Robot-assisted Ureteral Reimplantation Research Articles

A Systematic Review of Ureteral Reimplantation Techniques in Endometriosis: Laparoscopic Versus Robotic-Assisted Approach.

Introduction: Endometriosis, characterized by the presence of endometrial tissue outside the uterus, includes deep endometriosis (DE), which can affect the urinary tract. Ureteral endometriosis (UE) is a rare but significant manifestation that can lead to ureteral obstruction, hydronephrosis, and potential kidney loss. This systematic review evaluates the effectiveness and outcomes of laparoscopic versus robotic-assisted ureteral reimplantation techniques in patients with UE. Materials and Methods: A systematic literature search was conducted following PRISMA guidelines across PubMed, MEDLINE, Embase, Web of Science, and the Cochrane Library, from inception to July 2024. Studies included patients with UE who underwent ureteral reimplantation using laparoscopic or robotic-assisted techniques. Data on patient demographics, surgical technique, duration of surgery, complications, follow-up duration, and clinical outcomes were extracted and analyzed. Results: Twelve studies met the inclusion criteria, comprising 225 patients in the laparoscopic group and 24 in the robotic-assisted group. Lich-Gregoir ureteral reimplantation, with or without a psoas hitch, was the predominant technique used. The average surgery duration was 271.1 min for the laparoscopic group and 310.4 min for the robotic-assisted group. Recurrence rates for UE were 2.95% for laparoscopic and 5.9% for robotic-assisted procedures. The robotic-assisted group had a significantly shorter hospital stay (6.7 days vs. 9.1 days, p < 0.01). Postoperative complication rates were comparable between the two techniques (p = 0.422). Conclusions: Both laparoscopic and robotic-assisted techniques for ureteral reimplantation in UE are safe and effective, with the choice of technique guided by surgeon expertise and specific clinical scenarios. However, the limited number of robotic cases introduces a bias, despite statistical significance.

VJY04 ICG-guided Robotic-assisted ureteral reimplantation: Video presentation of two cases following radical cystectomy with ileal conduit and neobladder

VJY04 ICG-guided Robotic-assisted ureteral reimplantation: Video presentation of two cases following radical cystectomy with ileal conduit and neobladder

V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS

You have accessJournal of UrologyCME1 Apr 2023V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS Gabriel Frölicher, Christoph Schregel, Yasmin Trachsel, Tutal Mustafa, and Hubert John Gabriel FrölicherGabriel Frölicher More articles by this author , Christoph SchregelChristoph Schregel More articles by this author , Yasmin TrachselYasmin Trachsel More articles by this author , Tutal MustafaTutal Mustafa More articles by this author , and Hubert JohnHubert John More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video presents the surgical technique of robot-assisted ureteral re-implantation for distal ureteral fibrosis after open cystectomy and reconstruction with Studer orthotopic neobladder. A 59-year-old patient underwent open radical cystectomy and orthotopic urinary diversion for muscle-invasive bladder cancer. Postoperatively, left hydronephrosis and pyelonephritis occurred. Antegrade attempts to place an ureteral stent were unsuccessful. A nephrostomy drain was placed in the left side. The patient was then referred for laparoscopic robotic reconstruction. METHODS: The ports were placed in analogy to robot-assisted cystectomy. First an extended adhesiolysis was necessary. The intestinal loops were dissected guided by concomitant cystoscopy which revealed the borders between intestine and bladder wall. Finally, right ureter was identified in the proximity of the afferent loop of the Studer neobladder. After preparing and freeing, the right ureter was intubated with a Ch.8 mono-J catheter. The search for the left ureter continued. The left ureter was localised using Methylene blue applied antegrade by the nephrostomy tube. Several attempts to intubate the left ureter Ch.8 mono-J were frustrane due to the considerable long stricture. Further dissection into the retroperitoneal space was necessary. The ureter seemed totally fibrotic over several centimetres. Finally antegrade left ureteral catheterization and retrograde insertion of a Ch.8 mono-J catheter was successful. Accidental lesions of the afferent loop were closed with a 4-0 PDS suture. The ureters were re-implanted end-to-side with 4-0 Stratafix® running sutures. RESULTS: The patient was discharged on the 7th postoperative day after testing the uretero-neobladder anastomosis through a pouchography and a retrograde ureteropyelography and after removal of both mono-J stents. No perioperative complications were observed. Furthermore, the left renal function showed an increasing function 1 year postoperatively in the renal scintigraphy. CONCLUSIONS: This demanding robotic reconstructive ureteral re-implantation so far shows the feasibility and the clinical value of robotic minimal invasive approaches even in complex reconstructive surgeries after open urinary diversion. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e83 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriel Frölicher More articles by this author Christoph Schregel More articles by this author Yasmin Trachsel More articles by this author Tutal Mustafa More articles by this author Hubert John More articles by this author Expand All Advertisement PDF downloadLoading ...

VJY13 - Use of Indocyanine Green (ICG) in robotic assisted ureteral reimplantation after radical cystectomy

VJY13 - Use of Indocyanine Green (ICG) in robotic assisted ureteral reimplantation after radical cystectomy

Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter

PurposeTo describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants. Materials and methodsBetween April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4–12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented. ResultsAll operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III–IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected. ConclusionOur preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

V10-07 NEAR-INFRARED FLUORESCENCE IMAGING TECHNOLOGY APPLICATIONS IN UROLOGIC SURGERY

You have accessJournal of UrologyCME1 May 2022V10-07 NEAR-INFRARED FLUORESCENCE IMAGING TECHNOLOGY APPLICATIONS IN UROLOGIC SURGERY Riccardo Mastroianni, Gabriele Tuderti, Umberto Anceschi, Alfredo Maria Bove, Aldo Brassetti, Mariaconsiglia Ferriero, Leonardo Misuraca, and Giuseppe Simone Riccardo MastroianniRiccardo Mastroianni More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002623.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Clinical applications of near-infrared fluorescence (NIRF) with Indocyanine green (ICG) technology are rapidly growing. Potential improvements especially for functional outcomes have been described in different urologic procedures. In this video we highlights our experience with multiple clinical applications of NIRF-ICG technology in distinct urologic procedures. METHODS: In this video we collected multiple clinical applications of NIRF technology: ICG-marking of totally endophytic renal tumors selected for partial nephrectomy, assessment of thrombus extent during level III IVC tumor thrombectomy, identification of functioning adenomas during adrenal surgery, assessment of ureteral vascularization during robot assisted radical cystectomy and during ureteral reimplantation, identification of urethra and ejaculatory ducts during Madigan prostatectomy. RESULTS: First, NIRF-ICG technique was demonstrated useful to mark endophytic renal tumors in patients selected for purely off-clamp robotic partial nephrectomy. Lipiodol indocyanine green mixture was selectively delivered in the tertiary ordered arteries feeding the tumor. In this way, the use of NIRF imaging allow to easily recognize endophytic renal tumor. Therefore, parenchyma incision, margins scoring and deep part of enucleation were performed under NIRF imaging. Secondly, intravenous injection of ICG was used during robot-assisted radical nephrectomy with level III IVC tumor thrombectomy in order to better define thrombus boundaries, to control cranial IVC thrombus edge, to expect IVC lumen and to confirm proper restoration of IVC flow. Then, NIRF-ICG technology was used to easily identify hypervascularized adrenal mass during robotic partial adrenalectomy and to evaluate proper perfusion of distal ureters both during RARC and robot-assisted ureteral reimplantation. Finally, NIRF-ICG technology was reported as an essential tool during robot-assisted Madigan prostatectomy when ejaculation preservation is planned. A retrograde injection of ICG throw the urethral catheter placed on navicular fossa allowed to easily recognize proximal prostatic urethra, and therefore to preserve ejaculatory function avoiding unintended violation of the urinary tract. CONCLUSIONS: NIRF-ICG technology sounds a safe and feasible procedure. This technique allows to easy identify key anatomical landmarks, providing information about tissue vasculature and perfusion. NIRF-ICG technique demonstrated to potentially improve functional outcomes of robotic procedures even if larger series with longer follow-up are needed. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e850 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Riccardo Mastroianni More articles by this author Gabriele Tuderti More articles by this author Umberto Anceschi More articles by this author Alfredo Maria Bove More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF DownloadLoading ...

Hospital Ownership, Geographic Region, Patient Age, Comorbidities, and Insurance Status Appear to Influence Patient Selection Robot-Assisted Ureteral Reimplantation for Benign Disease: A Population-Based Analysis.

Background: Robot-assisted ureteral reimplantation (RAUR) is a relatively new minimally invasive procedure. As such, research is lacking, and the largest adult cohort studies include fewer than 30 patients. Our aim was to be the first population-based study to report on national utilization trends, factors associated with patient selection, inpatient outcomes, and the relative cost of RAUR for adults with benign ureteral disease (BUD). Materials and Methods: The National Inpatient Sample (2010-2015) was queried to identify all elective, nontransplant-related, open and robot-assisted reimplants for adult BUD. Survey-weighted logistic regression using Akaike Information Criterion identified patient-/hospital-level factors associated with robotic procedure. Survey-weighted regression models examined the association of robotic procedure with outcomes and charges. Results: A weighted total of 9088 cases were included: 1688 (18.6%) robot assisted and 7400 (81.4%) open. There were significantly increased odds of RAUR across consecutive years (odds ratio [OR] = 3.0, p < 0.001) and among patients operated on at private for-profit hospitals (OR: 2.1; p = 0.01), but significantly decreased odds among older patients (OR = 0.98, p < 0.001), those with Medicaid (OR = 0.5, p = 0.02), those with 2+ comorbidities (OR = 0.6, p = 0.009), and those operated on in western (OR = 0.5; p = 0.005) states. RAUR was significantly associated with a reduced length-of-stay (incidence rate ratio: 0.60; p < 0.001), decreased odds of blood transfusion (OR = 0.40; p < 0.001), and a lower mean ratio of total hospital charges (ratio: 0.71; p = 0.006). Conclusions: This is the first population-based study to report on the utilization and clinical benefits of RAUR for adult BUD. Open reimplantation remains the most common surgical technique utilized, despite the potential benefits of RAUR. Future research is needed to explore the mechanisms behind patient-/hospital-level factors and surgical selection. Work to investigate potential barriers in access to robotic procedure can help us provide equitable care across patient populations.

V02-04 ROBOT-ASSISTED MANAGEMENT OF URETERAL COMPLICATIONS IN KIDNEY TRANSPLANT PATIENTS: CASE SERIES AND DESCRIPTION OF SURGICAL TECHNIQUES

You have accessJournal of UrologyMisc. Benign Disease & Transplant & Renovascular (V02)1 Sep 2021V02-04 ROBOT-ASSISTED MANAGEMENT OF URETERAL COMPLICATIONS IN KIDNEY TRANSPLANT PATIENTS: CASE SERIES AND DESCRIPTION OF SURGICAL TECHNIQUES Joris Vangeneugden, Charles Van Praet, Liesbeth Desender, Caren Randon, Steven Van Laecke, Patrick Peeters, Evi Nagler, Jill Vanmassenhove, and Karel Decaestecker Joris VangeneugdenJoris Vangeneugden More articles by this author , Charles Van PraetCharles Van Praet More articles by this author , Liesbeth DesenderLiesbeth Desender More articles by this author , Caren RandonCaren Randon More articles by this author , Steven Van LaeckeSteven Van Laecke More articles by this author , Patrick PeetersPatrick Peeters More articles by this author , Evi NaglerEvi Nagler More articles by this author , Jill VanmassenhoveJill Vanmassenhove More articles by this author , and Karel DecaesteckerKarel Decaestecker More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001979.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral complications following renal transplant procedures are common and mainly include urinary leaks, ureteral stenosis, vesicoureteral reflux (VUR) and acute graft pyelonephritis. First approaches for the management of stricture and VUR include, respectively, percutaneous balloon dilation with or without laser incision and endoscopic injection of dextranomer/hyaluronic acid copolymer. In case of recurrence after a primary endourological approach, a stricture >1cm or complex anatomy in transplant patients, ureteral reimplantation should be performed. A robotic approach may reduce morbidity in a fragile transplant population. We describe our case series and surgical video of robot-assisted ureteral reimplantation in kidney transplant patients. METHODS: We present 20 renal transplant patients who suffered from ureteral complications: 15 with VUR and 5 with ureteral stenosis. Given the complex anatomy and/or failed first endoscopic treatments, ureteral reimplantation was indicated in all cases. As each case had a unique indication and anatomy, five different surgical approaches were used, as displayed in the video: Lich-Gregoir non-dismembered and dismembered, uretero-ureterostomy, and ipsilateral and contralateral pyelo-ureterostomy. All surgeries were performed using the Da Vinci Xi® robot. RESULTS: All surgeries were completed successfully without intraoperative complications. Median pre- and postoperative (3 months) GFR values were 53 ml/min (IQR 30-70) and 55 ml/min (IQR 43-66) respectively in patients who suffered from VUR and 29 ml/min (IQR 22-36) and 35 ml/min (IQR 29-49) in patients who suffered from stenosis. Median hospital stay was 3 days (IQR 2-4). One patient had postoperative laryngeal edema requiring intensive care admission (Clavien-Dindo grade 4), one patient needed repositioning of a dislocated JJ stent (grade 3b), one patient had erysipelas of the left arm and one patient had febrile urinary tract infection within 90 days requiring antibiotics (both grade 2). No other complications occurred and all patients were free from nephrostomy tube or double J stent at a median follow-up of 12 months (IQR 7-19). CONCLUSIONS: We demonstrate the safety, feasibility and surgical technique of robot-assisted ureteral reimplantation options in kidney transplant patients. This approach allows for high-quality realignment of the urinary tract, a quick recovery with low complication rate and preserved renal function in a fragile renal transplant population. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e134-e134 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joris Vangeneugden More articles by this author Charles Van Praet More articles by this author Liesbeth Desender More articles by this author Caren Randon More articles by this author Steven Van Laecke More articles by this author Patrick Peeters More articles by this author Evi Nagler More articles by this author Jill Vanmassenhove More articles by this author Karel Decaestecker More articles by this author Expand All Advertisement Loading ...

Robot-Assisted Ureteral Reimplantation: A Single-Center Comparative Study.

Background: Aim of this study was to report a single-center experience with robot-assisted ureteral reimplantation (RAUR) and to compare its outcomes with those of open ureteral reimplantation (OUR). Materials and Methods: Patients who underwent RAUR or OUR for ureteral disease between 2016 and 2020 were identified. Data collected included baseline, pathologic, perioperative, and postoperative features. The RAUR outcomes were compared with those of OUR. Results: Overall, 21 (42.8%) patients underwent RAUR, and 28 (57.2%) underwent OUR. The two groups were similar in terms of baseline and pathologic characteristics. There was a statistically significant difference in favor of RAUR for median operative time (216 vs 317 minutes, p = 0.01) and median blood loss (35 vs 175 mL, p = 0.001). No difference was observed in overall complication rate (33.3% vs 46.4%, p = 0.9), as well as major complications (Clavien-Dindo≥III grade) rate between RAUR and OUR groups. Median length of stay was shorter for RAUR (2 vs 6 days; p = 0.001), as well as median catheterization time (16 vs 28 days; p = 0.005). Conclusions: RAUR is a safe and effective minimally invasive surgical procedure for the management of mid to distal ureteral strictures. It can recapitulate the success rate of the gold standard OUR while offering a benefit in terms of lower surgical morbidity and faster postoperative recovery.

31 Pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy: A video case presentation

This presentation discusses a rare case of pessary incarceration complicated by vesicovaginal fistula requiring ureteroneocystostomy. The patient is an 81-year-old who presented to the office with continuous leakage of urine. She had a history of pelvic organ prolapse that was treated with a Gellhorn pessary for the past 5 years, however, she was lost to follow-up 2 years ago. On physical examination and cystoscopy, the patient’s pessary was found to be eroded into the bladder near the trigone. Office removal of the pessary was not possible. The patient initially underwent pessary removal under anesthesia with repair of her vesicovaginal fistula. On cystoscopy prior to and after the procedure, no efflux of urine was seen from the left ureter. A CT urogram performed on post-operative day 1 demonstrated hydronephrosis with obstruction of the left ureter, so a left nephrostomy tube was placed. A second CT urogram several weeks later demonstrated recurrence of the vesicovaginal fistula. One month following the initial procedure, she underwent a robotic-assisted ureteroneocystostomy with psoas hitch and vesicovaginal fistula re-closure. A postoperative CT urogram demonstrated patency of both ureters without leakage. Three weeks post-operatively she had only minor complaints, and denied leakage of urine from the vagina. A plan was made to repeat the CT urogram in 3 weeks and hopefully remove the left ureteral stent placed during her second surgery. This video enforces the importance of regular pessary follow-up, and highlights a rare but serious complication that could develop. It also showcases careful technique for robotic-assisted ureteral re-implantation.

Robotic-assisted ureteral reimplantation and psoas hitch after ureteral injury during cesarean section.

Ureteral injury during gynecological surgery can be managed in a variety of ways, from endoscopic stent placement to ureteroneocystotomy with accompanying psoas hitch and/or Boari flap. The majority of these occur during hysterectomy; therefore, gynecologic surgeons may not be as familiar with repair in women with intact uteri. Herein we present our technique for delayed robotic-assisted ureteral reimplant and psoas hitch in a woman with a ureteral injury sustained during cesarean section, which initially presented as a uretero-cervical fistula. In this video, we describe the evaluation and surgical management of a patient with delayed recognition of a left distal ureteral injury sustained during cesarean section. We present necessary modifications to robotic-assisted laparoscopic ureteroneocystostomy and psoas hitch to accommodate an intact uterus including the need for uterine manipulation, division of the round ligament, bladder mobilization from the lower uterine segment and development of the retropubic space, reimplantation steps, and psoas hitch. Simple modifications to a traditional technique of robotic-assisted ureteroneocystotomy effectively compensate for the presence of a uterus. Obstetricians should maintain a high index of suspicion for ureteral injury in women with new-onset severe urinary leakage post-cesarean section.

Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP® surgical system.

To describe the step-by-step techniques for robot-assisted ureteric reimplantation performed using the Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA), including different case scenarios with an educational purpose. Three consecutive patients diagnosed with distal benign ureteric strictures were counselled for ureteric reimplantation and consented to undergo surgery performed using the da Vinci SP surgical system. Demographics and peri-operative outcomes were collected after institutional review board approval (IRB 13-780). Patients provided informed consent having received an explanation for the adoption of the novel platform. The first patient was a woman referred to our institution for a left distal ureteric stricture after total hysterectomy for uterine fibroids with ureteric injury. The second patient was a man with BPH and recurrent UTIs, who was diagnosed with a 1.5-cm bladder stone and a large bladder diverticulum compressing the left distal ureter. The third patient was a man diagnosed with bilateral uretero-enteric anastomoses stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion for bladder cancer. The procedures were successfully completed. An extra port through a separate skin incision for the bedside assistant was placed for the first two procedures. In such cases, this additional port was used electively from the start of the procedure and did not represent a change in the treatment plan. Moreover, the port wound was used to accommodate the drainage. The bilateral ureteric reimplantation, however, was completed according to a pure single-site approach (no extra ports were placed out of the GelSeal cap). The mean operating times were 165, 150 and 180 min, respectively. Blood loss was 50 mL in all cases. No intra-operative complications occurred. Patients were discharged on postoperative days 1, 1 and 2, respectively, with normal serum creatinine levels. Neither transfusions nor major complications occurred. Robot-assisted reconstructive surgery for benign distal ureteric strictures is feasible and safe using the da Vinci SP surgical system.

V49 - Robot-assisted ureteral reimplantation with psoas hitching

V49 - Robot-assisted ureteral reimplantation with psoas hitching

Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux

Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide 'pneumovesicum'. To review outcomes of vesicoscopic cross-trigonal ureteral reimplantation and compare them with other minimally invasive approaches for the correction of reflux. All patients who underwent VR at the current institution were retrospectively reviewed. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome, and complications. The series consisted of 182 consecutive patients who underwent VR. There were 165 girls and 17 boys. Mean age was 7.03 years (range 16 months-38.2 years). Fifteen had failed prior injection therapy. Of the 182 patients, 135 underwent bilateral repairs and 47 unilateral. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Major complications included two ureteral obstructions: one resolved with stent placement and the other underwent re-operative reimplantation. Postoperative voiding cystourethrogram (VCUG) was obtained in 100 patients and was normal in 93 (93%). Four of these failures occurred in the first 30 patients. Of the last 49 patients tested, 48 were normal, suggesting a 98% effective success rate after the learning curve. Vesicoscopic ureteral reimplantation is an approach that completely recreates all aspects of open cross-trigonal repair. Complications were uncommon and success rates were very high in the current study. Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. After the learning curve at the current institution, success rates were found to be equivalent to open repair and were higher than published reports of robot-assisted procedures.

Robot-assisted Transplanted Ureteral Stricture Management

To assess the feasibility of robot-assisted transplanted ureteral reimplantation as a minimally invasive alternative to open surgery. Between August 2015 and March 2016, 5 patients presented with transplanted ureteral strictures after failure of a previous endoscopic management. All patients underwent robot-assisted ureteral reimplantation. Patients' demographics, perioperative outcomes, and complications are reported. All patients presented with deterioration of kidney function with or without recurrent urinary tract infection. Two patients had short strictures (<1 cm) and 2 had long strictures (>1 cm), whereas 1 patient had a nitinol ureteral stent in situ. The location of the stricture varied among these patients with 3 distal and 1 proximal. Intraoperatively, 3 patients had a modified Lich-Gregoir reimplantation and 2 patients had a pyelovesicostomy. The mean operative time was 164 (±52) minutes. There were no intraoperative complications, conversion to open surgery, or significant blood loss necessitating blood transfusion. There were no urine leaks in the immediate or late postoperative period. One patient developed a Clavien grade IVa complication (sepsis). The median length of stay, the duration of catheterization, and the duration of stenting were 1 day (range 1-5 days), 7 days (range 6-14 days), and 39 days (range 25-51 days), respectively. After a median follow-up of 79 days (range 40-139 days), no strictures or delayed leakages were identified. Robot-assisted transplanted ureteral reimplantation is technically feasible. With a larger number of cases and a longer follow-up, robot-assisted transplanted ureteral reimplantation may provide a new and effective, minimally invasive alternative for the treatment of this complex surgical problem.

Commentary to “Robotic versus open pediatric ureteral reimplantation: Costs and complications from a nationwide sample journal of pediatric urology”

Kurtz et al. [1] present a cautionary report comparing outcomes and costs associated with robot-assisted ureteral reimplantation (RALUR) after examining data contained within the Premier administrative database. The authors’ analysis demonstrates that RALUR is associated with a higher rate of complications and higher direct costs, compared to open ureteral reimplantation (OUR). Any study entirely predicated on a selfreported database with a geographic propensitydthe Premier database consists heavily of southern US small and mid-size hospitalsdcontains inherent bias, and they are manifest in this study. Still, in offering significant, though mostly intuitive, information related to cost and complications, this study reconfirms that RALUR is still a novel therapeutic modality, only recently being implemented at most institutions. As Kurtz et al. [1] report, 51% of the entire RALUR cohort analyzed for this study was accrued in the penultimate and final year of the study (2012e2013). And since the overall number of RALUR patients is very small (only 2.5% of the entire study population underwent RALUR), a comprehensive analysis is precluded. For example, although any new highly technical surgical procedure is associated with a steep learning curve, the small RALUR cohort precludes a power analysis of annual data trends to determine if increasing experience improves outcomes. The present analysis also cannot quantify the potential gains that are known to favor RALUR such as reduced

VE53 - Robot-assisted ureteral re-implantation with psoas hitching

VE53 - Robot-assisted ureteral re-implantation with psoas hitching

Robot-Assisted Ureteroileal Reimplantation for Postcystectomy Anastomotic Stricture

Introduction and Objectives: Ureteroileal anastomatic strictures after robot-assisted radical cystectomy (RARC) occur at a rate of 4% to 9% and pose a challenge in management. Although open surgical repair remains the standard treatment for anastomotic strictures, we present a case of effective postcystectomy robot-assisted laparoscopic ureteroileal reimplantation. Materials and Methods: Our patient is a 65-year-old woman with high-grade muscle-invasive urothelial carcinoma who underwent RARC and intracorporeal ileal conduit urinary diversion. Three months postoperatively, the patient developed recurrent urinary tract infections that necessitated hospital admission for left pyelonephritis. CT scan displayed left hydronephrosis and hydroureter. Antegrade nephrostogram revealed a complete ureteroileal anastomatic stricture, with confirmed severe obstruction on MAG-3 renal scan and left differential renal function of 16%. After failure of endoscopic dilation, the patient underwent exploratory laparoscopy and robot-assisted left ureteral reimplantation. Laparoscopic ports were placed similarly to RARC. We performed a lysis of adhesions and identified the proximal end of the ileal conduit, where the distal ureters were identified among significant fibrosis. We isolated each ureter separately and mobilized the left ureter posterior to the sigmoid colon using sharp dissection. We incised into the proximal end of the ileal conduit and confirmed identification of the left ureter through the protruding preplaced stent. We then ligated the distal most aspect of the left ureter after a frozen section confirmed no recurrence of tumor and advanced a guidewire through the conduit into the left distal ureter and renal pelvis. The ureter was spatulated and we completed a new left ureteroileal anastomosis over a Double-J stent using two running 4-0 Vicryl sutures. Results: Our operative time was just under 4 hours with an estimated blood loss of 100 mL. Jackson–Pratt (JP) drain was maintained until discharge on postoperative day 4. There were no intraoperative or postoperative complications. Five-month follow-up revealed marked improvement of left hydronephrosis on renal ultrasound and absence of obstruction on MAG-3 renal scan with a t½ of 8 minutes. Left renal function stabilized at 19%. Conclusions: Robot-assisted ureteral reimplantation for management of postcystectomy ureteroileal anastomatic stricture is feasible and safe in experienced hands. No competing financial interests exist. Runtime of video: 7 mins 56 secs

Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population

While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair. Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum. Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6±6.5 months. The RALUR children were significantly older (9.3±3.7 years) than the OUR patients (3.1±2.7 years; P<0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3±0.7 days; P=0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P=1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P=1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux. Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure. Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.

Extracorporeal ureteral tailoring during HIDES laparoscopic robotic-assisted ureteral reimplantation for megaureter

Although laparoscopic robotic-assisted intracorporeal ureteral tailoring is feasible and several authors have reported doing it, it adds a level of complexity to the surgery that many robotic surgeons are uncomfortable with. Also, some techniques for tailoring the ureter, like the one described by Ossandon, would be very difficult to perform intracorporeally or violate principles of hidden incision endoscopic surgery (HIDES) by adding extra ports in visible locations. Extracorporeal ureteral tapering is performed by extracting the ureter through a 10-mm step trocar placed in the midline at the level of the biking line. Once the ureter is tapered and a stent has been secured, the 10-mm trocar is replaced and the rest of the reimplant is performed in a way very similar to when performing a robotic apendicovesicostomy. Extracorporeal ureteral tailoring can be added to the bag of tricks that robotic surgeons can resort to when faced with the situation of a dilated ureter without compromising cosmesis.