Dissection Of Ureter Research Articles

Indocyanine Green for Assessment of Ureteral Vascularity Can Reduce the Rate of Ureteral Complications in Patients Undergoing Extended Hysterectomy.

Objectives: This study aimed to evaluate the effectiveness of using indocyanine green (ICG) for assessing ureteral vascularity to reduce ureteral complications in patients undergoing extended hysterectomy for deep endometriosis or oncological indications. Methods: A retrospective-prospective cohort study was conducted at the Centre of Gynecology in Opole, Poland, involving 555 patients who underwent hysterectomy from 2020 to 2023. Patients were categorized based on the Querleu-Morrow classification. ICG was used intraoperatively for vascular assessment in patients with deep endometriosis undergoing wide ureter dissection typical of Type C hysterectomy. Results: Ureteral complications occurred in 12 (2.2%) patients, with a significantly lower complication rate in those who underwent ICG testing (1.7%) compared to those who did not (22.7%, p = 0.001). Prophylactic double-J stenting further reduced the risk of complications. Conclusions: The use of ICG for intraoperative assessment of ureteral vascularity significantly reduces the risk of ureteral complications in complex hysterectomies. Further studies are needed to confirm these findings.

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.

V01-10 BILATERAL TESTICULAR VEIN SYNDROME MASQUERADING AS BILATERAL URETEROPELVIC JUNCTION OBSTRUCTION- LESSONS LEARNT

You have accessJournal of UrologyCME1 Apr 2023V01-10 BILATERAL TESTICULAR VEIN SYNDROME MASQUERADING AS BILATERAL URETEROPELVIC JUNCTION OBSTRUCTION- LESSONS LEARNT Ravimohan mavuduru, Shantanu Tyagi, Girdhar Bora, and Shrawan Singh Ravimohan mavuduru Ravimohan mavuduru More articles by this author , Shantanu TyagiShantanu Tyagi More articles by this author , Girdhar BoraGirdhar Bora More articles by this author , and Shrawan SinghShrawan Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vascular compression of ureter by aberrant lower polar vessels, retrocaval compression and ovarian vein has been described in the past. Still rarer is the ureteric obstruction with the crossing of testicular vein. We present a case of Bilateral testicular vein syndrome masquerading as Ureteropelvic junction obstruction (UPJO), its intra-operative diagnosis and management. METHODS: Index patient is a 18-year-old male, presented with history of bilateral flank pain since 7 months, colicky in nature, requiring intravenous analgesics. There was no significantly contributing past history. He was evaluated elsewhere with abdominal ultrasonography which was suggestive of bilateral gross hydronephrosis. Non-contrast computed tomography (NCCT), done during an acute episode revealed bilateral gross hydronephrosis with probable site of obstruction at UPJ. Diuretic renography in the form of DTPA Scan consolidated the findings of NCCT revealing bilateral compromised cortical function and obstruction to outflow at UPJ. With the given history and evaluation, patient was diagnosed to have Bilateral UPJO and planned for bilateral robot-assisted pyeloplasty. Intraoperatively, on the left side, at pyelotomy the ureter seemed dilated across UPJ raising questions over pre-operative diagnosis. Consequently distal patency check was undertaken to confirm the site of obstruction. After gentle distal ureteric dissection, extrinsic compression at the site of crossing left testicular vein was found to be the site of actual ureteric obstruction. To relieve this compression, the ureter was super positioned over a posteriorized gonadal vein with a subsequently successful distal patency check. Taking lessons from the left side, we started with distal ureteric dissection and surprisingly found extrinsic compression with right testicular vein on the right side as well. Site of compression was visualised as fibrosed ureteric segment which was excised and ureteroureterostomy was done super positioned over a posteriorized right gonadal vein. RESULTS: The patient had an uneventful post-operative course and bilateral double-J stents were removed at 3 weeks. Follow-up renogram at 3 months documented the resolving bilateral hydronephrosis and unobstructed drainage. CONCLUSIONS: Lessons learned from the given case are- Contrast-enhanced CT imaging could have suggested ureteric compression with gonadal vein pre-operatively, Distal patency check is vital when there is dilatation across PUJ, When in doubt, distal ureteric dissection is a better approach and preservation of ureteric vascularity is of paramount importance. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e82 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ravimohan mavuduru More articles by this author Shantanu Tyagi More articles by this author Girdhar Bora More articles by this author Shrawan Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

V09-12 INTRACORPORAL ROBOTIC LEFT ILEAL URETER REPLACEMENT: A STEP-BY-STEP GUIDE

You have accessJournal of UrologyCME1 Apr 2023V09-12 INTRACORPORAL ROBOTIC LEFT ILEAL URETER REPLACEMENT: A STEP-BY-STEP GUIDE Devin Boehm, Jonathan Rosenfeld, Emily Ji, and Ziho Lee Devin BoehmDevin Boehm More articles by this author , Jonathan RosenfeldJonathan Rosenfeld More articles by this author , Emily JiEmily Ji More articles by this author , and Ziho LeeZiho Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intracorporal robotic left ileal ureter replacement is a technically challenging procedure. Only a handful of reports exist in the literature. We describe our approach for intracorporal robotic left ileal ureter replacement and highlight key aspects of our surgical technique. METHODS: We demonstrate our technique on a 49-year-old woman with a 25-centimeter left pan-ureteral obliteration secondary to endoscopic stone surgery. Our technique involves five major steps: proximal ureteral dissection, bowel harvest, bladder dissection, distal anastomosis, and proximal anastomosis. In order to optimize access to the upper and lower urinary tracts, we use two distinct patient positions and port placement schemas based on the field of interest. Tilting the bed allows for toggling between the modified flank (upper tract) and modified supine positions (lower tract) without the need to reposition or redrape the patient. During reconstruction, the ileal ureter may be brought over to the left side by tunneling only the proximal segment or by tunneling the entire segment of ileum (Figure 1). RESULTS: For our index case, operative time was 340 minutes, estimated blood loss was 200 milliliters, and length of stay was 5 days. There were no 90-day major postoperative complications. Renal scan obtained at 4 months postoperatively demonstrated a T1/2 of 14 minutes. At 8 months follow-up there was no evidence of stricture recurrence. CONCLUSIONS: Intracorporal robotic left ileal ureter replacement is a reproducible technique for the management of pan-ureteral stricture disease. Adhering to a system and simplifying the technique into five steps may facilitate successful completion of this challenging procedure. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e840 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Devin Boehm More articles by this author Jonathan Rosenfeld More articles by this author Emily Ji More articles by this author Ziho Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Indocyanine Green–Assisted Retrograde Ureterolysis in Robotic Transvaginal NOTES for the Management of Stage IV Endometriosis with Obliterated Cul-de-sac

To explore the use of indocyanine green (ICG) in highlighting ureteral anatomical landmarks for the successful and safe execution of robotic-assisted transvaginal NOTES hysterectomy with resection of deeply infiltrated endometriosis. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 38-year-old G4P1031 with a symptomatic enlarged uterus secondary to adenomyosis and uterine myomas, dense adhesions between the posterior uterus, and left uterosacral ligament. Stage IV endometriosis with obliterated cul-de-sac is a challenging procedure in the surgical management of endometriosis. Ureterolysis is the key step to performing this surgery successfully and safely; however, the routine dissection of ureters from the sacral promontory level to the uterine artery is challenging in obliterated cul-de-sacs with pelvic side wall adhesions with the proximal ureter at greatest risk [1-4]. Using the ICG firefly technique allowed us to rapidly identify and safely dissect the ureter through robotic transabdominal endometriosis surgery [5,6]. The angle of approach in transvaginal NOTES surgery for hysterectomy with obliterated cul-de-sac endometriosis leads to far more difficulty in identifying the ureter at the beginning of surgery [3]. Therefore, an obliterated cul-de-sac was associated with a potentially increased risk of ureteral injury and bowel injury. We used ICG to help identify the ureter at the beginning of the case leading to reducing the risk of surgical complication, in which the concept of ureterolysis from the level of the uterine artery to the bifurcation of common iliac vessels in vNOTES surgery will be referred to as "vNOTES retrograde ureterolysis." With the cystoscope in place, a ureteral catheter was inserted into the right ureter and 5 cc of ICG was injected, and the same procedure was done on the left [1,5]. Bovie electrosurgical device was used to incise circumferentially around the cervix. The bladder was dissected off the pubovesical cervical fascia anteriorly and posteriorly with a combination of the Bovie as well as blunt and sharp dissection. Bilateral uterosacral and cardinal ligaments, as well as uterine arteries, were then clamped, transected with Mayo scissors, and secured. Entry into the anterior cul-de-sac was completed, and a stitch using 0 vicryl was used to tag the anterior peritoneum to the anterior vaginal cuff.Posterior entry was attempted unsuccessfully. The Gelpoint mini device was then placed, and the Da Vinci XI robot was docked. Bilateral ureters were identified and dissected out of bilateral pelvic sidewalls using the firefly mode at the level of the uterine artery. The ureters were easily dissected away from the uterus. The left broad ligament was then cauterized and transected using the vessel sealer. The plane between the uterus and the rectum was identified laterally, and the rectum was taken down from the uterus from the right to the left side.Bilateral broad ligaments were then cauterized and transected using the vessel sealer, followed by cauterization and transection of the round ligaments, utero-ovarian ligaments, and mesosalpinx bilaterally. The vaginal cuff angles were secured with a figure-of-eight stitch of 0 vicryl, and the vaginal cuff was then closed in a running fashion with 0 V-Loc.The patient was discharged in one day with reports of minimal pain (Videos 1-3). Robotic-assisted NOTES hysterectomy with deeply infiltrated endometriosis resection is feasible and safe with ICG-assisted ureteral labeling in a case of obliterated cul-de-sac. The unique green color labeling of ureters offers a prominent landmark in assisting the ureteral dissection while avoiding ureteral and bowel injury, resulting in the possibility of using vNOTES surgery in challenging cases.

Identification of Ureters with ICG Dye in Endometriosis and Benign Gynaecology

Study Objective The purpose of this video is to demonstrate the use of ICG dye to identify and facilitate dissection of ureters in endometriosis and other benign cases. Design Technical video demonstrating the laparoscopic identification of ureters with ICG dye (Canadian Task Force classification level III). Setting Minimally Invasive Surgery Gynaecology Unit, Liverpool Hospital. Patients or Participants 3 cases demonstrated. Interventions Indocyanine green (ICG) is a fluorescent dye that, when activated with a specific wavelength of near-infrared (NIR) light, permits the exact measurement of tissue vascularization in real time during surgery. The ICG irreversibly stains the lining of the ureter by binding to the proteins on the urothelial layer. The infrared signals are then captured by the console and electronically converts into green color which then facilitates easy identification of bilateral ureters thus reducing the risk of injury. This video presents one of its uses in benign gynaecology. Measurements and Main Results Thus, this is a technology allowing to intraoperatively enhance the visualization of the ureters, potentially reducing the risks and/or favoring an immediate identification of injuries, and will have a relevant clinical impact Conclusion We discovered that ICG is a useful method for identifying ureters in challenging situations, particularly those with retroperitoneal fibrosis. The purpose of this video is to demonstrate the use of ICG dye to identify and facilitate dissection of ureters in endometriosis and other benign cases. Technical video demonstrating the laparoscopic identification of ureters with ICG dye (Canadian Task Force classification level III). Minimally Invasive Surgery Gynaecology Unit, Liverpool Hospital. 3 cases demonstrated. Indocyanine green (ICG) is a fluorescent dye that, when activated with a specific wavelength of near-infrared (NIR) light, permits the exact measurement of tissue vascularization in real time during surgery. The ICG irreversibly stains the lining of the ureter by binding to the proteins on the urothelial layer. The infrared signals are then captured by the console and electronically converts into green color which then facilitates easy identification of bilateral ureters thus reducing the risk of injury. This video presents one of its uses in benign gynaecology. Thus, this is a technology allowing to intraoperatively enhance the visualization of the ureters, potentially reducing the risks and/or favoring an immediate identification of injuries, and will have a relevant clinical impact We discovered that ICG is a useful method for identifying ureters in challenging situations, particularly those with retroperitoneal fibrosis.

Robotic Trachelectomy: Surgical Techniques and Principles

<h3>Study Objective</h3> To demonstrate a technique for robotic assisted trachelectomy using EEA sizer as an alternative manipulator to colpotomizer cup. <h3>Design</h3> Description and demonstration of a surgical technique. <h3>Setting</h3> Tertiary care academic center. <h3>Patients or Participants</h3> A 66-year-old woman with previous supracervical hysterectomy and bilateral salpingo-oophorectomy who presented with extensive vaginal bleeding. On exam she had a cervical erosion and her workup included pap and cervical biopsies which were normal. <h3>Interventions</h3> Robotic assisted trachelectomy was performed for treatment of her vaginal bleeding. Mobilization of the ureters and dissection of the uterine arteries was performed. Uterine arteries were coagulated at their origins. Use of EEA sizer helped in vesicovaginal space dissection and delineating the landmarks for colpotomy. Vaginal cuff was sutured using barbed suture. <h3>Measurements and Main Results</h3> At 6 weeks, patient suffered no perioperative complications and reported no further bleeding. <h3>Conclusion</h3> EEA sizer is a good alternative to the use of colpotomizer cup and can be safely used when the colpotomizer cup is unavailable or cannot be placed. Ureteric dissection to the level of cervix can prevent intraoperative complications.

Unilateral pectineal suspension - A new surgical approach for apical correction of pelvic organ prolapse.

There are numerous vaginal and abdominal surgical approaches for the treatment of pelvic organ prolapse (POP). Even the standard techniques show great variability due to modifications depending on anatomy, available instruments and materials. Recently, the role of hysterectomy in prolapse surgery as well as the use of synthetic meshes have been questioned. Here, we present a standardised mesh-free minimally invasive pelvic floor reconstruction technique with uterus preservation. Unilateral pectineal suspension (UPS) is carried out in five defined steps with the use of the da Vinci Xi ® surgical system. The desired anatomical result is simulated by intraoperative uterus manipulation. The cranial part of the pectineal ligament is used for lateral fixation. A non-absorbable suture is placed between the pectineal ligament and the anterior cervix to suspend the uterus in its natural anatomical position. For outcome measurement, degree of prolapse was assessed pre- and postoperatively according to the POP-Q system. Unilateral pectineal suspension offers several advantages. Medial tension-free positioning of the uterus is achieved. The use of the cervix as fixation structure allows for excellent pelvic floor support and stable results. Normal pelvic floor mobility and natural axis of the vagina are restored. Unilateral pectineal suspension is an efficient minimal-invasive mesh-free procedure which allows uterus preservation and offers reliable level I support respecting the physiological pelvic anatomy. In addition, there is no need for ureteral dissection or bowel manipulation. The technique offers clinical standardization and can easily be integrated into the spectrum of modern surgical POP repair.

Surgical management of primary undifferentiated pleomorphic sarcoma of the rectum: a case report and review of the literature

BackgroundUndifferentiated pleomorphic sarcoma (UPS) is a malignant soft tissue tumor that has been reclassified from malignant fibrous histiocytoma with the development of the pathological diagnosis. It principally occurs in the extremities but rarely occurs in the rectum. We herein report a rare case of UPS arising in the rectum.Case presentationA 85-year-old woman was referred to our hospital with a complaint of anal pain, which had persisted for several months. Computed tomography (CT) showed a 53 × 58 × 75 mm mass on the left side of the rectum. Colonoscopy revealed a submucosal elevation in the rectum without any exposure of the tumor to the surface. Contrast-enhanced CT and magnetic resonance imaging revealed an 80-mm mass that originated in the rectal muscular propria, and we suspected a gastrointestinal stromal tumor. No lymph node metastasis or distant metastasis was observed. We performed a laparoscopic Hartmann’s operation. Intraoperatively, severe adhesion around the tumor caused tumor injury and right ureteral dissection. Thus, laparoscopic right ureteral anastomosis and ureteral stenting were additionally performed. The operation time was 6 h and 3 min, and the estimated blood loss was small. The patient was discharged without complications 25 days after surgery. A pathological examination showed that the tumor was composed of highly heterogeneous cells with no specific differentiation traits, leading to a diagnosis of UPS. Contrast-enhanced CT performed 2 months after surgery showed bilateral pelvic lymph node enlargement, which indicated recurrence. Considering the patient’s age, we performed radiotherapy (50 Gy/25 Fr targeting the pelvic region). At present, 16 months have passed since the completion of radiotherapy. Contrast-enhanced CT shows that the recurrent lymph nodes have disappeared, and no new distant metastasis has been observed.ConclusionsWe reported a case of UPS arising in the rectum. The surgical procedure and indication of preoperative therapy should be carefully selected because complete removal of the tumor is desirable in UPS.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Update on How to Improve the Outcome of Radical Cystectomy: A Systematic Review

Context Radical cystectomy (RCX) is the most difficult urologic procedure. It is usually performed in patients with morbidities and associated with a high rate of complications. So, every effort must be done to improve the outcome of this surgery. Objective This systematic review tries to put an up to date analysis of the literature on how to improve the outcome of RCX. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed from 1990 to July 2022 in English language using the keywords ‘‘radical cystectomy’, ‘Enhanced recovery’ and ‘Improved outcome’. Prospective studies were preferred; however, retrospective studies were used when no prospective studies were available. Evidence synthesis In all, 237 relevant articles were identified and 46 articles were included in this systematic review. RCX may be associated by complications that may reach 70%. Preoperative patient preparation, optimization and counseling are critical. Enhanced recovery after surgery protocols should be adopted. The radicality of surgery is affected by the use of neo-adjuvant and/or adjuvant therapy, timing of surgery, the presence of a well-organized team and the surgeon experience. Ureteral dissection, urethral stump preparation and nerve sparing are three important steps during RCX greatly affecting the function of the following reconstructive step. Close follow up after RCX especially in the first two years is critical. Conclusions Multiple factors should be followed to achieve good RCX. Regular skilled operative team, high volume surgeon, well equipped operative theater, excellent postoperative care are keys of success.

Robotic-assisted Lingual Mucosal Graft Ureteroplasty for the Repair of Complex Ureteral Strictures: Technique Description and the Medium-term Outcome

BackgroundRobot-assisted autologous graft ureteroplasty provides another treatment option for complex ureteral strictures, circumventing ileal ureter or renal autotransplantation. ObjectiveTo report the medium-term outcome of robotic ureteroplasty with a lingual mucosal graft (RU-LMG) for managing complex ureteral strictures. Design, setting, and participantsBetween June 2019 and September 2020, 12 patients underwent RU-LMG. The perioperative variables were prospectively collected, and the outcomes were assessed. Surgical procedureAfter ureteral stricture dissection, the narrow segment was cut longitudinally, and a lingual mucosal graft (LMG) of the required length was harvested, followed by double-J stent placement and LMG ventral onlay anastomosis. If the diseased ureter required transection, posteriorly augmented ureteral anastomosis could be performed before LMG harvest. Finally, the anastomotic area was wrapped by the omental flap. MeasurementsA descriptive statistical analysis was performed. The criteria for complete success included the absence of both clinical symptoms and obstruction on radiography. Results and limitationsSeven patients (58%) had a history of failed ureteral reconstruction. The mean (range) stricture length was 4.7 (3–6.5) cm, LMG length was 4.4 (3–7) cm, LMG width was 1.5 (1–2) cm, operative duration was 197.1 (130–346) min, estimated blood loss was 49.2 (10–200) ml, and the duration of postoperative hospitalization was 6 (4–14) d. No open conversions and intraoperative complications occurred. The median follow-up time was 15 mo (range: 13–27 mo). The overall success rate was 92% (11/12). ConclusionsThese medium-term follow-up results demonstrate that RU-LMG is a safe and feasible technique for repairing ureteral strictures. Patient summaryOur study proves that robotic ureteroplasty with a lingual mucosal graft is a safe and feasible technique for ureteral reconstruction that can serve as another choice for managing long, complex ureteral strictures.

Laparoscopic renal surgery using multi degree-of-freedom articulating laparoscopic instruments in a porcine model.

We evaluated the performance of a new multi-degree-of-freedom articulating laparoscopic instrument, ArtiSential, and compared it with that of a straight-shaped instrument and the da Vinci surgical system, in renal surgery using porcine model. Nine female Yorkshire pigs were equally divided into three groups. The three groups were compared at each surgical step in terms of objective and subjective parameters. The median operative times for renal pedicle clamping and ureter dissection were significantly shorter in ArtiSential group than robotic group (1.3 min vs. 4.7 min, p=0.002; 8.1 min vs. 11.1 min, p=0.015). The median operative time for bladder repair was significantly longer in ArtiSential group than robotic and straight-shaped groups (17.9 min vs. 5.5 min, p=0.002; 17.9 min vs. 9.3 min, p=0.026). There were no significant differences among groups in terms of blood loss or intraoperative complications. ArtiSential device was less useable for renorrhaphy (p=0.009) and bladder repair (p=0.002) compared to the robotic system. ArtiSential group was less accurate than robotic group in terms of tumor resection, renorrhaphy, and bladder repair. During ureter dissection, bladder cuff excision, and bladder repair, the surgeon experienced greater wrist discomfort but lesser back discomfort in ArtiSential group than robotic group. For most steps, ArtiSential performed as well as robotic and straight-shaped instruments. The development of specialized surgical techniques for ArtiSential will maximize the advantages of these instruments.

Robotic Cystotomy Repair and Ureteral Dissection Techniques

<h3>Study Objective</h3> The objective of this video is two-fold. First, to demonstrate the steps of cystotomy repair and highlight tips for post-operative management of cystotomies. Second, to review the anatomy and vascular supply of the ureter in order to describe safe ureteral dissection techniques. <h3>Design</h3> N/A. <h3>Setting</h3> The video presents clips of robotic-assisted cystotomy repair and ureteral dissection. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Understanding the steps of both repair and post-operative management of cystotomies is important for minimally invasive surgeons. Additionally, knowledge of the anatomy of the ureter in the pelvis can both aid in ureteral dissection and avoid ureteral damage at the common sites of injury.

Robotic-Assisted Uterus Retrieval from Living Donor for Uterine Transplantation: First Case in Brazil

<h3>Study Objective</h3> To present the first robotic-assisted uterus retrieval from a living donor for uterine transplantation in Brazil. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Three operating rooms were designated to carry out the transplantation: one for harvesting the donor's uterus by robotic surgery, another for the bench surgery, and another for the organ recipient. The donor was in the lithotomy position with steep Trendelenburg, intermittent pneumatic compression, and Allen Stirrups. She underwent robotic surgery with central docking. <h3>Patients or Participants</h3> The recipient was a 33-year-old patient with hypoplasia of the Müllerian duct system due to Mayer-Rokitansky-Küster-Hauser syndrome. The donor was a 50-year-old woman. <h3>Interventions</h3> Ureteral dissection was performed over its entire length. The vascular pedicles that emerged from the uterine arteries and the internal iliac arteries' posterior branches were clipped. The obliterated umbilical arteries, the internal iliac arteries, and the pelvic infundibulum ligaments were clipped and cut. The uterus was retrieved through a Pfannenstiel incision to avoid complications to the uterine vessels. The organ was transplanted in the recipient by end-to-end anastomosis of the internal iliac arteries and end-to-side anastomosis of the external iliac vein with a gonadal vein from the infundibulopelvic ligament. <h3>Measurements and Main Results</h3> Surgical intraoperative parameters were measured. The operative time from docking was 4 minutes. Robotic donor surgery took 400 minutes, bench surgery 62 minutes, and laparotomic recipient surgery was completed in 240 minutes. There were no intraoperative complications. The donor was discharged in 48 hours and the recipient in 5 days. <h3>Conclusion</h3> This is the first case in Brazil of uterine transplantation with a living donor to the best of our knowledge. Traditionally, patients who undergo uterine transplantation by minimally invasive surgery are managed by laparoscopy. However, this video demonstrates the feasibility of a robotic approach to uterine transplantation.

Robotic Approach to Ectopic Endometriosis in a Patient with Duplicated Ureters

<h3>Study Objective</h3> To demonstrate a minimally invasive approach to excision of ectopic urinary tract endometriosis in a patient with an anomalous duplicated left renal collecting system. <h3>Design</h3> Case report surgical video. <h3>Setting</h3> Single center academic institution. <h3>Patients or Participants</h3> A 45-year-old female with a history of endometriosis with prior robotic hysterectomy and left salpingo-oophorectomy presented with worsening urge incontinence, flank and pelvic pain. Patient was referred after evaluation revealed a mass adjacent to the left ureterovaginal junction and bladder trigone. <h3>Interventions</h3> Initial cystoscopy revealed a left non-intrusive bladder mass near the left ureteral orifices. A 2 cm firm, fixed nodule in the left fornix of the vagina was excised. Endometriosis was confirmed on frozen section. Upon laparoscopic entry, anatomy was noted to be distorted due to extensive scarring in the left pelvic sidewall including the vaginal cuff and bladder. The posterior cul-de-sac, pararectal, and paravesical spaces were then dissected open, allowing for visualization of the intersigmoid recess and the double ureters encased in scar tissue. After creating two small windows to open the peritoneum, continued dissection proceeded laterally along the pelvic sidewall. En bloc endometriosis was noted on the left infundibulopelvic ligament, vaginal cuff, bladder, and ureters. The scarred peritoneum was excised by encircling the affected areas. Concomitant ureteral dissection ensued with simultaneous removal of endometriotic nodules at the vaginal cuff and ureterovaginal junction. The patient then had an uncomplicated right salpingo-oophorectomy. <h3>Measurements and Main Results</h3> The patient was discharged home on postoperative day one and had an overall uncomplicated postoperative course. Final pathology was consistent with endometriosis. At her post-operative appointment, the patient experienced complete resolution of her symptoms. <h3>Conclusion</h3> In a patient with a known history of endometriosis and a newfound bladder mass, ectopic endometriosis should be considered. Robotic surgical excision is an appropriate minimally invasive approach after adequate preparation.

Benchmarks for 3-D Systems (Simbionix) Bladder Flap Module for the Xi Robot: Differentiating Novice from Experienced and Expert Surgeons

Study Objective To develop competency benchmarks for the 3-D Systems (Simbionix) Bladder Flap Module for the Xi Robotic System. Design Prospective cohort. Setting Multi-center, academic medical institutions. Patients or Participants Residents, fellows, and faculty in OBGYN were invited to participate at 3 institutions. Participants were categorized by hysterectomy experience level: <10 (novice), 10-49 (experienced), and 50+ (expert). Ten novice and 22 experienced/expert surgeons were included. Interventions The 3-D Systems Hysterectomy Modules for the DaVinci Xi, released in 2017, include ureter dissection, bladder flap development, colpotomy, and full hysterectomy. In a prior study, recordings of participant simulator performance were graded in duplicate using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) tool. The bladder flap module demonstrated correlation with experience. Competency benchmarks were developed for this module using contrasting group methods. Results were analyzed by comparing the novice participants to a combined experienced/expert group. Distributions of scores from both groups were plotted for domains of assessment where correlation had previously been demonstrated, and a cutoff score and its associated false positive (FP) and false negative (FN) rates were calculated. Measurements and Main Results Cutoff scores were developed for Depth Perception (cutoff=3.3), Bimanual Dexterity (cutoff 2.8), Efficiency (cutoff=3.25), Force Sensitivity (cutoff=3.15), and Overall Score (cutoff=1.9). Overall Score is scored from 1-3, while the other domains are on a 5-point Likert scale. Using the established cutoffs, the observed FP and FN rates for each domain were as follows: Depth Perception 0% (0/10) and 22.7% (5/22), Bimanual Dexterity 20% (2/10) and 27.3% (6/22), Efficiency 20% (2/10) and 40.9% (9/22), and Overall Score 30% (3/10) and 27.3% (6/22). Conclusion The development of target competency benchmarks is helpful to guide trainees and educators in the application of simulation tools. Using the robotic 3-D systems (Simbionix) simulator module with the strongest evidence of validity, we established benchmarks to aid in interpreting and anchoring resident simulator performance to experienced surgeons. To develop competency benchmarks for the 3-D Systems (Simbionix) Bladder Flap Module for the Xi Robotic System. Prospective cohort. Multi-center, academic medical institutions. Residents, fellows, and faculty in OBGYN were invited to participate at 3 institutions. Participants were categorized by hysterectomy experience level: <10 (novice), 10-49 (experienced), and 50+ (expert). Ten novice and 22 experienced/expert surgeons were included. The 3-D Systems Hysterectomy Modules for the DaVinci Xi, released in 2017, include ureter dissection, bladder flap development, colpotomy, and full hysterectomy. In a prior study, recordings of participant simulator performance were graded in duplicate using the Modified Global Evaluative Assessment of Robotic Skills (GEARS) tool. The bladder flap module demonstrated correlation with experience. Competency benchmarks were developed for this module using contrasting group methods. Results were analyzed by comparing the novice participants to a combined experienced/expert group. Distributions of scores from both groups were plotted for domains of assessment where correlation had previously been demonstrated, and a cutoff score and its associated false positive (FP) and false negative (FN) rates were calculated. Cutoff scores were developed for Depth Perception (cutoff=3.3), Bimanual Dexterity (cutoff 2.8), Efficiency (cutoff=3.25), Force Sensitivity (cutoff=3.15), and Overall Score (cutoff=1.9). Overall Score is scored from 1-3, while the other domains are on a 5-point Likert scale. Using the established cutoffs, the observed FP and FN rates for each domain were as follows: Depth Perception 0% (0/10) and 22.7% (5/22), Bimanual Dexterity 20% (2/10) and 27.3% (6/22), Efficiency 20% (2/10) and 40.9% (9/22), and Overall Score 30% (3/10) and 27.3% (6/22). The development of target competency benchmarks is helpful to guide trainees and educators in the application of simulation tools. Using the robotic 3-D systems (Simbionix) simulator module with the strongest evidence of validity, we established benchmarks to aid in interpreting and anchoring resident simulator performance to experienced surgeons.

V11-10 ROBOTIC RETROPERITONEAL NEPHROURETECTOMY FOR UPPER TRACT UROTHELIAL CARCINOMA

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-10 ROBOTIC RETROPERITONEAL NEPHROURETECTOMY FOR UPPER TRACT UROTHELIAL CARCINOMA Zachary McDowell, and James Porter Zachary McDowellZachary McDowell More articles by this author , and James PorterJames Porter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephroureterectomy is the standard of care for high grade upper tract urothelial carcinoma (UTUC) or low grade UTUC when nephron-sparing surgery is not possible, and a retroperitoneal approach can be advantageous in the setting of previous abdominal surgeries. The patient in this case is a 67 year old female that was found to have high grade urothelial carcinoma of the left renal pelvis. She underwent 3 cycles of gemcitabine and cisplatin chemotherapy, and subsequent nephroureterectomy. A retroperitoneal approach was chosen for this patient because she had a history of multiple abdominal surgeries including exploratory laparotomy. This video will demonstrate the retroperitoneal approach for robotic nephroureterectomy as definitive surgical management of this patient's high grade UTUC. METHODS: The surgery was performed using the daVinci Xi robot. The patient was placed in full flank position and 4 robotic ports were placed in a line midway between the iliac crest and the 12th rib. A 12mm high-flow insufflator assistant port was placed near the anterior superior iliac spine. The retroperitoneal space was developed using balloon dilation. The initial step was mobilization of the ureter. Once the ureteral dissection was carried distally to the point of decreased range of motion for the robotic arms, the arms were undocked, the boom rotated 180 degrees, and the direction of dissection was into the pelvis. An additional 5mm assistant port was placed cephalad to the robotic ports near the 11th rib. After completion of the ureteral and bladder cuff dissection the robot was redocked and returned to the initial arm configuration. We then proceed to adrenal sparing radical nephrectomy with retroperitoneal lymph node dissection. RESULTS: We have experience with 3 robotic retroperitoneal nephroureterectomies. All patients had high grade transitional cell carcinoma of the kidney as the indication for surgery, and all had history of significant abdominal surgery. The mean age was 70 years, mean operative time was 251 mins, mean estimated blood loss was 42 cc, mean lymph nodes removed was 13, and mean length of stay of 2 days. There were no complications, readmissions, and recurrences. CONCLUSIONS: The retroperitoneal approach is a safe and effective technique for robotic assisted nephroureterectomy. This approach allows complete access to the kidney, ureter and bladder cuff and avoids adhesions in patients with prior abdominal surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e860-e861 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zachary McDowell More articles by this author James Porter More articles by this author Expand All Advertisement Loading ...

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 ...

Can extended upper pole ureterectomy prevent ureteral stump syndrome after proximal approach for duplex kidneys?

ABSTRACTIntroduction:Symptomatic duplex kidneys usually present with recurrent urinary tract infection due to ureteral obstruction (megaureter, ureterocele or ectopic ureter) and/or vesicoureteral reflux. Upper-pole nephrectomy is a widely accepted procedure to correct symptomatic duplex systems with poor functioning moieties, also known as upper or proximal approach. The distal ureteral stump syndrome (DUSS) can be a late complication of this approach. There is no consensus upon the length of ureteral dissection and the better approach to symptomatic disease in duplex systems, so we aim to identify if extended ureteral dissection can prevent DUSS in top-down approach.Materials and Methods:Forty-four consecutive patients with symptomatic duplex system were retrospectively classified into two groups: those with limited ureteral excision after heminephrectomy (HN) (group-1) and those with extended ureterectomy after HN (group-2). Patients were followed-up for at least 36 months regarding outcomes of distal ureteral stump.Results:Overall complication was 20%. A total of 8 patients required unplanned further surgery in Group-1 (30%) whereas only 1 patient required unplanned surgery in group 2 (6%) (p=0.07). Subgroup analysis showed that Group-1 presented more DUSS requiring surgery during follow-up than group-2 (p=0.04). Factors possibly affecting complications incidence (such as ureterocele or ectopic ureter) did not differ between groups (p=0.72 and p=0.78).Conclusion:Upper pole nephrectomy should be performed with extended distal ureteral dissection to prevent ureteral stump complications.