Hitch Stitch Research Articles

Increase in robot assisted operating room efficiency: A quality improvement study

Pyeloplasties are time-sensitive, and the most common robot assisted intervention performed in pediatric urology. Early intervention is intended to avoid permanent loss of renal function with negative long-term effects if surgery is delayed when indicated. A need to increase capacity has become a premium value in patient care. Our aim was to reduce operative time, providing value by reducing total robotic console time in robot assisted pyeloplasty (RP) cases. We hypothesized that process improvement and supply management during RP leads to a significant reduction in operative time. Intraoperative surgical workflow was reviewed and routine tasks performed during the various sections were selected with the goal of reducing Operating room inactivity. We focused on robotic arm activity, and total operative time to assess our outcomes. Our intervention was to standardize an OR staff task list, a priori supply inventory procurement for each anticipated major step in the case, confirmed prior to each major step. Baseline RP duration data for a single Pediatric Urologist were identified and recorded before any interventions. A clinical standard work (CSW) was developed based on optimization of equipment/supplies for the RP procedure, compartmentalized into the 8 key steps for RP. These major steps included: patient positioning, docking, retroperitoneal and ureteral dissection, hitch stitch, pyelotomy, stent placement, and anastomosis. Balancing measures included percentage trainee console use, preparatory time, and OR block start/end time. Baseline data for RP cases performed between 11/2020 and 2/2022 were automatically extracted from charts and analyzed using AdaptX (Seattle, WA). Post-intervention was between 3/2022 to 3/2023. Mann-WhitneyU was used for continuous variables for non-parametric distribution. 37 patients underwent RP during the study period. 15 cases were performed prior to intervention and 22 post intervention Total console time prior to intervention was 152 vs 109min after intervention (p=0.0002). Dual instrument inactivity was reduced from 13.1% to 7.1% (p<0.0001). Dual consoles were used in 40% vs ∼69% pre-vs post-intervention, respectively (p=0.5000). No difference in patient age distribution between groups was seen (p=0.1498). Trainee operative time did not differ statistically pre- and post-intervention (63.0 vs 48.6%, p=0.0871). Decreasing surgical lapses and standardizing intraoperative tasks can result in more efficient case completion, potentially increasing OR capacity.

External Fixation of Upper Tracheal Stents in Complex Stenosis: Revising the "Hitch Stitch".

External Fixation of Upper Tracheal Stents in Complex Stenosis: Revising the "Hitch Stitch".

Thoracoscopic repair of congenital diaphragmatic hernia in neonates: Tips and tricks learned from an institutional experience.

Congenital diaphragmatic hernia (CDH) is an anomaly with significant morbidity in neonates. It has been traditionally managed by an open approach with a recent trend toward a minimally invasive approach. This is a retrospective study of our institutional experience with neonatal thoracoscopic management of CDH, with the impact of few technical nuances. The data was collected on neonatal thoracoscopic CDH repair between January 2015 and December 2018, in terms of the demographics, intra-operative parameters, post-operative status, recurrence, and mortality. While analyzing data, we found few technical modifications adopted by the surgeon such as trimming the margin of the defect, use of prosthetic mesh overlay reinforcement for repairs under tension, and to prefer extra-corporeal knotting along with higher placement of trocar, temporary increase in CO2, maximal use of muscle relaxant, extra-corporeal corner hitch stitch at some point, and continuation for further cases. An internal comparison was made to analyze the technical modifications influencing the outcomes, by dividing them into two groups, those with (group A) and without modifications (group B). The data was analyzed using SPSS software (IBM, Version 23). A P value of <0.05 was considered statistically significant. Out of 45 newborns 64.4% were males with an average birth weight of 2.6 kg. Baseline variables were comparable between the groups. The operating time significantly reduced after a higher-level camera port was used (P-value: 0.0001). The mean follow-up was 30.8 months. There were totally seven recurrences (6 in group A and 1 in group B), all within 12 months. Seven parents gave the overall post-treatment feedback as "unsatisfied". The operating time, recurrence rate, and parental satisfaction feedback were significantly less in group B (P-value: 0.001). We recommend trimming the margin of the defect, use of prosthetic mesh overlay reinforcement for repairs under tension, and to prefer extra-corporeal knotting along with higher placement of trocar, temporary increase in CO2, maximal use of muscle relaxant, extra-corporeal corner hitch stitch to reduce the operating time, and recurrence after thoracoscopic CDH repair.

A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency

The transition from laparoscopic to robot-assisted procedures leads to potential increase in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively study the learning curve to detect significant changes in operative timing and monitor complication rates. The objective of this study is to investigate the total and step-specific times for pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a single surgeon transitioning from laparoscopic to RAP. This prospective cohort study included 50 consecutive RAP procedures performed since the inception of our robotic program from June 2013 to January 2019. The CUSUM of RAP total operative time (OT) was calculated to determine the breakpoints between learning phases using piecewise linear regression. Cumulative-observed-minus-expected failure chart with 80% and 95% reassurance boundary lines was constructed using 5% acceptable and 10% unacceptable complication rates. Step-specific operative times were prospectively recorded by an independent observer for port placement, dissection and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port removal. Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2±46.0min. There was a significant difference in the mean OT between Learning (203.9±35.3min, the initial 13 cases), Proficiency (159.2±18.6min, the middle 16 cases), and Competency (126.6±19.7min, the last 21 cases) phases (p<0.001). The complication rate for RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at 8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency. Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant decrease in OT. Complication rates remained within acceptable limits throughout, indicating that RAP can be safely adopted, even in low volume RAP centres. Suturing competency seems to be a significant advantage of the robotic platform as suggested by early significant decrease in suturing times noted between the Learning and Proficiency phases. Future studies can confirm these findings and establish reference operative times to aid surgeons and trainees transitioning from laparoscopic pyeloplasty to RAP. Moreover, total OT decreases significantly and relatively soon after transition to RAP.

Double hitch stitch is a novel technique for fixation of tracheal stent in a case of tracheoesophageal fistula: a case report

BackgroundCaudal tracheal stent migration can be potentially life threatening by causing distal luminal obstruction. We present a rare double hitch stitch procedure (for prevention of migration of tracheal stent), which is an external fixation technique in a case of tracheoesophageal fistula with tracheal and esophageal self-expandable metallic stent (SEMS).Case presentationA 50-year-old male patient who presented with cough and dyspnea was a known case of carcinoma of the esophagus with esophageal stent in situ. Computed tomography (CT) scan showed tracheoesophageal fistula with esophageal stent (esophageal SEMS) migrating into the trachea. Tracheal stenting was done with SEMS. Patient was followed up after 1 month with recurrent complaints of cough on deglutition. On follow-up bronchoscopy, migration of stent was observed. A rare procedure of double hitch stitch was performed with fixation of the tracheal stent (tracheal SEMS) using a percutaneous anchoring stitch, embedded in the subcutaneous tissue. Follow-up bronchoscopy after 1 month of the procedure showed no migration of stent.ConclusionFor the treatment of large tracheoesophageal fistula, stenting of both the trachea and the esophagus along with the double hitch stitch proved to be lifesaving. Stent migration prevention using “double hitch-stitch” is simple, safe, and successful, without any complications.

Educational Value of YouTube Surgical Videos of Pediatric Robot-Assisted Laparoscopic Pyeloplasty: A Qualitative Assessment

Introduction: Surgeons and residents report using videos to prepare for procedures, with a preference for open access resources, specifically YouTube. The educational quality of online videos is uncertain. Videos are uploaded without quality assessment, and ranked by popularity. This study aims to better characterize the available pediatric robotic pyeloplasty videos on YouTube, and assess for conformity to LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS). Methods: The most viewed videos of "pediatric robotic pyeloplasty" on YouTube were reviewed for baseline characteristics, educational content, inclusion of critical domains of the procedure (positioning, ports, exposure, ureteral mobilization, renal pelvis dissection, hitch stitch, spatulation, and anastomosis), and conformity to LAP-VEGaS. Results: Once ranked by views, 23 videos met inclusion criteria. Views per video ranged from 40 to 15,664 (mean of 1912). The two oldest videos were uploaded in 2009, and had the highest number of views. Audio and written educational content accompanied videos, 22% and 48% of the time, respectively. United States and India were the most common countries of origin. Only six videos contained all critical steps of the procedure. No videos contained all 16 points of the LAP-VEGaS essential checklist (mean 7.6), and most videos neglected preoperative information and outcomes. Percentage conformity was 48% overall (range for each video was 25%-81%). The most viewed videos were not associated with higher conformity to LAP-VEGaS. Conclusions: Despite studies demonstrating preferences for YouTube videos as an educational tool, and pyeloplasty being the most commonly performed pediatric robotic procedure, there are currently few high value educational videos available on YouTube. Videos often lack important procedure domains, and demonstrate low conformity to LAP-VEGaS guidelines. This demonstrates an opportunity to improve the educational quality and value of open access videos, starting by adopting established video reporting guidelines.

Robot-assisted laparoscopic midureteral stricture repair and percutaneous stent placement in an infant

Mid-ureteral strictures in infants are a rare cause of hydronephrosis. In this surgical technique video we demonstrate a repair of a mid-ureteral stricture using a robot- assisted laparoscopic approach to mobilize and excise the stricture using the assistance of a hitch stitch as well as placement of a percutaneous stent. This technique was easily performed and successful for this patient.

Spinal Cord Suspension Using Dentate Ligament Hitch Stitches: A Novel Technique for the Repair of Ventral Spinal Cord Herniation

Idiopathic spinal cord herniation is usually repaired by releasing the spinal cord and inserting a dural patch to close the herniated segment of dura. However, reherniation is a potential limitation of this standard technique. To describe early results of a novel technique that utilizes the dentate ligament to hitch the spinal cord and prevent reherniation. Two patients underwent dural hernia repair and the dentate hitch technique was performed. Restored lower limb power and mobility, and satisfactory reduction of spinal cord herniation on magnetic resonance imaging in 2 patients at 6- and 24-mo follow-ups, respectively. The dentate hitch technique can achieve repair of spinal cord herniation, with satisfactory postoperative results and minimizes the risk of reherniation.

Laparoscopic cholangiogram in biliary atresia: a refinement in the gallbladder hitch technique.

The study describes a refinement in the gallbladder hitch stitch and assesses the value of the laparoscopic cholangiogram in children with suspected biliary atresia. Twenty children with neonatal jaundice and no drainage as shown on the HIDA scan underwent a diagnostic laparoscopy through an umbilical 5mm port. A 3mm laparoscopic needle holder inserted through a 3.5mm port to the left of the umbilicus was used to hitch the gallbladder to the abdominal wall. The stylet of a large bore 16F IV cannula then was used to penetrate the gallbladder to perform the laparoscopic cholangiogram. There was no need for conversion in all 20 children by this technique. Patent biliary anatomy was demonstrated in 11 children (11/20). These children had no further procedures. In 3 (3/20) children, the common bile duct was demonstrated, while the hepatic ducts were not. These children had a laparotomy for Kasai procedure after an open cholangiogram with a vascular bulldog clamp on the CBD confirmed the finding. Six (6/20) had no demonstrable patency; 3 had it confirmed when the abdomen was opened for the Kasai procedure; only those proceeding to Kasai portoenterostomy (3 hepatic duct atresia, 3 complete biliary atresias) had an epidural catheter placed by the anesthetist. The remaining 3 had no further procedure performed due to the advanced nodular liver with ascites and evidence of portal hypertension. The findings of laparoscopic cholangiogram were confirmed in all six children who underwent laparotomy for Kasai procedure. The laparoscopic cholangiogram using gallbladder hitch reliably demonstrates a patent biliary system (11/11) and was valuable in avoiding further invasive procedures in 70% (14/20) of babies.

The “Hitch Stitch”: An Effective Method of Preventing Migration in High Tracheal Stenosis

Background: The incidence of caudal stent migration in high tracheal stenting is 13-21% and is common with silicone stents. This can lead to major problems, including emergency repeat procedures. Several antimigration methods are described, but have limitations in terms of their success rate, availability, cost or ease of the procedure. Objectives: We describe an innovative method of stent migration prevention using a simple percutaneous anchoring “hitch stitch”, validated in a large series. Methods: After tracheal stent placement, an Ethilon suture was passed into the stent lumen through an 18-G needle. To take this suture back to the exterior to complete the stitch, a retrieval loop was passed through another 14-G percutaneous cannula inserted into the stent lumen. Bronchoscopically, using a forceps the first suture was pulled inside the loop, the loop was retracted, the suture was exteriorized, and the knot was completed and embedded subcutaneously. While removing the stent, an endoscopic scissor was used to cut the stitch to free the stent. Results: A total of 42 “hitch stitches” were done in 29 patients over 5 years, predominantly for silicone stents. Indications for stenting included postintubation tracheal stenosis (83.3%), malignancy (11.9%) and tracheoesophageal fistula (4.8%, metal stents). The procedure was successful in 41/42 (97.6%) patients. Stitch removal was uncomplicated. Conclusion: This is the largest series of an external stent anchoring procedure as a migration prevention strategy in high tracheal stenting, applicable to both silicone and metal stents. Stent migration prevention using this “hitch stitch” is simple, safe and successful, without any complications during stent removal.

V7-12 ROBOT-ASSISTED LAPAROSCOPIC PYELOURETEROSTOMY IN INFANTS WITH DUPLEX SYSTEMS WITH UPPER POLE URETERAL OBSTRUCTION: VARIATIONS IN DOUBLE J URETERAL STENTING TECHNIQUES

You have accessJournal of UrologyPediatrics1 Apr 2016V7-12 ROBOT-ASSISTED LAPAROSCOPIC PYELOURETEROSTOMY IN INFANTS WITH DUPLEX SYSTEMS WITH UPPER POLE URETERAL OBSTRUCTION: VARIATIONS IN DOUBLE J URETERAL STENTING TECHNIQUES Minki Baek, Jason Au, and Chester Koh Minki BaekMinki Baek More articles by this author , Jason AuJason Au More articles by this author , and Chester KohChester Koh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.569AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Duplex systems can be associated with upper pole ureteral obstruction. When severe loss of function has occurred, extirpative treatment is often performed. However, if functioning renal tissue is present, urinary tract reconstruction is recommended. The expanded use of robot-assisted laparoscopic surgery has allowed the option of minimally invasive surgery for many reconstructive procedures. We describe our technique for robot-assisted laparoscopic pyeloureterostomy in infants with duplex systems with upper pole ureteral obstruction. METHODS We applied our robot-assisted laparoscopic pyeloureterostomy technique in two female infants with right duplex systems with upper pole ureteral obstruction. Both patients were 6 - 7 months old. After the tortuous dilated upper pole ureter was dissected, the lower pole ureter was identified and the upper pole distal ureter was ligated and transected when vesicoureteral reflux was present. A Hitch stitch on the upper pole ureter or the lower pole renal pelvis allowed for better visualization for the renal pelvis incision or the pyeloureterostomy anastomosis. For the 1st case, we introduced the double J stent during the robotic operation and placed it in the recipient lower pole ureter. For the 2nd case, we inserted the double J stent during retrograde pyelography prior to the robotic procedure, and the proximal portion of the stent was placed across the anastomosis into the upper pole renal pelvis. RESULTS Postoperatively, each of the patients were discharged on postoperative day 1 without any perioperative complications. The double J stent was removed on postoperative 1 month in both patients. The postoperative renal ultrasound at 3 months demonstrated marked improvement of the right upper pole hydronephrosis in both patients. CONCLUSIONS Robotic-assisted laparoscopic pyeloureterostomy represents a minimally invasive option for upper tract reconstruction of duplex systems with upper pole ureteral obstruction even in infants. The double J ureteral stent can be placed at the beginning of or during the procedure. The ureteral stent can be placed in the lower pole ureter or across the anastomosis into the upper pole ureter. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e726 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Minki Baek More articles by this author Jason Au More articles by this author Chester Koh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Simple Cow Hitch Stitch Technique for Arthroscopic Rotator Cuff Repair and Stabilization Using Knotless Suture Anchors

The tissue-suture interface is the most vulnerable and challenging part of adequate restoration and fixation in rotator cuff repair. We describe a simple stitch technique for arthroscopic rotator cuff repair using knotless suture anchors based on the cow hitch. The simple cow hitch stitch technique is easy to perform, especially under difficult conditions, and provides excellent initial fixation strength as required for integration of the reinserted cuff and for shoulder stabilization.

Management of superior sagittal sinus injury encountered in traumatic head injury patients: Analysis of 15 cases.

Background:Significant dural sinus injury occurs in 1.5- 5% of all head injuries and injury to superior sagittal sinus accounts for 70-80% of these. Its management is also a challenging issue to every neurosurgeon.Materials and Methods:In a period of one year (Aug 2011 to july2012) out of 549 cases of head injuries operated in our department analysis of 15 cases (2.73%) shown to have superior sagittal sinus injury. Three dimensional reconstruction of skull bone during CT scan helped us to diagnose possible dural sinus injury pre-operatively.Results:SSS injury was due to direct impact of fracture segment (5 cases), extension of fracture line over sinus area (4 cases) or due to coronal suture diastases (6 cases). Injury to anterior third of sagittal sinus occurred in 12 cases (80%) and injury to middle third occurred in 3 cases (20%). Small tear over superior sagittal sinus was found in 7 cases (46.66%) and was managed with Gelfoam® compression only and in two cases (13.33%) were large tear, which was managed with sinoraphy. In four cases (36.34%) hitch stitches over Gelfoam® to adjacent bone given and in rest two cases (13.33%) a strip of bone was left over the sinus area and bilateral hitch stitches were applied.Conclusion:Injury to SSS in traumatic head injury patient though rarely encountered during surgery, the management is challenging to every neurosurgeon. Preoperative suspicion and combination of surgical techniques rather than one single technique may be effective in decreasing the sinus related mortality rate.

Clinical analysis of modified laparoscopic dismembered pyeloplasty in children with ureteropelvic junction obstruction

Objective To investigate the therapeutic effect of modified transperitoneal laparoscopic dismembered pyeloplasty in children with with ureteropelvic junction obstruction (UPJO).Methods The clinical data of 27 children with UPJO treated with transperitoneal laparoscopic dismembered pyeloplasty were analyzed retrospectively.The age ranged from 5 to 104 months (mean,37 months).All cases were diagnosed by ultrasonography,IVU,CT and/or renal radionuclide scanning.The antero-posterior pelvic diameter was more than 3 cm by ultrasound in all cases.Indications of surgery were as followings:symptoms of upper abdominal pain or low back pain and/or split renal function ＜40％ and/or progressive dilatation.Modified transperitoneal laparoscopic dismembered pyeloplasty was performed.Double hitch stitches were transfixed at the top of pelvis and ureter to be anastomosed,and a 6 F urethral catheter was inserted as a ureteral stent percutaneously through the puncture hole and was removed 7-9 days postoperatively without double-J stent.Results All operations were completed laparoscopically without conversion to open surgery.The mean operative time was 118 min (range,85 to 176),the mean blood loss was 16 ml (range,10 to 30) and the mean postoperative hospital stay was 10.5 days (range 9 to 13).The perinephric urine drainage occurred in 2 patients with about 200 ml/d,and reduced to 6 ml/d and 4 ml/d 5 to 6 days after operation.During the follow-up period for 12 to 36 months(mean,22 months) in 27 cases,there was no stricture at UPJ and the hydronephrosis reduced significantly or disappeared.Conclusion Laparoscopic dismembered pyeloplasty with double hitch stitches and an ordinary urethral catheter as an ureteral stent is an easy method with high successful rate and less operative time,which avoids reoperation to remove the double-J stent and is worthy of clinical popularization. Key words: Hydronephrosis; Laparoscopy; Children; Double hitch; Double-J stent

Robotic Pyeloplasty Step by Step

Introduction: Although open pyeloplasty has been the gold standard for management of ureteropelvic junction obstruction (UPJO), several options are available, including antegrade and retrograde endopyelotomy as well as laparoscopic and robotic pyeloplasty. Robotic pyeloplasty has developed into a successful approach to treat adults and children with UPJO. We present a detailed instructional video to demonstrate the individual steps of robotic pyeloplasty. Materials and Methods: A step-by-step account of our current surgical technique of robotic pyleoplasty is described in this video tutorial: retrograde pyelogram and placement of a ureteral stent; placement of trocars; isolation of the ureter; dissection of renal pelvis with placement of hitch stitch; mobilization of renal pelvis; spatulation of the ureter; reduction of renal pelvis; ureteral anastomosis; and/or removal of stone; closure of renal pelvis. Results: Tips that will aid in achieving optimal outcomes include complete mobilization of the renal pelvis, which is essential to provide a tension-free, water tight, mucosal to mucosal anastomosis. After mobilization, placement of a hitch stitch in the renal pelvis may facilitate stabilization of the anastomosis, particularly in the case of an intrarenal pelvis. In addition, spatulation of the ureter is best performed before complete transection. This step avoids spiraling of the spatulation. Successful Anderson-Hynes robotic dismembered pyeloplasty is a reproducible technique for surgical correction of UPJO. Success rates will be in the range of 96–99%. A crossing vessel is important to visualize, mobilize, and preserve in adult UPJO. Conclusions: Robotic pyeloplasty is a safe, feasible, and effectivez minimally invasive technique for treating UPJO. The standardization of each surgical step has improved the surgical outcomes utilizing a robot-assisted laparoscopic approach. No competing financial interests exist. Runtime of video: 5 mins 25 secs

Laparoendoscopic Single-Site Pyelolithotomy in a Pediatric Patient

Introduction and Objectives: The preferred treatment for patients with a large stone burden is percutaneous nephrolithotomy (PCNL). Although it offers excellent stone clearance rates, PCNL access and treatment can be challenging, with considerable potential morbidity. In the modern era of routine minimally invasive surgery, we offer a novel, endourologic approach for patients with significant nephrolithiasis who otherwise may be offered only PCNL or an open procedure, both of which may confer greater morbidity. Laparoendoscopic single site (LESS) is an emerging surgical approach with limited data. To our knowledge, a pyelolithotomy using pure LESS has not been described in the literature. Methods: In the accompanying video, we present this novel surgical technique in a child with cystinuria, recurrent stones, and previous complicated contralateral PCNL. Based on our larger initial experience with LESS in children, we use a variety of access devices and working instruments. Here we use a SILS-port access device (Covidien®) with articulating instruments (graspers, cauterizing L-hook) and articulating camera (Olympus®). We feel these instruments offer improved ergonomics and provide higher degrees of freedom. Results: A double-J stent is initially placed and the bladder filled to distend the renal pelvis. The patient is placed in mild flank and a 1.5 cm skin incision is used with a 2.5 cm fascial incision to accommodate the single port device. Optimal positioning of the operating table, viewing screens, and surgical team is essential for LESS. The camera and instruments are best triangulated in the access port device, with the working instruments on the same horizontal plane and of different lengths, and the camera angled to limit instrument collision. We favor a transmesenteric approach when possible, to minimize mobilization of bowel. Unlike LESS pyeloplasty, minimal dissection is needed to expose the pelvis for eventual mini-pyelotomy and stone extraction. A hitch stitch is used to stabilize the pelvis and another is used to lift the mesenteric vessels to improve visualization and facilitate incision of the pelvis. The stones are removed and the pelvis is reapproximated. We use a standard approach to facilitate knot tying during LESS with a straight needle driver and articulating grasper. The pelvis is closed around a stent and the stones are placed in a bag for removal. Conclusions: LESS-P is a novel approach for the treatment of extensive nephrolithiasis and it supplements current surgical options. For experienced laparoscopists, it can be less morbid than traditional alternatives. It should be considered whenever PCNL is not feasible, scarless surgery is desired, radiation exposure should be limited, or when pyeloplasty is also indicated. No competing financial interests exist. Runtime of video: 5 mins 56 secs

V577 PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC PYELOPLASTY IN HORSESHOE KIDNEY

You have accessJournal of UrologyPediatrics1 Apr 2013V577 PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC PYELOPLASTY IN HORSESHOE KIDNEY Candace F. Granberg, Daniel DaJusta, and Patricio Gargollo Candace F. GranbergCandace F. Granberg Rochester, MN More articles by this author , Daniel DaJustaDaniel DaJusta Louisville, KY More articles by this author , and Patricio GargolloPatricio Gargollo Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1973AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The surgical approach to ureteropelvic junction obstruction (UPJO) in horseshoe kidneys is challenging secondary to the inherent aberrant anatomy. Historically, some have recommended division of the isthmus, while others have advocated transection of crossing vessels, both of which carry risk of nephron damage or loss. With the advent of minimally-invasive surgery, robotic-assisted laparoscopic pyeloplasty (RALP) has become routine in otherwise anatomically normal kidneys; however, there is limited data on the robotic approach to UPJO in children with horseshoe kidneys. Thus, the objective of this video is to detail the surgical approach to RALP in the horseshoe kidney. METHODS Hidden incision endoscopic surgery (HIdES) was developed at our institution, and is applied in all RALP cases. One robotic port is placed infraumbilically, while all remaining ports are hidden below the level of a Pfannensteil incision, thus rendering them nonvisibile when wearing a bathing suit. A 5mm assist port is optional. Using a transmesenteric approach, the UPJ is localized. In this case, a mesenteric vessel overlying the UPJ was divided to maximize exposure of the UPJ and proximal ureter. High insertion was identified as the cause of UPJO in this case. No renal crossing vessels were found, and the isthmus was not a factor, thus was left intact. A hitch stitch is placed in the renal pelvis to elevate the UPJ. After transescting above the UPJ, the ureter is relocated to lie above the mesentery. The UPJ is excised and the ureter spatulated. 5-0 Vicryl is used for the anastomosis over a stent. RESULTS We have performed RALP for UPJO in 4 children with horseshoe kidneys, all of whom were male, with a mean age of 4.7 years. All cases of UPJO in this cohort occurred within the left renal moiety. Mean operative time in these four cases was 120 minutes. The isthmus and renal vasculature were maintained in all cases, and there were no intra- or post-op complications. All patients were dismissed within 24 hours. At mean follow-up of 9 months, all patients were radiologically and clinically improved. CONCLUSIONS In conclusion, RALP in children with horseshoe kidneys is safe and efficacious. Meticulous intraoperative examination of the anatomy is germane to ensure aberrant crossing vessels are not overlooked. Moreover, adequate drainage can be achieved without dividing the isthmus or renal vasculature, which not only maintains blood supply to all nephrons but also avoids inherent risks associated with these maneuvers. Thus, RALP is an excellent minimally-invasive approach for UPJO in children with horseshoe kidneys. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e236-e237 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Candace F. Granberg Rochester, MN More articles by this author Daniel DaJusta Louisville, KY More articles by this author Patricio Gargollo Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V578 INITIAL EXPERIENCE OF TRANSVESICOSCOPIC URETERAL REIMPLANTATION WITH URETERAL PLICATION IN REFLUXING MEGAURETER

mesenteric vessel overlying the UPJ was divided to maximize exposure of the UPJ and proximal ureter. High insertion was identified as the cause of UPJO in this case. No renal crossing vessels were found, and the isthmus was not a factor, thus was left intact. A hitch stitch is placed in the renal pelvis to elevate the UPJ. After transescting above the UPJ, the ureter is relocated to lie above the mesentery. The UPJ is excised and the ureter spatulated. 5-0 Vicryl is used for the anastomosis over a stent. RESULTS: We have performed RALP for UPJO in 4 children with horseshoe kidneys, all of whom were male, with a mean age of 4.7 years. All cases of UPJO in this cohort occurred within the left renal moiety. Mean operative time in these four cases was 120 minutes. The isthmus and renal vasculature were maintained in all cases, and there were no intraor post-op complications. All patients were dismissed within 24 hours. At mean follow-up of 9 months, all patients were radiologically and clinically improved. CONCLUSIONS: In conclusion, RALP in children with horseshoe kidneys is safe and efficacious. Meticulous intraoperative examination of the anatomy is germane to ensure aberrant crossing vessels are not overlooked. Moreover, adequate drainage can be achieved without dividing the isthmus or renal vasculature, which not only maintains blood supply to all nephrons but also avoids inherent risks associated with these maneuvers. Thus, RALP is an excellent minimallyinvasive approach for UPJO in children with horseshoe kidneys.

Ureteral Advancement in Patients Undergoing Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Vesicoureteral Reflux

Laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux has gained acceptance as a feasible treatment associated with minimal morbidity. However, ureteral advancement with this technique has not been attempted. We examined the usefulness of ureteral advancement via laparoscopy. A total of 30 patients with 51 refluxing ureters underwent laparoscopic extravesical ureteral reimplantation for treatment of vesicoureteral reflux between August 2009 and September 2011. Mean ± SD patient age was 60.8 ± 48.6 months. During the procedure 15 patients underwent ureteral advancement (advancement group), while 15 did not (nonadvancement group). We compared operative times and postoperative rates of urinary tract infections and persistent reflux between the groups. There was no significant difference in operative times in unilateral (mean ± SD 110 ± 25 vs 125 ± 42 minutes) and bilateral cases (mean ± SD 214 ± 52 vs 203 ± 40 minutes) between the nonadvancement vs advancement groups. All patients underwent voiding cystourethrography 3 to 4 months postoperatively. Reflux resolution rate for ureters was significantly higher in the advancement group (100%) than in the nonadvancement group (85%, p <0.05). No patient in the advancement group had postoperative urinary tract infection. Fixation of the ureter with the bladder muscularis at the proximal limit of the detrusor defect and/or a percutaneous hitch stitch placed in the ventral side of the proximal limit of the detrusor defect facilitated ureteral advancement. Ureteral advancement is a simple and feasible procedure in laparoscopic ureteral extravesical reimplantation and may improve the resolution rate of vesicoureteral reflux.

Pediatric Robot-Assisted Laparoscopic Pyeloplasty Using a Transmesenteric Approach

Introduction: Robot-assisted laparoscopic pyeloplasty is an emerging minimally invasive option in the pediatric population for the treatment of ureteropelvic junction obstruction. Since the first description of minimally invasive pyeloplasty in 1993,1 the robot-assisted technique has been applied to both primary and reoperative procedures in the pediatric population, achieving results comparable to open surgery.2–4 We describe our transmesenteric approach for robot-assisted laparoscopic pyeloplasties, which provides direct access to the pelvis without mobilization of the colon. Materials and Methods: After induction of anesthesia and insertion of a Foley catheter, the patient is secured with tape in the supine position with the ipsilateral side raised on a gel roll such that the patient is at a 45° angle to the bed. Initial access is performed using an open peritoneal (Hasson) technique. One 8.5- or 12-mm camera port, two robotic arm ports (5 or 8 mm), and one 5-mm accessory port are used for the procedure. The bed is then rotated to elevate the ipsilateral side. The Da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA) is docked over the ipsilateral side to the ports. A small window is made in the mesentery overlying the dilated renal pelvis while taking care to avoid major vasculature and the renal pelvis is dissected free. A “hitch stitch” is placed through the abdominal wall, through the renal pelvis, and then through the abdominal wall to provide exposure and traction during subsequent dissection and reconstruction. The ureteropelvic junction is transected proximal to the obstruction and the ureter is spatulated until a healthy lumen is visible. The ureteropelvic junction is then reconstructed with running 5-0 Monocryl sutures, using the strictured portion temporarily as a handle until excision just before completion of the anastamosis. Finally, the mesenteric window is closed with a running 4-0 Vicryl suture. Results and Conclusions: Robot-assisted laparoscopic pyeloplasty using a transmesenteric approach provides rapid identification of as well as easy access to the ureteropelvic junction obstruction in children. Observation of the dilated renal pelvis through the mesentery allows for exposure through avascular planes, obviating colon mobilization. Complete reconstruction can be performed without extensive colonic mobilization, preserving the retro-colic space. Transmesenteric robot-assisted laparoscopic pyeloplasty is an attractive alternative to previously described robotic pyeloplasty techniques for the treatment of ureteropelvic junction obstruction in children. No competing financial interests exist. Runtime of video: 7 mins 11 secs.