Psoas Hitch Research Articles

3034 Robotic-Assisted Ureteroneocystostomy and Psoas Hitch for Ureteral Endometriosis

Video Objective We present a case of extrinsic urethral endometriosis. We review the peri-operative management with renal function testing, pre-operative imaging and stent placement. The patient had a robotic-assisted ureteroneocystostomy with psoas hitch for her severe disease. The goal of this video is to review peri-operative management of urinary tract endometriosis and to demonstrate the surgical technique of ureterolysis in extrinsic ureteral endometriosis and ureteroneocystostomy with psoas hitch. Setting the patient was managed in the outpatient setting as well as the inpatient surgical suite. Interventions Surgical: ureteroneocystostomy with psoas hitch. Conclusion Ureteral endometriosis is a rare manifestation of pelvic endometriosis that can be managed with appropriately with a peri-operative work-up including renal functions tests and pelvic imaging. Ureteral re-implantation for severe distal disease must be considered.

Laparoscopic Ureteral Reconstruction- Three Steps for Any Ureteral Defect

Video Objective To demonstrate methods to compensate for large ureteral defects after extensive resection of ureteral endometriosis. I will present 3 methods, the psoas hitch, the Boari flap and ileal interposition. Setting Urban general hospital in Japan. Interventions These patients suffered from ureteral stenosis, hydronephrosis and hydroureter. We performed laparoscopic extensive resection of DIE and the resection of the involved ureter. As a result of the resection, we needed reconstruction of the urinary tract. The type of reconstruction depends on the size of the defect. We need intact and tension-free anastomosis of the ureter and the bladder. If the involved segment is small, we perform simple reimplantation of the ureter to the bladder. However, if the defect is larger, we need to perform a psoas hitch and sometimes a Boari flap in accordance with how much length of the ureter needs to be compensated for. In rare cases where there is a great deal of loss of ureteral length, we interpose a graft of the ileum. The harvest defect of the ileum in reconstructed with functional end-to-end anastomosis. Conclusion The laparoscopic psoas hitch, Boari flap and ilieal ureter are reconstructive techniques that allow for more extensive resection of endometriosis by minimally invasive surgery. These techniques provide tension-free adaptation after extensive resection of the ureter.

Minimally Invasive UV Fistula Repair with the Aid of Laparoscopic Ureteroneocystostomy

Video Objective We will present two cases which suffered from ureteral vaginal fistula after hysterectomy and underwent repair at our institute. Setting Urban general hospital Japan. Interventions Case 1 complained of fluid leakage two days after laparoscopic hysterectomy. CT showed leakage of urine from the lower ureter. Case 2 was referred to us from another institute after suffering from vaginal fluid leakage for four years. This case underwent abdominal hysterectomy four years ago and two weeks later the patient complained of fluid leakage. Six months later, an urologist made an attempt to repair the fistula but was unsuccessful due to the amount of adhesion the patient was suffering. For Case 1, we performed a laparoscopic uteroneocystostomy with a psoas hitch, which facilitated a tension-free anastomosis for this patient. The most important point of this surgery is meticulous dissection without impairing blood perfusion. This was extremely difficult in Case 2 due to extensive and severe adhesion. Laparoscopic skills for this reconstruction such as laparoscopic suturing and knowledge of fundamentals like tension and torsion free anastomosis are vital for the success of the surgery. No patients experienced stenosis or leaks and no other complications occurred and no blood transfusions were required. The fistulas were repaired without sequel. The patients were able to ambulate and take a normal diet the day after the surgery and could be discharged 4 days after surgery. Conclusion Although knowledge of reconstruction and laparoscopic skills such as intracorporeal suturing and ligation are difficult to master, this technique is valuable in its feasibility and patient friendliness.

Levator Avulsion: A Review of Surgical Anatomy and Repair Technique for Primary Posterior Perineal Hernias

Video Objective Perineal hernias are exceptionally uncommon gynecologic pathologies that may have a drastic impact on women's health. Hernias that contain pelvic visceral structures present an especially unique challenge that requires immediate attention. Evidence is lacking as to the optimal surgical approach. Our objective is to describe our minimally-invasive technique for the repair of primary posterior perineal hernias with symptomatic bladder prolapse. Setting This patient is a sixty-two year-old female who presented with a large bulge in her left buttock and a chief complaint of difficulty urinating that required reduction in order to void. Her medical history is significant for a prior vaginal delivery without complications, and a prior rectocele repair. Outpatient workup that included cystogram, CT and MRI imaging revealed a left perineal hernia that involved the entire bladder. She was diagnosed with a posterior perineal hernia. Interventions This patient's condition was treated via surgical management. Due to the large defect size and absent levator ani musculature, re-approximation for pelvic support was not feasible and thus a 5 × 4 cm segment of propylene mesh was placed and sutured between the left vaginal sidewall and left pelvic sidewall periosteum. Following, a sacrocolpopexy was performed to repair her perineal descent, and the prolapsed bladder was replaced with a psoas hitch procedure to the contralateral side. Conclusion Primary posterior perineal hernias with concomitant symptomatic bladder prolapse may be repaired with a sacrocolpopexy, paravaginal mesh placement, and a psoas hitch procedure. Using a robotic-assisted, minimally-invasive repair technique has been proven to have favorable short-term outcomes regarding symptomatology as well as anatomic replacement of pelvic viscera. Patients should be counseled about the option for surgical management of perineal hernias, as well as the need for future research to evaluate the long-term outcomes and quality of life markers following transabdominal laparoscopic perineal hernia repairs with use of mesh placement.

Prevention of Ureteric Injury & Laparoscopic Uretero-Neo-Cystostomy

Video Objective To elucidate the precautions involved in preventing ureteric injury in laparoscopy. To demonstrate management of ureteric injury and technique of ureteric re-implantation in diseased distal third of ureter Setting 39 yr old female with dysmenorrhoea & dyspareunia, diagnosed as having advanced endometriosis with recto-vaginal and ureteric involvement at our Tertiary Care University recognised Endoscopy Referral Unit Interventions Uretero - Neo - Cystostomy with Psoas Hitch to excise diseased distal third of ureter. Double cystotomy technique to draw in the ureter and suture internally to the bladder mucosa after achieving adequate mobilisation of the bladder and ureter in a tension free manner Conclusion Precautions and pre-operative planning and imaging can help avert injuries to vital structures. Ureteric injury, if encountered, can be handled laparoscopically if correct principles are followed, with a urologist standby for medico-legal purposes

Laparoscopic Boari Flap for Inadvertent Ureteral Injury During Die Resection

Video Objective To demonstrate minimally invasive strategies for inadvertent intraoperative ureteral injury. This case report shows how we managed an extensive ureteral injury while dissecting DIE. Setting Urban general hospital in Japan. Interventions This patient suffered from DIE and extensive and severe fibrosis. As a result of the severe and extensive fibrosis, the surgeon performing the DIE resection misrecognized the ureter for the deformed sacrouterine ligament and this structure was coagulated and resected. The author of this report was called to take over the repair and reconstruction of the ureter. The laparoscopic Boari flap with psoas hitch technique was performed to compensate for the large ureteral defect. In the Boari flap technique, the ureter is mobilized cranially and the bladder is also dissected and mobilized. Then a flap is cut from the wall of the bladder and this flap is suture fixed to the psoas fascia and enveloped to make a tunnel for the cut end of the ureter. Conclusion The patient was able to ambulate and take and normal diet the next day. No stenosis or leaks occurred and no blood transfusions were required. Although the technique is demanding, we are able to avoid open surgery, making this strategy a good, patient friendly option when a repair scenario is needed.

VE31 - Robotic ureteral reimplantation: Case of reimplant with psoas hitch and single institution clinical series

VE31 - Robotic ureteral reimplantation: Case of reimplant with psoas hitch and single institution clinical series

Advances in surgical repair of ureteral injury

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

Management of Ureteral Strictures and Ureteropelvic Junction Obstruction

The goals for management of ureteropelvic junction obstruction (UPJO) and ureteral stricture are to resolve obstruction, restore continuity, and preserve renal function while minimizing morbidity. The management of UPJO can be challenging and represents a spectrum of options that vary in the invasiveness and effective. These options include observation, long-term internal or external urinary drainage, and endoscopic or minimally invasive management. Mismanagement can potentially results in deterioration of loss of kidney function. This chapter discusses the foundations for successful management of UPJO and ureteral strictures. It also highlights the special clinical situations related to this disease entity and discusses the key advances in the field. This review contains 8 figures, 4 tables, and 73 references. Key Words: Boari flap, dismembered pyeloplasty, endopyelotomy, psoas hitch, pyeloplasty, ureteropelvic junction obstruction, ureteral obstruction, ureteral reconstruction, ureteral stricture, uretero-ureterostomy

V03-06 TRANSECTION-FREE SIDE-TO-SIDE DISTAL URETERAL REIMPLANTATION

INTRODUCTION AND OBJECTIVES:Distal ureteral strictures pose a potential risk for renal impairment. The surgical gold standard involves ureteroneocystotomy with transection of the ureter. We present the technique of side-to-side anastomosis as a useful treatment option that avoids aggressive distal ureteral dissection and further compromise of blood supply. Additionally, the presence of the native ureteral orifice allows for ureteroscopic access if required.METHODS:In this video, we show our robotic surgical technique for side-to-side anastomosis for distal ureteral stricture performed by three genitourinary reconstructive surgeons from three different institutions. Our technique involves the performance of adequate ureterolysis of the healthy, proximal and non-strictured segment. Extensive dissection of the posterior ureter towards the ureterovesical junction is avoided, preventing vascular compromise. Indocyanine dye can be used to demonstrate vascularity prior to anastomosis. A psoas hitch or bladder mo...

V03-05 ROBOTIC ASSISTED LAPAROSCOPIC BUCCAL MUCOSAL GRAFT URETEROPLASTY FOR RECURRENT UPPER AND LOWER URETERAL STRICTURES

INTRODUCTION AND OBJECTIVES:Recurrent ureteral strictures have higher complexity for repair compared to initial surgery for ureteral reconstruction. We describe a series of patients treated with robotic assisted laparoscopic (RAL) buccal mucosal graft (BMG) ureteroplasty and demonstrate techniques utilized to improve efficiency in these complex cases.METHODS:Retrospective review was conducted for the initial four cases of RAL ureteroplasty with BMG performed by a single surgeon between July and October 2017. Video recordings of these cases were reviewed to identify techniques utilized to facilitate completion of these complex cases using a RAL approach.RESULTS:All four cases were completed using RAL approach without need for conversion to an open procedure. Average patient age was 55 years. Two patients had lower ureteral strictures that initially resulted from prior pelvic surgery. Both of these patients developed recurrent lower ureteral strictures after prior ureteroneocystostomy with psoas hitch. The ...

Ureteral injury during abdominal and pelvic surgery: immediate versus deferred repair.

IntroductionThe incidence of ureteral damage during abdominal surgery is <1%. Repair of these lesions can be performed immediately when the injury is detected or deferred when it has been missed.Material and methodsWe retrospectively reviewed ureteral injuries that required surgical repair and were made during gynaecological and general surgery procedures between the years 2004 and 2016. We compared the clinical and functional outcomes between immediate and deferred repair.ResultsWe registered 84 lesions after 4000 abdominal procedures (2.1%). A total of 20 injuries were noted during general surgery interventions (24%) and 64 during gynaecological procedures (76%). The approach was laparoscopic in 66 of these cases and open in the other 18. Mean time of follow-up was 24 months. Immediate repair was accomplished in 35 cases (41%) and deferred in 49 (59%), with a median time to repair of 5.7 months. The laparoscopic approach was more frequent in deferred repairs (76% vs. 16%), while the open approach was more common in immediate repairs (54% vs. 40%). Procedures used for ureteral repair included 62 ureteral reimplantations using a psoas hitch technique, 8 end-to-end ureteral anastomoses, 6 ureterorraphies and 6 ureteral catheterisations. Two nephrectomies were also performed. Success rates and complications were similar for both immediate and deferred procedures (68% vs. 73% and 26% vs. 23% respectively, both p >0.05).ConclusionsThe occurrence of ureteral injury during abdominal surgery is low. Immediate repair is preferred when feasible, but delayed recognition of the injury is more common. We found no difference between immediate and deferred repair in terms of success rates.

Left total ureteral substitution using appendix after failed ureteral reimplantation, in infant affected by high vesico-ureteral reflux in a left functionally solitary kidney

A ureteric loss is a devastating event and can be corrected with intrinsic urinary tissue using different surgical techniques such as direct anastomosis, psoas hitch, Boari flap, transuretero-ureterostomy and renal autotransplantation. We report a case of successful left ureter total substitution with appendix after failed ureteral reimplantation and acute renal failure, in an infant affected by high grade vesicoureteral reflux in a left functionally solitary kidney.

Repair of iatrogenic ureteral injury with a combination of ‘’Boari flap’’ and ‘’Psoas Hitch’’ technique

A common cause of ureter trauma is iatrogenic, especially during gynecologic and obstetric procedures. Early diagnosis is of vital importance for the successful management of these patients and depends on the type, anatomic location and length of ureteral deficit. Preoperative placement of ureteral stent does not seem to reduce incidence of these cases. For extended length traumas, surgical techniques like Boari flap and Psoas hitch have been reported, in order to reconstruct ureter and accomplish ureteroneocystostomy. We describe the case of a patient, who presented with a deficit of 13 cm after sigmoidectomy. We performed a combination of Boari flap and Psoas hitch successfully and restored the continuity of urinary tract.

Oncological and renal outcomes of segmental ureterectomy vs. radical nephroureterectomy for upper tract urothelial carcinoma.

Segmental ureterectomy (SU) represents a promising alternative for the treatment of upper tract urothelial carcinomas (UTUCs) as it is a less invasive procedure and guarantees the preservation of renal units. The present study evaluated oncological outcomes and renal functions following SU when compared with radical nephroureterectomy (RNU). A total of 26 patients with UTUCs who underwent SU (n=12) or RNU (n=14) were retrospectively evaluated. SU was performed in patients with clinically unifocal disease. In the SU group, the following surgeries were carried out: 7 direct ureterocystoneostomy, 1 reimplantation on psoas hitch bladder, 1 reimplantation on Boari flap bladder, 2 ureteral end-to-end anastomosis and 1 subtotal ureterectomy. In the SU group, tumors were low grade urothelial carcinoma (UC) in 6 patients, high grade UC in 5 patients and high grade UC with squamous cell differentiation in 1 patient, as well as ≤pT1 in 5, ≥pT2 in 6 and pTis in 1 patient; 'p' refers to the pathological state. The 5-year overall, cancer-specific, recurrence free and metastasis free survival in the SU group were 77.8, 87.5, 34.4 and 80.8%, respectively, which all exhibited no significant differences when compared with those of the RNU group. With regard to renal function, postoperative estimated glomerular filtration rates were preserved in the SU group. The present study demonstrated that SU does not result in poorer cancer control when compared with RNU. Thus, SU is an acceptable alternative to RNU in selected cases, as it is less invasive and preserves renal functions.

V04-06 LAPAROSCOPIC LEFT URETERAL SUBSTITUTION USING CECAL APPENDIX AFTER EN-BLOC RESECTION RECTOSIGMOIDECTOMY: A CASE REPORT AND VIDEO DEMONSTRATION

You have accessJournal of UrologyReconstruction - Upper Urinary Tract1 Apr 2018V04-06 LAPAROSCOPIC LEFT URETERAL SUBSTITUTION USING CECAL APPENDIX AFTER EN-BLOC RESECTION RECTOSIGMOIDECTOMY: A CASE REPORT AND VIDEO DEMONSTRATION Cinthia Alcántara Q., José Marx Xavier, Luis G. C. Rogmanolo, Euvaldo Jorge, Armando F. Melani, Roberto D. Machado, Alexandre C. Santos, Wesley J. Magnabosco, Roberto L. Muller, and Eliney F. Faria Cinthia Alcántara Q.Cinthia Alcántara Q. More articles by this author , José Marx XavierJosé Marx Xavier More articles by this author , Luis G. C. RogmanoloLuis G. C. Rogmanolo More articles by this author , Euvaldo JorgeEuvaldo Jorge More articles by this author , Armando F. MelaniArmando F. Melani More articles by this author , Roberto D. MachadoRoberto D. Machado More articles by this author , Alexandre C. SantosAlexandre C. Santos More articles by this author , Wesley J. MagnaboscoWesley J. Magnabosco More articles by this author , Roberto L. MullerRoberto L. Muller More articles by this author , and Eliney F. FariaEliney F. Faria More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1023AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES On occasion, locally advanced pelvic tumors mandate en-bloc resection because they encroach on adjacent organs, such as the ureter 1. The treatment of ureteral division above the level of the iliac vessels carries a high degree of complexity and represents a challenge for the surgeon 2,3. Several options for ureteral reconstruction exist – such as reimplant, Boari flap, and the psoas hitch 4. A less commonly used option is the use of pedicled graft cecal appendix which can be used as a conduit interposed between bladder and ureter 5,6,7. The adoption of this technique on the right side is useful due to anatomic proximity, however the use on the left side is more challenging, particularly when performed laparoscopically. The aim of this video forum is to demonstrate the feasibility of laparoscopic reconstruction of the left urinary system utilizing an autografted native appendix during ureteral en bloc excision necessitated by extirpation of a locally advanced upper rectal adenocarcinoma. METHODS A 69-year-old male patient with a sigmoid colon tumor diagnosed at 13 cm from the anal verge and occupying 90% of the colon lumen. The patient underwent en-bloc Laparoscopic rectosigmoidectomy of the tumor with invasion of the left ureter above the iliac vessels. The left bladder wall demonstrated direct tumor invasion as well. The operation was completed laparoscopically, and a primary, end-to-end coloproctostomy was performed utilizing a double stapled technique. The next steps are demonstrated in the supplemental video forum. Specifically, the urinary tract was reconstructed using transposition of the appendix used as a conduit to bridge the gap from the divided segment of left ureter to the bladder. RESULTS While technically challenging, a laparoscopic re-implantation was successfully performed. The surgery had no intraoperative complications. The operative time was 310 minutes, there was no adverse sequelae, and at 12 month follow up renal scans demonstrated preserved urinary function. CONCLUSIONS This video demonstrates that the laparoscopic use of the cecal appendix in the reconstruction of the left ureter is a possible option and longer follow-up with additional patients is necessary to validate the efficacy of this approach. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e408 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Cinthia Alcántara Q. More articles by this author José Marx Xavier More articles by this author Luis G. C. Rogmanolo More articles by this author Euvaldo Jorge More articles by this author Armando F. Melani More articles by this author Roberto D. Machado More articles by this author Alexandre C. Santos More articles by this author Wesley J. Magnabosco More articles by this author Roberto L. Muller More articles by this author Eliney F. Faria More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Appendiceal Interposition With Right Lower Pole Calycostomy, Downward Nephropexy, and Psoas Hitch for the Management of an Iatrogenic Near-complete Ureteral Avulsion

Although iatrogenic ureteral injuries are rare, they have potentially devastating consequences for both patients and physicians, and their management remains challenging. We report a case of a 51-year-old morbidly obese (body mass index = 63) woman who suffered an iatrogenic 15-cm right ureteral avulsion during hysteroscopic biopsy. Preoperative antegrade and retrograde pyelograms demonstrated no true renal pelvis and a 3-cm blind-ending distal ureteral stump. The patient underwent a right robotic downward nephropexy, psoas hitch, lower pole calycostomy, and 11-cm appendiceal interposition. At 6 months postoperatively, renal scan demonstrated stable right renal function with no evidence of obstruction.

Laparoscopic Ureteroneocystostomy with a Vesicopsoas Hitch in 10 Steps

Study ObjectiveLaparoscopic ureteroneocystostomy with a vesicopsoas hitch has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described this procedure in 10 steps, which could help to understand and perform this procedure. MethodsThis video presents an approach to laparoscopic ureteroneocystostomy with a vesicopsoas hitch, which was clearly divided into 10 steps. The local institutional review board was consulted and ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. The patient cannot be identified, and she gave informed consent. ResultsThe 10 steps are as follows: step 1, identification of the healthy ureter; step 2, identification of the stenotic part; step 3, section of the ureter; step 4, bladder mobilization; step 5, anterior cystostomy; step 6, psoas hitch; step 7, closure of the anterior cystostomy; step 8, posterior spatulation of the ureter; step 9, cystostomy of the superolateral bladder dome; and step 10, ureteral suture to the bladder. ConclusionLaparoscopic ureteroneocystostomy with a vesicopsoas hitch is an effective technique for intrinsic ureteral endometriosis; it usually needs ureteral resection with end-to-end reanastomosis or reimplantation if the anastomosis is in tension. The 10 steps help to perform each part of surgery in logical sequence, making the procedure faster to adopt and learn. The standardization of laparoscopic techniques could help to reduce the learning curve.

A CASE OF URETEROUTERINE FISTULA AFTER CAESAREAN SECTION

The reported incidence rate of iatrogenic ureteral injury is 0.5 to 3% among abdominal surgery. We report a case of ureterouterine fistula after caesarean section. A 38-year-old woman visited our department with a complaint of urinary incontinence without dry time after caesarean section. Several examinations revealed right ureterouterine fistula.Ureteroneocystostomy using psoas hitch and hysterectomy was performed. We found a firm adhesion and stitches around right lower ureter over the uterus, which lead to an additional hysterectomy. After surgery, urinary incontinence had improved. Following two years after surgery, we observed no urinary incontinence or renal dysfunction.

205 - Robotic-Assisted Laparoscopic Management of Bilateral Ureteral Endometriosis: Ureterocystoneostomy with Psoas Hitch

205 - Robotic-Assisted Laparoscopic Management of Bilateral Ureteral Endometriosis: Ureterocystoneostomy with Psoas Hitch