Videourology Abstracts

Abstract

Robotic Culp de Weerd Pyeloplasty for Secondary Pelviureteral Junction Obstruction

Peter T.Grice, MBChB, MRCS,

Henry H.I. Yao, MBBS, BMedSc, PGDipSurgAnat, FRACS (Urol)

and Thomas J. Walton BM BS, DM, FRCS (Urol)

Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.

Introduction: Secondary pelviureteral junction obstruction (PUJO) may be defined as one or more of recurrent symptoms, renographic obstruction, and renal function deterioration after primary intervention for PUJO.¹ Causes include renal pelvis ischemia, anastomotic dehiscence, a failure to identify a crossing vessel, and ureteral stent blockage or migration.^2,3 Secondary pyeloplasty is associated with longer operating times, higher blood loss, and increased recurrence rates compared with primary pyeloplasty.⁴ Originally described in 1951, Culp de Weerd pyeloplasty (CdWP) utilizes a local renal pelvis flap to widen the pelviureteral junction without formal dismemberment, and thus may be particularly suited to stricturing caused by failed endopyelotomy or pyeloplasty.⁵ Robotic CdWP represents a novel approach for secondary PUJO, which is poorly described in published literature to date. We present three cases of robotic CdWP for secondary PUJO with one operative video demonstration.

Materials and Methods: All three patients had symptomatic recurrent PUJO on mercaptoacetyltriglycine (MAG-3) diuretic renography after previous Anderson-Hynes pyeloplasty (AHP), along with a capacious renal pelvis on cross-sectional imaging. Time from AHP to reoperation was 9, 7, and 2 years, respectively. At operation a three-way urinary catheter was inserted and the patient was placed in a lateral position with minimal table break. A standard three-port robotic technique was employed, utilizing two 8-mm da Vinci™ Si cannulas and an additional 5-mm cephalad assistant port. After completion of the posterior wall reconstruction a 4.8F × 26 cm Double-J ureteral stent was placed antegradely, with reflux of bladder irrigant confirming correct stent placement. A 15F drain was inserted at the end of the procedure. After inpatient discharge all patients underwent stent removal at 4 weeks, followed by repeat diuretic renography at 8 weeks. Further renography was performed at 12 and 24 months before formal hospital discharge.

Results: There were no intra- or postoperative complications. All patients experienced postoperative symptom resolution along with improved parameters on MAG-3 renography and stable serum renal biochemistry. Two cases have been discharged and a final case remains asymptomatic 3 months after surgery.

Conclusion: Robot-assisted CdWP appears a safe and effective technique for the management of secondary PUJO. Patient selection is of crucial importance, as an adequate volume of renal pelvis tissue is required to construct a spiral flap. Further studies are required to determine whether this technique confers additional clinical benefit over repeat dismembered pyeloplasty or endopyelotomy.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0090

Technique of Totally Tubeless Percutaneous Nephrolithotomy with a Safety Suture Thread

Andriy Sahalevych, MD, PhD,¹ Ruslan Korets, MD,²

Roman Sergiychuk MD,¹ Vladislav, Ozhohin, MD,¹

Andriy Khrapchuk, MD,¹ and Olexandr Vozianov, MD, PhD¹

¹ Department of Urology, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine.

² Division of Urology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Introduction: Placement of a nephrostomy tube at the conclusion of percutaneous nephrolithotomy (PCNL) has been traditionally considered a standard practice. However, in the past decade, tubeless or totally tubeless PCNLs have been performed more frequently. We present our technique of tubeless mini percutaneous nephrolithotomy (mPNL), utilizing a safety suture thread that still allows surgeons transitioning to a totally tubeless technique to maintain access to the percutaneous tract.

Materials and Methods: After informed consent, we performed the technique on 40 patients undergoing mPCNL. During the final stage of uncomplicated mPCNL we perform an antegrade pyelography to confirm satisfactory evacuation of the contrast agent from the renal collecting system. Next, a safety suture (Prolene No. 0, length 150 cm) is inserted into the distal lumen of the ureteral catheter and passed retrograde through the ureteral catheter into the renal pelvis. Once in the renal collecting system, the safety suture thread is grasped with forceps inserted through the nephroscope and removed through the flank. The ureteral catheter is then pulled backward by the urethral tip so that the distal end of a safety suture thread remains outside the urethra. The nephroscope sheath is removed while visually inspecting the tract for bleeding. The skin incision is closed and the proximal end of the suture thread is fixed to the skin, whereas the distal (urethral) end of the safety suture is affixed to a Foley catheter with adhesive tape.

In case of bleeding, upper tract obstruction, or fever, the suture can be used as a guidewire. This is accomplished by pulling the safety suture at both ends and either inserting a nephrostomy tube at the proximal side of the suture into the percutaneous tract to stop bleeding, or placing a nephroureteral stent along the suture, in a retrograde or antegrade manner.

Results: We utilized this technique in 40 patients undergoing mPNL. In 38 patients, no adverse events were noted in the postoperative period, and the safety suture thread was removed on postoperative day 1 with the Foley catheter without difficulty. In one patient, because of delayed bleeding from the percutaneous tract, the safety suture was utilized for antegrade placement of a nephrostomy tube as demonstrated in the video. Drain placement occurred in the procedure room on the ward under local anesthesia with ultrasonography guidance. In another patient, because of persistent leak from the percutaneous tract on postoperative day 1, decision was made to place a ureteral stent in an antegrade manner over the safety suture. Both of these cases avoided the use of operating room, general anesthesia, and cystoscopy.

Conclusions: The technique mimics a totally tubeless mPCNL, with a safety suture thread allowing maintenance of control over the percutaneous tract and the collecting system. In case of bleeding in the early postoperative period, it is possible to place a nephrostomy tube along the suture thread for hemostasis and drainage of the collecting system. The technique may be helpful as an intermediate step for surgeons who are considering transition to a totally tubeless PCNL technique.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0080

Single-Port Robotic Pyeloplasty in a Pediatric Patient

Niki Parikh, MD, MBA, MSBA, Timothy Boswell, MD,

Bridget Findlay, MD, Patricio Gargollo, MD,

and Candace Granberg, MD

Department of Urology, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: Pediatric surgery began with single-incision flank surgery and has evolved to standard multiport laparoscopic and robotic approaches. To decrease visibility of incisions, hidden incision endoscopic surgery was developed. Recent technological advances with the single-port (SP) robot have allowed for the transition back to single-incision surgery.

Materials and Methods: A 10-year-old girl with a history of bilateral vesicoureteral reflux presented to clinic after an episode of right pyelonephritis. Renal ultrasonography showed right hydronephrosis and Mag 3 Lasix renogram showed concerns of obstruction of the right ureteropelvic junction with estimated 27% function on the left and 73% on the right. Because of symptomatic right ureteropelvic junction obstruction and worsening hydronephrosis, the decision was made to perform the first SP robotic pyeloplasty procedure in a pediatric patient. The SP platform has one 2.5 cm, 4-channel port, a 12 × 10 mm articulating camera, and 6 mm multiwristed instruments, including the Maryland dissecting forceps, Cadiere forceps, wristed needle driver, and curved scissors.

Results: The port was placed in the Pfannenstiel line, and SP robotic pyeloplasty was completed without issues with space, triangulation, or articulation. There is loss of insufflation with use of laparoscopic instruments through an SP channel, as the seal on the port does not maintain a closed working system. The SP robot has since been utilized in seven patients with ages ranging from 23 months to 14 years. Six patients underwent robot-assisted dismembered pyeloplasty and one patient underwent robot-assisted Mitrofanoff using the da Vinci SP surgical system. Median operative time for all cases was 120 minutes, comparable with other robotic platforms. Estimated blood loss was <25 mL in all patients. All surgeries were completed through the SP without any intraoperative issues, need for extra ports, or conversion to alternate approaches. Minimal to no learning curve was present with the use of the SP system and observation from the approach did not differ from previous robotic systems. In older patients, no issues were present with instrument clashing, deploying the instruments, or achieving triangulation. Postoperatively, all patients were maintained on an alternating schedule of acetaminophen and ketorolac with no patients requiring opioid pain medications. All were discharged in <24 hours without complications. No postoperative adverse events were detected and all pyeloplasty patients had improvement with hydronephrosis. In addition, all parents were unanimously happy with the SP incision.

Conclusions: SP robotic surgery is feasible in pediatric patients, but patient selection is fundamental to success. To optimize use, a 10-cm working distance must be maintained, limiting use to older children and teenagers. A shorter distance limits wristing of instruments as was experienced in the 23-month-old pyeloplasty. To help improve working space a Gel-Port can be utilized with the port retracted outside of the body to gain working space. In addition, needles can be placed into the abdomen after incision and before port placement to prevent loss of insufflation. Future development of the platform is needed to widen application to smaller patients.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0112

Key Steps in Retzius-Sparing Robot-Assisted Radical Prostatectomy with a Novel Technique for Suspension of Parietal Peritoneum

Nejdet Karsiyakali, MD, FEBU,¹

Mahir Bulent Ozgen, MD,¹

Bora Ozveren, MD,² and Levent Turkeri, MD¹

¹ Department of Urology, Acibadem M.A. Aydinlar University, Altunizade Hospital, Istanbul, Turkey.

² Department of Urology, Acibadem M.A. Aydinlar University, School of Medicine, Altunizade Hospital, Istanbul, Turkey.

Introduction: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been associated with better functional outcomes when compared with conventional RARP.^1
–3 Nonetheless, it is technically a challenging operation because of the limited space within the surgical area. This video presentation aims to summarize the key steps of the RS-RARP and demonstrate a simple technique for suspension of the edge of parietal peritoneum after incision at the Douglas pouch for better exposure of the surgical area. In this context, we also present operative, oncologic, and functional outcomes in a consequent series of our patients who underwent RS-RARP with suspension of the peritoneum.

Materials and Methods: We retrospectively reviewed medical records of 92 patients who underwent RS-RARP in department of urology, Acibadem M.A. Aydinlar University, Altunizade Hospital, between July 2017 and June 2020. RS-RARP was performed using the DaVinci^® Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The key steps of the surgery is demonstrated.⁴ A simple technique to suspend the cut peritoneal edge by 0 vicryl suture with Weck^® Hem-o-lok^® clip at the tail end is also described.

Results: The mean age of the patients was 64.0 ± 7.0 years, mean prostate volume was 51 ± 23 cc, and the median prostate-specific antigen level was 6.12 (4.43–11.00) ng/mL. The mean body mass index of the patients was 26.47 ± 3.34 kg/m². The mean total operative time, which describes the interval between anesthesia induction and termination of the anesthesia, was 313 ± 94 minutes. The estimated blood loss was 100 (50–100) mL. Extended pelvic lymph node (LN) dissection was performed in 62 (67.4%) patients. The median total number of dissected LN and LN with metastatic deposits were 13 (9–18) and 0 (0–0), respectively. No intraoperative or late postoperative complications were observed in any patients, whereas early postoperative complication was observed in 8 (8.7%) patients. Clavien–Dindo (CD)-2, CD-3A, and CD-3B complications were observed in 1 (1.1%), 4 (4.3%), and 3 (3.3%) patients, respectively. The median length of hospital stay and catheterization duration was 2 (2–3) and 8 (7–10) days, respectively. The distribution of the patients in terms of International Society of Urologic Pathology-grade groups (−1, −2, −3, −4, and −5) was 5 (5.4%), 39 (42.4%), 32 (34.8%), 5 (5.4%), and 10 (10.9%), respectively. Clinically significant prostate cancer was observed in 88 (95.7%) patients according to Epstein's criteria. Surgical margin positivity was observed in 15 (16.3%) patients. Of these patients, pT2, pT3a, and pT3b disease were observed in 6 (40.0%), 5 (33.3%), and 4 (26.7%) patients, respectively. pT2 disease was present in 55 (59.8%) of the patients, whereas 26 (28.3%) and 11 (12.0%) of them had pT3a and pT3b disease, respectively. The median tumor volume was 3.00 (1.60–6.25) cm³. Complete urinary control (no leakage) rates in week-1, month-1, month-3, month-6, and month-12 were 67.1%, 80%, 87.1%, 95.7%, and 97.1%, respectively. In the same period, safety pad usage ratios were 20%, 8.6%, 8.6%, 4.3%, 2.9%, respectively. Of these patients, erectile dysfunction rates in month-1, month-3, month-6, and month-12 were 66.7%, 56.9%, 35.3%, and 25.5%, respectively.

Conclusion: Suspension of the peritoneum by 0 vicryl suture with an end-tail Weck^® Hem-o-lok^® clip can be considered for better and wider exposure of the surgical area during RS-RARP without compromising oncologic and functional outcomes.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0114

Augmentation Cystoplasty: Fourth-Line Therapy for Refractory Idiopathic Overactive Bladder

Lee Baumgarten, MD, Samantha Raffee, MD, and

Humphrey Atiemo, MD

Vattikutti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA.

Objective: Idiopathic overactive bladder (iOAB) refractory to conventional first-, second-, and third-line therapies is a challenging condition to manage. Fourth-line therapy, specifically urinary diversion or augmentation cystoplasty, has recently been added to the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction guidelines for patients who have severe symptoms and are refractory to all other therapies. In this video and short series, we describe the surgical technique and report on contemporary outcomes of augmentation cystoplasty for patients with iOAB.

Methods: Medical charts of patients undergoing augmentation cystoplasty for iOAB during the years 2012 to 2020 were retrospectively reviewed (n = 8). All patients were followed for at least 6 months with a median of 12 months. Baseline characteristics including patient demographics, preoperative fluorourodynamic parameters, and first-, second-, and third-line iOAB treatments were recorded. Outcomes studied included perioperative outcomes and American Urological Association Symptom Score (AUASS) and Incontinence Symptom Index scores. Wilcoxon signed-rank test was used to assess temporal significance; a two-sided p-value <0.05 was considered significant.

Results: The median age of the cohort was 54.5 years. All patients were women. The median preoperative bladder compliance was 39.8 cm water and the median preoperative bladder capacity was 134.5 mL. All patients had failed at least two drug regimens and had tried-and-failed either treatment with Botox (37.5%) or InterStim (100%). The median operative time was 6 hours and 10 minutes; the median blood loss was 150 mL. There were significant improvements in patient's AUASS and AUASS-quality of life scores after surgery (p = 0.032 for each).

Conclusions: As this video and small series demonstrate, for patients who fail to respond to first-, second-, and third-line treatments for iOAB, augmentation cystoplasty may be considered a fourth-line treatment for the most refractory of patients and is associated with statistically improved symptom scores.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0094

Fixation of a Mono-J-Ureteral Catheter by Using a Whistle Tip Catheter

Alina Reicherz, MD, Joachim Noldus, MD, and

Peter Bach, MD

Department of Urology, Ruhr-University Bochum, Marien Hospital, Herne, Germany.

Introduction: Until an ideal stent is reached, urologists make an effort to find a way of ureteral stenting that provides the best comfort and with few complications, whereas being affordable for the health system. Consensus on best practices for postoperative stenting has been difficult to reach. According to a recently published Cochrane analysis, most studies concerning this topic are limited by retrospective design and small sample size.¹ European and American guidelines on urolithiasis state that routine stenting after uncomplicated ureterorenoscopy (URS) is not necessary, and it is associated with higher postoperative morbidity and costs.^2,3 However, a recently published observational study (n = 17,129) from North America showed that guidelines and clinical practice appear to differ: Double-J insertion was performed in 86.2% of patients undergoing laser lithotripsy and in 70.5% of patients undergoing basket retrieval.⁴ An empirical study from Germany showed that after a primary and secondary URS, 79.6%, respectively 62.2%, of the urologic departments insert a Double-J catheter (unpublished data). To omit the downsides of a Double-J placement, the European guideline on urolithiasis states that a ureteral catheter can be transiently placed with similar results.³ We demonstrate an easily feasible and safe technique for the fixation of Mono-J-catheter to a Foley with a whistle tip.

Materials and Methods: After URS and Mono-J-catheter (Coloplast^®, Single loop ureteral stent, VORTEK^® 6 Ch) insertion, a Foley (UROMED, Silicone Balloon Catheter with Whistle tip, 18 Charr.) was placed through the Mono-J-catheter. After 6 hours, both the Foley and the Mono-J-catheter were removed by a nurse. Endpoints were dislocation and difficulties during the removal of the Mono-J-catheter. The technique was utilized during FaST 1 and 2, two consecutive single academic center studies conducted between 05/2014–08/2015 and 05/2016–04/2018, 245 patients with renal or ureteral calculi were initially treated with Double-J insertion.^5,6 Before secondary URS, patients were prospectively randomized into two groups: Double-J-insertion for 3 to 5 days vs Mono-J insertion for 6 hours and Mono-J-catheter insertion for 6 hours vs tubeless after URS. One hundred twenty-one patients received a Mono-J-catheter. FaST 1 and 2 studied patients quality of life and reintervention rates.

Results: No difficulties occurred during the removal of the Mono-J-catheter and Foley (0%; n = 0/121). In none of the cases, the Mono-J-catheter was displaced (0%; n = 0/121).

Conclusions: The placement of a Foley with a whistle tip through a Mono-J-catheter is easily feasible. It increases patients' comfort, as only one urine drainage bag is needed and eases patients' mobility. The described technique allows an easy and trouble-free removal. None of the Mono-J-catheters dislocated.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0117

Footnotes

1.

Rogers A, Hasan T. Management of secondary pelviureteric junction obstruction. Indian J Urol 2013;29:294–302.

2.

Pouliot F, Lebel MH, Audet JF, Dujardin T. Determination of success by objective scintigraphic criteria after laparoscopic pyeloplasty. J Endourol 2010;24:299–304.

3.

Rassweiler JJ, Subotic S, Feist-Schwenk M, et al. Minimally invasive treatment of ureteropelvic junction obstruction: Long-term experience with an algorithm for laser endopyelotomy and laparoscopic retroperitoneal pyeloplasty. J Urol 2007;177:1000–1005.

4.

Dirie NI, Ahmed MA, Wang S. Is secondary robotic pyeloplasty safe and effective as primary robotic pyeloplasty? A systematic review and meta-analysis. J Robot Surg 2020;14:241–248.

5.

Poulakis V, Witzsch U, Schultheiss D, Rathert P, Becht E. Die geschichte der operativen behandlung der harnleiterabgangsstenose (Pyeloplastik): Von trendelenburg (1886) bis zur gegenwart. Urologe - Ausgabe A 2004;43:1544–1559.

1.

Sayyid RK, Simpson WG, Lu C, Terris MK, Klaassen Z, Madi R. Retzius-sparing robotic-assisted laparoscopic radical prostatectomy: A safe surgical technique with superior continence outcomes. J Endourol 2017;31:1244–1250.

2.

Dalela D, Jeong W, Prasad MA, et al. A pragmatic randomized controlled trial examining the impact of the retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2017;72:677–685.

3.

Nyarangi-Dix JN, Gortz M, Gradinarov G, et al. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: functional and early oncologic results in aggressive and locally advanced prostate cancer. BMC Urol 2019;19:113.

4.

Chang KD, Abdel Raheem A, Choi YD, Chung BH, Rha KH. Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: Surgical technique and results of the first human trial. BJU Int 2018;122:441–448.

1.

Ordonez M, Hwang EC, Borofsky M, Bakker CJ, Gandhi S, Dahm P. Ureteral stent versus no ureteral stent for ureteroscopy in the management of renal and ureteral calculi. Cochrane Database Syst Rev 2019;2:CD012703.

2.

Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 2016;196:1153–1160.

3.

EAU Guidelines Office, ed. EAU Guidelines: Dilatation of the Upper Urinary Tract (UPJ and UVJ Obstruction). Arnhem, The Netherlands: EAU Guidelines Office, 2019.

4.

Mittakanti HR, Conti SL, Pao AC, et al. Unplanned emergency department visits and hospital admissions following ureteroscopy: Do ureteral stents make a difference? Urology 2018;117:44–49.

5.

Reicherz A, Maas V, Wenzel P, et al. Transient stent placement versus tubeless procedure after ureteroscopy retrograde surgery stone extraction (FaST 2): A randomized prospective evaluation. Int J Urol 2020;27:749–754.

6.

Bach P, Reicherz A, Teichman J, et al. Short-term external ureter stenting shows significant benefit in comparison to routine double-J stent placement after ureterorenoscopic stone extraction: A prospective randomized trial - the Fast track stent study (FaST). Int J Urol 2018;25:717–722.