Single-Port Robot-Assisted Laparoscopic Ureteral Extravesicular Reimplantation Utilizing Posterior and Anterior Approach to Manage Reflux
Teona Iarajuli, BS,1 Aditya Chauhan, BA,1 and Michael Stifelman, MD2
1Hackensack Meridian School of Medicine, Nutley, New Jersey, USA.
2Hackensack University Medical Center, Hackensack Meridian Health, Urology Department, Hackensack, New Jersey, USA.
Introduction: This video will discuss our experiences utilizing single-port robot-assisted laparoscopic bilateral ureteral extravesical reimplantation for management of vesicoureteral reflux. We compare anterior and posterior approaches for dissecting and isolating ureters.
Patient Presentation/Methods: The patient is a 20-year-old woman with recurrent urinary tract infections and a history of pyelonephritis secondary to persistent chronic bilateral vesicoureteral reflux despite prior hyaluronic acid/dextranome injections. The patient signed a written informed consent for video and audio recording. The definition of success is as follows: symptom-free, absence of hydronephrosis on imaging, and absence of any additional surgeries to correct the stricture after primary surgery.
Results: In this case, the operative time was 247 minutes, estimated blood loss (EBL) was 20 mL, and length of hospital stay was 1 day. No intraoperative complications were seen, and the patient tolerated the procedure well. We have performed a total of six robotic nonrefluxing ureteral reimplantation surgeries with mean operative time of 132.1 minutes (standard deviation = 26.5), median EBL of 27.5 mL (interquartile range [IQR] 20, 100), with 100% success rate and 0% complication rate (including no episodes of temporary urinary retention). The median length of hospital stay was 2 days (IQR 2, 2).
Conclusion: Single-port robot-assisted laparoscopic ureteral extravesical reimplantation presents an effective and safe treatment option for patients with severe vesicoureteral reflux. The anterior approach, involving ureter dissection anterior to the fallopian tube and ovary, presents an easier and safer option than the posterior approach. In addition, the da Vinci SP™ surgical system, in our experience, appears to be as safe, effective, and easy to use as its multiport counterpart.
Declaration of Competing Interest: T.I. and A.C. have no known competing financial interests or personal relationships that could have appeared to influence the study reported. M.S. is a lecturer for Intuitive, on the Scientific Advisory Board for CONMED, a consultant for VTI Medical, and performs educational activities for Ethicon.
Patient Consent Statement: This video publication received written informed consent for publication of the specific patient's case and was obtained from the patient. 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.2022.0045
Robotic-Assisted Retroperitoneal Excision of a Schwannoma
Dana Obery, MS,1,2 Jonathan Velasco, MD,1,2 Minia Hellan, MD,1,2 and Daniel Pucheril, MD, MBA1,2
1Kettering Health Network, Kettering, Ohio, USA.
2Wright State University Boonshoft School of Medicine, Beavercreek, Ohio, USA.
Clinical History: The patient is a 53-year-old man who presented to gastroenterology with complaints of abdominal pain. Endoscopy returned negative; however, CT of the abdomen demonstrated a right-sided heterogenous hypodense 2.6 × 2.7 cm retroperitoneal mass posterior to the inferior vena cava at the level of the renal hilum. PET CT demonstrated increased fluorodeoxyglucose avidity in the right retrocaval area with no evidence for metastasis. The case was then reviewed by surgical oncology and surgical excision was determined to be the best approach. Urology was ultimately consulted given the mass's retroperitoneal location.
Physical Examination: Vitals were within normal limits and the physical examination was benign, including abdominal examination (soft, nontender, no palpable masses, no evidence of distention, rebound tenderness, or guarding).
Diagnosis: Interventional radiology performed ultrasound-guided percutaneous biopsy, which stained positive for S100 and Sox 10, consistent with schwannoma.
Intervention: Robotic retroperitoneoscopic resection was determined to be the best approach given the mass's location. Urology was consulted given familiarity with the mass's location and the robotic retroperitoneoscopic approach. Upon entry into the retroperitoneum, a vertebral body osteophyte was encountered; however, careful attention to preoperative imaging and retroperitoneal landmarks enabled proper orientation and excision of the schwannoma with grossly negative margins.
Follow-Up/Outcomes: The console time was 120 minutes and estimated blood loss was 50 mL. The patient's postoperative course was uneventful, and he was discharged the next day. The patient was seen 6 months postoperative with no evidence of recurrence and has made a complete recovery.
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.2022.0054
Robot-Assisted Partial Nephrectomy with Ice Slush
Kenta Sumii, MD, PhD,1 Shun Kawamura, MD,1 Masato Okuno, MD,1 Isao Taguchi, MD, PhD,1 and Gaku Kawabata, MD, PhD1,2
1Department of Urology, Kansai Rosai Hospital, Amagasaki, Japan.
2Department of Urology, Hakuhokai Central Hospital, Amagasaki, Japan.
Introduction: Renal hypothermia during robot-assisted partial nephrectomy (RAPN) has not yet been fully described, because none of the methods using a minimally invasive approach has gained widespread acceptance. The aim of this study is to present our technique for achieving cold ischemia with ice slush during RAPN.
Materials and Methods: A total of 20 consecutive Japanese patients with solid renal masses underwent RAPN with cold ischemia by retroperitoneal approach between July 2016 and March 2020. An EZ Access (Hakko Co., Ltd., Medical Device Division, Nagano, Japan) port was used for the camera port. After the clamping of the renal artery with or without the renal vein, ice slush >1000 mL was injected through the EZ Access onto the surface of the kidney. After cooling for 10 min, tumor extraction was performed. Perioperative, and 3- and 12-month postoperative functional outcomes in the cold ischemia group were compared with those of a cohort of 32 patients who underwent RAPN with warm ischemia.
Results: Median RENAL nephrometry score was 9 (range: 4–10) in cold ischemia group and 7 (range: 4–10) in warm ischemia group. Mean cold ischemia time was 39.3 min (range: 22–53) and mean warm ischemia time was 23.6 min (range: 10–43). The mean postoperative rate of decline of estimated glomerular filtration rate evaluated at 3 months and 1 year was 8.3% ± 15.2% and 18.5% ± 9.6% in cold ischemia group and 6.5% ± 10.2% and 9.4% ± 16.8% in warm ischemia group, respectively. As for the functional outcomes, there were no significant differences between the two groups, despite tumor extraction tended to be technically difficult in the cold ischemia group. There were no postoperative severe complications. The limitations of this study include a small number of patients and short-term follow-up.
Conclusions: RAPN with renal hypothermia using intracorporeal ice slush is technically feasible and may improve postoperative renal function in the short term. Our method of introducing the ice slush was not complicated and highly reproducible.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0062
Robot-Assisted Laparoscopic Calyceal Diverticulectomy: A Safe and Feasible Technique
Alejandra Guevara, MD,1,2,3 Cinthia Galvez, MD,1,2,3 Daniel E. Nassau, MD,1,2 Christopher Olson,2 Andrew S. Labbie, MD,1,2 and Miguel Castellan, MD1,2
1Department of Urology, Miami University Medical School, Miami, Florida, USA.
2Department of Pediatric Urology, Nicklaus Children's Hospital, Miami, Florida, USA.
3This author contributed equally to this study.
Clinical History and Physical Examination: A 15-year-old female with Saethre–Chotzen syndrome without history of urinary tract infections or kidney stones presented with a 2-week history of fever, emesis, and left flank pain. Physical examination revealed left costovertebral angle tenderness and mild left upper quadrant pain to deep palpation.
Diagnosis: CT of abdomen revealed a 6.6-cm renal abscess in the upper left kidney. A drain was placed by interventional radiology and subsequent antegrade studies revealed a calyceal diverticulum (CD).
Intervention: After two unsuccessful interventions through endoscopic approaches, a robotic intervention was performed. First, a 5F ureteral catheter was placed through cystoscopy. The CD was then identified with the help of the prior nephrostomy tube placed on it. The CD was unroofed with a vessel sealer. The ostium was closed, and an omental flap was placed within the diverticular cavity. A closed suction drain, a left ureteral stent, and an indwelling Foley were left to optimize drainage. Operative time was 280 minutes. Estimated blood loss was 50 mL. A regular diet was started on postoperative day (POD) 1. She was discharged on POD 4.
Follow-Up: The Foley catheter, drain, and ureteral stent were removed sequentially on POD 2 and POD 9 and 7 weeks later, respectively. At 12-month follow-up, she remained asymptomatic.
Outcome: A robotic approach is a safe and feasible treatment modality in symptomatic pediatric patients with CD when endoscopic management has failed, even in cases complicated by chronic infection as demonstrated in this video.
Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Prior abstract presentations to: North America Urology Robotic Symposium (NARUS), Las Vegas, February, 2022; American Urology Association (AUA), New Orleans, May, 2022; European Society of Pediatric Urology (ESPU), Belgium, June 2022, NARUS 2022.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0048
First Robot-Assisted Laparoscopic Ureterolithotomy with HUGO Robot-Assisted Surgery System
Vicente Elorrieta, MD,1 Álvaro Kompatzki, MD,2 Rubén Olivares, MD,2 Alfredo Velasco, MD,2,3 and José A. Salvadó, MD2,3
1Urology Resident, Medicine Faculty, Finis Terrae University, Santiago, Chile.
2Urologist, Urology Department, Clínica Santa María, Santiago, Chile.
3Associate professor, Medicine Faculty, Finis Terrae University, Santiago, Chile.
Introduction and Objective: We report the case of a 60-year-old female patient afflicted by a 2.5 cm long and high-density mid left ureteral stone. This challenging case was discussed because of the possible surgical approaches we had. After consideration, we performed a robot-assisted surgery (RAS) laparoscopic ureterolithotomy and the patient was discharged on the third postoperative day with no complications. This case reveals how emerging technologies give us possibilities in the management of complex cases.
Methods: A 60-year-old woman, whose medical background included hypertension and a remitted breast cancer, was afflicted by intermittent left flank pain for the past 2 months. Creatinine levels in blood were 1.17 mg/dL. A computed tomography scan revealed 2.5 × 1 × 1 cm and 1700 Hounsfield units stone in her medium left ureter. We considered the size of the stone and density, which gave us a low likelihood of success and high risk of both intra- and postoperative complications. We also considered that an endourologic approach would require multiple interventions. After thorough discussion, we opted for a RAS laparoscopic ureterolithotomy, because of decreased recovery time and lower morbidity.
Results: The surgical procedure lasted 150 minutes (console 110 minutes). Under general anesthesia, and in a right lateral recumbent position, we proceeded with a left transperitoneal RAS laparoscopic ureterolithotomy. A 2-cm-long longitudinal ureterotomy was performed and the stone was removed. We proceeded with a longitudinal ureterotomy closure, leaving a Double-J stent as a tutor. After confirming hermeticity we placed a drain and proceeded with closure. The patient had an excellent postoperative evolution. The Double-J stent was removed after 4 weeks, with complete resolution of the clinical symptoms.
Conclusions: Indications for ureterolithotomy are rare in the modern era of endourology. Current indications include stones with a low likelihood of treatment success using extracorporeal shockwave lithotripsy, ureteroscopy, or percutaneous techniques. We opted for a safe and effective option, assisted by the recently launched HUGO™ RAS system (Medtronic, Minneapolis, MN), which could make a meaningful difference in expanding access to care to more patients around the world, because of its versatility, compatibility, mobility, and cost-effectiveness. Therefore, we were able to safely resolve a challenging case, by performing the first HUGO RAS laparoscopic ureterolithotomy, resulting in a stone-free procedure.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0060
