VIDEOUROLOGY ABSTRACTS

Prophylactic Mesh Placement at the Time of Ileal Conduit Creation: A Simple Sublay Technique

Da David Jiang, MD,^1,* Kyle A. Gillis, MD,² Kenneth Softness, MD,¹ Nicholas H. Chakiryan, MD,³ Alison Levy, MD,⁴ Vitaliy Poylin, MD,⁵ Andrew A. Wagner, MD,¹ and Peter Chang, MD¹

¹Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

²University of Iowa, Iowa City, Iowa, USA.

³Moffit Cancer Center, Tampa, Florida, USA.

⁴Lahey Hospital & Medical Center, Burlington, Massachusetts, USA.

⁵Northwestern Medical Group, Chicago, Illinois, USA.

*ORCID ID (https://orcid.org/0000-0003-3543-491X).

Background: A prospective randomized study of prophylactic mesh placement at the time of cystectomy and ileal conduit found a significant reduction the cumulative incidence of parastomal hernias by ∼50%.¹ We present a novel simple sutureless prophylactic sublay permanent mesh placement at the time of ileal conduit creation.

Materials and Methods: Robotic cystectomy is performed in the standard manner with intracorporeal diversion (n = 34). Open cases (n = 4) were performed through a lower midline incision. The stoma site is marked by the stoma nurse specialists during an outpatient visit before the procedure. The stomal skin and subcutaneous tissue is excised to the anterior rectus sheath. The anterior rectus sheath is incised in a cruciate manner revealing the rectus muscle. The rectus muscle is gently split bluntly between retractors revealing the posterior sheath. The space between the posterior sheath and the rectus is then bluntly dissected circumferentially with a finger. This is the space where the mesh will be placed. The mesh is prepared on the backtable. A 4″ × 6″ Bard Ventralight™ ST mesh is used. This is a permanent medium weight monofilament propylene mesh with an absorbable hydrogel barrier on the posterior side based on Sepra^® Technology (ST). A circular mesh with 6 cm in diameter is formed and a cruciate cut is made centrally to fit the diameter of the ileal conduit. The conduit is brought out of the stoma site and the mesh is thread over the conduit with the shiny ST side down; the ST side is in contact with the conduit and prevents adhesions. The mesh is then gently tucked into the dissected space. The rest of the conduit is matured in standard manner. We present two cases in this video of mesh placement at the time of ileal conduit.

Results: Initially, after observing our colorectal colleagues place mesh in this manner, we used subjective criteria when deciding to perform mesh placement. These factors primarily included body habitus, smoking history, and history of abdominal hernias. Using these criteria we performed mesh placement in 23 patients between March 2019 and July 2020. After having subjectively favorable outcomes without any mesh-related complications, mesh placement became standard for all ileal conduit patients after August 2020. To date, 38 cases have been performed; 34 through robotic intracorporeal diversion. Median follow-up is 4 months (IQR 2–8). There have been no mesh-related complications such as mesh erosion, mesh infection, mesh pain, or need for mesh explant. The follow-up is too short to determine efficacy; however, no clinically apparent parastomal hernias have developed. Twenty-one patients had available postoperative imaging for review by our team with specific attention to subclinical parastomal hernias. Of those, the median radiographic follow-up was 5 months (IQR 3–10); one patient from the robotic group (5%) had radiographic evidence of a parastomal hernia.

Conclusion: We present a novel simple sutureless technique for prophylactic mesh placement at the time of ileal conduit creation. With short follow-up, there are no evidence of mesh-related complications. Longer follow-up is needed to determine efficacy.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0026

Tubeless Mini-Percutaneous Nephrolithotomy with Antegrade Stent Tether in Preschool Children

Azimdjon Tursunkulov, MD, PhD,^1,* Dilmurad Yunusov, MD,² Rustam Anvarov,³ and Aziza Tavakkalova³

¹Urology Department, AkfaMedline Hospital, Akfa University, Tashkent, Uzbekistan.

²Urology Department, AkfaMedline Hospital, Tashkent, Uzbekistan.

³Akfa University, Tashkent, Uzbekistan.

*ORCID ID (https://orcid.org/0000-0002-1400-178X).

Background: Childhood urolithiasis is a major health problem in developing countries, especially in endemic regions. The incidence of childhood urolithiasis ranges increases in the endemic areas of the world, such as Uzbekistan. Percutaneous nephrolithotomy (PCNL) is useful with high stone clearance with low morbidity for upper urinary tract stones >1.5 cm. The miniaturizing of instruments has been shown to significantly reduce intra- and postoperative hemorrhage, renal parenchymal injury, postoperative pain, and length of hospital stay. The need for postoperative cystoscopy for ureteral stent removal is one of the limitations of tubeless mini-PCNL in children, which needs narcotics, postoperative urination discomfort, and sometimes hospital stays for children.

Objectives: This study aims to evaluate the safety and efficacy of mini-PCNL with antegrade stent tether in preschool children.

Materials and Methods: From 2018 to August 2021, in our medical center, 138 preschool children underwent tubeless mini-PCNL with antegrade stent tether. All procedures performed by Storz MIP system 12F nephroscope, using 16F metallic sheath. Stone fragmentation was performed by holmium laser and pneumatic lithotriptor. All cases were finished with antegrade stent placement with a proximal tether through the percutaneous tract, protected by a clear occlusive bandage. The polypropylene thread was sutured through the stent's proximal lumen and from inside to outside, which contributed to the easy removal whereas minimizing damage to surrounding tissue with the tip of the stent. Some ureteral stents come with a tether, which can be used in this technique, avoiding the polypropylene stitch. In these types of stents surgeons should pay attention to the thickness of tether, because thin tethers can tear during the removal.

Results: A total of 138 children—92 (66.6%) boys and 46 (33.3%) girls, with a mean age of 54.5 (17–75) months were included in this study. The mean size of the stones was 29.5 (19–41) mm. Renal stones were located in renal pelvis in 66 (47.8%) patient, in lower pole in 28 (20.2%) patient, in central region/upper pole in 17 (12.3%) and in 27 (19.5%) patients were staghorn stones. All intrarenal access was performed in the prone position under ultrasonography and fluoroscopic guidance. In 12 cases required additional access with 12F sheath. Stone-free rate was 98%. Mean operative time was 68.5 (45–92) minutes. Hospital stay time was 2–3 days in all cases. There was no significant bleeding that necessitated transfusion. Overall complications Clavien I–II were noted in 19 (13.7%) patients; none of the patients had severe complications (Grades III, IV, and V). In all cases, the ureteral stent was removed by tether through flank without anesthesia in the office, in 87 (63%) cases on the fourth day and in 51 (36.9%) cases on the sixth day after surgery. There was no incidence of bleeding and pain during stent removal.

Conclusions: Tubeless mini-PCNL with stent tether is a safe and effective technique for preschool children, which avoids the possibility of postoperative cystoscopy, additional anesthesia, hospital stay, and allows easy access to the caliceal system for second look nephroscopy when it needs.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Music: Yanni—The Flame Within.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0011

Robotic Suprarenal Cavectomy Without Reconstruction in Renal Cell Carcinoma With Inferior Vena Cava Thrombosis

Luis G. Medina, MD,¹ Alireza Ghoreifi, MD,^1,* Hatim Thaker, MD,¹ Aref S. Sayegh, MD,^1,** Vinay Duddalwar, MD,² and Hooman Djaladat, MD¹

¹The Catherine and Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

²Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

*ORCID ID (https://orcid.org/0000-0002-7368-7240).

**ORCID ID (https://orcid.org/0000-0001-9320-2987).

Introduction: Inferior vena cava (IVC) thrombosis occurs in <10% of renal cell carcinoma (RCC) patients.^1,2 Up to 25% of these cases will require IVC interruption, yet caval replacement is controversial.^3,4 We present a robotic suprarenal cavectomy without reconstruction in a patient with RCC.

Materials and Methods: A 50-year-old man was found to have a 9-cm right renal mass and level III thrombosis. The length of IVC thrombus was 112 mm, terminating 3.6 cm below the level of hepatic veins and occluded 100% of the IVC without distal bland thrombosis. CT showed suspicious lesion in liver and contralateral adrenal, although supplementary imaging ruled out liver metastasis. He underwent robotic right radical nephrectomy, IVC thrombectomy, and suprarenal cavectomy.

Results: Surgery was completed without intraoperative complication. Operating time was 6 hours and estimated blood loss was 300 mL. Intraoperative ultrasound showed the tip of the thrombus and helped to secure rommel control just above it. After securing down all controls, IVC was opened, and thrombus was removed. Cavectomy was deemed necessary because of tumor adhesions to inner part of IVC. Nephrectomy was completed and all specimens removed through Pfannenstiel incision. Postoperative course was uneventful and discharged home in 4 days. Baseline Glomerular Filtration Rate was 44 and at discharge was 49 mL/min/1.73 m². Pathology report endorsed clear cell RCC (pT3bN0), negative margins, and adherent tumors in middle section of IVC (noninvasive). No complication was reported within 90 days, postoperatively.

Conclusions: Robotic right radical nephrectomy and suprarenal cavectomy is feasible, yet more studies are needed.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0039

Demirtas–Erciyes Modification of Laparoscopic Transperitoneal Radical Prostatectomy

Şevket T. Tombul, MD,¹ Gökhan Sönmez, MD,¹ Türev Demirtaş, MD,^2–4 and Abdullah Demirtaş, MD¹

¹Department of Urology, Medical Faculty, Erciyes University, Kayseri, Turkey.

²Department of Medical History and Ethics, Medical Faculty, Erciyes University, Kayseri, Turkey.

³Department of Stem Cell Sciences, Genom and Stem Cell Center, Faculty of Medicine, Erciyes University, Kayseri, Turkey.

⁴Department of Emergency Medical Program, Halil Bayraktar Vocational Health College, Erciyes University, Kayseri, Turkey.

Objective: Minimally invasive surgery, especially robot-assisted laparoscopic prostatectomy (RARP), stands out among the current treatments in localized prostate cancer (PCA). RARP is technically advantageous because it enables the bladder neck and urethra protection to be more possible. However, since robotic systems are not always available, laparoscopic radical prostatectomy is still up to date. In this video report, we present our laparoscopic radical prostatectomy technique, which is a combination of Montsouris' technique and bladder neck and urethra preservation described for RARP by Cathelineau et al.¹ and Tunç et al.²

Materials and Methods: Data of 160 patients who were operated between July 2015 and December 2020 for localized PCA were analyzed retrospectively. Demirtas–Erciyes modification of laparoscopic transperitoneal radical prostatectomy (DE-LAP) technique could not be applied to 43 patients because of history of transurethral resection of prostate or presence of the median lobe protruding into the bladder. Preoperative prostate-specific antigen, prostate biopsies, preoperative erectile function status, operation time, transfusion rate, complications, pathology results of laparoscopic retropubic radical prostatectomy, postoperative erectile function, and continence status were recorded. Details of the surgical technique that was described previously by Tombul et al.³ are given in the video.

Results: The mean age of 117 patients was 64.5 ± 4.8 years old. In total, 73.7% of the patients had low-risk PCA according to the European Association of Urology Guideline on prostate cancer.⁴ The median operation time was 185 minutes. Lymph node dissection was performed in 24 patients (19.6%). Nerve sparing was performed in 74 patients (60.6%). Surgical margin positivity, extracapsular extension, and seminal vesicle invasion were detected in 11 (9%), 12 (9.8%), and 5 patients (4.1%), respectively. Rectal injury in three patients, ureter ligation in one patient, bladder perforation in one patient, and bladder neck stricture in five patients were detected. Continence rates at postoperative 3rd, 6^th, and 12th month were 84%, 94.7%, and 97%, respectively. Spontaneous or assisted erection was observed in half of the patients in whom nerve sparing was done.

Conclusion: DE-LAP stands out as a method that can be preferred among the minimally invasive treatment options of PCA.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0023

Retzius-Sparing Robot-Assisted Laparoscopic Prostatectomy with DaVinci Single-Port Robot

Joshua K. Palka, DO,¹ Alex L. Shiang, MD,² Grant M. Henning, MD,¹ Robert Sherburne Figenshau, MD,¹ and Eric H. Kim, MD¹

¹Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.

²Washington University School of Medicine, St. Louis, Missouri, USA.

Introduction and Objective: Retzius-sparing robot-assisted laparoscopic prostatectomy (RS-RALP) was first described in 2010. Since that time, a new single-port (SP) robotic platform was approved by the Federal Drug Administration for use in urology. We sought to describe our technique utilizing this new technology to perform RS-RALP and our experience for the first 29 cases.

Methods: After institutional review board approval was granted, we identified 29 patients who had undergone RS-RALP by the SP robotic platform. Patient demographics, intra-, and postoperative findings were evaluated and recorded.

Results: Of the 29 patients, mean age was 61 years (standard deviation [SD], ±8) with a mean body mass index of 28.6 (SD, ±4) and prebiopsy prostate specific antigen of 7.4 ng/mL (SD, ±5.7). Mean operative time was 208.7 minutes (SD, ±41.4) with 111.6 mL of estimated blood loss (SD, ±47.6). Mean length of stay was 0.34 days (SD, ±0.48) influenced by 19 patients who were discharged same day. Although overall clinically positive margin rate was 42.8%, this finding was trending toward improvement with experience with 46.7% in first 15 patients and decreased to 35.7% in final 14 patients. Only two (6.8%) Clavien–Dindo ≥3 occurred early in the series with infected lymphoceles requiring percutaneous drainage and antibiotics. We have since modified our procedure technique as shown in the video to prevent symptomatic lymphoceles. Twenty-six patients reported zero-pad continence (92.9%) and 23 (88.5%) patients reported satisfactory potency.

Conclusion: Utilization of the DaVinci SP robotic platform to perform RS-RALP is safe and effective and provides excellent vision with the ability to manipulate the camera deep in the pelvis.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0029

The Use of Three-Dimensional Augmented Reality During Robot-Assisted Living Donor Nephrectomy: A Case Report Technical Overview

Riccardo Schiavina, MD,^1,2 Lorenzo Bianchi, MD,^1,2 Francesco Chessa, MD,^1,2 Marco Salvador, MD,^1,2,* Laura Cercenelli,³ Barbara Bortolani,³ Simone Lodi,³ Giorgia Comai, MD,^2,4 Marco Busutti, MD,^2,4 Andrea Angiolini, MD,¹ Stefano Diciotti,⁵ Emanuela Marcelli,³ Eugenio Brunocilla, MD,^1,2 Gaetano La Manna, MD,^2,4 and Matteo Ravaioli, MD^2,6

¹Division of Urology, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

²University of Bologna, Bologna, Italy.

³eDIMES Lab—Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy.

⁴Nephrology, Dialysis and Kidney Transplantation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

⁵Department of Electrical, Electronic, and Information Engineering, “Guglielmo Marconi,” University of Bologna, Bologna, Italy.

⁶General Surgery and Transplantation Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

*ORCID ID (https://orcid.org/0000-0001-8906-7516).

Introduction and Objectives: The aim of this video is to describe the application of augmented reality (AR) technology of three-dimensional (3D) renal model during robot-assisted living donor nephrectomy (RALDN) for a safe and accurate hilum management.

Materials and Methods: We present the clinical case of a healthy 29-year-old woman who has met all inclusion criteria for living kidney donation to her male 39-year-old partner affected by end-stage renal disease. A virtual 3D reconstruction of the left kidney based on contrast-enhanced abdominal CT scan was elaborated with D2P™ software: renal parenchyma, urinary collecting system, ipsilateral adrenal gland, and ureter, aorta, main renal artery, and vein with main segmental branches, gonadal and adrenal vein were included in the model. An AR-dedicated workstation was used to intraoperatively match the camera (Da Vinci^® Xi/X™ Endoscope) video output with the AR-3D video stream. Processed images were sent back in real time to the surgeon's console through multi-input TilePro™ system. With right lateral position, one 8 mm optic robotic trocar was inserted in the left periumbilical site and pneumoperitoneum was achieved with 12 mm Hg CO₂ insufflation. We performed a Pfannensteil incision through which GelPort^® system was inserted. Additional two 8 and 12 mm robotic trocars and one 12 mm AirSeal^® trocar were placed. Firefly™ Fluorescence was used to verify adequate vascular supply of resected ureter. AR-3D video stream was then used for the exact identification and dissection of renal hilum: the 3D virtual model was manually oriented through the AR-dedicated workstation by the assistant engineer. The overlapped 3D images of the renal model allowed the surgeon to identify the precise anatomy of the renal hilum early and safely. Intuitive endowrist stapler 30^® was then used to seal and cut renal artery. Graft harvest was achieved with Applied Inzii Retrieval System^® through GelPort^® System to assure rapid graft retrieval, minimizing ischemia time.

Results: Overall operative time was 270 minutes. Console time was 178 minutes. Time from renal artery division to graft harvest was 2 minutes 56 seconds. Overall ischemia time was 140 minutes (including harvest, back table, and transplant). The patient was discharged 4 days after surgery. Neither early nor late complications were reported; renal function at time of discharge was within normal range. Graft transplantation was effective.

Conclusions: The use of AR during RALDN may improve the understanding of renal anatomy, thus facilitating the management of the hilum and enhancing the safety and the chances of an effective kidney transplant.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0019