- Email: [email protected]
106 Nerve sparing robotic retroperitoneal lymph node dissection for stage I NSGCT
video posters / european urology supplements 9 (2010) 519–530
of ureteric injuries. We present our initial experience with robot-assisted ureteroneocystostomy (RAUN) in regard to ergonomic advantages offered by the da Vinci Surgical system. Material and Methods: We present a video of the management of a 55-year-old woman, presented after a hysterectomy with bilateral iatrogenic ureteric transaction. The patient underwent a robot-assisted bilateral vesicopsoas hitch and RAUN with extravesical Lich-Gregoir technique. The camera is placed superior to the umbilicus and a similar port arrangement as for radical prostatectomy was used. We performed bilateral tension-free ureter reimplantations on the bladder dome using running sutures. Pig-tail catheters placed retrogradely and the detrusor was closed over the ureters to create a submucosal tunnel and a drain was placed. Results: The console time was 275 minutes. No intra-operative or post-operative complications were noticed and the estimate blood loss was 110 ml. The urethral catheter was removed after a cystogram showing no evidence of an anastomotic leakage on day 7 and the patient was discharged uneventfully from the hospital on the following day. The pig-tails removed after 3 weeks and the patient was asymptomatic after 2 months follow-up. Conclusion: The robotic surgical system is particularly well suited with superior visibility and ergonomics for complex reconstruction procedures where a precise dissection and stitching is needed. RAUN is a safe and effective treatment option with ergonomic advantages and excellent reconstructive capabilities of da Vinci system for bilateral ureteral reimplantation. 104 Transmesololic robot-assisted pyeloplasty G. Pini, F. Annino, S. Micali, M.C. Sighinolfi, S. De Stefani, G. Bianchi. University of Modena and Reggio Emilia, Modena, Italy Objectives: Robot-Assisted pyeloplasty results are comparable to those of open pyeloplasty, the standard option for ureteropelvic junction (UPJ) obstruction and it shows a less steep learning curve in comparison with laparoscopy. After 9 transperitoneal standard retrocolic procedures, the video shows our first approach with a transmesocolic robot-assisted left dismembered pyeloplasty. Methods: Patient: 22-year-old man with primary UPJO. Lombotomic position. Robot da Vinci on the back side of patient. Verres pneumoperitoneum and 5 transperitoneal trocar (3 robotic and 2 laparoscopic for assistant). Exposition and incision of the left mesentero-colic space. Exposition and dissection of ureter. Identification and free dissection of the renal pelvis in order to obtain an adequate lenght to perform a tension free-repair. Transection of the renal pelvis above the UPJ. The redundant renal pelvis is transacted and the UPJ is removed. Lateral ureter spatulation. Closure of the excess pyelotomy incision in running suture. Antegrade insertion of DJ stent. Anastomosis in multiple running 4/0 Monocryl suture. Summary of Results: Operative time 115 minutes, blood loss <25 ml; catheter removal post operative day (pod) 1; drain removal in pod 2, discharge pod 3; DJ removal after 20 days. At 12 month the patient is still asymptomatic and Intravenous Urography and diuretic renal scan show absence of hydronephrosis. Conclusions: The transmesocolic robot-assisted pyeloplasty is safe and feasible. The direct approach to the left UPJ provides a good operative field, lower bowel manipulation and decreasing in operative time. Above all, robotic system makes easier reconstructive and suturing time and it raises surgeon capabilities.
529
105 Remote proctoring using the da Vinci Connect system J. Porter. Swedish Medical Center, Seattle, WA, USA Objectives: The learning curve associated with robotic surgery requires intensive training and can be assisted with instruction by a qualified surgical proctor. It has been necessary for the proctor to be present in the operating room with the surgeon. This may require the proctor to travel long distances and be absent from medical practice. Recently, an internet based communication system, called da Vinci Connect, has been developed to facilitated remote proctoring. Methods: da Vinci Connect requires the da Vinci S system with additional hardware and software upgrade. The endoscopic view provided by the robotic camera is transmitted via a secure internet connection to a laptop at the remote proctor’s location. The proctor has the ability to perform telestration, which is seen on the surgeon’s console using the TilePro function. The operative suite is equipped with an auxiliary camera to provide an external view of the patient or the surgeon’s console. Twoway audio intercom allows real time communication between surgeon and proctor. Results: The first case involved proctoring a surgeon in Fort Lauderdale, Florida from Seattle, Washington who was performing a robotic prostatectomy. He had performed approximately 400 prostatectomies and was interested in improving his technique of nerve preservation. The procedure was completed with excellent preservation of the neurovascular bundles. The telestration feature was useful for guiding the console surgeon during dissection of the nerve bundles and the two-way audio allowed communication with minimal transmission delay or talk over. Conclusions: The da Vinci Connect system allows remote proctoring across a secure internet connection with excellent visualization and audio communication. The proctoring platform should facilitate surgeon to surgeon interaction without the need for the presence of the proctor. 106 Nerve sparing robotic retroperitoneal lymph node dissection for stage I NSGCT J. Porter. Swedish Medical Center,Seattle, WA, USA Objectives: Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for clinical stage 1 non-seminomatous germ cell tumor (NSGCT). Laparoscopic RPLND has been performed in an effort to decrease the morbidity of open RPLND. Robotic surgical techniques have recently been employed in urologic procedures with the noted advantages of 3-D vision and greater degrees of instrument freedom. To determine whether the advantages of robotic surgery could be applied to laparoscopic RPLND, we present our technique of robotic nerve sparing RPLND. Methods: Right robotic RPLND is performed via a transperitoneal approach using 4 robotic trocars and an assistant trocar. The fourth robotic arm is used throughout the procedure and is instrumental in providing exposure of the lymphatic tissue and retraction of the bowel and major vessels. A complete right template dissection is performed with dissection of the paracaval, retrocaval, interaortocaval and preaortic lymph nodes. Nerve sparing is performed within the template. The spermatic cord is dissected completely within the inguinal canal by repositioning the robot over the patient’s legs. Results: Right Robotic RPLND was performed successfully with preservation of the post ganglionic fibers from the sympathetic chain to the hypogastric plexus. Complete dissection was performed of the paracaval, retrocaval, interaortocaval, preaortic, and para-aortic lymph nodes. Operative time was
530
video posters / european urology supplements 9 (2010) 519–530
3.5 hours and blood loss was less than 50 cc. The patient was discharged on post operative day one, tolerated a low fat diet. Final pathology of the surgical specimen revealed 19 lymph nodes and the right spermatic cord without evidence of germ cell tumor. Conclusions: Robotic RPLND can be performed successfully and provides improved visualization and dexterity over conventional laparoscopic instrumentation. The sympathetic fibers are more clearly visualized with 3-D optics and the fibers can be preserved using the wristed technology of the robotic instruments. 107 Technique of robot assisted laparoscopic dismembered pyeloplasty – A multiinstitutional review of outcomes A. Sivaraman, M.A. Orvieto, R.F. Coelho, S. Chauhan, K. Palmer, V. Patel. Global Robotics Institute, Florida Hospital, Celebration, FL, USA Introduction: Historically, the standard treatment for ureteropelvic junction obstruction (UPJO) has been open pyeloplasty, however over the past 15 years, the laparoscopic approach has shown substantial efficacy, challenging this standard. The introduction of robotic assistance into laparoscopy has not only enabled more surgeons to attempt the laparoscopic approach to pyeloplasty, but also to perform more difficult cases, including previously failed surgical repairs. Herein, we report a multi-institutional experience with Robotic-Assisted Laparoscopic Dismembered Pyeloplasty (RALDP) for primary and secondary repair of UPJO and our technique of robotic pyeloplasty is also described. Materials and Methods, Including a Description of the Video: Between June 2002 and October 2008, a total of 168 patients, from 3 institutions underwent RALDP with stenting for UPJO. After IRB approval, a retrospective chart review was performed to collect demographic, preoperative, operative and postoperative endpoints between primary and secondary repair. The video of our technique is also presented highlighting the nuances needed to achieve optimal results. Results: Of the 168 patients, 21 (12.5%) were secondary repairs; of which 57% had a crossing vessel etiology, with 9 being initially treated with endopyelotomy. There were no statistically significant differences in any parameters between the patients undergoing a primary or secondary repair at a mean follow-up of 20.1 months. Overall, 96.9% of patients showed improved T1/2 after repair with a mean decrease of 32.5 min; 72.7% showed improved renal function with a mean increase of 4.5% in the affected renal unit. Conclusions: To our knowledge, this review represents the largest multi-institutional experience of RALDP with longterm follow-up. RALDP is a safe, efficacious and viable option for either primary or secondary repair of UPJO with excellent outcomes, high success rate, and a low incidence of complications. 108 Robotic kidney surgery: Variation of techniques Q.-D. Trinh, M. Patel, M. Menon, C. Rogers. Vattikuti Urology Institute, Detroit, MI, USA Objectives: In this video, we demonstrate different techniques for robotic partial nephrectomy and robotic radical nephrectomy and present our surgical outcomes. Methods: Different techniques used for robotic kidney surgery included variations in camera position (medially, laterally, or in-between), robotic instruments (monopolar hook vs. monopolar scissors with different robotic grasping instruments in nondominant hand), use of the fourth robotic arm for kidney retraction, use of TilePro for display of radiographic images,
hilar occlusion techniques (bulldog clamps vs. satinsky clamp), and renorrhaphy techniques (bolstered vs. no bolsters, sutures secured with Lapra Ty clips vs. sliding hemolock clip technique). For robotic radical nephrectomy, different techniques were used for ligation of hilar vessels (endovascular stapler vs. clips vs. suture ligation) and kidney extraction (midline vs. Gibson incision). Results: The fourth robotic arm and TilePro facilitated hilar dissection and tumor localization. Adoption of the sliding hemolock clip technique during renorraphy allowed for a tight closure without necessarily requiring bolsters. Conclusions: Robotic assistance for kidney surgery may be adapted to different techniques to accommodate different surgeon preferences for robotic partial nephrectomy and radical nephrectomy. 109 Robotic kidney surgery in patients with prior abdominal surgery Q.-D. Trinh, F. Petros, M. Patel, M. Menon, C. Rogers. Vattikuti Urology Institute, Detroit, MI, USA Objectives: Robotic kidney surgery may be challenging in patients with previous abdominal surgery. In this video, we demonstrate techniques for performing robotic kidney surgery in the setting of prior abdominal surgery, including direct-vision placement of the initial trocar using the 8 mm robotic camera and the utilization of a retroperitoneal robotic approach. We also describe our results with these techniques. Methods: For a transperitoneal approach, insufflation was obtained using a Veress needle. The initial trocar was placed under direct vision using an 8 mm robotic camera placed through the obturator of a 12 mm trocar. Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. For a retroperitoneal approach, an incision was made below the tip of the twelfth rib and the retroperitoneal space was developed with balloon dissection. A 12 mm balloon trocar was placed for the robotic camera. The two robotic instrument ports and a 12 mm assistant port were placed under the twelfth rib. The robot was docked over the head of the patient. Results: A total of 41 patients with prior abdominal surgery underwent robotic kidney surgery. There was no statistically significant difference between groups in operative time, blood loss, transfusion rates, and complication rates. An enterotomy during laparoscopic lysis of adhesions occurred in one patient, which was repaired robotically without sequelae. There were no access related injuries in the cases in which the robotic 8 mm camera was used for initial trocar placement. Retroperitoneal access was successfully achieved in ten patients who then underwent successful retroperitoneal robotic renal surgery. One patient undergoing retroperitoneal robotic nephrectomy for xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. Conclusions: Robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. Placement of the initial trocar using the 8 mm robotic camera allows for direct-vision access of the initial trocar without the need to switch to a smaller laparoscopic camera. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery in patients with prior abdominal surgery.
of ureteric injuries. We present our initial experience with robot-assisted ureteroneocystostomy (RAUN) in regard to ergonomic advantages offered by the da Vinci Surgical system. Material and Methods: We present a video of the management of a 55-year-old woman, presented after a hysterectomy with bilateral iatrogenic ureteric transaction. The patient underwent a robot-assisted bilateral vesicopsoas hitch and RAUN with extravesical Lich-Gregoir technique. The camera is placed superior to the umbilicus and a similar port arrangement as for radical prostatectomy was used. We performed bilateral tension-free ureter reimplantations on the bladder dome using running sutures. Pig-tail catheters placed retrogradely and the detrusor was closed over the ureters to create a submucosal tunnel and a drain was placed. Results: The console time was 275 minutes. No intra-operative or post-operative complications were noticed and the estimate blood loss was 110 ml. The urethral catheter was removed after a cystogram showing no evidence of an anastomotic leakage on day 7 and the patient was discharged uneventfully from the hospital on the following day. The pig-tails removed after 3 weeks and the patient was asymptomatic after 2 months follow-up. Conclusion: The robotic surgical system is particularly well suited with superior visibility and ergonomics for complex reconstruction procedures where a precise dissection and stitching is needed. RAUN is a safe and effective treatment option with ergonomic advantages and excellent reconstructive capabilities of da Vinci system for bilateral ureteral reimplantation. 104 Transmesololic robot-assisted pyeloplasty G. Pini, F. Annino, S. Micali, M.C. Sighinolfi, S. De Stefani, G. Bianchi. University of Modena and Reggio Emilia, Modena, Italy Objectives: Robot-Assisted pyeloplasty results are comparable to those of open pyeloplasty, the standard option for ureteropelvic junction (UPJ) obstruction and it shows a less steep learning curve in comparison with laparoscopy. After 9 transperitoneal standard retrocolic procedures, the video shows our first approach with a transmesocolic robot-assisted left dismembered pyeloplasty. Methods: Patient: 22-year-old man with primary UPJO. Lombotomic position. Robot da Vinci on the back side of patient. Verres pneumoperitoneum and 5 transperitoneal trocar (3 robotic and 2 laparoscopic for assistant). Exposition and incision of the left mesentero-colic space. Exposition and dissection of ureter. Identification and free dissection of the renal pelvis in order to obtain an adequate lenght to perform a tension free-repair. Transection of the renal pelvis above the UPJ. The redundant renal pelvis is transacted and the UPJ is removed. Lateral ureter spatulation. Closure of the excess pyelotomy incision in running suture. Antegrade insertion of DJ stent. Anastomosis in multiple running 4/0 Monocryl suture. Summary of Results: Operative time 115 minutes, blood loss <25 ml; catheter removal post operative day (pod) 1; drain removal in pod 2, discharge pod 3; DJ removal after 20 days. At 12 month the patient is still asymptomatic and Intravenous Urography and diuretic renal scan show absence of hydronephrosis. Conclusions: The transmesocolic robot-assisted pyeloplasty is safe and feasible. The direct approach to the left UPJ provides a good operative field, lower bowel manipulation and decreasing in operative time. Above all, robotic system makes easier reconstructive and suturing time and it raises surgeon capabilities.
529
105 Remote proctoring using the da Vinci Connect system J. Porter. Swedish Medical Center, Seattle, WA, USA Objectives: The learning curve associated with robotic surgery requires intensive training and can be assisted with instruction by a qualified surgical proctor. It has been necessary for the proctor to be present in the operating room with the surgeon. This may require the proctor to travel long distances and be absent from medical practice. Recently, an internet based communication system, called da Vinci Connect, has been developed to facilitated remote proctoring. Methods: da Vinci Connect requires the da Vinci S system with additional hardware and software upgrade. The endoscopic view provided by the robotic camera is transmitted via a secure internet connection to a laptop at the remote proctor’s location. The proctor has the ability to perform telestration, which is seen on the surgeon’s console using the TilePro function. The operative suite is equipped with an auxiliary camera to provide an external view of the patient or the surgeon’s console. Twoway audio intercom allows real time communication between surgeon and proctor. Results: The first case involved proctoring a surgeon in Fort Lauderdale, Florida from Seattle, Washington who was performing a robotic prostatectomy. He had performed approximately 400 prostatectomies and was interested in improving his technique of nerve preservation. The procedure was completed with excellent preservation of the neurovascular bundles. The telestration feature was useful for guiding the console surgeon during dissection of the nerve bundles and the two-way audio allowed communication with minimal transmission delay or talk over. Conclusions: The da Vinci Connect system allows remote proctoring across a secure internet connection with excellent visualization and audio communication. The proctoring platform should facilitate surgeon to surgeon interaction without the need for the presence of the proctor. 106 Nerve sparing robotic retroperitoneal lymph node dissection for stage I NSGCT J. Porter. Swedish Medical Center,Seattle, WA, USA Objectives: Retroperitoneal lymph node dissection (RPLND) is an accepted staging and treatment option for clinical stage 1 non-seminomatous germ cell tumor (NSGCT). Laparoscopic RPLND has been performed in an effort to decrease the morbidity of open RPLND. Robotic surgical techniques have recently been employed in urologic procedures with the noted advantages of 3-D vision and greater degrees of instrument freedom. To determine whether the advantages of robotic surgery could be applied to laparoscopic RPLND, we present our technique of robotic nerve sparing RPLND. Methods: Right robotic RPLND is performed via a transperitoneal approach using 4 robotic trocars and an assistant trocar. The fourth robotic arm is used throughout the procedure and is instrumental in providing exposure of the lymphatic tissue and retraction of the bowel and major vessels. A complete right template dissection is performed with dissection of the paracaval, retrocaval, interaortocaval and preaortic lymph nodes. Nerve sparing is performed within the template. The spermatic cord is dissected completely within the inguinal canal by repositioning the robot over the patient’s legs. Results: Right Robotic RPLND was performed successfully with preservation of the post ganglionic fibers from the sympathetic chain to the hypogastric plexus. Complete dissection was performed of the paracaval, retrocaval, interaortocaval, preaortic, and para-aortic lymph nodes. Operative time was
530
video posters / european urology supplements 9 (2010) 519–530
3.5 hours and blood loss was less than 50 cc. The patient was discharged on post operative day one, tolerated a low fat diet. Final pathology of the surgical specimen revealed 19 lymph nodes and the right spermatic cord without evidence of germ cell tumor. Conclusions: Robotic RPLND can be performed successfully and provides improved visualization and dexterity over conventional laparoscopic instrumentation. The sympathetic fibers are more clearly visualized with 3-D optics and the fibers can be preserved using the wristed technology of the robotic instruments. 107 Technique of robot assisted laparoscopic dismembered pyeloplasty – A multiinstitutional review of outcomes A. Sivaraman, M.A. Orvieto, R.F. Coelho, S. Chauhan, K. Palmer, V. Patel. Global Robotics Institute, Florida Hospital, Celebration, FL, USA Introduction: Historically, the standard treatment for ureteropelvic junction obstruction (UPJO) has been open pyeloplasty, however over the past 15 years, the laparoscopic approach has shown substantial efficacy, challenging this standard. The introduction of robotic assistance into laparoscopy has not only enabled more surgeons to attempt the laparoscopic approach to pyeloplasty, but also to perform more difficult cases, including previously failed surgical repairs. Herein, we report a multi-institutional experience with Robotic-Assisted Laparoscopic Dismembered Pyeloplasty (RALDP) for primary and secondary repair of UPJO and our technique of robotic pyeloplasty is also described. Materials and Methods, Including a Description of the Video: Between June 2002 and October 2008, a total of 168 patients, from 3 institutions underwent RALDP with stenting for UPJO. After IRB approval, a retrospective chart review was performed to collect demographic, preoperative, operative and postoperative endpoints between primary and secondary repair. The video of our technique is also presented highlighting the nuances needed to achieve optimal results. Results: Of the 168 patients, 21 (12.5%) were secondary repairs; of which 57% had a crossing vessel etiology, with 9 being initially treated with endopyelotomy. There were no statistically significant differences in any parameters between the patients undergoing a primary or secondary repair at a mean follow-up of 20.1 months. Overall, 96.9% of patients showed improved T1/2 after repair with a mean decrease of 32.5 min; 72.7% showed improved renal function with a mean increase of 4.5% in the affected renal unit. Conclusions: To our knowledge, this review represents the largest multi-institutional experience of RALDP with longterm follow-up. RALDP is a safe, efficacious and viable option for either primary or secondary repair of UPJO with excellent outcomes, high success rate, and a low incidence of complications. 108 Robotic kidney surgery: Variation of techniques Q.-D. Trinh, M. Patel, M. Menon, C. Rogers. Vattikuti Urology Institute, Detroit, MI, USA Objectives: In this video, we demonstrate different techniques for robotic partial nephrectomy and robotic radical nephrectomy and present our surgical outcomes. Methods: Different techniques used for robotic kidney surgery included variations in camera position (medially, laterally, or in-between), robotic instruments (monopolar hook vs. monopolar scissors with different robotic grasping instruments in nondominant hand), use of the fourth robotic arm for kidney retraction, use of TilePro for display of radiographic images,
hilar occlusion techniques (bulldog clamps vs. satinsky clamp), and renorrhaphy techniques (bolstered vs. no bolsters, sutures secured with Lapra Ty clips vs. sliding hemolock clip technique). For robotic radical nephrectomy, different techniques were used for ligation of hilar vessels (endovascular stapler vs. clips vs. suture ligation) and kidney extraction (midline vs. Gibson incision). Results: The fourth robotic arm and TilePro facilitated hilar dissection and tumor localization. Adoption of the sliding hemolock clip technique during renorraphy allowed for a tight closure without necessarily requiring bolsters. Conclusions: Robotic assistance for kidney surgery may be adapted to different techniques to accommodate different surgeon preferences for robotic partial nephrectomy and radical nephrectomy. 109 Robotic kidney surgery in patients with prior abdominal surgery Q.-D. Trinh, F. Petros, M. Patel, M. Menon, C. Rogers. Vattikuti Urology Institute, Detroit, MI, USA Objectives: Robotic kidney surgery may be challenging in patients with previous abdominal surgery. In this video, we demonstrate techniques for performing robotic kidney surgery in the setting of prior abdominal surgery, including direct-vision placement of the initial trocar using the 8 mm robotic camera and the utilization of a retroperitoneal robotic approach. We also describe our results with these techniques. Methods: For a transperitoneal approach, insufflation was obtained using a Veress needle. The initial trocar was placed under direct vision using an 8 mm robotic camera placed through the obturator of a 12 mm trocar. Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. For a retroperitoneal approach, an incision was made below the tip of the twelfth rib and the retroperitoneal space was developed with balloon dissection. A 12 mm balloon trocar was placed for the robotic camera. The two robotic instrument ports and a 12 mm assistant port were placed under the twelfth rib. The robot was docked over the head of the patient. Results: A total of 41 patients with prior abdominal surgery underwent robotic kidney surgery. There was no statistically significant difference between groups in operative time, blood loss, transfusion rates, and complication rates. An enterotomy during laparoscopic lysis of adhesions occurred in one patient, which was repaired robotically without sequelae. There were no access related injuries in the cases in which the robotic 8 mm camera was used for initial trocar placement. Retroperitoneal access was successfully achieved in ten patients who then underwent successful retroperitoneal robotic renal surgery. One patient undergoing retroperitoneal robotic nephrectomy for xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. Conclusions: Robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. Placement of the initial trocar using the 8 mm robotic camera allows for direct-vision access of the initial trocar without the need to switch to a smaller laparoscopic camera. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery in patients with prior abdominal surgery.