VIDEOUROLOGY ABSTRACTS

Abstract

The Vortex Effect in Minimally Invasive Percutaneous Nephrolithotomy

Willian E. Ito, MD¹, Dillon J. Prokop, BS², Crystal Valadon, MD¹, Bristol B. Whiles, MD¹, Donald A. Neff, MD¹, David A. Duchene, MD¹, and Wilson R. Molina, MD¹

¹Department of Urology, The University of Kansas Health System, Kansas City, Kansas, USA.

²School of Medicine, University of Kansas, Kansas City, Kansas, USA.

Introduction: Minimally invasive percutaneous (MIP) nephrolithotomy was initially discredited with assumptions of difficult stone fragment retrieval because of the equipment's smaller size. However, in 2008 Nagele et al. described a hydrodynamic phenomenon that allowed stone retrieval without the aid of endoscopic tools.^1
–3 This study aims to describe the physical principles of the “vortex effect” to better understand its applicability in MIP procedures.

Methods: Two acrylic phantom models were built based on the cross-sectional area (CSA) ratio of an MIP nephroscope and access sheaths (15/16F and 21/22F MIP-M™, Karl Storz^®). The nephroscope–phantom was 10 mm in diameter. The access sheaths had diameters of 14 mm (CSA ratio: 0.69) and 20 mm (CSA ratio: 0.30). The models were adapted to generate hydrolysis, and hydrogen bubbles enhanced flow observation on a green laser background. After calibration, the experimental flow rate was set to 12.0 mL/sec. Three 30-second trials assessing the flow were performed with each model. Computational fluid dynamic simulations were completed to determine the speed and pressure profiles.

Results: In both models, as the incoming fluid from the nephroscope–phantom attempted to move toward the collecting system, a stagnation point (SP) was demonstrated. No fluid entered the collecting system phantom. Utilizing the 14 mm sheath, we observed a random generation of several vortices and a pressure gradient (PG) of 114.4 Pa between the nephroscope's tip and SP. When the 20 mm sheath was examined, a significantly smaller PG (19.4 Pa) and no noticeable vortices were noted.

Conclusions: The speed of the fluid and equipment geometry regulate the PG and the vortices field, which are responsible for the production of the vortex effect. Considering the same flow rate, a higher ratio between the CSA of the nephroscope and access sheath results in improved efficacy of the vortex.

Patient Consent Statement: This is a bench study. No patients were involved in this study. Consent statements are not applicable to this type of study.

http://online.liebertpub.com/doi/full/10.1089/vid.2023.0035

Laparoscopic Heminephrectomy in Crossed Fused Renal Ectopia with Complex Cyst

Moacir Cavalcante de Albuquerque Neto, MD, Thomé Décio Pinheiro Barros Júnior, MD, Nayrton Kalys Cruz dos Anjos, MD, Heron Oliveira Schots, MD, Guilherme Bastos Palitot de Brito, MD, and Fabio de Oliveira Vilar, MD

Urology Clinic, Department of Surgery, Clinics Hospital, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.

Introduction: Crossed fused renal ectopia (CFRE) is a rare congenital malformation, which presents when the kidney is located in the midline fused with the contralateral kidney.^1,2 Clear cell renal carcinoma, although rare, is a condition that can be found in patients with CFRE.³ The vascular anatomy of the kidney is atypical and preoperative radiologic evaluation is important to surgical planning.⁴ Herein, we present a laparoscopic heminephrectomy in a patient with a complex cystic lesion in a CFRE.

Materials and Methods: The patient is a 40 years old woman complaining of dysuria for 2 months. Urinalysis identified microscopic hematuria and ultrasonography showed a 3.9 × 3.5 cm cyst in the right kidney. Contrast-enhanced computed tomography showed CFRE to the right and a Bosniak IV cystic lesion in the right kidney, measuring 7.7 × 6.1 × 5.0 cm. The width of the fused portion of the parenchyma was 3.4 cm. Tc-99m dimercaptosuccinic acid scintigraphy showed mildly decreased relative tubular function in the left kidney. The preoperative estimated glomerular filtration rate (eGFR) was 53 mL/min per 1.73 m². Right laparoscopic heminephrectomy was indicated. To better study the renal and vascular anatomy, an angiotomography was performed. The patient was positioned in the left lateral decubitus. The renal artery and renal vein were clipped using Hem-o-lok^® and then divided. The isthmus was isolated and sectioned with an Echelon^® vascular stapler. An abdominal drain was placed.

Results: The operative time was 130 minutes, with no intraoperative complications. The patient was discharged with preserved renal function. Six months after surgery and with nephrologic follow-up, the eGFR was 63 mL/min per 1.73 m². The histopathologic study showed cystic nephroma.

Conclusion: Laparoscopic heminephrectomy in CFRE is an unusual procedure. Preoperative study of renal and vascular anatomy is recommended. The use of the vascular stapler is an option for sectioning the isthmus.

Ethics Committee: The authors received and filed ethics committee consent for recording/publishing the video.

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.2023.0040

Robot-Assisted Revision of Bilateral Ureteroenteric Anastomotic Strictures

Nirupama Ancha, BBA¹, Safiya-Hana Belbina, MD¹, Sofia Gereta, BA¹, and Aaron Laviana, MD, MBA²

¹Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.

²Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.

Background: The incidence of ureteroenteric stricture (UES) after radical cystectomy is approximately 8%.^1

–4 UES is often managed with long-term indwelling ureteral stents or nephrostomy tubes, both of which can have a negative impact on quality of life and require frequent exchange. In this video, we are the first to describe bilateral robotic-assisted revision of UES in a neobladder with the assistance of Firefly and Indocyanine Green (ICG).

Clinical History: A 66-year-old male underwent an open cystoprostatectomy and open neobladder construction in 2016 due to bladder cancer. Seven years later, he presented with back pain and serum creatinine elevated to 3.5 mg/dL. He had no prior history of radiation.

Physical Exam: Physical exam was significant for an intact midline incision from previous procedures.

Diagnosis: Imaging revealed stable bilateral hydronephrosis from bilateral UES.

Intervention: On presentation, the patient was managed with indwelling nephroureteral stents connected to external drainage. The patient strongly preferred definitive revision to avoid continuous nephroureteral stent exchange. As such, we proceeded with a robotic-assisted revision of bilateral ureteroenteric anastomoses in a neobladder. The surgery began with laparoscopic lysis of adhesions from the previous open procedures. ICG was given through the bilateral nephrostomy tubes to facilitate ureteral and neobladder identification and highlight healthy ureteral tissue. The right ureter was mobilized and resected sharply, and the old ureteral stent was exchanged. The right ureter was then spatulated sharply at the anterior roof, and a cystostomy was made into the afferent limb. A running anastomosis was performed with 4-0 polydioxanone suture and reinforced with 4-0 vicryl suture. The same technique was repeated on the left ureter. Due to the shortened length of the left ureter, it was reimplanted into the top of the afferent chimney, the portion of the neobladder having the most mobility. Bilateral nephrostomy tubes were removed intraoperatively.

Follow-Up/Outcomes: The patient's postoperative course was uncomplicated. His serum creatinine normalized to 2.0 mg/dL. He was discharged home on postoperative day 5 with a foley catheter which was removed 10 days later. Both ureteral stents were removed cystoscopically and at 6 months postoperatively, he remains drain and stent free with a stable creatinine of 2.0 mg/dL. His hydronephrosis has also resolved. Overall, bilateral ureteroenteric anastomotic strictures are a significant complication of radical cystectomy and urinary diversion that are rarely documented. In this video, we are the first to validate the usefulness of a conventional robot-assisted system for simultaneous repair of bilateral UES in a neobladder.

http://online.liebertpub.com/doi/full/10.1089/vid.2023.0031

Donor-Gifted Allograft Staghorn Calculus Managed via Percutaneous Nephrolithotomy

Maria Veronica Rodriguez, MD¹, Octavio Herrera, MD¹, Brett Friedman, MD, MPH¹, Mario Moya, MD², andGaudencio Olgin, MD¹

¹Department of Urology, University of Texas at Rio Grande Valley, Doctors Hospital at Renaissance, Edinburg, Texas, USA.

²Department of Interventional Radiology, Doctors Hospital at Renaissance, Edinburg, Texas, USA.

Donor-gifted lithiasis presents in <1%. Presentation is asymptomatic given allograft denervation, but it can be associated with infections, hydronephrosis, or creatinine (Cr) elevations. Ultrasonography (US) offers the possibility to detect calculi that can be managed during transplantation. However, its use has remained controversial due to the infrequent occurrence of these events, making the benefits of imaging cadaveric kidneys unclear. Historically, the management can be achieved through medical expulsion therapy or any percutaneous procedures. For those stones <1.5 cm, extracorporeal shock wave lithotripsy is commonly used. Retrograde ureteroscopy is challenging since access to the reimplanted ureter is at the dome. For large stones, percutaneous nephrolithotomy (PCNL) is preferred to achieve high stone-free rates. In the past, open or percutaneous procedures were avoided due to high morbidity along with risks of immunosuppression, like poor wound healing.¹ However, multiple series have demonstrated favorable long-term outcomes in patients undergoing PCNL.^2,3 Late diagnosis can lead to graft rejection. The downfall of long-term observation in a denervated kidney is the potential for obstruction, silent hydronephrosis, and pyelonephritis/sepsis in an immunocompromised patient. There are concerns regarding PCNL's safety in immunosuppressed, as the surgery itself results in a grade 4 renal laceration, albeit controlled and targeted. Heterotopic allograft positioning in the iliac fossa creates challenges in obtaining a direct calyceal puncture, increasing risk for vascular injuries. Additionally, immunosuppressives generate an inflammatory capsule surrounding the allograft, which may limit pyelocaliceal dilation and nephroscope manipulation.^4,5 This is a rare presentation of a 53-year-old with a donor-gifted allograft staghorn calculus managed with PCNL. History included polycystic kidney that resulted in renal failure, hemodialysis was for 6 years prior to transplant. Postoperatively, a staghorn and multiple calyceal stones were diagnosed. Computed tomography was essential during planning to avoid inadvertent bowel injury while obtaining abdominal access. Interventional radiology placed two guidewires into the midpole through a 6F × 25 cm Terumo sheath. Intraoperatively, a 0.038″ hydrophilic guidewire was advanced to obtain through and through access given the short skin-to-stone distance and the risk of losing access. A dual lumen was placed over a guidewire following the markers to estimate the skin-to-stone distance and achieve optimal tract dilation. The 30F × 35 cm access sheath was placed, and the 25F nephroscope with a lithotripter was used to fragment stones. The flexible nephroscope with extraction devices were used to achieve a stone-free outcome. One consideration during this procedure is the short skin-to-stone distance in the abdomen compared to the traditional distance when working in the retroperitoneum. It is important to maintain placement of the sheath with the surgeon's nondominant hand to avoid dislodgement. Ultimately, a 6F × 22 cm stent was deployed (due to short ureteral distance). A 22F nephrostomy tube (NPT) was then placed. A 5F re-entry catheter was also inserted with the purpose of facilitating collecting system access for sequential NPT downsizing from a 22F to 10.2F Dawson–Mueller to improve healing. Ultimately, a 3-0 chromic was left untied at the NPT site to improve wound closure by tying it at the time of NPT removal to decrease leakage and enhance comfort. A 16F Foley catheter was also left in place for maximal drainage. Patient was discharged on day 3 voiding freely with NPT clamped (Cr 1.6/glomerular filtration rate [GFR] 34). The stent was removed 3 weeks postoperation. At week 5, the NPT was discontinued with satisfactory urinary output (Cr 1.5/GFR 36). The PCNL is an effective endourological technique for donor-gifted staghorn calculus, the patient was stone-free with no postoperative complications.

Music: The music used in the video is royalty-free from freemusicarchive.org. The title is “Endless story about sun and moon” by Kai Engel.

Patient consent: 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.2023.0041

Radial Artery Free Flap Urethroplasty

Helen H. Sun, MD^1,2, Crystal An, BA², Kirtishri Mishra, MD^1,2, Joseph Khouri, MD^2,3, and Shubham Gupta, MD^1,2

¹Urology Department, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

²Case Western Reserve University, School of Medicine, Cleveland, Ohio, USA.

³Department of Plastic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.

Introduction: Urethroplasty is essential for transmasculine individuals who desire the ability to perform standing micturition. Currently, a variety of techniques are employed, including staged phalloplasty with urethroplasty performed in a subsequent surgery.¹ This staged approach allows for gradual tissue healing, which may reduce the risk of complications such as wound breakdown, urethral fistulae, and infections. Some patients may not desire a functional urethra during initial consultation, or develop complications from their initial phalloplasty. Staged urethroplasty may incorporate a radial artery free flap, buccal mucosa graft, and labia minora flap.^2
–4 In this video, we demonstrate our technique for radial artery free flap urethroplasty (RAU) in an individual with an existing neophallus.

Materials and Methods: The following footage is from a transmasculine individual who had undergone abdominal phalloplasty 6 months prior. Outcomes of other patients who underwent RAU between January 2022 and May 2023 were reviewed. Preoperatively, the patient underwent permanent hair removal, and an Allen's test was performed on the donor extremity to ensure perfusion of the one hand after occlusion of the radial artery. The flap is designed to be 4 cm wide to allow for an tubularized urethra adequate for a 16F catheter, and length 3 cm longer than the existing neophallus to allow for a tension-free anastomosis. Two teams may work simultaneously, one harvesting and tubularizing the radial artery free flap, while the other prepares the existing neophallus. An external oblique fasciotomy is made to access the recipient artery, and a groin incision is used to access the recipient veins. The neophallus is detubularized and debulked as necessary to achieve a tension-free closure. Flap transfer is performed with a surgical microscope, anastomosing the radial artery with the deep inferior epigastric artery and cephalic vein with the greater saphenous system. The ilioinguinal nerve is coapted to the lateral antebrachial cutaneous nerve with the aid of an off-the-shelf nerve allograft. A microdoppler is used to assess perfusion prior to neophallus tubularization and wound closure. In the donor arm, the brachioradialis and flexor carpi radialis muscles are advanced over the proximal ends of the donor arteries, and the wound is covered with a split thickness skin graft. A negative pressure wound dressing is then applied. The ventral abdominal wall defect is closed and reinforced with resorbable polydiaxone mesh.

Results: The patient had an uneventful recovery and was discharged on postoperative day 5. Flushing of the neourethra with normal saline instilled via a small bore catheter into the meatus may be done to help remove debris starting 1 to 2 weeks postoperatively. Three patients have undergone RAU thus far, with follow-up periods of 11, 7, and 2 months. No reoperations or instances of flap failure have occurred. Two patients subsequently underwent neourethral anastomosis, scrotoplasty, glansplasty, and abdominal wound revision after a minimum of 5 months and are currently voiding orthotopically.

Conclusions: RAU appears to be an effective option for transmasculine patients with an existing neophallus without a neourethra, or for those with significant complications from a prior urethroplasty. This staged approach may reduce complications related to wound breakdown, flap failure, and infection.

Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Music Source: Recording of Partita in B-flat major, Hob.XVI:2 (Moderato) by Joseph Haydn, publisher Paris: Ivan Ilić, available under Creative Commons Attribution 3.0 from https://imslp.org.

http://online.liebertpub.com/doi/full/10.1089/vid.2023.0049

Robot-Assisted Simple Prostatectomy with Bladder Neck-Sparing Technique

Narmina Khanmammadova, MD¹, Jacob Basilius, MD¹, Andrei D. Cumpanas, MD¹, Tuan Thanh Nguyen, MD², Christian Im, MS¹, Caroline Nguyen, PA¹, Mohammed Shahait, MD³, and David I. Lee, MD¹

¹Department of Urology, University of California, Irvine, Irvine, California, USA.

²Department of Urology, University of Medicine and Pharmacy Ho Chi Minh City, Cho Ray Hospital, Ho Chi Minh City, Vietnam.

³Surgery Department, Clemenceau Medical Center, Dubai, United Arab Emirates.

Introduction: Benign prostatic hyperplasia (BPH) is the most common benign tumor in men in the United States and one of the most common causes of lower urinary tract symptoms.¹ Several modalities are utilized to manage BPH surgically including vaporization, laser enucleation of the prostate (LEP), and open, laparoscopic, and robotic-assisted simple prostatectomy (RASP). RASP is endorsed by American Urological Association (AUA) guidelines for patients with large (>100 mL) and very large prostates (>150 mL) as it has favorable outcomes including low perioperative morbidity rates, blood loss, transfusion rates, and short recovery time.^2
–4 The learning curve is significantly shorter with RASP compared to LEP.^4,5 RASP can also be utilized with same-day discharge pathway reducing the cost of care and healthcare burden.

Here we describe our bladder-neck sparing technique for RASP with emphasis on intraoperative technical aspects to hasten the recovery and avoid the use of continuous bladder irrigation.

Methods: Data were prospectively recorded from 24 patients who underwent outpatient RASP from September 2021 to March 2023 following the IRB approval. Patient demographics, preoperative, perioperative, and postoperative outcomes were collected. All patients followed an enhanced recovery after surgery protocol.

Results: The mean age was 71.5 ± 7.8 years, mean body mass index was 28.8 ± 4.5 kg/m², median preoperative Prostate Specific Antigen (PSA) was 5.9 (3.1–11) ng/mL, median preoperative AUA score was 20 (13.5–28.25), and 9 patients (37.5%) were in retention, median prostate size was 135 (101.5–158) mL, mean operative time was 138.3 ± 39.8 minutes, mean console time was 78 ± 20.1 minutes, estimated blood loss was 100 (50–100) mL, median weight of the removed specimen was 72.4 (47.1–95.1) mL, median hospital stay was 157 (116.5–180) minutes, median length of catheterization was 7-days. There were no perioperative complications, blood transfusions, conversions to open, or need for continuous bladder irrigation. Twenty-one (87.5%) patients were discharged home on the day of surgery. The median pain score at discharge time reported by 15 patients was 3 (0–5). Only 3 (25%) of 12 patients reporting on pain management needed to use opioids.

All patients were able to urinate after the catheter removal. One patient was readmitted for blood clot retention due to strenuous exercise at 3-weeks postoperatively (Clavien Dindo class II).

Incidental cancer (Gleason Score 3+3) was found in one patient (4.2%) who is now managed by monitoring the PSA levels every 3 months. The median postoperative 3-month PSA was 0.8 (0.48–1.65) ng/mL. Twenty patients reported their postoperative 3-month urinary continence status, and all of them were continent. The median postoperative 3-month AUA score reported by 15 patients was 5 (3–11). Only one patient needed reintervention postoperatively due to slowing of the urinary stream as he had a urethral mucosal flap from preoperative catheter injury.

Conclusions: Outpatient RASP is safe with the described technique and is an excellent option for men with enlarged prostates while also eliminating routine hospital stays.

Patient Consent Statement: Author(s) have received and archived patient consent for video recording/publication in advance of the video recording of the procedure.

http://online.liebertpub.com/doi/full/10.1089/vid.2023.0051

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