Extra-Anatomical Ureteral Bypass for the Definitive Treatment of Complex Ureteral Stenosis: Description of a Modified Technique in the Supine Position in 27 Cases
Ioannis Glykas, MD,1 Elena Tondelli, MD,1 Luigi Bevilacqua, MD,1 Eugenio Ventimiglia, MD,2 and Ioannis Kartalas Goumas, MD1
1Department of Urology, Istituto Clinico Beato Matteo, Vigevano, Italy.
2Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
Introduction and Objective: Benign and malignant ureteral obstruction is a challenging pathology, which has become more common in the past decades, especially in oncologic high-surgical-risk patients with a long life expectancy. Several types of procedures with different surgical approaches have been described, but the optimal management is still debated. The objective of this study is to describe our surgical technique of the DETOUR extra-anatomical ureteral bypass in the treatment of ureteral stenosis and to assess its safety and short-/long-term outcomes.
Material and Methods: Data from 27 patients who underwent the DETOUR extra-anatomical ureteral bypass were collected prospectively in our center from March 2016 to January 2021. In all cases the DETOUR® extra-anatomical bypass (Coloplast Ltd.) was inserted using a standardized technique. The procedure was conducted under general anesthesia and fluoroscopically and ultrasound guided. Clinical data were collected in a dedicated database. Intra- and perioperative variables and postoperative complications and outcomes of the DETOUR stents were assessed. A descriptive statistical analysis was performed.
Results: Mean operative time was 112 minutes. Twenty oncologic and seven nononcologic patients were included in the study. Mean hospitalization period was 20.9 days. Clavien–Dindo ≥ Grade 3 postoperative complications were observed in eight patients. Most common severe complication was explant (eight patients with early or late explant). At a mean follow-up of 18.6 months, 8 early and 6 late complications were observed in 14 cases (Clavien–Dindo 1–5).
Conclusions: Our technique of DETOUR ureteral bypass was considered rather safe and effective, with good long-term results in most patients treated for any type of complex ureteral obstruction in our center.
http://online.liebertpub.com/doi/full/10.1089/vid.2021.0081
Laparoscopic Management of Level 1 Renal Thrombosis: Point of Technique
Pavan Surwase, MS, DNB, Arvind Ganpule, MS, DNB, Abhishek Singh, MS, Mch, R.B. Sabnis, MS, Mch, and M.R. Desai, MS, FRCS
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India.
Background: Laparoscopic radical nephrectomy (LRN) has become the preferred method for the surgical treatment of T2 and T3 renal tumors. A thrombus in renal vein (RV) poses a challenge and mandates a high level of laparoscopic precision and dexterity. In this video we have demonstrated four different laparoscopic techniques deployed in the management of level I renal vein thrombus.
Details of Techniques: Technique 1: Milking of thrombus; this technique was demonstrated on a 42-year-old gentleman with right renal mass and renal vein thrombus reaching up to Inferior vena cava (IVC). Preoperatively patient underwent selective angioembolization with gel foam, followed by laparoscopic right radical nephrectomy. Renal vein was slung in Rumel tourniquet manner and synched to milk thrombus up. Then Weck clips were applied just below the thrombus on the renal vein. Technique 2: Application of Satinsky on the IVC; a 73-year-old gentleman underwent right laparoscopic radical nephrectomy for right renal mass with renal vein thrombus. Thrombus was extending beyond the ostium of renal vein into the IVC, so we decided to apply Satinsky on the IVC, and renal vein was incised just proximal to the Satinsky to remove the thrombus. The renal vein stump was sutured with Prolene 4-0. Technique 3: Management of left renal vein thrombus in right lateral position; renal vein was dissected as low as possible, and clips were applied. Frozen section of the margin came out to be positive, so additional margin was resected that was tumor free. Technique 4: Management of left renal vein thrombus in left lateral position; preoperatively the patient underwent angioembolization followed by laparoscopic radical nephrectomy. Deriving experience from the previous case, we decided to dissect renal vein up to the confluence with IVC. Initially left lateral position with right side up was given. Dissection of the IVC and renal vein confluence was done followed by renal vein clipping. Later the patient was turned to left side up position for completion of left radical nephrectomy.
Results: In our series of four patients of renal tumor with level I renal vein thrombosis, two patients had right-sided and two had left-sided tumors with level 1 thrombus. Median tumor size was 9.7 cm. Two patients underwent preoperative angioembolization. All the patients were managed effectively with the laparoscopic approach. Intraoperative Satinsky was used in one patient, thrombus was slung and milked up in one patient and Weck clips were applied directly on the renal vein just below the thrombus in the remaining two patients. Median estimated blood loss was 150 mL, median operative time was 125 minutes, and median length of hospital stay was 4 days. One patient had grade 2 Clavin–Dindo complication. Median follow-up was 18 months.
Conclusion: Renal tumors with level 1 renal vein thrombus can be managed effectively by the laparoscopic approach. Despite the learning curve, it offers a minimally invasive and oncologically safe surgical option.
Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording and publication of the procedure.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0002
Bilateral Robot-Assisted Inguinal Lymphadenectomy Using the Synchroseal Device: Description of the Technique
Safiya-Hana Belbina,1 Scott Spivey-Provencio,1 Pegah Taheri,1 Eric Giesler, MD,2 and Aaron A. Laviana, MD, MBA1
1Dell Medical School, University of Texas, Austin, Texas, USA.
2Urology Austin, Austin, Texas, USA.
Clinical History: This patient is a 75-year-old man with a history of balanitis and multiple urethral strictures. The patient developed discharge from his meatus, and biopsy of the distal urethra showed concern for papillary urothelial cancer. MRI confirmed infiltrative tumor. Given concern for involvement of the entire penile shaft, we next proceeded with a radical total penectomy and perineal urethrostomy. Four weeks after this procedure, he underwent a robot-assisted laparoscopic inguinal lymphadenectomy.
Intervention: The surgical video begins by describing the robotic port placement for this procedure and the suggested manner to establish pneumoderma. The surgery then proceeds with creating the surgical plane and working space by marching toward the inguinal ligament. During the dissection, the sartorius and adductor longus muscles were identified and served as the lateral and medial borders of the superficial inguinal lymph node dissection. Meticulous hemo- and lymphostases were achieved throughout the dissection using the SynchroSeal device. The SynchroSeal works both as a dissecting tool and as a lymphatic sealer, which helps shorten the duration of the operation and also reduces the burden on the bedside assistant. The procedure was then completed on the opposite groin in an identical manner. Total operative time was 215 minutes (175 minutes of robotic console time).
Follow-Up: Surgical pathology analysis revealed no evidence of metastasis in 22 nodes (10 left, 12 right). The patient was discharged home on postoperative day 2 with bilateral Jackson–Pratt (JP) drains, and these were removed after 2 weeks.
Author(s) 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.2022.0006
Ectopic Pyelolithotomy via a Combined Robotic and Endoscopic Approach
Andrew M. Higgins, MD, Alex A. Nourian, MD, Joshua A. Cohn, MD, and Justin I. Friedlander, MD
Einstein Healthcare Network, Philadelphia, Pennsylvania, USA.
Clinical History: A 35-year-old man with a history of nephrolithiasis presented to the emergency department with abdominal pain was found to have a pelvic kidney with mild hydronephrosis attributed to a 3.1 cm staghorn calculus and 1.3 cm cluster of lower pole stones.
Physical Examination: The patient's examination was only remarkable mild abdominal pain overlying his pelvic kidney.
Diagnosis: Preoperative computed tomography angiography demonstrated that the ectopic kidney was anterior to the bifurcation of the iliac vessels with overlying bowel, thus making a percutaneous approach challenging. However, the anterior orientation of the renal pelvis appeared amenable to combined robot-assisted laparoscopic and endoscopic pyelolithotomy.
Intervention: The kidney was accessed through a traditional pelvic surgery robotic port placement. The renal pelvis was incised to deliver the staghorn calculus in one specimen. A flexible cystoscope was then introduced through laparoscopic trocar and guided into the lower pole. These stones were removed a combination of basket extraction and aspiration through laparoscopic suction-irrigator. A ureteral stent was advanced through the pyelotomy into the bladder over guidewire. The renal pelvis was closed in a single layer with overlying reapproximation of perirenal fat and peritoneum.
Follow-Up/Outcomes: The patient was discharged on postoperative day one after removal of his Foley catheter and Jackson–Pratt drain. He underwent an uneventful stent removal in the office 6 weeks postoperatively. This case demonstrated that combined robot-assisted and endoscopic pyelolithotomy can be a safe and effective approach for pelvic kidney stone cases that may not be amenable to a single treatment modality.
Consent Statement: Authors have received patient consent for video recording/publication in advance of video recording of procedure.
Music Source: The music used in the video is under public domain: Vivaldi—“L'Estro Armonico, Op. 3, Concerto No. 12, in E major, for violin and strings, RV 265”
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0015
A Novel Transvesical Hood Robot-Assisted Radical Prostatectomy Technique for Organ-Confined Prostate Cancer
Vinayak G. Wagaskar, MD,1 Roy Berryhill Jr, PA-C,1 Kacie Schlussel, PA-C,1 Sneha Parekh, MD,1 Kenneth Haines III, MD,2 and Ash Tewari, MD1
1Department of Urology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA.
2Department of Pathology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA.
Introduction: Robot-assisted radical prostatectomy (RARP) is the most common form of treatment for localized prostate cancer.1 There have been a number of modifications in, and refinements to, surgical techniques to optimize continence after RARP. Although some modifications, including preservation of bladder neck, sparing of neurovascular bundles, and apical modified dissection, have been implemented to improve outcomes in postoperative continence and sexual function, achieving rapid recovery of continence and sexual function remains a huge challenge.1 This video demonstrates the novel “transvesical Hood technique” for RARP.
Materials and Methods: This was an institutional review board-approved prospective study. The technique was used on six patients with localized prostate cancer treated with the RARP transvesical technique at a major urban hospital between January 2019 and March 2019. Exclusion criteria were anterior tumor location based on biopsy or multiparametric magnetic resonance imaging, clinical T3 disease, Gleason score ≥8, and/or prior hormonal or radiotherapy for prostate cancer. All patients were followed up for a minimum of 12 months postoperatively with prostate-specific antigen (PSA) readings, assessment of the use of daily pads, and assessment of sexual function recovery.
Results: The median age at the time of surgery was 64 years (interquartile range [IQR] 56–69) and median body mass index was 27 kg/m2 (IQR 26–33). The median PSA level was 6.2 ng/mL (5.8–7.4). Preoperative prostate biopsies for these patients were 1 (17%), 4 (66%), and 1 (17%) with Gleason scores of 3 + 3, 3 + 4, and 4 + 3, respectively. Cystogram followed by catheter removal was performed on postoperative day 12. The continence rate (defined as completely pad free) at the 6th week after catheter removal was 4/6 (66%). Continence rates continued to improve at 12 weeks (5/6, 83%) and 24 weeks (6/6, 100%) after catheter removal. Sexual function recovery rate, defined as erection hard enough for penetration, was 1/6 (17%), 4/6 (66%), 5/6 (83%), and 6/6 (100%) at 6 weeks, 3 months, 6 months, and 12 months postoperatively, respectively. This study was conducted within a single health system and may not be generalizable. The study lacked randomization and a comparative arm.
Conclusions: The transvesical Hood RARP technique is feasible in organ-confined nonanterior prostate cancer patients with favorable oncologic and functional outcomes. Prospective randomized trials comparing different RARP approaches will provide further high-level evidence.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0011
Reference
1. Wagaskar VG, Mittal A, Sobotka S, et al. Hood technique for robotic radical prostatectomy-preserving periurethral anatomical structures in the space of retzius and sparing the pouch of douglas, enabling early return of continence without compromising surgical margin rates. Eur Urol 2021;80:213–221.
Tips and Tricks for Robotic Retroperitoneal Lymph Node Dissection in Testicular Cancer
David G. Ortega, MD, Alireza Ghoreifi, MD, Michael Chevinsky, MD, Laura C. Perez, MD, Akbar Ashrafi, MD, Kaylin Koh, BS, Wesley Yip, MD, Luis G. Medina, MD, Inderbir S. Gill, MD, and Hooman Djaladat, MD, MS
Institute of Urology, University of Southern California, Los Angeles, California, USA.
Introduction: Retroperitoneal lymph node dissection (RPLND) is a mainstay of surgical management for advanced testicular cancer, both in the first line and postchemotherapy settings. Robotic RPLND has been increasingly utilized in recent years as an alternative to the open approach. The aim of this video is to demonstrate some of the tips and tricks for an effective robotic RPLND.
Materials and Methods: Two patients are illustrated in this video. The first patient is a 24-year-old man with a history of right testicular mixed germ cell tumor (99% seminoma, 1% embryonal carcinoma), who underwent primary robotic bilateral nerve-sparing RPLND for a 1.8 cm lesion in the retroperitoneum (IIA) with mildly elevated beta human chorionic gonadotropin of 4.4 mIU/mL. The second patient is a 37-year-old man with a history of left testicular cancer 15 years prior (unknown pathology) who previously received 3 cycles of bleomycin, etoposide, and cisplatin postorchiectomy for the advanced stage. He underwent robotic postchemotherapy RPLND because of a 9.6 cm retroperitoneal mass with negative tumor markers.
Results: We first outline the appropriate patient positioning, port placement, and pneumoperitoneum. Next, we demonstrate how to secure the posterior peritoneum to the anterior abdominal wall. We then describe how to perform nerve sparing of the postganglionic sympathetic nerves. After this, we present the minimal tumor touch as well as the robotic split and roll techniques for thorough lymph node dissection. Finally, we include maneuvers that aid in dissection around the great vessels and the cisterna chyli in both primary and postchemotherapy settings. In both the aforementioned cases, no intra/perioperative complications were reported. Both patients were discharged on postoperative day 1.
Conclusions: In this video, we present some of the tips and tricks for facilitating robotic RPLND, which can assist in obtaining optimal oncologic and functional outcomes while minimizing perioperative complications.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0016
Robot-Assisted Laparoscopic Left Seminal Vesiculectomy and Distal Left Ureterectomy for a Patient with Zinner Syndrome
Safiya-Hana Belbina,1 Scott Spivey-Provencio,1 Rachel Wallace, PhD,2 and Aaron A. Laviana, MD, MBA1
1Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, Texas, USA.
2Department of Medical Education at the University of Texas, Austin, Texas, USA.
Clinical History: A 25-year-old man presented with a 1-year history of pelvic and perineal pain. On further work-up, he was found to have left renal agenesis but otherwise normal renal function. Magnetic resonance imaging revealed an enlarged and multiloculated left seminal vesicle complex. His constellation of symptoms along with his examination and imaging findings was consistent with Zinner syndrome. After discussing options, the patient elected for surgical excision of the seminal vesicle cyst for symptom management.
Intervention: This video demonstrates a robot-assisted laparoscopic approach to the removal of the left seminal vesicle cyst and ectopic ureteral remnant. The surgery was approached by incising the posterior peritoneum while lifting the bladder to identify the multiloculated left seminal vesicle cyst. In this video, one can appreciate the massive size of this complex cyst. The cyst was carefully dissected to preserve the anatomically normal right seminal vesicle and vas deferens. The ureteral remnant ectopically inserted into the seminal vesicle cyst and was dissected proximally to remove the entire ureteral remnant. The cyst wall was noted to be adherent to the bladder wall with invasion into the detrusor muscle. As such, cystorrhaphy was performed to make sure the entire cyst was removed. We then closed the peritoneal flap to re-retroperitonealize the space.
Follow-Up: The patient was discharged the same day without a drain. On follow-up, the patient's symptoms completely resolved, and his ejaculatory volume has remained unchanged. Final surgical pathology analysis revealed a benign complex seminal vesicle cyst and distal left ureter.
Consent: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Music: Underwater Cavern by Purrple Cat | https://purrplecat.com Music promoted by https://www.free-stock-music.com Creative Commons Attribution-ShareAlike 3.0 Unported https://creativecommons.org/licenses/by-sa/3.0/deed.en_US
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0008
A Novel Suction-Irrigation Cannula-Guided Hydrophilic Tip Guidewire Technique of Intraoperative Ureteral Stent Placement During Robot-Assisted Radical Prostatectomy
Vinayak G. Wagaskar, MD, Roy Berryhill Jr, Kacie Schlussel, and Ash Tewari, MD
Department of Urology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA.
Background: Patients with large median lobe, history of pelvic radiotherapy, or transurethral resection of the prostate are on the verge of ureteral orifice (UO) injury during robot-assisted radical prostatectomy (RARP). Not all aforementioned patients require ureteral stent placement. Intraoperative findings justify whether to proceed with ureteral stent placement or not. Previously described techniques of intraoperative stent placement involve use of transurethral cystoscopy or suprapubic skin incision, which makes procedure further difficult especially with robotic arms in place.1 Herein, we describe a simple and efficacious method Suction-Irrigation cannula-Guided Hydrophilic Tip guidewire (SIGHT) technique for intraoperative ureteral stent placement.
Technique: The case shown here is a 64-year-old gentleman with Gleason 8 prostate cancer and opted for RARP. After division of bladder neck, the interior of the bladder was routinely inspected and the UOs were found too close to the bladder margins. The decision was made to proceed with bilateral ureteral stents placement. To facilitate stent placement, bladder margin is held up using 4th arm of the robot. The bedside assistant inserted laparoscopic suction irrigation cannula from 5 mm assistant trocar. Cannula tip was held a couple of centimeters away from respective UO. A 0.038 Inch diameter, 150 cm long hydrophilic straight tip guidewire is fed into the abdomen through shaft of the cannula. The surgeon on console (A.T.) places the wire into UO and feeds it proximally until the resistance is met. The bedside assistant (R.B.) then feeds the stent over the wire into the abdomen, and the surgeon threads the stent over the wire. The assistance held back-tension on the wire. A pusher is then guided over the wire in similar manner and stent is advanced until distal end of the stent is seen. The wire is pulled out by the bedside assistant, and the distal end of the stent is confirmed with use of robot and secure inside the bladder. Surgery proceeded as usual. Stent placement was verified postoperatively by plain kidney, ureter and bladder radiograph. Patient was discharged next day. Catheter removal was done at postoperative day 7. Ureteral stents were removed under local anesthesia in the office at 4 weeks postoperative visit without complication.
Conclusions: Our SIGHT technique is safe, effective, and easily adaptable method for intraoperative ureteral stent placement during robotic procedures. It avoids intraoperative cystoscopy or suprapubic skin incision or use of additional guidewires thereby saving time during which patient is under anesthesia during surgery.
Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Music Source:
www.epidemicsound.com
Copyright: Author owns copyright/license for the music used in the video.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0014
Reference
1. Katz MH, Eng MK, Deklaj T, Zorn KC. Technique for ureteral stent placement during robot-assisted radical prostatectomy: Safety measure during vesicourethral anastomosis when ureteral orifices are too close for comfort. J Endourol 2009;23:827–829.
Robot-Assisted Level 3 Inferior Venecava Thrombectomy and Radical Nephrectomy with Suprahepatic Control of Inferior Vena Cava
Kishore Thekke Adiyat, MBBS, MS, DNB, Mch, MRCS (Edin), Deepak J. Kaddu, MD, Praful Bhagat, MD, Bikramjit Singh Sodhi, MD, and Biju Chandran, MD
Department of Urology and Integrated Liver Centre, Aster Medcity Hospital, Kochi, India.
Introduction: To present our experience in a series of patients with robot-assisted inferior venecava thrombectomy and radical nephrectomy (RAITRN) with emphasis on level 3 thrombus and suprahepatic control of inferior venecava (IVC). RAITRN with suprahepatic clamping has been previously reported only from a center in China.1,2 There have been studies on cadaveric model done by leading centers in the United States.3,4 Till now, the technique has not been reproduced in any centers outside China. The video depicts the technique of liver mobilization and suprahepatic control of IVC.
Materials and Methods: Retrospective analysis of data collected from two patients who had RAITRN from September 2019 to December 2021 was carried out. This study was approved by the ethics committee of Aster Medcity Hospital, Kochi, India, and written informed consent was taken from all the patients for the study. Da Vinci Si system (Intuitive Surgicals Sunnyvale, CA) was utilized. In level 3 thrombus, the patient was in supine position and the left lobe of liver was mobilized. The falciform ligament, left triangular ligament, and gastrohepatic ligaments were divided. The left lobe of liver was mobilized and suprahepatic IVC was dissected off the caudate lobe. Radical nephrectomy and right lobe liver mobilization were performed after converting the position to 90° flank right side up position. After mobilizing the right lobe of liver, a vascular loop was placed beneath the IVC from the right side directed toward the left side. Subsequently the patient was placed in 45° flank position, the vascular loop was retrieved from the left side of the IVC, and circumferentially encircled over the suprahepatic IVC. Finally, the patient was again tilted back to 90° right side flank up position and IVC thrombectomy was accomplished.
Results: Case I was a 58-year-old male patient with a body mass index (BMI) of 25.09 kg/m2 and a left-sided renal tumor with level 3 IVC thrombus, IVC clamp time was 21 minutes, thrombus length was 10.5 cm, console time was 270 minutes, total operative time was 370 minutes, and blood loss was 320 mL. Nadir postoperative creatinine was 1.2 mg%, pathologic staging was pT3N0M0 clear cell renal cell carcinoma, the patient received no adjuvant treatment, and was disease free at the end of 30 months after surgery. Case 2 was a 59-year-old male patient with a BMI of 24.95 kg/m2 and a right-sided renal tumor with a level 3 IVC thrombus, IVC clamp time was 26 minutes, thrombus length was 11 cm, console time was 280 minutes, total operative time was 440 minutes, and blood loss was 150 mL. Nadir postoperative creatinine was 1.5 mg%, pathologic staging was pT3N0M0 grade 4 papillary renal cell carcinoma, the patient received no adjuvant treatment, and was disease free at the end of 6 months after surgery.
Conclusions: RAITRN can be performed safely in level 3 thrombus where a suprahepatic clamping is required. An experienced multidisciplinary team including urologist, hepatobiliary surgeon, and a skilled bedside assistant is of paramount importance in these advanced robotic procedures. Prolonged operative time and multiple changes in position may be considered a limitation.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0010
References
1. Wang B, Huang Q, Liu K, et al. Robot-assisted level III-IV inferior vena cava thrombectomy: Initial series with step-by-step procedures and 1-yr outcomes. Eur Urol 2020;78:77–86.
2. Wang B, Li H, Huang Q, et al. Robot-assisted retrohepatic inferior vena cava thrombectomy: First or second porta hepatis as an important boundary landmark. Eur Urol 2018;74:512–520.
3. de Castro Abreu AL, Chopra S, Azhar RA, et al. Robotic transabdominal control of the suprahepatic, infradiaphragmatic vena cava to enable level 3 caval tumor thrombectomy: Pilot study in a perfused-cadaver model. J Endourol 2015;29:1177–1181.
4. Sood A, Jeong W, Barod R, et al. Robot-assisted hepatic mobilization and control of suprahepatic infradiaphragmatic inferior vena cava for level 3 vena caval thrombectomy: An IDEAL stage 0 study. J Surg Oncol 2015;112:741–745.
