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Flexible Ureteroscopy-Directed Retrograde Nephrostomy for PCNL

We herein describe flexible ureteroscopy-directed retrograde nephrostomy access using a puncture wire to achieve renal access. This is a natural extension of modern retrograde intrarenal surgical techniques and a modernization of the original Lawson technique for retrograde nephrostomy tract creation. In appropriately selected patients this approach is safe, easy to learn, and permits reduced radiation exposure.

A Retzius-sparing technique for robot-assisted laparoscopic radical prostatectomy: the Bocciardi approach

Robotic-assisted laparoscopic sacrouteropexy for bladder exstrophy

WCE

Techniques for potency preservation during robotic-assisted radical prostatectomy (RALP)

wce

Laparoscopic transvesical diverticulectomy

Orthotopic bladder substitution in women

Percutaneous renal stones extraction using suction through the nephroscope

Objectives: we present a video of a suction technique used during percutaneous renal surgery, for extraction of small stones, debris, or clots.
Materiel and methods: The nephroscope is used as a suction device by adapting the suction tube to the nephroscope operating channel. In the meantime, the irrigation tube is permuted from the irrigation channel to the drainage one. The vacuum technique is a sequence of 2 stages. It begins with a short phase of suction. Then the suction is stopped by closing the suction tube, to allow the expansion of the renal cavities. Simultaneously, the nephroscope is moved around in the renal cavities like a vacuum cleaner. The stone fragments are swiftly aspirated through the working channel of the nephroscope under direct vision.
Results: this technique is used with the first introduction of the nephroscope to remove blood clots, pus, and troubled urine in order to have a good visibility. Different fragments size can be extracted with the vacuuming technique. The smaller ones, up to 5 mm, are evacuated through the nephroscope working channel and recuperated in the aspiration container. Larger fragments, which can pass through the Amplatz sheath, can be dragged outside following the nephroscope using continuous aspiration. It is used, combined to aggressive nephroscopy, at the end of the PCNL procedure by doing a systematic sweeping of all the reachable pelvicalyceal system with rigid nephroscope, to remove all the clots, sand debris, and dust. This vacuuming method is the technique of choice for removing matrix stones.
Conclusion: This technique provides the greatest chances to have a “stone free” status, from even the fine sand debris.

Another Application of Natural Orifice Transluminal Endoscopic Surgery (NOTES): Transurethral Transvesical Approach to a Retrovesical Hydatid Cyst (SIU 2009)

Objective: Usually, open surgery is the recommended treatment of hydatid cyst. We present a novel technique for the treatment of a retrovesical hydatid cyst using a transurethral transvesical approach.
Material and methods: Mr. M. A. 57 years had a retrovesical hydatid cyst diagnosed by ultrasound, for irritative bladder symptoms (LUTS), confirmed by CT scan and serology test. He had received 800 mg daily of albendazole during 3 months prior to operation.
Operative technique: under spinal anesthesia, cystoscopy was performed using a 20.8 Fr nephroscope. The cyst was punctured using 18-gauge 36 cm needle, passed through the nephroscope operating channel. A 20 % saline solution was used as a scolicidal agent. The tract was dilated using balloon dilation over a guide wire. Then, the nephroscope was introduced into the cyst, and the hydatid material was aspirated. The cystic cavity and the bladder were drained using respectively a 14 Fr Foley catheter and 18 Fr Foley catheter. Postoperatively, the cystic cavity was treated by instillation of iodine-povidone during 5 days.
Results: endoscopic treatment of retrovesical hydatid cyst was possible in 40 min. no complication was noted postoperatively. The patient had an uneventful discharge and had continued albendazole chemotherapy during 3 months. At 3 months postoperatively, cystoscopy confirmed a complete healing of the communication between the bladder and the cystic cavity. After two years of follow-up with ultrasound and CT scan, the patient was free of symptoms with no evidence of residual or recurrent disease.
Conclusion: This transurethral transvesical approach was effective for the treatment of a retrovesical hydatid cyst with lower morbidity than open surgery, and confirmed that the bladder can be used as a portal to NOTES with no complications.

Retroperitoneal laparoscopic living donor nephrectomy

Laparoscopic management of incisional hernias at the site of extraction after robotic prostatectomy (SIU 2011)

Extraperitoneal robotic prostatectomy: Technique and comparison to transperitoneal approach (SIU 2011)

Complications during robotic radical prostatectomy (SIU 2011)

Recognition and management of rectal injury during laparoscopic or robotic radical prostatectomy (SIU 2011)

Laparoscopic anatrophic nephrolithotomy technical modifications with reduced ischemia time (SIU 2011)

Laparo-endoscopic single site transvesical bladder cuff excision (SIU 2011)

NOTES Hybrid transvaginal upper pole heminephrectomy copia (SIU 2011)

Laparoscopic partial nephrectomy - "zero ischemia" technique with controlled hypotension (SIU 2011)

Robotic repair of complex vesicovaginal fistulae II (SIU 2011)

Robotic repair of complex vesicovaginal fistulae (SIU 2011)

Complications of minimally invasive radical cystectomy (SIU 2011)

COMPLICATIONS OF MINIMALLY INVASIVE RADICAL
CYSTECTOMY
Rene Sotelo*, Caracas, Venezuela, Erik Castle, Phoenix, AZ,
Octavio Castillo, Providencia, Chile, Camilo Giedelman, Matteo
Spinelli, Jose Saavedra, Robert De Andrade, Oswaldo Carmona,
Caracas, Venezuela, David Canes, Boston, MA, Carlos Rodriguez,
Caracas, Venezuela
INTRODUCTION AND OBJECTIVES: Open Radical Cystectomy is
the standard treatment for high grade and muscle invasive bladder
cancer, with the significant potential of early complications even in
the most experienced hands and in high volume center. Over the
last decade, we have witnessed the emergence and progression of
minimally invasive surgery in urology including radical cystectomy.
Any new technique applied to the treatment of invasive bladder
cancer must be safe, maintain similar oncological principles as
ORC, and provide similar options for lower urinary tract
reconstruction. While many complications of radical cystectomy are
shared between approaches, recognition and management in the
robotic and laparoscopic surgery environment poses unique
challenges. The goal of this video is to present graphic illustrations
of complications during robotic or laparoscopic radical cystectomy.
METHODS: A multi-institutional collection of surgical videos was
compiled. These videos illustrate vascular injury, rectal injury,
benign ureteral strictures and the presence of vesicovaginal fistula
after surgery. Management techniques are illustrated where
appropriate.
RESULTS: This video shows the possible complications and how
often they are encountered, comparing the different approaches,
open, laparoscopic and robotic. In addition, short and middle term
complications in patient after Minimally invasive Radical Cystectomy
are characterized.
CONCLUSIONS: RARC and LRC must reproduce the robust
oncological outcomes seen with ORC while attempting to minimize
perioperative morbidity.
RARC and LRC incurs acceptably low postoperative morbidity, with
the vast majority of complications being low grade. High-grade
complications are infrequent and similar to those encountered after
ORC. Complications are similar in all approaches, but may be
surgeon or technique related. Early recognition and appropriate
management is essential when these complications occur.
Source of Funding: none

Expanding indications of transvesical LESS surgery (SIU 2011)

Extra-peritoneal robot assisted radical prostatectomy revisited (SIU 2011)

Introduction and objectives:
Robot assisted laparoscopic prostatectomy is being increasingly performed via the transperitoneal route. The extraperitoneal approach has been deemed to be more technically challenging in view of the limited working space. Herein we report our initial experience with the extraperitoneal approach.

Material and Methods
13 patients underwent robot assisted extraperitoneal laparoscopic prostatectomy. The mean age was 68.33 years. The median PSA was 6.5. Five patients had history of previous TURP and one patient had undergone a laparoscopic cholecystectomy in the past. All procedures were performed with the da-Vinci S surgical system. A five port technique was used. Patients were placed supine with 200 Trendelenburg tilt. A 1.5 cm transverse incision was given at the level of the umbilicus. The extraperitoneal space was developed behind the posterior rectus sheath first by blunt finger dissection and later by balloon inflation. A 12 mm camera was placed through this port followed by the insertion of 8mm robotic ports (8cm from the camera port) along the spino-umbilical line and the right and left hand assistant ports (12mm and 5mm respectively) just above the anterior superior iliac spines on either side. After incision of the endopelvic fascia and ligation of the DVC complex, the rest of the procedure proceeded along the lines of the transperitoneal approach. Pelvic lymphadenectomy was performed in one patient who had a biopsy gleason score of 4+4 and PSA value of 42ng/ml.

Results
The mean time required for creation of the extraperitoneal space was 12 mins. The mean console time was 88 min. The mean estimated blood loss was 75ml. None of the patients required blood transfusion. Soft diet was started 6 hours after surgery and patients were ambulatory from the evening of the surgery. The drain was removed on the morning of the first post-operative day in all patients.

Conclusions
For surgeons well versed in the transperitoneal approach the extraperitoneal route is the logical next step to minimize the invasiveness of the robotic approach further by avoiding peritoneal violation. This most closely mimics the traditional open approach and is both safe and feasible.

Hybrid laparoendoscopic single site radical prostatectomy (SIU 2011)

Hybrid minimally invasive urethroplasty for pan anterior urethral strictures (SIU 2011)

Introduction and objectives: Pan anterior urethral strictures are difficult to manage. Urethra in such cases is fibrotic and ischemic. Herein we describe our minimally invasive hybrid technique for treating pan-anterior urethral stricture and its results.
Material and methods: From Feb. 2009 till Jan. 2011 six patients with pan-anterior urethral stricture were operated in our unit. The mean age was 36(28-51) years with mean stricture length of 14.23 cm. Three of these were catheter induced and three were due to BXO. The patients were operated in the lithotomy position. A small vertical perineal incision was made. A unilateral mobilisation of bulbospongiosus muscle was carried out. A full thickness deep visual internal urethrotomy was made employing cold knife using pediatric /adult urethrotome to reach corpus cavernosum as the graft bed. A 14-16 cm long, 15-16 mm wide buccal mucosa graft (5 patients)/ lingual mucosa (1 patient) was harvested. A 2.5 cm dorso- lateral urethrotomy was done in the proximal bulbar urethra. The graft was incorporated in the urethra through the meatus and slid into an exact position till the urethrotomy ( as demonstrated in the video). The graft was sutured dorsally at the site of urethrotomy with 3-4 fixation sutures on one (left) side. A 16 fr. Foleys catheter was placed over the pre-placed guide wire. The other (right) edge of the graft was now sutured to the right edge of the urethrotomy. The graft was then sutured distally at the meatus along with meatoplasty. A meticulous pressure dressing was done to stabilise the graft on its bed for the next seven days.
Results: None of the patients developed oral complications. One patient developed perineal wound infection. Rest of the patients had uneventful convalescence. The Foleys catheter was removed after three weeks. Our mean follow up time is 11(2-24) months. All patients are voiding well following surgery with no adjuvant procedures.
Conclusions: Our hybrid technique provides good initial results. It combines benefits of minimal urethral mobilisation and optimal graft fixation while preserving the vascularity of the urethra.

Robotic assisted inguinal lymph node dissection (RAILND) (SIU 2011)

Introduction and objective:
Penile cancer with inguinal lymph node metastases is a common cancer in India.
Open inguinal lymphadenectomy is the gold standard to treat inguinal lym ph nodes.
We report the use of RAILND in two patients presenting with palpable lymph nodes
which to our knowledge is the first reported case series from India.
Material and m ethods:
The patients were placed in the supine position with the ipsilateral leg abducted and
padded and contralateral leg kept straight. A 2-cm transverse incision was made
approximately 25 cm inferior to the midpoint of inguinal ligament to develop the
subfascial space just deep to Camper’s fascia(as shown in the video). A blunt tip
balloon trocar was used for the midline robotic cam era port (0°).The two robotic
ports(8 cm away from camera port in a triangular fashion) and a 12-mm assistant
port was placed in between the camera and lateral robotic port. The da Vinci S
robotic system was docked at 30° to the contralateral thigh. The surgical approach
simulated the principles of open techniques. The dissected superficial and deep
nodal package were entrapped separately and removed with preservation of
saphenous vein. Tisseel® (Baxter, Deerfield, IL) was applied to the surgical bed
following dissection.
Results:
The total operative time was 90 -110 minutes with estimated blood loss of 50- 100
mL. The patient underwent dissection of the contralateral side (right) after 2 days in
the same admission. The patients were discharged home on postoperative day 2
with advice regarding drain care and 1-week course of oral antibiotics. No
postoperative complications developed. The indwelling drain was removed 10 days
after surgery when the output was less than 50 mL/24 hours. Pathologic examination
revealed no metastatic involvement in superficial and deep lymph nodes on left side
while 4 lymph nodes were having metastases on right side in case 1. In case 2 two
lymph nodes were positive for metastases on the left side.
Conclusions:
We believe that RAILND is an efficacious and safe procedure with minimal morbidity
and has a place in managing penile carcinoma patients in India. It also opens a new
chapter in the extended use of robotics in urology thus reducing cost and increasing
its m ultidimensional applicability.