VIDEOUROLOGY ABSTRACTS

Abstract

Cystoscopy-Guided Robot-Assisted Partial Cystectomy for the Treatment of an Inflammatory Myofibroblastic Tumor: A Video Case Report

Dries Develtere, MD, Ralf Veys, MD, Camille Berquin, MD, Benjamin Van Parys, MD, Elisabeth Pauwels, MD, Geert De Naeyer, MD, Ruben De Groote, MD, Peter Schatteman, MD, Alexandre Mottrie, MD, PhD, and Frederiek D'Hondt, MD

Department of Urology, Onze Lieve Vrouw Ziekenhuis Aalst, Aalst, Belgium.

An inflammatory myofibroblastic tumor (IMT) can arise anywhere in the body. IMT is a spindle-cell neoplasm not prone to metastasize although it has an important potential of local expansion. We report an IMT in a 55-year-old male who was initially treated with a transurethral resection of the bladder tumor (TURBT) and subsequently underwent a robot-assisted partial cystectomy. Step 1 of the procedure was installation of the patient. Since we performed the procedure with the Da Vinci Xi system^®, we were able to install the patient in supine position followed by side docking. Step 2 was marking the tumor in the peritoneum of the bladder dome. During step 3, we developed Retzius' space. Step 4 consisted of using simultaneous cystoscopy, performed by the bedside table assistant, guiding the dissection aiming for complete excision of the tumor with a negative surgical margin of at least 2 cm macroscopically. This was facilitated using the TilePro™ feature that allows simultaneous observation of cystoscopy and laparoscopy image inside the console. Since in this case the tumor originated from the bladder dome, step 5 consisted of excising the urachus en bloc with the tumor. During step 6, we placed the tumor in an Endo Bag. Step 7 consisted of closure of the bladder in two layers using V-lock 3-0. To finish of the procedure, a leakage test was performed, followed by extraction of the tumor in the Endo Bag. No postoperative problems were reported, and the patient was discharged the second day after surgery. Transurethral catheter was removed in the outpatient clinic on day 7, after cystography ensured no leakage was present. Definitive pathologic report confirmed the presence of a spindle-cell proliferation with eosinophilic cytoplasm. A follow-up cystoscopy 5 months after surgery showed no recurrence. Bladder capacity was excellent without any change in micturition pattern. Future follow-up will consist of yearly cystoscopy. When complete resection of IMT with TURBT is not feasible, a robot-assisted partial cystectomy with simultaneous cystoscopy is a minimally invasive option facilitating complete resection with negative surgical margins and maximal preservation of bladder function.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0137

Ultrasound-Guided Anterior Caliceal Approach in Supine Percutaneous Nephrolithotomy

Raguram Ganesamoni, MBBS, MS, MRCS, MCh, Jeslin Lekshmanan, MBBS, MD, and Soundarya Ramanatha Pandian, MBBS, DNB

Department of Urology, Ganesamoni Hospital, Nagercoil, India.

Introduction: Percutaneous nephrolithotomy (PCNL) is the current gold standard for the management of large renal stones. Traditionally PCNL has been done in prone position. Although supine PCNL was first described by Valdivia Uria et al in 1987, the use of supine position is becoming popular in the recent decades only.^1,2 Although supine PCNL has a lot of advantages, there are two disadvantages associated with this position.³ These are longer tract length and hypermobility of kidney during tract dilatation.³ We present our ultrasound-guided anterior caliceal approach in supine PCNL that can overcome these two problems in supine PCNL, making supine PCNL a more refined technique.

Patients and Methods: Between June 2016 and March 2020, 94 patients underwent supine PCNL in ultrasound-guided supine PCNL. Of these, six patients in whom anterior caliceal approach could not be used because of interference of colon or liver were excluded. All patients were evaluated using computed tomography scan preoperatively. Informed consent was obtained from all patients. The mean stone size was 2.7 cm. Patients were placed in supine oblique hemilithotomy position, in which the contralateral lower limb was kept in lithotomy and ipsilateral lower limb was kept straight on a pillow. The patient was tilted to 30°–45°. We do not use any arbitrary anterior limit for puncture site. We prefer lower anterior calix for entry. Ultrasound scan was used to find the most direct and shortest tract in all patients. Tranexamic acid was used in all patients as per the previously reported protocol.⁴ Tract was dilated using 14F screw dilator followed by a single-step teflon dilator over guide rod. The tract size used ranged from 14F to 22F. Stones were observed using 12F or 18.5F Wolf nephroscope and fragmented using pneumatic lithotripter. Flexible nephroscope was used when the tract size of 18F or above was used. Double-J stent was placed in all patients. Most of the patients underwent a tubeless procedure. Hemoglobin loss was estimated postoperative hemoglobin value on discharge. Stone clearance was assessed using kidney, ureter, and bladder radiograph and ultrasonogram on postoperative day 1 and after 1 month. Complete clearance was defined as stone fragment <4 mm in size.

Results: The mean operative time was 55 minutes (32–135 minutes). The commonly reported problems of long tract, difficulty in manipulation and hypermobility during tract dilatation were not encountered in any patient. Mean hemoglobin loss was 0.8 g/dL. None of the patients required blood transfusion. Nephrostomy tube was placed in selected patients with pelvic injury or previously treated infected hydronephrosis (7.9%). Complete stone clearance rate at 1 month was 93.1%.

Conclusions: Anterior caliceal approach in supine PCNL has a shorter tract length when compared with posterior caliceal entry. Moreover, the problem of hypermobility is avoided because of good support from posterior abdominal wall muscles. Use of ultrasound helps in assessing the shortest and direct tract, which is mostly through an anterior calix.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0064

References

1. Valdivia Uría JG, Lachares Santamaría E, Villarroya Rodríguez S, et al. Percutaneous nephrolithectomy: Simplified technic (preliminary report). Arch Esp Urol 1987;40:177–180.

2. Valdivia JG, Scarpa RM, Duvdevani M, et al. Supine versus prone position during percutaneous nephrolithotomy: A report from the clinical research office of the endourological society percutaneous nephrolithotomy global study. J Endourol 2011;25:1619–1625.

3. Proietti S, Rodríguez-Socarrás ME, Eisner B, et al. Supine percutaneous nephrolithotomy: Tips and tricks. Transl Androl Urol 2019;8(Suppl 4):S381–S388.

4. Kumar S, Randhawa MS, Ganesamoni R, Singh SK. Tranexamic acid reduces blood loss during percutaneous nephrolithotomy: A prospective randomized controlled study. J Urol 2013;189:1757–1761.

Great Saphenous Vein Sparing Robot-Assisted Video Endoscopic Inguinal Lymphadenectomy for Carcinoma of Penis: Video Demonstration

Yuvaraja B. Thyavihally, MCh(Urology), Santosh S. Waigankar, DNB(Urology), Preetham Dev, MCh(Urology), Abhinav P. Pednekar, MBBS, Srivathsan Ramani, MCh(Urology), and Varun Agarwal, MCh(Urology)

Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.

Introduction: Inguinal lymph node dissection in carcinoma of the penis is associated with significant wound complications such as flap necrosis, infection, and lower limb edema. Video endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive technique with a similar template of dissection as open surgery, but with reduced wound-related morbidity and equal oncologic outcomes. Robotic approach for VEIL (RVEIL) has additional advantages of ergonomics, three-dimensional enhanced vision, and flexible instrumentation. We report our experience and technique of great saphenous vein sparing (SVS)-RVEIL, highlighting its advantages.

Materials and Methods: From June 2012 to January 2019, 34 patients who underwent RVEIL at our institute were analyzed. Seven patients (five bilateral and two unilateral) underwent a SVS procedure, accounting for 12 groins (group 2). In the other 27 patients (53 groins), saphenous vein was sacrificed (group 1). All patients underwent either partial or total penectomy for the primary disease. SVS was done in clinically nonpalpable groins (cN0). We analyzed patients and tumor-related characteristics, compared limb edema, and compared oncologic outcomes between the two groups.

Surgical Steps: These include creating working space above fascia lata by finger dissection, placing the ports distal to apex of the femoral triangle, opening fascia lata, and dissection of tissue around the femoral artery and vein. This is followed by identification and dissection around the saphenofemoral junction. Ligating three named tributaries and dissection of the entire length of great saphenous vein (GSV) were done. Finally, all the lymphofatty tissue is dissected off from the skin flap.

Results: The median follow-up of the entire group was 34.5 months (interquartile range, 20.7–55.5), and the mean age of the patients was 57.3 years (range, 43–73 years). There was no difference in mean operative time between two groups [110 minutes (range, 70–180) for group 1 and 100 minutes (range, 70–170) for group 2 (p = 0.0245)]. The mean number of lymph nodes dissected in each groin was 10.52 ± 1.45 in group 1 and 11.11 ± 1.96 in group 2 (p = 0.0245). Blood loss was 50 mL in both groups (range 30–100 mL). None of the patients had flap necrosis. Six patients (19.4%) in group 1 developed mild-to-moderate edema of the leg in the postoperative period, and none in group 2. Final histopathology report showed 12 groins (22.64%) had pN+ disease in group 1, and 3 groins (25%) in group 2 (p = 0.890). During follow-up, one patient developed nodal recurrence that had pN+ disease in group 1, and none in group 2. The median overall survival was 62 months in group 1 and 56 months in group 2 (p = 0.356).

Conclusions: SVS-RVEIL is a safe and technically feasible option in managing cN0 inguinal lymph nodes in carcinoma penis, with a lesser incidence of postoperative limb edema while maintaining oncologic principles. Moreover, it facilitates good lower limb drainage and does not increase the chances of local recurrences. However, we need further studies with more number of patients to identify the role of sparing GSV and its benefits.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0077

Urinary Bladder in Giant Inguinal–Scrotal Hernia: Robotic-Giant Prosthetic Reinforcement of the Visceral Sac—the Modern Stoppa Technique

Francesco Coratti, MD,¹ Carlotta Agostini, MD,^1,2 Andrea Bottari, MD,^1,2 Laura Fortuna, MD,^1,2 Andrea Manetti, MD,¹ Giuseppe Barbato, MD,^1,2 and Fabio Cianchi, MD^1,2

¹AOU Careggi, Firenze, Italy.

²Università degli Studi di Firenze, Firenze, Italy.

Background: Inguinal hernia is a common surgical disease and is defined as “giant” when descending below the midpoint of the inner thigh of a patient in upright position. These types of hernia are extremely rare and may still be encountered especially after years of self-neglect.^1,2 With the evolution of technology, minimally invasive surgery is the choice in a large number of interventions. The robotic approach has recently been increasingly used for hernia repair, mostly with the transabdominal preperitoneal hernia repair (TAPP).^3,4

Materials and Methods: In our hospital between October 2019 and October 2020, three cases of giant inguinal hernia were performed. All of these are men, with a mean age of 69 years. The young patient had no comorbidities, the two elderly had hypertension and one also had cardiomyopathy associated with pacemakers implant and coronary stents, recurrent urinary infections, diabetes mellitus, and chronic renal failure. One patient had a body mass index > 30 kg/m². Two of those had an ASA (American Society of Anesthesiologists) classification = 2, one patient had an ASA score of 3. Preoperative CT showed bladder and perivisceral fat content in all patients. The postoperative course was regular. All patients received antibiotics for the first 72 hours and were fully mobilized by postoperative day 1. Dysuria was reported in two patients experiencing inguinal “discomfort” and scrotal hematoma with drainage removed in the clinic after dimission. No late recurrences were diagnosed or any long-term complication observed. There was an improvement in the post-operative quality of life (QoL). In particular, the patient with recurrent urinary infections resolved this pathological condition. Another one with stranguria regained normal urinary function. Finally, in all three cases the pain in the inguinal region is resolved. This video describes the challenging reparation of a right giant inguinal–scrotal hernia containing bowel loops and urinary bladder in an 80 year-old man. The patient had longer than 10 years history of this hernia of ∼20 cm in size, causing pain, pollakiuria, voiding dysfunction, thickened scrotal skin, and influencing the QoL. The CT scan shows the bladder in the hernial sac. The forward traction of the bladder caused a compression on the distal ureteral tracts, showing a fair dilation of the right ureter and a hydroureteronephrosis on the left ureter. A left inguinal hernia is also present.

Results: Hernias repairs are approached by TAPP with Stoppa's technique. In particular, the video shows the use of a polypropylene 22 × 18 cm mesh fixed by a few loose sutures and fibrin glue covering both hernia ports. In any hernia but especially in large hernias, we believe that the preperitoneal atraumatic dissection of peritoneal flap is very important.^5,6

Conclusion: Giant inguinal hernia is a rare variant of inguinal hernia. Its clinical and instrumental classification is important and patient comorbidities must be taken into account. Appropriate patients selection is important in limiting complications and satisfactory prognosis.^1,2,7 The robotic TAPP is a technique that seems a safe, feasible, and reproducible approach.³

Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0128

References

1. Tarchouli M, Ratbi MB, Bouzroud M, et al. Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: A case report. J Med Case Rep 2015;9:276.

2. Staubitz JI, Gassmann P, Kauff DW, Lang H. Surgical treatment strategies for giant inguinoscrotal hernia—A case report with review of the literature. BMC Surg 2017;17:135.

3. Aiolfi A, Cavalli M, Micheletto G, et al. Robotic inguinal hernia repair: Is technology taking over? Systematic review and meta-analysis. Hernia 2019;23:509–519.

4. Escobar Dominguez JE, Ramos MG, Seetharamaiah R, Donkor C, Rabaza J, Gonzalez A. Feasibility of robotic inguinal hernia repair, a single-institution experience. Surg Endosc 2016;30:4042–4048.

5. Coratti F, Trafeli M, Barbato G, Maggioni C, Manetti A, Cianchi F. The gauze technique: A simple method of dissection in laparoscopic inguinal hernia repair. Minerva Chir 2020;75:426–429.

6. Coratti F, Trafeli M, Nelli T, Manetti A, Cianchi F. The gauze technique for a rapid dissection of the pre-peritoneal space in laparoscopic inguinal hernia repair—A video vignette. Colorectal Dis 2020;22:598–599.

7. Anand M, Hajong R, Naku N, Hajong D, Singh KL. Giant inguinal herniae managed by primary repair: A case series. J Clin Diagn Res 201711:PR01–PR02.

“Crush Carving Technique” Using a Soft Coagulation Device: A Simple Method for Successful Laparoscopic Partial Nephrectomy Without Hilar Clamping

Yoshinobu Komai, MD, PhD, Kosuke Hamada, MD, Motohiro Fujiwara, MD, Kasumi Kaneko Yoshitomi, MD, Yudai Ishikawa, MD, Eri Fukagawa, MD, Ryo Fujiwara, MD, Tomohiko Oguchi, MD, PhD, Noboru Numao, MD, PhD, Takeshi Yuasa, MD, PhD, Shinya Yamamoto, MD, PhD, and Junji Yonese, MD, PhD

Department of Genitourinary Oncology, Canter Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.

Introduction: According to recent studies, kidney parenchymal volume preservation was significantly associated with ultimate renal function than hilar clamping in partial nephrectomy (PN) cases.^1,2 Off-clamp PN, however, has a role for chronic kidney disease (CKD) patients, the number of which has been rising.³ We herein describe our new method called “crush carving technique” in laparoscopic PN without hilar clamping.

Materials and Methods: By using a unique output mode called “soft coagulation,”⁴ we have developed a simple and novel method that can achieve both of bloodless operative field and minimal hilar clamping time during laparoscopic PN. The soft coagulation mode can automatically regulate output voltage and the kidney parenchyma can be effectively dissected according to a surgeon's planning with excellent hemostasis even without hilar clamping. Tumor resection was performed as follows: (1) the incision line was determined using intraoperative ultrasound guidance; (2) with a 0.5- to 1-cm margin from the tumor edge, we placed shallow incision of the depth within the renal cortex; (3) the deeper parenchymal area was dissected using crush carving technique with the use of a ball-shaped soft coagulation device, and the tumor was completely excised. In this study, we focused on pre-existing CKD (≥stage 3a) patients because not only remnant renal parenchyma but also reduced ischemia time appears to have a role for functional outcomes.

Results: This case series included six patients who had an imperative indication for PN because of stage 3a CKD as a comorbidity. All patients had a complex tumor of R.E.N.A.L. nephrometry score ≥8. All surgeries using the current technique were effectively completed by a single surgeon (Y.K.) without hilar clamping with satisfactory perioperative outcomes. Decrease in estimated glomerular filtration rate was minimal and progression of CKD stage was not observed in any case.

Conclusion: We present our new method called “crush carving technique,” which can provide both effective dissection and bloodless field in laparoscopic PN. The current technique may be useful especially in patients with pre-existing CKD.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0099

References

1. Simmons MN, Hillyer SP, Lee BH, Fergany AF, Kaouk J, Campbell SC. Functional recovery after partial nephrectomy: Effects of volume and ischemic injury. J Urol 2012;187:1667–1673.

2. Ginzburg S, Uzzo R, Walton J, et al. Residual parenchymal volume, not warm ischemia time, predicts ultimate renal functional outcomes in patients undergoing partial nephrectomy. Urology 2015;86:300–305.

3. Xie Y, Bowe B, Mokdad AH, et al. Analysis of the global burden of disease study highlights the global, regional, and national trends of chronic kidney disease epidemiology from 1990 to 2016. Kidney Int 2018;94:567–581.

4. Sakuragi T, Ohma H, Ohteki H. Efficacy of SOFT COAG for intraoperative bleeding in thoracic surgery. Interact Cardiovasc Thorac Surg 2009;9:767–768.

Modified Bricker Ureteroileal Anastomosis

Seetharam Bhat Kulthe Ramesh, MS, DNB,¹ Nivash Selvaraj, MS, DNB,¹ Kunal Dholakia, MS, DNB,¹ Sanjai Addla, FRCS(Urology),² and Narasimhan Ragavan, MD(Uro-oncology), FRCS(Urology)¹

¹Department of Urology, Apollo Hospitals, Chennai, India.

²Department of Urology, Apollo Hospitals, Hyderabad, India.

Introduction: Radical cystectomy remains to be the standard of care for muscle invasive bladder cancer. In most of the cases, ureteroileal anastomosis is commonly performed using Bricker technique. Here we describe a modified Bricker technique that minimizes anastomotic complications and helps to preserve the ureter vascularity.

Materials and Methods: In our study, 74 patients between January 2011 and January 2018 who underwent modification of Bricker technique at two different centers were analyzed retrospectively. The modified procedure involves an end-to-end anastomosis of the left ureter and an end-to-side anastomosis of the right ureter to the ileal segment. Left ureter was brought on right side of the retrosigmoid. Visible peristalsis, good color with healthy mucosa, and bleeding edges were considered as signs of good vascularity. The analyzed parameters were perioperative and postoperative outcomes.

Results: In this study, the mean operative duration was 307.2 minutes and duration for this step was 15 minutes. No major perioperative complications were recorded. The Single-J was removed between 8 and 10 days after surgery. No patient had ureteroileal anastomotic complications such as leakage or stricture after a median follow-up of 18 months. Recurrence was detected in one patient.

Conclusion: The described ureteroileal diversion is a safe efficacious procedure with low morbidity and may serve as an alternative for the standard Bricker technique. This technique negates our concern about the anastomotic complications and provides excellent functional results.

http://online.liebertpub.com/doi/full/10.1089/vid.2020.0125