Laparoscopic Urethra-Sparing Simple Prostatectomy in Average Size Prostates: A Paradigm Shift?
André Barcelos, MD,1 Pedro Bargão Santos, PhD,2 and Estevão Lima, PhD2
1Hospital CUF Tejo, Urology Department, Lisbon, Portugal.
2Hospital CUF Tejo, Lisbon, Portugal.
Introduction: Lower urinary tract symptoms (LUTS) are a growing problem in men >50 years old and they are often related to benign prostatic hyperplasia (BPH). Retrograde ejaculation is a major pitfall of BPH surgical treatment. To overcome this pitfall, Madigan described, in 1990, a simple prostatectomy with preservation of prostatic urethra for large benign prostate. With this technique higher rates of postoperative antegrade ejaculation were achieved. Later, laparoscopic and robot-assisted techniques were also developed and published with solid benefits in terms of blood loss, bladder irrigation, bladder catheterization time, hospital stay, and, more relevantly, ejaculatory function. With urethra-sparing technique, postoperative anterograde ejaculation rates were as high as 81%. However, according to data, urethra-sparing simple prostatectomy is only being performed for large size prostates (>80–100 g). There is no record of applying urethra-sparing simple prostatectomy to average size prostate (30–80 g).
Materials and Methods: We present a laparoscopic urethra-sparing simple prostatectomy performed in a patient with a 50 g prostate (transrectal ultrasound) willing to undergo BPH-related surgery and wishing maintaining anterograde ejaculatory function.
Results: With the use of this technique on an average size prostate, all the previously named benefits were achieved, namely discharge 2 days after surgery with no bladder catheter and normal anterograde ejaculatory function at follow-up.
Conclusions: Although currently excluded from the main BPH average size prostate surgical management algorithms, we strongly believe this technique may be a paradigm shift in surgical management of bothering LUTS in patients with prostates 40 to 100 g, wishing to preserve normal ejaculatory function.
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.2021.0079
Transvesical Single-Port Robotic Radical Prostatectomy on da Vinci Si: A Safe Access for Patients with Previous Open Surgery for Rectal Cancer
Yifan Chang, MD,1 Weidong Xu, MD,1 Jianping Wu, MD, PhD,2 Yutian Xiao, MD,1 Ye Wang, MD,1 Ming Chen, MD,2 Di Gu, MD, PhD,3 and Shancheng Ren, MD, PhD4
1Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China.
2Department of Urology, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China.
3Department of Urology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
4Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, China.
Objectives: To investigate the feasibility and safety of transvesical single-port robotic radical prostatectomy (tvspRRP) on patients with previous abdominal surgery and report their short-term function recovery outcomes.
Methods: From September 2019 to January 2021, 12 patients with localized prostate cancer and history of open surgery for rectal cancer were retrospectively included. tvspRRP was performed on da Vinci Si by two high-volume surgeons with suprapubic access. Operative time, estimated blood loss, conversion rate, Clavien–Dindo complication, continence recovery, and quality-of-life scores were evaluated.
Results: Patients were aged 62 to 79 years (mean ± SD, 70.4 ± 5.20 years), with a body mass index of 18.37 to 30.07 kg/m2 (mean ± SD, 24.2 ± 3.21 kg/m2). Baseline median prostate-specific antigen was 14.7 ng/mL (IQR: 8.78, 31.09) and median prostate volume was 32.8 mL (IQR: 31.07, 39.23). Mean operative time was 153.8 minutes (range, 80–310 minutes) with an estimated blood loss of 112.5 mL (range, 50–300 mL). No patient required blood transfusion. No Grade II or above complications were recorded. Positive surgical margin was 8.3% (1/12). No opioid analgesics or nonsteroidal anti-inflammatory drugs were used. Postoperative length of stay was 3.5 days (IQR, 2.25–4.25). Median follow-up time was 17.5 months (range, 8–24). Median biochemical recurrence-free survival was 17.0 months (IQR, 10.0, 20.25). A 3-, 6-, and 12-month continence recovery was 58.3% (7/12), 75.0% (9/12), and 87.5% (7/8), respectively.
Conclusions: tvspRRP on da Vinci Si is a safe and feasible approach, and can be considered as an alternative approach for localized prostate cancer patients with previous abdominal surgery.
Patient Consent: The 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.2021.0080
A Novel Technique for Ureteral Orifice Dilatation in the Infant
Kelly M. Caldwell, MD, Caitlin T. Coco, MD, Charles N. Ammah, CST, Shane F. Batie, MD, and Craig A. Peters, MD
University of Texas Southwestern Medical Center, Children's Health Dallas, Dallas, Texas, United Kingdom.
Clinical History: A 12-month child (10 kg) with ureteropelvic junction obstruction required ureteral stent placement during a robotic pyeloplasty. There was no history of ureteral instrumentation. We describe a novel technique for ureteral orifice dilatation in young children who cannot accommodate traditional ureteral dilators.
Physical Examination: The patient had normal external genitalia. A 10F rigid cystoscope was inserted into the bladder and the ureteral orifice was located. There were no abnormalities noted within the bladder.
Diagnosis: A 0.018 glide wire was passed through the ureteral orifice without resistance. A 4.8F ureteral stent would not pass beyond the ureteral orifice. Ureteral stent placement in infants can be challenging because of the small caliber of the orifice and lack of ureteral dilators smaller than 6F. This is typically discovered at time of surgery.
Intervention: This technique requires the Cook salivary access dilator set, a 0.018 straight glide wire, and a rigid cystoscope. The salivary duct dilators were sequentially passed over the wire starting with the 4F dilator followed by 5F and 6F dilators. This was performed alongside a cystoscope with direct observation for educational purposes but can also be performed under fluoroscopic guidance. Finally, a ureteral stent was advanced with ease.
Follow-Up/Outcomes: The patient has done well with his ureteropelvic junction repair. Salivary duct dilators offer a smaller caliber dilator that can facilitate retrograde stent placement in infants. We have used this technique with success in several infants whose ureteral orifice would not accommodate a 4.8F ureteral stent.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0003
Efficient Method for Percutaneous Nephrolithotomy Positioning Using Abdominal Binders
Kenneth A. Softness, MD, Suprita Krishna, MD, and Peter L. Steinberg, MD
Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Introduction: Percutaneous nephrolithotomy (PCNL) often requires prone positioning. In addition to difficulties with patient positioning, proning is a stressful task for the anesthesia team as well as nursing. We describe a method to improve the efficiency of patient proning during PCNL positioning using abdominal binders.
Methods: Two abdominal binders are placed on the patient's stretcher in the preoperative area at shoulder and hip height. When the patient is anesthetized, the surgical team uses the abdominal binders to strap the bolsters across the patient, in the location where they best position the patient for PCNL. The patient is then proned and the binders are cut off of the patient before beginning the procedure.
Results: We have anecdotally found improved pronation time and efficiency using our method. The chest roll often needs small adjustments; however, this has proven much more effective than proning the patient and hoping he/she lands correctly on the bolsters.
Conclusions: Prone positioning for PCNL using abdominal binders is a novel, safe, and efficient way to position patients before surgery.
http://online.liebertpub.com/doi/full/10.1089/vid.2021.0004
Robotic Pyeloplasty in Patients with Duplex Collecting System with Lower Pole Ureteropelvic Junction Obstruction and with Multiple Crossing Vessels: Tips and Tricks
Cody Savage, BS,1 Sheila Mallenahalli, BS,1 and Pankaj Dangle, MD1,2
1School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
2Children's of Alabama Hospital, Department of Urology, Birmingham, Alabama, USA.
Introduction: Anderson–Hynes dismembered pyeloplasty is the current gold standard for treating ureteropelvic junction obstruction (UPJO).
1
–3
Compared with open repair, robot-assisted laparoscopic pyeloplasty is equally effective and safe alternative for repair of UPJO.
4
–6
However, it can be more difficult to effectively complete this procedure in patients with complex anatomy such as UPJO with a duplex collecting system, multiple crossing vessels, and malrotation of the kidney. The presence of crossing vessels particularly has been shown to increase the likelihood of a negative surgical outcome.
7,8
In patients with UPJO and complex anatomy, there is currently no accepted gold-standard surgical approach. There is a paucity of literature on the subject, with even fewer cases of complex robot-assisted laparoscopic pyeloplasty described in the pediatric population.
9,10
Here, we describe the technical aspects of completing robot-assisted Anderson–Hynes dismembered laparoscopic pyeloplasty effectively in these patients as well as provide our insight into the technical aspect.
Materials and Methods: Two patients with complex renal and UPJ anatomy underwent robot-assisted Anderson–Hynes dismembered laparoscopic pyeloplasty. Preoperative assessment included split renal function with renal scan, and either renal bladder ultrasonography or computed tomography. A retrograde pyelogram was performed immediately preoperatively to get a complete understanding of UPJ anatomy in terms of stricture length, UPJ insertion (high vs low), renal pelvis size, any associated malrotation of the kidney, or presence of a polyp at the UPJ. Follow-up renal ultrasonographs were taken at scheduled 3-, 6-, and 9-month postoperative visits.
Results: Both patients had symptom resolution and significant improvement in their hydronephrosis at their 9-month follow-up. Neither patient experienced hematuria or developed a urinary tract infection. Both of their preoperative pain symptoms also resolved after corrective surgery. A retrograde pyelogram should be performed before obtaining a more complete understanding of the patient's UPJ anatomy. The reconstruction is based on the individual anatomical abnormality and tailored to address the issue. For example, if the length of the structure is the issue, we want to place the higher insertion of the UPJ to the most dependent part for adequate drainage. Any polyps should also be excised as they have the potential to traverse the UPJ into the ureter, longer ureteral strictures can be addressed with foley Y-V plasty. Lastly, in the case of malrotation, the retrograde pyelogram assists the surgeon how to properly orient the pelvis to the dependent part for adequate drainage. In renal duplication, it is important to identify the unobstructed upper pole ureter early and minimize the dissection between the two sets of ureters to preserve the intervening adventitial tissue intact for vascularity. For those with significant malrotation and multiple anomalous crossing vessels, the addition of a 4th robotic arm can be helpful to rotate the kidney laterally, as well as provide better observation of the hilum, UPJ anatomy, and the crossing vessels. Posterior dissection of the renal pelvis can cause excessive traction on the lower set of crossing vessels with potential for intimal injury. In the setting of multiple crossing vessels, it is critical to know the exact locations of the UPJ and the set of vessels to avoid angulation of the UPJ.
Conclusion: With advances in robotic technology, it is now technically feasible to complete Anderson–Hynes pyeloplasty in patients with complex UPJ anatomy such as duplex collecting system, lower pole UPJO with a crossing vessel, malrotated kidney, high insertion UPJO, and multiple crossing vessels.
http://online.liebertpub.com/doi/full/10.1089/vid.2021.0075
