Single-Position Robot-Assisted Laparoscopic Right Ileal Ureter Interposition
Labeeqa Khizir, BS,1 Juliana E. Kim, BA,1 Christina Fakes, MD,1 Alain Kaldany, MD,1 Hiren Patel, MD,1 Jafar Khan, MD,2 and Sammy E. Elsamra, MD, FACS1
1Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
2Seton Hall University, South Orange, New Jersey, USA.
Clinical History: The patient is a 45-year-old woman with a history of cervical cancer with radiation-induced pan-ureteral stricture. The patient was deemed to be essentially cancer free and was managed with stent placement for chronic duration. Upon further imaging, up-and-down-o-gram and cystoscopy demonstrated pan-ureteral stricture managed with right nephrostomy tube. Patient elected to proceed with right ureteral repair for definitive treatment with risks, benefits, and alternatives explained.
Physical Examination: No abnormal physical examination findings.
Diagnosis: Right pan-ureteral stricture.
Intervention: Ports were placed similar to pelvic procedure with tilted axis, skewing the right-sided ports up and skewing the left-sided ports down to allow for better reach up towards the right ureteropelvic junction. Specific port placement used for this ileal ureter interposition allowed for the patient to remain in a single dorsal lithotomy position throughout the entire procedure. Steps for the right ileal ureter interposition procedure included isolation and division of the ileum, side-to-side bowel anastomosis, anastomosis of distal ureter to bladder and placement of a Double-J stent from distal to proximal part of ileal loop, incision of renal pelvis, and side-to-side anastomosis between ileal segments and renal pelvis.
Follow-up/Outcomes: Patient's nephrostomy tube was removed intraoperatively. Estimated blood loss was 50 mL with no intraoperative complications. Patient was stable with an unremarkable postoperative course, and postoperative imaging demonstrated preserved renal function. Patient was discharged on postoperative day 2. Patient's stent was removed 4 weeks postoperatively with no restenosis. The procedure was performed effectively without postoperative complications, and patient had a follow-up mercaptuacetyltriglycine renal scan performed 3 months after surgery, which showed marked improvement of right hydroureteronephrosis. Patient was well at last follow-up, showing how robotic ileal ureteral reconstruction is a viable strategy for definitive repair of extensive ureteral defects.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0069
Modified Martius Flap Urethroplasty: A New Technique
Jacob Rust, MD, Jonathan A. Seaman, MD, and Christian O. Twiss, MD
Department of Urology, University of Arizona College of Medicine, Tucson, Arizona, USA.
Introduction: Female urethral strictures are rare, and there is no consensus on proper surgical treatment. The literature is primarily limited to case reports and small case series. Surgical treatment has frequently been extrapolated from male urethroplasty techniques. However, female urethroplasty differs significantly from male urethroplasty because it is performed directly across the urinary sphincter.
1
We describe our rationale and technique for female ventral urethroplasty utilizing a modified Martius flap.
Materials and Methods: Two female patients, aged 46 and 58 years, with chronic urethral strictures underwent a ventral modified Martius flap urethroplasty. After guidewire and open-ended ureteral stent placement across the stricture, an inverted U-flap incision was made from the distal urethra to the bladder neck. A full thickness incision into the urethral lumen was made, extending past the bladder neck, and sounded with a 30F urethral sound. An ∼5 × 2 cm portion of nonhair bearing inner labia tissue was harvested and mobilized on the anterior pedicle of a Martius flap. This was then tunneled under the vaginal wall and rotated over the area of the urethral defect. The flap was sutured in place with two 4-0 polyglactin running suture lines, covering the entire gap in the urethra with good mucosal apposition. The remaining fatty tissue of the Martius flap was rotated over the suture lines, adding an extra layer to the repair. The inverted U flap incision was closed over the repair and the skin edges of the Martius flap harvest site were closed in two layers with a deep 2-0 polyglactin layer and a superficial 4-0 poliglecaprone subcuticular suture, resulting in a cosmetic closure.
Results: Postoperative voiding cystourethrogram revealed an open bladder neck and no recurrent stricture for both patients. Average Uroflow peak flow was 18 mL/s. The patients had no complaints of stress incontinence (SUI) and a negative cough leak test at 1 month follow-up. At 6 months follow-up, both patients continued to deny any SUI and had no obstructive voiding complaints with minimal post-void residuals.
Conclusions: Our technique using a ventral approach to urethroplasty in women with a Martius flap is effective in the management of female urethral stricture disease. This approach offers lower risk of damage to the sphincter, avoids possible clitoral nerve injury, allows for better maintenance of urethral support, and is an approach familiar to most female pelvic medicine and reconstructive surgeons.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0013
Robotic Approach for Surgical Management of a Ureteroduodenal Fistula
Matthew Lee, MD, MBA, Julienne Jeong, BA, and Daniel Eun, MD
Department of Urology, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, Pennsylvania, USA.
Clinical History: A ureteroduodenal fistula (UDF) is an uncommon diagnosis associated with patient morbidity, including recurrent urinary tract infections, pneumaturia, and flank pain. Surgical management may be complex because of extensive fibrosis and scarring surrounding the UDF site secondary to chronic inflammation.
Physical Examination: The patient presented with right flank pain.
Diagnosis: We report the case of a 42-year-old woman with history of a right UDF secondary to iatrogenic injury causing urine extravasation during a ureteroscopy and laser lithotripsy procedure at an outside hospital 1 year prior. The patient was previously managed with chronic ureteral stent exchanges before surgery. A retrograde pyelogram was performed before definitive surgery, which demonstrated a fistula connecting the proximal right ureter to the third part of the duodenum.
Intervention: We demonstrate robotic repair of a UDF in a patient with an associated ipsilateral atrophic kidney. Intraoperatively, extensive retroperitoneal fibrosis and purulent debris were evident surrounding the right renal hilum and pelvis. Intraureteral indocyanine green was observed under near infrared fluorescence to aid in dissection. A total right nephrectomy was performed, leaving a 2-cm margin of kidney parenchyma and ureter that remained connected to the duodenal fistula. The general surgery team then performed a duodenotomy and primary repair with omental patch.
Follow-Up/Outcomes: Intraoperatively, estimated blood loss was 400 mL and operative time was 200 minutes. An upper gastrointestinal series was performed on postoperative day 3 that confirmed no duodenal leak. The patient was discharged on postoperative day 4 after an uncomplicated hospital course. At 16 months follow-up, there were no major (Clavien >2) postoperative complications. Robotic total nephrectomy and UDF repair may be performed effectively in a patient with UDF and associated ipsilateral atrophic kidney.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0075
Simultaneous Antegrade and Retrograde Endoscopic Management of Complete Short-Segment Ureteroileal Anastomotic Stricture: Technique and Early Outcome
Joao G.S. Porto, MD, Jonathan E. Katz, MD, and Hemendra N. Shah, MD
Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA.
Background: Ureteroileal anastomotic strictures have a prevalence of up to 10%. Although open surgical revision remains the gold standard treatment, endoscopic and robotic approaches are described to reduce morbidity.
1
Patients with complete occlusive strictures are usually not considered candidates for endoscopic management. There are limited publications with small number of patients who employed endoscopic management for complete occlusive ureteroileal anastomotic stricture.
Objective: The aim of this video is to describe surgical approach in a stepwise manner for endoscopic management of a complete short-segment (<1 cm) ureteroileal anastomotic stricture.
2
–6
Methods: A 51-year-old woman underwent an anterior pelvic exenteration and ileal conduit followed by adjuvant chemoradiotherapy for cervical cancer management. After 1 year, she underwent nephrostomy tube placement for pyelonephritis associated with a left hydroureteronephrosis. Subsequent antegrade nephrostogram demonstrated a complete ureteroileal anastomotic stricture. The patient was counseled regarding various management options, and she opted for endoscopic management. Under general anesthesia we initially performed a flexible cystoscopy through the ileal conduit and were unable to identify the left ureteroileal anastomotic site. We then dilated percutaneous renal access and placed 13F ultra-mini percutaneous nephrolithotomy sheath in kidney under fluoroscopic guidance. Antegrade simultaneous ureteroscopy and nephrostogram confirmed a short-segment complete stenosis of ureteroileal anastomosis. Using 200 micron holmium laser fiber at 1 J × 10 Hz, we incised the distal blind end of ureter near conduit allowing passage of the ureteroscope in periureteral tissue. We then incised the ileal conduit, allowing antegrade advancement of a guidewire into the conduit. This wire was retrieved cystoscopically through an ileal conduit and secured at the level of stoma. Finally, a 7F/14F endoureterotomy stent was placed followed by nephrostomy tube placement.
Results: The patient had an uneventful postoperative recovery and was discharged home the next day with an open nephrostomy tube. After 10 days, we confirmed free drainage of contrast into the conduit without extravasation on antegrade nephrostogram and clamped the nephrostomy tube. We later removed nephrostomy tube at 2 weeks and endoureterotomy stent by office cystoscopy at 6 weeks. At 3-month and 1-year follow-up, the patient remained asymptomatic. A renal ultrasonography revealed residual mild left hydronephrosis and a renal scan showed stable split left renal function of 25% with adequate drainage.
Conclusion: Our video provides detailed technical nuisances to novice endourologist for a safe and effective treatment of a complete short-segment ureteroileal anastomotic occlusion with simultaneous antegrade and retrograde endoscopic management.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0012
Redo Robotic Ureteroplasty After Prior Failed Ureterocalicostomy
Matthew Lee, MD, MBA, Julienne Jeong, BA, and Daniel Eun, MD
Department of Urology, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, Pennsylvania, USA.
Clinical History: Surgical management of patients with recurrent strictures after prior ureterocalicostomy for complex ureteropelvic junction obstruction is challenging because of extensive periureteral fibrosis and scarring that is present in this setting.
Physical Examination: The patient presented with left flank pain.
Diagnosis: We report the case of a 37-year-old male patient with a recurrent symptomatic stricture after undergoing a laparoscopic converted to open left ureterocalicostomy 12 years prior. Retrograde pyelogram showed a small filling defect and 1 cm narrowed segment at the ureter's insertion point into the lower pole calix.
Intervention: We describe our approach for robotic ureteral reconstruction for patients with recurrent strictures after prior ureterocalicostomy. We highlight the utilization of intravenous indocyanine green (ICG) to facilitate identification of the strictured aspect of the ureter. A longitudinal incision was made along the strictured segment and a buccal mucosa graft was anastomosed to the defect in onlay manner.
Follow-Up/Outcomes: Intraoperatively, operative time was 213 minutes and estimated blood loss was 100 mL. There were no intraoperative complications and the patient was discharged on the same day. At follow-up of 20 months, the patient had no flank pain and his postoperative renal scan showed normal split function and half washout time of 12 minutes bilaterally. Robotic ureteral reconstruction may be utilized for management of patients with recurrent ureteral strictures after prior ureterocalicostomy. Near infrared fluorescence with ICG may assist with identification of the strictured ureter in these complex settings. This surgical approach may reduce damage to the fragile periureteral blood supply and minimize the risk of stricture recurrence.
Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The study was approved by the institutional review board at Temple University (protocol number 20793).
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0074
The First Robotic Day Care Procedure in the Management of Testicular Vein Syndrome: A Rare Cause of Hydroureteronephrosis
Deerush Kannan, MBBS, MS, MRCS,1 Sindhu Sankaran, MBBS,1 Kunal Dholakia, MBBS, MS, MCh, Urology,1,2 Sateesh Ramamoorthy, MBBS, MD,2,3 and Narasimhan Ragavan, MBBS, MS, FRCS Eol, PG CTLCP, FRCS (Urol), MD1,4
1Department of Urology, Apollo Hospitals, Chennai, India.
2Department of Anesthesiology, Apollo Hospitals, Chennai, India.
3Department of Radiology, Apollo Hospitals, Chennai, India.
4Department of Uro-Oncology, The Tamil Nadu Dr MGR Medical University, Chennai, India.
Clinical History: A 46-year-old gentleman with no comorbidities presented with dull aching pain in the left loin for 6 months.
Physical Examination: Examination was unremarkable.
Diagnosis: He was evaluated with contrast-enhanced CT scan of the urinary tract that revealed left gross hydroureteronephrosis secondary to midureteral stricture caused by compression of the left testicular vein. Renogram (diethylenetriamine pentaacetate scan) was performed that showed 44% split renal function of the left kidney with a glomerular filtration rate of 86 mL/min.
Intervention: He underwent a day-case robotic ureteroureterostomy and intraoperatively the upper ureter was dilated with testicular vein transposing above the midureter that had a stricture, causing dilatation of proximal ureter with hydronephrosis. Upper ureter was transected above the stricture and brought anterior to the testicular vein and the constricted segment was excised. Ureteroureterostomy was performed over 5F/26 cm Double-J stenting using 2-0 Stratafix suture.
Outcomes: Follow-up included stent removal at 6 weeks and serial creatinine thereafter has been normal. Follow-up imaging was done in the form of ultrasonography that showed resolution of hydronephrosis at 3 months and 6 months.
Patient Consent Statement: Written informed consent was obtained from the patient to publish this research.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0005
Utilization of Non-Transecting Pyeloplasty Techniques for Management of Recurrent Ureteropelvic Junction Obstruction
Julienne Jeong, BA,1 Matthew Lee, MD, MBA,1 Joshua Kim, BS,1 Michael D. Stifelman, MD,2 Lee C. Zhao, MD, MS,3 and Daniel D. Eun, MD1
1Department of Urology, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, Pennsylvania, USA.
2Department of Urology, Hackensack Meridian School of Medicine at Hackensack University Medical Center.
3Department of Urology, New York University Grossman School of Medicine at New York University Langone Health System.
Introduction: Cases of recurrent ureteropelvic junction obstruction (UPJO) in patients who underwent a prior failed pyeloplasty may pose a difficult challenge for urologists. The increased findings of periureteral fibrosis and scarring in a reoperative field may increase the risk of ureteral devascularization and stricture recurrence. The goal of this study is to demonstrate three robotic non-transecting pyeloplasty techniques for patients in this setting.
Methods: We conducted a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients between April 2012 and September 2019 who underwent a secondary pyeloplasty for management of a recurrent UPJO after prior failed pyeloplasty. Transecting (dismembered) and non-transecting pyeloplasty (YV plasty, buccal mucosa graft ureteroplasty onlay, or Heineke–Mikulicz) were the techniques used for secondary pyeloplasty. YV plasty was utilized in patients with high insertion UPJO without a redundant renal pelvis. A buccal mucosa graft ureteroplasty onlay was utilized for patients with nonobliterative long-segment UPJO and/or significant peri-ureteropelvic junction fibrosis. The Heineke–Mikulicz technique was utilized in patients with short-segment (≤1.5 cm) UPJO. Symptomatic absence of flank pain and radiographic obstruction (computed tomography urogram, renal scan, and/or renal ultrasound) were measures used to assess for postoperative success. Using a p < 0.05 for statistical significance, we used nonparametric independent sample median tests and chi-square tests to compare perioperative variables between transecting and non-transecting pyeloplasty.
Results: Twenty-eight patients met the final inclusion criteria. Regarding preoperative variables, there was no difference in median operative time (p = 0.26) and estimated blood loss (p > 0.99) between both groups. In the non-transecting group, near-infrared fluorescence with indocyanine green was utilized more frequently (85.7% vs. 50.0%, p = 0.04). The non-transecting group also had a longer median stricture length (2.8 cm vs. 1.1 cm, p = 0.04). There was no difference in surgical success rates between both groups (85.7% for both groups, p > 0.99). Two patients who underwent a non-transecting buccal mucosa graft ureteroplasty onlay required postoperative management with percutaneous nephrostomy tubes caused by recurrent obstruction. Regarding postoperative variables, there was no difference in surgical success rates between both groups (p > 0.99).
Conclusions: In patients with recurrent ureteropelvic junction obstruction after prior failed pyeloplasty, non-transecting pyeloplasty techniques, including YV plasty, buccal mucosa graft ureteroplasty onlay, and Heineke–Mikulicz pyeloplasty, are safe and feasible options. Given the potential technical challenges involved with secondary repair, non-transecting pyeloplasty techniques may offer benefits in reducing the risk of ureteral devascularization and preserving the fragile ureteral blood supply.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0007
Single-Port Robotic Transvesical Simple Prostatectomy Step by Step
Joshua S. Jue, MD,1 Alexa R. Meyer, MD,2 and Lee Richstone, MD2
1Smith Institute for Urology, Department of Urology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
2Smith Institute for Urology at Lenox Hill Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA.
We detail the instruments required to perform a single-port robotic transvesical simple prostatectomy, as well as the surgical technique to perform this operation using the single-port robot. A 3-cm transverse incision is made three fingerbreadths above the pubic symphysis and a longitudinal cystotomy is made. The roll wound retractor rolling ring is inserted into the bladder lumen, with the access port, SP Short Entry Guide, and AirSeal trocar within it. The robot is then docked to the SP cannula, and the bladder is insufflated to 8 mm Hg. A semilunar incision is made through the bladder mucosa using the monopolar scissors along the posterior aspect of the bladder neck or median lobe. The forceps can be used to retract the prostatic adenoma, while using the monopolar scissors to further bluntly dissect the adenoma from the capsule. The prostatic adenoma can be removed en bloc, but is usually removed en lobe. A vesicourethral mucosal advancement flap is performed with 3-0 V-Loc suture from apex to base at 3-o-clock and 9-o-clock; a double-arm 3-0 V-Loc suture is then used to approximate the bladder and urethral mucosa, by running from 6-o-clock to 12-o-clock. Prostatic adenoma specimens can be removed from the SP Access Port directly or removed from the bladder using the robotic camera for observation. The cystotomy is closed in two layers with 3-0 Vicryl suture. The patient is observed for 2 hours on continuous bladder irrigation to determine ambulatory discharge eligibility. Follow-up is in 3 to 7 days for trial of void.
Disclosure: Portions of this video and title were presented at the AUA 2023 in the form of a video abstract and as an AUA Core Curriculum video. https://www.auajournals.org/doi/pdf/10.1097/JU.0000000000003288.06
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.2023.0002
