Videourology Abstracts

Robotic “Reverse-Seven” Ureteroileal Reimplantation: Step-by-Step Surgical Technique

David G. Ortega, MD, Anibal La Riva, MD, Laura C. Perez, MD, Aref S. Sayegh, MD, Enanyeli Rangel, MD, Luis G. Medina, MD, Christopher B. Riedinger, MD, and Rene Sotelo, MD

The Catherine and Joseph Aresty, Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Introduction: Ileoureteral replacements are complex surgeries performed when the length or location of the ureteral injury precludes primary ureteroureterostomy, Boari flap, or psoas hitch reconstruction. Bilateral ureteroileal reimplant adds even more complexity to this procedure.¹ Our objective is to present a step-by-step technique to effectively perform a bilateral ureteroileal reimplantation in a reverse-seven configuration.

Materials and Methods: A 51-year-old female with history of rectal adenocarcinoma treated with neoadjuvant chemoradiation and surgery presented with bilateral distal ureteral strictures managed with bilateral percutaneous nephrostomy tubes. At diagnosis, renal mercaptuacetyltriglycine scan showed 73% and 27% for the left and right kidney, respectively. The first step is identification of both ureters at the pelvic brim. Then, the ureters are incised longitudinally along the anterolateral surface. A cystotomy is performed at the bladder dome. Ileal segment is harvested after adequate measurement of the distance needed for the repair, and oriented in an isoperistaltic manner. The left and right ureters are then anastomosed to the proximal end of the harvested ileum. Finally, ileovesical anastomosis was carried out.

Results: The operative time was 5.25 hours, and the estimated blood loss was 50 mL. The postoperative course was uneventful, and discharge occurred on postoperative day (POD) 5. Jackson–Pratt drain was removed on POD 13, and the ureteral Double-J stents were removed on POD 20. Serum creatinine 9-month postoperatively was 2.37 mg/dL, from 2.43 mg/dL preoperatively. Baseline glomerular filtration rate increased from 14 to 23 mL/(min·1.73 m²). At 11-month follow-up, no complications were reported.

Conclusions: Robotic ureteroileal reimplantation in a reverse-seven configuration is a safe and effective technique for the management of bilateral ureteral injury at experienced centers.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0035

Indocyanine Green Angiography for Use in Robotic Spermatic Cord Denervation

Alan M. Makedon, BA,¹ Jeffrey C. Morrison, MD,² and Granville L. Lloyd, MD³

¹University of Colorado Anschutz School of Medicine, Aurora, CO, USA.

²Department of Surgery and Urology, University of Colorado Anschutz School of Medicine, Aurora, CO, USA.

³Department of Surgery and Urology, Rocky Mountain Regional VA, Aurora, Colorado USA; University of Colorado Anschutz School of Medicine, Aurora, CO, USA.

Introduction: Chronic orchialgia continues to be a challenge for urologists to treat and for patients to live with. Currently, conservative treatment (rest, anti-inflammatory drugs, physical therapy, and antidepressants) is the first-line therapy for men struggling with chronic orchialgia.¹ However, when these approaches fail, alternative therapies are required. Before resorting to orchiectomy, microsurgical spermatic cord denervation (MSCD) has been shown to significantly decrease pain with few side effects for the correctly selected patient.² Accurate microsurgical technique and especially avoidance of arterial injury is critical, especially for novice surgeons as well as in cases with aberrant anatomy. In this video presentation, we describe the novel use of indocyanine green (ICG) angiography in correlation with Doppler during robotic MSCD for the purpose of arterial localization and verification of preservation.

Methods: Robotic MSCD was performed in 10 cases of chronic orchialgia after failed conservative treatment and after an effective anesthetic cord block in the office. The procedure consists of a few distinct steps: division of the cremasteric muscle, isolation of the vas deferens and division of the central adipose tissue. ICG was injected twice in each procedure: to identify the testicular artery during central dissection and to confirm preservation of the artery at conclusion. Micro-Doppler was used adjunctly to confirm findings.

Results: In all 10 patients, ICG angiography identified the location and course of the testicular artery, including in cases of aberrant and reoperative anatomy. Doppler assessment confirmed this.

Conclusion: ICG angiography during robotic MSCD is a novel technique to clarify spermatic cord arterial anatomy and is especially useful in the setting of prior surgery and developmental abnormality. This technique is a valuable adjunct to this procedure for novice surgeons, as well as producing visual documentation of arterial preservation, without adding significant time or complication.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0031

Minimally Invasive No Touch Technique for Subinguinal Orchiectomy and Testicular Prosthesis Insertion

Elliot Anderson, MBBS,¹ Arun Arunasalam, MBBS,² Marc Holden, MD,^1,3 Chris Love, MBBS,³ and Darren J. Katz, MBBS^1,3,4

¹Department of Urology, Western Health, Victoria, Australia.

²Western Health, Melbourne, Australia.

³Men's Health Melbourne, Victoria, Australia.

Introduction: Minimally invasive no touch (MINT) technique approach aims to minimize infection and features the use of wound retractors and drapes to all but eliminate exposure to skin flora; it is done as part of a comprehensive perioperative anti-infection protocol, allowing the surgeon to completely insert a prosthesis in a patient without touching the skin. In addition, there is a theoretical advantage of protecting the wound edges from tumor cell implantation.¹ This technique was popularized in urology for use in the insertion of penile implants and has been shown to be effective in decreasing rate of infection to <1%.² The rate of infection after testicular prosthesis insertion is not well commented on within the literature but generally reported as <1.5%.^3,4 When infection does occur, it is associated with a high morbidity with most cases requiring removal of the implant. This is associated with significant cost to the health care system.

Methods: Each key step is demonstrated. After a wet shave and preparation, the first layer of MINT drapes is applied. A 3–4 cm subinguinal incision is made and the Alexis^® retractor is placed. The approximate cost of the Alexis retractor is $75 USD per piece. Once the Alexis is in place, this completes the setup for the MINT technique as skin is completely protected from the surgical field. Gubernaculum can be divided with easy readjustment and testis is removed. Gloves are then changed and prosthesis is prepared. The prosthesis is positioned through two anchoring sutures, helpfully the scrotal skin can be everted/repositioned smoothly through the retractor while the implant is secured. Wound closure is performed with a layered technique, the Alexis retractor can be used to assist with the deep layer closure before being removed.

Results: This single patient video is taken from a small series (N = 4) of patients in whom this easily reproducible technique was utilized. The underlying diagnosis for testicular removal before prosthesis insertion for all patients was testis tumor. There have been no patient complications reported after median follow-up of 12 months.

Conclusion: After viewing this video, the surgeon will understand each key step needed to perform the MINT technique with subinguinal orchiectomy and testicular prosthesis placement.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0018

Insertion of Trocar into the Cyst for Laparoscopic Management of Hydatid Kidney Disease

Emre Bülbül, MD,¹ Fahri Yavuz İlki, MD,² Abdullah Kağan Zengin, MD,³ Sami Berk Özden, MD,¹ and Emin Özbek, MD¹

¹Department of Urology, Istanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, Istanbul, Turkey.

²Department of Urology, Erzincan Binali Yildirim University Faculty of Medicine, Erzincan, Turkey.

³Department of General Surgery, Istanbul University-Cerrahpaşa Cerrahpaşa School of Medicine, Istanbul, Turkey.

Introduction: Renal hydatid cyst operation is usually performed laparoscopically.^1–3 In the laparoscopic treatment of the liver hydatid cysts' various methods of entry and drainage are used such as laparoscopic trocar⁴ and Perforator-Grinder-Aspirator Apparatus⁵ guided cyst evacuation. Palanivelu Hydatid System is used for the treatment of liver and kidney hydatid cysts for entry and drainage.^6,7 The aim of this study is to demonstrate the application of laparoscopic trocar insertion into the hydatid renal cyst.

Methods: We present two female patients undergoing laparoscopic treatment of renal hydatid cyst, a 20- and a 19-year-old, who were admitted with flank pain complaints. Both underwent CT scan; one of them had 150 × 143 × 119 mm loculated type 2 hydatid cyst (Gharbi Classification⁸) located at the upper central region of the right kidney and the other one had 69 × 54 × 48 mm loculated type 2 hydatid cyst located at the upper central region of the left kidney. Patients positivity for hydatid cyst has been approved with 1/320 and 1/2800 positive indirect hemagglutination test. The patients received oral albendazole 400 mg twice a day for 1 month before surgery. Trocar blades were inserted into the patients' transperitoneal space. The cysts were seen in the upper central region of the kidneys. The cysts were released from surrounding tissues. The cysts were covered with a gauze soaked in 10% povidone iodine. Skin-cyst distances of the patients were 26 and 57 mm on the CT images, respectively. The trocars used for cyst insertion were 10 cm in length. The blade of the 11-mm trocar was reinserted into the sheath used in the surgical field to provide more robust bulk for cyst penetration. The cyst lumens were easily penetrated and accessed with the trocar blade. The trocar blades were removed and the large lumen aspirators (10 mm diameter) were inserted through the trocar sheaths. The colloid-like cyst content was rapidly aspirated without obstructing the aspirator lumen. Scolicidal hypertonic saline was injected into the cysts to eliminate the remaining parasitic contents. The cyst contents had no contact with the neighboring viscera. The cysts were deroofed and partially resected. Drainage catheters were inserted into the surgical areas.

Results: The weights of the patients were 49 and 55 kg and the heights were 158 and 162 cm, respectively. Duration of the surgeries were 62 and 77 minutes. No peri-/postoperative complications occurred. The drains were removed 3 days after from the first patient, 4 days from the second patient, respectively. The patients were discharged with full recovery. Patients used oral albendazole therapy for the following 28 days after the surgery to prevent recurrences. The patients' follow-up periods were 6 and 18 months. They had no further complaints.

Conclusion: In this method, the cyst content had no contact within the abdominal viscera. The use of a larger lumen aspirator (instead of the Veress needle) prevented the aspirator system from obstruction with the cyst content. Thus, the duration of surgery was shortened. Inserting a trocar into the hydatid renal cyst is a safe and feasible method to remove the cyst contents without spillage.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0030

Stone Dissolution: Current Safe and Effective Use of Renacidin

Egor Parkhomenko, MD,^1,2 Vivian Williams, MSN, RN, CPNP,² and Michael P. Kurtz, MD^2,3

¹Department of Urology, Boston Medical Center, Boston, Massachusetts, USA.

²Department of Urology, Boston Children's Hospital, Boston, Massachusetts, USA.

³Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.

Introduction: Struvite stones cause significant morbidity in urologic congenitalism. Although stone-free rates have improved with advances in endoscopy, some anatomic circumstances make complete endoscopic removal impossible. Infusions of renacidin (citric acid, glucono-delta-lactone, and magnesium carbonate irrigation solution) to treat upper tract stones were popular in the 1960s, but after six deaths its use was banned by the FDA and not reapproved until the 1990s.^1,2 We wished to revive this therapy to treat a patient in an extraordinary circumstance, which presented challenges as renacidin therapy had not been used at our institution in 30 years. We present our experience and a step-by-step guide to restarting an infusion program.

Materials and Methods: We conducted a literature review and collected national expert opinion. Key stakeholders from nursing, pharmacy, nephrology, infectious diseases, intensive care unit (ICU), and biomedical engineering developed a safe protocol for renacidin infusion. The patient was monitored on a 1:1 staff to patient ratio in the ICU initially. As the medication is in vials with nonsterile exteriors, pharmacy cleaned the vials and pooled it under a sterile hood. The biomedical engineering team recommended a gravity drip, elevated to 30 cm H₂O above percutaneous nephrostomy tube entry site infused at 120 mL/hour (20 drips/minute) or 60 mL/hour (drop factor 10 drips/minute). A mock infusion was completed with a multidisciplinary team before the patient's admission. A 27-year-old woman with severe scoliosis, reconstructed bladder, thoracic displacement of the kidneys, and tortuous ureter from prior ureterostomies leading to limited options for renal access had struvite stone recurrence after multiple bilateral percutaneous nephrolithotomy. We established drainage with bilateral nephrostomy tubes,³ an antegrade ureteral catheter, and a urethral catheter. Daily electrolytes and urine cultures were drawn, and weekly computed tomography scans performed to assess stone burden. Renacidin was infused unilaterally at full or half rate, depending on patient tolerance (pain, fever, leakage, or backflow), during the day and physiologic saline was infused during the night at the same respective rate. Continuous culture directed IV antibiotics were administered throughout the infusion.

Results: Infusion was carried out for 60 days, initially on the left for 30 days (larger stone burden), and 30 days on the right. Total hospital stay was 71 days. The patient has been stone free since discharge and completion of renacidin therapy for ∼150 days. There were no episodes of mucosal hemorrhage or sepsis.

Conclusions: Renacidin infusion can be performed safely and effectively and may eliminate the nidus for recurrent struvite stone formation in patients who have failed endoscopic therapy for upper tract stones. An inpatient monitoring program and multidisciplinary collaboration is required for safe infusion.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0016

Many a Slip with Clips

Rohan Sharma, MBBS, MS, Abhishek G. Singh, MBBS, MS, MCh, Rohan Batra, MBBS, MS, DNB, Arvind Ganpule, MBBS, MS, DNB, Ravindra B. Sabnis, MBBS, MS, MCh, and Mahesh R. Desai, MBBS, MS, FRCS

Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.

Introduction and Objectives: Hem-O-Lok Weck Clip (HOLC) is widely used to achieve athermal hemostasis during minimal access urologic surgery, most commonly during prostatectomy and nephrectomy (donor as well as simple/radical/partial). Clip migrations after radical prostatectomy have been widely reported in literatures worldwide. Misfiring of clips has also been experienced intraoperatively, which if diagnosed during surgery can prevent dreadful postoperative complication and medicolegal issues.

Methods: Five patients who have developed intra- as well as postoperative complication related to clips or intraoperative misfiring of Weck clip have been described in this video presentation. Case 1: Slippage of the Weck clip applied over the left upper renal artery during laparoscopic donor nephrectomy. Case 2: Accidental clipping of right upper ureter during right robotic partial nephrectomy. Case 3: Accidental clipping of obturator nerve during obturator lymph node dissection during robot-assisted laparoscopic radical prostatectomy. Case 4: Patient presenting with obstructive lower urinary tract symptoms after 9 years of robotic radical prostatectomy. Cystoscopy showed multiple Weck clip migration at vesicourethral anastomosis. Case 5: Patient presenting with right flank pain after 9 years of right robotic partial nephrectomy. Flexible ureterorenoscopy showed multiple Weck clips migrated into the pelvicaliceal system.

Results: Case 1 was managed by applying the Weck clip again at the base of renal artery with 3 mm of residual stump. Application of clip over the bleeding artery stump in bloody field should be avoided to prevent worse complications. Cases 2 and 3 were managed by fulgurating the knob of Weck clip with harmonic scalpel and removing the clip. The defect created was sutured with Vicryl suture material. Cases 4 and 5 were managed by removing the Weck clips with forceps. None of the patients developed any complaint during the mean postoperative follow-up duration of 36 months (ranging from 12 to 84 months).

Conclusions: Hem-O-Lock Weck Clip should be used judiciously and cautiously near the vital structures and anastomotic site. Owing to its nature to migrate through the anastomotic site, free lying clips should be actively searched and removed to avoid postoperative morbidity and intervention.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0034