Videourology Abstracts

Abstract

A Purely Laparoscopic Nephroureterectomy with Bladder Cuff Using Three Ports Including the Camera Port and Same Position: A New Technique

Ali Al-Daghmin, MD,¹ Malek Gaashan, MD,¹ and Layana Al-halbouni²

¹Department of Urology, King Hussein Cancer Center, Amman, Jordan.

²King Hussein Cancer Center, Amman, Jordan.

Introduction: Primary urothelial carcinoma of the upper urinary tract accounts for ∼5% of all renal and urothelial malignancies. Although relatively uncommon, the incidence of upper tract transitional cell carcinoma (TCC) appears to be slowly increasing. Although alternative therapies, such as endoscopic ablation/resection and segmental ureteral resection, have been adopted, radical nephroureterectomy is considered the ideal treatment for upper tract TCC.¹ Upper tract TCC is frequently multifocal, has a higher rate of ipsilateral ureteral recurrence, is often associated with higher grade disease, and, therefore, carries a poorer prognosis compared with bladder TCC. Thus, in the presence of a normal contralateral upper tract, complete removal of the ipsilateral kidney, ureter, and bladder cuff remains the gold standard treatment for large, high-grade, or invasive TCC.² The procedure may be undertaken open or laparoscopically. The “standard” laparoscopic nephroureterectomy (LNU) technique has not been defined and continues to evolve. Variations include utilization of a pure laparoscopic technique vs a hand-assisted technique, transperitoneal vs retroperitoneal, and a myriad of approaches to deal with the lower ureter.³ Indeed, the issue of the most appropriate oncologic management of the lower ureter and bladder cuff has been the most debated and controversial aspect of this operation since McDonald et al. attempted to lessen surgical morbidity by advocating endoscopic resection of the distal ureter in 1952.⁴ Irrespective of the adopted technique, the challenge is to ensure adherence to principles of reproducibility of results, patient safety, and oncologic outcomes. We present a series of 12 patients with upper urinary tract urothelial carcinoma treated with a new technique of a purely laparoscopic approach for en-bloc dissection of the distal ureter and bladder cuff during nephroureterectomy that avoid the disadvantage of open “distal ureterectomy and bladder cuff excision” and patient repositioning.

Materials and Methods: Since 2016, patients with upper urinary tract urothelial carcinoma have been managed at our institution by purely LNU with bladder cuff using three trocars, including the camera trocar and the same position. Chart review identified 12 cases, including 3 ureteral tumors and 9 renal pelvis tumors. Baseline demographics collected included age at presentation, gender, location of the tumor indication, and preoperative serum hemoglobin and creatinine level. Perioperative data included operative time, estimated blood loss, blood transfusion, length of hospital stay, and duration of catheterization.

Results: Twelve patients (eight males, four females; age range: 42 to 70 years; median: 60) with upper urinary tract urothelial carcinoma underwent surgery using this technique. Overall, all the patients (100%) had localized upper urinary tract TCC without metastasis (eight in the right side and four in the left side). Median preoperative hemoglobin and serum creatinine were 13.4 g/dL and 1.09 mg/dL, respectively. The operative time ranged between 90 and 180 minutes (median: 130). Mean estimated blood loss was 100 mL (range: 20–300). The patients were discharged from the hospital on the second to fourth postoperative day. Complications were seen in three patients (25%). One patient developed clinical symptoms of urinary leakage after slippage of Foley catheter because of faulty balloon. The catheter was reinserted and removed later on after cystogram showed no leakage. The second patient developed urinary tract infection and he was treated with i.v. antibiotic. The third patient developed increase in serum creatinine level up to 3 ng/dL and he was treated conservatively with i.v. fluids. Overall, 33% of the patients harbored pathologic T3 disease. Lymph node invasion was present in no patients (0%) with a median number of 13 lymph nodes removed. All patients received intermediate unit care postoperative support and started regular diet on day 0. All patients were transferred to floor on day 1 postoperation. Median length of hospital stay was 2.9 day (2–4).

Conclusions: We describe an entirely laparoscopic removal of the kidney, ureter, and bladder cuff by a procedure that strictly adheres to oncologic principles (removal of the affected renal unit without opening the urinary tract), use only three ports (including the camera port) for accomplishing the whole procedure, and obviates the need for transurethral or open bladder cuff excision as well as intraoperative repositioning of the patient. This technique is efficient, technically feasible, and adheres to the oncologic principles of radical nephroureterectomy with bladder cuff.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0042

References

Munoz JJ, Ellison LM. Upper tract urothelial neoplasms: Incidence and survival during the last 2 decades. J Urol 2000;164:1523–1525.

Hall MC, Womack S, Sagalowsky AI, Carmody T, Erickstad MD, Roehrborn CG. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients. Urology 1998;52:594–601.

Tan BJ, Ost MC, Lee BR. Laparoscopic nephroureterectomy with bladder-cuff resection: techniques and outcomes. J Endourol 2005;19:664–676.

McDonald H, Upchurch WE, Sturdevant CE. Nephro-ureterectomy: a new technique. J Urol 1952;67:804–809.

Thulium Laser Enucleation of the Prostate: Median Lobe Enucleation, Step by Step, for a Beginner Surgeon

Mohamed Omar, MD

Department of Urology, Menoufia University, Shibin El Kom, Menoufia, Egypt.

Introduction and Objectives: Since 2010, Herrmann and colleagues¹ introduced thulium laser enucleation of the prostate (ThuLEP) as a versatile minimally invasive enucleation procedure, followed by number of studies that have confirmed its feasibility and efficacy such as holmium laser enucleation of the prostate (HoLEP). Our aim is to present a self-taught, ThuLEP, learning curve for a single surgeon with no previous HoLEP² experience.

Methods: Between February and August 2018, a well-trained endourologist, who did not perform laser enucleation of the prostate before, started reviewing the available literature, attended >15 procedures at another hospital, and participated in 3 laser enucleation of prostate workshop. A total of 18 patients with prostate size between 80 and 120 g underwent ThuLEP for the first time. We used Revolix DUO™ machine with a 40 watt setting for both cutting and coagulation with a 550μm fiber for all cases.

Results: In the first four cases, the surgeon was unable to completely enucleate the first lobe and ended with open prostatectomy. In the following four cases, one lobe was completely enucleated and morcellated, whereas the other lobe was finished by bipolar resection. The remaining cases were effectively enucleated and morcellated. All patients had a satisfactory voiding outcome with mean Q_max of 24.5 after surgery.

Conclusion: ThuLEP extraordinary hemostatic effect and its limited penetration depth may allow it to be an appropriate start for a beginner surgeon, while the after effect charring outcome may mask the capsular outline and would be its major drawback that could be avoided with lower watt and limited incisions.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0046

References

Herrmann TR, Bach T, Imkamp F, et al. Thulium laser enucleation of the prostate (ThuLEP): transurethral anatomical prostatectomy with laser support. Introduction of a novel technique for the treatment of benign prostatic obstruction. World J Urol 2010;28:45–51.

Fraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: Preliminary results. Eur Urol 1998;33:69–72.

Transperineal Fusion MR/Ultrasound Prostate Biopsy in the Patient with No Anus

Lauren E. Corona, MD,¹ Robert S. Wang, MD,¹ Matthew Davenport, MD,² Nicole Curci, MD,² Ardeshir R. Rastinehad, DO,³ Christof Kastner, MD,⁴ and Arvin K. George, MD¹

¹Department of Urology, University of Michigan, Ann Arbor, Michigan.

²Department of Radiology, University of Michigan, Ann Arbor, Michigan.

³Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

⁴Department of Urology, Addenbrooke's Hospital, Cambridge, England.

Introduction: Transrectal ultrasound (TRUS)-guided prostate biopsy has long been the gold standard for obtaining tissue in the diagnosis of prostate cancer. Even as newer techniques have developed including transperineal and MR/ultrasound (US) fusion-guided biopsies, it remains technically challenging in certain patient populations: specifically, in men who have undergone total colectomy or abdominoperineal resections (APR) who do not have a rectum or anus, and those with severe anal stenosis unable to accommodate an endorectal probe for imaging or needle guidance.^1
–3 All current options for biopsy in these men are technically challenging and inadequate. In this video, we describe a novel technique to perform transperineal MR/US fusion-guided prostate biopsy.

Materials and Methods: The procedure consists of MR acquisition, MR segmentation of the prostate and region of interest, ultrasound imaging of the prostate with sweep and segmentation, coregistration of the images, and finally the targeted biopsy followed by the standard of care systematic 12-core biopsy.

Results: An example of this technique is demonstrated with a patient who after APR underwent effective fusion-guided biopsy of his PIRADS 5 MR lesion using the already described technique. Pathology report showed prostate cancer in all three cores through the region of interest and was negative in the standard 12-core biopsy. This procedure has subsequently been effectively completed in six additional patients.

Conclusions: In conclusion, transperineal MR/US fusion-guided prostate biopsy is a novel, feasible, and safe procedure extending the benefits of prostate MRI and targeted biopsy to men who cannot undergo TRUS.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0044

References

Siddiqui M, Rais-Bahrami S, Truong H, et al. Magnetic resonance imaging/ultrasound-fusion biopsy significantly upgrades prostate cancer versus systematic 12-core transrectal ultrasound biopsy. Eur Urol 2013;64:713–719.

Puech P, Rouvière O, Renard-Penna R, et al. Prostate cancer diagnosis: Multiparametric MR-targeted biopsy with cognitive and transrectal US-MR fusion guidance versus systematic biopsy—prospective multicenter study. Radiology 2013;268:461–469.

Pinto P, Chung P, Rastinehad A, et al. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging. J Urol 2011;186:1281–1285.

Modified and Simple Single-Lobe (En Bloc) Technique for Holmium Laser Enucleation of Prostate: Our Experience with Short-Term Results

Ajay Bhandarkar, MCh, Vedant Lakhe, MD, and Dipen Patel, DNB Urology

Department of Urology, Sujay Urological Hospital, Vadodara, India.

Aims and Objectives: Holmium laser enucleation of prostate (HoLEP) is one of the important modalities in surgical treatment for obstructive benign prostatic hyperplasia (BPH). Classically it was described as three-lobe technique by Peter Gilling et al.¹ One of its significant drawbacks is steep learning curve. We hereby describe a single-lobe technique simplified in four easy steps for enucleation of adenoma.

Methods and Patients: Forty patients were included in our study of single-lobe technique for HoLEP between December 2014 and July 2016. All procedures were done by a single surgeon (A.D.B.) who had vast experience of >2000 cases. Average volume of prostate in our study was 79.82 cc (35–195 cc). All patients were evaluated preoperatively by International Prostate Symptom Score (IPSS), uroflowmetry, sonography of prostate and urinary tract for prostate volume and postvoid residual volume estimation, prostate-specific antigen and quality of life score. Postprocedure follow-up was done at 1 month, 3 months, 6 months, and 1 year. Procedure was done by 550 µm quartz fiber, 100 W holmium-YAG laser (Lumenis) at the settings of 2 J × 40 Hz frequency and 26 F Karl Storz continuous irrigation resectoscope set. Morcellation of enucleated adenoma was done by Wolf morcellator. Procedure was divided into four steps: (1) apical lobe enucleation around verumontanum, (2) incision at 12 o'clock and defining anterior capsule, (3) lateral lobe enucleation, and (4) peeling off adenoma from bladder neck and “en bloc” enucleation.

Results: Mean enucleation time for the prostate was 30.88 minutes (10–80 minutes) and estimated blood loss during the procedure was 49 mL (16–350 mL). Mean catheterization time was 45.25 hours and mean hospital stay was 47.65 hours. None of the patients required blood transfusion. Only one patient needed two-stage procedure. Clavien grade 1 complications were seen in five patients, grade 2 in three, and one patient needed prolonged irrigation for intermittent hematuria. Four patients had transient (<2 weeks) stress urinary incontinence. Two patients needed cystoscopy+visual dilatation of membranous urethral stricture. Significant improvement in IPSS, Qmax, and QoL was seen on follow-up of 3, 6, and 12 months.

Conclusions: HoLEP significantly relieves obstructive changes occurring because of BPH. Modifying technique of enucleation to single lobe helps in reducing operative time of enucleation. One may argue that vast experience of our operating surgeon (A.D.B.) may have contributed to lower morbidity in our study. We hypothesize that our simplified technique described in four steps can become useful in reducing the learning curve. Single-lobe technique with early recognition of important landmarks and repeating same steps for all sizes of prostate can ease the learning of this wonderful procedure.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0037

Reference

Gilling PJ, Kennett K, Das AK, Thompson D, Fraundorfer MR. Holmium laser enucleation of the prostate (HoLEP) combined with transurethral tissue morcellation: An update on the early clinical experience. J of Endourol 1998;12:457–459.

Lateral Tendinous Arch Reconstruction in Robot-Assisted Radical Prostatectomy

Andrea Benedetto Galosi, MD, Lucio Dell'Atti, MD, Luca Leone, MD, Guevar Maselli, MD, and Simone Scarcella, MD

Department of Urology, University Hospital Polytechnic University of Marche, Ancona, Italy.

Introduction: Robot-assisted radical prostatectomy (RARP) is the reference surgical approach for treatment of localized prostate cancer. The main side effect may be a stress urinary incontinence. Different pelvic floor reconstruction's surgical techniques for continence improvement have been developed over the years.¹ The effectiveness of reconstruction of the posterior musculofascial plane is still controversial and several articles with various levels of evidence, including randomized control trials, challenge the efficacy of the different proposed techniques reporting controversial outcomes. However, to date posterior reconstruction of the rhabdosphincter as described,² or with a modified approach, is performed by >50% of all robotic surgeons.³ As a matter of fact, different metanalysis reported significant functional advantages in the first 90 days after posterior reconstruction with low complications rates.⁴ We present our initial robotic technique for musculofascial reconstruction of the posterolateral plane using the tendinous arch as support of the pelvic floor structures. This procedure was suggested by pelvic floor reconstruction in radical cystectomy in which peritoneal flap is anchored to endopelvic fascia.^5,6

Materials and Methods: A total of 41 patients who underwent bilateral nerve sparing RARP from November 2017 to April 2018 were retrospectively evaluated. The surgical technique was developed and performed by a single surgeon (A.B.G.). In 20 patients was performed the lateral reconstruction of the musculofascial insertion of the Denonvilliers' attachment to the tendinous arch, whereas in the other 21 patients, no reconstruction was attempted. First step of the reconstruction begins with medial rectourethral muscle fixation to Denonvilliers' fascia; the second step is fixing the Denonvilliers' fascia laterally to endopelvic fascia through the support of the tendinous arch. The stitch is passed from the medial line to the lateral line, crossing superficially the tip of the neurovascular bundle (NVB), without clamping it. The NVB lies beneath the reconstructed plane that provides both a supplemental hemostatic action and is able to offer a support to the urethrovesical anastomosis providing a restoration of the fascial plane normally involved in urinary continence.

Results: There was no statistically significant difference in age, body mass index, surgical pathology grade, and stage between the two groups. Our reconstruction technique requires a median surgical time of 8.2 ± 4 minutes, without any specific technique-related complications such as acute urinary retention, perineal pain, rectal perforation, bladder neck stricture, or perianastomotic urinary leakages. At 6 months follow–up, patients subjected to posterolateral reconstruction technique showed better rate and faster time to continence recovery.

Conclusions: Our technique for reconstruction of the posterior musculofascial plane is feasible and reproducible. It, despite the small series of patients tested, could play a significant role working in synergy with the rhabdosphincter to ensure a better continence result. However, to date, it is not possible to assess whether continence advantage derives from the posterior reconstruction or to the lateral fixation; the superiority of this technique over the traditional posterior reconstruction is undefined yet. Longer follow-up and additional studies are warranted based on these encouraging results.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0050

References

Menon M, Muhletaler F, Campos M, Peabody JO. Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: Results of a 2 group parallel randomized controlled trial. J Urol 2008;180:1018–1233.

Rocco B, Cozzi G, Spinelli MG, et al. Posterior muscofascial reconstruction after radical prostatectomy: A systematic review of the literature. Eur Urol 2012;62:779–790.

Ficarra V, Wiklund PN, Rochat CH, et al. The European Association of Urology Robotic Urology Section (ERUS) survey of robot-assisted radical prostatectomy (RARP). BJU Int 2013;111:596–603.

Grasso AA, Mistretta FA, Sandri M, et al. Posterior musculofascial reconstruction after radical prostatectomy: An update systematic review and a meta-analysis. BJU Int 2016;118:20–34.

Ali-El-Dein B, Gomha M, Ghoneim MA. Critical evaluation of the problem of chronic urinary retention after orthotopic bladder substitution in women. J Urol 2002;168:587–592.

Puppo P, Introini C, Calvi P, Naselli A. Pelvic floor reconstruction before orthotopic bladder replacement after radical cystectomy for bladder cancer. J Urol 2005;65:174.

Total Extraperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy: Step-by-Step Approach

Kenneth Chen, MD, Xin Yan Yang, MD, Karine Sim, MD, Mahmood B. Mohammad, MD, Kae Jack Tay, MD, Allen Sim, MD, and John S.P. Yuen, MD

Department of Urology, Singapore General Hospital, Singapore, Singapore.

Introduction: The morbidities associated with transperitoneal route for robot-assisted radical prostatectomy are postoperative ileus and potential bowel injuries. The extraperitoneal approach avoids the peritoneal cavity and potential associated morbidity. We report our technique and the perioperative and short-term postoperative outcomes of our series.

Materials and Methods: Between May 2016 and April 2017, 15 consecutive patients who met inclusion criteria (body mass index [BMI] < 30, D'amico low- to intermediate-risk prostate cancer, prostate volume <60 mL, and no previous laparotomy) were recruited prospectively. The extraperitoneal space was created posterior to the subumbilical rectus sheath in the preperitoneal fat plane with a balloon dissector. A five- to six-port technique was used with reduced Trendelenburg angle. Antegrade dissection of prostate was performed. Vesicourethral anastomoses were by the Velthoven technique with modified Rocco's stitch. Patient demographics, characteristics, and peri- and postoperative short-term outcomes were analyzed.

Results: The median age was 64 (range 57–70) years and mean prostate volume was 46.3 ± 12.0cc. The mean prostate specific antigen (PSA) was 7.5 ± 2.8 µg/L. The mean BMI was 23.8 ± 2.2 kg/m². All 15 patients underwent extraperitoneal approach effectively. The mean umbilical to pubic symphysis distance was 15.0 ± 0.8 cm. The mean setup time (creation of extraperitoneal space and robot docking) was 25.7 ± 11.0 minutes and mean total operative time was 215.4 ± 43.5 minutes. The mean Trendelenburg degree was 17.1 ± 3.5. Mean estimated blood loss was 115.8 ± 71.8 mL. There was a small peritoneal breach during balloon dilatation in a patient with previous open appendicectomy and another with previous open hernia repair. Two (13.3%) and 14 (93.3%) patients had standard pelvic lymph node and nerve-sparing dissections, respectively. Postoperatively no patients had ileus, intraabdominal, or other significant Clavien–Dindo complications. Thirteen (86.7%) patients passed flatus and had diet on postoperative day (POD) 1. Nine (60.0%) patients were discharged within 24 hours and the rest on POD 2. All patients received paracetamol 1 g when needed, whereas four required single dose intramuscular pethidine for breakthrough pain. Pathologic stage was pT0, pT2a, and pT2c in 1 (6.7%), 12 (80.0%), and 2 (13.3%) patients, respectively, representing downstaging in 1 (6.7%, pT0 in the prior-transurethral resection of prostate patient). One patient had focal (<1 mm) positive margins (anterior apical) with the majority (93.3%) having complete resection. At a mean of 126 ± 85.7 days, 14 patients (93.3%) achieved undetectable nadir PSA (<0.03 µg/L). Overall continence rate was 86.7% at 3 months. The follow-up duration was not long enough to meaningfully report recovery of erectile function.

Conclusion: Total extraperitoneal resection of prostate, an extraperitoneal organ, in selected patients enables ileus-free early discharges.

http://online.liebertpub.com/doi/full/10.1089/vid.2018.0036