Efficiency of the Firefly System for Mesenteric Vessel Identification During Total Intracorporeal Urinary Diversion Following Radical Cystectomy Using the Da Vinci Xi Robot
Stefan Jeglinschi, MD, Mathieu Carlier, Louis Denimal, Daniel Chevallier, MD, Brannwel Tibi, MD, Matthieu Durand, MD, PhD, and Youness Ahallal, MD
Department of Urology, University Hospital Centre Nice, Nice, France.
Objective: To show the feasibility and efficiency of near-infrared fluorescence using indocyanine green (ICG), in identifying and preserving mesenteric perfusion during total intracorporeal urinary and digestive reconstruction after radical cystectomy using the Da Vinci Xi robot.
Methods: After approval by the institutional review board, we studied all consecutive patients who underwent robot-assisted radical cystectomy (RARC) and intracorporeal urinary derivation with the Da Vinci Xi robot using ICG and the Firefly system, in our institution from January 1, 2018 to September 15, 2018. Primary endpoint was adequate mesenteric vessel identification after injection of 0.2 mg/kg of ICG (Infracyanine®; Laboratoire Serb, Paris, France) before each bowel division. Secondary endpoint were ischemia-related complications and return of bowel function.
Results: After a median follow-up of 4.6 months (interquartile range [IQR] 3.2–7.5), we prospectively included 25 patients. ICG allowed adequate mesenteric identification in all the cases. Complementary intraoperative resection of bowel segment for inadequate perfusion in Firefly mode was performed in two cases (8%). Median return to bowel function was 3 days for gas (IQR 2–5) and 5 days for stool (IQR 3–6). Only one patient (4%) presented with postoperative bowel obstructive syndrome. There were 2 (8%) urinary leaks. There were no digestive fistulas recorded. Nine patients (36%) were readmitted within 30 days for complications.
Conclusions: Total intracorporeal urinary diversion during RARC using ICG and the Firefly system of the Da Vinci Xi allowed adequate vessel identification and seemed to allow a quicker bowel function recovery and to lower urinary and digestive complications. This might be explained by better vascularization of the ileal conduit and the digestive anastomosis by using ICG in the dissection phase, therefore avoiding ischemia. A limitation that surgeons should be careful about is when blood containing ICG spills over tissue making it light up permanently making the dissection more difficult. Larger randomized controlled studies evaluating ICG are needed to confirm the usefulness of ICG use for total intracorporeal urinary diversion during in radical cystectomy.
Multiquadrant Hidden Incision endoscopic Surgery for Pediatric Ureteroureterostomy and Distal Ureterectomy
Hatim Thaker, MD and Paul J. Kokorowski, MD, MPH
1Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
2Division of Urology, Children’s Hospital Los Angeles, Los Angeles, California.
Introduction: Hidden incision endoscopic surgery (HIdES) has gained increasing acceptance in pediatric robotic pyeloplasty, nephrectomy, and ureteral extravesical reimplantation cases.1,2 In addition to the benefits of laparoscopy (smaller incisions, shorter hospital stays, and decreased pain or narcotic use), HIdES adds significant improvement in cosmetic outcomes while maintaining similar operative times as compared with traditional port placement techniques.3 In this report, we describe another application of HIdES to perform multiquadrant robotic ureteroureterostomy (UU) and distal ureterectomy using only three hidden incisions.
Materials and Methods: The index patient was a 15-month-old boy with an antenatal diagnosis of right hydronephrosis, and was found to have a duplex kidney on postnatal imaging. Specifically, the upper pole moiety was dilated with associated hydroureter. Voiding cystourethrogram showed a normal urethra, smooth bladder wall, and reflux into a dilated right ureter when voiding. This was suggestive of an ectopic insertion. Nuclear imaging demonstrated an upper pole function of 28% and poor drainage with a t½ of 40 minutes. Cystoscopy with retrograde stenting of the lower pole ureter was performed. A HIdES approach was utilized for laparoscopy, with one 8.5 mm multipurpose port placed at the umbilicus, and two working ports hidden at the level of a Pfannenstiel incision. The upper pole ureter was mobilized, ligated, and then spatulated. An end-to-side anastomosis was performed to the stented lower pole ureter. The robot was then rotated, reoriented, and retargeted toward the pelvis using the same three ports for the distal ureterectomy to the level of ectopic insertion. Two additional patients, both 7-month-old girls, had severe upper pole hydronephrosis in unilateral duplex kidneys (one left and one right) because of ectopic ureteral insertion. Parenchymal function was retained on nuclear imaging. Both girls underwent three port HIdES approach for UU with distal ureterectomy in a similar manner.
Results: An effective UU and excision of distal ureter was performed on all three children. Operative times ranged from 176 to 199 minutes (mean 189), with 108–152 minutes of console time (mean 125). Two patients were discharged on postoperative day (POD) 1. One 7-month-old patient had a postoperative ileus, and was discharged on POD 7. There were no postoperative readmissions or unexpected visits to the emergency room. Patients required between one and six doses of narcotics postoperatively. All patients had their stents removed between 4 and 6 weeks postreconstruction; renal ultrasonography 1 month later showed improvement in upper pole hydronephrosis.
Conclusions: HIdES is a feasible approach for multiquadrant pediatric UU and distal ureterectomy in a duplex kidney, with improved cosmetic outcomes compared with traditional port placement or open surgery.
Gargollo PC. Hidden incision endoscopic surgery: Description of technique, parental satisfaction and applications. J Urol 2011;185:1425–1431.
Villanueva CA. Extracorporeal ureteral tailoring during HIDES laparoscopic robotic-assisted ureteral reimplantation for megaureter. J Pediatr Urol 2015;11:362–363.
Hong YH, DeFoor WR, Reddy PP. Hidden incision endoscopic surgery (HIdES) trocar placement for pediatric robotic pyeloplasty: Comparison to traditional port placement. J Robot Surg 2018;12:43–47.
Robot-Assisted Renal Transplantation Using Indocyanine Green and the Firefly System for Graft Perfusion Evaluation
Stefan Jeglinschi, MD,1,2 Youness Ahallal, MD,1 Yohan Bodokh,1 Daniel Chevallier, MD,1 Matthieu Durand, MD, PhD,1 and Brannwel Tibi, MD1
1Department of Urology, University Hospital Centre Nice, Nice, France.
2Department of Urology, Hospital Centre Grasse, Grasse, France.
Objective: After robot-assisted renal transplantation, graft perfusion evaluation is usually confirmed by visual cues. We sought to describe an extra tool for graft perfusion evaluation after robot-assisted renal transplantation by incorporating indocyanine green (ICG) and the Firefly® system in the procedure.
Materials and Methods: After side docking the Da Vinci X robot, the left external iliac vessels were dissected and looped. A deceased-donor right kidney was prepared in an ice bag and introduced inside the recipient through an Alexis® system. A common practice at our institution was to invert kidneys to have the renal pelvis on the anterior part, therefore, right kidneys are transplanted in the left fossa and vice versa. This allows easier access to the pelvis in case of long-term urinary complications. After passing the vein under the external iliac artery, a terminolateral venovenous anastomosis was performed by two running sutures of Gore-Tex 5-0 after double clamping the external iliac vein with a robotic bulldog clamp. The passage of the vein underneath the artery is another common practice at our institution to leave the anterior part of the artery free, this facilitates the arterial anastomosis. The arterioarterial anastomosis was then performed in a method similar to the venous anastomosis. An ureterobladder reimplantation was performed in a classic Lich Gregoire technique with two running sutures of Vicryl 4-0, after retrograde placement of a Double-J stent. ICG and the Firefly system were used once the transplantation was complete to evaluate graft perfusion.
Results: Three patients underwent robotic renal transplantation using the Firefly system. Mean operative time was 168 minutes, warm ischemia in the recipient was 68 minutes, and peroperative blood loss was 103 mL. The recipients recovered a normal urine output on average after 1.7 days. Serum creatinine improved progressively and normalized on average on day 14. The patient was discharged on average on day 14. Only one patient presented a Clavien II complication. The other two patients did not present complications. The Firefly system allowed adequate graft perfusion evaluation for all three patients.
Conclusions: Robot-assisted renal transplantation using ICG and the Firefly system allowed an adequate graft perfusion evaluation in three simple cases. Larger studies are needed to evaluate the Firefly system in robotic renal transplantation in complex cases wherein visual cues are not enough such as grafts with multiple arteries requiring reconstruction on bench, or a small polar artery requiring a separate anastomosis.
Ultraminilaparoscopic Radical Prostatectomy: Incorporating 2.7 mm Instruments in Urology
Alberto Pérez-Lanzac, PhD, MD
Department of Urology, Ruber Internacional Hospital, Madrid, Spain.
Purpose: The introduction of reduced caliber laparoscopic instruments has diminished invasiveness while preserving the triangulation laparoscopy principle. Needlescopy (2 mm), microlaparoscopy (<2 mm), and minilaparoscopy (3 mm) aim to reduce invasiveness and improve esthetic and perioperative outcomes.1–3 Our objective was to present the preliminary outcomes related to cosmesis and pain control assessment in ultraminilaparoscopic radical prostatectomy with three-dimensional imaging using a new set of 2.7 mm laparoscopic instruments and optics. We report the first use of this armamentarium in urology.
Methods: Four men were operated on using these instruments between November 1, 2017, and March 31, 2018. Data were collected in a prospective manner. All participants signed the consent form before the surgery and were granted strict confidentiality. Postoperative cosmetic and pain evaluation was assessed with the use of both the visual analog scale (VAS) at discharge and the Patient Scar Assessment Questionnaire (PSAQ) score 1 and 2 weeks after the surgery. A 5-item global rating scale for laparoscopic surgeries was used for the assessment of surgeon's performance.4
Results: A total of three radical prostatectomies were performed. One surgery could not be completed because of a peritoneal infection. Patients were aged 66 to 71 years, with a body mass index between 25 and 32 kg/m2. The surgical time was between 105 and 120 minutes and there were no complications. No extra intravenous analgesia was required. The VAS 1 week after the surgery rated from 1 to 3 and the PSAQ 1 and 2 weeks after the surgery ranked from 31 to 41, and 31 to 44, respectively. The surgeon's perception was positive in all the cases.
Conclusions: This new ultraminilaparoscopy (UML) set showed good results in all the surgeries. Despite its smaller diameter, outcomes and safety were not compromised. Moreover, UML offered excellent cosmetic and pain control outcomes. Surgeon perception of the surgeries was adequate in terms of deep perception, bimanual dexterity, efficiency, tissue handling, and autonomy.
Pérez-Lanzac A, García-Baquero R. Minilaparoscopy in urology: Systematic review. Actas Urol Esp 2018;42:299–308.
Pini G, Porpiglia F, Micali S, Rassweiler J. Minilaparoscopy, needlescopy and microlaparoscopy: Decreasing invasiveness, maintaining the standard laparoscopic approach. Arch Esp Urol 2012;65:366–383.
Pérez-Lanzac A, Romero E, Álvarez-Ossorio JL. Dolor postoperatorio y resultados cosméticos de la nefrectomía minilaparoscópica frente a la técnica convencional [Postoperative pain and cosmetic results of minilaparoscopic nephrectomy compared to the conventional technique]. Actas Urol Esp 2019;43:124–130.
Vassiliou MC, Feldman LS, Andrew CG, Bergman S, Leffondré K, Stanbridge D, Fried GM. A global assessment tool for evaluation of intraoperative laparoscopic skills. Am J Surg 2005;190:107–113.
Overcoming Challenges in Robot-Assisted Kidney Transplant: A Video Presentation
1Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.
2Department of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, California.
Purpose: To find and evaluate strategies to overcome challenges during robot-assisted kidney transplant (RAKT).
Materials and Methods: We reviewed recordings of our 25 RAKT patients. We analyzed the intraoperative complications and strategies to overcome it. We also analyzed the challenges posed by RAKT and how to overcome them.
Results: Creation of graft jacket is required to maintain proper cold ischemia of graft. Pfannenstiel incision as against Gelpoint has the benefit of being cheaper and provides prompt access in case of bleeding. During this engraftment, bladder should be well mobilized to prevent accidental injury to bladder. There should be proper tacking sutures to maintain proper orientation of graft. In case of graft anastomosed upside down, the donor ureter can be anastomosed end to end to native ureter. Bench preparation is appropriate for dual donor renal arteries anastomosed end to side. In case of mild plaque in external iliac artery, it can be fixed with Prolene sutures and internal iliac artery can be used for anastomoses in case of severe plaque in external artery. There should be meticulous bench preparation, ligating all tissue to prevent postclamp release graft surface bleeding, which may be difficult to control at times. Good peritoneal flap dissection and retroperitonealization of graft with windows are must for good graft biopsy if required postoperatively and prevent lymphocele formation.
Conclusion: Although the feasibility has been shown, there is no standardization of procedure. These risk-reduction strategies would lead to safe better RAKT outcomes and be a boon to obese end stage renal disease patients.
Prostatic Artery Preservation: A Novel Technique for Robot-Assisted Radical Prostatectomy
Keegan Zuk, MD, Halle Foss, MD, Viraj Maniar, MD, Andrew Radtke, MD, Scott Johnson, MD, and Kenneth Jacobsohn, MD
Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin.
Introduction: Oncologic control without untoward effects on patient continence or potency remains the goal of robot-assisted radical prostatectomies (RARPs). Prostatic artery preservation (PAP) during Retzius-sparing RARP is a novel technique aimed at preserving the lateral prostatic arteries and, as a result, the perfusion to the neurovascular bundle. Rather than clipping these arteries as they course through the posterior–lateral pedicles, the arteries are preserved within the interfascial plane by ligating more distal perforating arterial branches as they enter the prostate. The ultimate goal is to maintain perfusion to the veil of spared nerves and thus improve rates of postprocedure continence and potency. This video serves as a tool to describe the technique and to review our early experience and outcomes.
Materials and Methods: PAP was developed by a single surgeon (K.J.). Patients who underwent RARP with PAP from March 2018 until August 2018 were identified. Retrospective chart review was performed to collect demographics, operative details, staging, and clinical outcomes for each patient. The International Consultation on Incontinence Modular Questionnaire–Urinary Continence Short Form (ICIQ-UC SF) and the Sexual Health Inventory for Men (SHIM) were used to assess preoperative and 6-week postoperative urinary continence and erectile function.
Results: Twenty-one patients who underwent RARP with PAP were identified. Fifteen underwent bilateral PAP and six underwent unilateral PAP. Mean age and body mass index were 60 years and 27.28 kg/m2, respectively. Mean operative time was 168 minutes and mean estimate blood loss was 129 mL. There were no complications. At 6 weeks postprocedure, the mean decrease in SHIM was 12 (54%) in patients who underwent unilateral PAP and 4.7 (25%) in those who had bilateral PAP. Of patients with adequate preoperative erections (SHIM > 17), 2 of 6 (33%) and 6 of 10 (60%) patients had erections sufficient for intercourse at 6 weeks postoperation for unilateral and bilateral PAP, respectively. All 15 patients who had bilateral PAP and 4 of 6 (66%) patients who had unilateral PAP were using 0 pads per day. Average increase in ICIQ-UC SF postoperatively was 2.4/21 for unilateral PAP and 1.3/21 for bilateral PAP.
Conclusions: The RARP with PAP represents a novel approach to the robotic prostatectomy with promising early return of postoperative continence and erectile function. Longer term follow-up and further technical refinement are warranted given these encouraging outcomes.
