Robot-Assisted Excision of a Challenging Case of Left Recurrent Seminal Vesicle Cyst: Surgical Nuances and Management of Intraoperative Complication
Sanjoy Kumar Sureka, MD, Ankit Misra, MCh Urology, Anil Baid, MD, and Uday Pratap Singh, MD
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Clinical History: A 44-year-old gentleman presented with a 4 year history of voiding and storage lower urinary tract symptoms in the setting of multiple interventions (transrectal and open).
Physical Examination: A well-healed suprapubic catheter site was noted on the lower abdomen. External genitalia were normal. Rectal examination revealed a boggy smooth swelling anterior to the rectum.
Diagnosis: MRI pelvis revealed a multiloculated cystic lesion without solid elements occupying the pelvis. On voiding cystourethrogram, the alignment of the posterior urethra was displaced to the right.
Intervention: Cystoscopy revealed obliteration of the urethral lumen caused by extrinsic compression beyond the bulbar urethra. On laparoscopy the peritoneal fold overlying the cyst was incised and vas cleared to reveal the cyst wall that was incised, producing clear fluid for aspiration. The cyst was circumferentially mobilized amidst dense adhesions using sharp and blunt dissection. During mobilization of the cyst wall off of the posterior urethra, an iatrogenic urethral injury was noted and repaired over a 16F Foley catheter. Total operative time was 5 hours with blood loss of 500 mL.
Follow-Up/Outcomes: Micturating cystourethrogram/retrograde urethrogram performed at 4 weeks revealed no extravasation. The histopathology report suggested benign characteristics. Three-month follow-up revealed no recurrent LUTS. Treatment refractory seminal vesicle cysts are challenging because of their rarity and distortion of anatomy caused by multiple interventions. Patients may be at high risk for iatrogenic injuries caused by desmoplasia from prior treatment; however, with meticulous dissection complete laparoscopic excision can result in durable outcomes even in treatment refractory cases.
http://online.liebertpub.com/doi/full/10.1089/vid.2022.0078
Total Transperineal Biopsy with Ultrasound-MRI Coregistration for Patients with No Rectum Access
Sara Moreno Sorribas, MD,1 Enrique Gómez Gómez, MD,1 Julia Carrasco Valiente, MD,1 Guillermo Lendinez Cano, MD,2 José Valero Rosa, MD,1 Daniel López Ruiz, MD,3 and Francisco José Anglada Curado, MD1
1Urology Department, Reina Sofía University Hospital, Córdoba, Spain.
2Urology Department, Virgen del Rocío University Hospital, Sevilla, Spain.
3Radiology Department, Reina Sofía University Hospital, Córdoba, Spain.
Objective: To describe a new approach to perform ultrasound-MRI-guided prostate biopsies in patients without access to the rectum.
Methods: Patients with elevated prostate-specific antigen (PSA) levels and absent rectum approach to perform a traditional transrectal prostate biopsy (TPB) pose a challenge in clinical practice. In this study, we describe a useful new device to guide biopsy in patients with target lesions in a multiparametric-MRI (mpMRI) and no availability of TPB.
Results: We present two different cases of patients with PSA elevation and mpMRI lesion and no possibility of TPB. They underwent a modified single-port transperineal biopsy technique using MRI coregistered images and eTRAX device-assisted, to accurately guide the biopsy to the target lesion. The target biopsy diagnosed significant prostate cancer in both cases and no complications occurred after the procedure.
Conclusion: In patients with no rectum access, ultrasound MRI coregistration biopsies assisted by eTRAX device seem to be an alternative minimally invasive approach since it is effective, reproducible, and safe.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0010
Extraperitoneal Laparoscopic Simple Prostatectomy for Benign Prostate Hyperplasia
Amit Sharma, MCh Urology, Deepak Biswal, MCh Urology, RT Raghavendra, MS General Surgery, and Pradhuman Yadav, MS General Surgery
Department of Urology and Renal Transplant, AIIMS, Raipur, India.
Clinical History: A 62-year-old man presented with history of lower urinary tract symptoms of 2 years duration. His international prostate symptom score (IPSS) was 21/35, 4/6 (both irritative and obstructive). He had failed to respond to medical management.
Physical Examination: His serum prostate specific antigen levels were 12 ng/mL and digital rectal examination was not suspicious of malignancy. The uroflowmetry suggested flow rate of 8 mL/min and total voided volume of 340 mL. There was significant postvoid residual urine of 120 mL. Ultrasonography suggested 170 g prostate with thickened bladder wall and normal upper tracts.
Diagnosis: With the diagnosis of benign prostatic hyperplasia, the patient underwent laparoscopic simple prostatectomy (LSP).
Intervention: The patient underwent LSP. The operative time was 90 minutes. There was no significant bleeding intraoperatively. The postoperative course was uneventful. On the second postoperative day, bladder irrigation was stopped and drain was removed. He was discharged on the third postoperative day. Histopathology analysis suggested benign glandular stromal hyperplasia.
Follow-Up: At follow-up, his uroflowmetry parameters were Qmax 22 mL/sec, total voided volume 400 mL, and postvoid residual urine 30 mL. IPSS also had decreased to 9.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0023
Lined Gauze Plug-In Prevention of Stone Migration in Supine Percutaneous Nephrolithotomy
Deerush Kannan, MS,1 Praveen G. Sekaran, MS,2 Jatin Soni, MS,1 Rajesh Paul, MS,1 Pratik Taur, MS,1 and Nitesh Jain, MS1
1Department of Urology, Apollo Main Hospital, Chennai, Tamil Nadu, India.
2Department of General Surgery, Saveetha Medical College Hospital, Chennai, Tamil Nadu, India.
Introduction: Stone migration during any endoscopic urologic procedure is a disappointing event both for the patient and the urologist. Residual stone fragments postpercutaneous nephrolithotomy (PCNL) can occur in up to 8% of patients.
1
In certain scenarios of supine PCNL, it is more commonly encountered.
2
Creation of multiple tracts or by endoscopic combined intrarenal surgery (ECIRS), the residual fragments can be dealt, the operative time and instrumentation are more in ECIRS and the blood loss is exponentially more with the number of punctures.
3,4
In this study, we portray a novel method of prevention of stone migration in supine PCNL by packing the upper pole calyx/central region by lined sterile gauze and removing the same after confirming stone clearance.
Materials and Methods: In this study, we deliver a technique that is ideal in cases of renal pelvic calculus or central region—lower calyceal calculi. With the patient in the Galdakao-modified Valdivia position and after making the puncture and dilating the tract, a nephroscope is deployed and the stone location is confirmed. The ostium of the upper pole calyx is plugged with a lined gauze of size 3 × 2 cm (with radio-opaque lining) as soon as the ostium is seen. Poststone fragmentation and extraction of the stones, imaging confirmed that there are no residual fragments in the upper pole and the gauze plug is removed in toto.
Results: In our case, the technique used was easy to adapt and it was fruitful in preventing migration of residual fragments. The wet gauze helped in capturing some minute fragments that were released poststone fragmentation. There was no complication pertinent to the adaptation of this technique, though other routine complications of PCNL are not studied or compared secondary to adaptation of this technique.
Conclusion: Plugging a calix with sterile material like a gauze can prevent stone migration into the calix and there are no associated complications associated with it. Sterile gauze with radio opaque lining is well visible on imaging that adds to its safety in case the surgeon finds it difficult to retrieve the gauze at any point during the procedure.
Patient Consent Statement: 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.2023.0024
Robotic Transabdominal Graft Nephrectomy for Renal Mass in the Transplant Kidney
Deerush Kannan, MS,1 Praveen G. Sekaran, MS,2 Aarthy Panneerselvam, MS,1 Jatin Soni, MS,1 and Nitesh Jain, MS1
1Department of Urology, Apollo Main Hospital, Chennai, India.
2Department of General Surgery, Saveetha Medical College Hospital, Chennai, India.
Introduction: Graft nephrectomy is one of the challenging surgical procedures, and the most common indication for a graft nephrectomy is for a failed renal allograft. This procedure has been done by open technique traditionally. Herein we portray a video on robotic graft nephrectomy that was performed for a renal mass in the transplant kidney.
Materials and Methods: A 40-year-old lady with diabetes, hypertension, and hypothyroidism with chronic kidney disease since 2013 underwent live related renal transplant in 2015. She had rejection in 2022 and was back on dialysis since then. She had recurrent epigastric pain and was found to have chronic calcific pancreatitis, and imaging at that point revealed a mass in the graft kidney for which she was taken up for graft nephrectomy. Before the procedure, renal angiogram was reviewed by the radiologist so that it could aid in identification of the vasculature intraoperatively. The donor renal artery (single artery) was anastomosed to the internal iliac artery and donor renal vein (single vein) to the external iliac vein. The patient was placed in supine position with a slight tilt by a support on the left side so that the right side of the pelvis could be reached with ease. Based on the triangulation principle, the ports were placed (images are attached in the video).
Results: The total operative time was 80 minutes and the robot dock time was 42 minutes with a blood loss of <50 mL. Postoperative period was uneventful and the patient was ambulated on the same day of surgery and was discharged the next day. The histopathology analysis was reported as renal cell carcinoma with tubulopapillary features with all margins negative (pT3a) and features of chronic allograft nephropathy.
Conclusion: Though graft nephrectomy is technically demanding with a high potential for complications, with preoperative angiogram and patient counseling, robotic graft nephrectomy can be an attractive option. In obese patients, reaching the hilum using robotic graft nephrectomy is easier. Difficulties could occur when the graft artery is anastomosed with the external iliac artery making dissection and clipping of the graft renal artery tricky. More data can provide insight regarding the operative difficulties and outcomes in this challenging procedure.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0028
Robot-Assisted Transabdominal Single-Position Simultaneous Bilateral Pyeloplasty with Hidden-Incision Trocar Layout: Two Cases Experience
Chunru Xu, MD,1 Kunlin Yang, MD,1 Zhihua Li, MNS,2 Jian Lin, MM,1 Liqun Zhou, MD,1 and Xuesong Li, MD1
1Department of Urology, Peking University First Hospital, Institution of Urology, Peking University, Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, National Urological Cancer Center, Beijing, China.
2Department of Urology and Department of Nursing, Peking University First Hospital, Institution of Urology, Peking University, Beijing Key Laboratory of Urogenital Diseases (Male) Molecular Diagnosis and Treatment Center, National Urological Cancer Center, Beijing, China.
Introduction: Owing to the relative rarity and surgical difficulty of bilateral ureteropelvic junction obstruction (UPJO) in adults, simultaneously bilateral pyeloplasty has been rarely reported.
1
The robot-assisted system helped urologists to overcome this challenge, but in previous reports, intraoperative changes in position and lateralization were still required to accomplish the operation.
2,3
This video aims to sharing two effective cases of robot-assisted transabdominal single-position simultaneous bilateral pyeloplasty combined with the hidden-incision technique.
4
Materials and Methods: Perioperative information and patient follow-up results were collected from our Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER) database. The procedure is performed in the lithotomy, Trendelenburg, head-down position.
5
A trocar layout below the level of the external superior iliac spine line was utilized to achieve the principle of a hidden incision that could be concealed by underwear after surgery. The surgeon followed the procedure of exposing the obstruction site—dissecting the ectopic vessels, renal pelvis, and ureter—V–Y anastomosis: (1) clipping of the posterior wall of the renal pelvis to form a V-shape flap and longitudinal clipping of the posterior wall of the ureter to ensure that the two lengths are the same; (2) a single suture at the lowest end of the split ureter and the tip of the flap, followed by continuous anastomosing of one side of the ureter to the flap; (3) excision of the stenotic segment of the ureter and the redundant tissue of the ureter and renal–pelvic wall; (4) placement of a Double-J stent; and (5) continuous anastomosis of the other side of the ureter and renal pelvic flap to re-establish the pelvic–ureteral junction and to close the renal pelvis—wrapping the mesentery. The contralateral side can be handled similarly without intraoperative position changes and redocking. The operation duration, estimated bleeding, time to discharge, interoperative time for catheter removal, perioperative renal function, and drainage volume in both patients were included in the analysis. Analysis of variance (ANOVA) was used to analyze preoperative, intraoperative, and postoperative changes in estimated glomerular filtration rate (eGFR), and a two-sided p < 0.05 was defined as statistical significance.
Results: Both surgeries were completed effectively, with operation duration 319 minutes 13 seconds and 257 minutes 47 seconds, respectively. Both patients had their drains removed on postoperative days 4 and 3 and were discharged from the hospital on postoperative days 6 and 4. No perioperative complications were observed. Both patients were effectively removed from the Double-J stents at 2 months postoperatively. Their postoperative eGFR showed a slight rebound in both cases.
Conclusion: Robot-assisted transabdominal single-position simultaneous bilateral pyeloplasty can safely and effectively manage patients with bilateral UPJO with severe hydronephrosis or other symptoms. The hidden-incision technique can improve a patient's quality of life and aesthetic needs after the procedure.
Patient Consent Statement:
The study was approved by the ethics committee of Peking University First Hospital (approval number: 2020-2283) and individual consent for this retrospective analysis was waived.
http://online.liebertpub.com/doi/full/10.1089/vid.2023.0038
