Videourology Abstracts

Internal Suspension Technique in Retroperitoneal Laparoscopic Partial Nephrectomy

Miguel Angel Bergero, MD,^1,* Patricio E. Modina, MD,¹ and Patricio Garcia Marchiñena, MD²

¹Santario Privado San Gerónimo, Santa Fe, Argentina.

²Hospital Italiano de Buenos Aires. Buenos Aires, Argentina.

*ORCID ID (https://orcid.org/0000-0002-8972-0623).

Introduction: Internal suspension technique in retroperitoneal laparoscopic partial nephrectomy for the management of renal tumors was described with good perioperative results. The objective of this video is to show the steps to perform this technique and the results obtained in the patients treated.

Methods: Between January 2013 and January 2021, a total of 301 patients with a renal tumor underwent retroperitoneal laparoscopic partial nephrectomy. In patients who were treated with the internal suspension technique, the tumors were either ventral or in the lateral border. The surgeon preserved the perinephric fat with the renal tumor as a suspension traction measure when separating the kidney, so it exerted traction on the tumor during its resection. Patients' characteristics as well as intraoperative and postoperative outcomes were described.

Results: Twelve patients were treated with the internal suspension technique. The average age was 59.7 (SD 10.22) years. Of the patients, 65% were women and 58% presented a tumor in the right kidney. A total of 58.3% patients had low-complexity tumors (R.E.N.A.L score <6) and none had high-complexity tumors; 65% of the tumors were located between the polar lines. The estimated glomerular filtration rate (eGFR) was 75.1 (SD 12.73) mL/min. Operative time was 95.83 (SD 13) minutes. Warm ischemia time was 19.42 (SD 9.26) minutes. Tumor size was 2.68 (SD 0.8) cm. Estimated blood loss was 110 (SD 29.17) mL. Postoperative eGFR was 70.1 (SD 17.28) mL/min. Of the patients, 66.7% presented clear cell carcinoma and none had positive surgical margins. Trifecta outcomes were achieved in 72.7% of the cases. One patient presented urine leakage that required a Double-J stent.

Conclusion: As shown in this video, the internal suspension technique is a feasible and safe procedure in retroperitoneal laparoscopic partial nephrectomy. With this approach we were not only able to stabilize the tumor in a right position maintaining the traction during incision, but we were also able to suture the parenchyma easily.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0057

Bilateral Mini-Percutaneous Nephrolithotomy in a 7-Month-Old Child with Renal Fungus Balls

Coralie Defert, MD, MSc,¹ Sébastien Faraj, MD, PhD,² Elise Launay, MD, PhD,³ Marc-David Leclair, MD, PhD,² and Thomas Loubersac, MD²

¹Department of Pediatric Urology and Surgery, Children's University Hospital of Rennes, CHU de Rennes, Rennes, France.

²Department of Pediatric Urology and Surgery, Children's University Hospital of Nantes, CHU de Nantes, Nantes, France.

³Department of Pediatrics, Division of Pediatric Infectious Diseases, Children's University Hospital of Nantes, CHU de Nantes, Nantes, France.

Introduction: Fungus ball (FB) is a rare condition that often requires surgical management.¹ Percutaneous nephroscopy is rarely described in children to remove FB.² We report the case of a two-step bilateral mini-percutaneous nephrolithotomy (PCNL) in an infant. We admitted a 7-month-old boy with a history of severe bilateral ureterohydronephrosis who displayed an early relapse of renal candidiasis after a 5-week treatment with antifungal medication (AF) for bilateral pyelonephritis with Candida albicans. He displayed fatigue and lumbar pain 1 week after the end of the AF treatment. Biology showed a renal insufficiency and bilateral FBs were found out on ultrasound-scan. He required nephrostomies in emergency but after 3 days of treatment, US-scan showed FBs in the right ureter and kidney with a dilation of the pelvis. We decided to perform right mini-PCNL to remove them. The puncture needle was inserted in the right inferior calix under fluoroscopy and ultrasonography guidance. We used a sheath of 11F and a rigid nephroscope of 7.5F. The extraction was completed with a 7.5F flexible ureteroscope through the percutaneous access. Cavities of the right kidney were free of FB after surgery. Four days later, US-scan showed persistent FB on the left side and still, a free right pelvis. The same procedure was performed of the left side. The patient quickly improved and he recovered normal renal function. Three months after the surgery, he was doing well and US-scan was unremarkable.

Conclusion: To our knowledge, it is the first bilateral mini-PNCL undergone in an infant to extract FB.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0064

Retrograde Intrarenal Surgery for an Uncommon Case of Foreign Body in the Renal Pelvis

Andrea Di Stasio, MD, Francesca Ambrosini, MD, Vikiela Galica, MD, Barbara Cavallone, MD, and Armando Serao, MD

Department of Urology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.

Introduction: Various treatments have been reported for encrusted foreign bodies (FBs) in the upper urinary tract, but a consensus on the best therapeutic approach is lacking. We reported a case of a calcified piece of wire in the upper urinary tract that was effectively managed with an endoscopic procedure.

Materials and Methods: A 77-year-old man had been referred to another institute for a left ureteral stone of ∼1 cm, in 2016. First, a percutaneous nephrostomy tube and an antegrade ureteral Double-J stent had been placed. Subsequently, the patient had undergone left ureteroscopy and laser lithotripsy. In December 2020, he presented to our department for recurrent left flank pain. A computed tomography (CT) scan showed a calcified tubular FB of ∼10 cm, extending from the renal pelvis to the upper ureter. The patient was submitted to retrograde intrarenal surgery. Holmium:YAG laser lithotripsy was carried out. Proceeding with the fragmentation of the stone burden, a sheared wire was released. When complete stone clearance was achieved, the wire was grabbed with a Nitinol basket, and it was removed. At the end of the procedure, a Double-J stent and a Foley catheter were placed.

Results: No intra- and postoperative complications were recorded. The operative time was 135 minutes. A CT scan at 1 month after surgery showed complete stone clearance, except for clinically insignificant residual fragments in the inferior renal calices.

Conclusion: The endourologic management of calcified FBs could be a safe and feasible alternative to open or percutaneous surgery.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0065

Robotic Ureteral Reimplantation: Nonrefluxing Intravesical and Extravesical Techniques

Srikar Kuppa, BS,^* Matthew Lee, MD, MBA, Chinonyerem Okoro, MD, and Daniel D. Eun, MD

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.

*ORCID ID (https://orcid.org/0000-0002-1428-3318).

Introduction: Nonrefluxing ureteral reimplantation is the gold standard surgical management of patients with symptomatic vesicoureteral reflux (VUR).^1,2 Intravesical and extravesical ureteral reimplantation were traditionally performed with an open approach through the Cohen, Lich-Gregoir, Glen-Anderson, and Politano-Leadbetter techniques.³ However, there has been recent adoption of minimally invasive approaches including the use of robotic assistance.¹ Moreover, these nonrefluxing ureteral reimplantation techniques have been primarily described in the pediatric population rather than in adults.² We demonstrate our techniques and describe outcomes of adult patients undergoing nonrefluxing intravesical and extravesical robotic ureteral reimplantation (RUR).

Materials and Methods: We reviewed our institution's own robotic ureteral reconstruction database to identify consecutive adult patients with a history of VUR who underwent nonrefluxing intravesical or extravesical RUR between September 2016 and November 2020. Indications for surgery included patients with symptoms of flank pain and/or recurrent infections secondary to VUR. Our primary outcome was surgical success, which we defined as the absence of postoperative flank pain and radiographic absence of VUR on voiding cystourethrogram or obstruction on diuretic renal scan.

Before beginning the procedure, all patients underwent cystoscopy, cystogram, and/or retrograde pyelogram. Robotic ports are placed similarly for both techniques through the standard prostatectomy configuration without a fourth robotic port or the right lateral 12 mm assistant port. A 5 or 12 mm assistant port is placed between the camera and the right robotic port. Meticulous dissection of the distal ureter to preserve its fragile blood supply is performed for both techniques. In the robotic intravesical technique, adapted from the Politano-Leadbetter technique, the ureter is redirected through a new supratrigonal hiatus and submucosal tunnel created in a 5:1 ratio.⁴ The neoureteral orifice (UO) is relocated distally (subtrigonometry) and medial to the orthotopic UO.

In the robotic extravesical technique, adapted from the Lich-Gregoir technique, a mucosa sparing extravesical tunnel is created according to the Paquin guidelines with a 5:1 length to diameter ratio.^5,6 In patients who have a previous ureteroneocystostomy complicated by reflux symptoms, the existing reimplant site can be left intact and revised with an extravesical tunnel to prevent reflux.

Results: Three patients met inclusion criteria. Two patients underwent nonrefluxing extravesical RUR and one patient underwent intravesical RUR. The patient who underwent an extravesical RUR had a history of reimplantation that was complicated by severe reflux-related symptoms. Intraoperatively, the mean estimated blood loss was 50 mL and mean robotic console time was 162 minutes. Postoperatively, none of the patients experienced major (Clavien >2) complications. With regard to surgical success, at a mean follow-up of 20.5 months, all patients were free of urinary tract infections and obstructive flank pain symptoms. In addition, all patients achieved complete resolution of VUR on postoperative voiding cystourethrogram or renal scan.

Conclusions: Nonrefluxing intravesical and extravesical RUR may be safely and effectively utilized for surgical management of adult patients with symptomatic VUR. Moreover, the nonrefluxing extravesical RUR can be used to revise select patients with prior reimplantation complicated by symptomatic reflux.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0066

Robotic Ureteroplasty with Buccal Mucosa Graft: Technique for Complex Ureteral Strictures

Cecile T. Pham, MD,^1,2,* Bishoy Hanna, MD,^1,** Amanda Chung, MD,^1,2,3,4 and Matthew Winter, MD^1,2,3,4

¹Department of Urology, North Shore Urology Research Group, Sydney, Australia.

²Department of Urology, Northern Beaches Hospital, Frenchs Forest, Australia.

³Department of Urology, Royal North Shore Hospital, St Leonards, Australia.

⁴Department of Urology, North Shore Private Hospital, St Leonards, Australia.

*ORCID ID (https://orcid.org/0000-0002-5954-565X).

**ORCID ID (https://orcid.org/0000-0002-1463-9644).

Introduction: Reconstruction of proximal and mid-ureteral strictures is challenging. Robotic ureteroplasty allows for three-dimensional observation, technical precision, and dexterity over the traditional open approach. The first robotic ureteroplasty with buccal mucosa graft was described in 2015 by Zhao et al.¹ The technique has not been widely adopted yet and there are scarce visual demonstrations in the literature. We present two cases of traumatic ureteral stricture treated with robot-assisted ureteroplasty with buccal mucosa graft.

Materials and Methods: Two cases of robot-assisted ureteroplasty with buccal mucosa graft were performed by two experienced surgeons in a high-volume robotic center using the da Vinci Xi surgical system. Standard robotic pyeloplasty port placement was undertaken and the patient was placed in lateral decubitus lithotomy position. The colon was medialized. The ureter was identified and dissected from the mid-ureter to the pelviureteral junction. The gonadal vein was medialized to ensure safe dissection and ureterolysis was performed because of extensive periureteral fibrosis. Indocyanine green (ICG) fluorescent imaging and flexible pyeloscopy was used to identify the stricture location. Ureterotomy was made along the anterior ureteral wall over the pyeloscope. The stricture length was measured and an appropriately sized buccal mucosa graft was harvested. Ventral onlay ureteroplasty was performed with 4-0 vicryl on a cutting needle. Flexible pyeloscopy was performed to confirm patency and a 4.8F Double-J ureteral stent was inserted. An onlay wrap with vascularized periureteral fat was performed with 3-0 vicryl and ICG was used to confirm vascularity of the ureter-graft complex. The peritoneum was closed with 2-0 V-Loc and a drain was placed.

Results: There were no intra- or postoperative complications. The drain was removed and patients were discharged on postoperative day 2. There was no evidence of hydronephrosis on retrograde pyelogram when the ureteral stent was removed 6 weeks postoperatively and on repeat ultrasound 6 months postoperatively for either case. There was no recurrence of the stricture.

Conclusion: Robot-assisted ureteroplasty with buccal mucosa graft is a safe, feasible, and reproducible surgical approach for complex ureteral strictures.²

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0069