft in a female patient with history urethral stricture and bothersome urinary symptoms. The patient has undergone multiple dilations in the past with recurrence of the stricture.
The patient underwent successful buccal mucosal graft urethroplasty and now has significant improved urinary symptoms as well as urine flow rates.
Dorsal onlay buccal mucosa graft is a versatile tool in the Urologist's armamentarium when facing the challenge of a complicated female urethral stricture.
Brenton Armstrong
Dan Hoffman
Lee Zhao
Victor W. Nitti
Benjamin Brucker
Female Urethroplasty with Buccal Mucosal Graft for Stricture Disease
|Female Pelvic Medicine
Abstract: V2-07
Sources of Funding: None
Female urethral strictures are rare and occur in less than 1% of women. Common causes are trauma, iatrogenic injury, inflammatory diseases or idiopathic. Diagnosis is suspected when a patient reports obstructive symptoms, urodynamics shows outlet obstruction and/or cystourethroscopy reveals urethral narrowing or fibrosis. Surgical treatment depends on location and length of the stricture, and the optimal approach is not well established. In this video, the technique for female urethroplasty with a dorsal onlay buccal mucosal graft is demonstrated.
A 48-year-old female patient presented with long-standing, symptomatic urethral stricture disease. She previously failed conservative management with urethral dilations and elected to pursue urethroplasty with buccal mucosal graft. Following informed consent, video recording of intraoperative surgical procedure was performed. Video editing and narration was standardized to highlight key steps of the procedure.
The patient was taken to the OR for urethroplasty with a dorsal onlay buccal mucosal graft. First, a cystoscopy was performed and a suprapubic tube was placed to allow for sufficient postoperative healing. The buccal mucosal graft was harvested, defatted and soaked in normal saline. Circumferentially around the urethral meatus hydrodissection is used with care taken to avoid the clitoral tissue and nerves. The urethra was dissected to the level of the bladder neck and the full extent of the stricture was identified then incised. Stay sutures were placed in the superior and inferior apices to facilitate placement of the graft. Superior apical sutures were threaded through the graft and additional interrupted sutures were placed circumferentially. The graft was trimmed to size, threaded with the inferior apical stay sutures and secured in place. The surgical bed and graft were joined to enhance revascularization. The patient did well postoperatively, with no recurrence of stricture and healthy buccal mucosa graft on cystoscopy.
Urethroplasty with dorsal buccal mucosal graft placement can be a feasible and effective treatment for female urethral strictures.
Alexander Small
Carrie Mlynarczyk
Henry Tran
Doreen Chung
A New Limited Open Technique for Complete Removal of Retropubic Synthetic Midurethral Sling Mesh
|Female Pelvic Medicine
Abstract: V2-08
Sources of Funding: none
While synthetic midurethral sling placement is generally a safe and effective treatment for female stress urinary incontinence, a small percentage of patients will require sling excision for post-operative complications including urinary obstruction, mesh exposure, or pain. Though many of these complications can be addressed with suburethral or local sling excision, refractory chronic pain may require total mesh excision._x000D_ _x000D_ One of the greatest concerns for surgeons performing total mesh excision of a retropubic sling is the potential morbidity of the operation, including wound complications associated with extensive retropubic dissection to localize the sling arms. With these concerns in mind, we present a technique for total retropubic sling excision which limits the extent of retropubic dissection._x000D_
A 48 year old female patient underwent retropubic synthetic sling placement in 2010, followed by vaginal, urethral, and suprapubic pain, as well stranguria, incomplete emptying and persistent urgency, frequency and urgency incontinence. After preoperative evaluation, in light of her chronic suprapubic pain, she was offered total retropubic sling excision. She elected to proceed after discussion of risks, benefits, and alternatives. _x000D_ _x000D_ The novelty of our procedure is seen in the limited retropubic dissection. Each arm of the sling mesh is mobilized vaginally to the level of the endopelvic fascia. The retropubic space is entered via a vaginal approach and developed bluntly. Only then is abdominal exposure sought; at this point, gentle traction on the sling arm can be seen from above, allowing for only a tiny fascial incision to be made directly over the sling arm location. The retropubic portion of the mesh is then traced to the vaginal portion, and the sling arm is freed in its entirety. This is repeated on the contralateral side._x000D_
At four week follow up, the patient reported greater than 90% improvement in her pain, with improved ease of voiding. She had no wound complications.
Our novel technique allows for complete retropubic sling mesh removal with limited retropubic dissection, which may minimize the surgical morbidity and decrease the risk of wound complications.
Elodi Dielubanza
Jessica Lloyd
Howard Goldman
Laparoscopic cervicosacropexy and vaginosacropexy techniques as treatment of pelvic organ prolapse and urinary incontinence
|Female Pelvic Medicine
Abstract: V2-09
Sources of Funding: None
In the presence of genital prolapse with apical descent, sacrocolpopexy and vaginal sacrospinous fixation are current available procedures. They focus on restoring apical support usually with a piece of mesh made of different materials, undefined length and shape and different fixation sides in the small pelvis. Thereby, non-physiological fixation of cervix/vagina and bladder may result and may be followed by urinary incontinence. _x000D_ Following DeLancey and Ulmsten, we developed a bilateral replacement of the uterosacral ligament (USLs) which are the physiological holding structures. _x000D_ In this study we describe the laparoscopic cervicosacropexy (LACESA) and vaginosacropexy (LAVASA) techniques in the treatment of genital prolapse with apical descent and urinary incontinence. _x000D_
The laparoscopic LACESA) and LAVASA techniques involves substituting both damaged USLs with purpose designed (identical in length and shape) PVDF-structures (polyvinylidene fluoride)._x000D_ The anterior fixation area of the PVDF-structure was centrally placed on the vault / cervical stump with 3 non-absorbable sutures. _x000D_ After identification of the L5-S1, the peritoneum was horizontally blunt dissected and the prevertebral fascial layer of S1/S2 sacral vertebra was prepared. _x000D_ The anatomical path of each USL was tunnelled and the ligament augmentation part of the PVDF-structure was placed. Using a fixation device, the PVDF-structure was attached to the lateral margin of the right and left prevertebral fascial layer of the S1/S2 sacral vertebra with 3 titanium helices on each side._x000D_
We report 94 women who underwent the laparoscopic CESA or VASA procedure for apical descent with a medium follow-up of 18 months. Mean age was 68 years. Preoperative, 67 women had POP-Q stage II, 21 women POP-Q stage III and 6 women POP-Q stage IV. Average operating time was 107 minutes (47 - 129 min.). 69 women had coexisting urinary incontinence (UI). No major intraoperative complications were noted except a bladder lesion and one relapse of prolapse. Within follow-up no mesh erosions were noted. Postoperative, all women had POP-Q stage 0. A 74% continence rate for urinary incontinence was noted.
The LACESA and LAVASA techniques yielded excellent anatomical correction of prolapse. The mesh used is made of PVDF, which cause milder tissue reaction and minimizing the risk of mesh shrinkage/erosions. The unique design of the PVDF structure allows restoration of the USLs with clearly defined surgical steps, making the procedure standardised and reproducible.
Sebastian Ludwig
Sokol Rexhepi
Wolfram Jäger
|Female Pelvic Medicine
Abstract: V2-10
Sources of Funding: none
Total colpocleisis is an excellent treatment option utilizing native tissue for complete vault eversion in older women not interested in coital function. This video illustrates our surgical technique for total colpocleisis.
An 88 year-old female presented with pelvic organ prolapse (POP) after failing conservative management. She complained of concomitant storage and voiding lower urinary tract symptoms (LUTS), particularly stress urinary incontinence (SUI) with a pessary in place. Examination revealed complete procidentia and SUI with POP reduction. She elected to undergo total colpocleisis, and transobturator midurethral sling placement.
The procedure began by marking of four quadrants, from the apex to bladder neck, posterior and lateral vaginal walls. Lidocaine with epinephrine was used for hydrodissection and hemostasis. The vaginal epithelium was dissected and excised in each quadrant. Purse string sutures were placed sequentially at 2-3 cm from each other until the entire prolapse was reduced. Cystoscopy was performed to ensure patency of the ureters. The anti-incontinence procedure (not shown) was performed. The anterior vaginal wall was closed, followed by posterior vaginal wall closure including a tight perineorrhaphy.
On examination at 6 months, no recurrence of her prolapse was noted. Further, the patient reported that her SUI and LUTS had resolved. Colpocleisis remains an effective and minimally invasive option for women with severe POP who are not interested in maintaining sexual function.
Rena Malik
Carlos Finsterbusch
Catherine Harris
Maude Carmel
High uterosacral hysteropexy for the management of pelvic organ prolapse
|Female Pelvic Medicine
Abstract: V2-11
Sources of Funding: None
Hysterectomy at the time of pelvic organ prolapse repair is controversial. Uterine preserving procedures for prolapse repair may be beneficial as this allows preservation of fertility, body image and sexual function and potentially avoids an unnecessary procedure. In this video, we present our technique for transvaginal high uterosacral hysteropexy as an alternative mesh-free uterine-preserving procedure for prolapse repair and analyse our institutional outcomes.
This video illustrates a step by step video sequence of our technique for high uterosacral hysteropexy in a patient with symptomatic Stage III pelvic organ prolapse. We also performed a single institution, single surgeon retrospective analysis of patients treated by either high uterosacral hysteropexy or hysterectomy with high uterosacral suspension for their prolapse between 2013 and 2015. Institutional Review Board approval was obtained. We directly compared operative blood loss, pre-operative POP Q evaluation with post-operative POP Q evaluation as well as pre and post-operative American Urologic Association (AUA) Symptom scores in these 2 groups.
Surgery time was 3 hours 24 minutes. No immediate or early complications were noted and repair was successful on follow up. The outcomes of 20 patients were assessed and summarized in the table below. Nine patients underwent high uterosacral hysteropexy alone and 11 patients underwent hysterectomy and high uterosacral suspension. Follow up was for a minimum of 6 months. Blood loss was significantly reduced in the high uterosacral hysteropexy cohort (mean: 88mls vs 232mls, p=0.004) and there was no difference in post-operative AUA symptoms scores or POP Q evaluation between the 2 treatment groups.
We present our technique of high uterosacral hysteropexy and show that this results in a significantly reduced blood loss compared to non uterine-preserving techniques and comparable post-operative outcomes suggesting that this a suitable option for pelvic organ prolapse management.
Naveen Kachroo
Solafa Elshatanoufy
Humphrey Atiemo
Vesicovaginal Fistula repair in orthotopic neobladder with pedicled island skin flap
|Female Pelvic Medicine
Abstract: V2-12
Sources of Funding: none
51 y/o female patient with history of bladder cancer and subsequent orthotropic neobladder vesicovaginal fistula. She failed two attempts at closure due to necrosis of the vaginal wall. She was averse to using muscle flaps and was considering conversion to urinary diversion. A martius flap with a skin island was used to correct the defect on the anterior vaginal wall.
An inverted U incision was made on the vaginal wall. The intestinal mucosa was carefully separated from the anterior vaginal wall. The neobladder defect was closed in an interrupted fashion with 3-0 polyglactin sutures. A 3 x 1.5 centimeter skin island was isolated from the labia and the underlying fibrofatty tissue was mobilized. The anterior portion of the graft is ligated leaving the fibrofatty graft supplied by the posterior labial artery from the internal pudendal artery. A tunnel is developed from the vaginal incision to the labia and the graft is transferred through the tunnel to cover the vaginal wall defect. The skin island was secured to the vaginal defect with interrupted 3-0 polyglactin sutures. An indwelling foley catheter and a suprapubic tube were left in place.
8 weeks postoperatively the patients graft had excellent uptake. Cystoscopy was performed and there was no evidence of the neobladder defect. The neobladder was filled with methylene blue and there was no leakage to suggest persistence of the fistulous tract. 12 weeks post operatively the patient did not have recurrence of fistulous tract.
Transvaginal correction of orthotropic neobladder vesicovaginal wall fistula with martius flap and a skin island is a viable alternative for repair of large complex defects.
Daniel Hoffman
Victor Nitti
Technical considerations for a horseshoe kidney and a posteriorly occurring renal mass: The use of intravenous indocyanine green and 4th arm in robot-assisted partial nephrectomy
|Renal Oncology
Abstract: V3-01
Sources of Funding: None
Horseshoe kidney is a congenital anomaly in which the fused kidneys fail to ascend to their normal position. Anatomic aberrations including renal malrotation and the presence of an isthmus can make access to the posterior renal anatomy challenging. Persistent embryonic arteries combined with variations in origin, number, and size of renal arteries contribute to the increased potential of excess blood loss during surgery. Taken together, these anatomic variations make minimally invasive surgery in horseshoe kidneys technically challenging. Although minimally invasive techniques have been utilized for partial nephrectomy (PN) in horseshoe kidneys, reporting on technical modifications during robot-assisted techniques is minimal. Here, we present a case of a renal mass located in a horseshoe kidney and describe our technique for robot-assisted PN in this patient population.
A 65-year-old female presented with an incidental finding of a 5.6 cm posteriorly occurring enhancing renal mass on the left lower pole of her previously undiagnosed horseshoe kidney. Workup included a CT angiogram for further evaluation of renal vasculature. Nephrometry score was 2+1+3+P+2= 8-P-H. The left moiety was fed by two renal arteries with significant distance between them, and a single renal vein inserting more distally into the inferior vena cava. The patient ultimately opted for robot-assisted PN. A fourth arm Grasping Retractor was utilized early for improved hilar retraction, and later for folding the kidney on its isthmus to create posterior access and optimal exposure during tumor enucleation. Intravenous indocyanine green (ICG) instillation was used in conjunction with near infrared fluorescence to attempt selective arterial clamping and improve intraoperative understanding of renal perfusion as well as the renal mass.
Console time was 157 minutes with an estimated blood loss of 300 mL. Warm ischemia time was 19 minutes. The patient was discharged on post-operative day one. There were no perioperative complications. Pathology revealed a 5.7 cm oncocytoma.
We demonstrate that using ICG and the 4th arm are technical considerations that can assist with robot-assisted PN in a horseshoe kidney, especially for posteriorly occurring tumors.
Randall Lee
Laura Giusto
Benjamin Waldorf
Daniel Eun
Transperitoneal Robot Assisted Inferior Vena Cava Filter Extraction: You Already Know How to Do This!
|Renal Oncology
Abstract: V3-02
Sources of Funding: none
In this video we present a technique for robotic removal of an inferior vena cava filter (IVCF) not amenable to endovascular retrieval. Our technique mirrors our established technique for robotic removal of a level I or level II caval thrombus associated with renal cell carcinoma. The index patient is a healthy 31-year old male experiencing epigastric discomfort attributed to a permanent caval filter placed 10 years prior, with radiographic evidence of IVC extrusion.
The patient is positioned in the right-side-up modified flank position. The colon is mobilized and athermal Kocherization of the duodenum is performed with awareness that any extruding struts of the IVCF may perforate adjacent organs. The filter is easily visualized within the exposed cava. After circumferential dissection of the cava above and below the IVCF, occlusion of the IVC is accomplished by placing modified Rummel tourniquets in the form of vessel loops doubly wrapped around the IVC and the bilateral renal veins. To avoid significant blood loss, it is crucial to ligate, bipolar, or staple all lumbar veins. Intravascular heparin is given before tightening the tourniquets. Control of the renal arteries is not necessary. Cavotomy is performed once all inflow is controlled so that a bloodless field is maintained during IVCF extraction. Struts of the filter that have eroded through the vena cava may be broken and removed prior to opening the cava, otherwise the struts can be pulled into the lumen of the vena cava once open, with minimal risk of caval tearing. Caval reconstruction is accomplished with a running 4-0 permanent monofilament suture. Heparinized saline is flushed through the cavotomy prior to closure and before releasing tourniquets to reestablish blood flow.
Operative time was 189 minutes. IVC occlusion time was 25 minutes. Estimated blood loss was 800 ml in this case due to an unrecognized lumbar vein. The patient was discharged to home on postoperative day two. There were no intraoperative or postoperative complications. The patient was continued on 81 mg aspirin at discharge and prophylactic enoxaparin for three weeks. Pain symptoms had improved at 3 month follow up.
This video demonstrates a stepwise technique for transperitoneal robot assisted IVC filter extraction. Urologists with adequate robotic experience in robotic nephrectomy with level I-II IVC tumor thrombus should feel comfortable approaching robotic IVC filter retrieval. It is important to have multidisciplinary support, adequate preoperative imaging, and be familiar with the IVC filter design.
Sean McAdams
Haidar Abdul-Muhsin
Victor Davila
Sailendra Naidu
Samuel Money
Erik Castle
Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy: Primary Description of Novel Supine, Single-dock Approach.
|Renal Oncology
Abstract: V3-03
Sources of Funding: None.
Initial descriptions of robotic management of renal cell carcinoma with Inferior Vena Cava (IVC) thrombus employ a lateral approach predicated on early IVC exposure and control. However, for left-sided renal masses and associated tumor thrombi, this approach requires re-positioning and re-docking steps, as well as pre-operative left renal artery embolization. Herein, we describe a novel supine, single dock technique for robotic left nephrectomy and caval thrombectomy.
We perform robotic nephrectomy and caval thrombectomy on a 79 y.o. male with a 6cm left renal mass and level II IVC thrombus. The patient is placed supine, in steep trendelenburg. We employ a 6-port trans-peritoneal technique and dock the robot such that arms are directed cephalad. Key steps critical to the procedure include: 1) Exposure of the retroperitoneum 2) IVC exposure and control 3) Left Renal Hilar Control 4) Cavotomy, thrombectomy, and reconstruction 5) Nephrectomy and lymph node dissection (LND). Peri-operative outcomes are reported and compared to previously published case series.
Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach.
We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, single-dock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient re-positioning.
Monty Aghazadeh
Spencer Craven
Alvin Goh
Precision Surgery in Robotic Partial Nephrectomy
|Renal Oncology
Abstract: V3-04
Sources of Funding: None
Current paradigms in partial nephrectomy (PN) for localized renal tumor support a minimally-margin size with limited ischemia where possible, even in the most complex of cases. However, there is as yet no standardized assessment or planning procedure for Robotic partial nephrectomy (RPN).
Here we present our technique for Robotic Partial Nephrectomy Precision Surgery. This technique combines patient-specific imaging assessment by Virtual PN and surgical navigation intra-operatively with cognitive fusion.
Case1: The 49-year-old woman, with right non-functional kidney was referred by the 5.2cm left renal tumor located in the renal hilum and tumor thrombus in the renal vein in a functional solitary kidney. The tumor biopsy revealed the clear cell carcinoma. After administration of molecular targeted medicine for 6 months with tumor shrinkage to 4.7cm, R.E.N.A.L. nephrometry score 10a, RPN was conducted. Preoperative Virtual PN revealed that the selecting clamping was not appropriate for this case, and provided the case specific margin size (1-2mm) and anatomical visualization of the intrarenal structures, tumor, renal arteries, veins, tumor thrombus, and renal pelvis, and their location in color-coded manner. RPN was performed with intra-operational image guidance in 19 min warm ischemia time (WIT), 50ml estimated blood loss (EBL), and negative surgical margin. Post-operative creatinine level was same as pre-operative level 0.89, and the dialysis was not required. Case 2: 56-year-old woman with totally endophytic renal tumor sized in 2.5cm and the nephrometry score was 8a was underwent RPN. Prior the operation, the 3rd arterial branch was identified for the point of selective clamping by the Virtual PN. RPN was performed with intra-operational image guidance of the targeted artery, with WIT being 18 min, with EBL being 100ml and with negative surgical margin. Pre-operative creatinine was 0.59 and post-operative creatinine was 0.58. There were no complications in either case.
Robotic Partial Nephrectomy combined with 3D navigation, Virtual PN, and intra-op surgical navigation may allow "Precision Surgery� to preserve renal function by minimizing the excision margin and limiting ischemic area.
Shuji Isotani
Michael Stifelman
Shigeo Horie
Robotic assisted laparoscopic tumor enucleation with artery hypothermic perfusion combined with neoadjuvant target therapy for a multifocal solitary kidney cancer
|Renal Oncology
Abstract: V3-05
Sources of Funding: none
Our patient is a 61 year old female who underwent radical nephrectomy on the right side 8 years ago. Multiple renal masses were found by ultrasound during the latest follow up. Subsequent imaging confirmed 3 tumors in the left kidney with 5.5cm in the greatest dimension.
This patient underwent 3 circles of neoadjuvant target therapy with Axitinib. All of three tumors shrinked after therapy with decreased enhancement and clearer tumor capsule in the CT imaging. A balloon was placed into the left renal artery by an interventional radiologist before surgery. We began the procedure by mobilizing the colon. Then we identified the renal vein and all of its branches. After the lumbar vein was disconnected, the renal artery can easily be dissected. After defat, the kidney was totally mobilized. After occlusion of the artery, the renal vein was clamped. During infusion of cold Ringer's solution, we started enucleation from the largest tumor. The parenchyma close to the tumor was resected until the capsule was identified. The tumor was enucleated by combining sharp and blunt dissection using tumor capsule as the anatomical landmark, with no visible rim of normal parenchyma. Tumor thrombosis was find invading into the branch of the renal vein and was separated from the tumor. The second tumor was identified at the edge of the first tumor and was enucleated with the same technique. The thrombosis was resected and no visible tumor was left on the tumor bed. Collecting system was found ruptured and was closed by running suture with 3-0 monofilament. No additional suture was performed on the tumor bed. The parenchyma defect was closed with horizontal interrupted 2-0 Monocryl sutures with Hem-o-lok clips placed on the kidney capsule. The third tumor at the upper pole was enucleated similarly. Once the stitches were placed, the clamp of the renal vein was removed and occlusion of the artery was released.
Perioperative date revealed estimate blood loss of 200 ml and warm ischemia time of 68 minutes. The patient underwent anuria for 2 hours and the serum creatinine elevated to 3.4 mg/dl 48 hours after surgery and dropped down to 1.5mg/dl after one month. Final pathology revealed a pT3a clear cell carcinoma. No residue tumor was revealed in the enhanced CT during follow up.
In summary, complicated renal cancer, especially solitary cancer need individualized treatment. Tumor enucleation assisted with target therapy and robotic technique seems like a feasible strategy to realize tumor free and maintain renal function.
Xiaozhi Zhao
Hongqian Guo
Conventional Laparoscopic Radical Nephrectomy with inferior vena cava thrombectomy
|Renal Oncology
Abstract: V3-06
Sources of Funding: none
In the past decade, the options of targeted therapy agents, for the treatment of advanced and metastatic renal cell carcinoma (RCC) has significantly increased. This increase has lead to a migration of targeted therapy agents from salvage to the neoadjuvant setting for large unresectable masses, venous tumor thrombus involvement, and patients with imperative indications for nephron sparing._x000D_ Venous tumor thrombus involvement of Inferior vena cava (IVC) is a complicating factor that occurs in up to 10% of cases of patients with renal cell carcinoma (RCC), of which nearly one-third of patients also have concurrent metastatic disease. The surgical management with laparoscopic technique for renal cell carcinoma with IVC tumor thrombus remains challenging and technically demanding in urological oncology. Our objective is to describe the surgical technique of a right pure conventional laparoscopic Radical Nephrectomy with (IVC) thrombectomy in a patient with level II thrombus who receive neoadjuvant target therapy.
A 78-year-old male with lung metastatic renal cell carcinoma cT3bN1M1, received target therapy in neoadjuvant setting and after improving in the Memorial Sloan-Kettering Cancer Center Score for Metastatic Renal Cell Carcinoma (MSKCC/Motzer) and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic scores, underwent cytoreductive nephrectomy with thrombectomy of IVC._x000D_ We report one case of right pure conventional laparoscopic radical nephrectomy and thrombectomy of the level II (infrahepatic) tumor thrombus in the IVC._x000D_ To do this, IVC was isolated, the right gonadal and lumbar veins were ligated and transected. The infrarenal IVC, left renal vein and infrahepatic IVC blood flow were controlled with a bulldog clamp. After thrombectomy of the IVC, the wall defect was sutured with continuous Prolene suture and then a laparoscopic radical nephrectomy was performed._x000D_
The operative time was 300 min and the IVC clamping time was 15min. The estimated blood loss was 700 ml, and no major intraoperative or postoperative complications occurred. The patient was discharged from hospital 3 days after the surgery without needing critical care unit.
Laparoscopic radical nephrectomy with thrombectomy for renal cell carcinoma with tumor thrombus level II is a safe, reproducible and technically feasible technique, which can be applied to a specific population of patients but also is challenging and requires advanced laparoscopic skills.
Giuliano Guglielmetti
Henrique Nonemacher
George Lins de Albuquerque
Rafael Coelho
Mauricio Cordeiro
Willian Nahas
Salvage Robotic Partial Nephrectomy After Cryoablation
|Renal Oncology
Abstract: V3-07
Sources of Funding: None
Focal therapy with cryoablation (CA) or radiofrequency ablation (RFA) is a treatment option for small renal masses, however reported recurrence rates are 10-13% (Novick, 2009). Salvage partial nephrectomy after CA is challenging due to significant desmoplastic reaction and scarring, which has been noted to be more severe than RFA. Increased complications have also been reported in post CA versus RFA patients. Robotic salvage partial nephrectomy is uncommonly reported. We describe a unique case of salvage robotic partial nephrectomy 5 years after CA.
A 60 year old healthy male was found to have a 2.8 cm right lower pole mass and he was treated with cryoablation therapy. He was asymptomatic, but remained on surveillance with periodic imaging. Five years later, he was found to have a 3.2 cm enhancing renal mass with calcifications, concerning for malignancy. He was referred to us for salvage robotic partial nephrectomy.
We utilized a standard transabdominal approach using a 6 port robotic technique. The colon was reflected medially. The inferior vena cava was identified. The ureter was significantly scarred and was in close proximity to the mass. Hilar dissection revealed a single renal artery and two renal veins. The kidney and mass were exposed. The ureter was adherent to the tumor and was carefully freed. Ultrasound guidance was used to demarcate the tumor. After hilar clamping, the mass was excised using a monopolar scissors. 3-0 v-loc suture was used to repair the calyceal openings and oversew the tumor bed. A 2-0 V-loc suture was used for the renorraphy using the running sliding hem-o-lok clip technique. Clamps were removed and good hemostasis was confirmed. Surgicel and Tisseel were applied to the defect. A JP drain was placed. Operative time was 162 minutes with 34 minutes of warm ischemia time. _x000D_ _x000D_ The foley catheter was removed the day after surgery. The patient was discharged home on postoperative day 1 with the drain despite drain creatinine being consistent with serum. It was removed in the office on postoperative day 3. Final pathology was grade 2 pT1a clear cell renal cell carcinoma with negative margins. Renal function was normal at four and 6 month follow up. Imaging did not reveal any evidence of recurrence.
In experienced hands, salvage robotic partial nephrectomy after cryoablation is challenging but feasible with acceptable warm ischemia time. As demonstrated in the video, robotic approach allows for adequate visualization and meticulous renorrhaphy.
Joan C. Delto
Alan M. Nieder
Akshay Bhandari
Partial nephrectomy of an Endophytic Mass in a Horseshoe Kidney
|Renal Oncology
Abstract: V3-08
Sources of Funding: none
Nephron sparing surgery, specifically robotic assisted laparoscopic partial nephrectomy, has become a widely accepted treatment choice for small renal masses. Renal fusion abnormalities, such as horseshoe kidney, are uncommon congenital findings with a frequency of approximately 1 in 200 in the general population. Renal fusion abnormalities change the position and orientation of the kidney, and complicate the treatment of renal disorders. We demonstrate our technique for the management of a complex, endophytic cT1b renal mass in a horseshoe kidney.
A 73-year-old African-American gentleman with a history of CHF as well as COPD and a 50-pack-year history of cigarette smoking had an incidentally discovered horseshoe kidney on a contrasted CT scan of the abdomen ordered for abdominal pain, as well as an endophytic, complex cystic mass within the superior pole of the left portion of the kidney measuring 4.7 x 4.5 x 3.7 cm. This mass was assigned a 10AH on the nephrometry scoring scale. He placed in the modified flank position and the da Vinci Xi surgical system was used to target the left flank. After dropping the colon and the colorenal ligaments, we were able to identify the hilum, including the renal hilum, and the complex vascular anatomy. We used endoscopic ultrasound to target the tumor, and we undertook a circumferential resection of the mass. Final warm ischemia time was 24 minutes 32 seconds. We performed a two layer renorrhaphy, which was hemostatic at the conclusion of the procedure.
The patient did well postoperatively. His serum creatinine preoperatively was 1.3, and at the time of his discharge on postoperative day 3, it had returned to baseline. Final pathology showed papillary renal cell carcinoma type 1, Fuhrman nuclear grade 3, 4.2cm in maximal dimension. The surgical margin was negative for malignancy. The patient is currently awaiting follow up cross sectional imaging.
Robotic assisted laparoscopic partial nephrectomy can be a valuable addition to the urologist's armamentarium for the treatment of complex renal masses identified in horseshoe kidneys.
Gregory Mitchell
Russell Libby
Jonathan Silberstein
Raju Thomas
Nephron-sparing laparoscopic partial nephrectomy after superselective embolization of a renal tumor in a hybrid operating room: a new approach of zero ischaemia
|Renal Oncology
Abstract: V3-09
Sources of Funding: none
To perform nephron-sparing surgery, arterial clamping is often required. Operative bleeding control is difficult in laparoscopic techniques. We imagined a novel technique for "zero ischemia" nephron-sparing surgery using a hybrid opearating room: clampless laparoscopic partial nephrectomy was performed after superselective tumoral embolization. Our objective is to describe this new technique.
The patient is a 46 year old patient with no prior medical history, who had a 3 cm large localized renal tumor on the convexity of the left kidney. The lesion was heterogeneous, medial, partially endophytic and of moderate complexity (RENAL 8p). The procedure was realized in a hybrid operating room by a double team: interventional radiologist and urologist.
A first renal arteriography was made to visualize the arterial vascularization of the left kidney. With a guidance software, the tumoral artery was catheterized superselectively. The tumor and its arteries were embolized by microspheres and coils. A 3D arteriography showed the exclusion of the tumor from the renal vascularization. Then, the patient was positionned for laparoscopic partial nephrectomy, thas was performed without dissecting the renal pedicule, nor clamping of the renal artery. Operative bleeding was insignificant. No suture was necessary. A final control 3D arteriography showed no arterial bleeding and preservation of healthy renal parenchyma. Follow-up was uneventful. Preoperative renal function was maintained. The tumor was a clear cell renal carcinoma. Surgical margins were negative.
This is the first experience of superselective tumoral embolization followed immediately by laparoscopic partial nephrectomy in a hybrid operating room. Resection of a localized renal cancer of moderate complexity was performed clampless, sutureless and without intraoperative bleeding.
Paul Panayotopoulos
Antoine Bouvier
Pierre Bigot
Robotic-assisted laparoscopic nephrectomy of an auto-transplanted kidney for recurrent renal cell carcinoma
|Renal Oncology
Abstract: V3-10
Sources of Funding: None
Advances in robotic technology continue to expand the boundaries of minimally invasive renal surgery for both benign and malignant conditions. A single report has previously described the use of the robotic approach in transplant nephrectomy for a failed allograft. _x000D_ Herein, we present the first robotic-assisted laparoscopic nephrectomy of an auto-transplant kidney for a tumor recurrence, in a unique case of a solitary kidney that had previously undergone ex vivo partial resection for a complex renal cell carcinoma.
The patient is a 64-year-old man with a history of a solitary left kidney after a radical right nephrectomy several years ago for a clear cell renal cell carcinoma. After discovery of a new centrally located left renal mass on surveillance, he underwent nephron-sparing surgery by laparoscopic nephrectomy followed by ex vivo partial nephrectomy and auto-transplant to the right iliac fossa. He subsequently developed a recurrence near the renal pelvis which was initially stable for four years on tyrosine kinase inhibitor therapy. The tumor then increased in size after therapy was discontinued due to toxicity. He was counseled on his surgical options for a radical auto-transplant nephrectomy and elected for a robotic approach. The procedure was completed transperitoneally using the da Vinci Si Surgical System. The patient was positioned supine with the robot side-docked over the right iliac fossa. Three robotic arms were utilized in addition to two assistant ports.
The total operative time was 387 minutes with an estimated blood loss of 800 mL. The patient received 2 units of packed red blood cells intraoperatively. The patient had an unremarkable postoperative course and was discharged on day 3. There were no perioperative complications. Pathology revealed recurrent 8.2cm clear cell renal cell carcinoma, Grade IV involving the renal vein with negative surgical margins.
Robotic transplant nephrectomy has previously been shown to be safe and feasible in the management of a failed allograft. We report on our technique and experience with the additional technical demands of a previously operated auto-transplant kidney. A minimally-invasive approach can potentially reduce the morbidity of this uncommon and complex procedure. _x000D_
Belinda Li
Parth Patel
Alex Gorbonos
Robotic partial nephrectomy involving intracorporeal cold ischemia for post cryoablation failure
|Renal Oncology
Abstract: V3-11
Sources of Funding: none
The reference standard treatment for small renal masses is partial nephrectomy, and the robotic approach has become rapidly adopted in this setting. However, minimally invasive approach to partial nephrectomy can be complicated by previous surgery or percutaneous renal ablative therapy. The ideal approach to partial nephrectomy is unknown in this setting. We present a surgical video of a 62 year old female with a previous left renal cryoablation, who developed an ipsilateral recurrent left renal mass in the previous ablative zone. We performed a robotic partial nephrectomy utilizing intracorporeal cold ischemia. Our surgery is technically innovative in that we introduce a method for providing cold ischemia through a minimally invasive robotic approach in the setting of cryotherapy failure.
The Da Vinci Xi (Intuitive Inc, Sunnyvale, CA, USA) robotic platform was utilized with a 4 arm approach. Robotic ports were placed in a linear configuration lateral to the rectus muscle and an assistant port near the umbilicus. An additional 15mm accessory port is placed near the 12th rib for introduction of ice slush. Modified 20mL syringes are used to deploy ice slush through the 15mm accessory port. The renal artery is clamped and the tumor completely excised. Renorrhaphy was performed with adequate hemostasis.
Estimated blood loss was 50mL Cold ischemia time was 83 minutes. Final pathology revealed clear cell renal cell carcinoma, Fuhrman grade 2, 2.0cm, with negative margins, pT1a. Follow up renal functional studies showed a GFR >60 mL/min/1.73m2 at 6 month follow up.
Robotic partial nephrectomy in the setting of percutaneous ablative failure is technically feasible and can be performed with the addition of ice slush cold ischemia. Further study is requisite to confirm these results.
Zachary Hamilton
Omer Raheem
Ithaar Derweesh
Robot Assisted Partial Nephrectomies – 12 Tumors, 1 Kidney
|Renal Oncology
Abstract: V3-12
Sources of Funding: None
Tuberous sclerosis is a rare hereditary disorder caused by the decrease or loss of expression of the TSC1 or TSC2 tumor suppressor gene, resulting in an increase in activation of the mTOR pathway. Renal angiomyolipomas (AMLs) occur in up to 60% of patients with tuberous sclerosis. The risk of hemorrhage from AMLs increases with tumors larger than 4 centimeters. Elective AML treatment includes arterial embolization, ablation or nephron-sparing excision, if possible. Everolimus, an mTOR inhibitor, is FDA approved to reduce angiomyolipoma size in patients with tuberous sclerosis. We hypothesize that Everolimus may decrease the vascularity of the tumors and help minimize bleeding during surgery.
An 18 year-old female was referred to our clinic for evaluation of multiple bilateral angiomyolipomas. She had been on Everolimus for several years and had undergone several unsuccessful embolizations at an outside facility. MRI of the abdomen showed more than 30 angiomyolipomas in the left kidney and more than 20 in the right kidney. The largest tumors in the left kidney measure 4 centimeters, 2.7 centimeters, and 2 centimeters. A renal scan indicated relatively equal kidney function. The patient went to the operating room for robot assisted left partial nephrectomies. Twelve tumors were enucleated without hilar clamping. The 2 largest tumor defects were closed with a sliding clip technique renorrhaphy. Hemostatic matrix was placed for additional hemostasis. Total operative time was 3 hours and total robot console time was 2.5 hours.
Twelve tumors were excised with the largest measuring almost 5 centimeters. There were no intraoperative or postoperative complications. Her hemoglobin nadir was 10.2 g/dL from a preoperative value of 11.7 g/dL. Postoperatively her creatinine stayed stable at 0.6 mg/dL. She was discharged home on postoperative day 2.
Robot partial nephrectomies for multiple angiomyolipomas is a feasible, safe, and effective option in patients with tuberous sclerosis who wish to preserve renal function while pursuing surgical management. Everolimus may contribute to the lack of vascularity noted in these lesions with minimal bleeding during surgery.
Karen Stern
Catherine Chen
Gwen Grimbsy
Thai Ho
Erik Castle
Patient specific rehearsal using 3D printing for complex partial nephrectomy cases
Abstract: V4-01
Sources of Funding: none
The benefits of surgical simulation have been previously demonstrated to enhance technical skills with a downstream effect of improved patient outcomes. However, other methods to utilize simulation technology remain under-explored. One area of simulation that has proven to be difficult is the creation of a high fidelity process that accurately and reproducibly simulates individual anatomy and pathology (i.e. patient specific simulators). Advances in 3-D printing and polymer technology, coupled with software that incorporates imaging data into a computer design, make it possible to develop individualized models from patient imaging data. We present the feasibility of patient-specific preoperative rehearsal using 3D processing & printing in complex partial nephrectomy cases.
Three patients with enhancing renal lesions suspicious for renal malignancy with complex tumor morphology or significant comorbidities were chosen for preoperative simulation and rehearsal. DICOM files of patients C.T. angiography (CTA) were imported into 3D processing software to create virtual models of kidney parenchyma incorporating the tumor, renal vasculature, and pelvicalyceal system. Surgical phantoms were created using 3D printing and polymer hydrogels, for patient-specific surgical rehearsal. For whole task preoperative surgical rehearsal, other relevant anatomical elements (bowel, perinephric fat, solid organs and bony structures) were incorporated into a replicated hemiabdomen. _x000D_
All 3 preoperative simulations were completed prior to the live case. Partial nephrectomy was successful in all 3 cases with an average blood loss of 300cc and WIT of 20 minutes. For the first case, preoperative 3D processing and hydrogel kidney aided in assessing the depth of resection of a completely endophytic tumor and predicted violation of the pelvicalyceal system in the live case. In the 2nd case, the preoperative rehearsals ascertained the feasibility of completing partial nephrectomy in a 9 cm upper pole mass. In the final case, the preoperative rehearsals confirmed the feeding vessel and viability of selective ischemia with his existing coagulopathy and nephropathy. _x000D_
This initial trial demonstrates that patient-specific procedural rehearsal is effective for enhancing the performance of surgeons during a complex minimal invasive procedure. This transition from generalized to patient-specific simulation may have the potential to impact patient outcomes by permitting preoperative rehearsal. _x000D_
Jonathan Stone
Rachel Melnyk
Guan Wu
Hani Rashid
Jean Joseph
Ahmed Ghazi
Gold Nano-Particle Directed Focal Laser Ablation for Prostate Tumors using US and MR Fusion Technology
Abstract: V4-02
Sources of Funding: Funded Trial by Nanonspectra Biopsciences
: A growing collective proficiency in multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies for prostate cancer (PCa) screening has given way to an increasing interest in the application of these technologies for targeted therapy. Various targeted therapies have been developed and evaluated; however, these treatments focus energy at a region of the prostate, as opposed to directly at the tumor. Gold nanoparticle (GNP) therapy is a novel treatment that results in tumor-specific ablation, sparing surrounding tissue and structures. Herein, we report the first two cases in the world using gold nanoparticle-directed focal laser ablation of prostate tumors targeted with ultrasound (US) and MR/US fusion technology.
Patients were enrolled in a phase II trial, &[prime]A Study of MRI/US Fusion Imaging and Biopsy in Combination with Nanoparticle Directed Focal Therapy for Ablation of Prostate Tissue.&[prime] Treatment and follow up plan are as follows: intravenous infusion on day 0, which allows GNP deposition into the tumors with the goal of achieving a 15.2 µg/cc tumor concentration required for excitation/ablation. On day 1, the patient presents for focal laser excitation of the GNPs. Laser catheters are placed using a combination of US and a transperineal electromagnetic-tracked MR/US fusion device (Invivo, Gainesville, FL). 48 hours' post-ablation, the patient is imaged, fig 1, followed by re-imaging and MR/US fusion guided biopsy (FBx) at 3 months. All patient demographics, clinical variables, and complications were recorded.
To date, 2 patients have been enrolled in the trial, both with localized Gleason 7 PCa diagnosed using MR/US FBx. Mean age was 67 + 4.3 years and mean prostate specific antigen was 6.1 + 0.06 ng/ml. The mean tumor volume was 0.40 + 0.05 cc with a solitary lesion in each patient. The mean PSA decrease was 3.6 + 0.6 ng/ml, a 40.9% decrease at 1 month. No short-term complications were observed. The first patient underwent a follow up FBx at 3 months with no detectable cancer.
Increasing interest in image guidance technologies and focal therapies has sparked a new generation of PCa treatment modalities. We have demonstrated the first safe and effective use of ultra-focal therapy using MR/US fusion technology in concert with GNP directed therapy to treat prostate tumors.
Funded Trial by Nanonspectra Biopsciences
Jared S Winoker
Pratik A Shukla
Michael A Carrick
Harry Anastos
Cynthia J Knauer
Ashutosh K Tewari
Bachir M Taouli
Sara C Lewis
Jon A Schwartz
Joshua M Stern
Steven E. Canfield
Ardeshir Rastinehad
CT/MRI-US Fusion Guided Renal Mass Biopsy: Initial Experience
Abstract: V4-03
Sources of Funding: None
The Real-time Virtual Sonography (RVS) system allows image-fusion of real-time live US with pre-operative contrast-enhanced CT/MRI. Both real-time US and fused-image of CT are real-timely displayed in parallel in US-machine. The objectives are to assess the feasibility and safety of a pilot study for offie RVS-guided renal mass biopsy (RMB)._x000D_
Pre-operative: After 8 hours of fasting, the patient is placed in prone position in outpatient facility and monitored. US/CT registration: The DICOM data of a previous CT scan or MRI is loaded into the RVC system. The image is rotate to be at the same orientation of the patient. The kidney of interest and the plane with a reference point that a shows a good window to puncture the renal mass is selected.The kidney of interest is then US-scanned and the images are compared with the CT scan. When the images match to each other the plane with the reference point is fused with pre-operative contrast CT scan using the RVS system. The kidney is scanned and the best location to target the renal mass is selected. Co-axial needle technique: A 17G hollow needle is connected to a needle-guide under 21-degree inclination and attached to the US probe. Under local anesthesia, a 17G hollow-needle, is first placed along the planned puncturing dotted-line toward the renal mass up to the Gerota&[prime]s fascia. Biopsy: A 18G biopsy-gun is inserted through the co-axial-outersheath, advanced along the planned puncturing dotted-line upto the tumor and is fired to obtain the biopsy-tissue from the tumor. Usually two to three cores are taken, all through the hollow needle.
From April to June of 2014, 13 patients underwent RMB. Only single-use of local anesthesia was required in all cases. Co-axial needle technique facilitated (i) visualization of the biopsy-needle in live US, (ii) multiple-sampling through it, and (iii) decreasing the seeding risk of malignant cells. RVS system facilitated targeting the contrast-enhanced lesion, as it improved visualization of important anatomical landmarks. Intra-operatively accompanied pathology-team was important to determine the adequacy of tissue-sampling. Biopsy histology was concordant with surgical specimen in 7 of 10 patients undergoing surgery. Additionally, 2 patients with histology of oncocytoma chose active surveillance. There were no complications.
Outpatient RMB performed by urologist is safe and promising. This was achieved using local anesthesia, co-axial needle technique, and intra-operative co-operation with pathology-team, and introduction of real-time image-fusion technology of live US with contrast CT/MRI.
Andre Abreu
Sameer Chopra
Carlee Beckler
Masakatsu Oishi
Nariman Ahmadi
Toshitaka Shin
Andre Berger
Mihir Desai
Monish Aron
Inderbir Gill
Osamu Ukimura
Novel Use of Fluorescence Lymphangiography During Robotic Groin Dissection for Penile Cancer
Abstract: V4-04
Sources of Funding: none
Indocyanine green (ICG) lymphangiography has been used to detect lymphatic channels under fluorescent light and to aid in the excision of affected lymph nodes. We describe our novel technique of robotic inguinal lymphadenectomy with near infrared fluorescence imaging using ICG to facilitate lymph node identification during robotic groin dissection for penile cancer.
Using a high definition recording system and iMovie software with narrative and annotative editing, we created a video of our novel technique for robotic inguinal lymphadenectomy with near infrared fluorescence imaging using the Surgical Intuitive Da Vinci Xi robot. Robotic ports are placed in a V configuration at the tip of the femoral triangle after development of the working space by blunt finger dissection. Intradermal ICG is injected at the penile stump or base (0.5 ml of 2 mg/kg concentration in normal saline) and the lymphatic channels and nodes are visualized with near infrared fluorescence imaging in the robotic console approximately 15 minutes after injection. The surgical template established via the open approach is then replicated.
A total of 8 groin dissections have been completed using this technique with a mean lymph node yield of 8 per groin (range 5-16 lymph nodes). With a follow up ranging from 3-16 months, there have been no post-operative infections, lymphatic leaks, wound breakdown, or necrosis. All pathologically proven nodes were identified intra-operatively with ICG.
Our novel technique of robotic inguinal lymphadenectomy with fluorescence lymphangiography using ICG facilitates identification of lymph channels and nodes. It is reproducible, safe, and helps ensure complete excision of both superficial and deep lymph nodes during groin dissection for penile cancer. This technique may dramatically decrease the morbidity compared to the open technique without compromising oncologic efficacy. Further prospective studies are required to assess the long term results of this procedure.
Alexander P. Kenigsberg
Marc A. Bjurlin
Alon Y. Mass
Lee C. Zhao
William C. Huang
Impact of the 20 G all-seeing needle and 4.8 Fr micro PCNL with the High Definition Image Guide (HDIG) system
Abstract: V4-05
Sources of Funding: None
PCNL is the first-line therapy for large and complex renal calculi. To perform PCNL safely and effectively, the most important step is the formation of a nephrostomy tract and tract dilatation. Furthermore, as fine a nephroscope as possible is required for micro PCNL. In this clinical study, renal puncture using 20 G all-seeing needle and 4.8 Fr micro PCNL were performed for large renal stone using a micro-optic disposable scope.
The Φ0.65 mm scope with the High Definition Image Guide (HDIG) system reported in previous WCE held in Taiwan (2014) was adopted. The scope consists of an integrated light lead and the micro fiber optic including a Φ0.5 mm precise object lens and optical glass fiber, where real-time HD images can be seen through the digital image processing device. The scope can be set inside a 20 G puncture needle or 4.8 Fr metal sheath which can simultaneously include the micro-optic scope, 0.018 inch guidewire and 200 µm laser fiber. These devices are developed as part of a collaborative research with Takei Medical & Optical Co. Ltd. (Tokyo, Japan) and Sumita Optical Glass Inc. (Saitama, Japan) funded by Utsukushima Next-Generation Medical Industry Agglomeration Project between 2012 and 2014. After evaluating safety, optical quality and operation performance in an animal study, the clinical study authorized by the ethical committee of Okayama University Hospital was carried out from June 2013. The procedures of micro PCNL are as follows; ultrasound-guided renal puncture using 20 G all-seeing needle, removal of the scope followed by insertion of 0.018 inch guidewire, dilatation by metal introducer, insertion of 4.8 Fr metal sheath into renal calyx, insertion of the HDIG scope into the sheath, complete fragmentation of calculi by Ho-YAG LASER without removal of the fragments.
A 68-year old male with renal calculi 21 mm in diameter in left lower calyx once underwent the puncture and the micro PCNL. After the operation, spontaneous discharge of fragmented calculi through lower urinary tract was observed and abdominal X-ray on POD 21 showed no fragment in his left kidney. No adverse event was occurred except slight elevation of serum creatinine during only a week postoperatively.
The micro-optic disposable scope with the HDIG system is extremely useful for safer puncture and finer PCNL. We are now planning to adopt it to percutaneous procedure for urothelial carcinoma in upper urinary tract.
Koichiro Wada
Hiromi Kumon
Ryuta Tanimoto
Yosuke Mitsui
Takuya Sadahira
Atsushi Takamoto
Yasuyuki Kobayashi
Katsumi Sasaki
Motoo Araki
Toyohiko Watanabe
Yasutomo Nasu
Abstract: V4-06
Sources of Funding: none
The vast majority of resident surgical teaching in the United Sates is performed in the operating room. Instructional feedback on technique is nearly exclusively given at the time of surgery. However, this current model poses problems in the modern era due to pressures for increased surgical throughput and resident duty hour restrictions. We have developed a web-based, interactive platform that uses novel video technology (compatible with most media devices) to enhance surgical teaching. We have taken the first step in implementing the training platform by assessing the platform's usability to teach the robotic simple prostatectomy and to ensure trainee participation using a validated, industry standard questionnaire.
All urology surgical trainees at our institution were given access to a web-based surgical training platform. This platform allows trainees to easily upload video segments of surgeries they performed for expert (attending physician) review. The experts are alerted through email and are prompted to give text based comments as feedback. The feedback is embedded within the video and is time congruent to the task being performed. The trainees are alerted to the reviewer's comments and are prompted to review the video containing expert feedback. To evaluate the platform as a teaching tool, the trainees were given access to the platform, asked to watch the steps of a robotic simple prostatectomy, leave comments, and then complete the System Usability Survey (SUS). This is a 10 question, survey to assess the perceived usability of web-based products. The SUS is an industry standard and has been proven and validated by a large database of web-based platforms to effectively differentiate usable and unusable products.
Out of the 21 trainees at our institution, all accessed the website during the study period. A total of 17/21 (81%) used the platform and completed the SUS. The average SUS score was 85 for our platform, which correlates to a usability in the top 10% of technology based systems. The SUS score of 85 also correlates with continued usage and increased likelihood that users would recommend the platform to other trainees.
Our web-based surgical training platform has shown very favorable usability, which makes it likely to be utilized by residents as a teaching tool. The platform is well equipped for teaching robotic simple prostatectomy or other relatively low volume surgical procedures. Future studies are aimed at tracking and quantifying resident platform utilization and correlating this to resident surgical skill progression.
Nicholas Kavoussi
Igor Sorokin
Jeffrey Gahan
Contrast-Enhanced Ultrasound (CEUS): Evaluation of High Intensity Focused Ultrasound (HIFU) ablation of the prostate
Abstract: V4-07
Sources of Funding: none
No consensus or guidelines exist on imaging follow up for ablation therapies. The objective is to evaluate Contrast-Enhanced Ultrasound (CEUS) in High Intensity Focused Ultrasound (HIFU) ablation of the prostate.
We performed CEUS immediately pre- and post-ablation, and during follow up of the patients who underwent HIFU for localized prostate cancer using either Ablatherm® or Sonacare®. After conventional trans-rectal US (TRUS) examination (GE Healthcare, Chicago, IL), a 1.5 cc bolus of the ultrasound contrast agent LUMASON® (sulfur hexafluoride lipid-type A microspheres) was injected intravenously. Two minutes cine images of the regions of interest were obtained and time intensity curves (TIC) were concurrently generated.
From Dec/2015 to Sep/2016, 12 consecutive patients that underwent HIFU were evaluated by CEUS. Median (range) age, PSA and prostate volume were 64 yr (55-83), 6.25 ng/ml (2.8-19.6) and 29 cc (18-51), respectively. Hemi/subtotal/whole-gland HIFU were performed in 9/1/2 patients, respectively. In a median follow up of 5.3 months (2.2-10), the PSA decreased 88% (35-98). In one patient the PSA did not decrease and biopsy confirmed local recurrence. _x000D_ CEUS findings: 1) On pre-HIFU, the cancer area demonstrated higher peak intensity (PI) and shorter time to peak than the non-cancer area. 2) The PI was at about 25 sec and the wash out continued up to the end of the 2 min recording. 3) The TIC provided quantification of enhancement of treated and untreated prostate, therefore decreasing subjectiveness. 4) CEUS provided real time visualization of ablated area with clear and sharp margins. 5) CEUS provided confirmation that the targeted region of interest was precisely treated as planned. 6) The treated area could be visualized immediately after ablation and the ablation defect persisted on follow up (Figure)._x000D_
CEUS provides a real time feedback with visualization and quantification of the actual treated and untreated areas on intraoperative and follow up evaluation of patients undergoing HIFU ablation of the prostate.
Andre Luis Abreu
Daniel Freitas
Daniel Park
Toshitaka Shin
Masakatsu Oishi
Carlos Fay
Suzanne Palmer
Frank Chen
Andre Berger
Rene Sotelo
Edward Grant
Osamu Ukimura
Inderbir Gill
Mittul Gulati
Preliminary Results of Advanced Image-Guided Renal Biopsy and Thermal Ablation Utilizing Cone-Beam Computerized Tomography: A Surgeons Procedure.
Abstract: V4-08
Sources of Funding: none
Introduction: The diagnosis of incidental small renal masses (SRM) has increased partly due to the use of cross sectional imaging. Partial nephrectomy is now considered the &[Prime]Gold&[Prime] standard whereas thermal ablation (TA) is an alternative option for sub-optimal surgical candidates. TA in most institutions is performed by Interventional Radiologists with little participation by Urologic Oncologists (UO). In this study patients with SRM were treated by TA using cone-beam computerized tomography (CBCT) [Artis-X, Siemens Healthcare, GmbH] coupled with digital fluoroscopy. Using &[Prime]I-Guide&[Prime] software, needle placement is facilitated and simplified. _x000D_ Objective: To demonstrate the CBCT renal biopsy (RB) and TA technique for select patients with SRM as performed by UO.
20 patients with SRM underwent RB and TA between January and September 2016 (Table 1). Procedures were performed under general anesthesia. 1-3 TA probes were placed (Cool-tip radiofrequency needle, Covidien, Boulder CO, USA). The number of ablation cycles, core biopsies, amount of radiation and contrast used, and intra-operative complications were individualized and recorded. Post-operative complications were evaluated using the Clavien-Dindo classification of surgical complications.
With a median 3 month follow up there were no technical failures and all patients had 6 week contrast enhanced CT demonstrating no enhancement (Table 2). _x000D_
With access to appropriate image guidance tools, Urologists can become more involved in the diagnosis and treatment of SRM. Advanced targeting is now simplified making it possible for oncologic surgeons to perform TA on select patients. Further follow up on this cohort is essential.
Emily Kelly
Raymond Leveillee
MRI Guided Salvage Cryoablation of Recurrent Prostate Cancer
Abstract: V4-09
Sources of Funding: none
Prostate cancer is the most common non-cutaneous malignancy in men in the United States, and cancer recurrence after definitive therapy can be as high as 30%. Recurrent cancer presents many challenges. Finding the site of recurrence is difficult, and once found, the optimal treatment modality must be determined. We present a patient with MRI detected, biopsy proven local recurrence treated with MRI guided salvage cryoablation.
A 57 year old man underwent open radical retropubic prostatectomy for a Gleason 3+4 T3a N0 R0 prostate cancer. At his 6 year follow-up, his PSA rose to 1.3 ng/dL and he underwent salvage intensity modulated radiation therapy. 2 years later, his PSA was 1.9 ng/dl and MRI and TRUS biopsy demonstrated a 1.1 by 2 cm mass in the left vesicourethral anastomosis. CT imaging and bone scan demonstrated no evidence of metastatic disease.
After extensive discussion of therapeutic options, the patient elected to proceed with MRI guided salvage cryoablation. Initial treatment was with four cryoprobes spaced 1 cm apart. Two freezing cycles were performed with 7 minutes of freezing time. Post-ablation, his PSA nadired at 0.22 ng/mL, and repeat MRI demonstrated a residual 7 mm by 7 mm mass in the left vesicourethral anastomosis. Repeat TRUS biopsy demonstrated a Gleason 4+4 prostate cancer. The patient underwent a second ablation separating the cryoprobes by 5 mm and using 3 cycles of freezing. Since then, his PSA has remained undetectable with no evidence of disease for 5 years.
MRI allows precise placement of the cryoprobes. In addition, active imaging provides ice ball monitoring that improves the safety and precision of cryotherapy. In the appropriate patient, this technique may provide durable cancer-free survival.
David Y Yang MD
David A Woodrum MD, PhD
Lance A Mynderse MD, FACS
"URODYNAMIC 4D-CT" Evaluation is a Highly Effective Technique for the Assessment of Urinary Conditions.
Abstract: V4-10
Sources of Funding: none
Male patients with LUTS have been examined using methods such as UFM, CMG, PFS and VCUG. Although PFS is thought to be specifically effective for assessing the degree of bladder outlet obstruction (BOO), it requires some skill to perform and is invasive to the patient. In addition, it is difficult to evaluate urinary disorders comprehensively in a single examination. Area Detector CT was applied to urodynamic study in a technique we call "Urodynamic 4D-CT�. We have already demonstrated the clinical effectiveness and convenience of "Urodynamic 4D-CT� imaging in the assessment of urinary conditions. In this clinical study, we examined urinary evaluations that combined Urodynamic 4D-CT with PFS.
A Toshiba Aquilion ONE 320 CT scanner (running on ZIO STATION 2) was used for scanning dynamic urinary flow images. After normal intravenous administration of a contrast agent as per regular CT scanning, 4D-CT images were taken during urination with the patient maintaining a half-seated position on the CT table. While shooting the X-rays, testis were protected from radiation exposure with a lead plate.
Using "Urodynamic 4D-CT�, 94 cases with LUTS were assessed to determine details regarding BPH, BNC and urethral stricture. The Bladder / prostate angle and the widest point in the prostatic urethra and bladder neck were demonstrated to be significantly improved after effective Holmium Laser prostatectomy (HoLEP). Movement of the upper bladder had been limited before performing the HoLEP operation, however, it is clear to see how bladder function improved dramatically once supported by the pubo-prostatic ligament post-operation. Urodynamic 4D-CT was shown to be effective at evaluating BOO status before treatment and predicting the outcomes of HoLEP for patients with BPH. Compared to the use of previous techniques, urination disorders were far easier to diagnose and understand when synchronizing PFS with Urodynamic 4D-CT.
Urodynamic 4D-CT was demonstrated to be a safe, thorough and revolutionary new method for assessment of urinary condition in a single examination. Urodynamic 4D-CT was able to illustrate the dynamic shape transition realized on the entire urinary tract chronologically, simply, and less invasively than other techniques. When used in conjunction with PFS, the possibility was clearly demonstrated for 4D-CT scanning to help accurately evaluate urinary conditions, as well as assess patient operability, with an efficiency superior to previous techniques.
Shintaro Mori
Masanori Inoue
Masahiro Jinzaki
Ryoichi Shiroki
MRI-Guided Transurethral Ultrasound Ablation in Patients with Localized Prostate Cancer: Primary Outcomes of a Prospective Phase I Study
Abstract: V4-11
Sources of Funding: This study was sponsored by Profound Medical Inc.
MRI-guided transurethral ultrasound ablation (TULSA) is a novel minimally-invasive technology for ablation of benign and malignant prostate tissue. The transurethral device emits directional ultrasound producing an ablation volume that is shaped to patient-specific anatomy and pathology using active MRI thermometry feedback control. The aim of this multi-center, prospective Phase I study was to assess the safety and feasibility of MRI-guided TULSA for near whole-gland ablation in patients (pts) with localized prostate cancer (PCa).
This trial treated 30 pts with biopsy-proven organ confined PCa (T1c-T2a, PSA upto 10 ng/ml, Gleason Score 3+3, and upto 3+4 in Canada only). MRI-guided TULSA was delivered with 3 mm margins at the gland periphery, and expected 10% residual viable prostate tissue around the capsule. Primary endpoints were safety (adverse events), and feasibility (spatial precision of conformal ablation). Exploratory outcomes included PSA, quality of life, MRI and 12-core TRUS-guided biopsy.
Median (IQR) age was 69 (67-71) years, with 24 (80%) low-risk and 6 (20%) intermediate-risk cancers and PSA 5.8 (3.8-8.0) ng/ml. Treatment time and prostate volume, respectively, were 36 (26 - 44) min and 44 (38 - 48) cc. Spatial control of thermal ablation was +/- 1.3 mm. Adverse events (CTCAE v4) included urinary tract infections (10 pts G2), acute retention (3 pts G1; 5 pts G2), and epididymitis (1 pt G3). There were no rectal injuries or fistulae observed. Pre-treatment IPSS of 8 (5-13) and IIEF of 13 (6-28) were recovered to, respectively, 6 (4-10) at 3 mo and 13 (5-25) at 12 mo. Median PSA decreased 87% at 1 month (mo), stable to 0.8 (0.6 - 1.1) ng/ml at 12 mo. Positive biopsies at 12 mo show 61% reduction in total cancer length, clinically significant disease in 9/29 pts (31%), and any disease in 16/29 pts (55%). Following positive biopsy results at 12 mo, 3 pts underwent salvage radical prostactetomy, and 1 pt opted for investigational MRI-guided focal laser ablation.
MRI-guided TULSA is a well-tolerated, safe procedure for pts with localized PCa. TULSA can offer a low morbidity profile while keeping post treatment salvage therapy options open if necessary. The multicentre TULSA-PRO Ablation Clinical Trial (TACT) is currently underway, to evaluate safety and effectiveness of whole-gland ablation with reduced margins in 110 pts.
This study was sponsored by Profound Medical Inc.
Joseph Chin
James Relle
Michele Billia
Valentin Popeneciu
Timur Kuru
Jason Hafron
Matthias Roethke
Maya Mueller-Wolf
Zahra Kassam
Fayruz Kibria
Mathieu Burtnyk
Heinz-Peter Schlemmer
Sascha Pahernik
Simulation model for ultrasound and fluoroscopy guided percutaneous renal access: step by step tutorial
Abstract: V4-12
Sources of Funding: none
Percutaneous renal access has been a leading toping in urology for years, given the widespread use of nephrostomy and percutaneous nephrolitotomy (PCNL). Systematic training routine is known to be helpful in laparoscopic and robotic surgery in order to shorten the learning curve. Nevertheless, there is a shortage of training models regarding percutaneous renal access.
We present materials and methods to build a percutaneous renal access model. We propose a homemade devise that allows training using simulated fluoroscopy guided puncture, contributing to shorten learning curve and reduce radiation during this period. Using jelly, our model permits practising the ultrasound guided puncture, both combined with simulated fluoroscopy or independently. In order to make our simulator, we use materials available in any home improvement store.
The materials required to make our model cost less than 130 euros. About 3 hours are required to set up the simulator. We have built a structure that allows rotation and permits fluoroscopy guided puncture at 0 and 30 degrees angle, as the standard technique to identify the position of the needle in the upper-lower and anterior-posterior axis. Furthermore, our simulator permits using simultaneously ultrasound guidance. We have improved imaging using a pinhole system and reflected light in order to avoid magnifying of movements of the needle. With our proposal, we can restore and re-use the jelly puncture model, thereby clearing any puncture tracks.
There is a scarcity of training models covering renal kidney access, one of the main topics in urological surgical access. The lack of simulation sessions results in longer learning curve and additional exposure to ionizing radiation. We propose a complete, versatile and effective model to train both the fluoroscopy and the ultrasound guided renal access.
Manuel Carballo-Quinta
Sabela López-GarcÃa
Máximo Castro-Iglesias
Grethel Rivas-Dangel
Sheila DomÃnguez-Almúster
Moisés ElÃas RodrÃguez-Socarrás
Miguel Pérez-Schoch
Jorge Sánchez-Ramos
MarÃa Elena López-DÃez
Antonio Ojea-Calvo
Holmium Laser Enucleation of the Prostate as Retreatment after UroLift Device: Feasibility and Technical Considerations
|BPH and Voiding Dysfunction
Abstract: V5-01
Sources of Funding: none
In this video we demonstrate the feasibility of Holmium laser enucleation of the prostate (HoLEP) for retreatment of persistent lower urinary tract symptoms (LUTS) after previous treatment with the UroLift device. Technical considerations with regards to both enucleation and morcellation of resected tissue are discussed. Benign prostatic hyperplasia (BPH) affects millions of men worldwide. The UroLift system (NeoTract Inc., Pleasanton, CA) was recently introduced as a means to perform prostatic urethral lift (PUL) procedure for lateral lobe hypertrophy in patients with obstructive voiding symptoms. Urolift has been associated with a retreatment rate of 7% at 2 years and 14% at 4 years. Retreatment with TURP, photovaporization of the prostate and repeat UroLift has been described without notable issue, but retreatment with HoLEP has not yet been described.
We included two patients who had undergone PUL with UroLift system at outside institutions and presented with recurrent LUTS. Patients were evaluated by cystoscopy, uroflowmetry, transrectal ultrasound of the prostate, and urodynamics to define the etiology of their urinary symptoms and determine appropriate therapy. HoLEP was performed under general anesthesia as previously described. Morcellation of the resected adenoma was performed with the VersaCut reciprocating morcellator (Lumenis Inc, Santa Clara, CA).
Enucleation was successfully completed in both patients. Monofilament sutures of the Urolift device were easily visualized and transected with the holmium laser. At the bladder neck, both patients were unexpectedly found to have the outer nitinol tab portions of UroLift devices located within the capsule of the prostate, rather than in the intended extracapsular location. Auxiliary maneuvers were required for removal of these nitinol tabs. The inner stainless steel portions of the UroLift device were encountered during morcellation of the resected adenoma. In each instance, the metal tabs became lodged in the reciprocating blades of the morcellator, requiring withdrawal of the morcellator instrument and manual removal of the tab from the morcellator blade. This resulted in brief disruptions in the procedure. There were no operative complications.
To our knowledge, we present the first description of HoLEP with morcellation of adenoma tissue after previous prostatic urethral lift surgery with the UroLift device. HoLEP can be performed safely and effectively post Urolift, however morcellation of the adenoma tissue is complicated by the metallic implants of the Urolift device.
Sean McAdams
Mitchell Humphreys
Voiding urethrocystoscopy: a new concept for benign prostatic obstruction characterization.
|BPH and Voiding Dysfunction
Abstract: V5-02
Sources of Funding: None
The role of urethrocystoscopy (UC) in male lower urinary tract symptoms (LUTS) assessment regarding benign prostatic obstruction (BPO) is unclear. However, the last EAU guidelines advise to perform an UC prior to minimally invasive/surgical therapies if the findings may change treatment. We assessed the feasibility of voiding urethrocystoscopy (VUC) in males with (LUTS) and describe the characteristics of dynamic movements of the prostatic lobes during micturition, with further implications for surgical approach such as preservation ejaculatory function.
All consecutive patients with LUTS and willing to preserve their ejaculatory function scheduled for BPO relief surgery in a tertiary reference center were included in this prospective evaluation. After emptying the bladder, an UC with a 16-Fr flexible endoscope was performed and the bladder was filled up to 500mL to generate a desire to void. The patient was asked to void once the tip of the endoscope facing the veru montanum. Movements of the prostatic lobes during micturition were characterized. Endoscopic movements of the prostatic lobes were video-recorded, and categorized based on the dynamics of the lateral lobes, the posterior lobe and the bladder neck.
192 procedures were conducted. In 161 cases (84%), the patient was able to void. Among these patients, 126 cases were stated as "closed� (coalescent), without opening of the initial part of the urethra and the bladder neck. In 38 cases, there was no opening of the lateral lobes (type 1A), and in 47 cases a partial opening of the distal parts of the lateral lobes was seen (type 1B). In 31 cases, a fixed posterior bladder neck was seen (type 2A) and in 10 cases a mobile median lobe, with a rolling ball effect, was seen (type 2B). In 25 cases, the lumen was completely open and equivocal in 10 cases.
This study demonstrates the feasibility of VUC and describes for the first time the dynamics of prostatic lobes during micturition. This functional description may be useful to evaluate preoperatively the possibility of partial surgery, meaning removal of the only visually obstructive responsible structure to restore correct urinary flow, and subsequently preservation of ejaculatory function. In this study, 70% of patients could benefit of such surgery since the obstruction was partial (types 1B, 2A and 2B).
Bertrand Lukacs
Steeve Doizi
Robot-assisted periprostatic artificial urinary sphincter implantation in male patient with neurogenic stress urinary incontinence
|BPH and Voiding Dysfunction
Abstract: V5-03
Sources of Funding: none
_x000D_ In men with urinary incontinence due to neurogenic intrinsic sphincter insufficiency, it is recommended to place artificial urinary sphincter (AUS) cuff around the bladder neck to spare antegrade ejaculation, to avoid the risk of pressure ulcers at the perineal incision site and to limit the risk of cuff erosion due to clean-intermittent-self-catheterization (CISC). The objective of this study was to describe a surgical technique of periprostatic AUS implantation in neurogenic male patients._x000D_
The technique of periprostatic AUS implantation in men is described in this video. We present the case of a 50 year-old male with a past medical history of cauda equina syndrome and stress urinary incontinence due to neurogenic intrinsic sphincter deficiency. The patient performed 5 to 6 CISC per day due to underactive bladder. The urethral closure pressure was 33 cm H2O on urodynamics and the amount of urine leakage was 350 g/24 hour according to the pad test.
The procedure is performed under general anesthesia. The patient is placed in a 23° Trendelenburg position. A laparoscopic transperitoneal approach is performed and five ports are placed in total, including three ports for the robotic arms and one 12 mm-port for the assistant surgeon to allow the insertion of the AUS cuff. First, the peritoneum is opened just above the seminal vesicles. The space between the posterior part of the prostate and the seminal vesicles is dissected. The bladder is then released down and the Retzius space is dissected. The lateral sides of the prostate are dissected and the endopelvic fascia is opened on both sides. A Prograsp forceps is used to open the angle between seminal vesicles and bladder on both sides from inside to outside. A measurement tape is then passed around the bladder neck and the AUS cuff is inserted through the 12-mm port. The balloon is implanted in the Retzius space through a 3 cm suprapubic incision and the pump is placed in the scrotum by a subcutaneous passage made from the suprapubic incision_x000D_
This video report the feasibility of robot-assisted periprostatic AUS implantation in male patient with neurogenic stress urinary incontinence. The benefits of positionning the AUS cuff around the bladder neck (vs. bulbar urethra) and of the robot-assisted approach to perform this periprostatic implantation (vs. open or laparoscopic approaches) remain to be proven by clinical research studies.
benoit peyronnet
sébastien vincendeau
pierre grison
quentin alimi
lucas freton
lauranne tondut
baptiste gires
karim bensalah
nelly senal
jacques kerdraon
andrea manunta
Combined photovaporisation of prostate and laser cystolithotripsy using GreenLight Laser
|BPH and Voiding Dysfunction
Abstract: V5-04
Sources of Funding: None
Bladder stones in elderly men are commonly associated with bladder outlet obstruction. To date, there are many different treatment modalities have been presented for both these conditions. The aim of this study is to evaluate the safety and feasibility of a novel approach to photovaporise prostate as well as laser cystolithotripsy as an alternative method of utilizing GreenLight laser only.
In a prospective study conducted between January 2013 to July 2016, 23 patients with significant bladder outlet obstruction with presence of bladder calculi underwent both photovaporisation of prostate and cystolithotripsy in a single operation using single instrument via GreenLight laser. Patients diagnosed with bladder calculi and concurrent prostate hyperplasia underwent lithotripsy using greenlight photovaporisation side firing after completion of photovaporisation of the prostate were included in this study.
_x000D_ Twenty five patients underwent simultaneous laser cystolithotripsy and photovaporisation of prostate. The median Median patient age was 67 years (range 59-89). Median pre-operative prostate volume was 70cc (range 38-160). Stone size ranging from 1 - 4cm with variable number of stones (1-18) were fragmented with good results, bladder debris washout. There were no complications. An average of 316000 Joules were used to treat both vesical calculi and BPH. Majority of calculi analysis showed mixture of calcium oxalate, calcium phosphate and uric acid. Laser fiber lasted through both procedures without damage and not requiring replacement throughout the surgery. One case required percutaneous cystostomy for stone extraction.
The findings on this study shows that GreenLight laser is a minimally invasive and safe technique to treat both enlarged prostate with bladder calculi. This method can be used as an alternative method of treatment by using single instrument approach and could possibly prevent potential open procedure.
Darren Ow
Marlon Perera
Damien Bolton
Nathan Lawrentschuk
Prostate Artery Embolization prior to robotic simple prostatectomy in a patient with high bleeding risk
|BPH and Voiding Dysfunction
Abstract: V5-05
Sources of Funding: none
Prostate artery embolization (PAE) is an alternative to surgery for patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) who are poor surgical candidates. We describe a novel use of PAE as a preoperative measure to reduce perioperative bleeding risk in a high-risk patient undergoing robotic simple prostatectomy.
A 61 year-old man presented with LUTS refractory to medication that progressed to hematuria and urinary retention. Cystoscopy and CT urogram demonstrated a markedly enlarged prostate >110gm. The patient elected for robotic-assisted simple prostatectomy. However, he was a Jehovah&[prime]s Witness on chronic anticoagulation and refusing blood transfusions. The decision was made to perform PAE preoperative to reduce bleeding risk. PAE was performed the day prior to surgery. A catheter was inserted into femoral artery to the external iliac artery to the internal iliac artery. Digital Subtraction angiography was used to identify the prostatic arteries, which were embolized with 100-300 and 300-500 µm Tris-acryl Gelatin Microspheres (Embosphere; Merit Medical Systems Inc, South Jordan, Utah, USA), until there was no appreciable flow to the prostate from either artery. Intraprocedural cone beam CT was performed, which yielded detailed vascular anatomy and confirmed targeted embolization. The following day, the patient underwent robotic-assisted simple prostatectomy. _x000D_
The prostate enucleation planes were noticeably avascular, allowing for minimal blood loss and good visualization. Console time was 189 minutes with an estimated blood loss of 100mL and no postoperative hematuria. Whole-mount pathology demonstrated mild ischemic changes and confirmed presence of microspheres within prostatic tissue, indicative of successful PAE. The patient had an uneventful postoperative course and was discharged on postoperative day 2 with no complications. He successfully passed a trial of void and reported resolution of urinary symptoms.
We describe a novel multidisciplinary approach using PAE prior to prostate surgery for BPH as a means of preoperative risk reduction in a high-risk patient. Preoperative PAE could potentially be used for risk reduction in other high-risk patients requiring complex surgery for BPH and could be combined with the surgical approach preferred by the surgeon.
Craig Rogers
Dan Pucheril
Kaila Wilcher
Riaz Rehan
Maria Zanini
Scott Schwartz
Robot-assisted simple prostatectomy in patients with large volume BPH (>100 ml): indications, technique and results based on 81 procedures
|BPH and Voiding Dysfunction
Abstract: V5-06
Sources of Funding: none
Open adenomectomy (OSP) is still considered the gold standard surgical treatment for patients with large volume benign prostatic hyperplasia (BPH). Recently, minimally invasive techniques has been proposed in order to reduce the morbidity and complication rates. Here we present the technique and results of our Robot-assisted simple prostatectomy (RASP) series.
81 patients with large volume BPH (>100 ml) underwent RASP through a transperitoneal access. All the procedures were performed with the DaVinci Si robotic system in a four arm configuration. Patients were preoperatively assessed with transrectal ultrasound and uroflowmetry. Baseline functional parameters including International Prostate Symptom Score (IPSS), Maximum Flow Rate (Qmax) and Post-Void Residual (PVR) were assessed postoperatively during the follow-up. Perioperative outcomes included operative time (OR time), catheterization time (CV time) and length of hospital stay (LOS). Complications were recorded and graded according to the Clavien-Dindo classification.
The median age was 69 years (IQR 66-76) and 48 (62%) of the patients had a Charlson Comorbidity Index of 2 or more. The median prostate volume was 130 ml (IQR 111–190) and 28 (34%) patients had an indwelling catheter prior surgery. Patients showed a significative improvement of functional outcomes, with a median Qmax improvement of +15 ml/s and a decrease of the IPSS and PVR of -20 and -73 ml respectively. The median OR time was 105 min (IQR 85-150) and the median estimated blood loss was 250 ml (IQR 105-320). The median CV time and LOS time was 3 and 4 days respectively. The overall postoperative complication rate was 31% with no grade 4 and 5 complications.
In our RASP series we obtained a significative improvement of functional outcomes with an acceptable risk of peri-operative complications. This technique could be considered an interesting option for surgeons that have completed their learning curve performing an adequate number of robot-assisted radical prostatectomys and in case of concomitant pathologies needing a surgical approach as vescical stones, bladder diverticula or inguinal hernia.
Paolo Umari
Nicola Fossati
Alexander Heinze
Ruben De Groote
Geert De Naeyer
Peter Schatteman
Alexandre Mottrie
Perineal Artificial Urinary Sphincter (AUS) with High Submuscular (HSM) Placement of Pressure Regulating Balloon (PRB)
|BPH and Voiding Dysfunction
Abstract: V5-07
Sources of Funding: Educational Grant from Boston Scientific
In patients undergoing Artificial Urinary Sphincter (AUS) placement, with a history of major pelvic surgery, avoidance of the Space of Retzius with traditional placement of the Pressure Regulating Balloon (PRB) may be beneficial. This video presents perineal AUS placement with high submuscular placement (HSM) of the PRB.
A perineal incision provides excellent exposure of the bulbar urethra for proximal bulbar urethral cuff placement. Via a separate 2cm high scrotal incision the external inguinal ring is identified. A pediatric Deaver is placed within the superficial ring and blunt finger dissection used above the transversalis fascia develops a space below the rectus that accommodates the PRB. Using one's index finger the PRB is then easily placed in the HSM space without any additional instrumentation. Finally through this same incision a subdartos pouch is created for pump placement. The AUS is cycled and deactivated and the wound is closed in multiple layers.
There is no difference in revision rates between HSM PRB placement versus Space of Retzius placement.
HSM placement of the PRB at the time of AUS implantation avoids the Space of Retzius with associated potential bladder, bowel, or vascular injury and/or complications. HSM placement avoids peritoneal placement post-robotic prostatectomy. HSM placement is safe, effective, can easily be learned and implemented, and may be used with concomitant IPP placement.
Educational Grant from Boston Scientific
Billy Cordon
Allen Morey
"TOP-DOWN" HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HoLEP) TECHNIQUE
|BPH and Voiding Dysfunction
Abstract: V5-08
Sources of Funding: None
In this video, we demonstrate our version of the novel anterior-posterior HoLEP dissection technique.
Video of the surgical technique accompanied by slides and voiceover explanation of the steps
A novel anterior-posterior HoLEP dissection technique allows faster operation time and potential continence improvement. We demonstrate our version of this technique and present early operative outcomes. After cystoscopy a posterior groove is created at the 6 o'clock position in a bilobar gland. If there is a prominent median lobe the groove is cut at either 5 or 7 o'clock. The groove is extended to the veramontanum and to depth of capsule. The edges of the lateral lobes on either side of the veru are incised. The scope is rotated to visualize the anterior commissure and retracted to identify the edge of the lateral lobes and the sphincter. The anterior commissure is then incised at 2 Joules/20 Hz Setting. The dissection plane is located anteriorly with a series of short incisions. We identify this plane on both sides at this point as it can be difficult to find it later once a lateral lobe is completely resected on one side._x000D_ _x000D_ Once the plane is apparent, lateral lobe dissection is begun. The lateral lobe is dissected from the top down, allowing faster dissection time than the traditional technique. The mucosal strip is easily visualized as the apical dissection is performed from top down. This eliminates the need to encircle the mucosal strip reducing enucleation time. Given sphincter proximity, 2 Joules/20 Hz laser setting is again used. Once the entire lobe dissection is completed, the lobe is pushed into the bladder. The residual cavity is inspected and hemostasis controlled. Finally, tissue is morcellated with a Wolf PIRANHA instrument. _x000D_ _x000D_ Retrospective review of HoLEPs from December 2015 to April 2016 was performed. 49 patients who underwent anterior posterior technique were compared with 37 who underwent traditional posterior to anterior enucleation. Mean enucleation time and mean enucleation rate were both faster with the novel, top-down approach. _x000D_
We demonstrate a novel top-down HoLEP enucleation technique with promising early operative results.
Nadya E. York
Casey A. Dauw
Michael S. Borofsky
James E. Lingeman
Holmium Laser Enucleation of a Prostatic Abscess
|BPH and Voiding Dysfunction
Abstract: V5-09
Sources of Funding: None
A prostatic abscess is a commonly encountered localized genitourinary infection, best treated with surgical resection. Traditional transurethral resection places the urinary sphincter in jeopardy of thermal injury in the event of an apically located abscess.
We present a 69 year old male with a several week history of dysuria and back pain. He presented to his local physician for evaluation and after CT imaging was diagnosed with a psoas abscess, diskitis/osteomyelitis and a prostatic abscess. The prostatic abscess was noted to be in an extremely apical location posing a significant risk of thermal injury with a standard resection. Therefore, a holmium laser enucleation of the prostatic abscess was performed.
After initial inspection of the bladder demonstrated asymptomatic ureteroceles, an incision was made at the bladder neck and carried to the depth of the surgical capsule distally to the verumontanum. The lateral dissection expresses purulence almost immediately and a large abscess pocket is encountered during the anterior dissection. The remainder of the enucleation is performed without complication. The patient was spontaneously voiding by POD 2 and discharged with IV antibiotics for 6 weeks to treat his osteomyelitis.
Holmium laser enucleation of a prostatic abscess can be performed safely and effectively to both maximally reduce the abscess cavity and risk of excessive thermal injury when treating an apically located abscess.
Marcelino Rivera
James Lingeman
Amy Krambeck
|BPH and Voiding Dysfunction
Abstract: V5-10
Sources of Funding: none
Laparoscopic simple prostatectomy has been introduced with the purpose of reducing the morbidity associated with classical and standard open surgery. The extraperitoneal (pré-peritoneal) approach adds no technical difficulty, and additionally, allows no surgical violation of the peritoneum. The purpose of this work (video), is to show step-by-step a video-endoscopic extraperitoneal simple prostatectomy technique and present a series of cases of patients treated with this approach, with residents as first surgeons.
To create an educational video that shows in a didactic way the video-endoscopic extraperitoneal simple prostatectomy procedure. Eighteen consecutive cases performed with this technique were analysed. Demographic data and main perioperative outcomes were registed and analyzed. Pre and post-operative International Prostate Symptom Score and maximum flow rate were registered as indicators of relieving of bladder outlet obstruction (BOO). A questionnaire for surgery feasibility was applied to the surgeons.
An educational video that shows in a didactic way the simple video-endoscopic extraperitoneal simple prostatectomy is presented. The results of a series of 18 consecutive cases are presented: mean prostate volume was 98 ml; mean estimated blood loss was 150 ml (no transfusions required). No intraoperative complications or conversion were recorded. Mean length of hospital stay was 3,5 days. Post-operative complications occurred in a 5,6% rate (self-limiting prolonged haematuria). A significant improvement was observed of subjective and objective indicators of BOO (p<0.05). Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. The surgeons assessment reveals that the technique was easy to perform.
This work proves that the video-endoscopic extraperitoneal simple prostatectomy is a safe and effective procedure and certainly a good option for the surgical treatment of high volume benign prostatic hyperplasia. Additionally, in our opinion this surgery appears to be a good procedure for iniciating laparoscopic training, due to the near absence of oncologic concern, and because of its feasibility.
Paulo Mota
Nuno Carvalho
Emanuel Carvalho-Dias
Agostinho Cordeiro
João Torres
Nuno Morais
Mário Cerqueira-Alves
Riccardo Autorino
Estevão Lima
Robotic simple prostatectomy: the retropubic approach
|BPH and Voiding Dysfunction
Abstract: V5-11
Sources of Funding: None
Several surgical options for the management of BPH. We present the case of a patient with a large prostate gland on TRUS during prostate biopsy and transient urinary retention. GIven size of the gland and long distance to bladder neck as well as patient's status as Jehovah's witness, decision made to use retropubic approach to robotic simple prostatectomy.
Video recorded of surgical procedure
Patient with minimal blood loss during the procedure, no additional need for transfusion. Patient discharged on post-op day 3 after uncomplicated hospital course. Small leak seen on post-op VCUG resulted in additional week of catheter use and resolution on repeat imaging. Patient with resolution of lower urinary tract symptoms.
Retropubic approach to robotic simple prostatectomy can be an option for surgical management of large glands and a safe and effective alternative to the transvesical approach.
Unwanaobong Nseyo
Yahir Santiago-Lastra
Jill Buckley
Holmium Laser Enucleation of the Prostate After Prostatic Urethral Lift
|BPH and Voiding Dysfunction
Abstract: V5-12
Sources of Funding: None
Prostatic urethral lift (PUL) has emerged as a minimally invasive option for treatment of benign prostatic hyperplasia (BPH) and bothersome lower urinary tract symptoms (LUTS) especially in young males who would like to avoid sexual and ejaculatory dysfunction. To date, there is no long-term data concerning the durability of the PUL in the management of LUTS. The bladder outlet is opened by placement of retention devices which effectively lift the lateral lobes towards the prostatic capsule. This device consists of a nitinol capsular anchor attached to a non-absorbable suture which spans the prostate tissue and is anchored by a stainless steel urethral end piece. Patient selection is critical, and PUL should be avoided in those with obstructing bladder necks, large median lobes or with glands larger than 100g. Holmium laser enucleation of the prostate (HoLEP) is a safe, effective and durable option for management of BPH in any size gland. Also, the powerful cutting effects of the holmium laser and visualization afforded to the surgeon with HoLEP make it an excellent surgical option to deal with urethral foreign bodies after failed PUL.
A 51 year old male presented with persistent lower urinary tract symptoms after two prior PUL procedures and urodynamic evidence of obstruction. Cystoscopy showed a high bladder neck. The patient chose to undergo HoLEP, and this was performed using Storz 28 French sheath and 550 micron Boston Scientific holmium laser fiber at 80 watts. Hemostasis was achieved at 40 watts. Morcellation was carried out using the Storz offset nephroscope and the Wolf Piranha morcellator.
The enucleation time was 23 minutes. Four stainless steel urethral end pieces were removed. 5g of prostate tissue was morcellated in 7 minutes. A urethral end piece did bind the morcellator momentarily, however at this point, the prostate tissue was small enough to be grasped and removed through the scope. The catheter was removed after one day. At four months follow-up, the patient had a post-void residual of 0 mL and subjective improvement in his symptoms with International Prostate Symptom Score of 4 and Quality of Life score of 0.
HoLEP is an effective option for managing the unique situation of BPH and urethral foreign bodies after failed PUL.
Andrew Navetta
Erin Bird
Marawan El Tayeb
Midline Extraperitoneal RPLND in Testis Cancer: Minimizing Surgical Morbidity
|Misc. GU Oncology and Transplant
Abstract: V6-01
Sources of Funding: none
Retroperitoneal lymph node dissection (RPLND) is an important component of the management of testicular germ cell tumor (GCT) but its surgical morbidity is not insignificant. Herein we describe our updated experience with a midline extraperitoneal (EP) approach to RPLND for seminomatous and non-seminomatous GCT.
Between 2010 and 2015, from a prospectively collected IRB approved database, 122 consecutive patients underwent RPLND. Patients requiring aortic resection, retrocrural dissection or access to intraperitoneal disease were excluded. The remaining 69 patients underwent midline EP-RPLND. All post-chemotherapy (PC) cases underwent bilateral template dissection; all primary cases underwent extended ipsilateral templates. Perioperative and long-term outcomes were analyzed and a descriptive analysis using SAS was performed.
68 patients underwent midline EP-RPLND successfully (98.6%). Median age was 28 years (range=17-55). Median follow up was 15.3 months (IQR: 5.7-24.3). On pre-operative imaging the size of retroperitoneal mass or lymphadenopathy was <2 cm in 29 patients, 2-5 cm in 15 patients, and >5 cm in 24 patients, of which 19 were >10cm. 3 patients underwent cavectomy. Median EBL was 325 mL (IQR: 200-612.5). Median number of lymph nodes (LN) resected was 36 (IQR: 24.5-49); median number of positive nodes was 1 (IQR: 0-4). Median return of bowel function was 2 days (1-3) and LOS was 3 days (2-4). There were no cases of ileus. 13 patients (19.1%) had complications within 90-days: 12 were Clavien grade 2 (17.6%), there was 1 grade 3b complication (1.5%). Antegrade ejaculation rates were 91.6% in the primary group and 96.8% in the PC group.
Midline EP-RPLND can be performed safely without compromising completeness of resection. This approach is associated with a faster return of bowel function, lower rates of ileus and shorter LOS.
Sumeet Syan-Bhanvadia
Soroush Bazargani
Thomas Clifford
Hooman Djalaat
Anne Schuckman
Siamak Daneshmand
Post Chemotherapy Robotic Retroperitoneal Lymph Node Dissection for Non-Seminomatous Germ Cell Tumor
|Misc. GU Oncology and Transplant
Abstract: V6-02
Sources of Funding: None
Retroperitoneal lymph node dissection (RPLND) is indicated for patients with non-seminomatous germ cell tumor (NSGCT) who have completed a primary regimen of chemotherapy and have a residual retroperitoneal mass greater than 1 cm with normal tumor markers. In the post chemotherapy (PC) setting, previous series have reported on the benefits of robotic retroperitoneal lymph node dissection (R-RPLND) with reduced morbidity, reduced hospital stay, and comparable nodal yield when compared to the open approach.
We present the technique of R-RPLND using both the daVinci Si and Xi robot. The supine approach is preferable to a lateral approach as it allows a full bilateral dissection to be performed from one position without the need to re-dock or reposition the patient. Nerve sparing technique is performed in patients undergoing bilateral dissection. There is significant reaction and fibrosis surrounding the residual retroperitoneal mass after chemotherapy and special considerations include the complete resection of the adherent mass, avoidance and control of vascular injuries, and nerve sparing techniques.
All patients were diagnosed with NSGCT and had completed 3-4 cycles of BEP. They were noted to have residual retroperitoneal mass with normal tumor markers. Mean operative time was 339. Mean estimated blood loss was 125cc. Mean number of lymph nodes excised was 28. There were no transfusions and no open conversions. Pathology showed benign fibrosis and necrosis in two (50%), teratoma in two (50%), and no viable germ cells were found.
R-RPLND in the PC setting is feasible and offers patients the benefits of a minimally invasive approach. The robotic approach, while technically challenging, offers the ability to perform bilateral template dissections and repair vascular injuries if encountered.
James Porter
Gerald Heulitt
Synchronous and Simultaneous Posterior Reroperitoneoscopic Bilateral Adrenalectomy.
|Misc. GU Oncology and Transplant
Abstract: V6-03
Sources of Funding: none
Laparoscopic bilateral adrenalectomy is a challenging procedure that usually requires patient repositioning and long operative time. Posterior retroperitoneoscopic adrenalectomy, by providing direct access to the gland, allows two surgical teams to work together, avoiding patient repositioning. This is an interesting approach in patients with bilateral affection. _x000D_ We describe the technique of synchronous and simultaneous posterior retroperitoneoscopic bilateral adrenalectomy in a patient with neurofibromatosis syndrome type 1 and bilateral pheocromocytomas.
A 25-year-old man with neurofibromatosis syndrome type 1 and past medical history of kidney transplant was referred for a 1 year long severe refractory hypertension. A thorough evaluation was performed for possible secondary causes of hypertension. Clinical suspicion of pheochromocytoma was confirmed by 24 hour urinary catecholamines level and CT scan of abdomen. The CT scan showed right sided adrenal mass of 45 mm and left adrenal mass of 43 mm. With patient placed in prone position, using 3 trocars per side and with two surgical teams working simultaneously a posterior retroperitoneoscopic bilateral total adrenalectomy was performed.
The operation time was 120 minutes, intraoperative blood loss was 300 ml. With no postoperative complications, the patient had a fast postoperative recovery and was discharged on the third postoperative day. Blood pressure became normal from 1st post operative day without any drug. Differed histopathology exam confirmed that both adrenal tumors were pheochromocytomas. There was no clinical or biochemical relapse during a follow up period of 6 months.
Synchronous and Simultaneous Posterior Retroperitoneoscopic Bilateral Adrenalectomy is a safe and feasible technique in patients with bilateral pheochromocytomas.
Patricio Garcia Marchiñena
Miguel Basualdo
Oscar Damia
Guillermo Gueglio
Alberto Jurado
Retroperitoneal compartment syndrome in Renal Transplantation —How do we salvage the graft?
|Misc. GU Oncology and Transplant
Abstract: V6-04
Sources of Funding: None
Early allograft dysfunction (EAD) can be caused by a number of technical factors including vascular complications such as thrombosis and kinking. Retroperitoneal compartment syndrome (RACS) is an under-recognized vascular cause of EAD with potentially devastating consequences, and may even result in a lost graft. The graft can be salvaged with early recognition and intervention through a mesh hood fascial closure (MHFC) technique.
Here we describe, in video, a 23-years-old male recipient diagnosed with renal failure secondary to chronic reflux. He has a 6 months history of peritoneal dialysis and is currently on hemodialysis. The patient received an anonymous living-donor right kidney from our paired exchange program. His BMI is 22. The graft had a single renal artery and single renal vein. A standard anastomosis was performed and subsequent urine output was brisk. The fascia was closed without tension. However, urine production ceased after the fascia was fully closed. A case of RACS was suspected and intraoperative Doppler ultrasound showed no blood flow in the graft. Immediately re-exploration revealed the graft to be abnormal in color and turgor.
These abnormalities resolved after pressure was relieved. The kidney was then placed in the optimal position within the iliac fossa and a large ellipsoid piece of polypropylene mesh was draped loosely and without tension over the graft. The mesh was attached to the posterior fascial edges using interrupted #1 polypropylene sutures. Skin closure then was completed over a closed suction drain placed in the retroperitoneal space lateral to the kidney. Doppler ultrasound after skin closure showed good flow and the postoperative course was unremarkable.
RACS could be associated with small android pelvis and lack of compliance in the retroperitoneal cavity secondary to peritoneal dialysis. Suspected RACS require prompt intervention to prevent irreversible graft dysfunction. We have shown that MHFC is an effective and safe method to treat EAD secondary to RACS.
Wen Xie
Karen Pineda-Solis
Omar Ali
Alp Sener
Patrick Luke
Robotic partial adrenalectomy for symptomatic aldosterone-secreting adenomas: technique and outcomes
|Misc. GU Oncology and Transplant
Abstract: V6-05
Sources of Funding: none
Partial adrenalectomy for functioning adrenal masses is significantly underused. Preliminary experiences suggested the effectiveness of partial adrenalectomy for functioning adrenal adenomas. _x000D_ We describe surgical technique and present perioperative and functional outcomes of a two center series including nine symptomatic aldosterone-secreting adenomas treated with robotic partial adrenalectomy (RPA)._x000D_
From June 2014 to October 2016 RPA was performed in 9 consecutive patients with symptomatic aldosterone-secreting adrenal adenomas._x000D_ Surgical steps include: Incision of Gerota' s fascia at the level of the upper pole of the kidney and exposure of the adrenal gland; careful dissection of the medial aspect of the gland, preserving adrenal vessels with a selective control of vessels feeding the adrenal mass; progressive dissection of the mass with a pure enucleation technique in order to maximize the amount of adrenal parenchyma spared; specimen retrieval into an endocatch bag; hemostasis and closure of adrenal defect with a sliding clip technique._x000D_ Two cases are demonstrated in the video._x000D_ Baseline, perioperative and early functional outcomes data are reported._x000D_
All cases were completed robotically. Intraoperative blood loss was negligible, postoperative course was uneventful in all cases, except for 1 patient who required antibiotic therapy for post-operative fever (Clavien grade 2 complication). Median hospital stay was 3 days (IQR: 2-3)._x000D_ Patients became normotensive immediately after surgery. Aldosterone and plasmatic renin activity levels decreased and returned within the normal range after surgery as well._x000D_
Robotic Partial Adrenalectomy is a safe and feasible technique. Thanks to surgical skills acquired with partial nephrectomy, an increasing adoption of adrenal sparing surgery among minimally-invasive urologists is likely to be anticipated.
Giuseppe Simone
Gabriele Tuderti
Leonardo Misuraca
Antonio Celia
Bernardino De Concilio
Antonio Stigliano
Francesco Minisola
Mariaconsiglia Ferriero
Giuseppe Romeo
Salvatore Guaglianone
Michele Gallucci
Robotic-Assisted Thoracoscopic Transdiaphragmatic Adrenalectomy: A Novel Surgical Approach
|Misc. GU Oncology and Transplant
Abstract: V6-06
Sources of Funding: None
In patients who have previously undergone trans-peritoneal or retroperitoneal surgeries, extensive adhesions may limit the feasibility of conventional transperitoneal laparoscopy. Herein, we introduce the technique of robotic-assisted thoracoscopic transdiaphragmatic adrenalectomy (RATTA) in a patient with a history of transabdominal surgeries.
Our patient is a 56-year-old female with a history of clear cell renal cell carcinoma (ccRCC) treated in 2004 with a left hand-assisted laparoscopic total nephrectomy, with negative surgical margins. In 2010, she was found to have enlargement of left retroperitoneal and common iliac lymph nodes and underwent chemotherapy with subsequent retroperitoneal lymph node dissection for a persistent left para-aortic mass. In 2015, she developed a 2.3 cm left (ipsilateral) adrenal nodule and had interval growth of a right lower lung nodule. Biopsy of the adrenal nodule demonstrated metastatic ccRCC. The patient was counseled and elected to undergo concomitant right robotic-assisted thoracoscopic pulmonary wedge resection and left RATTA. After completion of the pulmonary wedge resection by thoracic surgery, the patient was placed in a prone position. A double lumen endo-tracheal tube allowed for single (right) lung ventilation. With the left lung down, an 8 mm (camera) trocar was inserted into the thoracic cavity just superior to the 4th rib and pneumothorax was induced. Under direct vision, two additional 8 mm ports were placed approximately 6 cm on either side of the camera port. A 12 mm assistant port was then placed in a far lateral position. The diaphragm was incised, starting at the left crus and extending laterally through the diaphragmatic muscle exposing the retroperitoneal space and fat. The adrenal gland with mass was identified, dissected from surrounding structures, and extracted. The diaphragm was then closed using Ethibond® suture with PTFE felt pledgets. A 22-Fr chest tube was placed in the thoracic cavity. _x000D_
Operative and post-operative courses were uncomplicated. The chest tube was removed on post-operative day (POD) 2 with no residual pneumothorax. The patient was discharged on POD 4. Pathology confirmed metastatic ccRCC in both the left adrenal and right lung nodules with negative surgical margins.
We present the first described case of robotic-assisted thoracoscopic transdiaphramatic adrenalectomy. This novel technique represents a feasible alternative to transperitoneal or retroperitoneoscopic approaches in patients with previous abdominal and retroperitoneal surgeries.
Christopher M. Russell
Simpa S. Salami
Amir H. Lebastchi
Kiran H. Lagisetty
Khaled Hafez
Rishindra M. Reddy
Alon Z. Weizer
Intracorporeal partly stapled Padua Ileal Bladder using robotic staplers: surgical technique, perioperative and early functional outcomes of a prospective single center series
|Misc. GU Oncology and Transplant
Abstract: V6-07
Sources of Funding: None
Robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladders is a challenging surgical procedure. The potentially increased risk of neobladders stone formation consequent to the use of staplers to create the neobladders is still a matter of debate. Robotic staplers have been recently made commercially available. In this prospective study (www.clinicaltrials.gov NCT02665156) we assessed the feasibility, safety and time efficiency of RARC with intracorporeal partly stapled "Padua Ileal Bladder� using robotic staplers.
Twenty-two consecutive patients with muscle invasive or high grade recurrent urothelial carcinoma of the bladder were treated between March 2016 and October 2016. Baseline, perioperative and follow-up data were prospectively collected and maintained into an IRB approved database. Key steps of surgery include: selection of 45 centimeters of ileum and division of the distal and proximal part of the ileum using robotic staplers; detubularization of the ileal loop; creation of the neo-bladder neck with one stapler load; double folding of the proximal ileal loop using two-three stapler loads; hand-sewing of the posterior neobladders wall with barbed suture; uretero-ileal anastomoses on JJ stents with a modified split-nipple technique; urethroneobladder anastomos is performed according to Van Velthoven; hand-sewing of the anterior neobladders wall with barbed suture.
All procedures were successfully completed; open conversion was never necessary. Median total operative time ("skin to skin�) was 270 minutes (IQR:255-295). Operative time was < 300 minutes in all patients but two (345 and 350 minutes, respectively)._x000D_ One patient (4,5%) had wound infection (CLavien grade 1), three patients (13.6%) had Clavien grade 2 complications (blood pack trasfusion, urinary tract infection requiring antibiotics, hypoxaemia requiring oxygen treatment), one patient (4.5%) needed urethral catheter replacement in the OR (Clavien grade 3b) and one patient (4.5%) had acute kidney failure requiring temporary dialysis (Clavien grade 4a). Median hopsital stay was 9 days (IQR 8-11). Three patients (13.5%) required readmission after discharge (Candidaemia requiring medical treatment [Clavien grade 2] and nephrostomy tube insertion in two patients [Clavien 3a]). Overall complication rate was 40.1% and overall severe complication incidence was18.2%; 59.5% of patients did not experience any complication. At a median follow-up of 3 months, no patients developed recurrence, daytime continence rate was 59%._x000D_
We first report safety and time efficiency in the use of robotic staplers to create orthotopic neobladder. This preliminary report highlights feasibility of this technique and favorable perioperative and functional outcomes._x000D_ _x000D_
Giuseppe Simone
Salvatore Guaglianone
Francesco Minisola
Mariaconsiglia Ferriero
Leonardo Misuraca
Gabriele Tuderti
Giuseppe Romeo
Michele Gallucci
Robotic Ureteral Reconstruction for Ureteral Complications of Kidney Transplants
|Misc. GU Oncology and Transplant
Abstract: V6-08
Sources of Funding: None
Urologic complications after kidney transplantation are a significant cause of morbidity leading to decreased graft function or graft loss. Ureteral stricture is the most common complication with a reported incidence ranging between 0.6% to 10.6%. The reported incidence of vesicoureteral reflux (VUR) causing graft pyelonephritis is 0.1% to 3.5%._x000D_ _x000D_ Uretero-pyelostomy and uretero-ureterostomy utilizing the native ureter are well established surgical methods of transplant ureteral reconstruction._x000D_ _x000D_ The aim of this study is to evaluate the technique, feasibility and results of robotic-assisted laparoscopic reconstruction of the transplanted ureter with the native ipsilateral ureter._x000D_
We retrospectively reviewed six patients (3 male, 3 female) who underwent 5 robotic-assisted uretero-pyelostomies and 1 uretero-ureterostomy between 2013 and 2016. Mean follow-up time was 18 months (range 2 to 37 month)._x000D_ _x000D_ Four patients had significant ureteral obstructions and 2 had recurrent pyelonephritis due to VUR. 2 patients with obstruction had nephrostomy tubes (NT) at time of surgery and 2 had double J stents._x000D_ _x000D_ All patients were evaluated preoperatively with a voiding cysto-urethrogram (VCUG), cystoscopy and retrograde pyelography and MAG3 renal scan. 4 patients had a preoperative nephrostogram. Baseline post-transplant serum creatinine, pre-reconstruction serum creatinine, post-reconstruction serum creatinine were evaluated. A MAG3 renal scan was obtained post-operatively in case of increased creatinine._x000D_ _x000D_ All patients had postoperative cystograms and were followed with serum creatinine-GFR._x000D_
Each transplant ureteral reconstruction were completed successfully. There was one conversion to an open uretero-pyelostomy. Mean hospital stay was 3 days (range 2-4 days). One patient had a ureteral obstruction due to kinking of the JJ stent requiring a NT placement. _x000D_ After ureteral reconstruction. serum creatinine returned to baseline for all patients. No recurrent strictures were demonstrated by increasing serum creatinine or MAG3 renal scans. No recurrent episodes of pyelonephritis were found. There was no graft loss. _x000D_
Robotic-assisted reconstruction of the transplant ureter by uretero-pyelostomy or uretero-ureterostomy using the native ureter is feasible and can be safely performed with graft survival and low complication rates.
Kevin Yang
David Canes
Alireza Moinzadeh
Andrea Sorcini
Novel Robotic Approach to Inguinal and Pelvic Lymphadenectomy for Metastatic Melanoma in a 44 Year Old Male
|Misc. GU Oncology and Transplant
Abstract: V6-09
Sources of Funding: None
To describe a new approach to pelvic lymphadenectomy designed to reduce complication rates.
This case describes the treatment of a 44 year old male requiring an inguinal lymph node dissection. This case was approached robotically in order to minimize complications. This video describes and demonstrates the robotic technique, as well as, the patient's clinical course and follow-up under the care of one surgeon at a large, academic hospital.
Complete resection of the inguinal lymph nodes using the Da'Vinci Xi robot resulted in no complications with no signs of recurrence at follow-up.
Continued expectations to provide exceptional oncological care while minimizing morbidity have lead surgeons to novel treatment approaches for inguinal lymphadenectomy. Open inguinal lymph node dissections continue to have significant rates of complications. The vast majority of complications are due to tissue necrosis, wound dehiscence, seroma formation, and lymphedema. Previously published rates of seroma formation are as high as 32% for the open technique, while the instance of lymphedema may be as high as 40%. Wound infections also comprise a significant portion of morbidity at 24% and skin flap complications are reported at 52%. With this technique our cohort experienced one total Clavien grade II complication (20%) and had an average length of stay under two days which is similar to other minimally invasive techniques. _x000D_ Our oncological outcomes with this technique have been equivalent to the open approach to date. No patients have had recurrent disease. Our lymph node count per side ranges from 1-54; however, 60% of the groins contain 6 or greater lymph nodes. _x000D_ Robotic inguinal lymph node dissection represents a promising alternative to the traditional open technique with the possibility of lower overall morbidity. Additional studies should be conducted evaluating the oncologic efficacy of this approach. _x000D_
Nathan Jung
Hugh Smith
Alan Hyde
Alvaro Valle
Chris Keel
Robotic kidney transplant – our initial experience and technique.
|Misc. GU Oncology and Transplant
Abstract: V6-10
Sources of Funding: None
Kidney transplant is the treatment of choice for CKD stage 5. Though open surgery is the gold standard, it has disadvantages like pain, wound related morbidity and inferior cosmesis. Therefore, minimally invasive surgical techniques are being established. Our objective is to present our initial experience and technique of robotic kidney transplant.
We retrospectively studied twelve procedures conducted from April 2016 to October 2016. The demographic, operative, complication, and outcome data were analysed. Kidney was wrapped in an ice slush jacket and then inserted into the abdomen of the recipient through a midline umbilical (9 patients) or Pfannenstiel incision (three patients). A Gel-point port was used to seal the mid-line incision. The gel point was used to introduce kidney, ice-slush and a vascular punch for arteriotomy. Renal arterial anastomosis was done end to side to external iliac artery and renal venous anastomosis end to side to external iliac vein.
Age of patients ranged from 9 to 50 years. The combined arterial and venous anastomosis time ranged from 35 to 50 minutes. Mean operative blood loss 120± 20 ml. Mean hospital stay of 8 days. There were no surgical complications and no conversions to open. Mean serum creatinine at discharge, at one & 3 month were 2.6 mg/dl; 1.2 mg/dl & 1.3 mg/dl respectively.
Robotic approach confers advantages of decreased wound morbidity, better cosmesis and no lymphocele. However, long term follow up of large number of patients is needed to establish its place. It is more expensive than open procedures.
Anant Kumar
Anil Gulia
Samit Chaturvedi
Manoj Kumar
Ruchir Maheshwari
Karamveer Singh Sabharwal
Laparoscopic Radical Heminephrouretectomy in Horseshoe Kidney with High-Grade Urothelial Cell Carcinoma and Single-Port Bladder Cuff Management: First Case Report.
|Misc. GU Oncology and Transplant
Abstract: V6-11
Sources of Funding: None
Horseshoe kidney is a renal fusion congenital disorder, affecting up to 0.25% of the general population. High-grade urothelial carcinoma represents about 5-7% of all renal tumors._x000D_ We describe the laparoscopic approach of hemi-nephroureterectomy and lymphadenectomy with the single-port bladder cuff resection in a horseshoe kidney with upper urinary tract urothelial cell carcinoma.
Male, 50 years old patient with an incidental endoscopic finding of a right renal pelvic tumoral lesion. The imaging studies revealed a horseshoe kidney._x000D_ _x000D_ The angio-MRI of the abdomen reveals a tumor in the renal pelvis and in the first two-thirds of the ureter. The vascular artery study reveals a renal artery supplying blood to the tumoral lesion and the second artery to the inferior pole of the kidney._x000D_
Right laparoscopic radical hemi-nephroureterectomy with Isthmectomy and lymphadenectomy (perihiliar, paraaortic, precaval, and paracaval) whit single-port bladder cuff was performed without complications. The surgical specimen was all removed by the suprapubic incision of the single port._x000D_ _x000D_ The pathology shows a tumor confined to the renal pelvis; ureter tumor extension recognized with partial obstruction in its proximal two-thirds, without recognizing infiltration ureteral wall. lymph node negative for tumor involvement. TNM: pT1 High-Grade N 0 M 0. _x000D_ Six months follow-up is satisfactory without relapse._x000D_ _x000D_
This is the first case reported which describes the laparoscopic approach for hemi-nephroureterectomy with lymphadenectomy and simultaneously by single-port bladder cuff in horseshoe kidney with upper urinary tract urothelial cell carcinoma._x000D_ _x000D_ The single-port technique, allows an intravesical approach with a safe surgical margin while still attaining the benefits of a minimally invasive surgery._x000D_ _x000D_ This procedure is viable and safe, inclusive in structural anomalies such as the horseshoe kidney with favorable oncologic short-term results._x000D_ _x000D_
Marino Cabrera
Jose Gustavo Ramos
Claudia Lucia Ochoa
Angie Ramirez
Rodolfo Varela
Jorge Forero
German Godoy
Transvescicoscopic bladder cuff excision in laparoscopic nephroureterectomy
|Misc. GU Oncology and Transplant
Abstract: V6-12
Sources of Funding: None
To describe the management of the distal ureter during laparoscopic radical nephroureterectomy with the transvesical laparoscopic approach.
The patient was placed in the modified lithotomy position with abducted thighs. The procedure started with cystoscopic examination of the bladder and ureteral orifices. After a small skin incision, a 5-mm-diameter trocar was introduced into the bladder dome. The anterior bladder wall was suspended to the abdominal wall to prevent the trocar from slipping out and 2 more 3-mm-diameter trocars were placed. The ureter was mobilized with hook electrocautery and dissected ureteral end was placed in extravesical space. Bladder was repaired with 4-0 vicryl. Then patient was placed in lateral position and conventional laparoscopic radical nephroureterectomy was performed. While dissection of distal ureter, the distal end of ureter was smoothly removed from perivesical space without any difficulty.
The patient was a 61-year-old female. The patient's CT scan showed right proximal ureteral mass and the result of previously performed ureteroscopic biopsy was transitional cell carcinoma, low grade. The operation time of transvesical bladder cuff excision was 50 minutes, and laparoscopic nephroureterectomy was performed for 120 minutes. Estimated blood loss of whole procedure was 300ml and there was no intraoperative or postoperative complication. Foley catheter was removed at 1 week. After 6 months postoperatively, there's no evidence of recurrence or metastasis.
Our initial experience with transvesicoscopic bladder cuff excision in laparoscopic radical nephroureterectomy demonstrated that the procedure is feasible and safe.
Young Eun Yoon
Sang Woon Kim
Hyung Ho Lee
Jang He Han
Seung Hwan Lee
Won Sik Ham
Koon Ho Rha
Woong Kyu Han
Intraoperative MRI-Guided Navigation of the Pelvic Floor During Exstrophy Closure
Abstract: V7-01
Sources of Funding: none
Radical dissection of the urogenital fibers and the thickened smooth and striated muscle fibers connecting the posterior urethra and bladder plate to the diastatic pubic rami is crucial for adequate placement of the posterior vesicourethral unit deep within the pelvis during classic bladder exstrophy (CBE) and cloacal exstrophy (CE) closure, as well as ensuring successful outcomes. Intraoperative magnetic resonance imaging (MRI) guided navigation of the pelvic floor offers a novel technique for identification of the urogenital diaphragm fibers and the thickened muscular attachments between the posterior urethra, bladder plate and pubic rami during CBE closure.
Institutional review board and Food and Drug Administration approval was obtained for use of Brainlab® (Munich, Germany) intraoperative MRI-guided navigation of the pelvic floor anatomy during closure of CBE at the authors' institution. Pre-operative pelvic MRI was obtained one day prior to exstrophy closure in patients necessitating pelvic osteotomies. Intraoperative registration was performed after pre-operative planning with a pediatric radiologist utilizing five anatomic landmarks immediately prior to initiation of surgery. Accuracy of identification of pelvic anatomy was assessed by three pediatric urologic surgeons and one pediatric radiologist.
32 patients with CBE and 2 patients with CE closed at the authors' institution have successfully utilized Brainlab® technology to navigate and guide the dissection of the pelvic floor intraoperatively. All patients had 100% accuracy in correlation of gross anatomic landmarks with MRI identified landmarks intraoperatively, and all have had successful closure without any complication.
Brainlab® intraoperative MRI-guided pelvic floor navigation and dissection is an effective way to accurately identify pelvic anatomy during CBE and CE closure. Future assessment of real-time changes in pelvic floor anatomy comparing pre-closure to post-closure MRI will allow quantification of pelvic floor anatomy in these patients and may allow for intra-institutional telementoring in this most important first step of exstrophy reconstruction.
Heather Di Carlo
Aylin Tekes
John Gearhart
Robotic Assisted Ileovesicostomy & Cecostomy Tube
Abstract: V7-02
Sources of Funding: None
Robotic surgical techniques have been adopted for procedures in pediatric urology but reconstruction for neurogenic bladder has been an area where it is underutilized. The reasons for this may include the need to create a bowel anastomosis, relative inexperience with robotics or perceived limitations of the technology. Our objective is to demonstrate the successful use of robotics in creating an ileovesicostomy incontinent urinary diversion with a complete intra corporeal bowel anastomosis and cecostomy tube placement.
A 15 year-old female with myelomeningocele and neurogenic bladder had multiple failed attempts at compliance with clean intermittent catheterization program. She developed acute kidney injury and it was recommended that she undergo incontinent urinary diversion. We utilized the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of botox into the detrusor muscle. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. A cecostomy tube was also placed robotically to manage the patient's neurogenic bowel. The ileovesicootomy stoma was created in the left lower quadrant by extending the left arm robotic port site.
The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning she was taken to the operating room for the procedure. Total operative time was 406 minutes. Anesthesia induction was 17 minutes, cystoscopy and botox injection was 10 minutes and port placement and laparoscopic dissection took 22 minutes. Total console time was 244 minutes and closure time was 14 minutes. The remaining 96 minutes was for patient positioning and preparation. A foley catheter was placed per her urethra temporarily to keep her bladder decompressed to aid in wound healing and was removed prior to discharge. She was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4 with no surgical drainage tubes except for her urostomy. At 5-month follow-up her creatinine remains at her baseline of 0.9 and her ultrasound shows no hydronephrosis. She has no leakage per urethra.
Robotic assisted ileovesocostomy is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery can be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer.
Christina Ching
Molly Fuchs
Christopher Brown
Daniel DaJusta
Robotic Partial Nephrectomy with Selective Clamping for Renal Mass in <15kg Pediatric Patient: Techniques Adapted from Adult Urology
Abstract: V7-03
Sources of Funding: None
Robotic partial nephrectomy (RPN) provides for nephron sparing and renal preservation with a minimally invasive approach. Though commonly utilized in adults for resection of renal masses, it is less commonly applied for tumors in children. To optimize outcomes in these patients, techniques from the adult setting were translated to the pediatric realm, with the goals of fostering bi-directional transfer of expertise and knowledge and of achieving safe and effective application of this surgical approach.
A collaborative team was formed and consisted of a pediatric urologist trained in minimally invasive and oncologic surgery as primary surgeon with an adult minimally invasive oncologic urologist as proctor. Key aspects for translation to the pediatric setting included: port placement, lower insufflation pressure, choice and size of instruments and supplies, and minimization of potential hemorrhage and ischemia with selective clamping/early unclamping technique. This approach was applied to a 14 kilogram, 3 year old female with a right lower pole lesion with cystic and solid components, concerning for malignancy.
The mass was resected with negative margins and demonstrated benign pathology. Clamp time was 14 minutes, and EBL was minimal. There were no intra- or post-operative complications. The patient's creatinine was unchanged, and a follow-up ultrasound demonstrated no residual mass in a normal appearing right kidney.
Collaboration of experienced pediatric and robotic teams allows for successful adaptation of adult techniques to pediatric patients. Specific considerations must be made in order to achieve safety and feasibility of RPN with selective clamping for renal preservation in cases of pediatric renal masses.
Patricia S. Cho
Michael V. Hollis
Briony K. Varda
Erin R. McNamara
Richard N. Yu
Andrew A. Wagner
Richard S. Lee
Mons Plasty: A Technique for Optimal Aesthetic Outcome
Abstract: V7-04
Sources of Funding: None
It has been suggested that women who have undergone repair for exstrophy-epispadias complex (EEC) have unsatisfactory cosmetic results possibly leading to decreased self-esteem. Here we aim to show a mons plasty technique to be incorporated at the initial EEC closure that creates anatomically correct external female genitalia as well as improves the aesthetic outcome.
Briefly, the surgical technique incorporates approximation of the bifid clitoris in the midline, aligning the labia minora along the lateral aspect of the introitus, creation of a clitoral hood, superomedial rotation of the labia majora, and finally mobilization of peripubic adipose to create a mons.
In our experience the surgical technique was successful in creating anatomically normal appearing external genitalia with subjective parental satisfaction. The patient has not had any complications. A post-operative VCUG showed grade 3 left vesicoureteral reflux. She is not yet potty trained but does have apparent normal voiding with dry periods throughout the day.
The technique described restores normal anatomic appearance as well as improves the cosmetic outcome. This technique should be considered in one-stage female EEC closure.
Kelly Nast
Diana Cardona-Grau
George Chiang
Antoine Khoury
Robotic Assisted Laparoscopic Adrenalectomy In The Setting Of An Incidental Adrenal Mass
Abstract: V7-05
Sources of Funding: none
Since Rudolf Virchow first described abdominal "glioma� tumors in children, neuroblastoma has come to be recognized as the most common malignancy in infants and the most common solid malignancy in children. Resection in neuroblastomas that are classified as low risk is often curative. Traditionally the standard operative management has been open surgical resection. More recently however, a shift towards minimally invasive approaches has been described. Here we report a case of neuroblastoma managed with robotic assisted laparoscopic adrenalectomy. This is the first robotic adrenalectomy performed at our institution and, to the best of our knowledge, the first performed on a Da Vinci Xi robot.
A single case was reviewed and reported.
A 2-year-old female with a history of a febrile urinary tract infection found to have a poorly functioning left upper pole moiety with ectopic ureter initially underwent a successful robotic assisted left upper pole partial nephrectomy. On her postoperative renal ultrasound, she was found to have a new right sided adrenal mass. This was confirmed with MRI and MIBG scan. Metanephrinies, homovanillic acid, and vanillylmandelic acid levels were obtained to evaluate for pheochromocytoma and were within normal limits. Robotic assisted laparoscopic right adrenalectomy was then performed. Intraoperatively, a small iatrogenic cavotomy was made and repaired. There were no further complications and the patient tolerated the procedure well. She had an uneventful recovery and was discharged home on post-operative day two.
Robotic assisted laparoscopic adrenalectomy represents a viable option for surgical excision of adrenal tumors and can be accomplished with rapid recovery time, decreased surgical morbidity, and comparable oncologic outcomes. Injury to surrounding vessels presents a known complication to adrenalectomy. Our case demonstrates the advantage of a Da Vinci Xi surgical system for laparoscopic vascular repair and tumor excision. In our experience, while adhering to sound oncologic surgical principles, a robotic assisted laparoscopic approach can be considered as an alternative to traditional open adrenalectomy for select children with neuroblastoma.
Eli Thompson
Evalynn Vasquez
Andy Chang
Paul Kokorowski
Abstract: V7-06
Sources of Funding: None
Laparoscopy is the gold standard for diagnosis and treatment of boys with non-palpable testicles. In an effort to reduce the invasiveness of laparoscopic orchiopexy, various strategies have been employed including use of laparoendoscopic single site surgery (LESS) and needlescopic surgery. Needlescopic instruments have limited functionality due to their small size and are more prone to intrabdominal organ injury. LESS has been criticized when used in children due to the requirement of a much larger 3 cm incision. In this video we will demonstrate the feasibility of a novel percutaneous externally assembled laparoscopic (PEAL) surgery paradigm for orchiopexy which is designed to reduce the invasiveness of the procedure while maintaining instrument triangulation.
The PEAL surgical paradigm is composed of a reusable handpiece and a disposable 2.96 mm instrument shaft and interchangeable disposable 5 mm instrument tips. This video will demonstrate how the PEAL instruments are externally assembled and brought back into the abdomen without a trocar to perform the surgery. Due to their small size and because they are assembled externally, they produce an essentially scarless outcome. This video will demonstrate the PEAL surgical paradigm for the performance of Fowler-Stephens orchiopexy._x000D_ _x000D_
Using this innovative new paradigm, a 9 month-old infant underwent first stage and a 9 year-old child underwent second stage successful bilateral Fowler-Stephens orchiopexies. Operative times were 65 minutes for the first stage and 180 minutes for the second stage. Blood loss was minimal in both cases. Both patients were discharged the day of surgery with no complications. At follow up, the objective cosmetic results were excellent and the second patient&[prime]s testis was palpable in the scrotum and well-positioned.
Due to its improved cosmesis and ease of performance, the PEAL surgical paradigm shows promise in reducing the invasiveness of pediatric Fowler-Stephens orchiopexy. In addition it shows promise with a wide variety of minimally invasive surgical applications.
David Ruckle
Samuel Abourbih
Minh-Hang T. Chau
Mohamed Keheila
Jim Shen
Patrick Yang
Salim Cheriyan
Nazih Khater
D. Duane Baldwin
Robotic Bladder Neck Reconstruction with Sling and Split Appendix Technique for Appendicovesicostomy and MACE
Abstract: V7-07
Sources of Funding: None
Robotic surgical techniques have been adopted for procedures in pediatric urology even in reconstruction for neurogenic bladder. Our aim was to expand on the previously described bladder neck reconstruction with sling and Appendicovesicostomy (APV), by showing that the well described open split appendix technique can also be perform robotically, allowing for the creation of both APV and MACE. This video is to our knowledge, the first to demonstrate the use of robotic split appendix technique.
A 6 year-old male with myelomeningocele, neurogenic bladder and bowel was not able to achieve urinary continence on a standard regiment of IC and anticholinergic. Urodynamic showed adequate bladder capacity at 300 ml with low storage pressure and adequate compliance. Unfortunately he had a low leak point pressure indicating poor outlet resistance. Thus indication for a bladder neck reconstruction with APV was made. There was also a need for implementing a good bowel regiment and after evaluation at our Center for Colorectal and pelvic Reconstruction by the colorectal surgeon, indication for a MACE was also made. We selected to utilize the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of Botox into the detrusor muscle, we placed ureteral catheter for easy ureteral orifice identification during bladder neck reconstruction and an 8 French Foley catheter. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance.
The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning he was taken to the operating room for the procedure. Total operative time was 7 hours. Total console time was 6 hours. A 10 French Foley catheter was placed through the APV channel and an 8 French feeding tube was placed through the MACE. A 5 French feeding tube was left stenting the urethra and was removed prior to discharge. He was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4.
Robotic assisted bladder neck reconstruction with split appendix technique to create both APV and MACE is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery will continue to be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer.
Molly Fuchs
Christina Ching
Christopher Brown
Richard Wood
Mark Levitt
Rama Jayanthi
Daniel DaJusta
Laparoscopic Nephrectomy for Prenatally diagnosed Wilms' Tumor
Abstract: V7-08
Sources of Funding: None
The most common diagnosis of neonatal renal mass is congenital mesoblastic nephroma. However, Wilms' tumor has been reported sporadically in the literature. We report the diagnosis, management and surgical approach to a prenatally diagnosed Wilms' tumor.
The patient was a newborn female found to have an abnormal renal ultrasound on routine 2nd trimester prenatal ultrasound. The mass was seen on subsequent ultrasounds at 32 weeks and again 37 weeks. Neonatal ultrasound confirmed the mass. A contrast-enhanced CT scan was performed on day 10 of life, revealing a centrally-located, multifocal, enhancing left renal mass. The remainder of staging work up was negative. She underwent a Laparoscopic radical left nephrectomy with lymph node sampling on day 26 of life. Intraoperative frozen pathology was consistent with Wilms' tumor; therefore, a port-a-cath was placed under the same anesthetic for administration of adjuvant chemotherapy. The case presentation and surgical management are described in the video.
The final pathology revealed favorable histology Stage II Wilms' tumor. There was extension into the renal sinus. Surgical margins were negative. There was no lymph node involvement. The patient was dismissed on post operative day 1. She received adjuvant chemotherapy with Vincristine and Dactinomycin based on the EE4A regimen. Port placement was performed using the novel HIdES (Hidden Incision Endoscopic Surgery); which renders the scar profile nonvisible if the patient is wearing a bathing suit.
Although the most common cause of neonatal renal mass is nephrogenic mesoblastic nephroma, Wilms' tumor cannot be excluded. Therefore, a timely management is warranted. A minimally-invasive surgical approach to radical nephrectomy and lymph node sampling is safe and feasible in the neonatal period.
Amir Toussi
Candace Granberg
Patricio Gargollo
Pediatric Robot-assisted Lower Pole Heminephrectomy with Intraureteral Indocyanine Green in a Duplicated Collecting System Not Following Weigert-Meyer Law
Abstract: V7-09
Sources of Funding: None
Duplicated collecting systems that violate Weigert-Meyer law are rare, and have only been reported in a handful of case reports. Indocyanine green (ICG), a dye that can be visualized under near-infrared fluorescence, may be used as a real-time contrast agent in the surgical management of patients with atypical ureteral anatomy. We describe a robot-assisted lower pole heminephrectomy with intraureteral ICG in a 13 year old pediatric patient with a duplicated collecting system not following Weigert-Meyer law.
Magnetic resonance urography demonstrated that the lower moiety renal pelvis was severely dilated proximal to a ureteropelvic junction obstruction and that the ectopic lower moiety ureter inserted into the prostatic urethra. Renal scan demonstrated an essentially functionless left lower moiety. The patient's family consented to off-label use of ICG after full disclosure. Intraoperatively, 10 milliliters of indocyanine green solution (25 milligrams indocyanine green in 10 milliliters distilled water) was injected into the lower moiety ureter through a ureteral catheter. Near-infrared fluorescence was toggled on and off throughout the procedure to visualize the green-fluoresced ureter throughout the case.
The patient's left lower pole moiety kidney and ectopic ureter were removed en-bloc. Use of intraureteral ICG allowed for definitive identification and precise dissection of the lower moiety ureter. Operative time was 235 minutes and estimated blood loss was 450 milliliters. On postoperative day one, the patient's Foley catheter was removed and the patient was discharged. There were no intraoperative or postoperative complications.
Exceptions to Weigert-Meyer law are uncommon. In such cases, the use of intraureteral ICG may be used as a contrast agent to definitively delineate ureteral anatomy intraoperatively.
Ziho Lee
Michael Packer
Gregory Dean
Jonathan Roth
Daniel Eun
Robotic assisted laparoscopic dismembered tapered ureteral reimplantation for megaureter
Abstract: V7-10
Sources of Funding: None
Children with megaureters may have elements of obstruction, reflux, or both and are at risk for upper tract deterioration if left uncorrected. We present a series of 5 pediatric patients ranging from 14 months old to 11 years old with symptomatic megaureter and describe a novel technique for surgical correction involving a minimally-invasive, robotic-assisted approach with a dismembered extravesical ureteroneocystostomy following extracorporeal ureteral tapering.
We retrospectively reviewed 5 pediatric cases of megaureter managed in similar fashion with a novel surgical technique. Outcomes were assessed via chart review with a focus on postoperative improvement in clinical symptoms and in radiographic findings.
After a mean follow up of 24 months, all patients have demonstrated clinical improvement in their symptoms, radiographic improvement of hydronephrosis, or both. This pattern persists in the two patients with longest follow ups of 44 and 54 months. Repeat voiding cystourethrogram following surgery is done as clinically indicated and has not yet been performed in all patients who had preoperative reflux.
In conclusion, robotic-assisted laparoscopic dismembered ureteroneocystostomy with extracorporeal ureteral tapering is a feasible, minimally-invasive method for managing patients with symptomatic megaureter who have components of obstruction, reflux, or both.
Jared Manwaring
Jonathan Riddell
Robotic-Assisted Laparoscopic Partial Nephrectomy for a Renal Mass in a Two-Year-Old
Abstract: V7-11
Sources of Funding: None
Robotic-assisted laparoscopic extirpative renal surgery has been well described for benign indications in children, primarily for resection of non-functioning renal moieties. However, it has rarely been described for resection of potentially malignant masses. The following clinical case demonstrates successful robotic-assisted laparoscopic partial nephrectomy (RALPN) for a renal mass in a two-year-old child. Because the methods used for neoplasms differ significantly from those employed for benign resection, they have been described in detail and demonstrated in the accompanying video.
The patient is a 15kg, otherwise healthy, two-year-old girl with an incidentally discovered 1.2cm left lower pole renal mass. The small size and polar location of the lesion made it particularly amenable to RALPN with plans for frozen section analysis and possible regional lymphadenectomy and conversion to radical nephrectomy.
The procedure was performed using an 8mm umbilical camera port, two 8mm robotic arm ports, and a 12mm assistant port. After medializing the descending colon, the ureter was traced up to the renal hilum. Renal vessels were encircled with vessel loops. The Gerota's fascia and fat overlying the lower pole of the kidney was dissected and sent to pathology, exposing the underlying mass. Intra-operative ultrasound confirmed the presence and depth of the mass. The renal artery was clamped with laparoscopic bulldog. The mass was excised with cold scissors. Renorrhaphy was performed using sliding clip technique. Warm ischemic time was 32 minutes. Frozen sections showed narrow margins but was inconclusive regarding the tumor's malignant potential and so a decision was made to defer further surgery until definitive diagnosis. Estimated blood loss was 10cc. The patient was discharged from the hospital on day two. Final pathology demonstrated adenomatous perilobar nephrogenic rest, a known precursor lesion to Wilms' tumor. At last follow-up 3.5 months postoperatively, the patient is doing well with renal ultrasound demonstrating a normal appearing and symmetrical left kidney.
RALPN is a safe and effective modality for resecting potentially malignant renal masses, even in very small children. We believe it offers significant advantages over the large open incisions and radical resections often still utilized for small pediatric renal masses. The accompanying video further illustrates our technique.
Ramsey Al-Khalil
Wai Lee
April Adams Szafran
Wayne Waltzer
Ezekiel Young
Abstract: V7-12
Sources of Funding: None
Ectopic ureteral insertion is a rare condition. Ectopic ureters in males may present with flank pain, lower urinary tract symptoms, or epididymoorchitis. We present a case of a male patient with a dysplastic, ectopic, left kidney with an ectopic ureter managed with robotic-assisted laparoscopic nephroureterectomy._x000D_ _x000D_
A 10 year old male presented with chronic, left epididymal pain. Urinalysis was unremarkable. The patient was born with a solitary functioning right kidney detected on prenatal ultrasound. Additionally, he had a known left sided pelvic cyst, consistent with a nonfunctioning, ectopic, left kidney. The ectopic, dysplastic, left kidney had been followed with regular ultrasounds and the dilated renal pelvis had increased in size by 8 mm over the last five years. Routine ultrasound demonstrated a 4.5 cm, tubular, cystic structure behind the bladder. Follow up MRI revealed an atrophic, ectopic, dilated left kidney with ectopic ureter inserting into the left seminal vesicle. The patient was taken for robotic assisted laparoscopic left nephroureterectomy.
Pathologic analysis revealed an ectopic ureter with associated epithelial-lined cyst. No renal parenchyma was identified in the pathologic specimen. There were no complications. Estimated blood loss was 20 milliliters. The patient was dismissed from the hospital on postoperative day 1.
Robotic-assisted laparoscopy proved to be a safe and efficacious platform for dissection and removal of an ectopic, nonfunctioning kidney with an ectopic ureter draining into the seminal vesicle. All structures were accessed from a single docking point, and the procedure was well-tolerated, providing a minimally-invasive option for management of this congenital abnormality.
George Bailey
Candace Granberg
Focal Laser Ablation: Path to a clinic treatment for prostate cancer
|Prostate and Renal Oncology
Abstract: V8-01
Sources of Funding: Medtronic Navigation, Inc. via Physician-Sponsored Research Agreement with Regents of University of California and National Cancer Institute (R01CA158627).
Focal therapy of prostate cancer (CaP) is of keen interest, but data obtained via clinical trials are scarce. In this video, a path from targeted prostate biopsy to focal laser ablation (FLA) is demonstrated in 4 ensuing chapters: (1)Targeted Biopsy, (2) Preliminary Studies, (3) MRI-guided In-bore FLA, and (4) In-clinic FLA. Clinical trial data are included to support each step along the path.
The path started with targeted biopsy via MRI/US fusion (Artemis), now performed in >1500 men at UCLA since 2009; these data laid groundwork for FLA. Preliminary studies using interstitial laser energy (in vitro and in vivo) were then assembled. After that, FLA in-bore was performed in 8 men, using direct MRI guidance for targeting and MR thermometry for temperature monitoring. Then, FLA was performed in-clinic in 10 men using (1) the fixed arm of the Artemis device for stabilization of the intra-prostatic laser fiber, (2) MRI/US fusion for tumor localization and targeting, and (3) direct thermal probes for safety monitoring during treatment. In-clinic FLA was performed using local anesthesia + midazolam.
Initial work with targeted biopsy showed that index CaP lesions could be accurately defined and other serious lesions ruled out in >80% of cases (Filson, CA, 2015). Preliminary studies showed that interstitial laser energy could ablate prostate tissue safely and effectively. Then, In-bore FLA was shown to be safe and effective in 8 men (Natarajan, J.Urol., 2016), but was cumbersome and expensive. Ultimately, the path led to an FDA-approved Phase I trial of out-of-bore (in-clinic) FLA in 10 men, all with intermediate-risk CaP. Short-term results were similar to those obtained in-bore, but simpler (3 vs 6 personnel), quicker (minutes vs hours), and less expensive (thousands vs tens of thousands of dollars). In-clinic FLA resulted in prostate-confined ablation zones averaging 4.3 cc (range, 2.1-6.0 cc); no man incurred incontinence or ED; and at 6-month targeted biopsies, successful ablation of intermediate-risk CaP was found in 6/10 men. Defining adequate margins of treatment remains a challenge.
A path from targeted biopsy to focal laser ablation of prostate cancer was followed; the potential for safe and effective treatment of intermediate-risk CaP ---under local anesthesia in a clinic setting---has been established.
Medtronic Navigation, Inc. via Physician-Sponsored Research Agreement with Regents of University of California and National Cancer Institute (R01CA158627).
Leonard Marks
Shyam Natarajan
Alan Priester
Daniel Margolis
|Prostate and Renal Oncology
Abstract: V8-02
Sources of Funding: none
A physical damage can occur to the neurovascular bundles during the procedure, due to the use of cautery and tractions.Nowadays bio-engineeringis developing novel devices with the aim of co-operate the neural renewal.Among them chitosan seems to be promising with neuro-regenerative properties. In our Institution we tried to use chitosan membranes as scaffold for neural renewal after nerve-sparingrobot-assisted radical prostatectomy (RARP)._x000D_ In laboratory setting results were promising so we designed a prospectivestudytrying to confirmchitosanproperties in_x000D_ clinicalpractice._x000D_ Primary end-point: to evaluate the feasibility of the application of chitosan membrane on neuro-vascular bundles after nerve-sparing RARP. Secondary end-point: To evaluate the recovery of erectile function at 1, 2, and 3 months postoperatively by performing a matched-pair analysis comparing the group of patients who underwent chitosan application to a control group who did not.
47patients who underwent nerve sparingRARP (07/2015 - 01/2016) were enrolled. Criteria for inclusion was an IIEF>17._x000D_ A control group of patients was selected. Potency recovery was defined as erection enough for intercourse or masturbation._x000D_ Membranes were adequately prepared by immersion in saline solution and cutting. After that reconstructive phase of RARP was performed,chitosan membranes were introduced and applied on the bundles.
Baseline data of patients in the Groups were comparable.Concerning intraoperative data, no modifications of operative time was recorded in the Chitosan Group;No intraoperative complications occurred.Postoperative complications rate was not affected by the application of the membrane.Concerning the functional data, a faster erectile function recovery was recorded in the cohort of patients who underwent chitosan application.
In our experience, the application of chitosan membranes on the neurovascular bundles after robot-assisted RP was easy and safe. Preliminary functional outcomes showed a faster recovery of erectile function in the cohort of patients who underwent the application of the membranes.Larger sample size and randomized trials are needed in order to confirm these preliminary outcomes.
Francesco Porpiglia
Riccardo Bertolo
Enrico Checcucci
Matteo Manfredi
Sabrina De Cillis
Roberta Aimar
Stefano Geuna
Cristian Fiori
Robot assisted radical nephrectomy and inferior vena cava thrombectomy: surgical technique, perioperative and oncologic outcomes
|Prostate and Renal Oncology
Abstract: V8-03
Sources of Funding: none
In this video we highlight surgical steps of a right radical nephrectomy and level IIIb inferior vena cava (IVC) thrombectomy using an occluding balloon Fogarty catheter to control the upper boundary of IVC thrombus under transesophageal ultrasound guidance. Perioperative and oncologic outcomes of our first 35 patients treated with robotic radical nephrectomy and inferior vena cava thrombectomy in two tertiary referral centers were reported.
Key surgical steps are higlighted in the video. _x000D_ Preoperative arterial embolization was performed. A right template retroperitoneal lymph node dissection was performed and all lumbar veins were secured to achieve a complete IVC control; the left renal vein and the distal IVC segment were prepared and encircled with Roummel Tourniquet. Short hepatic veins were secured with Ligasure and the posterior aspect of the IVC was prepared. Proximal IVC was encircled and right renal vein was stapled._x000D_ The distal IVC and left renal vein Tourniquets were cinched down and a small cavotomy was performed to insert a Fogarty catheter with an occluding balloon tip. To ensure the correct placement of the catheter tip at the cranial edge of the thrombus we used transesophageal ultrasound. Once the balloon was inflated and distally attracted, cavotomy was performed and the thrombus progressively mobilized and secured into an endocatch bag. IVC lumen was inspected to ensure absence of any residual thrombus fragment and the balloon was deflated to restore IVC flow throw the major hepatic veins. The cava was sutured with a 3/0 Visi black monocryl suture. _x000D_ Thirty-five consecutive patients with renal tumor and IVC thrombus were treated between July 2011 and September 2016 in two tertiary referral centers; perioperative and oncologic data were reported._x000D_
Fogarty catheter was successfully used in 7 (20%) cases. Open conversion was necessary in one case (2.8%). Median operative time was 300 minutes. Ten patients (28.6%) required blood transfusion (Clavien grade 2); one patient (2.8%) had a Clavien grade 3a complication (gastroscopy); two patients (5.7%) had Clavien grade 3b complications (reintervention due to bleeding from adrenal gland and subphrenicascess requiring drainage, respectively); one patient (2.8%) experienced a PRESS syndrome requiring ICU admission (Clavien 4a). _x000D_ Out of 13 patients who underwent cytoreductive nephrectomy and IVC thrombectomy, only one patient died of disease progression 14 months postoperatively. Both 2-yr cancer specific and overall survival rates in this subpopulation were 88.9%._x000D_ Twenty-two patients received surgery with curative intent and 5 of these experienced disease recurrence: 2-yr metastasis free, cancer specific and overall survival rates were 56%, 100% and 94.4%, respectively._x000D_
The increasing experience with robotic surgery has made nephrectomy and IVC thrombectomy a feasible and safe treatment option in tertiary referral centers, associated with favourable perioperative outcomes and encouraging short term oncologic outcomes.
Giuseppe Simone
Leonardo Misuraca
Gabriele Tuderti
David Hatcher
Mariaconsiglia Ferriero
Andre Luis De Castro Abreu
Francesco Minisola
Monish Aron
Salvatore Guaglianone
Mihir Desai
Inderbir Singh Gill
Michele Gallucci
Percutaneous Externally Assembled Laparoscopic (PEAL) Nephrectomy
|Prostate and Renal Oncology
Abstract: V8-04
Sources of Funding: None
Laparoendoscopic single-site nephrectomy (LESS) provides excellent cosmetic outcomes, but is technically challenging due to loss of triangulation and increased instrument collision. A novel Percutaneous Externally Assembled Laparoscopic (PEAL) surgical paradigm was developed to simplify minimally invasive surgery while providing a nearly scarless outcome. In this video, we will demonstrate how PEAL instruments restore triangulation and simplify LESS nephrectomy.
The PEAL instrument is composed of a reusable handpiece and a disposable 2.96 mm shaft and interchangeable 5 mm instrument tips. These instruments are inserted without a trocar which minimizes their cosmetic impact. This video will demonstrate a PEAL nephrectomy in a 69 year-old female with a nonfunctional duplicated right kidney. Initially a multi-access port was inserted into the umbilicus and used to take down adhesions from a previous surgery. Adhesions to the liver were left intact to provide liver retraction. A 2.96 mm instrument shaft was introduced in the right mid-clavicular line at the level of the umbilicus using a special introducer tip. It was brought out through the multi access port and switched to a 5 mm grasper tip. This PEAL instrument was able to reestablish triangulation and upon its removal required no wound closure.
The use of the PEAL surgical paradigm restored triangulation and allowed a nearly scarless nephrectomy despite this patient's giant duplicated kidney. This 2.96 mm instrument shaft was inserted through a small puncture and maintains the nearly scarless cosmesis of LESS surgery. The 5 mm grasping tip, which can be changed through any conventional laparoscopic port, was robust and allowed for the effective manipulation of this giant kidney. The estimated blood loss was 100 cc and the operative time was 310 min. The patient tolerated the procedure well without any perioperative complications. The patient was discharged home on POD 1 and required no narcotic pain medications.
The addition of the PEAL instrument facilitated the completion of LESS nephrectomy in a patient with complicated anatomy. By using these externally assembled instruments, PEAL provides a functional, robust 5 mm tip and reestablishes instrument triangulation, thereby greatly simplifying LESS surgery. In addition the <3mm shaft maintains a nearly scarless cosmetic outcome. The PEAL instruments can be used to simplify LESS, reduce the invasiveness of conventional laparoscopic surgery or as stand-alone surgical paradigm. For these reasons we feel that the PEAL paradigm is a promising new surgical approach
Jerry Thomas
Mohamed Keheila
Samuel Abourbih
Patrick Yang
Nazih Khater
Jim Shen
Salim Cheriyan
D. Duane Baldwin
Successful endovascular control of renal artery in a transplant kidney during nephron sparing surgery for large centrally located tumor
|Prostate and Renal Oncology
Abstract: V8-05
Sources of Funding: CryoLife LTD
Renal cell carcinomas (RCC) which comprise 4.6% of malignant neoplasms in patients following kidney transplantation occurs more frequently than in the general population. Native kidneys are affected in 90% of cases compared with 10% of the transplanted kidneys. _x000D_ Nephron Sparing Surgery (NSS) is the treatment of choice, although graft nephrectomy is chosen in cases with large lesion,decreased functioning graft, and locally advanced disease. One of the main technical challenges is obtaining adequate vascular control._x000D_ Herein we present a rare case of large centrally located hilar tumor in a kidney 18 years after transplantation._x000D_
Open Nephron Sparing Surgery (NSS) is described. Considering possible difficulties in approaching the renal pedicle due to adhesions and the location of the tumor, arterial catheterization of the Iliac artery was performed in the operating room prior to surgery. An arterial occlusion balloon catheter was inserted into the renal transplant artery in order to ensure adequate haemostatic control without the need to expose and clamp the friable transplant renal artery.Under general anesthesia, through the previous right lower abdominal transplant's incision the kidney was exposed and freed from the surrounding structures, the ureter was identified and then the arterial balloon located in the transplant artery was inflated. Surface cooling was achieved with ice slush and the centrally located lesion was enucleated intact and opening of the collecting system as well as exposed blood vessels were individually sutured. Tumor bed closure was carried out with 15 ml of BioGlue® tissue adhesive. After the enucleation the arterial balloon was deflated. No signs of bleeding or urinary extravasations were seen.
Post-operative course was uneventfull, and after one year of follow-up no recurrence was observe an serum creatinine is stable and slightly elevated.
we demonstrate an unusual case of renal cell carcinoma in transplanted kidney managed by NSS despite the lesion high RENAL score. A novel approach was used to achieve vascular control by using intra arterial balloon catheterization prior to surgery. In order to preserve maximal function tumor bed closure was made with tissue adhesive BioGlue®. We believe that this unique choice of treatment can be used in cases of NSS where the access to the renal pedicle is limited.
CryoLife LTD
Sagi Shprits
Boaz Moskovits
Robert Sachner
Ofer Nativ
Advanced Reconstruction of Vesico-Urethral Support during Robot-assisted Radical Prostatectomy: experience with 526 cases
|Prostate and Renal Oncology
Abstract: V8-06
Sources of Funding: none
To date, several modifications of robot-assisted radical prostatectomy (RARP) aimed at improving continence have been introduced. In 2014, we presented Advanced Reconstruction of Vesico-Urethral Support (ARVUS) - innovative reconstruction technique during RARP using fibres of levator ani muscle as support for the anastomosis. We conducted a randomized trial [1], which showed improved continence rates of ARVUS compared to posterior reconstruction of rhabdosphincter according to Rocco. We then implemented the new technique into our daily practice. Here we present functional results on larger group of patients from a single center.
Between July 2014 and July 2016, we performed consecutive 526 RARPs using ARVUS technique. We prospectively collected all the oncological and functional data. Continence was defined as using 0 pads per day. The time points for evaluation were 24h after catheter removal, then 4 and 8 weeks and 6 and 12 months. Erection was assessed using International Index of Erectile Function (IIEF-5) questionnaire. Patients who required radiotherapy and patients lost to follow up were excluded from the analysis.
Median age was 63.2 years with median preoperative PSA 7.4 ng/ml. Median console time was 87 minutes and median blood loss 160 ml. Nerve sparing surgery had 78% of the patients. The positive surgical margin rate was 11.97%. Urinary continence assessed after 24 hours showed 20.91% (110/526) continence rate. In 4 weeks the continence rate was 60.45% (318/526), 68.06% (358/526) in 8 weeks, 73.8% (279/378) in 6 months and 84.94% (220/259) in 12 months. There were no major side effects associated with the reconstruction technique, no patient experienced perineal pain or urinary retention. Erection was evaluated in patients with initial IIEF-5 score ?19. In 12 months the potency rate was 71.04%.
ARVUS technique in our setting showed good functional results with no major side effects. Nevertheless, we believe that multi-center external validation is needed. _x000D_ _x000D_ 1. Student V Jr, Vidlar A, Grepl M, Hartmann I, Buresova E,Student V. Advanced Reconstruction of Vesicourethral Support (ARVUS) during Robot-assisted Radical Prostatectomy: One-year Functional Outcomes in a Two group Randomised Controlled Trial. Eur Urol. 2016 Jun 6 [Epub ahead of print]._x000D_
Vladimir Jr. Student
Igor Hartmann
Ales Vidlar
Michal Grepl
Eva Buresova
Vladimir Student
Modified Milan Sling technique during robot-assisted radical prostatectomy for early recovery of urinary continence without nerve-sparing: A pilot study
|Prostate and Renal Oncology
Abstract: V8-07
Sources of Funding: The Stiftelsen Japanese Swedish Research Foundation Japanese Section
_x000D_ Urinary incontinence after radical prostatectomy for localized prostate cancer strongly influences patients' quality of life. Postoperative urinary continence tends to recover early since robot-assisted radical prostatectomy has been introduced, but the results of the procedure are still not satisfactory. Various modifications of pelvic floor reconstruction during radical prostatectomy, including pelvic floor structure preservation with nerve-sparing technique, have been reported for the purpose of early recovery of urinary continence. However, wide excision without nerve-sparing is necessary depending on a case, such as high risk stratified group, while it may cause poor recovery of urinary continence. We modified the previously reported Milan vas deferens sling technique by adding reinforcement of under-anastomosis layers during robot-assisted radical prostatectomy, which significantly accelerates early recovery of postoperative urinary continence in cases without nerve-sparing.
_x000D_ Modified sling technique;_x000D_ Sling suture was made from autologous vas deferens. After putting the vas deferens sling on the sub-urethral perirectal fat, three independent layers were constructed below the urethrovesical anastomosis, and a single anterior layer was made. Then, both ends of the sling were transfixed to Cooper ligaments bilaterally with adequate sling suspension._x000D_ Between October 2015 and July 2016, consecutive 35 patients who underwent robot-assisted radical prostatectomy without nerve-sparing at our institution with a single surgeon were investigated. The patients were classified into two groups: 15 using the sling technique (sling group) and 20 using the non-sling technique with simple posterior reconstruction (nonsling group). Urinary continence defined as 0 or safety 1 pad use daily was compared between the groups._x000D_
_x000D_ Patients' characteristics were comparable between the groups. Urinary continence rate significantly improved in the sling group (60.0%, p=0.0365) as compared to the nonsling group (25.0%) at 1 month despite no difference at 3 months (86.7% in the sling group vs. 65.0% in the nonsling group, p=0.1467) postoperatively. Postoperative complications related to sling procedure were not detected.
_x000D_ Despite a small sample size in the single-institution study, this sling technique may improve early urinary continence recovery after robot-assisted radical prostatectomy even without nerve-sparing. A larger study is needed to confirm its efficacy.
The Stiftelsen Japanese Swedish Research Foundation Japanese Section
Yuji MAEDA
Toshimitsu MISAKI
Osamu UEKI
Tetsuyuki KUROKAWA
Yukinosuke OSHINOYA
Ken-ichi NAGANO
Haruo HISAZUMI
Purely off-clamp robotic partial nephrectomy
|Prostate and Renal Oncology
Abstract: V8-08
Sources of Funding: none
The negative impact of ischemia on renal function (RF) has led surgeons to develop minimally ischemic techniques to perform partial nephrectomy (PN). The aim of this video is to describe our surgical technique and report perioperative, 3-yr oncologic and functional outcomes of a single centre series of 308 patients treated with robotic off-clamp PN (OFF-RPN).
A prospective renal cancer database was queried and data of all patients treated with OFF-RPN between 2010 and 2015 in a high-volume centre were collected. _x000D_ Patients were placed in an extended flank position and a 5-port access with a side docking was performed. Hilar vessels were not clamped in any case; pure tumour enucleation or enucleoresection were the resection techniques used; renorraphy was omitted for small and exophytic masses and minimized with a "point specific haemostasis� for hilar tumours. _x000D_ Perioperative complications, 3-yr oncologic and functional outcomes were reported. Univariable and multivariable analyses were performed to identify independent predictors of RF deterioration._x000D_
Out of 308 patients treated, 41 (13.3%) experienced perioperative complications, 2.9% of which were Clavien grade ?3. Three-yr local recurrence free survival and renal cell carcinoma specific survival rates were 99.5% and 97.9%, respectively._x000D_ No patient with preoperative CKD-stage ?3B developed severe RF deterioration (CKD-stage 4) at 1-yr follow-up._x000D_ At multivariable analysis, preoperative eGFR (p=0.005) was the only independent predictor of a new onset CKD-stage ?3 in patients with preoperative CKD-stages 1 or 2._x000D_
OFF-RPN is a safe surgical approach in tertiary referral centres, with adequate oncological outcomes and negligible impact on RF.
Giuseppe Simone
Leonardo Misuraca
Gabriele Tuderti
Francesco Minisola
Mariaconsiglia Ferriero
Giuseppe Romeo
Manuela Costantini
Salvatore Guaglianone
Michele Gallucci
Robot Assisted Radical Prostatectomy For Prostates Over 100 Grams: Technique And Outcomes
|Prostate and Renal Oncology
Abstract: V8-09
Sources of Funding: None
Benign prostatic hyperplasia (BPH) is seen in more than 30% of men over 60 years age. It is not uncommon to encounter men with BPH having significant prostate cancer seeking treatment. Radical prostatectomy is technically challenging in very large prostate. We present our experience of robot assisted laparoscopic radical prostatectomy (RALP) in prostate weighing more than 100 gram. There are few studies reporting varying outcomes for >70 gm prostate. We compared RALP operative parameters and functional outcomes between 70-100 gm prostate with >100 gm prostate
We retrospectively reviewed our IRB approved prostate cancer database. RALP specimen weighing more than 100 gram in 183 men (Group 1) and 70 to 100 gram in 647 men (group 2). We compared demographic, operative, oncologic and functional outcomes between these two groups. In this video we describe the technical nuances during RALP for very large prostate with prostate cancer and present their outcomes. Early ligation of dorsal venous complex (DVC) reduces venous blood loss during further dissection. Proper identification of bladder neck and anterior entry favors recognition of median lobe. After visualizing bilateral ureteric orifice, constant upward traction of median lobe by fourth arm is important to enter proper posterior plane. Mobilization of the prostate and retraction can be challenging in these patients. Fish-mouth reconstruction of bladder neck helps watertight vesico-urethral anastomosis and urinary continence
Patient profile, operative parameters, oncologic and functional outcomes are shown in table 1. Operative time and estimated blood loss was higher in group 1. Many of these patients were not potent or had low SHIM scores and therefore did not have full NS. Chance of achieving bilateral full nerve spare was less in group 1. Higher incidence of extra capsular extension was observed in group 2 but positive surgical margin was similar between groups. At 12 months more than 95% achieved continence and there was no difference in biochemical recurrence, continence and potency between groups
Very large prostate size has slightly longer operative time and more blood loss. Prostate size >100 gm may challenge bilateral full NS. But, oncological and functional outcomes are not compromised by prostate size in experienced surgeons hands
Hariharan Palayapalayam Ganapathi
Gabriel Ogaya-Pinies
Eduardo Hernandez
Travis Rogers
Vipul Patel
Robotic Salvage Retroperitoneal and Pelvic Lymph Node Dissection for "Node-only" Recurrent Prostate Cancer
|Prostate and Renal Oncology
Abstract: V8-10
Sources of Funding: none
Despite primary treatment of prostate cancer with surgery or external radiation therapy, 20-40% of patients relapse within 5 years and 25-35% progress to metastatic disease. Salvage lymph node dissection has been proposed in patients with biochemical recurrence from prostate cancer and nodal involvement only, although the optimal template remains a question of debate. Herein we describe the technique of robotic high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for "node-only" recurrent prostate cancer.
Twenty patients underwent robotic sRPLND+PLND for "node-only" recurrent prostate cancer after definitive primary treatment as identified by carbon-11 acetate PET/CT. Our anatomic template extends from bilateral renal artery and vein cranially up to Cloquets node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees. Meticulous node-mapping assessed nodes at 4 prospectively-assigned anatomic zones.
Median age at salvage RPLND was 64 (45-76), median BMI was 26.4 kg/m2 (21.4 - 41.2), previous primary treatment was radical prostatectomy in 17 patients (85%) and external radiation therapy in 4 patients (15%), median time from primary treatment was 32 months (4-160) and median PSA at sRPLND+PLND was 2.1 ng/dl (0.28 - 38.17). Median operative time was 5 hours (3.5-5.8), blood loss was 100 ml (50-300), and hospital stay was 1 day (1-3). No patient had intra-operative complication, open conversion or blood transfusion. Four patients had Clavien II post-operative complications: flank/scrotal ecchymosis in 1 patient (5%), chylous ascites in 2 patients (10%) and neuropraxia/foot drop in 1 patient (5%). Final histology confirmed positive nodes in 16 patients (20%). Mean and median (range) number of nodes excised per patient was 89 and 80 (41-132) respectively. Mean and median (range) number of positive nodes was 21 and 6 (0-109) respectively. At 2 months post-operatively median (range) PSA was 0.76 ng/mL (<0.01-2 ng/mL).
Herein we describe the detailed technique of robotic high-extended salvage RPLND+PLND for "node-only" recurrent prostate cancer and present the initial experience. Robotic sRPLND+PLND duplicates open surgery, with superior nodal counts and decreased morbidity compared to the published literature. Longer follow-up is necessary to assess oncologic outcomes.
Carlos Fay
Andre Abreu
Daniel Park
Niero Rajarubendra
Daniel Melecchi Freitas
Giovanni Cacciamani
Inderbir Gill
The Use of a Novel Curved-tip Suction Device in Laparoscopic and Robotic Urologic Surgery
|Prostate and Renal Oncology
Abstract: V8-11
Sources of Funding: none
To describe the merits of a novel curved-tip suction device in laparoscopic and robotic urologic surgery.
A prototype for a laparoscopic curved-tip suction device was designed and produced by a manufacturer of laparoscopic instruments. The curve tip is designed to fit 5 mm, 8 mm, 10 mm, 11 mm and 12 mm laparoscopic trocars. The prototype was then used in over 150 laparoscopic and robotic-assisted prostatectomies, cystectomies, partial and radical nephrectomies and pediatric urology cases
Our experience with the curved-tip suction device for laparoscopic and robotic surgery has been promising in over 150 cases. The concave design facilitates optimal visualization of the focal point of dissection by keeping the working area clear without the suction shaft obscuring the surgical field as with conventional suction devices. This allows laparoscopic and robotic instruments to access tight work spaces without colliding with the suction device. The contour of this suction tip permits suctioning in recesses obscured by organs and bony prominences, which is particularly important when operating in the pelvis as we have seen with robotic prostatectomies and cystectomies. In cases of improper port placement, this device salvages operative conditions by optimizing exposure. Finally, this device allows for more precise and ergonomic tissue retraction without excessive torque that results in tissue injury as with conventional suction devices.
Based on our experience in laparoscopic and robotic urologic surgery, the use of a curved-tip suction device allows for better visualization of the surgical field, increased space for laparoscopic and robotic instruments to maneuver in the area of dissection and precise atraumatic tissue retraction.
Mina Fam
Michael Esposito
Gregory Lovallo
Thomas Christiano
Christopher Wright
Mutahar Ahmed
Combining antegrade and retrograde dissection during salvage robotic radical prostatectomy
|Prostate and Renal Oncology
Abstract: V8-12
Sources of Funding: None
Recently published series of salvage robotic radical prostatectomy for radiorecurrent prostate cancer showed the feasibility and the safety of this complex surgical procedure with favorable perioperative and satisfactory functional outcomes. This video shows surgical steps of a salvage robotic radical prostatectomy with pelvic lymph node dissection for radio recurrent prostate cancer.
_x000D_ _x000D_ We present a case of a 60 yr old patient who underwent primary radiation therapy in 2007 for a G7(3+4) prostate cancer. Due to a raising PSA, a prostate biopsy showed a G7(4+3) prostate cancer of the right lobe. A 18F Choline PET/CT was negative for nodal and distant metastasis. _x000D_ With the patient in a steep trendelenburg position a five trocar access was performed. Bilateral extended pelvic lymph node dissection was completed. The Retzius space was developed and the endopelvic fascia bilaterally incised. After sealing the dorsal vein complex with Ligasure, urethral stump was meticulously prepared and transected. The apex was retrogradely dissected up to identifying the Denonvilliers fascia, before moving to bladder neck isolation. Bladder neck was isolated and sectioned and seminal vesicles dissected. The Denonvilliers fascia was identified and opened and the dissection plane, previously prepared retrogradely, was identified. Bilateral extrafascial radical prostatectomy was completed. A Van Velthoven anastomosis with posterior muscolo-fascial reconstruction was performed. _x000D_ _x000D_
Operative time was 132 minutes. Blood loss was 300 ml. Postoperative course was uneventful and the patient was discharged on 3rd postoperative day. Pathologic examination showed a pT2bN0 G7(4+3) prostate cancer with negative surgical margins. One-mo PSA levels were 0.01 ng/mL. At 6 month follow up PSA level remained 0 and patient was continent._x000D_ _x000D_
Combining retrograde and antegrade dissections during salvage robotic radical prostatectomy may contribute to a safe development of the posterior dissection plane. Salvage robot assisted radical prostatectomy is a feasible treatment option for patients with radiorecurrent prostate cancer. _x000D_ _x000D_
Mariaconsiglia Ferriero
Giuseppe Simone
Riccardo Mastroianni
Gabriele Tuderti
Leonardo Misuraca
Francesco Minisola
Salvatore Guaglianone
Michele Gallucci
Three-Dimensional Photography as a Tool for Characterization of Penile Deformity in Peyronie's Disease
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-01
Sources of Funding: Columbia University College of Physicians & Surgeons
Non-curvature penile deformities are prevalent and bothersome manifestations of Peyronie's disease (PD) that can result in functional impairment and psychological distress. The quantitative metrics that are currently used to describe these deformities are inadequate and non-standardized, which has historically been a barrier to clinical research and patient care. Our aim is to introduce three-dimensional photography as a technique to improve the evaluation of patients with PD, partially by the measurement of erect penile volume (EPV) and percent erect penile volume loss (EPVL), and to assess the reliability of measurements acquired by 3D photography.
Six penis models were constructed using computer-assisted design software, and physical models were produced using a 3D printer. 3D photographs of each model were captured in triplicate by 4 observers using an inexpensive 3D camera (Structure Sensor, Occipital, San Francisco, CA). Computer software (Blender, Amsterdam, Netherlands) was used to generate automated measurements of EPV, penile length, minimum circumference, and maximum circumference. 3D images were then digitally reconstructed to restore each image to a non-deformed shape. Percent EPVL was calculated for each model as the percent difference between the EPV of the original model and the EPV after digital reconstruction. The automated measurements were then statistically compared to measurements obtained using water displacement experiments and a tape measure.
On average, 3D photography was accurate to within 0.1% for measurement of penile length. It overestimated maximum and minimum circumference by averages of 5.0% and 1.8%, respectively; overestimated EPV by an average of 8.6%; and underestimated percent EPVL by an average of 1.9%. All inter-test, inter-observer, and intra-observer ICC values were greater than 0.75, reflective of excellent methodological reliability.
Erect penile volume and percent EPVL are novel, highly descriptive metrics that may be useful in describing all variants of non-curvature, volume-loss deformities resulting from PD. These metrics can be quickly, accurately, and reliably determined using computational analysis of 3D photographs. Clinical research using 3D photography for assessment of EPV and percent EPVL will empower clinicians and researchers to better understand the clinical impact of penile volume-loss deformities and to study how these deformities respond to therapy.
Columbia University College of Physicians & Surgeons
Ezra Margolin
Carrie Mlynarczyk
Doron Stember
Peter Stahl
Complete Vestibulectomy for Neuro-Proliferative Vestibulodynia (NPVD): Urologic Surgical Technique and Outcomes
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-02
Sources of Funding: none
The vestibule, derived from the endodermal urogenital sinus and homologue of the male penile urethra is defined as introital tissue between vulva and vagina and surrounds the female urethral meatus. Vestibular pathology is commonly associated with introital dyspareunia. Women often complain of lower urinary tract symptoms and bladder pain, secondary in part to high tone pelvic floor dysfunction, and are often misdiagnosed with interstitial cystitis. Vestibulodynia is diagnosed by vestibular examination and cotton swab testing. Patients with diffuse vestibular pain may have NPVD, a mast cell disease of endoderm resulting in an increased density of C afferent nociceptors in the vestibule. Successful urologic surgery may require complete excision of the vestibule, from hymen to Hart&[prime]s line, passing within a millimeter of the meatus. Vaginal flap reconstruction is required to cover the defect from excised vestibule. We review a single urologist&[prime]s technique and surgical outcomes over a 7-year period showing complete vestibulectomy to be a safe outpatient urological treatment for NPVD._x000D_
In lithotomy position, the labia minora are retracted laterally. The incision is outlined 1 mm right/left of the urethral meatus, extending superiorly for several centimeters, passing laterally to Hart&[prime]s line and inferiorly 2 cm below the posterior fourchette. Medially the incision passes inferiorly from meatus to hymenal tissue extending 2-3 mm below the hymenal ring. Liposomal bupivacaine is used to hydro-dissect vestibular epithelium off the subcutaneous tissue. The 3 mm deep specimen is sharply dissected en bloc. Reconstruction involves left/right anterior repair to close the dead-space bringing together urethral meatus to vulva. Posterior repair involves developing a vaginal tissue advancement flap with finger dissection of rectovaginal fascia. Anchoring sutures are placed from rectovaginal fascia though vaginal wall. Final repair brings together vagina to vulva. Additional liposomal bupivacaine is placed for post-op pain control. _x000D_
60 patients from 2009-2016 underwent complete vestibulectomy for NPVD with mean operative time 60 minutes, and mean intra-op blood loss 75 ml. There were no anesthesia complications, post-operative infections, flap complications, or acute re-explorations. No patient experienced worsened pain and 80% were pain free at 1 year.
A safe technique with wide resection for outpatient complete vestibulectomy has been reviewed.
Rachel Rubin
Ashley Winter
Paulina Plascencia
Irwin Goldstein
Randomized Clinical Trial of the No-Flip ShangRing Circumcision for Adolescents and Adults in Africa
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-03
Sources of Funding: The Bill & Melinda Gates Foundation (Global Health Grant Number OPP1084493) to EngenderHealth and Weill Cornell Medicine
Male circumcision (MC) provides a variety of medical benefits, including a 50-60% reduced risk of HIV transmission. The ShangRing is one of two WHO-prequalified MC devices and it comprises a key component of the scale-up of MC services in Africa. The No-Flip ShangRing circumcision technique represents a further simplification of this procedure. The objective of this study was to evaluate the outcomes of this technique in African adults and adolescents with regard to procedure duration, pain, adverse events, healing time, and patient satisfaction. Further, we sought to compare safety, healing rates and patient satisfaction after ring removal at 7 days versus spontaneous detachment.
We enrolled patients 10 years of age or older at two study sites in Kenya. All procedures were performed by physicians or nurses trained in the No-Flip ShangRing technique. Patients were randomized in 1:1 fashion to ring removal at 7 days versus spontaneous detachment. Outcomes were assessed weekly until 42 days or complete wound healing.
230 patients were enrolled in this study, age ranges 10 to 54. Over 80% of circumcisions were performed by nurses trained in the No-Flip technique. All patients (230/230) were suitable for ShangRing MC regardless of the presence of phimosis or adhesions. On subgroup analysis of patients 10-15 years of age versus >15 years, though more patients in the younger group required a dorsal slit and breaking down of adhesions prior to ring insertion, there was no difference in operative time and all circumcisions were successfully completed (Table 1). There was no difference in pain or adverse events between the age groups, and there was ≥97% patient satisfaction in both groups. Within the group randomized to spontaneous detachment, 72.4% of patients experienced detachment at median 14 days; 27.6% of patients requested ring removal due to pain or discomfort. There were no differences between spontaneous detachment and 7-day removal with regard to healing time, adverse events, or patient satisfaction.
The No-Flip ShangRing procedure is simple, safe, effective, and acceptable for use in patients 10 years of age or older. Spontaneous detachment is safe and effective, and has the potential to reduce the burden of service provision in resource-poor settings.
The Bill & Melinda Gates Foundation (Global Health Grant Number OPP1084493) to EngenderHealth and Weill Cornell Medicine
Benjamin V Stone
Omar Al Hussein Alawamlh
Phil V Bach
Ryan Flannigan
Quentin Awori
Marc Goldstein
Mark Barone
Philip S Li
Richard K Lee
One-stage transvesical laparoendoscopic single-site surgery (T-LESS) for removal of two bladder diverticula in a female patient.
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-04
Sources of Funding: None
Bladder diverticula are usually encountered in males, and they are a rarity in women, especially in the absence of obstruction. Open surgery, as well as laparoscopic or robotic, or single-port surgery have been applied successfully to remove bladder diverticula. To the best of our knowledge, no single-port diverticulectomies have been performed in women. We present the case of using the transvesical laparoendoscopic single-port surgery (T-LESS) for excision of two bladder diverticula in a woman
In August 2016, we carried out the T-LESS access on a 67-year old woman to remove two symptomatic bladder diverticula in one session. The patient was placed in the lithotomy position and was under general anesthesia. _x000D_ The procedure was performed transvesically (percutaneous intraluminal approach) with a single-port device (Tri-Port+) via a 1.5-cm incision made 3 cm above the pubic symphysis. Standard 10-mm optic and straight laparoscopic instruments were used. The diverticula were dissected and removed from the bladder with a combination of standard laparoscopic and endoscopic instruments introduced through the TriPort+ or the urethra. The bladder wall openings were closed by running absorbable 2/0 polyglactin sutures. An 18F Foley catheter was left in place for 6 days._x000D_
The operation lasted 120 minutes. Blood loss was minimal, and no complications were observed. The postoperative period was uneventful. The patient was discharged within 18 hours of surgery. During a nine-week follow-up, the patient reported the significant improvement in the severity of symptoms. Laboratory examination results were all within the normal range.
The T-LESS procedure can be considered as a valuable option for diverticulectomies in female patients because of its minimal invasiveness, short hospital stay and fast recovery time
Marek Roslan
Maciej Przudzik
Michal Borowik
Miroslaw ?esiów
Laparoscopic varicocelectomy using intraoperative navigation: indocyanine green angiography and indigo carmine lymphatic dye
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-05
Sources of Funding: None
Varicocelecomy is widely performed to treat of male infertility, scrotal pain, and testicular atrophy. A variety of techniques have been reported. Laparoscopic varicocelectomy is still a commonly used method for varicocele repair. However, the most popular surgery for varicocele uses a microsurgical inguinal or subinguinal approach mainly because of the disadvantages of a retroperitoneal approach including a high incidence of varicocele recurrence and hydrocele formation. Failure is usually caused by preservation of persistent tiny veins and postoperative hydrocele is caused by cutting of lymphatics. On the other hand, a laparoscopic procedure should allow preservation of the testicular artery in a majority of cases and preservation of lymphatics. It is extremely vital to eliminate spermatic venous flow completely to reduce the recurrence rate as much as possible. To facilitate the identification of spermatic vessels and ensure the ligation of veins as well as arterial and lymphatic preservation, we performed laparoendoscopic single-site (LESS) varicocelectomy using intraoperative navigation.
An umbilical incision of 25 mm was made. We placed a GelPOINT? Mini Advanced Access Platform (Applied Medical, Rancho Santo Margarita, CA, USA), which has one 12 mm trocar and two 5 mm trocars. After exposing of the spermatic cord, 2 ml of indigo carmine was injected into the space between the tunica vaginalis and tunica albuginea. Then, 1 ml of indocyanine green (ICG, 2.5 mg/ml) was injected intravenously. Spermatic veins were cauterized by bipolar forceps. The spermatic artery and lymphatics were preserved. ICG was injected again to confirm preservation arterial blood flow and that there were no remaining veins.
A few seconds after injection of indigo carmine, one bundle of lymphatics was stained. About 20 s after injection of ICG, fluorescence of gonadal arterial flow was detected clearly. About 20 s after that, gonadal veins were observed somewhat dully. The artery and lymphatics could be preserved and the veins were cut. Finally, we performed ICG angiography again. Arterial flow was preserved and venous flow was not observed. 3 months later, color Doppler ultrasonography confirmed complete disappearance of the varicocele.
LESS varicocelectomy using ICG angiography and indigo carmine lymphatic dye facilitates visualization and identification of spermatic vessels. Continued investigation should determine whether it could reduce the disadvantages of laparoscopic varicocelectomy.
Keiji Tomita
Eiki Hanada
Susumu Kageyama
Kazuyoshi Johnin
Mitsuhiro Narita
Akihiro Kawauchi
Robot Assisted Penile Inversion Vaginoplasty: A Novel Technique
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-06
Sources of Funding: none
Gender confirmation surgery is an essential component in the management of gender identity disorder. However, short vaginal length, vaginal stenosis, or complications in the perineal dissection are significant limitations of current techniques in male to female surgery. Here we describe our technique for the robot assisted penile inversion vaginoplasty that addresses these needs.
The patient is prepped and draped in low lithotomy position. The penis is degloved through a circumcision incision. The neurovascular bundle, urethra and corpora cavernosa are dissected out. _x000D_ A six cm bulbar perineal incision is then made, and the dissection is carried to the bulbar urethra. The dissected urethra, neurovascular bundle, glans and corpora are delivered through this incision. The bilateral corpora are transected at their most proximal limit and overswen. The penile skin is inverted and gently retracted to allow a two cm incision above the neovagina for the neoclitoris. Immediately below this, an incision for the neomeatus is made. The urethra is brought through this incision and sutured to the skin. The remaining urethral tissue is used as an inlay onto the incised dorsal epithelial surface of the penile skin. _x000D_ The robotic portion of the surgery uses 4 port incisions: periumbiical Gelport with two pre-placed robotic trocars, right and left lateral ports, and an assistant port in the upper right abdomen. The dissection is from the posterior prostate, staying above Denonviller's fascia to reach the endopelvic fascia. Under direct vision, the endopelvics are opened sharply from below and opened to a width of two fingerbreadths. The neovagina is passed into robotic field and pexed to the anterior reflection of the posterior peritoneum. The peritoneal reflection is then closed._x000D_ The neoclitoris is fashioned from the glans penis and approximated. Labia majora and minora are fashioned with local skin flaps. A foley catheter is left indwelling as well as a vaginal stent. _x000D_
The index case required 7 hours of surgical time with an estimated blood loss of 100 mL. The vaginal length was greater than 15 cm. The patient was discharged home on post-operative day three, with no complications. The patient endorses sensation at the neoclitoris and anterior neovagina, and finds the vaginal depth satisfactory
Our novel method for robot assisted penile inversion vaginoplasty is an important step in optimizing outcomes for our patients. This technique achieves maximal vaginal length in a safe and reproducible manner.
Temitope Rude
Kiranpreet Khurana
Aaron Weinberg
Jamie Levine
Michael Stifelman
Lee C. Zhao
Microsurgically-Assisted Inguinal Hernia Repair
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-07
Sources of Funding: Frederick J and Theresa Dow Wallace Fund of the New York Community Trust & the Agency for Healthcare Research and Quality (T32HS00066)_x000D_ _x000D_ This work was supported in part by the Urology Care Foundation Research Scholar Award Program and AUA New York Section Research Scholar Fund
: Inguinal hernia repair is the most commonly performed general surgical procedure, with mesh repair being the favored method. Complications such as chronic pelvic pain and iatrogenic vasal obstruction can occur in up to 19% and 3% of patients, respectively. Better intraoperative visualization of the ilioinguinal nerve has been associated with decreased postoperative pelvic pain. The operating microscope offers the best visualization of inguinal structures and is commonly used in highly precise male infertility procedures. We describe the rationale, technique, and surgical outcomes of microsurgically assisted inguinal hernia repair.
We conducted a retrospective review of 252 microsurgically assisted hernia repairs with mesh performed by a single surgeon (M.G.). In all procedures, the vas deferens, deferential vessels and nerves, ilioinguinal nerve, genital branch of the genitofemoral nerve, and spermatic vasculature were identified and preserved under 6-25X magnification. Surgical outcomes and complications were abstracted retrospectively from patient charts.
Mean follow-up was 26.7 months. Mean patient age was 50.5 years. 196/252 (78%) of patients were symptomatic from their hernias. 215/252 (86%) of patients were undergoing concomitant microsurgical fertility related procedures such as varicocelectomy (56%) and hydrocelectomy (28%). No chronic post-operative pain or vasal injuries were reported. Additionally, no sensory loss or infections were reported. The only complications were one post-operative one hematoma (0.4%) that was managed conservatively and one recurrence (0.4%).
Operating microscopes have an established record of facilitating extremely difficult male infertility procedures. The application of the operating microscope for inguinal hernia repair resulted in very low complication rates under 1%. Remarkably, there were no instances of chronic post-operative pain or sensory loss, representing significantly improved surgical outcomes compared to those reported in the literature.
Frederick J and Theresa Dow Wallace Fund of the New York Community Trust & the Agency for Healthcare Research and Quality (T32HS00066)_x000D_ _x000D_ This work was supported in part by the Urology Care Foundation Research Scholar Award Program and AUA New York Section Research Scholar Fund
Ryan Flannigan
Brian Dinerman
Phil Bach
Michael Shulster
Philip Li
Marc Goldstein
Male Infertility Microsurgery Training – Tricks of the Trade
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-08
Sources of Funding: Supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust.
Male infertility microsurgery (MIM) is physically, technically and mentally challenging, with surgical outcomes that are heavily dependent on the surgeon&[prime]s skills. MIM training programs that incorporate systematic evaluation protocols offer an excellent platform to teach microsurgical skills while avoiding the acquisition of bad habits. In this report, we describe the most common mistakes made by trainees who attended our MIM training program.
We conducted a retrospective review of prospectively collected data from five trainees who attended the MIM training program between July 2015 and December 2015. _x000D_ _x000D_ Briefly, the IRB-approved MIM training program at Weill Cornell Medicine is a two-week training course offered to urologists of all levels that is held in a dedicated MIM training lab. During the first week, trainees are introduced to the operating microscope, microsurgical instruments and sutures, and focus on developing basic microsurgical suturing skills. During the second week, the trainees start to perform live MIM procedures (vasovasostomy and vasoepididymostomy) on a rodent model. Instructors provide intense supervision and continuous evaluation throughout all phases of the training. Trainees are also able to observe surgical cases performed at our institution. Evaluations are conducted four times throughout the training course using a structured score form measuring 18 items, each on a 5-point Likert scale._x000D_ _x000D_ Trainee scores were assessed and compared for improvement over the course of the training course._x000D_
The most common mistakes made by our trainees revolved around sitting position, hand tremor, instrument handling, needle control, suture placement, and knot tying. The errors were most prevalent early on and there were statistically significant improvements across all domains by the end of the MIM training course (Table).
A MIM training program is an effective tool for teaching MIM skills. By incorporating intense supervision and continuous evaluation into an MIM training program, MIM trainees can avoid the development of bad habits that may be difficult to overcome and potentially have a negative impact on surgical outcomes.
Supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust.
Phil V. Bach
Filipe Neto
Ryan Flannigan
Benjamin Stone
Omar Al Hussein Alawamlh
Miriam Feliciano
Richard Lee
Peter Schlegel
Marc Goldstein
Philip Li
Robot-assisted Laparoscopic Management of Inflatable Penile Prosthesis Reservoir Migration into Bladder with Utilization of Cryopreserved Amniotic Membrane and Umbilical Tissue
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-09
Sources of Funding: None
At our institution robot assisted laparoscopy has been adopted for many types of exploratory and reconstructive procedures. We have also utilized cryopreserved amniotic membrane and umbilical cord matrix to facilitate healing in hostile tissue environments. Here we present a 70 year old male with a history of inflatable penile prosthesis placement after radiation and salvage prostatectomy who presented with lower urinary tract symptoms. He was discovered to have reservoir migration into the bladder and was offered a robot assisted laparoscopic exploration with prosthesis reservoir explant and reimplant.
We performed a robot-assisted laparoscopic exploration and inflatable penile prosthesis reservoir removal and reimplant. We utilized a cryopreserved amniotic membrane and umbilical tissue graft along the suture line to assist in tissue healing.
Our patient tolerated procedure well and his lower urinary tract symptoms are improved. He has not experienced infection of his prosthesis and it remains functional.
Robot assisted laparoscopic management of migrated prosthesis reservoirs may be a safe and feasible approach in select patients. We will continue to explore the use of cryopreserved amniotic membrane and umbilical cord matrix in patients with tissue environments hostile to normal healing.
Mark Ferretti
Gregory Lovallo
Michael Stifelman
Mutahar Ahmed
Transurethral resection of ejaculatory ducts: a step-by-step guide
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-10
Sources of Funding: None
Ejaculatory duct obstruction (EDO) is a rare but surgically correctable cause of male infertility. Transurethral resection of the ejaculatory ducts (TURED) serves as an important therapeutic management option for partially and/or completely obstructed ejaculatory ducts (EDs) that may result in significant improvement of semen parameters and pregnancy rate. The aim of this study is to demonstrate the key components for completing a successful TURED. _x000D_
We present a case of a 40-year-old man who presented with primary infertility. His past medical history was otherwise not significant. Physical examination revealed non-tender 14cc testes bilaterally with present and non-tender vas deferens and epididymis. Hormone studies were within the normal range. Semen analysis was abnormal (pH 6.4, volume of 0.7cc, concentration 16 million/cc and 7% motility). A trasnrectal ultrasonography revealed dilated seminal vesicles measuring more than 1.5 cm and seminal vesicle aspiration detected no sperm in the aspirate. _x000D_ We began the procedure by placing the patient in the conventional lithotomy position. Transrectal ultrasonography-guided seminal vesicle puncture was performed and methylene blue was injected into both seminal vesicles. Cystoscopy was performed focusing in the area of the verumontanum to assess for methylene blue drainage in order to more precisely proceed with resection of the ejaculatory ducts._x000D_ Vesiculography was performed by placing a 5 French ureteral into the freshly opened EDs in order to assess for patency and confirm both sides had been opened. Hemostasis was performed carefully in order not to occlude the newly open EDs. _x000D_
Patient was discharged home with foley catheter in place with a voiding trial performed one day later. He returned to clinic at 2 weeks for a post-operative evaluation. Semen analysis revealed improved parameters (pH 7.2, volume of 1cc, concentration 20 million/cc and 60% motility). _x000D_
The key portions for performing a successful TURED includes seminal vesicle instillation of methylene blue for easier ED identification. Vesiculography is performed near the end of the procedure to ensure both EDs have been opened as well as to assess for passive drainage of the seminal vesicles through the newly open EDs._x000D_
Luis Savio
Joseph Palmer
Nachiketh S Prakash
Raul Clavijo
Desmond Adamu
Ranjith Ramasamy
Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-11
Sources of Funding: None
Many men suffering from erectile dysfunction (ED) are overweight with separate generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length. We present a novel surgical concept of suprapubic fat pad excision with concomitant placement of inflatable penile prosthesis (IPP).
A transverse incision is made starting 2 cm inferior and medial to the ASIS and carried across the infrapubic region in a curvilinear fashion, passing approximately one finger breath above the base of the penis. The incision continues in a symmetric fashion to the contralateral side. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the IPP is placed via an infrapubic approach following our standard protocol for prosthetic insertion. The wound is reapproximated and two drains are placed, one subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump.
A total of eight patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average BMI of our patient cohort is 36.6. One patient required explant secondary to prosthetic infection after inadvertent removal of his JP drains immediately post-op. At last follow up, all other patients have excellent cosmetic and functional outcomes.
Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with placement of IPP in appropriately selected patients. Functional outcomes of our initial series have been excellent. This procedure can lead to enhanced patient satisfaction in those with concurrent erectile dysfunction and significant suprapubic fat pad.
Adam Baumgarten
Jonathan Beilan
Michael Bickell
Justin Parker
Gerard Henry
Rafael Carrion
Fertility recovery after laparoscopic removal of hypertrophic seminal vesicle
|Infertility, ED, and Reconstruction Lower Tract (II)
Abstract: V9-12
Sources of Funding: None
Zinner syndrome is a rare condition which include unilateral renal agenesis, ipsilateral seminal vesicle cyst and ejaculatory duct obstruction. It is generally diagnosed during the third or the fourth decade of life. While some patients may remain asymptomatic and are discovered incidentally, others present with symptoms related to seminal vesicle cysts or ejaculatory duct obstruction. Invasive treatment should be restricted to symptomatic cases. We present a case of fertility recovery after surgical treatment.
A 20-year-old man presented with azoospermia and perineal discomfort. An abdominal ultrasound documented a left kidney agenesis and a MRI confirmed the presence of left seminal vesicle cyst. The patient qualified for laparoscopic removal of the left seminal vesicle cyst because of persistent pain.
The procedure lasted 145 minutes, with no intra operative complications. The estimated blood loss was 40 mL. The patient was discharged from the hospital on the third postoperative day. Histopathologic examination confirmed the dysgenetic nature of the left seminal vesicle. At the 6-months follow-up the patient was asymptomatic. At the sperm analysis we found a fertility recovery with 1.8 millions sperms with 88% motility.
Zinner syndrome is uncommon and should be treated only in symptomatic cases. This case suggest that surgical treatment could have a role in fertility recovery, probably due to a contralateral compression of seminal ducts. Our experience confirm that laparoscopic approach is a valid, non-traumatic, safe removal technique.
Gaetano Chiapparrone
Giovanni Liguori
Nicola Pavan
Grazia Bianchi
Andrea Lissiani
Carlo Trombetta