iclinics.org

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.

Bilateral simultaneous laproendoscopic single site surgery (LESS) pyeloplasty in a 4 month old child (SIU 2011)

Introduction.
Reports regarding LESS in infants are scant. Reconstructive procedures in these small patients are accompanied with difficulties in suturing and need for smaller instruments. In this video we demonstrate a case of simultaneous bilateral LESS pyeloplasty in a 4 month old child.

Material and methods
The 4 month old infant presented with antenatal detected bilateral hydronephrosis with proven obstruction on diuretic renogram. The patient was planned for simultaneous LESS pyeloplasty. Standard laparoscopic instruments were used with the R-port TM as the access port. The Olympus endoeye TM camera was used for the purpose. An Antegrade ureteric splint was placed preoperatively .

Procedure:-
An Antegrade ureteric splint was placed prior to pyeloplasty An ultrasound guided percutaneous renal access was obtained. Telescopic metal two part needle was passed into the kidney over a guide wire. A second guide wire is passed through the Telescopic metal two part needle. The tract is dilated with 14 Fr screw dilator. Over one guide wire, a 5 Fr ureteric catheter is passed and coiled in the renal pelvis. Over the other wire, a 14 Fr Malecot catheter is placed as Nephrostsomy.
The same procedure was repeated on the other side. A R-port was inserted through a umbilical skin crease incision. The right side was done first. The Ureteropelvic junction was dissected. A Anderson Hynes pyeloplasty was performed with reduction. The ureteric catheter placed prior was not in proper position on the right side hence an intraoperative DJ was placed. On the left side a similar procedure was repeated. The ureteric catheter placed Antegrade preoperatively was passed into the ureter after the posterior wall suturing was completed.
Conclusion:
This video demonstrates the feasibility of LESS in children as young as 4 months of age. The video also demonstrates that Ultrasound guided ante grade nephroureteral ureteral splint for infant laparoscopic pyeloplasty is safe. It avoids the need for urethral instrumentation for insertion and removal of stents in these small patients

Laparoscopic ileal conduit: an intracorporeal ureteroileal anastomotic technique (SIU 2011)

Initial experience with the reusable X-cone single port system for laparoscopic urologic procedures (SIU 2011)

Introduction and Objective: LESS is gaining popularity for minimally invasive urologic procedures. Despite the known benefits of LESS, most systems use disposable material, thus reducing cost effectiveness. We tested the applicability of the newly developed reusable X-Cone system for basic urologic procedures.

Materials and Methods: We herein present our initial experience with the Storz® X-Cone single port system for pelvic lymphadenectomy (PL; n=8) in prostate cancer patients prior to radiation therapy, for marsupilalization of large renal cysts (CM; n=2), for simple nephrectomy (NE; n=2) of non-functional atrophic kidneys and for left varicocelectomy in adults (VE; n=12). The Storz® X-Cone single port consists of two L-shaped steel half shells that are connected to an autostatic X-shaped funnel. A silicone rubber cap with four 5 mm and one 12.5 mm working channels is used for sealing. A rigid 5 mm 30° laparoscope is used together with a curved and a straight laparoscopic instrument. A second curved instrument can be inserted for static retraction.

Results: Mean follow-up was 12 weeks. Mean patient age and BMI was 73 years and 28 in the PL group, 66 years and 27 in the CM group, 64 years and 27 in the NE group and 26 years and 24 in the VE group. A transumbilical incision was used in the PL and VE group. A medioclavicular paraumbilical incision was used in the CM and NE group. The incisional length was approx. 5 cm for NE and 2.5 cm for all other procedures. Mean operating time was, 109 min for PL, 67 min for CM, 121 min for NE and 47 min for VE. Blood loss was < 50 ml for all procedures. In PL and NE an additional 3 mm port was routinely used. In one case of NE conversion to conventional laparoscopy was necessary due to CO2 leakage at the port insertion site. In the PL group the average yield of pelvic lymph nodes was n=10. In the VE group the testicular artery was preserved. No postoperative complications occurred and cosmetic outcomes were favorable in all patients. Hospital stay was 1 day in the VE group and 2 days in all other groups. Technical limitations include CO2-leakage through the 5 mm working channels and crowding of instruments while using a second curved grasper for static retraction.

Conclusion: The reusable Storz® X-Cone single port is safe, easy to handle and cost effective for standard urologic procedures. Minor technical flaws need to be addressed before expanding the use of this promising LESS system.

Percutaneous nephrolithotomy (PCNL) in patient with severe spinal deformity (SIU 2011)

BACKGROUND AND PURPOSE: To assess the feasibility and efficacy of percutaneous nephrolithotomy (PCNL) in patient with spinal deformities.
PATIENTS AND METHODS: A 70 years old severe kyphotic male presented with left renal and bladder calculus. He was cardiorespiratory compromised. Under local anaesthesia and propped up position bladder stone was removed with flexile cystoscope . Ureteric catheter was passed in the left pelvicalyceal system. For PCNL neither prone nor supine position was possible, so patient was turned to right lateral position and under local anaesthesia USG guided access was made and stone completely cleared. No DJ stent was kept as removal would require flexible cystoscopy. Nephrostomy was removed on 2nd postoperative day.
RESULTS- Patient tolerated the procedure well. Only two doses of analgesic required in postoperative period. There was no complication and hemoglobin drop was 0.5 mg %.Patient was discharged on 3rd postoperative day in satisfactory condition.
CONCLUSION: PCNL in sever spinal deformity require proper preoperative planning and procedure is safe in experienced hand

Micro PCNL: The new cutting edge technology in renal stone (SIU 2011)

Introduction: PCNL has been widely established as a standard technique for treatment of renal stones. Now further technological advancement has made it possible to manage the renal stones by decreasing the tract size to micro levels.

Materials and Methods: We demonstarates the technique of micro PCNL which employs use of special set of micro-instruments which is a three part 5.5 Fr optical needle housing 0.8mm flexible fibreoptic telescope for direct visualisation during puncture.As in standard PCNL,cystoscopy and ureteric catheter is passed on operating side and patient turned to prone position. After puncturing the stone bearing calyx,three way connector is attached to micro needle through which irrigations,telescope and laser fibre is introduced for fragmentation of stone. Another 8 Fr sheath is also used in case lithoclast is used to fragment the stone.After complete clearance DJ is placed and no nephrostomy kept.

conclusion: Micro-PCNL is a new technological advancement with potential of reducing morbidity associated with conventional PCNL in selective cases.

A novel intra-corporeal knotting technique for laparoendoscopic surgery (SIU 2011)

A Novel Intra-corporeal Knotting Technique for Laparoendoscopic Surgery

Philippe Grange, Paul Rouse, Amrith Rao, Anya Kypke,

London, United Kingdom

INTRODUCTION AND OBJECTIVE:

Laparoendoscopic Single Site (LESS) urological procedures are gaining popularity across the globe. Most reported series/case reports of reconstructive LESS urological procedures such as partial nephrectomy and pyeloplasty describe the use of an additional port (2- 5mm) to aid dissection and to accomplish an intra-corporeal knot. We will demonstrate with this high-definition video, a step-by-step guide to achieve complete intra-corporeal knotting technique on the box trainer and subsequently the application of this technique to complex urological reconstructive procedures, in this case of laparoscopic partial nephrectomy.

MATERIALS AND METHODS:

Initial design of the knotting technique and proof of concept was on a box trainer. A commercially available single port device along with the needle holder and a grasper are used to demonstrate the knotting technique. Along with the video, clear illustrations that can be easily understood and reproduced by others will be shown. We have since applied this technique for complex LESS reconstructive procedures such as no-clamp partial nephrectomy and pyeloplasty.

RESULTS:

As demonstrated in the illustrations and the video, step one of the knotting involves the needle within the needle holder to rotate three times in a clockwise direction. This forms three loops around the shaft of the needle holder. The needle is then transferred across to the grasper, which frees the needle holder to grasp the short end of the suture. The knot is tightened by a push and pull method as opposed to the horizontal method that can be achieved in the traditional multiport laparoscopic technique. The knot is further secured by repeating the above steps in the opposite direction.

CONCLUSIONS:

We have demonstrated with the video demonstration a complete intra-corporeal knotting technique that can be utilized without the need for any additional port or clip devices achieving LESS procedure. This technique will be useful for pure LESS procedures such as such as partial nephrectomy, pyeloplasty and other reconstructive urological operations.

AH-1 stone removal system to treat bladder stones (SIU 2011)

AH-1 Stone Removal System to Treat Bladder Stones

Aihua Li, Binghui Zhang，Honghai Lu, Sikuan Liu, Feng Zhang, Xiaoqiang Qian， Hui Wang and Wei Fang

Department of Urology, Yangpu District Central Hospital, Shanghai 200090, China

Purpose：To recommend AH-1 Stone Removal System (SRS) and introduce the structure and function to treat bladder stones.

Materials: SRS is composed by illuminant and imaging component, continuous-flow component, a jaw to grab and extract stone, lithotripsy tube, handle and sheath. During surgical procedure, SRS was inserted into bladder to search stone, first stone was grabbed and fixed using jaw，then lithotripsy was performed with holmium laser or pneumatic lithotripter through lithotripsy tube. Fragments could be extracted using jaw through sheath synchronously. If there were more residual small fragments, Ellik evacuator could be connected with sheath to wash out them.
The device was designed by Aihua Li, M.D. and manufactured by Hangzhou Tonglu Shikonghou Medical Instrument Co.,Ltd,China.

Results:
In the experiment in vitro, sphere larger than 60 mm in diameter can be fixed with jaw, sphere less than 15 mm can be grabbed directly and sphere less than 8 mm can be extracted through sheath. Inner diameter of sheath is 8.2 mm and lithotripsy tube is 1.4 mm. The jaw, like a ring in longitudinal, is located at the front of objective lens and open downward, and the central part still is a circular cavity when it is closed. The lithotripsy tube is located at the lower edge of objective lens, which facilitates fragmentation in direct vision. Two jaw pieces are frame-shaped, which is favorable to grab and fix stone. Two little bars are installed at the far end of jaw so that it can be used to extract stone fragments through sheath as a trawler and more fragments can be extracted at one time. On other hand, Ellik evacuator can be connected with sheath to wash out small fragments. The principle of swing flow is applied in design，which makes the device can collect fragments automatically. In stone fragmentation, holmium laser fiber or pneumatic lithotripter probe can be transited through lithotripsy tube to crush stone.
Between January 2008 to July 2010, 37 cases of bladder stone were successfully treated by SRS.

Conclusion: SRS is a novel endoscope with multiple functions to treat bladder stone. Our study shows that multiple functions such as fixing stone, crushing stone, automatically collecting stone, extracting stone, washing out stone and continuous-flow can be expected in cystolithotripsy. Especially, it can be used to automatically collect stone by swirling flow and extract more stones by jaw through sheath at one time, which can reduce stone removal time and surgical damage to urethral mucosa.