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V499 LAPAROENDOSCOPIC SINGLE-SITE (LESS) URETEROLITHOTOMY
Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011
THE JOURNAL OF UROLOGY姞
V498
V500
RENAL ARTERY ANEURYSM TREATED WITH EX-VIVO RECONSTRUCTION AND AUTOTRANSPLANTATION
ROBOTIC-ASSISTED LAPAROSCOPIC URETEROURETEROSTOMY FOR OBSTRUCTING RETROCAVAL URETER
Christina Ching*, Cleveland, OH; Una Lee, Los Angeles, CA; Ho Yee Tiong, Venkatesh Krishnamurthi, David Goldfarb, Cleveland, OH INTRODUCTION AND OBJECTIVES: Distally located renal artery aneurysms are a surgical difficulty. We performed a successful ex-vivo left renal artery aneurysm repair with autotransplantation in the distal left anterior segmental renal artery after determining this case was not amenable to endovascular or in situ repair. Computed tomographic arteriography (CTA) with 3-dimensional (3D) reconstruction helped to determine management of this patient. METHODS: A 64 year old man with gross hematuria was found to have a left renal artery aneurysm. The patient had a history of hypertension, peripheral vascular disease, and 70 pack years of smoking. A CTA with 3D reconstruction demonstrated a 2.2 cm saccular aneurysm arising from the distal left anterior segmental artery. Despite significant atherosclerosis of the aorta and iliac vessel, the aneurysm was non-calcified. Due to this fact as well as the aneurysm size and patient symptoms, surgical therapy was recommended. Given the distal location of the aneurysm and the possibility of branching arteries off the aneurysm, the decision was made for ex-vivo aneurysmal repair with autotransplantation in order to preserve as much renal parenchyma as possible. RESULTS: The patient underwent a successful autotransplant with ex-vivo aneurysmal repair without complications. Intraoperatively, we confirmed the presence of multiple arterial branches off the aneurysm which could only have been managed through an ex-vivo repair. The operative time was roughly 6.5 hours. The warm ischemia time was ⬍3 minutes and the cold ischemia time was roughly 2.5 hours. The estimated blood loss was about 300ml. The discharge creatinine was 0.7. CONCLUSIONS: Renal artery aneurysms, while uncommon, have been increasing in diagnosis likely secondary to improved imaging techniques. CT arteriography with 3-D rendering was instrumental in preoperative planning for this complex aneurysm. Source of Funding: None
V499 LAPAROENDOSCOPIC SINGLE-SITE (LESS) URETEROLITHOTOMY Aly Abdel-Karim*, Ahmed Moussa, Salah Elsalmy, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: In this video we present the technique of LESS ureterolithotomy in obese patient. METHODS: The case that we present in this video is a twenty eight years old male presented with left lion pain. His body mass index was ⬎ 30. His intravenous urography showed large (2.6 cm), impacted left upper third ureteric stone with marked left hydronephrosis. LESS ureterolithotomy was done using the R-port and curved instruments. The left ureter was identified and grasped above the level of the stone. Ureterotomy was made and the stone was delivered from the ureter, where the hook was used as a dissector to release the stone. Ureter was calibrated antegradly through the triport, and then closed by interrupted sutures using 4/0 vicryl suture. No stent was left inside the ureter. RESULTS: Operative time was 170 minutes. There were no intraoperative or postoperative complications. Blood loss was ⬍ 50 c.c. Hospital stay was 24 hours. Radiological follow-up of the patient showed marked improvement of left hydronephrosis. CONCLUSIONS: Less ureterolithotomy is technically feasible, effective and safe option for treatment of ureteric stones, even in obese patients. Less ureterolithotomy could be an alternative to other minimally invasive procedures for treatment of highly impacted and large ureteric stones. Source of Funding: None
e203
Tim Leroy*, David Thiel, Todd Igel, Jacksonville, FL INTRODUCTION AND OBJECTIVES: Widespread use of the da VInci surgical system (Intuitive Surgical, Sunnyvale, CA) has led to the expansion of robotic technology for use in complex reconstructive procedures of the urinary tract. We present our technique for roboticassisted laparoscopic ureteroureterostomy for obstructing retrocaval ureters. METHODS: Pre-operative imaging, patient selection, patient positioning, port placement, intra-operative dissection, retrocaval ureter excision and repair are all demonstrated in this video. Special attention is given to robotic docking technique for this complex dissection and reconstruction. RESULTS: Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for an obstructing retrocaval ureter. CONCLUSIONS: Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for obstructing retrocaval ureter. Source of Funding: None
V501 LAPARO-ENDOSCOPIC SINGLE SITE TRANSVESICAL BLADDER CUFF EXCISION Rene Javier Sotelo*, Juan Arriaga, Oswaldo Carmona, Robert De Andrade, Camilo Giedelman, Caracas, Venezuela; Zehnder Pascal, Los Angeles, CA; Brian Irwin, Burlington, VT; Aron Monish, Mihir Desai, Inderbir Gill, Los Angeles, CA; Jose Saavedra, Caracas, Venezuela INTRODUCTION AND OBJECTIVES: To present a novel technique for the management of the bladder cuff during distal ureterectomy under pneumovesicum using a single port device inserted transvesically. BACKGROUND: A variety of techniques have been used to manage the distal ureter during minimally invasive nephroureterectomy for benign and malignant diseases. Each technique has distinct advantages and disadvantages that may impact intra-operative and postoperative outcomes. A general concensus has not been established. METHODS: We present two cases. The first case demonstrates the technique in a patient with malignant disease in an 80 year old man with a 5cm left renal pelvic tumor. The second case shows the techniques application in a benign disease in a 25 year old woman with history of recurrent urinary tract infections in whom a CT scan showed complete duplication of the left collecting system with upper pole hydroureteronephrosis. RESULTS: The first patient underwent left laparoendoscopic single site (LESS) radical nephroureterectomy with retroperitoneal lymph node dissection and bladder cuff excision under pneumovesicum for a left renal pelvic transitional cell carcinoma; final histopathology revealed pathologic G3 T3 N0 with 7 negative nodes. The operative time was 375 minutes including 45 minutes for bladder cuff excision, and estimated blood loss was 250cc. Length of stay was one day. No post-operative complications or evidence of recurrence were noted after one year of follow up. The second patient underwent LESS upper pole heminephroureterectomy for treatment of a duplicated left collecting system and upper pole hydronephrosis. Final pathology revealed chronic pyelonephritis. The operative time was 210 minutes including 30 minutes for bladder cuff excision and estimated blood loss was 400cc. The patients length of stay was three days. Postoperatively the patient was found to have lower pole renal vein thrombosis at her first postoperative visit.
THE JOURNAL OF UROLOGY姞
V498
V500
RENAL ARTERY ANEURYSM TREATED WITH EX-VIVO RECONSTRUCTION AND AUTOTRANSPLANTATION
ROBOTIC-ASSISTED LAPAROSCOPIC URETEROURETEROSTOMY FOR OBSTRUCTING RETROCAVAL URETER
Christina Ching*, Cleveland, OH; Una Lee, Los Angeles, CA; Ho Yee Tiong, Venkatesh Krishnamurthi, David Goldfarb, Cleveland, OH INTRODUCTION AND OBJECTIVES: Distally located renal artery aneurysms are a surgical difficulty. We performed a successful ex-vivo left renal artery aneurysm repair with autotransplantation in the distal left anterior segmental renal artery after determining this case was not amenable to endovascular or in situ repair. Computed tomographic arteriography (CTA) with 3-dimensional (3D) reconstruction helped to determine management of this patient. METHODS: A 64 year old man with gross hematuria was found to have a left renal artery aneurysm. The patient had a history of hypertension, peripheral vascular disease, and 70 pack years of smoking. A CTA with 3D reconstruction demonstrated a 2.2 cm saccular aneurysm arising from the distal left anterior segmental artery. Despite significant atherosclerosis of the aorta and iliac vessel, the aneurysm was non-calcified. Due to this fact as well as the aneurysm size and patient symptoms, surgical therapy was recommended. Given the distal location of the aneurysm and the possibility of branching arteries off the aneurysm, the decision was made for ex-vivo aneurysmal repair with autotransplantation in order to preserve as much renal parenchyma as possible. RESULTS: The patient underwent a successful autotransplant with ex-vivo aneurysmal repair without complications. Intraoperatively, we confirmed the presence of multiple arterial branches off the aneurysm which could only have been managed through an ex-vivo repair. The operative time was roughly 6.5 hours. The warm ischemia time was ⬍3 minutes and the cold ischemia time was roughly 2.5 hours. The estimated blood loss was about 300ml. The discharge creatinine was 0.7. CONCLUSIONS: Renal artery aneurysms, while uncommon, have been increasing in diagnosis likely secondary to improved imaging techniques. CT arteriography with 3-D rendering was instrumental in preoperative planning for this complex aneurysm. Source of Funding: None
V499 LAPAROENDOSCOPIC SINGLE-SITE (LESS) URETEROLITHOTOMY Aly Abdel-Karim*, Ahmed Moussa, Salah Elsalmy, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: In this video we present the technique of LESS ureterolithotomy in obese patient. METHODS: The case that we present in this video is a twenty eight years old male presented with left lion pain. His body mass index was ⬎ 30. His intravenous urography showed large (2.6 cm), impacted left upper third ureteric stone with marked left hydronephrosis. LESS ureterolithotomy was done using the R-port and curved instruments. The left ureter was identified and grasped above the level of the stone. Ureterotomy was made and the stone was delivered from the ureter, where the hook was used as a dissector to release the stone. Ureter was calibrated antegradly through the triport, and then closed by interrupted sutures using 4/0 vicryl suture. No stent was left inside the ureter. RESULTS: Operative time was 170 minutes. There were no intraoperative or postoperative complications. Blood loss was ⬍ 50 c.c. Hospital stay was 24 hours. Radiological follow-up of the patient showed marked improvement of left hydronephrosis. CONCLUSIONS: Less ureterolithotomy is technically feasible, effective and safe option for treatment of ureteric stones, even in obese patients. Less ureterolithotomy could be an alternative to other minimally invasive procedures for treatment of highly impacted and large ureteric stones. Source of Funding: None
e203
Tim Leroy*, David Thiel, Todd Igel, Jacksonville, FL INTRODUCTION AND OBJECTIVES: Widespread use of the da VInci surgical system (Intuitive Surgical, Sunnyvale, CA) has led to the expansion of robotic technology for use in complex reconstructive procedures of the urinary tract. We present our technique for roboticassisted laparoscopic ureteroureterostomy for obstructing retrocaval ureters. METHODS: Pre-operative imaging, patient selection, patient positioning, port placement, intra-operative dissection, retrocaval ureter excision and repair are all demonstrated in this video. Special attention is given to robotic docking technique for this complex dissection and reconstruction. RESULTS: Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for an obstructing retrocaval ureter. CONCLUSIONS: Tips presented in this video may aid in successful completion of robotic ureteroureterostomy for obstructing retrocaval ureter. Source of Funding: None
V501 LAPARO-ENDOSCOPIC SINGLE SITE TRANSVESICAL BLADDER CUFF EXCISION Rene Javier Sotelo*, Juan Arriaga, Oswaldo Carmona, Robert De Andrade, Camilo Giedelman, Caracas, Venezuela; Zehnder Pascal, Los Angeles, CA; Brian Irwin, Burlington, VT; Aron Monish, Mihir Desai, Inderbir Gill, Los Angeles, CA; Jose Saavedra, Caracas, Venezuela INTRODUCTION AND OBJECTIVES: To present a novel technique for the management of the bladder cuff during distal ureterectomy under pneumovesicum using a single port device inserted transvesically. BACKGROUND: A variety of techniques have been used to manage the distal ureter during minimally invasive nephroureterectomy for benign and malignant diseases. Each technique has distinct advantages and disadvantages that may impact intra-operative and postoperative outcomes. A general concensus has not been established. METHODS: We present two cases. The first case demonstrates the technique in a patient with malignant disease in an 80 year old man with a 5cm left renal pelvic tumor. The second case shows the techniques application in a benign disease in a 25 year old woman with history of recurrent urinary tract infections in whom a CT scan showed complete duplication of the left collecting system with upper pole hydroureteronephrosis. RESULTS: The first patient underwent left laparoendoscopic single site (LESS) radical nephroureterectomy with retroperitoneal lymph node dissection and bladder cuff excision under pneumovesicum for a left renal pelvic transitional cell carcinoma; final histopathology revealed pathologic G3 T3 N0 with 7 negative nodes. The operative time was 375 minutes including 45 minutes for bladder cuff excision, and estimated blood loss was 250cc. Length of stay was one day. No post-operative complications or evidence of recurrence were noted after one year of follow up. The second patient underwent LESS upper pole heminephroureterectomy for treatment of a duplicated left collecting system and upper pole hydronephrosis. Final pathology revealed chronic pyelonephritis. The operative time was 210 minutes including 30 minutes for bladder cuff excision and estimated blood loss was 400cc. The patients length of stay was three days. Postoperatively the patient was found to have lower pole renal vein thrombosis at her first postoperative visit.