Videourology Abstracts

Abstract

The First Disposable Morcellator for Benign Prostate Obstruction: The Cyber Blade Morcellator System

Luca Carmignani, MD, Oskar Blezien, MD, Filippo Molinari, MD, Claudia Signorini , MD, Elisabetta Finkelberg, MD, Stefano Picozzi, MD,Pietro Acquati, MD, Robert Stubinski, MD, Dario Ratti, MD, Gloria Motta, MD, and Sebastiano Nazzani, MD

Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.

Introduction: Bipolar and laser (thulium and holmium) enucleation of the prostate are nowadays commonly performed procedures.¹ They represent an optimal minimally invasive alternative to open adenomectomy and transurethral resection of the prostate that is still the therapeutic gold standard according to European Association of Urology guidelines for benign prostatic obstruction.² One of the major concerns about enucleation of the prostate is the second critical step of the procedure, morcellation.³ Morcellation is necessary to extract the prostatic adenoma detached during the procedure and several factors could impact on its performance. First, visibility could be suboptimal because of intraoperative bleeding and it could affect the operatory time and the patient safety. Second, in large prostates the morcellation time is not trivial and it might increase the risk of bladder damages. Third, the type of morcellator that allows the best performance has not been yet recognized. Different types of morcellator are now available on the market with different characteristics. The most commonly used are the Richard Wolf Piranha, with a rotating toothed blade, the Karl Storz DrillCut,⁴ with an oscillating toothed blade and the Lumenis Versacut with a nontoothed guillotine blade. The Richard Wolf Piranha and the Karl Storz DrillCut are oscillating morcellator, whereas the Lumenis Versacut is a reciprocating morcellator. These morcellators are different, but none of them is completely disposable.

Materials and Methods: In this study, we present our early experience of thulium enucleation of prostate with Quanta System Cyber™ 200 W and with morcellation using the Quanta System Cyber Blade™ Morcellator System a whole disposable system. The device is a single-use rotating toothed-blade morcellator. Blade length is 370 ± 5 mm and blade diameter is 4.5 mm. We treated five consecutive patients with this technique.

Results: No complications occurred during the procedures. However, the morcellator suction channel was blocked by prostatic tissue during two procedures and was subsequently immediately replaced. Finally, the quality of the pathologic specimen was comparable with nondisposable devices.

Conclusion: The Quanta System Cyber Blade Morcellator System is the first disposable morcellator and appears to have a good safety and operative profile. Moreover, it could improve infection rates and allows to rapidly replace the whole system in case of damages. However, further studies are needed to determine the clinical value of this instrument.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0001

Robot-Assisted Laparoscopic Partial Cystectomy for Bladder and Distal Ureteral Urothelial Carcinoma

Shuo Liu, MD, Taylor C. Peak, MD, Ram A. Pathak, MD, and Ashok K. Hemal, MD

Department of Urology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.

Introduction: Partial cystectomy has been purported as a less morbid alternative to radical cystectomy in carefully selected patients affected by urothelial carcinoma (UC).^1,2 Selection criteria include solitary lesion without concomitant carcinoma in situ in an otherwise normally functioning bladder. Herein, we present three separate cases of robot-assisted laparoscopic partial cystectomy (RALPC) in which the UC involved the bladder, the bladder diverticulum, and the distal ureter.

Materials and Methods: The study has been approved by the institutional review board at Wake Forest Baptist Medical Center (WFBMC). We present three surgical scenarios related to localized UC and their subsequent surgical approaches: (1) high-grade muscle invasive bladder tumor involving the right anterolateral aspect of the bladder wall, (2) high-grade localized intradiverticular UC in proximity to the left ureteral orifice, and (3) low-grade urothelial lesion of the distal ureter requiring bladder cuff excision and ureteroneocystostomy.³

Results: During a standard RALPC, the patient was placed in low lithotomy position. After port placement and robot docking, flexible cystoscopy under pneumovesicum was performed to allow direct observation of the tumor and to guide cystotomy. More recently we have utilized fluorescence imaging with submucosal injection of indocyanine green (ICG) to outline surgical excision site for the surgeon at the console using the Williams cystoscopic injection needle. ICG can also be helpful in directing pelvic lymph node dissection (PLND).⁴ To minimize disease contamination, surgical specimen containing the tumor was suspended with the robotic third instrument arm during the excision process. It was then immediately placed within the specimen retrieval bag when completely resected off the rest of the bladder. Frozen sections were obtained from the edges of the cystotomy site to ensure oncologic clearance. The bladder was then closed in two layers using an inner 3-0 absorbable monofilament and an outer 3-0 barbed suture for watertight closure. Bilateral PLND was performed. In the patient with intradiverticular UC, an anterior vertical cystotomy was performed to observe the diverticular neck. A stent was placed to the adjacent ureteral orifice. The mucosa overlying the diverticular ostium was scored and then immediately closed with sutures to minimize tumor spillage. A combination of intra- and extravesical dissection was undertaken to free the sac. Anterior and posterior bladder defects were then closed. For the patient with low-grade distal ureteral disease, the ureter was identified with 30° down-angled endoscope near its crossing over the common iliac artery. Distal ureterectomy with ureteroneocystostomy was performed followed by ipsilateral PLND. A bladder psoas hitch was necessary to facilitate a tension-free reconstruction. The ureteral stent was removed at 4 weeks. Foley catheter was placed for bladder drainage in all cases until outpatient cystogram was obtained on postoperative day 10. No local, regional, and distant disease recurrences were detected for any of the patients on their 12-month follow-up visit.

Conclusions: RALPC is safe and effective, and can be offered to suitable candidates with little surgical morbidity. Precautions and measures should be undertaken to avoid tumor spillage.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0040

Treatment of Nonmuscle Invasive Bladder Cancer Using a Novel Zedd Scissors

Belthangady Monu Zeeshan Hameed, MS, Milap Shah, MS, Padmaraj Hegde, MS, Nithesh Naik, BE,Kanthilatha Pai, MD, and Bhaskar Somani, DM, FEBU, FRCS (Urol)

¹Department of Urology, Kasturba Medical College, MAHE, Manipal, India.

²Department of Mechanical and Manufacturing Engineering, Manipal Institute of Technology, MAHE, Manipal, India.

³Department of Pathology, Kasturba Medical College, MAHE, Manipal, India.

⁴Department of Urology, University Hospital Southampton NHS Trust, Southampton, United Kingdom.

Introduction: Treatment of nonmuscle invasive bladder cancer (NMIBC) usually requires piecemeal resection of the tumor. En bloc resection emerges as a promising technique for small bladder tumors <3 cm. The completeness of resection is defined by the presence of the detrusor muscle (DM) in the specimen. Contrary to the advantages of en bloc resection, there are several drawbacks of electrocautery for the resection of tumor. These include absence of DM, presence of obturator jerk because of dissipation of heat, perforation of bladder, and charring of the specimen. We share our experience of cold en bloc excision (CEBE) technique for nonmuscle invasive bladder tumor using the novel Zedd scissors.

Methods and Materials: This was a single center prospective study carried out at department of urology at Kasturba Medical College, Manipal, India, from July 2019 to October 2019. Patient consent was obtained and a total of 12 patients were included in the study who had pedunculated tumors of size ≤3 cm, and up to three lesions in total. Any patient with endoscopic suspicion of carcinoma in situ, upper tract transitional cell carcinoma, broad base tumors >3 cm, and more than three tumors was excluded from the study. A novel Zedd scissors that could be passed through the working channel of 20.8F mini nephroscope was used for CEBE of the tumors with minimal use of electrocautery to coagulate the bladder base. The excised specimen was sent for histopathologic examination and patients were followed up at 3 months with check cystoscopy.

Results: A total of 12 patients underwent CEBE using the Zedd scissors. The mean size was 1.6 cm (range: 1–2.6 cm). The mean excision time was 4 min 26 sec. None of the patients had obturator jerk or bladder perforation. There was no significant drop in hemoglobin in the postoperative period. Patients were discharged after 48 hr of the procedure. The histopathologic findings were T1 (n = 7), Ta (n = 4), and T2 (n = 1). Ten patients had presence of DM in the specimen. Follow-up at 3 months with cystoscopy did not show any recurrence.

Conclusion: CEBE using Zedd scissors is safe and efficacious with confirmed presence of DM in the specimen. It avoids charring of the tissues, and the risk of perforation because of obturator jerk is almost negligible. It is also an economical alternative to various other modalities used for resection of NMIBC.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0031

Abdominal Wall Retraction Sutures for Laparoscopic Trocar Insertion in Children

Bülent Önal, MD, Deniz Abdullahoğlu, MD, Emre Bülbül, Elif Altınay Kırlı, MD, and Fahri Yavuz İlki, MD

Department of Urology, Istanbul University-Cerrahpaşa School of Medicine, Istanbul, Turkey.

Introduction: The laparoscopic and robot-assisted laparoscopic surgeries are widely accepted in the pediatric urology practice.¹ The small abdominal cavity and the elastic abdominal wall make it difficult to insert a trocar safely into the abdominal cavity because of tenting, especially in infants.^2
–4 The Hasson technique is preferred for insertion of initial trocar because of lower complication rates.5 Although the pneumoperitoneum that is created by using an initial trocar allows a direct observation by moving the intra-abdominal organs away from the abdominal wall, the insertion of the instrument trocar requires special care.2,6 Also, unbounded twisting movements and the excessive force that is applied to pass through the elastic abdominal wall may mislead the trocar in the abdomen, leading to vascular or visceral injury. We overcame tending problem by sling the abdominal wall with two retraction sutures before inserting the instrument trocar. This trocar insertion technique reduces the abdominal wall flexibility and the tenting of the peritoneum, providing an easy, fast, and safe penetration into the abdomen.

Materials and Methods: Sixty-eight trocar accesses were evaluated retrospectively in 32 pediatric patients, who underwent laparoscopic (n = 11) and robot-assisted laparoscopic surgery (n = 21) in terms of duration to create pneumoperitoneum and insert instrument trocar along with the complications (January 2018 to December 2019). Surgical technique: initial paraumbilical trocar access and pneumoperitoneum were achieved by the Hasson open technique. After making a 0.3–0.5 cm skin crease incision and dissecting the subcutaneous tissue, fascia was identified. Full-thickness abdominal wall (fascia, muscle, and peritoneum) sling sutures were placed under direct vision. The suture placement has to include the peritoneum for maximum benefit. The suture material should be selected depending on the patients' anatomy (4.0 or 3.0 Vicryl [CT-1, -2, or -3]). Elevating sling sutures at the corners of incision supports and strengthens the abdominal wall, reducing the flexibility of fascia and tenting of the peritoneum. During the trocar instrument insertion, sling sutures were elevated, and a minimal force was applied to the trocar with controlled twisting movements.

Results: The median age of 32 patients was 8.4 years (range 6 months to 17 years). The median time of initial trocar insertion (n = 32) was 4 minutes (range 3–6 minutes), whereas the median time of an instrument trocar insertion (n: 68) was 2 minutes (range 1–3 minutes). The average follow-up time after surgery was 21 months (range 8–41 months). We did not experience any periods of pressure drop; neither we recorded any perioperative (vascular or visceral laceration) or postoperative (wound infection or incisional hernia) complications.

Conclusion: Abdominal wall sling with two sutures reduces the flexibility of fascia and tending of the peritoneum, providing an easy, fast, and safe way to insert the instrument trocar into the abdominal cavity. To discuss the superiority of the method, further studies with comparison groups are required.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0051

Performance of Thulium Super Pulse Laser for Endoscopic Ablation of Urothelial Cell Carcinoma: Results of the First Cases in North America

Bristol B. Whiles, MD, Raphael V. Carrera, MD, Moben Mirza, MD, Jeffrey M. Holzbeierlein, MD, and Wilson R. Molina, MD

Department of Urology, University of Kansas, Kansas City, Kansas, USA.

Introduction: Tumor laser ablation (LTA) is a valuable option for treatment of urothelial cell carcinoma (UCC) in patients who are not amenable to nephroureterectomy. Recent in vitro studies demonstrate efficacy of the SOLTIVE™ Super Pulse Thulium Fiber Laser (SPTF) for lithotripsy and a safety profile comparable with those of Ho:YAG systems.^1

–5 Previous reports on ex vivo models have demonstrated similar cutting depth and better coagulation properties favoring the SPTF.6,7 However, the clinical use of this novel technology for LTA has not been described. The purpose of this study is to report the first cases of upper tract and bladder UCC treated endoscopically with the newly released thulium super pulse.

Materials and Methods: In this retrospective chart review, we identified patients with upper tract and/or bladder UCC treated with the thulium super pulse between November 2019 and December 2019. Patient characteristics, intraoperative parameters/images, surgeon subjective assessments, and postoperative outcomes were obtained.

Results: A total of four patients, mean age 75.3 years, underwent LTA with the thulium super pulse during the study period. Procedures were unilateral in three patients with one patient undergoing bilateral upper tract and bladder LTA. Although not the routine indication for endoscopic LTA at our institution, the patients in our cohort presented here had high volume or high-grade disease, but declined more invasive therapies such as nephroureterectomy. All had undergone biopsy before endoscopic ablation. Laser fiber size was 150 or 200 μm. Mean laser time was 19.4 ± 11.4 minutes, total energy was 22.2 ± 21.7 kJ, and operative time was 146 ± 40.1 minutes. The most commonly used laser setting was 0.6 J and 12 Hz in the upper tract and 0.6 J and 26 Hz in the bladder. All surgeries were outpatient, except for one patient who stayed because of postoperative oxygen requirement. There were no specific complications related to use of the laser. On subjective surgeon assessment, increased satisfaction with the thulium super pulse laser was thought to be secondary to a more precise and controlled ablation, excellent tissue hemostasis, and improved visualization.

Conclusions: Initial LTA with thulium super pulse fiber laser seems promising regarding tumor ablation, hemostasis, and intraoperative safety. This novel technology has the potential to potentially become the gold standard for the treatment of UCCs in the future with further study patients who are more amenable to endoscopic ablation such as those with low grade and low volume of tumor burden. Prospective studies comparing this new laser platform with current standard of care system (Ho:YAG) are required for further conclusions.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0069

Robotic Partial Nephrectomy for Completely Endophytic and Hilar Renal Tumors

Alp Tuna Beksac, MD, Kirolos Meilika, MD, Kennedy Okhawere, MD, and Ketan K. Badani, MD

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Introduction: Robot-assisted partial nephrectomy can be challenging in patients with completely endophytic tumors because of the difficulties in observation of the tumor. Endophytic tumors are especially challenging when they are in proximity to the renal hilum. We describe our technique to safely perform robotic partial nephrectomy (RPN) in this complex scenario and report on outcomes.

Patients and Methods: In total, 498 patients from a single surgeon series of transperitoneal RPN were analyzed. After bowel mobilization, ureter identification, and hilar dissection, farm of the Da Vinci Xi^® model was used to stabilize the kidney. Using the Tilepro™ feature, intraoperative ultrasonography (US) was performed to localize the tumor, delineate the edges, and assess the depth of the tumor precisely. Subsequently, the healthy parenchyma above the tumor was excised. US was repeated and tumor excision performed. Two-layer renorrhaphy was performed using 3.0 barbed polyglyconate suture and 0 polyglactin sutures. Nineteen (3.85%) patients with completely endophytic and hilar renal masses were analyzed. Results were compared with the rest of the partial nephrectomy cohort (n = 479, 96.15%) to compare perioperative outcomes. Renal tumors were classified based on R.E.N.A.L nephrometry score. Baseline demographic, clinic, and tumor-specific characteristics, and perioperative and postoperative outcomes were compared between both cohorts. Owing to the uneven sample sizes, patients were 1:2 propensity matched.

Results: All baseline characteristics were similar except for R.E.N.A.L. score. After propensity score matching, 34 (64.15%) nonendophytic and nonhilar and 19 endophytic and hilar (35.85%) patients were compared. R.E.N.A.L. score was the only significantly different variable after matching (6 vs 9; p < 0.001). There was no significant difference in ischemia time (15 minutes vs 15 minutes, p = 0.948), operative time (153 minutes vs 154 minutes, p = 0.698), estimated blood loss (50 mL vs 50 mL, p = 0.665), intraoperative complication (1% vs 0%, p = 1.000), length of stay (1 day vs 1 day, p = 0.848), all complications (8.8% vs 15.79%, p = 0.443), and surgical margin rates (3.76% vs 7.7%, p = 0.443).

Conclusion: Hilar and endophytic tumors are the most challenging locations in partial nephrectomy. Using intraoperative US and a methodological approach, partial nephrectomy can be effectively performed robotically without the expense of increased complication rates.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0049

Footnotes

1. Jeon BJ, Chung H, Bae JH, Jung H, Lee JG, Choi H. Analysis of present status for surgery of benign prostatic hyperplasia in Korea Using Nationwide Healthcare System Data. Int Neurourol J 2019;23:22–29.

2. Professionals S-O. EAU Guidelines: Management of non-neurogenic Male LUTS. Uroweb n.d. https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts (accessed September 10, 2019).

3. Patel NH, Uppaluri N, Iorga M, Schulman A, Bloom JB, Phillips J, et al. Device malfunctions and complications associated with benign prostatic hyperplasia surgery: Review of the Manufacturer and User Facility Device Experience Database. J Endourol 2019;33:448–454.

4. Ibrahim A, Elhilali MM, Elkoushy MA, Andonian S, Carrier S. DrillCutTM vs VersaCutTM prostate tissue morcellation devices after holmium laser enucleation: A prospective, randomized controlled trial. Can Urol Assoc J 2018:266–270.

1. Capitanio U, Isbarn H, Shariat SF, et al. Partial cystectomy does not undermine cancer control in appropriately selected patients with urothelial carcinoma of the bladder: A population-based matched analysis. Urology 2009;74:858–864.

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3. Singh I, Kader K, Hemal AK. Robotic distal ureterectomy with reimplantation in malignancy: Technical nuances. Can Urol Assoc J 2009;16:4671–4676.

4. Pathak RA, Hemal AK. Utilization of fluorescence-enhanced molecular imaging in robot-assisted uro-oncologic surgery. Videourology 2019;33; DOI: 10.1089/vid.2018.0030.

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4. Godbole PP, Koyle MA, Wilcox DT. Pediatric endourology techniques. London: Springer, 2007.

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1. Traxer O, Keller EX. Thulium fiber laser: The new player for kidney stone treatment? A comparison with Holmium:YAG laser. World J Urol 2020;38:1883–1894.

2. Ventimiglia E, Doizi S, Kovalenko A, Andreeva V, Traxer O. Effect of temporal pulse shape on urinary stone phantom retropulsion rate and ablation efficiency using Holmium:YAG and Super Pulse Thulium Fiber lasers BJU Int 2020;126:159–167.

3. Chew BH, Knudsen BE, Molina WR. (MP10-09) Comparing dusting and fragmenting efficiency using the new Super Pulse Thulium Fiber Laser vs a 120W Holmium:YAG laser. J Endourol 2019;33(S1):A118.

4. Knudsen BE, Chew BH, Molina WR. (MP10-16) Super Pulse Thulium fiber laser compared to 120W Holmium:YAG laser: Impact on retropulsion and laser fiber burn back. J Endourol 2019;33(S1):A121.

5. Molina WR, Chew BH, Knudsen BE. (MP21-19) Temperature rise during laser lithotripsy: Comparison of Super Pulse Thulium Fiber LASER (SPTF) vs high power 120W Holmium-YAG LASER (Ho:YAG). J Endourol 2019;33(S1):A238.

6. Molina WR, Chew BH, Knudsen BE. (MP11-06) Hemostatic properties of Super Pulse thulium fiber (SPTF) laser: Comparison with high power 120W holmium:YAG laser (Ho:YAG) in an ex-vivo porcine kidney model. J Endourol 2019;33(S1):A126.

7. Chew BH, Knudsen BE, Molina WR. (MP11-02) Tissue incision, excision and ablation using Super Pulse thulium fiber (SPFL) laser: Comparison with high power 120W Holmium-YAG laser (Ho:YAG). J Endourol 2019;33(S1):A125.