Videourology Abstracts

Introduction: The purpose of this study is to describe the intracorporeal laparoscopic Y-pouch urinary diversion in patients with muscle invasive bladder cancer.

Materials and Methods: The operation was performed in three patients with muscle invasive bladder tumor. Percutaneous nephrostomies were placed bilaterally to all patients preoperatively. After entering the abdomen and creating pneumoperitoneum, cystoprostatectomy was performed. All steps of the procedure, including the urinary diversion, were made entirely laparoscopically. Step 1: Ileal segment selection. Approximately 45–50 cm of ileum, 25 cm proximally to the ileocecal valve, was selected and folded. The tip of the folded segment was opened and an anastomosis between the bowel and the urethra was performed. Step 2: Y-pouch formation. The bowel segment that was chosen for the pouch was isolated and the continuity of the intestine was restored with endoGIA staplers. The folded segment was stabilized with sutures and was opened longitudinally with ultrasonic scissors. Then, the pouch was formed with sutures on the posterior and anterior surface. The latter task can also be performed using endoscopic staplers. Step 3: Double-J insertion. Guidewires are guided in the ureters with the use of a percutaneous endoscopic surgery needle. The Double-Js are inserted over the guidewires after the removal of the needle. The left ureter was not transposed to the right side. Step 4: Implantation of ureters. The ureters were spatulated and implanted in end to end fashion in the cephalad part of each side (horn) of the pouch.

Results: All three surgeries were completed in 4.5–5 h without any intraoperative complication or need for blood transfusion. Only one patient had fever postoperatively (Clavien Grade I). The pouches have a capacity of 300–450 cc. One patient has mild day and nighttime incontinence. The remaining two have no daytime incontinence and one of them uses one pad during the nighttime.

Conclusions: Intracorporeal laparoscopic Y-pouch urinary diversion is a safe and feasible procedure for experienced urologists and provides satisfactory postoperative functional results.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0052

A Novel Technique of Robotic Radical Prostatectomy with Combined Anterior–Posterior Approach to Preserve Early Continence Mechanism: A Feasibility Study

Arora Sohrab MCh 1 Banerjee Indraneel MCh 2 Mallya Ashwin MCh 2 Ahlawat Rajesh Kumar MCh 2 1 Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan. 2 Fortis Escorts Kidney and Urology Institute, New Delhi, India.

Introduction: A major secondary goal of robotic radical prostatectomy (RARP) is continence. We report a new technique of RARP with a combined anterior–posterior approach involving anatomic preservation of the continence mechanism. This phase 1 study was designed to assess the safety and feasibility of the new procedure.

Materials and Methods: Eight patients with localized prostate cancer underwent this procedure and completed a minimum of 1 year of follow-up. The surgical steps are as follows:

1. The procedure starts posterior to the bladder. The vasa are identified and cut. Seminal vesicles from either side are then dissected out. Bilateral lymphadenectomy, wherever indicated, and Retzius space dissection are done in a standard manner.

2. The bladder neck is then divided without opening the endopelvic fascia. The prostate is left attached to all its surrounding anatomical supports. Posterior bladder neck is then incised, revealing the already dissected vas and seminal vesicles, which are delivered out.

3. Posterior plane is then developed between the Denonvillier's fascia and the prostate, unless indicated otherwise. This posterior plane is developed until the urethra in midline and to the neurovascular bundles on either side of the prostate.

4. Anterolateral plane is then developed underneath the pelvic fascia, preserving all tissue around the prostate. This, in fact, is the Bocciardi's plane described with the Retzius-sparing approach. Access to this plane from the anterior side provides larger working space. With subsequent division of prostate pedicles, rest of the dissection proceeds in this plane without division of puboprostatic collar or the Santorini's plexus.

5. Unilateral or bilateral nerve-sparing procedures are done depending upon the preoperative and intraoperative findings.

6. Reconstruction is started with a Rocco stitch using a barbed suture. Urethrovesical anastomosis is then done in a standard manner with a barbed suture. Anterior reconstruction is done at the end of the procedure, approximating the detrusor apron to the bladder as a second layer around the urethrovesical anastomosis.

Complications were reported using the Clavien–Dindo classification. Continence was assessed using 0-pad, and 1-pad definitions at 1 month, 2 months, 3 months, 6 months, and 1 year after the procedure.

Results: Out of the eight patients with a minimum follow-up of 1 year, distribution of the clinical stage of the patients was T2a (n = 1), T2b (n = 3), T2c (n = 1), and T3a (n = 3). Median (IQR) prostate specific antigen was 23.09 (9.85–48.61) ng/dL. The mean console time was 178.5 minutes; median estimated blood loss was 100 mL. None of the patients had Clavien grade 2 or above complications. Margins were positive in three cases, each of them having clinical T2a, T2c, and T3a disease at baseline. Apical margin was positive in one case. Six out of eight (75%) patients were continent (0 pad) at 3 months and seven (87.5%) were continent (0 pad) at 6 months. All patients were continent (1 pad) at 6 months of follow-up.

Conclusions: Combined anterior–posterior approach of RARP with anatomic preservation of continence mechanism is feasible and safe. This initial series also demonstrates excellent early continence outcomes.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0051

Transperitoneal Laparoscopic Pyeloplasty for Retrocaval Ureter: Single Surgeon's Experience and Literature Review

Seo Ill Young MD, PhD Oh Tae Hoon MD Department of Urology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine and Hospital, Iksan, South Korea.

Introduction: Retrocaval ureter (RCU) is a rare congenital anomaly resulting from dysplasia of the inferior vena cava (IVC). This anomaly has a segment of compressed and obstructed ureter posterior to IVC, and it can induce hydronephrosis and renal dysfunction progressively. Treatment involves cutting the compressed ureter of retrocaval segment, anteposition, and ureteroureteral or ureteropelvic anastomosis, which are generally performed with open approach because it has technical difficulties. So far, this surgery is effective, but it is quite invasive, putting a lot of strain on the patient. Laparoscopic reconstruction for RCU was performed, showing less invasiveness and more cosmetic advantage than open surgery. However, the number of articles published to date is not large, just sporadic reports of single cases. Herein, we present surgical techniques and operative results of laparoscopic pyeloplasties for seven patients with RCU.

Materials and Methods: Seven patients with RCU were enrolled in this study from April 2005 to October 2016. The mean age (five males and two females) was 36.3 years. The chief complaint was flank pain in five patients; the remaining patients were detected incidentally. All patients showed hydronephrosis and typical S-shaped deformity of the ureter on imaging studies. Three patients showed obstructed patterns on renal scans. A single surgeon performed laparoscopic pyeloplasties with transperitoneal approaches. The ureter was divided at the most distal segment of the dilated proximal ureter and renal pelvis, and the inserted guidewire was identified. The distal ureteral stump was spatulated. A portion of the redundant pelvis was excised proximally, and the ureter was repositioned anteriorly to the IVC. The proximal end of the guidewire was pulled from the ureter, and then a Double-J ureteral stent was inserted over the guidewire. Anastomosis between the spatulated distal ureter and renal pelvis was performed with interrupted 4-0 Vicryl sutures, which were placed from the posterior side to the anterior side. The operative and follow-up results were checked and compared with published articles from MEDLINE database.

Results: All laparoscopic pyeloplasties were effectively completed without conversion to open surgery. The mean operative time was 171.8 minutes (range 97–240 minutes). The estimated blood loss was 184.3 mL (range 50–332 mL). No operative complications were encountered. There were no obstruction and symptoms after the mean follow-up of 16.3 months (range 6–30 months). We found seven articles from PubMed, which were large series of laparoscopic reconstruction of RCU. A total of 65 patients, including our patients, underwent surgery and were all effective.

Conclusion: Our results show that transperitoneal laparoscopic pyeloplasty is a safe and effective treatment for RCU. Data from published articles and ours summarize clinical parameters of RCU, and suggest that laparoscopic reconstruction can be a standard treatment for it.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0062

Modified “Blue Spritz” Technique for Ureteroscopic Localization and Management of Caliceal Diverticula

Soni Samit D. MD Scott Department of Urology, Baylor College of Medicine, Houston, Texas.

Introduction and Objective: Renal caliceal diverticula often present a significant management challenge for the urologist. Although not all caliceal diverticula present with symptoms, patients may experience a wide range of symptoms including persistent flank pain, recurrent infections, and even hematuria. Currently, a variety of effective management techniques are utilized for symptomatic caliceal diverticula, including ureteroscopic approaches, percutaneous approaches, and robotic/laparoscopic approaches. However, precise localization of the diverticular neck poses a significant challenge in many cases, particular when ureteroscopic localization is attempted. The diverticular neck can often be pinhole sized and, therefore, not apparent on ureteroscopy even with careful inspection. For ureteroscopy cases in which the diverticular neck is not easily observed, the “blue spritz” technique is a simple technique that enables the surgeon to localize the diverticulum using readily available colored dye agents. A minor modification that involves injection of a 50:50 mixture of methylene blue and iodine contrast allows for fluoroscopic confirmation of filling of the diverticulum, and also further accelerates the localization of the diverticulum with fluoroscopic guidance.

Materials and Methods: To demonstrate this technique, we have selected a 63-year-old male with a 1.8 cm symptomatic right interpolar caliceal diverticulum with milk of calcium deposits. He has not undergone prior treatment for the caliceal diverticulum, and presented complaining of chronic right flank pain. After thorough discussion regarding the ureteroscopic, percutaneous, and robotic/laparoscopic approaches, the patient elected to proceed with ureteroscopic management. A difficult-to-find diverticulum with a pinhole-sized neck became readily apparent once the modified “blue spritz” technique was employed, and a holmium laser incision of the diverticular neck was effectively performed.

Results: This modified “blue spritz” technique has proven effective for diverticulum localization in a series of three ureteroscopy cases with a variety of diverticular sizes and locations. Two patients had milk of calcium deposits in the diverticulum, whereas the other patient did not. The mean age (57 years), diverticulum diameter (1.8 cm), operating time (52 minutes), and duration of follow-up (11 months) were noted. To date, all three patients have remained symptom free after ureteroscopic laser incision of the diverticular neck.

Conclusions: The modified “blue spritz” technique appears to be an effective strategy for rapid ureteroscopic localization of any caliceal diverticulum in which fluid passes into the diverticulum on retrograde filling. The addition of a contrast agent to the colored dye agent enables confirmation of diverticular filling on fluoroscopy, and also facilitates more rapid localization of the diverticulum.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0003

Off-Clamp Robotically-Assisted Partial Nephrectomy in Polycystic Kidney Disease

Glaser Alexander P. MD de Oliveira Soares Ricardo Manuel MD, FEBU Nadler Robert B. MD Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

Introduction: Partial nephrectomy (PN) in autosomal dominant polycystic kidney disease (PCKD) is desirable in the setting of chronic kidney disease, but presents a technical challenge because of the presence of innumerable cysts and abnormal renal architecture. Prior reports of PN in PCKD have described prolonged warm ischemia time and decreased postoperative renal function. ¹ Off-clamp, or zero-ischemia, PN may mitigate renal function losses after oncologic surgery. ² Here, we present a video describing our technique for off-clamp robot-assisted PN in PCKD.

Methods: In this Institutional Review Board-approved study, we used the Northwestern University Enterprise Data Warehouse to perform a retrospective review of patients with PCKD who underwent off-clamp robot-assisted PN.

Results: Two patients with PCKD underwent off-clamp robot-assisted PN. In the presented case, a 66-year-old man presented with a 4-cm right renal mass. MRI and contrast-enhanced ultrasonography were used preoperatively to delineate the mass, and interventional radiology biopsy was consistent with malignancy. The kidney was mobilized and the hilum was isolated laparoscopically in the usual manner. At our training institution, laparoscopic mobilization is utilized to improve and maintain laparoscopic skills. A large cyst was decorticated to provide adequate access to the mass. The da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was docked for tumor excision. The renal mass was excised sharply, using judicious bipolar electrocautery with the Maryland bipolar forceps or LigaSure device (Medtronic, Minneapolis, MN) to control feeding vessels. Typical sliding-clip renorrhaphy was omitted because of the lack of normal renal parenchyma, and instead the remaining feeding vessels were oversewn with absorbable suture before the application of hemostatic agents over the resection bed (FloSeal; Baxter Healthcare, Deerfield, IL and Surgical; Ethicon, Somerville, NJ). Final pathology analysis revealed pT1b renal cell carcinoma, mixed papillary types 1 and 2, high grade. Estimated blood loss was 200 mL, postoperative hemoglobin was 10.9 g/dL from 11.7 g/dL, and the patient's most recent estimated glomerular filtration rate (GFR) was unchanged from preoperative baseline (49 mL/min). In the second case, pathology analysis revealed pT1b papillary renal cell carcinoma, estimated blood loss was 500 mL, and postoperative laboratories were also stable from baseline (hemoglobin 10.6 g/dL from 10.7 g/dL; estimated GFR was 41 mL/min from 37 mL/min).

Conclusions: Off-clamp robot-assisted PN may be feasible in some cases wherein the tumor is not in close contact with thick renal parenchyma. Limitations of this study include small sample size; however, zero-ischemia PN should be considered in patients with PCKD and chronic kidney disease.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0064

References

1 Karnik V , Nguan CY , Caumartin Y , Luke PP . Case report: Technical and functional implications of hand-assisted laparoscopic partial nephrectomy in a patient with autosomal dominant polycystic kidney disease. J Endourol, 2007; 21:625–627. a-4 2 Simone G , Gill IS , Mottrie A , et al. Indications, techniques, outcomes, and limitations for minimally ischemic and off-clamp partial nephrectomy: A systematic review of the literature. Eur Urol, 2015; 68:632–640. a-5

Robot-Assisted Laparoscopic Partial Cystectomy, Urachal Resection, and Pelvic Lymphadenectomy for Urachal Adenocarcinoma

Fedelini Paolo MD Chiancone Francesco MD Fedelini Maurizio MD Fabiano Marco MD Meccariello Clemente MD Department of Urology, A. Cardarelli Hospital, Naples, Italy.

Introduction: Urachal cancer is a rare and aggressive type of cancer. There is no consensus regarding the management of urachal cancer. ¹ The surgical excision can achieve long-term tumor control. No advantage to radical cystectomy compared with en bloc partial cystectomy with clear margins has been demonstrated. ² The role of pelvic lymphadenectomy is still controversial. ³ The benefit of adjuvant chemotherapy remains unclear. It is usually reserved for relapsed and recurrent disease that cannot be surgically removed. ⁴ This video describes the main steps of robot-assisted laparoscopic partial cystectomy with en bloc resection of the urachus and bilateral pelvic lymphadenectomy for a mucinous urachal adenocarcinoma. ⁵

Materials and Methods: From January 2016 to June 2017, three male patients were referred to our attention with a diagnosis of urachal mucinous adenocarcinoma. Preoperative imaging was negative for lymph node or distant metastases in all patients. All patients were treated with a robotic approach. With the patient in supine position, five ports were placed transperitoneally. The patient was placed in the 28° Trendelemburg position. After the cranial dissection into Retzius' space, the bladder dome was excised with the urachus and the umbilicus. The bladder was closed in two layers with continuous running sutures. Bilateral pelvic lymphadenectomy was performed. Mean values with standard deviations (±standard deviation [SD]) were computed and reported for all items.

Results: The mean (±SD) operative time was 123.3 ± 25.2 minutes. The mean blood loss was 56.7 ± 25.2 mL. No intraoperative and postoperative complications occurred. The patients were discharged 4.3 ± 0.58 days after surgery. The Foley catheter was removed 7.3 ± 1.2 days after surgery. The pathology report described in all cases a poorly differentiated adenocarcinoma with extensive extracellular mucin deposition. In two patients, all lymph nodes were free of metastases. In the case described in this video, 2 out of 17 lymph nodes were positive for metastases. All patients were managed by the hospital multidisciplinary team for urologic tumors and were enrolled in a strict follow-up protocol. At a follow-up at 14.3 ± 8.7 months, all patients are disease free.

Conclusions: Robot-assisted laparoscopic partial cystectomy, urachal resection, and pelvic lymphadenectomy are feasible approaches to treat urachal cancer. It could reduce surgical morbidity, postoperative pain, and recovery time, while maintaining the oncologic principle of safe local excision.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0057

References

1 Siefker-Radtke A . Urachal carcinoma: Surgical and chemotherapeutic options. Expert Rev Anticancer Ther, 2006; 6:1715–1721. a-6 2 Santucci RA , True LD , Lange PH . Is partial cystectomy the treatment of choice for mucinous adenocarcinoma of the urachus?. Urology, 1997; 49:536–540. a-7 3 Ashley RA , Inman BA , Sebo TJ , et al. Urachal carcinoma: Clinicopathologic features and long-term outcomes of an aggressive malignancy. Cancer, 2006; 107:712–720. a-8 4 Siefker-Radtke AO , Gee J , Shen Y , et al. Multimodality management of urachal carcinoma: The M.D. Anderson Cancer Center experience. J Urol, 2003; 169:1295–1298. a-9 5 Williams CR , Chavda K . En bloc robot-assisted laparoscopic partial cystectomy, urachal resection, and pelvic lymphadenectomy for urachal adenocarcinoma. Rev Urol, 2015; 17:46–49. a-10

Novel Use of a Magnetic Retraction Device in Robotic Urologic Surgery

Samson Patrick MD Mistry Preeya MD Kavoussi Louis MD Richstone Lee MD The Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York.

Introduction and Objective: The advancement of robotic technology has revolutionized surgical treatment for prostate cancer. Although the robot has facilitated surgery in narrow working spaces, it still has its shortcomings such as the collision of robotic and laparoscopic instruments both inside and outside the patient. Magnetic anchoring and guidance system (MAGS) technology provides extra tools within the patient without the use of additional trocars or bulky instruments. MAGS has not yet been described in robotic urologic surgery.

Methods: We present two robotic urologic cases in which we used a magnetic retractor device. The magnetic retractor is inserted through the air seal trocar and deployed with a laparoscopic handheld device by the bedside assistant. The retractor is then coupled to a handheld magnet that is placed outside of the patient's abdominal wall in the desired position. The device is designed for use in patients of body mass index between 20 and 34 kg/m². Although the external magnetic controller is reusable, the handheld device and the detachable tip are disposable. The first case is a 56-year-old man who was found to have Gleason 7 prostate cancer on prostate biopsy. He elected for nerve-sparing robot-assisted laparoscopic prostatectomy (RALP). The second case is a 56-year-old man with recurrent urinary tract infections and a history of transurethral microwave thermotherapy of the prostate who presented with two large bladder diverticula. He elected for a transurethral button vaporization of the prostate and robot-assisted laparoscopic bladder diverticulectomy (RABD) in the same operative setting.

Results: In the RALP, the magnetic retractor provided anterior retraction of the vasa deferentia during the dissection of the seminal vesicles. The magnetic retractor was then used to retract the vasa and seminal vesicles to facilitate posterior dissection of the prostate, whereas the fourth robotic arm provided cephalad retraction of the bladder. During the dissection of the neurovascular bundles and prostatic pedicles, the magnetic retractor was helpful in pulling the prostate medially without the use of the fourth robotic arm. There were no intraoperative complications. In the RABD, the magnetic retractor was used for additional retraction of the bladder in angles that the robotic fourth arm was not able to provide. There were no intraoperative complications.

Conclusions: The use of a magnetic retraction device facilitates certain steps in RALP and may be useful in other robotic urologic surgeries.

http://online.liebertpub.com/doi/full/10.1089/vid.2017.0070