Total Console Time Research Articles

Deconstructing the Operative Times of Robotic Pancreaticoduodenectomy.

Despite numerous benefits offered, robotic procedures take longer than "open" procedures. With the intent to reduce operative duration, we examined the degree each operative step contributes to operative duration in robotic pancreaticoduodenectomy. With IRB approval, we prospectively followed 88 patients to determine the duration of robotic pancreaticoduodenectomy, and the duration of 12 key steps. Each operative step was regressed against the operation date, from most distant to most recent operation date. Data are presented as median (mean ± SD) for illustrative purposes. Patients were 73 (71 ± 10.2)years old; 53% were men. Total time patient spent in the operating room was 471 (488 ± 93.3)minutes. Total operative time was 399 (421 ± 90.7)minutes. Total console time was 293 (297 ± 68.0)minutes. The 3 longest portions of the operation were (1) mobilization of the specimen and specimen extraction; (2) construction of the duodenojejunostomy; and (3) closure. A third of the operative time is spent off the console. Over half of the steps required more than 20minutes each to complete. Since robotic operations are associated with shorter LOS and without increased complication rates relative to "open" operations, salutary benefit can be gained by decreasing operative times of robotic procedures. Operative duration is an important metric that needs to be addressed. We need to target the most time-consuming steps, and break them into smaller pieces, to reach optimal efficiency and provide the benefits of decreased operative duration to the patients, hospitals, and providers.

Total robotic liver transplant: the final frontier of minimally invasive surgery

The use of robotic surgery in transplantation is increasing; however, robotic liver transplantation (RLT) remains a challenging undertaking. To our knowledge, this is a report of the first RLT in North America and the first RLT using a whole graft from a deceased donor in the world. This paper describes the preparation leading to the RLT and the surgical technique of the operation. The operation was performed in a 62-year-old man with hepatitis C cirrhosis and hepatocellular carcinoma with a native Model for End-Stage Liver Disease score of 10. The total console time for the operation was 8 hours 30 minutes, and the transplant hepatectomy took 3 hours 30 minutes. Warm ischemia time was 77 minutes. Biliary reconstruction was performed in a primary end-to-end fashion and took 19 minutes to complete. The patient had an uneventful recovery without early allograft dysfunction or surgical complications and continues to do well after 6-months follow-up. This paper demonstrates the feasibility of this operation in highly selected patients with chronic liver disease. Additional experience is required to fully understand the role of RLT in the future of transplant surgery. Narrated video is available at https://youtu.be/TkjDwLryd3I.

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.

Comparison of Short-Term Surgical Outcomes of Two Types of Robotic Gastrectomy for Gastric Cancer: Ultrasonic Shears Method Versus the Maryland Bipolar Forceps Method

BackgroundThis study investigated the impact and short-term surgical outcomes of two different main energy devices for robotic gastrectomy for gastric cancer. The outcomes of robotic gastrectomy with ultrasonic shears and those of robotic gastrectomy with conventional forceps were compared. MethodsWe retrospectively evaluated 171 patients who underwent robotic distal gastrectomy or total gastrectomy for gastric cancer. We classified patients into the ultrasonic shears (US) and Maryland bipolar (MB) forceps groups according to the main energy device used for robotic gastrectomy. ResultsWe extracted 58 patients from the US group and 58 patients from the MB forceps groups using propensity score matching. The total console time (310 min [interquartile range (IQR), 253–369 min] and 332 min, [IQR, 294–429 min]; p = 0.022) and the console time to gastrectomy (222 min [IQR, 177–266 min] and 247 min [IQR, 208–321 min]; p = 0.004) were significantly shorter in the US group than in the MB forceps group. Less blood loss occurred in the US group than in the MB forceps group (20 mL [IQR, 10–40 mL] and 30 mL [IQR, 16–80 mL]; p = 0.014). The postoperative complication rate and postoperative hospital stay length were similar between groups. A multivariate multiple linear regression analysis demonstrated that the use of an ultrasonically activated device was one an independent factor that reduced the operative time of robotic gastrectomy. ConclusionUsing ultrasonic shears as the main energy device may contribute to better surgical outcomes after robotic gastrectomy for gastric cancer.

P06.07 Learning Curve in Robotic-Assisted Thoracoscopic Pulmonary Resection: Experience of a Brazilian Surgeon

The learning curve for robotic-assisted thoracoscopic (RATS) lung resection is yet to be defined, being suggested between 20 to 40 procedures to achieve proficiency. The generability of this data in Brazil is limited due to differences between publications’ methods and the Brazilian thoracic surgeon daily practice. The aim of this study is to determine how many resections are needed for proficiency in Brazil, comparing the patients’ characteristics and postoperative outcomes during the learning curve evolution. Retrospective study based in a prospective RATS database. We included patients who underwent anatomic lung resection performed by the main author between March 2015 and December 2020. Patients missing data regarding total duration of surgery and total console time were excluded. Scatterplots were used to determine the number of procedures to achieve proficiency. We divided the patients in tertiles, with the first one comprising the patients treated before proficiency, and the rest of them evenly distributed in the other tertiles. Subsequently we compared the groups regarding patients’ characteristics and postoperative outcomes. A total of 268 patients were included. The scatterplot revealed a learning curve of 20 procedures. There was no statistical difference regarding patients’ characteristics and outcomes between the groups, except for ASA classification (p<0.001). There was no mortality in 30 days in our study. Lobectomy was the main resection performed, with an increase without statistical significance in the complexity of resections. The total console time and total duration of surgery decreased across the learning curve (204 to 110 minutes, p<0.001 and 272.50 to 157 minutes, p<0.001, respectively),Table 1Patients characteristics and postoperative outcomesCharacteristics (268)1º tertile2º tertile3º tertilep valueFemale sex (n=268)6 (30.00)65 (52.00)70 (56.91)0.081Age (n=268)67.47 [58.06-71.18]65.72 [57.96-70.56]66.00 [59.00-72.00]0.817VEF1 (%) (n=181)81 [71-98]88 [78.5-97]88.5 [80-100]0.310Smoking history (n=257)15 (75.00)65 (54.62)55 (46.61)0.052CPOD (n=256)7 (35.00)18 (15.38)25 (21.01)0.106Hipertension (n=255)12 (60.00)56 (48.28)57 (47.90)0.591Cardiac disease (n=256)3 (15.00)18 (15.38)20 (16.81)0.949Diabetes (n=256)3 (15.00)17 (14.53)23 (16.80)0.600Renal disease (n=256)2 (10.00)4 (3.42)1 (0.84)0.056Diagnosis (n=252) Benign Adenocarcinoma Epidermoid Neuroendocrine tumor Pulmonary metastasis0 (0.00) 17 (85.00) 2 (10.00) 0 (0.00) 1 (5.00)7 (5.79) 88 (72.73) 7 (5.79) 12 (9.92) 7 (5.79)8 (7.21) 79 (71.17) 7 (6.31) 10 (9.01) 7 (6.31)0.817ASA (n=255) 1 2 313 (65.00) 6 (30.00) 1 (5.00)32 (27.83) 72 (62.61) 11 (9.57)18 (15.00) 92 (76.67) 10 (8.33)<0.001Pathological Staging 0 IA1 IA2 IA3 IB IIA IIB IIIA IIIB0 (0.00) 0 (0.00) 6 (31.58) 5 (26.32) 2 (10.53) 1 (5.26) 2 (10.53) 2 (10.53) 1 (5.26)7 (6.80) 20 (19.42) 32 (31.07) 14 (13.59) 11 (10.68) 0 (0.00) 6 (5.83) 10 (9.71) 3 (2.91)4 (5.33) 22 (29.33) 15 (20.00) 6 (8.00) 15 (20.00) 1 (1.33) 6 (8.00) 4 (5.33) 2 (2.67)0.098Resection (n=268) Lobectomy Lobectomy with bronchoplasty Segmentectomy Bilobectomy Pneumonectomy20 (100.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00)93 (74.40) 3 (3.23) 31 (24.80) 1 (0.80) 0 (0.00)90 (73.17) 2 (2.22) 31 (25.20) 1 (0.81) 1 (0.81)0.236Number of lymph nodes evaluated (n=227)12 [7,5-14]11 [7-15]7.5 [6-11]0.001Number of stations evaluated (n=226)5 [4.5-6]6 [5-7]6 [5-7]0.082Total duration of surgery (n=268)272.50 [204.50-327.50]170 [130-205]157 [132-190]<0.001Total console time (n=268)204 [137.50-251.50]130 [90-160]110 [85-140]<0.001Days of chest tube drainage (n=255)2 [1-2]2 [1-3]1.5 [1-3]0.217Length of stay (n=254)3 [2-4]3 [2-5]3 [2-5]0.820Discharge with chest drainage (n=256)1 (5.00)7 (5.65)3 (2.68)0.485Complications (n=257)3 (15.00)26 (21.14)24 (20.62)0.892 Open table in a new tab Despite the differences in the daily practice, our learning curve was comparable to the literature, achieving proficiency after 20 lung resections. The group treated more recently presented higher functional limitation, however, the safety of the procedure was stable over time, with no increase in postoperative morbidity.

V09-10 URETERAL SIDE-TO-SIDE ANASTOMOSIS FOR TRANSECTING INJURY OF COMPLETELY DUPLICATED COLLECTING SYSTEM

You have accessJournal of UrologyUpper Tract Reconstruction (V09)1 Sep 2021V09-10 URETERAL SIDE-TO-SIDE ANASTOMOSIS FOR TRANSECTING INJURY OF COMPLETELY DUPLICATED COLLECTING SYSTEM Randall Lee, Aeen Asghar, David Strauss, Michael Metro, and Daniel Eun Randall LeeRandall Lee More articles by this author , Aeen AsgharAeen Asghar More articles by this author , David StraussDavid Strauss More articles by this author , Michael MetroMichael Metro More articles by this author , and Daniel EunDaniel Eun More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002052.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Iatrogenic injuries commonly occur at the distal ureter. The gold standard for distal ureteral injury is ureteroneocystotomy, however new techniques such as side-to-side (StS) anastomosis have demonstrated safe and comparable outcomes. In a duplicated collecting system, two ipsilateral ureters may drain the kidney into the bladder independently or as a single common ureter which may complicate preoperative planning for ureteral reconstruction. Currently limited literature exists regarding iatrogenic distal ureteral injuries to duplicated collecting systems. METHODS: 51 year old female with a history of left robot assisted hysterectomy which was complicated by flank pain post operatively. Imaging work up revealed a duplicated left collecting system with left hydronephrosis concerning for ureteral injury and obstruction. After failed ureteral stent placement patient underwent percutaneous nephrostomy drainage of both left renal moieties. Patient was evaluated and scheduled for a robotic ureterolysis and reconstruction, and ultimately underwent a robotic assisted side-to-side anastomosis and ureteroneocystotomy as described in our video. RESULTS: Total console time was 241 minutes with an estimated blood loss of 150 mL. There were no intraoperative complications. Patient was discharged with ureteral stent and foley on post operative day one. On follow up, patient with no clinical or radiographic evidence of left ureteral obstruction. CONCLUSIONS: We demonstrate that robot-assisted StS ureteral anastomosis with an intravesical non-refluxing ureteroneocystotomy in a duplicated collecting system is a safe and effective option. This technique allows maximal preservation of ureteral perfusion and reimplantation of one ureter. ICG helps facilitate ureteral dissection and assess ureteral blood supply intraoperatively to aid in successful reconstruction. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e690-e690 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Randall Lee More articles by this author Aeen Asghar More articles by this author David Strauss More articles by this author Michael Metro More articles by this author Daniel Eun More articles by this author Expand All Advertisement Loading ...

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population.

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

RSILS: initial clinical experience with single-port robotic (SPr) right colectomy.

The da Vinci Single-Port (SP) robot is a novel platform designed to facilitate single-incision robotic surgery (rSILS). The objective of this study was to describe our initial experience using this platform for SP robotic (SPr) right colectomy. Under a Food and Drug Administration-regulated feasibility study and Institutional Review Board approval, a patient with cecal adenocarcinoma underwent an SPr right colectomy. The primary endpoint was the safety and feasibility of the first SPr right colectomy performed in the USA. Secondary endpoints included perioperative metrics, morbidity and mortality. An SPr Standard right colectomy was performed through a 4-cm single incision without the need for conversion or additional port placement. Estimated blood loss was 100mL and there were no intraoperative complications. The robot was docked once with a docking time of 19min. Total console time was 116min and operative time was 219min. The patient tolerated clear liquids on postoperative day (POD) 0 and a low-residue diet on POD 1. The patient had flatus and a bowel movement on POD 1. She was discharged home on POD 3. Final pathology showed pT3N0 cecal adenocarcinoma with negative margins and 0/24 lymph nodes positive for disease. Our initial experience demonstrates that an SPr right colectomy is feasible and can be safely completed. We completed an oncologic resection of a cecal adenocarcinoma without complications. The SP robot facilitates the utilization of robotic technology in a single-incision platform to perform colorectal procedures and offers promising benefits in the advancement of robotic surgery.

Da Vinci Single-Port robot-assisted transanal mesorectal excision: a promising preclinical experience

IntroductionRobotic single-port platforms represent a viable option for advanced surgical procedures. This preclinical study investigated the dual-field, single-port, robot-assisted transanal total mesorectal excision (taTME).TechniqueIn a male human cadaver, we employed the novel da Vinci® SP™ Surgical System, sequentially, to realize the transanal and abdominal parts of the taTME procedure. We evaluated the feasibility of the one-team approach.ResultsWe showed that single-port access for the taTME was technically feasible with the current da Vinci® SP™ Surgical System in both surgical fields. The total console times were 189 min for the juxta-anal purse-string suture placement, partial intersphincteric resection, and bottom-up mesorectal dissection to where it meets the peritoneal reflection and 43 min for the abdominal procedure. A good quality specimen was achieved. The surgeon comfort was high during simulated surgery. The task load was highly acceptable (NASA-TLX global score: 35), even though it was the surgeon’s first use of this platform.ConclusionThis preclinical study demonstrated that the robotic, single-port taTME was feasible and could be performed with the da Vinci® SP™ Surgical System, beginning at the level of the dentate line. Further simulations are necessary to confirm this promising approach.

V03-07 TECHNICAL CAVEATS IN ROBOT-ASSISTED RADICAL NEPHROURETERECTOMY WITH RETROPERITONEAL LYMPHADENECTOMY FOR POST CHEMOTHERAPY UPPER TRACT UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVE: Upper tract urothelial carcinoma (UTUC) forms 5% of all urothelial cancers.Urothelial carcinoma has been known for tumors developing lymphatic metastases at a relatively high incidence of 20–30%. Post chemotherapy UTUC with residual lymph nodes represents a distinct surgical challenge because of severe desmoplastic reactions. Radical nephroureterectomy with retroperitoneal lymphadenectomy provides a technically feasible and safe option in such patients. A robotic approach is being increasingly used to perform this complex oncologic procedure in view of its distinct advantages. We hereby present a video of robot assisted radical nephroureterectomy with retroperitoneal lymph node dissection for post chemotherapy UTUC and discuss a few points of technique related to it. METHODS: A 64 year female was incidentally found to have left renal pelvis urothelial carcinoma. CECT KUB revealed a poorly defined mildly enhancing lesion distending the left renal pelvis and left upper ureter. Multiple retrocaval lymph nodes was present. Left ureteroscopy showed upper ureteric and pelvis wall thickening with 2-3 cm sized protruding mass in the left renal pelvis. Biopsy was taken which came out as high grade urothelial carcinoma. Chemotherapy (Gemcitabine + Cisplatin) x 3 cycles was given after which FDG avidity and number of lymph nodes decreased. Transperitoneal robot assisted radical nephroureterectomy with retroperitoneal lymphadenectomy was then performed. Patient was first placed in standard left lateral position. Pneumoperitoneum created using Veress needle. Standard right kidney 7 ports made, 4 of 8 mm, 1 of 5 mm and 2 of 12 mm. Da Vinci Xi docked. Right colon reflected along the white line of Toldt, duodenum kocherized. Right gonadal vein identified, traced up, clipped and divided. IVC dissected, pre caval, para caval and inter aortic caval lymph node dissection done till proximal right common iliac vein (crossing of ureter). Right renal vein dissected gently and lymph node tissue behind renal vein removed. Large lymphatic vessels clipped before cutting.Hemostatsis confirmed. Robot undocked, ports removed and closed, keeping 2, 12 mm assitant port in situ. Patients position changed to right lateral decubitus. Standard left kidney 4 robotic ports inserted. Left ureter and gonadal vein identified and lifted. Pre and para aortic lymph node dissection done till left proximal common iliac artery (crossing of ureter) with the combination of sharp and blunt dissection. Renal vein identified and Hilar dissection done. Gonadal vein along with adjacent lymph nodes traced proximaly upto the renal vein where they were ligated and divided. Lumbar veins draining to renal vein clipped and divided. Stapling of renal hilum with endo GIA stapler was done. Ureteric clipping was done before mobilization of kidney. Kidney mobilized from all its attachements. Ureter mobilized as inferiorly as possible. Camera and right robotic arm instruments switched. Left lower ureter dissected. Left ueretrovesical junction identified. Bladder dissected distally and Stay V - loc 3.0 suture taken. Lower end of left ureter removed along with cuff of bladder wall. Bladder closed in one layer with V loc. Haemostasis ensured & drain placed. Robot undocked & Specimen retrieved through a pfannensteil incision. Abdomen closed in layers and ports removed under vision. Port site closed. RESULTS: Total console time was 425 minutes and blood loss was 50ml. Per urethral catheter and drain were removed on POD 5 and 1 respectively. Patient was discharged in stable condition on POD 2. Histopathology revealed urothelial carcinoma-pT3N0M0. CONCLUSIONS: In post chemotherapy UTUC, severe desmoplastic reaction as well as larger-volume residual disease requires more extensive retroperitoneal dissection. This increase the technical demands of the surgery and make it one of the most difficult and dangerous operations. Robot assisted RNU with RPLND remains a technical feasible and safe option in such patients. Source of Funding: None

Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve.

Introduction:The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol.Methods:After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis.Results:Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50–82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191–370) and 80 min (range: 65–90), respectively. The median estimated blood loss was 300 cc (range: 50–500). The median length of stay was 8 days (range: 4–30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1–17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1–34).Conclusions:While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.

Urology robotic journey: demonstrating the learning curve in robot-assisted pyeloplasties (RALP)

The advantages of robot-assisted pyeloplasties (RALP) have been widely documented and increasingly familiar. A ‘learning curve’ (LC) is difficult to define and its objective review remains problematic. We aimed to evaluate the LC, and outcomes, of RALP performed at our newly established robotic centre. After the appropriate training, robot-assisted surgery (RAS) commenced at our centre. A prospective database was maintained regarding demographics and intra-operative timings of all cases, post-operative stay and complications. The data were statistically interrogated and linear regression analysis was performed. Between April 2014 and September 2018, 29 urological RAS were performed including 23 RALP. The total operating and total console times were significantly decreased over time, with no significant differences seen in length of stay or complication rates. Regression analysis predicted achievement of open pyeloplasty time (148 min) at 26 cases and ‘expert’ console time (58 min) by case 34. Median length of stay was 2 days and operative success rate 96%. RAS is proliferating across the globe. LC is difficult to define objectively. We suggest that the points described here in this ‘learning journey’ can be applied to other nascent departments and that RALP is safe and feasible within a developing urology unit.

Robotic Single-Site Plus One Port: Pancreas Enucleation

PurposeLaparoscopic approaches to enucleation of the pancreas have been frequently described. Here we present a case of robotic single-site plus one port pancreas enucleation. To our knowledge, this enucleation surgical technique is the first to be reported in the medical literature. MethodsA 46-year-old male patient without previous medical or surgical history was incidentally diagnosed with a pancreatic mass during evaluation of intermittent right flank pain. Robotic single-site plus one port pancreas enucleation was performed using the Da Vinci single-site surgical platform with one additional port on November 16, 2016. Usual robotic instruments such as hook, bipolar, and vessel sealer with endo-wrist function could be used to facilitate effective surgical procedure with the additional port. The resected specimen was delivered through the umbilicus and a drain was not inserted. ResultsTotal operation time was 124 min with total console time of 73 min. Estimated blood loss was 50 cm3. Final pathology result was neuroendocrine tumor, grade 1. The patient was discharged without any complications on postoperative day #4. ConclusionsRobotic single-site plus one port pancreas enucleation seems feasible with acceptable perioperative outcomes.

Robotic-assisted ipsilateral adrenalectomy after robotic-assisted partial nephrectomy: a case report

Robotic-assisted adrenalectomy (RA) was established since 2001 as an alternative to open and laparoscopic adrenalectomy, although re-operative RA after upper pole partial nephrectomy is uncommon. Here, we describe RA for presumed renal cell carcinoma (RCC) recurrence after ipsilateral upper pole robotic-assisted partial nephrectomy (RPN), using the da Vinci Xi. A 43-year-old male underwent left RPN in November 2017 for a 3.3 cm upper pole enhancing solid renal mass. Pathology revealed clear cell, RCC, FG 2, pT1a, negative margins. Seven months later, routine surveillance CT scan demonstrated a 2.09 cm enhancing left adrenal nodule, suspicious for recurrent RCC. MRI was performed and confirmed the presence of enhancing adrenal nodularity suspicious for tumor recurrence. Percutaneous biopsy of the adrenal lesion was performed and it was inconclusive. The multidisciplinary tumor board recommended excision, and a robotic approach was selected. The RA was performed using three 8 mm robotic Xi trocars, one midline 12 mm blunt tip Hasson trocar, and one 5 mm AirSeal trocar for assistant ports. The 8 mm robotic Xi instruments (fenestrated bipolar forceps, monopolar curved scissors and permanent cautery hook) were used during the procedure. Total operation time was 249 minutes. Total console time was 134 minutes. Blood loss was 250 mL and there were no complications. He was discharged on post-operative day one. Pathology showed adrenal gland without significant histopathological changes. The gland measured 8.3 cm × 7.6 cm × 2.8 cm and weighed 63.2 grams. The final pathology report showed that there was no evidence of involvement by RCC. The post-operative course was unremarkable. The da Vinci Xi RA is a safe and feasible procedure for adrenal masses after ipsilateral RPN. Surgeons attempting the procedure should be comfortable with the inflammation and adhesions encountered in re-operative surgery and should work with an experienced team to avoid damage to surrounding organs (such as the spleen, pancreas, colon and stomach) and major vessels (such as the aorta, renal artery and vein). For masses of unclear etiology proceeding with adrenal mass biopsy prior to re-operative surgery should be considered as false-positive imaging results are possible.

Robotic-assisted dual kidney transplantation.

Aim:The aim of this study was to report the feasibility of robotic-assisted dual kidney transplantation (DKT) in a marginal donor.Materials and Methods:The case was a 53-year-old male, who with IgA nephropathy underwent a robotic-assisted robotic DKT.Results:The total operating time was 265 min, total console time was 215 min, and anastomotic time was 39 min for both the kidneys, and blood loss was 220 ml. The total drain output was 150 ml on the 1st day. The drain was removed after 48 h and Foley catheter was removed after 5 days. Nadir creatinine was 1.1 mg/dl and time to nadir creatinine was 7 days. The patient received one unit of blood transfusion. Total postoperative hospital stay was 7 days and bilateral ureteric stents were removed after 14 days. At the end of 3 months, creatinine was 1.0 mg% and epidermal growth factor receptor was 82 ml/min/1.73 m2.Conclusion:Robotic DKT offers solutions to the challenges faced in open DKT.

V7-07 ROBOTIC BLADDER NECK RECONSTRUCTION WITH SLING AND SPLIT APPENDIX TECHNIQUE FOR APPENDICOVESICOSTOMY AND MACE

You have accessJournal of UrologyPediatrics1 Apr 2017V7-07 ROBOTIC BLADDER NECK RECONSTRUCTION WITH SLING AND SPLIT APPENDIX TECHNIQUE FOR APPENDICOVESICOSTOMY AND MACE Molly Fuchs, Christina Ching, Christopher Brown, Richard Wood, Mark Levitt, Rama Jayanthi, and Daniel DaJusta Molly FuchsMolly Fuchs More articles by this author , Christina ChingChristina Ching More articles by this author , Christopher BrownChristopher Brown More articles by this author , Richard WoodRichard Wood More articles by this author , Mark LevittMark Levitt More articles by this author , Rama JayanthiRama Jayanthi More articles by this author , and Daniel DaJustaDaniel DaJusta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1925AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgical techniques have been adopted for procedures in pediatric urology even in reconstruction for neurogenic bladder. Our aim was to expand on the previously described bladder neck reconstruction with sling and Appendicovesicostomy (APV), by showing that the well described open split appendix technique can also be perform robotically, allowing for the creation of both APV and MACE. This video is to our knowledge, the first to demonstrate the use of robotic split appendix technique. METHODS A 6 year-old male with myelomeningocele, neurogenic bladder and bowel was not able to achieve urinary continence on a standard regiment of IC and anticholinergic. Urodynamic showed adequate bladder capacity at 300 ml with low storage pressure and adequate compliance. Unfortunately he had a low leak point pressure indicating poor outlet resistance. Thus indication for a bladder neck reconstruction with APV was made. There was also a need for implementing a good bowel regiment and after evaluation at our Center for Colorectal and pelvic Reconstruction by the colorectal surgeon, indication for a MACE was also made. We selected to utilize the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of Botox into the detrusor muscle, we placed ureteral catheter for easy ureteral orifice identification during bladder neck reconstruction and an 8 French Foley catheter. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. RESULTS The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning he was taken to the operating room for the procedure. Total operative time was 7 hours. Total console time was 6 hours. A 10 French Foley catheter was placed through the APV channel and an 8 French feeding tube was placed through the MACE. A 5 French feeding tube was left stenting the urethra and was removed prior to discharge. He was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4. CONCLUSIONS Robotic assisted bladder neck reconstruction with split appendix technique to create both APV and MACE is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery will continue to be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e825 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Molly Fuchs More articles by this author Christina Ching More articles by this author Christopher Brown More articles by this author Richard Wood More articles by this author Mark Levitt More articles by this author Rama Jayanthi More articles by this author Daniel DaJusta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V7-02 ROBOTIC ASSISTED ILEOVESICOSTOMY & CECOSTOMY TUBE

You have accessJournal of UrologyPediatrics1 Apr 2017V7-02 ROBOTIC ASSISTED ILEOVESICOSTOMY & CECOSTOMY TUBE Christina Ching, Molly Fuchs, Christopher Brown, and Daniel DaJusta Christina ChingChristina Ching More articles by this author , Molly FuchsMolly Fuchs More articles by this author , Christopher BrownChristopher Brown More articles by this author , and Daniel DaJustaDaniel DaJusta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1920AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgical techniques have been adopted for procedures in pediatric urology but reconstruction for neurogenic bladder has been an area where it is underutilized. The reasons for this may include the need to create a bowel anastomosis, relative inexperience with robotics or perceived limitations of the technology. Our objective is to demonstrate the successful use of robotics in creating an ileovesicostomy incontinent urinary diversion with a complete intra corporeal bowel anastomosis and cecostomy tube placement. METHODS A 15 year-old female with myelomeningocele and neurogenic bladder had multiple failed attempts at compliance with clean intermittent catheterization program. She developed acute kidney injury and it was recommended that she undergo incontinent urinary diversion. We utilized the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of botox into the detrusor muscle. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. A cecostomy tube was also placed robotically to manage the patient's neurogenic bowel. The ileovesicootomy stoma was created in the left lower quadrant by extending the left arm robotic port site. RESULTS The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning she was taken to the operating room for the procedure. Total operative time was 406 minutes. Anesthesia induction was 17 minutes, cystoscopy and botox injection was 10 minutes and port placement and laparoscopic dissection took 22 minutes. Total console time was 244 minutes and closure time was 14 minutes. The remaining 96 minutes was for patient positioning and preparation. A foley catheter was placed per her urethra temporarily to keep her bladder decompressed to aid in wound healing and was removed prior to discharge. She was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4 with no surgical drainage tubes except for her urostomy. At 5-month follow-up her creatinine remains at her baseline of 0.9 and her ultrasound shows no hydronephrosis. She has no leakage per urethra. CONCLUSIONS Robotic assisted ileovesocostomy is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery can be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e823 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Christina Ching More articles by this author Molly Fuchs More articles by this author Christopher Brown More articles by this author Daniel DaJusta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V9-10 TECHNICAL CAVEATS IN ROBOTIC PARTIAL NEPHRECTOMY IN UPPER POLAR RENAL TUMOR

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-10 TECHNICAL CAVEATS IN ROBOTIC PARTIAL NEPHRECTOMY IN UPPER POLAR RENAL TUMOR Varun Mittal, Gagan Gautam, Puneet Ahluwalia, and Rajesh Ahlawat Varun MittalVarun Mittal More articles by this author , Gagan GautamGagan Gautam More articles by this author , Puneet AhluwaliaPuneet Ahluwalia More articles by this author , and Rajesh AhlawatRajesh Ahlawat More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1201AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron sparing surgery has become the standard of care for T1a small renal masses. A robotic approach is being increasingly used to perform this complex oncologic reconstructive procedure in view of its distinct advantages. Partial nephrectomy in upper polar tumors represents a distinct surgical challenge in view of its anatomical location. Aberrant vascular anatomy adds to the intricacy. We hereby present a video of robot assisted partial nephrectomy for an upper polar right renal mass with an accessory upper polar artery and discuss a few points of technique in context to the tumor location. METHODS A 47 year female was incidentally found to have 4 cm right upper polar renal mass. Multi-phasic CT revealed RENAL 7 x right upper polar mass with an accessory artery to the upper pole. Transperitoneal robot assisted partial nephrectomy was performed in standard nephrectomy position using total 7 ports, including three 8 mm robotic ports, one 12 mm camera port, two 12 mm assistant ports and one additional 5 mm port for liver retraction. Ports were placed cephalic to the usual location. Ureteric catheter was not used and only limited mobilization of the colon was done. Complete mobilization of the upper pole from the liver and adrenal was done till psoas muscle as an initial step. Ureter and gonadal vein complex was sparingly dissected just to identify the hilum. Laparoscopic ultrasound probe was used to delineate the tumor. Main renal vessels were clamped separately and as the accessory artery was directly going into the tumor, it was clipped and divided. After tumor excision and repair of pelvicalyceal system, vessels were unclamped early and renal defect was repaired in two layers. RESULTS Total console time was 130 minutes and warm ischemia time was 13 minutes and 27 seconds. Per urethral catheter and drain were removed on POD 1 and 2 respectively. Patient was discharged in stable condition on POD 2. Histopathology revealed grade 2 clear cell RCC with clear margins. CONCLUSIONS Upper polar renal tumors represent a distinct surgical challenge for partial nephrectomy. Slight cephalad port placement, limited mobilization of the colon and ureter gonadal vein complex and initiating the complete mobilization of the kidney from the upper pole, avoids unnecessary dissection and may decrease overall operative duration while facilitating access to and excision of upper pole renal masses. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e862-e863 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Varun Mittal More articles by this author Gagan Gautam More articles by this author Puneet Ahluwalia More articles by this author Rajesh Ahlawat More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V6-02 ROBOTIC PYELOLITHOTOMY IN ECTOPIC PELVIC KIDNEY: SIDE DOCKING IN SUPINE POSITION AND A FOUR-ARM APPROACH

You have accessJournal of UrologyUrolithiasis1 Apr 2015V6-02 ROBOTIC PYELOLITHOTOMY IN ECTOPIC PELVIC KIDNEY: SIDE DOCKING IN SUPINE POSITION AND A FOUR-ARM APPROACH Ahmad Al-Marzouq, Rawan Al-Yousef, and Saad Aldousari Ahmad Al-MarzouqAhmad Al-Marzouq More articles by this author , Rawan Al-YousefRawan Al-Yousef More articles by this author , and Saad AldousariSaad Aldousari More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.467AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ectopic kidney is a congenital malformation occurring in 1 in 900 births. Only about one in 10 of these are diagnosed. Patients with ectopic kidneys can be completely asymptomatic and discovered incidentally or they present with symptoms owing to urinary tract infection, obstructive uropathy or nephrolithiasis. Ectopic kidneys with renal pelvic stones can be challenging to treat. We report our experience in managing a case of ectopic pelvic kidney with a renal pelvic stone by robotic pyelolithotomy. Our objective is to present our approach to Robotic Pyelolithotomy in the management of renal pelvic stone in ectopic pelvic kidney. METHODS Our case is a 46 year old male with 2 months history of vague lower abdominal pain. No other urological symptoms. During his work-up a Computed Tomography (CT) scan showed left ectopic pelvic kidney with an 8 × 12 × 11 mm stone in an anomalous renal pelvis showing multiple compartments connected by narrow channels. Two attempts at flexible ureteroscopy (URS) failed to reach the stone. After placing a 4.7 French double J stent we proceeded with left pelvic robotic pyelolithotomy. Side docking was utilized with the patient in supine trendelenburg position. Port placements were similar to robotic assisted laparoscopic prostatectomy. RESULTS Docking time was 35 minutes and total Console time was 150 minutes. There were extensive adhesions in the region of the left pelvic kidney. Multiple attempts failed to follow the course of the ureter in order to locate the renal pelvis. We subsequently opened the renal pelvis directly and used the flexible cystoscope to basket the stone out the renal pelvis through a narrow infundibulum. Estimated Blood Loss (EBL) was < 100 mls. A suction drain was inserted. The patient was discharged in < 48 hours postoperatively after removal of the drain. CONCLUSIONS Stones in ectopic pelvic kidneys pose a great challenge due to altered surgical anatomy. Robotic pyelolithotomy is a safe and feasible approach providing exceptional exposure and easier dissection. It is imperative to have a detailed understanding of ectopic kidney anatomy to ensure safety and procedure success. Utilization of flexible cystoscopy aided in the localization and extraction of the stone in an anomalous renal pelvis. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e577 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmad Al-Marzouq More articles by this author Rawan Al-Yousef More articles by this author Saad Aldousari More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V7-07 COMBINED ROBOTIC AND OPEN APPROACH TO EXCISION OF ACCESSORY BLADDER AND URETHRAL TRIPLICATION

You have accessJournal of UrologyPediatrics1 Apr 2015V7-07 COMBINED ROBOTIC AND OPEN APPROACH TO EXCISION OF ACCESSORY BLADDER AND URETHRAL TRIPLICATION Diana K. Bowen, Alex P. Glaser, Jonathan W. Bush, Earl Y. Cheng, and Edward M. Gong Diana K. BowenDiana K. Bowen More articles by this author , Alex P. GlaserAlex P. Glaser More articles by this author , Jonathan W. BushJonathan W. Bush More articles by this author , Earl Y. ChengEarl Y. Cheng More articles by this author , and Edward M. GongEdward M. Gong More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1938AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Management of urethral and bladder duplication anomalies focuses on prevention of recurrent infections and preservation of renal function. We describe a case of urethral triplication and bladder duplication, and the combined robotic and open approach to surgical excision. METHODS A 17 year-old male presented with ten days of intermittent fevers and abdominal pain. He was found to have two accessory urethras – both along the dorsal penile shaft – in addition to a normal orthotopic ventral meatus. A large cavity anterior to the bladder was identified on CT scan and a drain was placed by interventional radiology with return of purulent fluid. He was placed on culture-directed antibiotics and improved. RESULTS Cystoscopy revealed two accessory urethral channels that were both blind-ending, the more proximal one just under the pubic symphysis. The patient then underwent open excision of the urethral triplication followed by robotic excision of the bladder duplication. Total console time for the robotic portion was 2 hours 18 minutes and estimated blood loss was 30 ml. Final pathology revealed non-keratinizing squamous lining of the accessory urethras, with chronic inflammation and marked fibrosis of the distal-most channel, but acute inflammation of the proximal channel. The accessory bladder specimen had a urothelial lining with reactive changes and inflammation within the lamina propria. CONCLUSIONS To our knowledge, this is the first reported case of robotic excision of a urethral/bladder duplication anomaly. There was significant scarring due to the patient's prior recurrent infections, but visualization with the robotic approach was excellent and the patient healed well with a short recovery time. We conclude that robotic excision of a bladder duplication anomaly is a technically feasible operation. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e661 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Diana K. Bowen More articles by this author Alex P. Glaser More articles by this author Jonathan W. Bush More articles by this author Earl Y. Cheng More articles by this author Edward M. Gong More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...