Ureteral Stricture and Urolithiasis: A Robot-Assisted and Endoscopic-Combined Approach
Luca Carmignani, MD, Dario Sessa, MD, Andrea Baudo, MD, Matteo Tallini, MD, Michele Croce, MD, Roberto Di Benedetto, MD, Andrea Conti, MD, Damiano Vizziello, MD, Elisabetta Finkelberg, MD, Pietro Acquati, MD, and Claudia Signorini, MD
Urology Department, IRCCS Policlinico San Donato, Milan, Italy.
Introduction: The development of ureteral strictures is a known complication of the endoscopic treatment for impacted ureteral stones.1–3 Although the smaller caliber of the recent endoscopic equipment has reduced its occurrence, it still is a statistically important complication, ranging from 14.2% and 24% in the older studies to 7.8% of the newer ones.4 The contemporary robotic techniques have also proven to be an effective approach to the ureteral surgery demonstrating the same postoperative outcomes as open surgery with a reduction in the hospital stay.5,6
In this video we present the advantages of a robotic and endoscopic combined approach for the treatment of ureteral stricture associated with impacted urolithiasis. In our case series, we showed the perioperative outcomes of robotic ureterectomy with termino-terminal ureteroureterostomy.
Materials and Methods: From December 2019 to December 2021, we performed eight robotic ureterectomies with termino-terminal ureteroureterostomy with a combined endoscopic approach for ureteral stenosis caused by previous treatment of impacted stones. All patients were studied with a CT urogram and a renal scintigraphy. A preliminary ureteroscopy with pyelography was performed to better highlight the ureteral stenosis and its length. When possible a ureteral stent was placed and removed the day before robotic surgery. We also collected perioperative data and follow-up. In our experience, we removed the abdominal drainage the second day after surgery, the bladder catheter and the ureteral stent after 1 and 3 weeks after surgery, respectively, in outpatient care.
Results: Eight patients (three women and five men) underwent robotic ureterectomy with termino-terminal ureteroureterostomy with a combined endoscopic approach for impacted stones. The mean age was 54 years with a mean American Society of Anesthesiology score of 1.5. In four cases the stenosis affected the mid ureter, whereas the proximal ureter was involved in the other four patients. We performed five left and three right robotic ureterectomies, one of which in a patient with a solitary kidney. The mean length of the stenosis was 2.25 cm. The mean operative time was 227 minutes. The drop of hemoglobin after surgery was 1.45 g/dL. In our case series, we had only one case of reintervention for re-stenosis and two cases of urinary infection treated with a targeted antibiotic therapy. No bleeding or leakages occurred after surgery. The mean follow-up was 15 months.
Conclusion: The robotic and endoscopic-combined approach offers the opportunity to execute a precise ureteral resection under vision, sparing healthy ureteral tissue, which is useful especially in long strictures. This procedure allows carrying out the termino-terminal ureteroureterostomy with less tension, reducing the risk of restenosis. Moreover, in case of multiple lithiasis the use of endoscopy allows the mobilization of the stones granting the complete removal at the end of the procedure. The robotic procedure is safe and effective with a low risk of complication in our series.
Patient consent: Written consent was acquired for research purpose.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0020
References
1. Roberts WW, Cadeddu JA, Micali S, et al. Ureteral stricture formation after removal of impacted calculi. J Urol 1998;159:723–726. https://doi.org/10.1016/S0022-5347(01)63711-X.
2. Robert WW, Caddedu JA, Fabrizio MD, et al. Ureteral stricture formation following removal of impacted calculi. J Urol 1999;161(Suppl):376.
3. Brito AH, Mitre AI, Srougi M. Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi. Int Braz J Urol 2006;32(3):295–299; doi: 10.1590/s1677-55382006000300006.
4. Fam XI, Singam P, Ho CC. Ureteral stricture formation after ureteroscope treatment of impacted calculi: A prospective study. Korean J Urol 2015;56(1):63–67; doi: 10.4111/kju.2015.56.1.63.
5. Buffi NM, Lughezzani G, Hurle R, et al. Robot-assisted surgery for benign ureteral strictures: Experience and outcomes from Four Tertiary Care Institutions. Eur Urol 2017;71(6):945–951; doi: 10.1016/j.eururo.2016.07.022.
6. Autorino R, Eden C, El-Ghoneimi A, et al. Robot-assisted and laparoscopic repair of ureteropelvic junction obstruction: A systematic review and meta-analysis. Eur Urol 2014;65(2):430–452; doi: 10.1016/j.eururo.2013.06.053.
Saline-Assisted Fascial Engorgement Nerve Preservation Guided by Microultrasound During Robot-Assisted Radical Prostatectomy
Adriana M. Pedraza Bermeo, MD, Vinayak G. Wagaskar, MBBS, MCh, Kacie Schlussel, PA-C, Roy Berryhill, PA-C, Ian Haas, PA-C, Krunal Pandav, MD, and Ashutosh K. Tewari, MBBS, MCh, FRCS
Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.
Introduction: Nerve sparing determines functional outcomes after radical prostatectomy. Given the impact on positive surgical margin (PSM) rates, neural tissue preservation should be carefully balanced against the risk of extracapsular extension (ECE).1,
2 To achieve this goal and improve erectile function (EF) outcomes, we have proposed an innovative nerve-sparing technique denominated saline-assisted fascial engorgement (SAFE) guided by microultrasound (MUS).
Materials and Methods: This pilot study included 36 consecutive cases of potent men (sexual health inventory for men [SHIM] ≥ 17) who underwent robot-assisted radical prostatectomy between October 2021 and January 2022 by a high-volume surgeon, and who had a unilateral risk of ECE between 21% and 73%.3 The first 19 and the next 17 men underwent standard dissection and SAFE, respectively. The SAFE nerve-sparing technique was performed in real time after the early release of the neurovascular bundle. After identification of the plane between Denonvilliers' fascia and prostatic capsule, and starting from the apex toward the base, 20 mL of normal saline solution was injected with a 22-gauge × 177.8 mm spinal needle. To create the surgical planes, the SAFE technique was tailored according to the visualized integrity of the prostatic capsule with a transrectal MUS.4 EF was assessed by SHIM score preoperatively, 6 weeks, and 3 months after surgery. Continence rate was defined as completely pad-free.
Results: Men who underwent the SAFE technique achieved higher SHIM scores at 6 weeks (p = 0.037) and 3 months (p = 0.016) follow-up. As per protocol, all patients received PDE5i before and after surgery. Potent patients in the SAFE group did not require intracavernosal injections (ICIs), whereas two patients in the control group needed ICI at 3 months follow-up. No difference was found in urinary continence (p = 0.75). All patients had negative surgical margins in final pathology analysis irrespective of the group.
Conclusion: SAFE nerve preservation guided by MUS is a practical, harmless, and easy technique to perform. It improves postoperative SHIM scores in patients at high risk for ECE without increasing PSM rates.
Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.The authors declare that there is no conflict of interest in connection with this video.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0025
References
1. Zhang L, Zhao H, Wu B, et al. Predictive factors for positive surgical margins in patients with prostate cancer after radical prostatectomy: A systematic review and meta-analysis. Front Oncol 2020;10:539592.
2. Chalfin HJ, Dinizo M, Trock BJ, et al. Impact of surgical margin status on prostate-cancer-specific mortality. BJU Int 2012;110:1684–1689.
3. Martini A, Cumarasamy S, Tewari AK, et al. An updated approach to incremental nerve sparing for robot-assisted radical prostatectomy. BJU Int 2019;124:103–108.
4. Lughezzani G, Saita A, Lazzeri M, et al. Comparison of the diagnostic accuracy of micro-ultrasound and magnetic resonance imaging/ultrasound fusion targeted biopsies for the diagnosis of clinically significant prostate cancer. Eur Urol Oncol 2019;2:329–332.
Feasibility of Robotic Partial Prostatectomy for Isolated Anterior Prostate Cancer
Mark G. Biebel, MD,1 Gerald L. Andriole, MD,1 Brijesh Patel, MD,1 Joe E. Ippolito, MD,2 R. Cody Weimholt, MD,3 Ramakrishna Venkatesh, MD,1 Robert Sherburne Figenshau, MD,1 and Eric H. Kim, MD1
1Division of Urologic Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
2Department of Radiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
3Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
Introduction: Ablative focal therapy for localized prostate cancer (PCa) is becoming more prevalent. In 2017, Villers et al reported 17 partial prostatectomies for low- and intermediate-risk PCa. They had excellent postoperative continence and potency, but their positive surgical margin (PSM) rate was 53%.1 In 2021, Sood et al described their “precision prostatectomy” in 88 patients, which involves surgical excision of the PCa lesion and >90% of the surrounding prostatic tissue. The prostatic capsule and contralateral seminal vesicle/vas deferens are left intact. They showed great urinary and sexual functional outcomes. Overall PSM rate was 42%, of which the majority were focal (<3 mm) and Gleason 3 + 3 = 6. In their series, biochemical recurrence was rare and there were no patients with metastasis at mean 36-month follow-up.2,3 To our knowledge, these are the only two clinical studies examining focal therapy through surgical excision (i.e., partial prostatectomy) for PCa. In this study, we describe our initial experience with robot-assisted partial prostatectomy (RAPP) for isolated anterior PCa lesions with an associated video.
Materials and Methods: We identified five patients with isolated anterior low- to intermediate-risk PCa. None of these patients had baseline erectile dysfunction or incontinence. All cases selected for RAPP underwent MRI with a systematic and targeted biopsy, revealing PCa isolated to the anterior MRI lesion. The pathology report of the preoperative targeted biopsies was Gleason 3 + 3 = 6 PCa in one patient and Gleason 3 + 4 = 7 PCa in four patients. Patient consent was obtained. During surgery, the PCa lesion was marked by ultrasound-guided transperineal needle placement. Robotically, we developed the space of Retzius, opened endopelvic fascia, ligated the dorsal venous complex, and excised the lesion with electrocautery. We used the needles as boundary guides and our knowledge of the MRI to excise the lesion. In four cases, extravesical fat was sutured over the defect. In one case, entry into the urethra could not be avoided, so the bladder neck was closed over this area.
Results: Mean patient age was 72.6 years. Mean preoperative prostate specific antigen (PSA) was 4.4 ng/mL. Mean lesion size was 2.0 cm. Mean operative time was 129.2 minutes. Mean follow-up was 9.4 (standard deviation 7.9) months. Final pathology report demonstrated Gleason 3 + 4 PCa in three patients and Gleason 4 + 3 in two. A positive margin was noted in three cases (60%), and two of these were focal (<3 mm). No patients have reported changes from preoperative urinary and sexual function. Mean postoperative PSA was 1.2 ng/mL (73% reduction) at first follow-up. There were no intra- or postoperative complications.
Conclusions: For patients who desire preservation of functional outcomes and who understand the oncologic trade-offs associated with focal therapy, RAPP is a technically feasible intervention for isolated anterior PCa. More patients and longer follow-up are needed to establish the oncologic efficacy of RAPP, specifically the long-term impact of microscopic PSM after RAPP on residual and/or recurrent clinically significant PCa. Improved intraoperative margin localization will help to improve the adoption of RAPP as a viable alternative to ablative focal therapy.
Patient Consent Statement: 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.2022.0029
References
1. Villers A, Puech P, Flamand V, et al. Partial prostatectomy for anterior cancer: Short-term oncologic and functional outcomes. Eur Urol 2017;72(3):333–342; doi: 10.1016/j.eururo.2016.08.057.
2. Sood A, Jeong W, Palma-Zamora I, et al. Description of surgical technique and oncologic and functional outcomes of the precision prostatectomy procedure (IDEAL stage 1–2b study). Eur Urol 2022;81(4):396–406; doi: 10.1016/j.eururo.2021.10.017.
3. Sood A, Jeong W, Keeley J, et al. Subtotal surgical therapy for localized prostate cancer: A single-center precision prostatectomy experience in 25 patients, and SEER-registry data analysis. Transl Androl Urol 2021;10(7):3155–3166; doi: 10.21037/tau-20-1476.
Laparoscopic Vesicocapsular Adenoidectomy in Large Benign Prostate Glands
Vigneswara Srinivasan Sockkalingam Venkatachalapathy, MCh Urology, Datson P. George, MCh Urology, and George P. Abraham, MCh Urology
Department of Urology, VPS Lakeshore Hospital, Kochi, India.
Introduction: Minimally invasive simple prostatectomy is one of the recommended treatment options for large prostatic adenomas,1 and laparoscopic simple prostatectomy (LSP) is favored at the authors' institution when the prostate volume is >150 cc. LSP can be performed using transvesical, transcapsular, and transvesicocapsular approaches.1 In our experience, vesicocapsular adenoidectomy provides good observation and works well for large benign prostate glands. We present our surgical technique with video demonstration and report the outcomes.
Materials and Methods: The procedures were performed by a single surgeon with good experience in laparoscopic radical prostatectomy. The patients were positioned in Trendelenburg position. After transperitoneal access, urinary bladder was mobilized completely and the prostate was exposed. The endopelvic fascia was incised and puboprostatic ligament was partially divided. The dorsal vein complex was then ligated.2 Hemostatic stiches were not routinely placed on the lateral pedicles of the prostate before enucleation. Bladder neck was identified and adequate anterior vertical vesicocapsular incision was made. Circumferential enucleation of the prostatic adenoma was completed from the prostatic base to apex. Care was taken not to injure the external sphincter during apical dissection. Retrigonization was performed by suturing the bladder trigonal mucosa to posterior wall of the urethra and/or posterior prostatic capsule.3 The anterior vesicocapsular incision was closed over a Foley catheter. Data of patients with prostate volume >150 cc in transabdominal ultrasonography and who had undergone LSP during the period between January 2014 and December 2020 were collected retrospectively.
Results: Five patients were available for the analysis. The mean age was 70.6 ± 5.727 years (range 63–77 years). The mean prostate volume in preoperative transabdominal ultrasonography was 188.4 ± 23.426 cc (range 160–224 cc). The mean preoperative international prostate symptom score (IPSS) was 24.2 ± 3.271 (range 21–29). The mean operative time was 121 ± 19.494 minutes (range 90–140 minutes). The mean intraoperative blood loss was 130 ± 21.213 mL (range 100–150 mL). None of the patients needed blood transfusion during or after surgery. The mean weight of the excised adenoidectomy specimens was 158 ± 21.389 g (range 125–180 g). The mean duration of hospitalization was 4.6 ± 0.548 days (range 4–5 days). The histopathology report was benign in all cases. The mean duration of Foley catheterization after surgery was 8.2 ± 1.304 days (range 7–10 days). None of the patients needed Foley reinsertion after initial removal. The mean postoperative IPSS score at 3 months was 12 ± 1.581 (range 10–14). None of the patients had incontinence at 3 months follow-up.
Conclusions: LSP using the vesicocapsular approach for large benign prostatic adenomas is effective and safe. By this approach, morbidity can be kept to a minimum, prostate symptoms can be alleviated, and continence can be preserved. To our knowledge, this study is the first of the LSP techniques focused exclusively on prostate glands >150 cc. Prospective multicentric studies will help in assessing reproducibility of similar outcomes in a larger population. Also, comparative studies with other laparoscopy and robot-assisted techniques are required to clearly define the role of laparoscopic vesicocapsular adenoidectomy in the management of large benign prostate glands.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0032
References
1. Autorino R, Zargar H, Mariano MB, et al. Perioperative outcomes of robotic and laparoscopic simple prostatectomy: A European-American multi-institutional analysis. Eur Urol 2015;68(1):86–94; doi: 10.1016/j.eururo.2014.11.044.
2. Mariano MB, Tefilli MV, Graziottin TM, et al. Laparoscopic prostatectomy for benign prostatic hyperplasia—A six-year experience. Eur Urol 2006;49(1):127–131; discussion 131–132; doi: 10.1016/j.eururo.2005.09.018.
3. Stolzenburg J-U, Kallidonis P, Qazi H, et al. Extraperitoneal approach for robotic-assisted simple prostatectomy. Urology 2014;84(5):1099–1105; doi: 10.1016/j.urology.2014.06.045.
Robotic Partial Nephrectomy in the Treatment of a Posterior Excluded Caliceal Diverticulum with a Renal Calculus
Kevin H. Alter, MD,1 Sho Yoshitake, MD,2 Joshua Sterling, MD,2 Ji Hae Park, MD,2 and Sammy E. Elsamra, MD2
1Department of Surgery, Westchester Medical Center, Westchester, New York, USA.
2Division of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Clinical History: A 64-year-old woman with a history of nephrolithiasis presented with intermittent severe left flank pain. CT scan showed a 1-cm left renal calculus within the periphery of the kidney. The renal parenchyma eroded around the calculus, suggesting a caliceal diverticulum (CD). Shockwave lithotripsy treatment of stone within the CD was ineffective. Owing to the supracostal location and averse to nephrostomy tube and ureteral stent, the patient opted for a partial nephrectomy (PN).
Physical Examination: NAD, AAOx3. Abdomen was soft, nontender, and nondistended. No costovertebral tenderness.
Diagnosis: Right CD with kidney stones.
Intervention: Robot-assisted laparoscopic right PN with intraoperative ultrasonography was performed. The CD was noted with stones within, and extracted without incident. Warm ischemia time was 15 minutes with excellent hemostasis and repair. There were no intraoperative complications and the patient was stable after the procedure.
Follow-Up/Outcomes: Patient had an uncomplicated hospital course and was discharged home on postoperative day 1. Pathology analysis was consistent with an excluded diverticulum with renal calculi. Postoperative noncontrast CT of abdomen/pelvis showed complete treatment of the stone burden and CD. Patient was symptom free at 1-, 3-, 6-, and 12-month follow-up visits and no stones were seen on imaging. Our series of patients includes the aforementioned patient who underwent a retroperitoneal PN and another patient who underwent transperitoneal PN for large upper pole CD. The second patient reported history of recurrent urinary tract infections, which have since resolved. Her 3-month CT was unremarkable and she is symptom free. Both patients were refractory to extracorporeal shockwave lithotripsy treatment done previously.
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.2022.0037
