Technical Aspects of Robot-Assisted Laparoscopic Lymphocele Excision with Intraperitonealization
Sida Niu, MD,1 Scott Pate, MD,2 and David Duchene, MD1
1Department of Urology, University of Kansas Medical Center, Kansas City, Kansas.
2Department of Urology, Mayo Clinic Health System Franciscan Health Care in La Crosse, La Crosse, Wisconsin.
Introduction: Roughly 70% of prostatectomies were accompanied by pelvic lymph node dissection (PLND) in 2010–2011.1 PLND can provide staging information that may help further determine extent of disease and guide subsequent treatment.2 Symptomatic lymphoceles after robot-assisted laparoscopic prostatectomy with PLND occur in 2%–15% of patients depending on the extent of the node dissection.3 Lymphoceles can lead to significant morbidity resulting from infections and recurrence. The best treatment option for pelvic lymphoceles resulting from PLND has not been defined. Conservative management with sclerosis and percutaneous drainage is often used as an initial management strategy. Subsequent surgical excision can be challenging because of significant scarring from failed conservative attempts.
Materials and Methods: Three prostate cancer patients treated with robot-assisted laparoscopic prostatectomy with bilateral PLND developed recurrent infected bilateral lymphoceles despite long-term antibiotics. They were referred to our institution after multiple failed attempts at sclerosis and percutaneous drainage by interventional radiology. All three elected to proceed with robot-assisted laparoscopic lymphocele excision with intraperitonealization. Standard prostatectomy port placement was used for the procedure. We have selected one of the cases to highlight our technique for robot-assisted intraperitoneal excision of the symptomatic lymphoceles.
Results: Extensive adhesions are often present from prior prostatectomy and treatment attempts. Identifying landmarks, preoperative imaging, and intraoperative ultrasound can help guide dissection. Excision of the medial lymphocele wall and surrounding fibrotic tissue is essential to prevent recurrence. Lateral wall excision and argon beam coagulation should be performed with great care to minimize the risk of damage to the iliac vessels and obturator nerve. Instillation of dye into the bladder is useful in confirming bladder integrity at the end of the case. Dye can also be injected into percutaneous drains, when present, at the beginning of the procedure to help locate and delineate the lymphocele walls, thereby facilitating complete surgical excision. This is a descriptive video of our technique that has been performed on a total of three patients. None have had a recurrence to date. Because of the rarity of this procedure, no statistical analysis was calculated.
Conclusion: Repeated attempts at sclerosing and drainage of pelvic lymphoceles should be limited to minimize formation of scarring and fibrosis. Identification of landmarks, preoperative imaging, and intraoperative ultrasound are key for finding lymphoceles and avoiding damage to surrounding structures. Dye injection can be helpful in localizing the lymphoceles as well as confirming bladder integrity. Aggressive excision of the medial lymphocele wall is necessary to achieve adequate intraperitonealization. The internal surface of the external lymphocele wall should be cauterized to minimize the risk of recurrence. Finally, laparoscopic marsupialization is associated with low recurrence risk and may be an appropriate upfront treatment option. Transposition of omental flap into the marsupialized lymphocele may further prevent recurrence. Peritoneal flaps have been used at the time of node dissection to prevent development of symptomatic lymphoceles.
Zorn KC, Katz MH, Bernstein A, et al. Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications. Urology 2009;74:296–302.
Messing EM, Manola J, Sarosdy M, Wilding G, Crawford ED, Trump D. Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer. N Engl J Med 1999;341:1781–1788.
Raheem O, Bazzi W, Parsons JK, Kane CJ. Management of pelvic lymphoceles following robot-assisted laparoscopic radical prostatectomy. Urol Ann 2012;4:111–114.
Piecemeal Retrograde Removal of Encrusted and Encased Stuck Ureteral Stent: Video Tips and Tricks
Amelia Pietropaolo, MD, FEBU, Lily Whitehurst, MD, and Bhaskar K. Somani, MD
Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
Introduction: Ureteral stent encrustation leads to morbidity related to ureteral obstruction along with urinary tract infection or sepsis. The time duration it takes for stent encrustation is variable, but the risk1 increases with stent dwell time. Removal of encrusted stent where these encrustations completely2 encase the stent can be extremely challenging. In this video we show a case of complete stent encasement where we used a piecemeal technique to remove the stent through retrograde ureteroscopy (URS) and laser incision.3
Materials and Methods: Three cases of piecemeal removal of encrusted encased stents were performed. The stents were heavily encrusted, and a retrograde URS under a general anesthesia was performed with a laser to cut the stent, with piecemeal removal of the pieces. Cutting the stent allowed to create space to improve visibility and mobility in the ureter, as the ureteroscope progressed proximally, freeing and removing the distal cut portion of the stent.
Results: The removal of stent using a cystoscopic grasper was not possible because of heavy encrustation associated with it, encasing the stent. A cystoscopic-guided safety wire was inserted to the kidney. A storz semirigid ureteroscope was then inserted parallel to the stent. Owing to stent encasement and lack of space to navigate the ureteroscope proximally, the distal end of the stent was cut by a laser. Using the ureteroscope, the encrustations around the stent were then laser fragmented (0.4–0.6 J, 5–10 Hz) using the Ho:YAG laser to gradually release the encrustations. The stent was then divided using the cutting setting (1–1.5 J, 5–10 Hz). This allowed to create space and a gradual step-by-step proximal progression of the ureteroscope to release the next segment of the stent. The cut fragments of the stent were progressively removed using Ngage basket. The process was repeated to allow complete removal of the stent retrogradely. We had to divide the stent several times to finally release and remove it. The procedure was carried out effectively and no intra- or postoperative complications were noted. The piecemeal removal of stent strategy was effective in all three patients. A vigilant approach and early intervention should be adopted in patients with a high risk4 of stent encrustation, which includes patients with recurrent urinary tract infections, urease producing bacteria, history of cystine or uric acid stone, and avoiding prolonged stent dwell time. Most encrusted stents can be removed intact but in severe encrustations that encase the stent completely and intact removal is not possible, then piecemeal removal might be the only way to remove the stent endoscopically. Stent material, design, and coatings all influence biofilm formation and stent encrustations, and this should be borne in mind while choosing it for a given patient.
Conclusion: Piecemeal stent removal is necessary in extreme cases of stent encrustation where it is encasing the stent completely. This approach allowed effective retrieval of stents in all cases, which otherwise may have needed percutaneous or an open surgical approach.
Kawahara T, Ito T, Terao H, Yoshida M, Matsuzaki J. Ureteral stent encrustation, and colouring: Morbidity related to indwelling times. J Endourol 212;26:178–182.
Aravantionos e, Gravas S, Karatzas AD, Tzortzis V, Melekos M. Forgotten, encrusted ureteral stents: A challenging problem with an endourologic solution. J Endourol 2006;20:1045–1049.
Acosta-Miranda AM, Milner J, Turk TM. The FECal double-J: A simplified approach in the management of encrusted and retained ureteral stents. J Endourol 2009;23:409–415.
Thomas A, Cloutier J, Villa L, Letendre J, Ploumidis A, Traxer O. Prospective analysis of a complete retrograde ureteroscopic technique with holmium laser stent cutting for management of encrusted ureteral stents. J Endouol 2017;31:476–481.
Sutureless Technique in Robot-Assisted Partial Nephrectomy
1Department of Urology, Robotic Surgery Center, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
2Department of Urology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.
Introduction and Objectives: Bleeding is one of the most unfavorable postoperative complications of partial nephrectomy. It is generally accepted that renorrhaphy is necessary for hemostasis because conventional coagulation is uncertain for hemostasis of renal tumor bed. In soft coagulation mode, the output voltage is regulated <190 V and generates Joule heat without producing sparks that cause tissue carbonization. Carbonized tissue sometimes drops off and it leads to bleeding; however, protein degeneration caused by Joule heat is durable. We introduce our minimally invasive sutureless technique using soft coagulation in robot-assisted partial nephrectomy (RAPN).
Materials and Methods: We performed RAPN for 76 consecutive patients with cT1 renal tumor from December 2014 to March 2019. We utilize VIO 300D (ERBE, Germany) for hemostasis of renal tumor bed. The device was set in a “soft coagulation” mode with a power setting of effect 7 and 80 W. In each case, the renal artery was clamped without cooling. During tumor excision, the assistant used a suction/irrigator and a monopolar electrocautery coagulating renal tissue concurrently with the resection of tumor. The renal artery was unclamped after the bleeding was controlled using soft coagulation (early unclamping). After unclamping, additional coagulation was done until complete hemostasis was gained. We did not suture the renal parenchyma when sufficient hemostasis was achieved. The renal artery was reclamped if there was an arterial bleeding and additional coagulation was done.
Results: Twenty-four out of 76 cases underwent RAPN by complete sutureless technique that was carried out with neither suture nor renorrhaphy. There was no case with >10 points of R.E.N.A.L nephrometry score, 6 cases were with scores between 7 and 9 points, and 18 cases were with score <6 points. The median age was 65 (39–85) years and the median body mass index was 24.6 kg/m2 (19.3–31.8). The median console time was 106 minutes (71–169) and the median estimated blood loss was 21 mL (0–250 mL). The median tumor size was 2.3 cm (1.1–4.0 cm) and the median warm ischemic time was 9.0 minutes (6.0–29.1 minutes). All cases had negative surgical margins. The median rate of change in estimated glomerular filtration rate was −3.9% (−22.7% to 24.4%) 1 month postoperatively. Clavien–Dindo Grade IIIa urinoma occurred in two patients and postoperative bleeding was not observed in all cases. In the first case of urinoma, no obvious opening of collecting system was observed during the surgery for deep endophytic 31 mm tumor. To assure whether there is leakage, retrograde pyelography was performed after wound closure. Minor leakage from renal calix was found and ureteral stent was positioned. Urinoma of the second patient was found with the stricture of ureteropelvic junction in 6 months after partial nephrectomy. The effect of soft coagulation might have been conducted because there was only a couple of millimeters between the ureteropelvic junction and the tumor bed. Ureteral stent was also positioned for the patient.
Conclusion: Soft coagulation is an effective technology for tissue hemostasis. Sutureless hemostasis together with early unclamping is a safe and feasible minimally invasive technique for RAPN.
Department of Urology, Aster Medcity, Cochin, India.
Introduction: Robot-assisted kidney transplantation (RAKT) has recently been introduced as a management option for patients with end-stage renal disease. Although open kidney transplant (OKT) remains the gold standard, RAKT is increasingly being adopted across the world as a technique with equivalent outcomes and lesser complications especially for obese patients. The challenges encountered during the performance of vascular anastomosis owing to multiple renal vessels and right-sided renal allograft transplant (short renal vein) are potential reasons for nonselection of patients for RAKT as well as open conversion.
Objective: To demonstrate technical feasibility of RAKT in right-sided (with short renal vein) and multiple vessel renal allografts.
Materials and Methods: This is a retrospective study of 22 patients who underwent RAKT with right-sided (04) and multiple vessel (18) renal allografts in a quaternary private hospital setting. The results were compared with 22 OKT patients. All the surgeries were performed by a single surgeon with >5 years experience in RAKT and OKT. Clinical data were collected in a Microsoft Excel-based database. A descriptive statistical analysis was performed.
Surgical Procedure: The techniques used for managing multiple vessel renal allograft were side-to-side trousering of multiple vessel renal allograft on the bench (5 in RAKT vs 1 in OKT) followed by robot-assisted vascular anastomosis, end-to-side anastomosis of single renal artery to external iliac artery (8 in RAKT vs 10 in OKT), anastomosis of smaller caliber, accessory renal allograft artery to the inferior epigastric artery (2 in RAKT vs 1 in OKT) and double barrelled anastomosis of double vessel renal allograft to two separate arteriotomy incisions made in the external iliac artery (3 in RAKT vs 6 in OKT).
Results: Total of 44 patients underwent kidney transplant in this study (22 RAKT and 22 OKT). The mean age of the recipients was 37.1 ± 13.2 and 35.2 ± 12.8 years in RAKT and OKT groups, respectively. The mean time from clamping to perfusion of the renal allografts was 74 ± 16.3 minutes (RAKT) and 69.4 ± 15.3 minutes (OKT group; p-value 0.332). The mean operating time was 165 ± 22 vs 175 ± 33 minutes in RAKT and OKT groups, respectively (p-value 0.344). The mean hospital stay was 6.71 ± 1.7 days (RAKT) vs 7.75 ± 2.3 days (OKT), respectively (p-value 0.17), and the time to nadir creatinine was 6.5 ± 1.23 days in the RAKT group as compared with 5.9 ± 1.1 days in the OKT group (p-value 0.6). The pain score on day 4 and mean analgesia requirement on postoperative day 1 were significantly lower in the RAKT group than in the OKT group (p-value 0.0004 and 0.02, respectively). The mean incision length was also significantly (p-value 0.0001) smaller in the RAKT group (8.2 ± 0.9 cm) than in the OKT group (17.1 ± 2.9 cm).
Conclusion: RAKT is a feasible option for patients receiving right-sided and multiple vessel renal allografts and the challenges could be safely overcome by the techniques described.
1Department of Urology, Federal University of Minas Gerais, Belo Horizonte, Brazil.
2Department of Urology, United Hospital Center, Bridgeport, West Virginia.
Introduction: Prostatic cysts are rare lesions that may cause compression of the ejaculatory ducts resulting in azoospermia.1 Transrectal ultrasound (TRUS) may identify midline cysts that may be acquired or congenital.2,3 Transurethral resection of the ejaculatory ducts (TURED) may be an effective treatment for obstructive azoospermic infertile men.4,5 The aim of this study was to describe our experience with TRUS and TURED as diagnostic and therapeutic tools in the management of ejaculatory duct obstruction caused by prostatic cysts and causing male infertility.
Methods: We report a clinical case of male infertility to demonstrate the role of TRUS in performing effective TURED for obstructive azoospermia caused by midline cyst. Patient presented with azoospermia, low ejaculate volume (0.2 mL), and low ejaculate pH (6.4). Vasal aplasia and ejaculatory disorders were excluded by physical examination and analyzing postejaculatory urine. TRUS revealed a cystic lesion located in the middle of the prostate. During the procedure we injected methylene blue into each seminal vesicle under TRUS guidance. TURED near the verumontanum in the midline was then performed using only cutting current to minimize damage to the ejaculatory ducts that could cause restenosis. The level of resection was guided by synchronous TRUS to verify location of the cyst and avoid inadvertent injury to the rectum. At the correct level of resection, methylene blue was seen flowing from the opened ducts. Patient required urethral catheter for 24 hours postoperatively. After the TURED procedure, ejaculation was resumed after 2 weeks, when a formal semen analysis was carried out and then repeated every month until the seminal parameters stabilized.
Results: Even though the seminal volume improvement (10.1 mL) was seen in the first month of follow-up, it took about 6 months for semen quality parameters (230.6 million count, 51% motility and 43% morphology) to reach their peak values. Watery ejaculate occurred and spontaneous pregnancy was achieved.
Conclusions: TRUS is an essential instrument that allows to confirm the diagnosis of prostatic cysts and guide TURED. In our experience this combination was effective in reestablishing free passage of semen with potential recovery of fertility.
Saito S. Transrectal ultrasound-guided puncture, drainage, and minocycline hydrochloride sclerotherapy for the symptomatic prostatic cyst. J Endourol 2002;16:693–695.
Manohar T, Ganpule A, Desai M. Transrectal ultrasound- and fluoroscopic-assisted transurethral incision of ejaculatory ducts: A problem-solving approach to nonmalignant hematospermia due to ejaculatory duct obstruction. J Endourol 2008;22:1531–1535.
Modgil V, Rai S, Ralph DJ, Muneer A. An update on the diagnosis and management of ejaculatory duct obstruction. Nat Rev Urol 2016;13:13–20.
Avellino GJ, Lipshultz LI, Sigman M, Hwang K. Transurethral resection of the ejaculatory ducts: Etiology of obstruction and surgical treatment options. Fertil Steril 2019;111:427–443.
Robot-Assisted Laparoscopic Posterior Urethroplasty Using the da Vinci Single Port Robot
Min Suk Jun, MS, DO, Wen Liu, MPH, MD, Geolani W. Dy, MD, Xiaosong Meng, MD, PhD, and Lee C. Zhao, MS, MD
New York University Langone Health, New York, New York.
Introduction and Objective: To describe our technique and outcomes for the treatment of posterior urethral stenosis with the da Vinci Single Port (SP)® platform.
Methods: We retrospectively reviewed five patients who underwent SP robot-assisted laparoscopic posterior urethroplasty (SPRALPU) by a single surgeon from October 2018 to January 2019. Compared with multiport robotics, the SP robot allows for improved exposure and less instrument clashing in the deep pelvis. Variables included patient demographics, diagnosis and etiology, prior interventions, intraoperative variables, functional outcomes, and complications. Success was defined as passage of a 17F flexible cystoscope or absence of urinary symptoms. The operative technique involves SP port placement at a periumbilical location for transabdominal mobilization of the bladder neck and urethra. Cystoscopy is used to identify the level of the urethral stenosis. The stenotic segment is excised and the anastomosis completed using either excision and primary anastomosis or Y-V plasty. Combined abdominoperineal approach may be used for distal urethral mobilization to reduce tension.
Results: The mean age was 64.8 years (range 51–77). Posterior urethroplasty was performed for vesicourethral anastomotic strictures (VUAS) (n = 1), VUAS with rectourethral fistula (n = 1), bladder neck contracture (BNC) (n = 1), BNC with bulbar urethral stricture (n = 1), which were caused by prostate cancer treatment (brachytherapy, radiation therapy, and prostatectomy), and prostatic urethra false passage (n = 1) because of traumatic intermittent catheterization in a patient with neurogenic bladder. Prior interventions included endoscopic balloon dilatation, urethral incision under direct vision, and Foley catheter placement. Four patients underwent SPRALPU without open conversion. Mean operative time was 417 minutes, estimated blood loss 220 mL, and length of stay 5.2 days. There were no intraoperative complications, although one case required open conversion because of SP robot failure; however, surgery was subsequently completed robotically using the Xi robot. Postoperative complications included ileus (n = 2), small bowel obstruction (n = 1), deep venous thrombosis (n = 1), urinary tract infection (n = 3), hematuria (n = 1), urethrocutaneous fistula (n = 1), abscess (n = 1), and osteomyelitis (n = 1). Catheters were removed at a median time of 32.5 days. All cases had patent urethral anastomoses with a median follow-up of 2.5 months. No patients experienced de novo urinary incontinence.
Conclusion: SPRALPU is a feasible approach to an otherwise difficult reconstructive procedure because of challenges in exposure.
