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V10-06 ROBOTIC REDO PYELOPLASTY: BRIDGING THE GAP WITH BUCCAL
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
V10-05 TENSION PNEUMOTHORAX FROM OCCULT DIAPHRAGMATIC HERNIA DURING ROBOTIC PYELOPLASTY - STEP-BY-STEP MANAGEMENT Michael Kurtz*, Russell Jennings, Amar Nijagal, Petra Meier, Bartley Cilento, Boston, MA INTRODUCTION AND OBJECTIVES: Diaphragmatic hernia is a rare condition, and may be undiagnosed preoperatively. In transperitoneal procedures such as Robot-Assisted Laparoscopic Pyeloplasty (RALP), a diaphragmatic hernia allows intraperitoneal pressure to communicate freely with the pleural space, which mimics the physiology of a tension pneumothorax. Thus, recognition and treatment of this condition is critical. METHODS: We present the case of a 9-year-old boy with a history of heterotaxy and repaired congenital cardiac disease who presented with a symptomatic right ureteropelvic junction obstruction. At the time of infant cardiac surgery his mediastinum and right pleural space were drained with infracostal exit of the right chest tube. These had been removed 48 hours postoperatively. RESULTS: 8 years later, the patient underwent RALP with transperitoneal approach. On insufflation, elevated end-tidal carbon dioxide and increased peak inspiratory pressure heralded the possibility of thoracic communication of insufflated gas. A diaphragmatic hernia was identified. Immediate management is discussed and demonstrated, including placement of a chest tube under thoracoscopic guidance. This minimizes risk of injury to the lung parenchyma while rapidly correcting mediastinal shift. The diaphragmatic hernia was repaired using free-hand laparoscopy and the majority of the existing ports. Passage of an additional instrument near the costal margin greatly facilitated closure by placing the laparoscopic fulcrum closer to the area being repaired. Interrupted and figure-of-eight braided non-absorbable suture repaired the defect. The chest tube was removed at the case terminus, and a post-removal film demonstrated no pneumothorax. The patient did not have an oxygen requirement or chest morbidity and was discharged 22 hours postoperatively. CONCLUSIONS: In patients with a history of infracostally exiting chest tubes, diaphragmatic hernia may result with immediate lifethreatening physiologic consequence when the abdomen is later insufflated. Early recognition and urgent chest drainage are critical. A transperitoneal approach to diaphragmatic closure is feasible with no postoperative thoracic morbidity. As pyeloplasty presents unusual positioning for diaphragmatic surgery, placement of additional laparoscopic ports assists closure.
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mobilized laparoscopically, and once the robot was docked, the ureteropelvic junction was dissected out from surrounding fibrosis. A vertical incision was made on the anterior surface of the renal pelvis through the ureteropelvic junction, until pliable ureter was encountered distally, revealing a 5cm defect. The pre-existing stent was removed, and through a percutaneous 14-gauge angiocath, a new 4.7Frx22cm stent was placed antegrade over a glidewire. Buccal grafts were then harvested from each cheek and defatted. They were delivered via 8mm robotic ports individually, and anastomosed to the anterior surface of the ureter as an onlay graft, with the mucosal side towards the lumen, using running 6-0 PDS suture. Omentum was then quilted over the grafts, using interrupted 50 vicryl suture. RESULTS: The patient’s stent was removed 6 weeks postoperatively, and at 3 months after redo robotic pyeloplasty, he is asymptomatic with ultrasound showing decreased hydronephrosis. The same technique (robotic redo pyeloplasty with buccal graft) was used in a 16 year old patient who had failed pyeloplasty and endoscopic management of recurrent ureteropelvic junction obstruction. At 18 months follow-up, she is asymptomatic with improved hydronephrosis on imaging. CONCLUSIONS: Robotic redo pyeloplasty with buccal graft is safe and feasible in the pediatric population. Long-term outcomes need to be assessed.
Source of Funding: none
Source of Funding: None
V10-07 ROBOTIC REDO PYELOPLASTY: BRIDGING THE GAP WITH BUCCAL
COMPLEX ROBOTIC RECONSTRUCTION FOR LARGE RADIATION RECTOURETHRAL FISTULA AND URETHRAL STRICTURE: SALVAGE PROSTATECTOMY, POSTERIOR URETHROPLASTY, LOW ANTERIOR RESECTION, WITH REANASTOMOSIS
Jennifer J Ahn*, Jonathan S Ellison, Thomas S Lendvay, Seattle, WA
David Canes*, Jason Hall, Alex Vanni, Burlington, MA
INTRODUCTION AND OBJECTIVES: Pyeloplasty failure rates have been reported at 5-10%. Management options for failure include redo pyeloplasty, endopyelotomy, ureterocalicostomy, ileal ureter, auto-transplant, and nephrectomy; yet the success rates are highly variable. Buccal mucosa graft is used for reconstruction of the urethra and vagina, and its use has more recently been described in a handful of cases of ureteral reconstruction. Here, we sought to describe our experience with using buccal mucosa graft for robotic redo pyeloplasty in the pediatric population. METHODS: A nine-year old patient presented with recurrent pain and obstruction after three prior pyeloplasties. The decision was made to perform left robotic redo pyeloplasty with buccal mucosa graft. Our technique was as follows. With the patient in left plank position, a total of four ports were placed (Figure 1). The colon was
INTRODUCTION AND OBJECTIVES: Radiation rectourethral fistula (RUF) is a devastating iatrogenic complication of prostate cancer treatment. Traditional perineal approaches incorporating various techniques including buccal mucosal graft onlay, gracilis muscle flap interposition, primary rectal closure have excellent success rates. However, occasional cases will not be amenable to this approach, in particular very large defects or cases with significant radionecrosis of the prostate. These patients most frequently undergo both urinary and fecal diversion. METHODS: We present a 53 year-old man who received combination IMRT and brachytherapy for Gleason 8 prostate cancer 2 years ago and was cancer free. He developed a wide 4 cm RUF fistula with extensive prostate radionecrosis, and a transsphincteric urethral stricture, but a normal bladder and intact external anal sphincter. He
V10-06
Vol. 195, No. 4S, Supplement, Monday, May 9, 2016
V10-05 TENSION PNEUMOTHORAX FROM OCCULT DIAPHRAGMATIC HERNIA DURING ROBOTIC PYELOPLASTY - STEP-BY-STEP MANAGEMENT Michael Kurtz*, Russell Jennings, Amar Nijagal, Petra Meier, Bartley Cilento, Boston, MA INTRODUCTION AND OBJECTIVES: Diaphragmatic hernia is a rare condition, and may be undiagnosed preoperatively. In transperitoneal procedures such as Robot-Assisted Laparoscopic Pyeloplasty (RALP), a diaphragmatic hernia allows intraperitoneal pressure to communicate freely with the pleural space, which mimics the physiology of a tension pneumothorax. Thus, recognition and treatment of this condition is critical. METHODS: We present the case of a 9-year-old boy with a history of heterotaxy and repaired congenital cardiac disease who presented with a symptomatic right ureteropelvic junction obstruction. At the time of infant cardiac surgery his mediastinum and right pleural space were drained with infracostal exit of the right chest tube. These had been removed 48 hours postoperatively. RESULTS: 8 years later, the patient underwent RALP with transperitoneal approach. On insufflation, elevated end-tidal carbon dioxide and increased peak inspiratory pressure heralded the possibility of thoracic communication of insufflated gas. A diaphragmatic hernia was identified. Immediate management is discussed and demonstrated, including placement of a chest tube under thoracoscopic guidance. This minimizes risk of injury to the lung parenchyma while rapidly correcting mediastinal shift. The diaphragmatic hernia was repaired using free-hand laparoscopy and the majority of the existing ports. Passage of an additional instrument near the costal margin greatly facilitated closure by placing the laparoscopic fulcrum closer to the area being repaired. Interrupted and figure-of-eight braided non-absorbable suture repaired the defect. The chest tube was removed at the case terminus, and a post-removal film demonstrated no pneumothorax. The patient did not have an oxygen requirement or chest morbidity and was discharged 22 hours postoperatively. CONCLUSIONS: In patients with a history of infracostally exiting chest tubes, diaphragmatic hernia may result with immediate lifethreatening physiologic consequence when the abdomen is later insufflated. Early recognition and urgent chest drainage are critical. A transperitoneal approach to diaphragmatic closure is feasible with no postoperative thoracic morbidity. As pyeloplasty presents unusual positioning for diaphragmatic surgery, placement of additional laparoscopic ports assists closure.
e947
mobilized laparoscopically, and once the robot was docked, the ureteropelvic junction was dissected out from surrounding fibrosis. A vertical incision was made on the anterior surface of the renal pelvis through the ureteropelvic junction, until pliable ureter was encountered distally, revealing a 5cm defect. The pre-existing stent was removed, and through a percutaneous 14-gauge angiocath, a new 4.7Frx22cm stent was placed antegrade over a glidewire. Buccal grafts were then harvested from each cheek and defatted. They were delivered via 8mm robotic ports individually, and anastomosed to the anterior surface of the ureter as an onlay graft, with the mucosal side towards the lumen, using running 6-0 PDS suture. Omentum was then quilted over the grafts, using interrupted 50 vicryl suture. RESULTS: The patient’s stent was removed 6 weeks postoperatively, and at 3 months after redo robotic pyeloplasty, he is asymptomatic with ultrasound showing decreased hydronephrosis. The same technique (robotic redo pyeloplasty with buccal graft) was used in a 16 year old patient who had failed pyeloplasty and endoscopic management of recurrent ureteropelvic junction obstruction. At 18 months follow-up, she is asymptomatic with improved hydronephrosis on imaging. CONCLUSIONS: Robotic redo pyeloplasty with buccal graft is safe and feasible in the pediatric population. Long-term outcomes need to be assessed.
Source of Funding: none
Source of Funding: None
V10-07 ROBOTIC REDO PYELOPLASTY: BRIDGING THE GAP WITH BUCCAL
COMPLEX ROBOTIC RECONSTRUCTION FOR LARGE RADIATION RECTOURETHRAL FISTULA AND URETHRAL STRICTURE: SALVAGE PROSTATECTOMY, POSTERIOR URETHROPLASTY, LOW ANTERIOR RESECTION, WITH REANASTOMOSIS
Jennifer J Ahn*, Jonathan S Ellison, Thomas S Lendvay, Seattle, WA
David Canes*, Jason Hall, Alex Vanni, Burlington, MA
INTRODUCTION AND OBJECTIVES: Pyeloplasty failure rates have been reported at 5-10%. Management options for failure include redo pyeloplasty, endopyelotomy, ureterocalicostomy, ileal ureter, auto-transplant, and nephrectomy; yet the success rates are highly variable. Buccal mucosa graft is used for reconstruction of the urethra and vagina, and its use has more recently been described in a handful of cases of ureteral reconstruction. Here, we sought to describe our experience with using buccal mucosa graft for robotic redo pyeloplasty in the pediatric population. METHODS: A nine-year old patient presented with recurrent pain and obstruction after three prior pyeloplasties. The decision was made to perform left robotic redo pyeloplasty with buccal mucosa graft. Our technique was as follows. With the patient in left plank position, a total of four ports were placed (Figure 1). The colon was
INTRODUCTION AND OBJECTIVES: Radiation rectourethral fistula (RUF) is a devastating iatrogenic complication of prostate cancer treatment. Traditional perineal approaches incorporating various techniques including buccal mucosal graft onlay, gracilis muscle flap interposition, primary rectal closure have excellent success rates. However, occasional cases will not be amenable to this approach, in particular very large defects or cases with significant radionecrosis of the prostate. These patients most frequently undergo both urinary and fecal diversion. METHODS: We present a 53 year-old man who received combination IMRT and brachytherapy for Gleason 8 prostate cancer 2 years ago and was cancer free. He developed a wide 4 cm RUF fistula with extensive prostate radionecrosis, and a transsphincteric urethral stricture, but a normal bladder and intact external anal sphincter. He
V10-06