2022 Misc Benign Transplant Renovascular (v05)
2022 Misc Benign Transplant Renovascular (v05)
2022 Misc Benign Transplant Renovascular (v05)
Before starting the isolation of renal mass a careful identification of the CONCLUSIONS: In selected cases, robotic approach can be
aorta was attempted. However, after exposure of the left gonadal vein, successfully used in management of surgical complication after RARC,
the aorta was identified laterally to the isolated renal artery. Therefore, in tertiary referral centres. ICG near infrared uorescence is a useful tool
the surgeon realized that the isolated artery was the right renal one. The in identication of anatomical structures and allows a real-time
vessel loop was removed, the left renal artery identified and isolated assessment of tissue vascularity, in order to prevent complications
and the PN with warm ischemia was performed. strictly related to ischemic injuries.
RESULTS: Operative time was 240 min, estimated blood loss
Source of Funding: None
was 300 ml and no complications occurred. Final pathology revealed a
clear cell RCC with eosinophilic variant, pT1b-pNx-R0.Follow-up period
was uneventful and 2-y postoperative GFR was 52 ml/min. After a V05-05
specific surgical audit the predisposing factors for our NM were REPAIR OF ENTERO-CONDUIT FISTULA USING
identified: suboptimal evaluation of preoperative CT scan, no 3D ROBOT-ASSISTED LAPAROSCOPY
reconstructions available, abundant visceral fat, left-sided surgery and Aeen Asghar*, David Strauss, Daniel Eun, Philadelphia, PA
direct access to the renal pedicle without identification of gonadal vein.
CONCLUSIONS: Procedural errors in the OR may come along INTRODUCTION AND OBJECTIVE: We present a case high-
with tremendous complications for the patient. The identification of the lighting surgical management of an entero-conduit fistula (ECF), with
anatomical landmarks is mandatory and the discussion of the potential robot-assisted laparoscopy (RAL). The patient is a 71-year-old male
NM helps the prevention of adverse dangerous events. In our case, with a history of non-invasive high-grade urothelial carcinoma (UC) of
failure to recognize the error would result in serious complications, the left distal ureter who underwent a RAL distal ureterectomy and
especially if a radical nephrectomy had been planned. ureteroneocystostomy and subsequent left RAL completion
Source of Funding: None nephroureterectomy and eventual RAL radical cystoprostatectomy
(RC) and intracorporeal ileal conduit (IC) diversion due to recurrence
despite an induction course of intravesical BCG. Most recently, he
V05-04 developed metastatic disease to his right lung and underwent robot-
ROBOTIC MANAGEMENT OF SURGICAL COMPLICATIONS AFTER assisted right lobectomy. Currently, the patient is disease-free. Nearly
ROBOT-ASSISTED RADICAL CYSTECTOMY WITH two years after RC, he presented with food particles and air per his
INTRACORPOREAL DIVERSION urostomy. He also had a positive poppy seed test. Initially,
Leonardo Misuraca*, Riccardo Mastroianni, Gabriele Tuderti, pouchoscopy identified a pinpoint ECF tract at the proximal end of
Umberto Anceschi, Aldo Brassetti, Mariaconsiglia Ferriero, the IC. A 6-month trial of conservative management was
Alfredo Maria Bove, Salvatore Guaglianone, Michele Gallucci, unsuccessful with multiple episodes of pyelonephritis of his solitary
Giuseppe Simone, Rome, Italy right kidney requiring prophylactic antibiotics. Here, we demonstrate
our approach to RAL ECF repair.
INTRODUCTION AND OBJECTIVE: RARC is a complex and METHODS: We began with pouchoscopy, which revealed a
morbid procedure, even when performed in a minimally invasive larger ECF, able to be cannulated by a 5 Fr open-ended catheter.
fashion. It is affected by a 90-day complication of approximately 59%, Injection of contrast highlighted the ECF. A simultaneous pouchogram
with an high-grade complication rate which ranges from 15 to 30%. revealed reflux to the solitary right kidney. Access was obtained
Many of this postoperative complications, occasionally necessitate re- using a 5mm optical trocar without difficulty. We noted no significant
exploration, which could benet in turn from a minimally invasive intra-abdominal adhesions despite his past surgeries. Four 8mm
approach. In this video, we describe our surgical technique used to robotic ports and a 5mm assistant port were used as outlined in the
manage two relatively frequent complications. video. The ureteral anastomosis was easily identified, and further
METHODS: In both cases, patient was placed in steep Tren- dissection revealed the ECF in proximity to the bowel-bowel
delenburg position and a conventional 5 or 6 trocars access for pelvic anastomosis staple line. We upsized the left 8 mm robotic port to
surgery was adopted. The rst case is a reimplantation for uretero-ileal 12 mm to use a 45 mm robotic stapler. The ECF tract was stapled
anastomosis stricture after RARC with orthotopic neobladder. Ureter and oversewn using 4-0 silk sutures. Omentopexy and interposition
was gently isolated and ICG near infrared uorescence imaging was flap was performed by mobilizing the omentum and fixating it in
used to better individuate the ischemic portion of distal ureter. Ureter between the bowel and IC using 4-0 silk sutures to prevent recurrence.
was clipped with hem-o-lok, transected and spatulated. Cystostomy RESULTS: Operative console time was 98 minutes with 25 mL
was performed before proceeding with a direct reimplantation with 3/ of blood loss. He was discharged on the same day. The red rubber
0 interrupted sutures. A double J stent was placed over a guide wire, catheter, which was secured to the IC, was removed at his 2-week post-
through a 5 mm trocar and cystostomy was closed with a 2/ operative visit. He remains symptom-free at the time of his 6 month
0 monocryl running suture. A water tightness test proved the suture follow up visit.
sealing. A nal check with ICG near infrared uorescence CONCLUSIONS: First-line treatment of ECF is conservative
demonstrated a normal vascularity of the re-anastomosis area.The management, with surgical repair reserved for rare failure. This case
second case is an ileal-neobladder stula in a 66-yr old male, who shows the feasibility of RAL ECF repair and revisions for urinary
underwent RARC. Ports placement was particularly dicult due to diversion-related complications. Additionally, it highlights a potential
multiple and extensive adhesions. A meticulous adhesiolysis was benefit of RAL given minimal adhesion development despite multiple
performed in order to expose the neobladder and individuate the stula prior major intra-abdominal surgeries done using the robotic approach.
location. Neobladder was irrigated with a mixture of ICG and saline
Source of Funding: None
solution and near infrared uorescence imaging allowed to individuate
the afferent and the efferent ileum loop stulized with neobladder,
which were both divided with a 60 mm laparoscopic stapler. A new V05-06
latero-lateral ileal-ileal anastomosis was then performed. A 2/ ROBOTIC BILATERAL PELVIC URETERAL SUBSTITUTION AND
0 monocryl running suture was used to cover the surgical staples, in AUGMENTATION CYSTOPLASTY WITH ILEAL LOOP FOR DISTAL
order to prevent further future adhesions. Ileal loop stulized with the URETERAL STRICTURE AND RADIATION CYSTITIS: RESULTS
neobladder was completely excluded from intestinal transit and bowel AFTER 1-YEAR FOLLOW UP
continuity restored. Testino, Enrico Vecchio, Flavia Carlini,
Francesca Ambrosini*, Nicolo
RESULTS: Conversion to open surgery was not necessary in Marco Borghesi, Nazareno Suardi, Giovanni Camerini, Carlo Terrone,
any procedures. Operative time was 146 and 120 minutes, respectively, Genova, Italy
with negligible EBL. No intra- nor perioperative complications were re-
ported and patients were discharged on 4th and 5th POD, respectively.
e518 THE JOURNAL OF UROLOGYÒ Vol. 207, No. 5S, Supplement, Saturday, May 14, 2022
INTRODUCTION AND OBJECTIVE: Patients with bilateral pain, which were unsuccessful. Computed tomography of the
ureteral strictures and associated reduced bladder capacity post pelvic abdomen revealed a compressed left renal vein. In the context of his
radiation therapy are commonly condemned to indwelling ureteral clinical presentation, laboratory reports and, and imaging findings, a
stents or nephrostomy tubes. We report the case of a woman submitted presumptive diagnosis of nutcracker syndrome was made. The
to robot-assisted bilateral ureteral substitution and augmentation patient was counseled regarding the various treatment options for this
cystoplasty with ileal loop for the management of bilateral pelvic condition and elected to proceed with robotic-assisted left renal vein
ureteral strictures and impaired bladder capacity, at one-year follow up. transposition.
METHODS: In January 2020, neoadjuvant chemo and radio- RESULTS: The patient tolerated the procedure well. Total
therapy for locally advanced squamous cell carcinomas of the cervix operative time was 152 minutes, there were no complications, and the
were administered to a 31-year-old female. In April 2020, she patient was discharged home on postoperative day one. At his six-week
underwent radical hysterectomy, adnexectomy and pelvic follow-up visit, the patient reported resolution of left flank pain and
lymphadenectomy (ypT0, ypN0), followed by adjuvant chemotherapy. hematuria, and ultrasound revealed no abnormalities.
3 months after surgery, bilateral hydronephrosis due to bilateral pelvic CONCLUSIONS: Robotic-assisted left renal vein transposition
ureteral stricture and a vesico-vaginal fistula (VVF) were detected. is a safe and effective treatment for nutcracker syndrome. This
The patient underwent supratrigonal laparoscopic VVF repair and approach to left renal vein transposition should be achievable for sur-
bilateral ureteral stenting. After stents removal, the patient developed geons experienced with robotic retroperitoneal lymph node dissection
pyelonephritis. Bilateral nephrostomies were placed. A robot-assisted and caval thrombectomy.
substitution of bilateral pelvic ureters and augmentation cystoplasty
Source of Funding: n/a
with U-shaped ileal loop was planned. The ureters were identified
above the stricture and sectioned at the level of the iliac vessels. A
20 cm ileal loop was sectioned with an engoGIA. The bladder dome V05-08
was transversally opened for 10 cm, and the ileo-bladder ROBOTIC-ASSISTED LAPAROSCOPIC LEFT SEMINAL
anastomosis was completed with a continuous suture. Each ureter is VESICULECTOMY AND DISTAL LEFT URETERECTOMY FOR A
spatulated and anastomosed on double-J stents to the end of each PATIENT WITH ZINNER SYNDROME
bowel chimney. Abdominal ultrasound was performed at 1 and Safiya-Hana Belbina*, Scott Spivey-Provencio, Austin, TX;
3 months. An abdominal CT scan at 6 and 12 months was Rachel Wallace, Austin, TX; Aaron Laviana, Austin, TX
recommended. Renal function was monitored every 3 months.
RESULTS: The post-operative course was uneventful. The INTRODUCTION AND OBJECTIVE: This video discusses the
abdominal drain was removed on 5th post-operative day (POD) and surgical technique of a robotic-assisted laparoscopic left vesiculectomy
the nephrostomy tubes were closed on 7th POD. A cystogram and distal left uretectomy for a 25-year-old male patient found to have
2 weeks after surgery showed no urinary leakage. Thus, the Foley Zinner Syndrome. Zinner Syndrome is a rare syndrome first described
catheter and the ureteral stents were removed. At a 3-month follow- in 1914 as a congenital mesonephric duct malformation. Since its
up the patient was asymptomatic with adequate bladder capacity, no discovery, only approximately 200 cases have been described in the
post void residual urine, no hydronephrosis. The same results were literature. Historically, the only surgical options for a vesiculectomy
confirmed at 1-year follow-up. On 1-year CT scan mild left were an open approach via transabdominal or transperineal.
hydroureter was detected, with regular bladder capacity and renal Currently, laparoscopic, and robotic assisted surgery may be
function. considered as these minimally invasive techniques offer reduced
CONCLUSIONS: The robot-assisted approach is effective for blood loss, shorter hospital stays, and faster recovery. In this video,
pelvic ureteral substitution and augmentation enterocystoplasty in we present the robotic approach for a left vesiculectomy and distal
patients presenting with side effects of previous surgery and left ureterectomy in a young patient plagued by perineal discomfort.
radiotherapy. METHODS: The patient is a 25-year-old male who presented to
his urologist with a one-year history of pelvic and perineal pain. On
Source of Funding: None
further workup, he was found to have left renal agenesis but
otherwise normal renal function. His constellation of symptoms along
V05-07 with his exam and imaging findings were consistent with Zinner
ROBOTIC-ASSISTED LAPAROSCOPIC LEFT RENAL VEIN Syndrome. After discussing options, the patient elected for surgical
TRANSPOSITION FOR TREATMENT OF NUTCRACKER excision of the seminal vesicle cyst for symptom management.This
SYNDROME surgical video demonstrates a robotic-assisted laparoscopic approach
Robert Harrison*, Tanner Corse, Michael Stifelman, Hackensack, NJ to the removal of the left seminal vesicle cyst and ectopic ureteral
remnant. The surgery was approached by incising the posterior
INTRODUCTION AND OBJECTIVE: Nutcracker syndrome is peritoneum while lifting the bladder to identify the multiloculated left
an uncommon clinical condition in which the left renal vein is com- seminal vesicle cyst. In this video, one can appreciate the massive
pressed between the superior mesenteric artery and aorta. Patients size of this complex cyst. The cyst was carefully dissected to
most commonly present with hematuria or left flank pain, and a wide preserve the right seminal vesicle and vas deferens as they were
range of treatment modalities are available to treat symptomatic anatomically normal.
nutcracker syndrome. One such intervention is left renal vein trans- RESULTS: The patient was discharged home the same day
position, which has produced excellent results when performed with an without a drain. We left a Foley catheter for 9 days and passed his
open approach. Minimally-invasive techniques have revolutionized how voiding trial at his follow-up appointment. On further follow-up, the
many surgical procedures are performed, but despite the increasing patient's symptoms have completely resolved, and his ejaculatory
popularity of robotics, the literature on robotic-assisted left renal vein volume has remained unchanged.
transposition remains limited. In this study, we describe our robotic CONCLUSIONS: This video showcases the rare urogenital
left renal vein transposition technique in a patient with nutcracker anomaly of Zinner syndrome. The patient's uncomplicated post-
syndrome. operative course and full resolution of symptoms highlight the
METHODS: The patient was a 19-year-old male with a 12- advantages of this minimally invasive robotic approach as a viable
month history of left flank pain, gross hematuria, and early satiety. and effective treatment option for symptomatic patients with this
The patient had a thin body habitus, with a body mass index of condition. Furthermore, although Zinner syndrome is rare, it should be
17.7 kg/m2. Physical examination was unremarkable. His baseline considered in the differential diagnosis of cystic masses within the
serum creatinine was 0.8 mg/dL, and urinalysis showed moderate male pelvis.
blood and no proteinuria. The patient initially attempted conservative
Source of Funding: n/a
treatment options, including weight gain and acetaminophen for flank
Vol. 207, No. 5S, Supplement, Saturday, May 14, 2022 THE JOURNAL OF UROLOGYÒ e519
V05-09 ICG is retained in the lower pole on left picture.C ActivSight perfusion
VIRTUAL LEARNING AND COLLABORATIVE WORKING IN A demonstrated in the entire kidney on right picture. No intraoperative
PANDEMIC - HOW TO CHANGE A SUPRAPUBIC CATHETER adverse events were noted.
CONCLUSIONS: We demonstrate that ActivSight LSCI is a dye
Damiete Harry*, Barking, United Kingdom
free, repeatable, real-time adjunct of renal parenchymal perfusion.
INTRODUCTION AND OBJECTIVE: With the centralisation of Applicability in robotic renal surgery is hypothesised to complement
urological services in the UK it is not always possible to have straight the technology of ICG guidance, increasing digitally active surgery.
forward procedures such as exchange of suprapubic catheters (SPC) Further follow-up utility and clinical trial assessment of ActivSight
performed by a member of the urology team. Moreover, during the should follow.
height of the COVID pandemic a significant number of urology junior
doctors were redeployed to ITU, thus not available for changes of SPCs
on the ward.
METHODS: A questionnaire-based study of regional core
surgical and foundation trainees was performed to ascertain their
confidence level and knowledge surrounding catheterisation and
exchange of SPCs. The results of this study formed the basis for the
production of a YouTube video on how to change an SPC.
RESULTS: 45.8% of all core surgical trainees surveyed had
never changed a suprapubic catheter; 35.4% of all core surgical
trainees felt this should only be performed by a member of the urology
team. 86.6% foundation trainees had never changed a suprapubic
catheter; 56.7% of all foundation trainees felt this should only be per-
formed by a member of the urology team. After watching the video they
were seen to have an increase in confidence with the post teaching
feedback showing only 12.2% of those studied stating only the urology
department should perform suprapubic catheter changes.
CONCLUSIONS: The training video was created and it has
been found that the confidence of the junior doctors was increased. This
video has now been incorporated in the regional induction curriculum for
foundation trainees. It is a useful tool for distanced learning and
adequate for giving colleagues the confidence to perform this simple
procedure.
Source of Funding: Self funded
V05-10
ACTIVSIGHT LASER SPECKLE CONTRAST IMAGING COMPARED
TO INDOCYANINE GREEN IN RENAL PERFUSION OF AN ANIMAL
MODEL
Jonathan Noe € l, Celebration, FL; Anya Mascarenhas, Boston, MA;
Chibueze Nwaiwu, Yao Liu, Providence, RI; Vasiliy Buharin,
John Oberlin, Alyson Dechert, Boston, MA; Marcio Moschovas*,
Celebration, FL; Peter Kim, Providence, RI; Vipul Patel, Celebration, FL
signs of XGPN of right kidney: an enlarged kidney with important After port placement, the cecum was dropped to expose the retro-
dilation and densification of the collecting system, caused by urinary peritoneum. A fan retractor was utilized to retract bowel away from the
stones. The patients were admitted to the urology ward and started surgical field. The right ureter was identified at the level of the common
on intravenous (IV) antibiotics. Patient 1 was submitted to ultrasound- iliac artery and mobilized to the lower pole of the right kidney. With
guided percutaneous nephrostomy and psoas drain placement and assistance from the neurosurgery team, the lateral border of the tumor
was discharged after 9 days, with both catheters and oral antibiotics. was identified lateral to the psoas muscle. The femoral nerve was
She was readmitted after 3 months for the elective right nephrectomy. identified running anterolateral to the tumor and preserved. The tumor
Patient 2's also had a percutaneous nephrostomy placed by the was separated from the right common iliac artery inferiorly and from the
Urology team and a hepatic drain in an abscess placed by the posterior abdominal wall posteriorly. With guidance from the neuro-
Radiology team. The patient stayed in the hospital for 2 weeks and surgeons, the tumor was separated from the vertebral bodies medially.
was discharged after drains removal. Her right nephrectomy was Care was taken to ensure preservation lumbar plexus by neuro-
scheduled for 1.5 months after. The definitive treatment of this monitoring. After the mass was excised, motor-evoked potentials pre
condition is surgical with nephrectomy, drainage of concomitant and post-operatively showed no change. A Blake drain was left in
abscesses and removal of the involved tissues. Our video presents place with urethral catheter and nephrostomy tube to gravity.
and compares these patients' laparoscopic surgeries. RESULTS: Operative time was 400 minutes with an estimated
RESULTS: The surgical time was 2 hours in patient 1 and 4 blood loss of 100 mL. The patient tolerated the procedure well and
hours in patient 2, with no intraoperative complications. Patient 1 transferred to the floor. On post-operative day (POD) 2, patient was
recovered quickly and was discharged after 3 days. Patient 2 was noted to have 4/5 right lower extremity strength. MRI pelvis and
required to stay on bowel rest with a nasogastric tube placed for 3 days. lumbar spine showed expected post-surgical changes with lumbar
She started solid food ingestion on day 5 with great tolerance and was nerve roots intact. The patient was subsequently discharged home on
discharged on post-operative day 8. No post-operative complications POD3 after clearance from physical therapy and neurosurgery.
were observed. The pathology report was similar for both patients: CONCLUSIONS: A minimally invasive approach is safe and
terminal kidney with XGPN. feasible for peripheral nerve tumors of the retroperitoneum. With the
CONCLUSIONS: Laparoscopic management of xanthogranu- assistance of the neurosurgical team, an excellent neurologic and
lomatous pyelonephritis is challenging due to the loss of anatomical urologic outcome can be achieved.
planes and inflamed tissues, so a systematic approach is advisable.
The management of pyeloduodenal fistulas can also be made by lap-
aroscopy, as demonstrated in our video, the first reported case of
laparoscopic treatment of this kind of fistula.
Source of Funding: None
V05-12
ROBOTIC-ASSISTED LAPAROSCOPIC EXCISION OF
RETROPERITONEAL GANGLIONEUROMA
Jeffery Lin*, David Ortega, Edward Forsyth, Inderbir Gill, Los Angeles,
CA