Watertight Anastomosis Research Articles

"Double Intravascular Stenting (dIVaS): Optimizing Watertight Anastomosis for Ectatic-Type Lymphatics During Lymphaticovenous Anastomosis".

"Double Intravascular Stenting (dIVaS): Optimizing Watertight Anastomosis for Ectatic-Type Lymphatics During Lymphaticovenous Anastomosis".

V09-08 LAPAROSCOPIC BILATERAL URETERO-ILEAL RE-IMPLANTATION AFTER OPEN RADICAL CYSTECTOMY: STEP BY STEP

You have accessJournal of UrologyCME1 Apr 2023V09-08 LAPAROSCOPIC BILATERAL URETERO-ILEAL RE-IMPLANTATION AFTER OPEN RADICAL CYSTECTOMY: STEP BY STEP Andreia Cardoso, Sara Anacleto, Catarina Laranjo Tinoco, Ricardo Matos Rodrigues, Ana Sofia Araújo, Mariana Capinha, Vera Marques, Carlos Oliveira, Mário Cerqueira-Alves, João Pimentel Torres, Miguel Mendes, and Emanuel Carvalho-Dias Andreia CardosoAndreia Cardoso More articles by this author , Sara AnacletoSara Anacleto More articles by this author , Catarina Laranjo TinocoCatarina Laranjo Tinoco More articles by this author , Ricardo Matos RodriguesRicardo Matos Rodrigues More articles by this author , Ana Sofia AraújoAna Sofia Araújo More articles by this author , Mariana CapinhaMariana Capinha More articles by this author , Vera MarquesVera Marques More articles by this author , Carlos OliveiraCarlos Oliveira More articles by this author , Mário Cerqueira-AlvesMário Cerqueira-Alves More articles by this author , João Pimentel TorresJoão Pimentel Torres More articles by this author , Miguel MendesMiguel Mendes More articles by this author , and Emanuel Carvalho-DiasEmanuel Carvalho-Dias More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) with urinary diversion (UD) is the gold-standard treatment for muscle-invasive bladder cancer. Ureteroenteric (UE) anastomotic stricture is a known complication, with sequelae such as kidney injury (KI) and urinary tract infection (UTI), requiring intervention. UE strictures present multifactorial etiology, yet, periureteral fibrosis and scarring secondary to ischemia or urine leakage at the anastomotic site are thought to be the main reasons. Classical open revision was the gold-standard for these strictures; however, minimally invasive approaches are arising. METHODS: An open RC (ORC) with Bricker UE anastomosis in ileal conduit (IC) complicated with bilateral stricture after 2 months (M). Patient presented recurrent UTI and KI, so, bilateral percutaneous nephrostomies (PN) were placed. Endoscopic balloon dilation was attempted, but impossible on the left. Thus, we performed a laparoscopic (lap) 5-port bilateral UE re-implantation due to uretero-ileal stenosis, 6.5M after ORC. RESULTS: Extensive peritoneal adhesions and fibrotic peri-ureteral tissue were found. Identification of anatomical landmarks, careful dissection and structures release was done. After IC release, we dissected the right ureter (the least fibrotic and with previous mono J stent) until the uretero-ileal junction. The left ureter revealead marked fibrosis and devascularization. After maximum fibrosis excision and ureteral spatulation, we performed an UE Bricker re-implantation over 7Ch mono J stents, using 4-0 Vicryl in 8 simple interrupted sutures, bilaterally. On the right, we used the previous site on the IC for re-implantation. On the left, due to fibrosis, we chose a different location. Operative time was 2 hours. Stents were removed after 4 weeks (right) and 2M (left). Patient had some UTI, but remains stents-free 9M after. CONCLUSIONS: Laparoscopy allows direct visualization of known UE anastomosis issues that contribute to strictures: ureteral skeletonization with blood supply compromise leading to ischemia; not tension-free and water-tight anastomosis, facilitating urine leak; tension and angled pathway of left ureter under the sigmoid mesocolon. In re-implantation surgery, correcting these problems is challenging, but essential for success. Careful dissection, using traction and counter-traction, anatomical planes and structures correct identification and preservation is mandatory. After maximum possible excision of fibrosis, suture with mucosa apposition rather than strangulation is required for a quality UE anastomosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e839 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andreia Cardoso More articles by this author Sara Anacleto More articles by this author Catarina Laranjo Tinoco More articles by this author Ricardo Matos Rodrigues More articles by this author Ana Sofia Araújo More articles by this author Mariana Capinha More articles by this author Vera Marques More articles by this author Carlos Oliveira More articles by this author Mário Cerqueira-Alves More articles by this author João Pimentel Torres More articles by this author Miguel Mendes More articles by this author Emanuel Carvalho-Dias More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of continuous and interrupted suture techniques in pyeloplasty: a systematic review and meta-analysis.

Pelvi-ureteric anastomosis is a critical step to ensure good outcome of pyeloplasty. Continuous suturing technique, especially for laparoscopic surgeries, may offer faster operative time while allowing water-tight anastomosis and remains an alternative to interrupted suturing technique. There has been mixed data on comparison of outcomes of continuous and interrupted suturing techniques. This systematic review and meta-analysis aim to assess the outcomes of pyeloplasty based on continuous and interrupted suturing techniques. Following protocol registration on PROSPERO (CRD42021269706), a systematic review was performed in accordance with Cochrane Collaboration. A literature search was performed in September 2021 across Medline, EMBASE, Scopus, Cochrane Library, and ClinicalTrials.gov. Records comparing pyeloplasty outcomes between continuous and interrupted suture techniques were included. Five studies were identified for inclusion (2 prospective, 3 retrospective). Three studies involved pediatric patients. Three studies exclusively assessed laparoscopic technique. Four outcomes were meta-analyzed: operative time, length of stay, complications, and pyeloplasty failure. Interrupted sutures had longer OR time (mean difference 33.14min [95% CI 29.35-36.94], p < 0.0001) and length of stay (mean difference 1.08days [95% CI 0.84-1.32], p < 0.0001). However, there were similar complication (OR 1.73 [95% CI 0.98-3.06], p = 0.06) and failure rates (OR 1.21 [95% CI 0.43-3.43], p = 0.71) between the two suture types. The overall risk of bias in the studies was high. While limited by the number of studies available, continuous sutures for pelvi-ureteric anastomosis appear to confer benefits of faster operative time and decreased length of stay without increasing complication rates or failures.

V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022V04-08 ROBOT-ASSISTED REPAIR OF BENIGN DISTAL URETEROENTERIC STRICTURES FOLLOWING RADICAL CYSTECTOMY Victoria Maxon and Alvin Goh Victoria MaxonVictoria Maxon More articles by this author and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002560.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video aims to provide a step-by-step approach for robot-assisted repair of benign distal ureteroenteric strictures (UES) following radical cystectomy (RC). METHODS: We demonstrate the feasibility and safety of robotic repair through three clinical scenarios after different forms of diversion and open primary surgery. UES repair is performed in the setting of an open RC and neobladder (NB), an open Indiana pouch and a repeat repair after RC and ileal conduit (IC). The RC/IC and Indiana pouch patients were placed in the modified lateral position with right side up. Port placement was directed at the right lower quadrant. The RC/NB patient was placed in the supine position and port placement was similar to that of RC. The operation consists of extensive lysis of adhesions, mobilization of the diversion and ureter, identification of the UES, excision of ureteral scar tissue and spatulation, assessment of ureteral perfusion using indocyanine green (ICG) fluorescence and the creation of a tension-free and watertight anastomosis. RESULTS: All cases were completed successfully without the need for open conversion. There were no intraoperative complications. Operative times ranged from 174-273 minutes. Estimated blood loss ranged from 10-50ml. Patients were discharged on postoperative day 1. No major complications occurred within 90 days of discharge. Renal function remained stable in all three patients at 6 weeks postoperatively. Patients were followed with functional renal imaging at 3 months postoperatively. CONCLUSIONS: Robot-assisted repair of UES is feasible and safe, even in the setting of extensive prior open abdominal surgery. This is the ideal approach for UES repair because it requires less mobilization of surrounding structures, allows for intraoperative ureteral assessment with ICG fluorescence and can successfully create a tension-free and watertight anastomosis. Our patients recovered quickly and without complications. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e369 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Victoria Maxon More articles by this author Alvin Goh More articles by this author Expand All Advertisement PDF downloadLoading ...

Open ureteroplasty with buccal mucosa graft for long proximal strictures: A good option for a rare problem.

PurposeTo report a single surgeon experience with one year follow-up after open ureteroplasty with buccal mucosa graft (OUBMG) in the rare situation of long segment proximal ureteral strictures.Materials and MethodsFour patients with long segment proximal ureteral stricture underwent OU-BMG between February and July 2017. Functional outcome was assessed by pre- and postoperative serum creatinine, ultrasound and renal scintigraphy as well as patient reported outcomes.ResultsFour patients with an average stricture length of 4 cm underwent OU-BMG between February and July 2017. No major postoperative complications occurred. Retrograde uretero-pyelography 6 weeks postoperatively revealed a watertight anastomosis followed by immediate emptying of the renal pelvis and ureter in all four patients. Ureteroscopy at this time showed a wide lumen with well-vascularized pink mucosa. After a mean follow-up time of 12.5 (12–14) months, postoperative serum creatinine was unimpaired. Renal scintigraphy revealed no signs of renal obstruction. With regard to intraoral surgery, no difficulties with mouth opening or intraoral dryness or numbness were reported.ConclusionsFor patients with long segment ureteral strictures OU-BMG is a safe technique with excellent surgical and functional outcomes. Hence, the application of this technique should be encouraged and regarded as one of the standard options in case of this rare problem.

Ideal timing of indwelling catheter removal after robot-assisted radical prostatectomy with a running barbed suture technique: a prospective analysis of 425 consecutive patients

ObjectiveTo compare prospectively early outcome and complications of catheter removal after robot-assisted radical prostatectomy (RARP) on the 4th or 7th day with a standardized running barbed suture technique.IntroductionThe time point of removing the indwelling catheter after RARP mainly depends on institute’s/surgeon’s preferences. Removal should be late enough to avoid urinary leakage and complications such as acute urinary retention (AUR) but early enough to avoid unnecessary catheter indwelling.Materials and methodsA consecutive single-institutional series of patients underwent RARP between July 2015 and August 2017 and were entered in a prospectively maintained data base. Between July 2015 and December 2016 a cystogram was performed on 7th postoperative day (group A), thereafter the cystogram was performed on 4th postoperative day (group B). Incidence of acute urinary retention (AUR), urinary tract infections (UTI) and adverse events between the two cohorts was compared.Results425 patients were analyzed (group A: n = 231; group B: n = 194). Both cohorts were comparable regarding demographic and oncological parameters. Watertight anastomosis was present in 84.8% in group A and in 82.5% in group B, respectively. AUR within 4 weeks after RARP occurred in 2.2% (n = 3) in A and 9.4% (n = 15) in B (p = 0.001). AUR within 72 h after catheter removal occurred in group A: 1% (n = 2) and in group B: 6.3% (n = 10) (p = 0.005). Symptomatic urinary tract infections occurred in 8.2% (n = 16) in group A and in 6.9% (n = 11) in group B. There were no differences in the rate of secondary anastomosis dehiscence. Age, BMI, prostate size, surgeon, or intraoperative bladder neck reconstruction were not correlated to the occurrence of AUR or UTI.ConclusionsThe removal of indwelling catheter on day 4 after a RARP with a running barbed suture shows similar anastomosis leakage rates as on the 7th postoperative day. However, AUR rates are higher for early removal. Patients scheduled for early removal should be carefully informed about the increased risk for AUR. Catheter indwelling time does not represent a risk factor for UTI.

Application of Surgiflo® in Tracheal Resection Anastomosis: Not Just a Hemostatic Agent But May Have a Potential Impact on the Healing Process

Background: Partial cricotracheal resection (PCTR) is considered the treatment of choice for high grade subglottic/tracheal stenosis. One of the principal surgical concern is non-tension water tight anastomosis with proper healing. Surgiflo® (Ethicon, Somerville, USA) is a commonly and safely used active flowable hemostatic matrix that may cause significant histopathological alterations, such as inflammation, adhesion and fibrosis, which may facilitate healing at the anastomotic site. Methods: We have reviewed our experience in Mansoura University Hospitals, Egypt; with the use of Surgiflo® in cases of PCTR. This study included 1 female patient with upper tracheal adenoid cystic carcinoma and 11 male patients with severe post-traumatic subglottic/tracheal stenosis. Significant comorbidities were reported in 6 adult patients (50%) in the form of neurological problems (n=3), COPD (n=2), OSAS (n=1), unilateral vocal fold paralysis (n=1) and morbid obesity (n=2). Eight patients (66.7%) had a history of previous airway surgery. The adopted surgical technique was standardized by the authors for all patients and Surgiflo® was applied at the end of surgery over the whole operative field including the anastomotic area. Findings: At the end of proper surgical intervention, 11 patients were successfully extubated with effortless breathing. None of the frequently reported complications like granulation tissue formation at the site of anastomosis, restenosis, surgical emphysema requiring intervention or wound seroma were reported in this series. On a follow up period of 6 - 12 months, 91.7% of the studied patients didn't have any further surgical intervention and all of them returned to their usual life activity. Interpretation: Direct Surgiflo® application in the operative field can be recommended as an adjuvant to surgery in patients undergoing PCTR especially when associated with comorbidities. Funding Statement: The authors stated: No. Declaration of Interests: No competing interest to declare. Ethics Approval Statement: A written consent was obtained from either the patient or the patient’s guardian. The study was approved by Mansoura faculty of Medicine Institutional Research Board (IRB: R.19.08.597).

An experimental study on magnetic esophageal compression anastomosis in piglets

IntroductionFashioning a patent, watertight anastomosis in patients with esophageal atresia is a challenging task in pediatric surgery, particularly when performed under tension. A reproducible suture-less alternative would decrease operative time. We evaluated magnetic esophageal compression anastomoses in a novel bypass-loop swine model. MethodsEight-week-old piglets underwent thoracotomy to mobilize the esophagus at the carina to create a U-shaped loop. Custom-made 8 mm diameter Neodymium Magnets were inserted into the esophagus proximal and distal to the loop, then mated side-to-side at the future anastomosis site. Pigs were observed for 8 (n = 4), 10 (n = 6), and 12 (n = 2) days and then sacrificed. The magnetic compression anastomosis was evaluated macroscopically, by radiography, burst pressure testing, and histology. ResultsAll 12 pigs survived until the endpoint. Separation of the magnets occurred at a median of 9 days. Contrast esophagrams showed patency and no leak. All anastomoses withstood pressures well over 13 kPa without leak. Histopathology showed epithelialized circular scar tissue. ConclusionMagnetic compression anastomoses of the esophagus using our specially-designed magnets are formed between the 8th and 10th postoperative day, are patent and mechanically resistant to supraphysiologic intraluminal pressures. These data lay the basis for a potential clinical application in patients born with esophageal atresia. Level of evidenceNot applicable (experimental animal study).

Time of catheterization as an independent predictor of early urinary continence recovery after radical prostatectomy

The purpose of the present study was to investigate the potential impact of catheter removal time on immediate and early urinary continence recovery in a series of patients who underwent radical prostatectomy (RP). We prospectively collected and analyzed the clinical records of 197 patients who underwent open RP between January 2014 and December 2016. A single surgeon using the urethral fixation technique performed all procedures. Patients receiving surgery between Monday and Wednesday performed a cystogram on postoperative day (POD) 2. Conversely, other cases treated on a Thursday or Friday performed a cystogram on the following Monday (POD 3 or 4). The catheter removal was planned the day after the cystogram if there was a watertight anastomosis or with a little extravasation (<5%). Urinary continence recovery was evaluated 1 week, 1, 2 and 3 months after catheter removal. Patients self-reporting no urine leak were considered continent. Logistic regression analysis was used to identify independent predictors of urinary continence recovery at different follow-up durations. The median catheterization time was 3 (IQR: 3-4.2) days and acute urinary retention (AUR) was observed in 13 (6.5%) cases. At median follow-up of 12 (IQR: 9-12) months, no case of bladder neck contracture was observed. Urinary continence probabilities were 43%, 63%, 87%, 91% and 95% after 1 week, 1, 3, 6, and 12 months, respectively. On multivariable analyses, time of catheter removal was an independent predictor of urinary continence recovery after 1 week (OR 1.2; P=0.02); 1 month (OR 1.2; P=0.01); 3 months (OR 1.1; P=0.04) and 6 months (OR 1.1; P=0.03) after catheter removal. Time of catheterization should be considered as a postoperative parameter able to influence the immediate and early urinary continence recovery in patients undergoing RP. The impact of new surgical techniques on urinary continence recovery should be tested also considering such potential confounding factor.

PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III1 Apr 2017PD18-01 RANDOMIZED STUDY EVALUATING SHORT-TERM FUNCTIONAL OUTCOMES OF ROBOT-ASSISTED RADICAL PROSTATECTOMY IN LOW-RISK PROSTATE CANCER PATIENTS Alexander Govorov, Dmitry Pushkar, Konstantin Kolontarev, Pavel Rasner, and Vladimir Dyakov Alexander GovorovAlexander Govorov More articles by this author , Dmitry PushkarDmitry Pushkar More articles by this author , Konstantin KolontarevKonstantin Kolontarev More articles by this author , Pavel RasnerPavel Rasner More articles by this author , and Vladimir DyakovVladimir Dyakov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many techniques have been described to optimize functional outcomes of robot-assisted radical prostatectomy (RARP). Our objective was to test the impact of surgical technique on post-operative urinary continence recovery (UCR), urinary bother symptoms and erectile function (EF) recovery in a randomized study in high-volume center. METHODS From July to December 2015 89 low-risk PCa patients signed the IC and were randomized in Group 1 (n=45, RARP with full bilateral nerve sparing (NS) and lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap) and Group 2 (n=44, conventional RARP with bilateral NS). Posterior rhabdosphincter reconstruction (PRR) was performed in all cases. Patients started tadalafil 5 mg OAD from Day of catheter removal. Groups were comparable for clinical and pathological variables. We evaluated: 1) UCR rate, defined as the use of 0 pad/day; 2) post-op urinary bother symptoms measured using the QoL question in the IPSS questionnaire (no bother, score 0-2; bother, score 3 and more); 3) EF recovery rate, defined as IIEF-5>17. RESULTS Patients with full NS, preservation of lateral prostatic fascia and amniotic membrane use had significantly higher rates of UCR at 1 week, 1 and 3 months and EF recovery rates at 3 and 6 months. Urinary bother scores were lower in these men at 1, 3 and 6 months post-RARP (table 1). There was no difference in positive surgical margins and intra- /post-RARP complication rate. Results were confirmed on multivariable analyses (odds ratio for Group 1 vs. Group 2 - 2.2 for UCR [p=0.006], 1.8 for EF recovery [p=0.004] and 3.6 for urinary bother [p=0.01]). CONCLUSIONS Lateral prostatic fascia preservation with amniotic membrane allograft nerve wrap significantly improved the rate of post-RARP urinary continence, urinary bother and EF recovery in a group of low-risk PCa patients with bilateral NS and PRR in a randomized study. This in turn can translate into a higher post-operative QoL and/or patient satisfaction. The definition of surgical Pentafecta describing intraoperative technical manoeuvers optimizing functional outcomes may include 1) bilateral nerve sparing, 2) preservation of lateral prostatic fascia, 3) PRR, 4) amniotic membrane allograft use and 5) watertight anastomosis. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e359 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alexander Govorov More articles by this author Dmitry Pushkar More articles by this author Konstantin Kolontarev More articles by this author Pavel Rasner More articles by this author Vladimir Dyakov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives.

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

Retroperitoneoscopic ureteroplasty for retrocaval ureter: report of nine cases and literature review

Objective: The aim of this study was to report the experience of retroperitoneal laparoscopic ureteroplasty for nine cases of retrocaval ureter.Material and methods: Six males and three females were referred with a diagnosis of retrocaval ureter. A retroperitoneal laparoscopic approach was taken in all patients, who were diagnosed by intravenous pyelography (IVP), computed tomography urography and retrograde pyelography. After the dilated proximal ureter was mobilized, the ureter was transected just above the retrocaval segment, which was repositioned to the anterior of the vena cava. The retrocaval segment was observed and evaluated to enable a decision as to whether or not to reserve. Then, tension-free, water-tight anastomosis was performed with absorbable sutures using intracorporeal suturing techniques over a double-J stent, which was laparoscopically inserted in an antegrade manner. The stent was removed 4–6 weeks postoperatively.Results: The ureteroplasty was accomplished in all cases. The retrocaval segment of the ureter was reserved with a grossly normal appearance in six cases; the abnormal retrocaval segment was excised in the three other cases. The mean operative duration was 103 min (range 89–110 min) and the mean hospital stay was 7 days (range 6–9 days). No serious complications occurred. Follow-up by ultrasonography and IVP, lasting 6 months to 4 years, revealed considerable improvement in hydronephrosis and upper ureteral dilatation. No ureteral stenosis was found at the anastomotic site.Conclusion: Retroperitoneoscopic ureteroplasty should be recommended as the first line treatment for retrocaval ureter because of its advantages of minimal invasion and shorter hospital stay than open surgery. Skilled laparoscopic anastomosis with a retroperitoneal approach can shorten the operative duration.

Surgical techniques in type A dissection.

Acute aortic dissection is a surgical emergency that must be urgently managed, with the primary goal of restoring flow to the dominant true lumen in the downstream aorta. Our preference at the Cleveland Clinic is for an open distal anastomosis technique without aortic clamping, as it permits more accurate approximation of dissected layers and more homeostatically secure anastomosis. During this procedure we employ right axillary end-to-side graft perfusion, followed by deep hypothermic circulatory arrest and antegrade brain perfusion. The distal anastomosis is performed without felt strips or glue. Critical to achieving a successful outcome is meticulous de-airing of the arch, diligent myocardial protection, and a water-tight anastomosis prior to discontinuing cardiopulmonary bypass.

V1-10 ROBOT ASSISTED TRANSPLANT URETERONEOCYSTOSTOMY

You have accessJournal of UrologyRobotics-Bladder/Reconstruction1 Apr 2016V1-10 ROBOT ASSISTED TRANSPLANT URETERONEOCYSTOSTOMY Haidar Abdul-Muhsin, Kelli Gross, Karen Stern, Nitin Katariya, and Erik Castle Haidar Abdul-MuhsinHaidar Abdul-Muhsin More articles by this author , Kelli GrossKelli Gross More articles by this author , Karen SternKaren Stern More articles by this author , Nitin KatariyaNitin Katariya More articles by this author , and Erik CastleErik Castle More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2124AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Anastomotic ureteral strictures are one of the most common complications after kidney transplantation. Early diagnosis and management is key in preserving graft function. Definite surgical intervention provides durable cure and has a high success rate. However, it is technically challenging and associated with more morbidity due the dense fibrotic tissue around the transplanted ureter. In this video we will describe our technique in performing robot assisted transplant ureteroneocystostomy with a brief description of outcomes in a case series METHODS These procedures were performed through the collaboration of our urology and transplantation surgical teams. The procedure was performed through a transperitoneal approach in lithotomy position. The ports were placed in a similar location to robot assisted radical prostatectomy. This video will highlight the technical aspects of this procedure. These are: (1) Identification of the transplanted ureter. (2) Proximal and distal dissection of the ureter. (3) Techniques of approximation of the distal end of the transplanted ureter to the bladder (4) Urethrovesical anastomosis RESULTS Location of the transplanted ureter is variable and can be identified after careful dissection of the paravesical space. This should not be confused with medial the umbilical ligament, vas difference and native ureter. Preoperative stenting and intermittent filling of the bladder during dissection can help identify the ureter. It is important to ensure complete excision of the stenotic ureter to prevent recurrence. Previous balder wall defect should be closed in a water tight fashion to prevent urine leak. A stented, spatulated, tension free, water tight anastomosis should be done with absorbable sutures. In order to bridge the gap between the distal end of the ureter and the bladder the same techniques that are used in non-transplant patients can still be utilized. This includes psoas hitch, release of the contralateral pedicle in addition to release of the transplanted kidney from the anterior abdominal wall. The plane between the transplanted kidney and the anterior abdominal wall is an avascular plane that can be relatively easily to develop. This technique was successfully implemented in three cases with complete resolution of obstruction, no anastomotic leakage and no complications. All patents were discharged on day 1 with a foley catheter for a week. A nephrostogram was performed at 7 days. The stent was removed in 4-6 weeks. CONCLUSIONS Robot assisted ureteroneocystostomy can be performed with acceptable initial results and the robotic platform provide benefits of early recovery © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e64 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Haidar Abdul-Muhsin More articles by this author Kelli Gross More articles by this author Karen Stern More articles by this author Nitin Katariya More articles by this author Erik Castle More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Total Anatomical Reconstruction During Robot-assisted Radical Prostatectomy: Implications on Early Recovery of Urinary Continence

BackgroundThe introduction of robotics revolutionized prostate cancer surgery because the magnified three-dimensional vision system and wristed instruments allow microsurgery to be performed. The advantages of robotic surgery could lead to improved continence outcomes in terms of early recovery compared with the traditional surgical methods. ObjectiveTo describe the total anatomical reconstruction (TAR) technique during robot-assisted radical prostatectomy (RARP). Primary endpoint: evaluation of the continence rate at different time points. Secondary endpoint: evaluation of urine leakage and anastomosis stenosis rates related to the technique. Design, setting, and participantsJune, 2013 to November, 2014; prospective consecutive series of patients with localized prostate cancer (cT1-3, cN0, cM0). Surgical procedureRARP with TAR was performed in all cases. Lymph node dissection was performed if the risk of lymph nodal metastasis was over 5%, according to the Briganti updated nomogram. MeasurementsPreoperative, intraoperative, postoperative, and pathological variables were analyzed. Enrolled patients were arbitrarily divided into three groups according to a time criterion. The relationships between the learning curve and the trend of the above-mentioned variables were analyzed using LOESS analysis. Continence was rigorously analyzed preoperatively and at 24h, 1 wk, 4 wk, 12 wk, and 24 wk after catheter removal. Results and limitationsIn total, 252 patients were analyzed. The continence rates immediately after catheter removal and at 1 wk, 4 wk, 12 wk, and 24 wk after RARP were 71.8%, 77.8%, 89.3%, 94.4%, and 98.0%, respectively. Multivariate analysis revealed that the nerve sparing technique, D’Amico risk groups, lymph node dissection, and prostate volume were involved in the early recovery of urinary continence. One ileal perforation requiring reoperation was recorded. The transfusion rate was 0.8%. Thirty-one (12.3%) postoperative complications were recorded up to 6 mo after surgery. Among these, eight acute urinary retentions (3.2%) and three urine leakages (1.2%) were recorded. There was a lack of randomization and comparison with other techniques. Both anatomical dissection of the prostatic apex and TAR were used. The results may not be generalized to low-volume centers. ConclusionsThe TAR technique showed promising results in the early recovery of urinary continence, as well as watertight anastomosis and a low rate of urine leakage. The oncologic results were not affected. Comparative studies are needed to support the quality of reported results. Patient summaryOn the basis of our findings, it seems that the risk of urinary incontinence following radical prostatectomy can be lowered via meticulous anatomical reconstruction using a robotic system. Comparative studies are required to support the reported results.

V10-05 ROBOT ASSISTED BLADDER AUGMENTATION AND BILATERAL URETERAL REIMPLANTATION

INTRODUCTION AND OBJECTIVES: Despite use of barbed suture during robot-assisted radical prostatectomy or partial nephrectomy, concerns have been raised about a high early failure rate when used during minimally-invasive pyeloplasty (MIP). In this video, we present our technique of robotic pyeloplasty using barbed suture, review the literature on barbed suture for MIP and discuss the controversies, tips, and tricks. METHODS: We present a case of a 55 year old man with rightsided uretero-pelvic junction obstruction (UPJO). The patient was placed in the modified flank position. Port placement was a 12 mm camera port, two 8 mm robotic ports, and a 5 mm assistant port. The robot was docked at a 30-degree angle to the flank. A robotic cautery hook was used to aid with fine hemostatic dissection. The renal pelvis and upper ureter were mobilized to reveal a crossing vessel. Round tip scissors were used to perform dismemberment and spatulation (Anderson-Hynes technique). The ureter was transposed over the crossing vessel and anastomosis was performed using a unidirectional barbed suture (3-0 Stratafix ; Ethicon, Somerville, NJ, USA) in a running fashion. Following completion of the posterior layer, an antegrade ureteral stent was placed followed by closing the anterior layer in a similar fashion. RESULTS: Strategies for successful robotic pyeloplasty using barbed suture include: (1) selection of appropriate barbed suture e suture composition, absorbability, distribution of barbs and needle type vary between manufacturers (2) minimizing tension during suture placement to avoid tissue necrosis (3) use of round tip scissors to avoid spiral spatulation of the ureter (4) use of the obstructing UPJ tissue as a handle-hold for manipulation (5) avoid use of 12 mm assistant port for needle entry by utilizing needle placement via a robotic port. Advantages of barbed suture include no loss of tension as seen in non-barbed monofilament suture with possibility of suture loosening, and use of a “continuous interrupted” method; the barbs allow the anastomotic tension to be evenly spread to avoid gaps and mimic interrupted suture. Of 18 patients who have undergone laparoscopic or robotic pyeloplasty using barbed suture at our institution, the success rate was 17/ 18 (94%). CONCLUSIONS: Barbed suture for MIP provides a watertight anastomosis that is technically easier to perform. A key principle is to know your barbed suture as incorrect suture selection may compromise success. Our results demonstrate excellent success rates when using the barbed suture for MIP.

Surgical results of anderson-hynes dismembered pyeloplasty without internal drainage in adults with ureteroplevic junction obstruction.

Background:Anderson-Hynes dismembered pyeloplasty is the gold standard therapeutic approach to ureteropelvic junction obstruction (UPJO). Use of a drainage method to protect the suture line from leakage is a matter of controversy.Objectives:We have compared the surgical outcome of Anderson-Hynes dismembered pyeloplasty for UPJO repair, with or without internal stenting.Patients and Methods:Eighty-two patients with UPJO were evaluated from 1996 to 2002. Complicated or emergent cases were excluded. Classic standard dismembered pyeloplasty was performed. Internal drainage, with a double j catheter, was performed in several patients, randomly. Another drain was also placed in the retroperitoneal space. The follow-up of patients was planned weekly, with patient visits and urine analysis and intravenous pyelography (IVP) and diethylene-triamine-pentaacetate (DTPA) scan after one month.Results:The study group consisted of 51 male and 31 female patients, who were mostly in the age range of 20 - 40 years. Comparing the two techniques of pyeloplasty with or without internal drainage, there was no significant difference between groups regarding extravasation and anastomosis complications, such as leakage, stenosis, urinoma formation or evidence of obstruction on postoperative IVP or DTPA scan. However, a higher incidence of catheter related urinary symptoms and flank pain was reported among those with internal stent.Conclusions:Pyeloplasty, with adequate spatulation, hemostasis and a watertight anastomosis, represents the mainstay of successful pyeloplasty and there may be no significant benefit for urethral stenting, especially in non-complicated cases.

Bladder neck contractures and the prostate cancer survivor.

To summarize the cause and diagnostic and treatment concerns for bladder neck contractures (BNCs) in the prostate cancer survivor. BNC rates have decreased significantly in the last 2 decades, likely because of improvement in the surgical technique and increased utilization of laparoscopic and robotic surgery, which may allow better visualization of the vesicourethral anastomosis. Despite these improvements, risk factors such as smoking and coronary artery disease contribute to BNC development. Furthermore, although recent reports have questioned the classical tenets of anastomotic technique such as water-tight anastomoses, there is no evidence that these principles contribute to the risk of BNC development and should continue to be observed. The results of minimally invasive procedures such as urethral dilation and transurethral incision of the bladder neck may be improved with the use of injectable agents. There is little consensus regarding BNC therapy. Although several risk factors contributing to BNC development have been identified, strategies to reduce the risk are unclear. A number of therapeutic options are available, however. In the event of BNC development, treatment should be structured in a hierarchical fashion which minimizes the risk of urinary incontinence.

V7-11 ROBOT ASSISTED LAPAROSCOPIC PELVOVESICOSTOMY AND BLADDER HITCH FOR URETEROPELVIC JUNCTION OBSTRUCTION OF A RIGHT PELVIC KIDNEY WITH RETAINED URETERAL STENT

You have accessJournal of UrologyTrauma/Robotics1 Apr 2014V7-11 ROBOT ASSISTED LAPAROSCOPIC PELVOVESICOSTOMY AND BLADDER HITCH FOR URETEROPELVIC JUNCTION OBSTRUCTION OF A RIGHT PELVIC KIDNEY WITH RETAINED URETERAL STENT William Brubaker, Jack Zuckerman, Justin Watson, and Shaun Wason William BrubakerWilliam Brubaker More articles by this author , Jack ZuckermanJack Zuckerman More articles by this author , Justin WatsonJustin Watson More articles by this author , and Shaun WasonShaun Wason More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2041AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteropelvic junction (UPJ) obstruction occurs in one third of pelvic kidneys. The majority of cases are treated with dismembered pyeloplasty. The current patient presented with the additional complication of a retained and calcified ureteral stent that was refractory to endoscopic removal. Preoperative DMSA renal scan demonstrated 21% function in the right pelvic kidney, thus definitive repair was the objective. In this video we demonstrate a case in which a 31-year-old female with a right UPJ obstruction and a retained stent in a pelvic kidney is managed by robot assisted laparoscopic pyelovesicostomy with bladder hitch to the sacral promontory. METHODS The patient was taken to the operating room for robot assisted laparoscopic pyelovesicostomy. The operation was performed utilizing dorsal lithotomy and steep Trendelenburg positioning. After incising the retroperitoneum the right ureter was traced posterior to the fallopian tube as it entered the bladder. The right ureter was divided distal to the UPJ and the retained stent as well as a more recently placed ureteral stent were both removed. The UPJ was widely spatulated. Pyeloscopy with a flexible cystoscope was performed demonstrating minimal stone debris. The bladder was filled and tunneled posterior to the right fallopian tube. The sacral promontory was cleared and the bladder was then hitched to the presacral fascia to ensure a tension-free anastomosis. The bladder was opened transversely and a watertight anastomosis of the right renal pelvis and bladder was performed. RESULTS The patient recovered well and was discharged home on post-operative day one. She had a Foley catheter left indwelling for seven days. Post-operative CT urogram demonstrated no extravasation of urine. Renal Lasix scan at 6 weeks demonstrated excellent drainage through the right kidney and the patient continues to do well. CONCLUSIONS The treatment for UPJ obstruction in a pelvic kidney can be safely and effectively performed through a minimally invasive approach. This allowed for removal of retained stent and pelvovesicostomy utilizing a hitch to the sacral promontory in a single session. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e738 Advertisement Copyright & Permissions© 2014MetricsAuthor Information William Brubaker More articles by this author Jack Zuckerman More articles by this author Justin Watson More articles by this author Shaun Wason More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Recurrent Foley catheter puncture and displacement: a complication of the use of barbed polyglyconate suture to facilitate vesicourethral anastomosis during robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) has been rapidly adopted as an option for surgical management of clinically localized prostate cancer. A challenging aspect of the operation is producing a watertight vesicourethral anastomosis (VUA). The use of unidirectional barbed polyglyconate absorbable suture (V-Loc 180, Covidien, Mansfield, MA, USA) for posterior reconstruction and VUA during RARP was initially described in 2010 [1, 2] and has been shown to safely improve anastomotic times [3–6]. We describe a unique postoperative complication of the use of barbed suture during RARP: recurrent puncture and displacement of the urethral catheter.