Videourology Abstracts

Abstract

Robot-Assisted Laparoscopic Partial Cystectomy for Bladder Paraganglioma

Brendan Wallace, MD,¹ Stan Van Uum, MD, PhD,² Tayyab Khan, MD, MPH,² Anita Cave, MD,³ Hani Rjoob, MD,² Dor Golomb, MD,¹ and Stephen Pautler, MD¹

¹Division of Urology, Department of Surgery, Western University, London, Ontario, Canada.

²Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Ontario, Canada.

³Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada.

Introduction: Paraganglioma of the urinary bladder is a rare neuroendocrine tumor accounting for <1% of all pheochromocytomas and <0.05% of bladder tumors.¹ These paragangliomas may be functioning or nonfunctioning and have a variable clinical presentation. Our case is of a 49-year-old female patient presenting with a 5-year history of episodes of headache and hypertension triggered by urination. Normetanephrine was elevated on 24-hour urine studies at 4.1 (normal <3.4) µmol/day. Metaiodobenzylguanidine (MIBG) scan showed increased focal activity on the right side of the urinary bladder corresponding to a mass seen on magnetic resonance imaging. We felt a paraganglioma was likely given the clinical presentation, elevated urine normetanephrines, and positive MIBG scan.

Materials: A rigid 24F Olympus cystoscope was used with a Collings' knife to outline the intravesical border of the mass using electrocautery. The Da Vinci Si robot system was used for partial cystectomy and extirpation of the bladder paraganglioma.

Methods: The patient was admitted 4 days before surgery because she could not tolerate alpha blockade as an outpatient caused by orthostatic hypotension. For the following 4 days, titration of an alpha blocker was effective with aggressive intravenous hydration. To start the case, the patient was placed in the cystolithotomy position and cystoscopy was carried out. A Collings' knife was used to fulgurate a margin around the paraganglioma. A 5F ureteral catheter was placed up the right ureter for easy identification. A Hassan technique was used to gain access into the abdomen and a six-port approach was used for the robot. The space of Retzius was developed to drop the bladder. A cystotomy was made and a holding stitch was placed through a cuff of normal bladder to allow for manipulation of the bladder paraganglioma. The mass was dissected out by following our outline intravesically. Feeding vessels were isolated and clipped. Once the mass was removed, the cystotomy was closed in two running layers. At the end of the case, a catheter and drain were left in situ.

Results: The patient remained vitally stable throughout the entire case and she was extubated after surgery. She stayed in hospital for 3 days after surgery and remained clinically stable. Admission to the intensive care unit was not required. A cystogram on postoperative day 10 showed no evidence of a urine leak so the catheter and drain were removed. Pathology report showed a completely resected paraganglioma. On further follow-up, she reported cessation of her symptoms and repeat 24-hour urine collection showed normal catecholamines and metanephrines. Genetic testing came back negative for a pathogenetic mutation.

Conclusions: Taking a careful history and completing the appropriate work-up is critical for this rare clinical presentation. Making the correct diagnosis will help with surgical planning because the standard of care is complete removal of the mass with appropriate preoperative preparation. We show that a robotic partial cystectomy is a practical and safe way to remove a bladder paraganglioma.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0040

Single-Port Robotic Radical Cystectomy with Intracorporeal Creation of Neobladder: Description of Technique and Perioperative Outcomes

Mubashir S. Billah, MD,¹ Rohan Sawhney, MD,² Nikhil Gopal, MD,³ Michael Stifelman, MD,^1,4 David Ali, MD,² Salma Ahsanuddin, MD,² Robert Harrison, MD,¹ Gregory Lovallo, MD,^1,4 and Mutahar Ahmed, MD^1,4

¹Department of Urology, Hackensack University Medical Center, Hackensack, New Jersey, USA.

²Department of Urology, Rutgers New Jersey Medical School, Newark, New Jersey, USA.

³Department of Urology, New York Medical College, Valhalla, New York, USA.

⁴Department of Urology, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.

Objective: The single-port robotic system was first introduced in 2018 and its use has been reported widely in the field of urology but there have been scant reports of its use in cystectomy. To date, there has been no literature on the use of the single-port system with radical cystectomy with intracorporeal creation of neobladder. This study aims to demonstrate and describe this technique in males and females.

Methods: This is an institutional review board approved prospective cohort study on robotic radical cystectomy. We selected one patient as a representative sample of single-port robotic radical cystectomy with intracorporeal neobladder creation. We performed surgery by duplicating the institutional steps of the multiport approach.

Results: In total, we have performed single-port radical cystectomies with intracorporeal neobladder effectively performed in six patients. There were no conversions to multiport. There were no intraoperative or immediate postoperative complications.

Conclusions: This video demonstrates the feasibility of single-port radical cystectomy with intracorporeal neobladder creation in both genders. More extensive multi-institutional studies comparing single-port and multiport radical cystectomy are needed to determine this approach's benefits.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0056

Completely Intracorporeal Robot-Assisted Bilateral Ileal Ureter and Bladder Augmentation: Step-by-Step Surgical Technique

Weijie Zhu, MD,* Shubo Fan, MD, Kunlin Yang, MD, Zhihua Li, MD, and Xuesong Li, MD

Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Centre, Beijing, China.

*ORCID ID (https://orcid.org/0000-0003-2699-8377).

Introduction: Urinary tract complications after treatment of advanced gynecologic malignance are among the most serious medical conditions.¹ Bilateral ureteral stricture and bladder contracture caused by pelvic radiotherapy are more difficult and more complicated to deal with. Although ureteral reconstruction is a definite option, it is limited by the complexity of surgery and tissue degeneration or adhesions caused by radiation.^2,3 In this video presentation, we describe a step-by-step technique to effectively perform completely intracorporeal robot-assisted bilateral ileal ureter and bladder augmentation.

Materials and Methods: A 53-year-old female with history of cervical cancer treated with neoadjuvant chemoradiation and surgery presented with bilateral distal ureteral strictures managed with bilateral percutaneous nephrostomy tubes. At diagnosis, cystography showed reduced bladder volume and bladder contracture. The first step is localization of both ureters at the pelvic brim. Then, the ureters proximal to the injury site was widely spatulated for following anastomosis. A 40-cm ileum segment was finally isolated and bowel continuity was restored with side-to-side anastomosis. The distal ileal segment was incised on the antimesenteric border and then the two medial borders of the ileal segment were oversewn in a U-shaped augmentation pouch. The left and right ureters are then anastomosed to the proximal end of the harvested ileum. A cystotomy combined with “autologous augmentation” is performed at the bladder dome. Finally, the mucosa of the U-shaped augmentation pouch was sutured to the dissected bladder wall.

Results: Surgery was completed without intraoperative complication. Operating time was 361 minutes and estimated blood loss was 100 mL. Postoperative course of the patient was uneventful and the patient was discharged home in 7 days. Baseline glomerular filtration rate was 47.580 mL/(min·1.73 m²) and at discharge it was 68.908 mL/(min·1.73 m²). No complication was reported within 90 days, postoperatively.

Conclusions: Completely intracorporeal robot-assisted bilateral ileal ureter and bladder augmentation are feasible, which provides the advantage of minimal-invasive techniques. More cases are needed to validate their applications.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0077

Stricture Rate of Wallace Ureteroileal Anastomosis in Robot-Assisted Radical Cystectomy

Zaher Bahouth, MD, and Philip J.S. Charlesworth, MD

The Harold Hopkins Department of Urology, Royal Berkshire NHS Trust, Reading, Berkshire, United Kingdom.

Objectives: To report the stricture rate in our contemporary robot-assisted radical cystectomy (RARC) using the slightly modified Wallace technique.^1

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Patients and Methods: This study included 113 patients treated with RARC with intracorporeal urinary diversion performed by a single surgeon between June 2016 and December 2020 at our department and had at least 6 months of follow-up. Patients' demographics and perioperative data were retrieved from our prospectively maintained database and analyzed retrospectively. The reconstruction started with two parallel incisions made in the distal ureters (∼2 cm proximal to the clipped end) and elongated proximally for ∼3 cm. Posterior plate of Wallace is created by suturing the medial wall of the right ureter with the lateral wall of the left ureter using 4/0 Monocryl. The ureters are then stented. A 3/0 double-armed Quill suture is then used to complete the anastomosis between the bowel and the ureters.

Results: This study included 86 men and 27 women with an average age of 65 ± 10 years. The average time of the anastomosis decreased over time to ∼24 minutes. In a median follow-up of 31 months, only three patients (2.6%) had Ureteroenteric stricture.

Conclusions: Our standardized Wallace ureteroenteric anastomosis has a relatively low stricture rate.

Patient Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0068

Robot-Assisted Laparoscopic Ureterocalicostomy for Persistent Ureteropelvic Junction Obstruction After Failed Renal Pyeloplasty

Wei Zheng So, MBBS,^1,* and Ho Yee Tiong, MBBS (Hons), FAMS (Urology), ASTS^2,3,**

¹Yong Loo Lin School of Medicine, National University Singapore, Kent Ridge, Singapore.

²Department of Urology, National University Hospital, Kent Ridge, Singapore.

³Division of Surgical Oncology, National University Cancer Institute, Kent Ridge, Singapore.

*ORCID ID (https://orcid.org/0000-0002-2303-0750).

**ORCID ID (https://orcid.org/0000-0003-0077-7904).

Introduction and Objective: Ureterocalicostomy has been regarded as a well-established treatment choice for patients suffering from recurrent ureteropelvic junction (UPJ) obstruction refractory to previous surgical management, or in the presence of an anatomically intrarenal pelvis. We detail a case of robot-assisted laparoscopic ureterocalicostomy after failed renal pyeloplasty, with the incorporation of the Da Vinci robotic system.

Methods: A 28-year-old female patient had a significant history of right proximal ureteral stricture, of which right pyeloplasty was previously performed to relieve the obstruction. Despite so, she subsequently presented with non-specific intermittent right loin pain of 6 months' duration. Prior imaging performed revealed gross hydronephrosis and UPJ narrowing in the right kidney, with cortical thinning and a minimal extrarenal pelvis. Relative differential right renal function was determined to be 30.4%. Bearing the findings, ureterocalicostomy was preferentially indicated because of the presence of cortical thinning and relatively poorer preservation of the lower pole calix. A transperitoneal approach was adopted in a left lateral position with five trocars. After the right ureter and renal lower pole calix were dissected and exposed, the hydronephrotic lower pole was incised at the lowest dependent area for creation of a wide opening for anastomosis. Retrograde intrarenal surgery was then done to rule out a narrow infundibulum to the upper and middle calices. Lastly, ureterocaliceal anastomosis was completed with continuous 4-0 absorbable Vicryl sutures.

Results: Total operative duration was 185 minutes. The immediate postoperative course was uneventful. At 6 weeks follow-up, radiologic evidence demonstrated slight UPJ obstruction with diminished differential renal function. However, this was seen in the presence of normal creatinine levels and an asymptomatic clinical picture. Elective cystoscopy, ureteroscopy, and retrograde pyelogram were then performed and no strictures were observed. A patent anastomosis was also seen. She was stable post-procedure and discharged for stent removal in 4 weeks' time.

Conclusion: Robot-assisted laparoscopic ureterocalicostomy is a safe and feasible option for patients with recurrent UPJ obstruction, rendering superior intraoperative field observation and freedom of wrist movement compared to the conventional laparoscopic method.

http://online.liebertpub.com/doi/full/10.1089/vid.2021.0040

References

Chang YK, Chiang IN, Chen CH, et al. Paragangliomas of the urinary bladder: A report of 6 cases and review of the literature. Urol Sci, 201; 26:111–114.

Atuhairwe S, Busingye RB, Sekikubo M, Nakimuli A, Mutyaba T. Urologic complications among women with advanced cervical cancer at a tertiary referral hospital in Uganda. Int J Gynaecol Obstet, 2011; 115:282–284.

Song SH, Pak S, Jeong IG, et al. Outcomes of stent-change therapy for bilateral malignancy-related ureteral obstruction. Int Urol Nephrol, 2015; 47:19–24.

Jeong IG, Han KS, Park SH, et al. Ileal augmentation cystoplasty combined with ileal ureter replacement after radical treatment for cervical cancer. Ann Surg Oncol, 2016; 23:1646–1652.

Rai BP, Bondad J, Vasdev N, et al. Robotic versus open radical cystectomy for bladder cancer in adults. Cochrane Database Syst Rev 2019;4:CD011903.

The British Association of Urological Surgeons. Cystectomy Outcomes Data, 2019. https://www.baus.org.uk/patients/surgical_outcomes/cystectomy/ Accessed January 8, 2021.

Witjes JA, Bruins HM, Cathomas R, et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. Eur Urol, 2021; 79:82–104.

Goh AC, Belarmino A, Patel NA, et al. A population-based study of ureteroenteric strictures after open and robot-assisted radical cystectomy. Urology, 2020; 135:57–65.

Davis NF, Burke JP, McDermott T, Flynn R, Manecksha RP, Thornhill JA. Bricker versus Wallace anastomosis: A meta-analysis of ureteroenteric stricture rates after ileal conduit urinary diversion. Can Urol Assoc J, 2015; 9:E284–E290.

10.

Ericson KJ, Thomas LJ, Zhang JH, et al. Uretero-enteric anastomotic stricture following radical cystectomy: A comparison of open, robotic extracorporeal, and robotic intracorporeal approaches. Urology, 2020; 144:130–135.

11.

Parekh DJ, Reis IM, Castle EP, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): An open-label, randomised, phase 3, non-inferiority trial. Lancet, 2018; 391:2525–2536.

12.

Christoph F, Herrmann F, Werthemann P, et al. Ureteroenteric strictures: A single center experience comparing Bricker versus Wallace ureteroileal anastomosis in patients after urinary diversion for bladder cancer. BMC Urol, 2019; 19:100.

13.

Hosseini A, Dey L, Laurin O, et al. Ureteric stricture rates and management after robot-assisted radical cystectomy: A single-centre observational study. Scand J Urol, 2018; 52:244–248.

14.

Khan MS, Gan C, Ahmed K, et al. A single-centre early phase randomised controlled three-arm trial of open, robotic, and laparoscopic radical cystectomy (CORAL). Eur Urol, 2016; 69:613–621.

15.

Ahmadi N, Ashrafi AN, Hartman N, et al. Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy. BJU Int, 2019; 124:302–307.