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288 ROBOTIC-ASSISTED LAPAROSCOPIC DISMEMBERED PYELOPLASTY: THE ZURICH EXPERIENCES IN 32 CASES WITH OBSTRUCTIVE URETEROPELVIC JUNCTION OBSTRUCTION(UPJO)
P16 UROGENITAL RECONSTRUCTION 1 Thursday, 22 March, 09.15-10.45, Room 11A
285
286
Motility pattern of the classic ileal ureter versus the reconfigured antirefluxive ileal ureter in dogs
Robot-assisted laparoscopic pyeloplasty – 5-year follow-up in a single center
Ali-El-Dein B.1, El-Assmy A.1, Abdel-Aziz A.A.M.1, Sarhan M.2, Bazeed M.A.1
Schwentner C., Lunacek A., Pelzer A., Neururer R., Horninger W., Bartsch G., Peschel R.
Urology and Nephrology Center, Mansoura University, Urology, Mansoura, Egypt, Urology and Nephrology Center, Mansoura University, Physiology, Mansoura, Egypt 1
2
Introduction & Objectives: To investigate whether the classic ileal ureter and the reconfigured antirefluxive ileal ureter are actively conductive to urine and to evaluate the type of motility. Material & Methods: Between January 2004 and July 2005, 12 dogs (mean body weight 15.7 Kg) were included into this study and randomly assigned to 2 groups, 6 dogs each. The lower 10 cm of the right ureter was replaced by classic ileal ureter in group I and reconfigured antirefluxive ileal ureter in group II. The latter new technique is based on the Yong-Monti principle. It entailed isolation of 3 cm of ileum, division of this segment in to 2 halves, longitudinal incisions of the 2 segments on opposite sides close to the mesentery, unfolding, fashioning of a single intestinal plate, tubularization of this plate, proximal ureteroileal anastomosis and distal nonrefluxing submucosal ileovesicostomy. Motility was tested in both groups after 1 and 6 Months by measuring the intraluminal pressure of the ileal segment and by recording movement of the ileal segment by video and serial capture screens to measure changes in dimensions of the segment during contraction. Results: Good peristalsis of the ileal segment was seen in both groups after 1 month. At 6 months, this activity was maintained in group II and decreased significantly in group I. In group I the mean width of the ureter decreased from a resting value of 2 to 0.9 cm and the length from 10 to 7 cm during contraction at 1 month. At 6 months, the segment became dilated, the mean width decreased from a resting value of 3.2 to 2.4 cm and the length from 11 to 9 cm. In group II the mean width decreased from a resting value of 0.8 to 0.3 cm and the length from 10 to 6.8 cm during contraction at 1 month. At 6 months, there was no dilatation of the segment and the values were almost maintained. The mean intraluminal pressure increased from a resting value of 3 to 10 cm H2O at the contraction rings and to 6 cm H2O in-betweens contractions in group I at 1 month, while it just increased from 2 to 5 cm H2O at the contraction sites and to 3 cm H2O in between after 6 months. In group II, the mean pressure increased from a resting value of 4 to 18 cm H2O at the contraction rings and to 8 cm H2O in between contractions at 1 and 6 months. Conclusions: A good peristalsis causing unidirectional urine flow is achieved after the reconfigured antirefluxive ileal ureter. It is comparable to that of the classic ileal ureter in the short term. After 6 months, this activity is preserved in the reconfigured ureter, while it decreases with progressive dilatation of the ileum in the classic ileal ureter.
287
Medical University, Urology, Innsbruck, Austria Introduction & Objectives: Minimal-invasive techniques are becoming increasingly important treating ureteropelvic junction obstruction (UPJO). Besides endourological techniques laparoscopic pyeloplasty has gained major interest. A reduction of postoperative pain as well as a shorter hospital stay are common features of laparoscopic surgery. However, standard laparoscopic pyeloplasty requires high operative skills and a correspondingly long learning curve limiting its widespread availability. Robot-assisted pyeloplasty is easier to learn and the learning curve is shortened particularly due to facilitated intracorporeal suturing. Herein we present our 5-year experience with this technique. Material & Methods: Between 2001 and 2006 92 patients (48 men and 44 women, mean age 35.13 years) underwent robotic, transperitoneal pyelopasty using the DaVinciR-system. Preoperative diagnosis was made on the basis of presenting symptoms and diuretic renography. A conventional Anderson-Hynes procedure was carried out in 82 whereas non-dismembered techniques were applied in 10. Three robotic ports and one assistant port were used in all cases while a JJ-stent was left in place for 6 weeks. Both primary UPJO – including horseshoe kidneys - (n=80) as well as redo (n=12) cases were considered eligible. Postoperative controls included ultrasound, excretory urography and renal scans. Results: During a mean follow-up of 37.7 months (9-69), UPJO was successfully cured in 89 patients (96.7%) while 3 required additional procedures. Anastomotic insufficiency and urine extravasation occurring in the early postoperative period were causes of failure. Mean operative time, including the set-up of the robot, was 108.34 minutes (72-215). Mean duration of docking and surgery significantly decreased with experience (p=0.03). Average hospital stay was 4.57 days (3-8) while no perioperative transfusions had to be administered. Overall, split renal function improved from 37.63% to 41.88%. No cases of secondary UPJO were recorded in the extended follow-up period. Conclusions: Robotic pyeloplasty using the DaVinciR-system is a safe and effective technique achieving similar long-term success rates as traditional open surgery. Postoperative convalescence occurs much faster than after open pyeloplasty. The three-dimensional versatility of the robot enables the surgeon to precisely recapitulate the open procedure. The postoperative results are durable with no case of late complications. This fact may corroborate the outstanding accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelviureteric anastomosis. Moreover, the robotic approach yielded a brief learning curve for both the surgical and the technical staff. Therefore, robotic pyeloplasty is our preferred technique to treat UPJO.
288
Laparoscopic transperitoneal pyeloplasty using a remote-controlled robotic surgical system (Da Vinci®). 97 cases and one year follow-up
Robotic-assisted laparoscopic dismembered pyeloplasty: the Zurich experiences in 32 cases with obstructive ureteropelvic junction obstruction(UPJO)
Hubert J.1, Egrot C.1, Chammas Jr M.1, Feuillu B.1, Coissard A.2
Schmid D.M., Strebel R., John H., Sulser T.
CHU Nancy-Brabois, Urology, Vandoeuvre les Nancy, France, 2CHU NancyBrabois, Anesthaesiology, Vandoeuvre les Nancy, France
University Hospital Zurich, Department of Urology, Zurich, Switzerland
1
Introduction & Objectives: Dismembered pyeloplasty is the gold standard for uretero-pelvic junction syndrome. Laparoscopic dismembered pyeloplasty has been developed recently but is a challenging procedure. Developments in robotic assisted remote laparoscopy offers the surgeon a real benefit in this type of surgery. Our objective is to evaluate the results of laparoscopic robotic pyeloplasty. Material & Methods: From 11/2001 to 10/2006, 97 transperitoneal laparoscopic robotic assisted pyeloplasties for UPJ obstruction were performed. Four ports were used: 3 for the robotic arms and 1 for the assistant. Suture was completed with 6/0 running sutures and a ureteral JJ stent was introduced peroperatively. Mean patient age: 38.7 years, 36 men and 61 women. Control IVU was performed 3 and 12 months after surgery. Results: 97 pyeloplasties (33left, 64right) were completed laparoscopically with the robot. There was 1 open conversion. An inferior polar pedicle had to be uncrossed in 53 cases. Mean operative time was 126 min (including antegrad JJ placement) ; mean suturing time 34.5 min ; mean hospital stay 5.5 days. Bladder catheter was removed at day 3.1. There were 5 post-operative cystitis which resolved with antibiotic treatment. Average length of follow-up was 23.7 months. At 3 and 12 months follow-up all the patients were clinically improved, and of the 67 and 43 available IVUs there was a 96% and 98 % improvement respectively. Conclusions: Our clinical results for robotic-assisted Anderson-Hynes pyeloplasty appear encouraging. Laparoscopic robotically assisted pyeloplasty is safe and reproducible, showing results comparable to those obtained in open surgery with the advantages of a minimally invasive approach.
Eur Urol Suppl 2007;6(2):94
Introduction & Objectives: We evaluated the efficiency and safety of robotic assisted laparoscopic pyeloplasty with the DaVinci System (Intuitive®) in a prospective open label study. Material & Methods: Since 2004, a total of 32 pat. (19 m, 13 f, mean age 27 y.) with UPJO underwent robotic-assisted laparoscopic pyeloplasty analogous to the Anderson-Hynes technique. UPJO was assessed with iv. renographies pre- and 3 mths. postop. A four troicar transperitoneal access technique was used. After dissection of UPJ, anterior crossing vessels were preserved and the ureter was excised at its obstructed part and obtionally the pyelon was reducted. After ureter spatulation (1 cm), anastomosis was performed using a 4-0 vicryl running suture. A drain was left in place and removed before discharge after 2 days. The doubleJ stent was removed after 4 weeks. Results: All patients underwent successful procedure without any conversion or blood transfusion. The mean blood loss was 57 ml (0-100 ml). In 28 patients we found a crossing anterior vessel, 4 patients had intrinsic UPJO. The average op-time was 185 min. (135-240 min.), the op-time at the console 150 min. The anastomosis time averaged 40 min. (25-60 min.). No intraop. complications occurred, postop. We saw 1 passing macrohematuria and 1 subcutaneous trocar hematoma but no urine extravasation. The average hospitalisation time was 5 days. The mean follow-up is 6 months. The control urography showed 17x reduction of hydronephrosis Gd. IIIà 0-I, 15x IIIà I-II, 31 x prompt and symmetric contrast medium excretion and improved drainage. There was no evidence of recurrent obstruction in all patients and they all presented completely symptomfree in the 3- and 6- months cheque-ups. Conclusions: Robotic-assisted laparoscopic pyeloplasty is a favourable, safe, minimal invasive op-technique for UPJO and shows good clinical and radiolocical short-term results.
285
286
Motility pattern of the classic ileal ureter versus the reconfigured antirefluxive ileal ureter in dogs
Robot-assisted laparoscopic pyeloplasty – 5-year follow-up in a single center
Ali-El-Dein B.1, El-Assmy A.1, Abdel-Aziz A.A.M.1, Sarhan M.2, Bazeed M.A.1
Schwentner C., Lunacek A., Pelzer A., Neururer R., Horninger W., Bartsch G., Peschel R.
Urology and Nephrology Center, Mansoura University, Urology, Mansoura, Egypt, Urology and Nephrology Center, Mansoura University, Physiology, Mansoura, Egypt 1
2
Introduction & Objectives: To investigate whether the classic ileal ureter and the reconfigured antirefluxive ileal ureter are actively conductive to urine and to evaluate the type of motility. Material & Methods: Between January 2004 and July 2005, 12 dogs (mean body weight 15.7 Kg) were included into this study and randomly assigned to 2 groups, 6 dogs each. The lower 10 cm of the right ureter was replaced by classic ileal ureter in group I and reconfigured antirefluxive ileal ureter in group II. The latter new technique is based on the Yong-Monti principle. It entailed isolation of 3 cm of ileum, division of this segment in to 2 halves, longitudinal incisions of the 2 segments on opposite sides close to the mesentery, unfolding, fashioning of a single intestinal plate, tubularization of this plate, proximal ureteroileal anastomosis and distal nonrefluxing submucosal ileovesicostomy. Motility was tested in both groups after 1 and 6 Months by measuring the intraluminal pressure of the ileal segment and by recording movement of the ileal segment by video and serial capture screens to measure changes in dimensions of the segment during contraction. Results: Good peristalsis of the ileal segment was seen in both groups after 1 month. At 6 months, this activity was maintained in group II and decreased significantly in group I. In group I the mean width of the ureter decreased from a resting value of 2 to 0.9 cm and the length from 10 to 7 cm during contraction at 1 month. At 6 months, the segment became dilated, the mean width decreased from a resting value of 3.2 to 2.4 cm and the length from 11 to 9 cm. In group II the mean width decreased from a resting value of 0.8 to 0.3 cm and the length from 10 to 6.8 cm during contraction at 1 month. At 6 months, there was no dilatation of the segment and the values were almost maintained. The mean intraluminal pressure increased from a resting value of 3 to 10 cm H2O at the contraction rings and to 6 cm H2O in-betweens contractions in group I at 1 month, while it just increased from 2 to 5 cm H2O at the contraction sites and to 3 cm H2O in between after 6 months. In group II, the mean pressure increased from a resting value of 4 to 18 cm H2O at the contraction rings and to 8 cm H2O in between contractions at 1 and 6 months. Conclusions: A good peristalsis causing unidirectional urine flow is achieved after the reconfigured antirefluxive ileal ureter. It is comparable to that of the classic ileal ureter in the short term. After 6 months, this activity is preserved in the reconfigured ureter, while it decreases with progressive dilatation of the ileum in the classic ileal ureter.
287
Medical University, Urology, Innsbruck, Austria Introduction & Objectives: Minimal-invasive techniques are becoming increasingly important treating ureteropelvic junction obstruction (UPJO). Besides endourological techniques laparoscopic pyeloplasty has gained major interest. A reduction of postoperative pain as well as a shorter hospital stay are common features of laparoscopic surgery. However, standard laparoscopic pyeloplasty requires high operative skills and a correspondingly long learning curve limiting its widespread availability. Robot-assisted pyeloplasty is easier to learn and the learning curve is shortened particularly due to facilitated intracorporeal suturing. Herein we present our 5-year experience with this technique. Material & Methods: Between 2001 and 2006 92 patients (48 men and 44 women, mean age 35.13 years) underwent robotic, transperitoneal pyelopasty using the DaVinciR-system. Preoperative diagnosis was made on the basis of presenting symptoms and diuretic renography. A conventional Anderson-Hynes procedure was carried out in 82 whereas non-dismembered techniques were applied in 10. Three robotic ports and one assistant port were used in all cases while a JJ-stent was left in place for 6 weeks. Both primary UPJO – including horseshoe kidneys - (n=80) as well as redo (n=12) cases were considered eligible. Postoperative controls included ultrasound, excretory urography and renal scans. Results: During a mean follow-up of 37.7 months (9-69), UPJO was successfully cured in 89 patients (96.7%) while 3 required additional procedures. Anastomotic insufficiency and urine extravasation occurring in the early postoperative period were causes of failure. Mean operative time, including the set-up of the robot, was 108.34 minutes (72-215). Mean duration of docking and surgery significantly decreased with experience (p=0.03). Average hospital stay was 4.57 days (3-8) while no perioperative transfusions had to be administered. Overall, split renal function improved from 37.63% to 41.88%. No cases of secondary UPJO were recorded in the extended follow-up period. Conclusions: Robotic pyeloplasty using the DaVinciR-system is a safe and effective technique achieving similar long-term success rates as traditional open surgery. Postoperative convalescence occurs much faster than after open pyeloplasty. The three-dimensional versatility of the robot enables the surgeon to precisely recapitulate the open procedure. The postoperative results are durable with no case of late complications. This fact may corroborate the outstanding accuracy of robot-assisted intracorporeal suturing and the subsequent quality of the pelviureteric anastomosis. Moreover, the robotic approach yielded a brief learning curve for both the surgical and the technical staff. Therefore, robotic pyeloplasty is our preferred technique to treat UPJO.
288
Laparoscopic transperitoneal pyeloplasty using a remote-controlled robotic surgical system (Da Vinci®). 97 cases and one year follow-up
Robotic-assisted laparoscopic dismembered pyeloplasty: the Zurich experiences in 32 cases with obstructive ureteropelvic junction obstruction(UPJO)
Hubert J.1, Egrot C.1, Chammas Jr M.1, Feuillu B.1, Coissard A.2
Schmid D.M., Strebel R., John H., Sulser T.
CHU Nancy-Brabois, Urology, Vandoeuvre les Nancy, France, 2CHU NancyBrabois, Anesthaesiology, Vandoeuvre les Nancy, France
University Hospital Zurich, Department of Urology, Zurich, Switzerland
1
Introduction & Objectives: Dismembered pyeloplasty is the gold standard for uretero-pelvic junction syndrome. Laparoscopic dismembered pyeloplasty has been developed recently but is a challenging procedure. Developments in robotic assisted remote laparoscopy offers the surgeon a real benefit in this type of surgery. Our objective is to evaluate the results of laparoscopic robotic pyeloplasty. Material & Methods: From 11/2001 to 10/2006, 97 transperitoneal laparoscopic robotic assisted pyeloplasties for UPJ obstruction were performed. Four ports were used: 3 for the robotic arms and 1 for the assistant. Suture was completed with 6/0 running sutures and a ureteral JJ stent was introduced peroperatively. Mean patient age: 38.7 years, 36 men and 61 women. Control IVU was performed 3 and 12 months after surgery. Results: 97 pyeloplasties (33left, 64right) were completed laparoscopically with the robot. There was 1 open conversion. An inferior polar pedicle had to be uncrossed in 53 cases. Mean operative time was 126 min (including antegrad JJ placement) ; mean suturing time 34.5 min ; mean hospital stay 5.5 days. Bladder catheter was removed at day 3.1. There were 5 post-operative cystitis which resolved with antibiotic treatment. Average length of follow-up was 23.7 months. At 3 and 12 months follow-up all the patients were clinically improved, and of the 67 and 43 available IVUs there was a 96% and 98 % improvement respectively. Conclusions: Our clinical results for robotic-assisted Anderson-Hynes pyeloplasty appear encouraging. Laparoscopic robotically assisted pyeloplasty is safe and reproducible, showing results comparable to those obtained in open surgery with the advantages of a minimally invasive approach.
Eur Urol Suppl 2007;6(2):94
Introduction & Objectives: We evaluated the efficiency and safety of robotic assisted laparoscopic pyeloplasty with the DaVinci System (Intuitive®) in a prospective open label study. Material & Methods: Since 2004, a total of 32 pat. (19 m, 13 f, mean age 27 y.) with UPJO underwent robotic-assisted laparoscopic pyeloplasty analogous to the Anderson-Hynes technique. UPJO was assessed with iv. renographies pre- and 3 mths. postop. A four troicar transperitoneal access technique was used. After dissection of UPJ, anterior crossing vessels were preserved and the ureter was excised at its obstructed part and obtionally the pyelon was reducted. After ureter spatulation (1 cm), anastomosis was performed using a 4-0 vicryl running suture. A drain was left in place and removed before discharge after 2 days. The doubleJ stent was removed after 4 weeks. Results: All patients underwent successful procedure without any conversion or blood transfusion. The mean blood loss was 57 ml (0-100 ml). In 28 patients we found a crossing anterior vessel, 4 patients had intrinsic UPJO. The average op-time was 185 min. (135-240 min.), the op-time at the console 150 min. The anastomosis time averaged 40 min. (25-60 min.). No intraop. complications occurred, postop. We saw 1 passing macrohematuria and 1 subcutaneous trocar hematoma but no urine extravasation. The average hospitalisation time was 5 days. The mean follow-up is 6 months. The control urography showed 17x reduction of hydronephrosis Gd. IIIà 0-I, 15x IIIà I-II, 31 x prompt and symmetric contrast medium excretion and improved drainage. There was no evidence of recurrent obstruction in all patients and they all presented completely symptomfree in the 3- and 6- months cheque-ups. Conclusions: Robotic-assisted laparoscopic pyeloplasty is a favourable, safe, minimal invasive op-technique for UPJO and shows good clinical and radiolocical short-term results.