Editorial Comment for Molinari et al.

The authors present a simple and effective technique for the intraoperative placement of ureteral stents during robot-assisted radical prostatectomy (RARP). Although rarely indicated, intraoperative stent placement can be helpful in RARP patients with large median lobes and/or patients in whom dissection will be/has been performed close to the orifices. The technique demonstrated here allows for easy placement of a guidewire into the ureteral orifices in retrograde fashion without the need for a flexible cystoscope, which would be difficult to manipulate given the typical location of the robot. Instead, the authors demonstrate placement of the guidewire via a Foley catheter followed by retrograde insertion of the stent using robotic manipulation of the stent and wire.

It is always helpful to be aware of the best options for managing rare problems intraoperatively encountered during RARP. Examples might include: How to safely and efficiently remove a Hem-o-lok clip that has been placed in an inappropriate location; how best to manage external iliac vein injury; how to deal with accessory pudendal vascular anatomy; and, of course, how to handle a large prostatic median lobe.

In this article, the authors have provided a clear, step-by-step description of how to protect the ureteral orifices during the rare cases in which dissection of a median lobe is likely to cause ureteral injury and/or edema. Protecting them with temporary Double-J stents is certainly prudent in some of these cases. I find the authors' approach to be both clever and intuitive. It is the one I will try first when this issue comes up in my operating room, although it is always useful to know other approaches to intraoperative robotic ureteral stent placement if one's first choice does not work as easily as anticipated in a specific case.