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335 Laparoscopic transperitoneal pyeloplasty using a remote-controlled robotic surgical system (da Vinci®). 37 cases
334
333 USE OF SINGLE-LAYER SMALL INTESTINAL LONGSEGMENT URETERAL REPLACEMENT: Assmv A., Hafez Bazeed M. Urology
A., El-Sherbiny
M., Abd
SUBMUCOSA A PILOT
El-Hamid
(SIS) STUDY
M., Mohsen
FOR
T., Nour
E.,
TRANSVERSELY SEGMENTAL Ozkan -1
B. Demirkesen
University Istanbul,
& Nephrology
Centre,
Department
of Urology,
Mansoura,
Egypt
INTRODUCTION & OBJECTIVES: Previous studies have demonstrated successful use of SIS as a tube for replacement of short segment (11-mm) midureteral defects. However, such small segment ureteral defects could be managed by resection re-anastomosis. This study aims at evaluation of the use of singlelayer SIS as a tube in replacement of long-segment ureteral defects. MATERIAL & METHODS: The ureters of five female mongrel dogs were accessed through a median laparotomy incision. A segment of 4-cm midureter was resected on the right side. The right ureteral segments were replaced by tubularised SIS segments using 610 PDS interrupted sutures. Internal pigtail stents were left for 6 weeks. All animals were sacrificed at 12 weeks. The patency of the ureters was assessed by intravenous urography (IVU) and magnetic resonance urography (MRU) at 7 and 12 weeks from the initial procedures, while inflammation and regeneration were assessed grossly and histologically. RESULTS: At 12 weeks, all the ureters on the experimental side were completely occluded with significant hydroureteronephrosis with subsequent deterioration of kidney function, At autopsy, there was failure to calibrate any of the experimental ureters with a 3F catheter. Although histologically, urothelium and muscular cells had proliferated over the graft, they were embedded in an intense fibrotic and inflammatory process. CONCLUSIONS: Technically, single-layer SIS was easily modelled, providing conditions for a watertight anastomosis. Regeneration of urothelium and muscle were induced and supported by the graft. However; functional replacement was not successful. Single-layer SIS is not a suitable material for replacement of longsegment (4-cm) ureteral defects.
AND
of Istanbul, Turkey
RETUBULARISED TOTAL URETERAL
BOWEL REPLACEMENT
O., Cetinel
S., Ataus
S., Cetinel
Cerrahpasa
School
of Medicine,
SEGMENT IN PIGS
B. Department
of Urology,
INTRODUCTION & OBJECTIVES: The aim of the present study is to evaluate the results of transversely retubularised bowel segment (TRBS) that was described by Yang and Monti in 1997, for segmental and total ureteral replacement in pigs. MATERIAL & METHODS: We have performed segmental ureteral replacement in eight pigs by using one ileal TRBS tube (Group 1) and total ureteral replacement in six pigs by using two ileal TRBS tubes (Group 2). Right ureters were left untouched and used as controls. Pigs were evaluated by excretory urography approximately 3 months after surgery and then sacrified thereafter, harvesting the kidneys, ureters and the bladders en bloc for macroscopic and histologic examination by light and electron microscopes. RESULTS: Three pigs died in the early postoperative period in Group 1 and two pigs in Group 2. The remaining five pigs in Group 1 and four pigs in Group 2 were followed for 82 to 112 days and 70 to 80 days, respectively. In Group 1, postoperative excretory urograms revealed moderate ureterohydronephrosis in two, mild ureteral dilatation in one and normal upper tracts in two. Two pigs with moderate ureterohydronephrosis had had midline incisions and exploration at the scarification session of these pigs revealed many intestinal adhesions to the anastomotic region. Catheterisations were easy through ileal TRBS tubes and histologic examination thereafter demonstrated all ileal ureteral segments including anastomotic sites were patent. In Group 2, postoperative excretory urograms revealed moderate-severe ureterohydronephrosis and delayed excretion of contrast material. Stenosis was detected at the anastomosis regions between the two TRBS tubes. The other sites of anastomoses were patent. In the histologic evaluation, at the anastomosis sites between the two ileal tubes and in the surrounding connective tissue, moderate to marked fibrosis was seen consistent with stenosis. CONCLUSIONS: Ureteral replacement by TRBS technique seems to be a safe and effective surgical treatment option in segmental ureteral defects, while it was unsuccessful in total ureteral replacement according to the results in the current study. Further animal studies should be done in order to clarify this subject.
335 LAPAROSCOPIC TRANSPERITONEAL A REMOTE-CONTROLLED ROBOTIC (DA VINCI@). 37 CASES
PYELOPLASTY SURGICAL
USING SYSTEM
336 ROBOTIC-ASSISTED RESULTS Peschel R. I, Neururer
Hubert CHU
J., Feuillu Nancy
B., Mourey
- Brabois,
E., Ferchaud
Department
J., Prevot
of Urology,
Nancy,
L., Mangin France
MATERIAL & METHODS: From November 2001 to September 2003 we performed 37 transperitoneal laparoscopic pyeloplasties for UPJ obstruction with a remote-controlled robotic surgical system (Da Vinci@). 4 ports were used: 3 for the robotic arms and 1 for the assistant. Suture was completed with 6/O running sutures and a ureteral JJ stent was introduced preoperatively and left indwelling for 4 weeks. Mean patient age: 37 years (17.81), sex ratio: 12 men and 25 women. Control IVU was performed 3 months after surgery RESULTS: 36 pyeloplasties (12 left, 24 right) were completed laparoscopically with the robot. There was 1 open conversion related to difficulties of ureteropelvic dissection on a large inflammatory left kidney. An inferior polar pedicle had to be uncrossed in 22 cases. Mean operative time was 135 min (80-210). Mean suturing time was 38 min (l&60), including JJ stent placement. Mean hospital stay was 6.5 days (5-11). Bladder catheter was removed at day 3 (2-9). There were 3 post-operative urinary infections which resolved with antibiotic treatment. At 3 months follow-up, all the patients were clinically improved. Of the 24 available IVU’s there was a good ureteral excretion at 10 minutes in 23 patients (one patient was slightly improved). CONCLUSIONS: Robotics offers many undeniable advantages: 3-dimensional vision, image magnification, precision of movements, ergonomic surgeon position. It allows the open surgeon to transfer his surgical skill to the laparoscopic approach. Laparoscopic robotic pyeloplasty is performed with anatomical results comparable to those obtained in open surgery with magnification glasses, and with a now equivalent operative time. Robotic surgery will probably have an outstanding impact in the treatment of UPJ syndrome. Urology
Supplements
3 (2004)
No. 2, pp. 86
LAPAROSCOPIC R.i, Bartsch
PYELOPLASTY:
G.‘, Chow G.2, Gettman
CLINICAL
M.2
P.
INTRODUCTION & OBJECTIVES: Dismembered pyeloplasty is the gold standard treatment for uretero-pelvic junction (UPJ) syndrome. Laparoscopic dismembered pyeloplasty has been developed for few years but is a challenging procedure. Recent developments in robotic assisted remote laparoscopy offer the surgeon a real benefit in this type of surgery. Objective: To evaluate the feasibility and results of laparoscopic robotic pyeloplasty.
European
FOR
iuniversity Hospital Innsbruck, Department of Urology, Clinic, Department of Urology, Rochester, United States
Innsbruck,
Austria,
*Mayo
& OBJECTIVES: The Da Vinci robotic system has been introduced with a goal of simplifying complex laparoscopic tasks like intracorporeal suturing. Laparoscopic pyeloplasty is an effective treatment modality for ureteropelvic junction obstruction, but intracorporeal suturing may limit clinical applicability. We reviewed our clinical results with Da Vinci-assisted laparoscopic pyeloplasty. INTRODUCTION
& METHODS: From June, 2001 through August, 2003,45 patients with symptomatic ureteropelvic junction obstruction (UPJO) underwent Da Vinci-assisted laparoscopic pyeloplasty using a 4-port transperitoneal approach. Anderson-Hynes and non-dismembered pyeloplasty were performed in 35 and 10 patients, respectively. All steps of laparoscopic pyeloplasty were performed by the surgeon from a remote control unit and a scrubbed assistant surgeon. Perioperative results and radiographic follow-up data were retrospectively reviewed.
MATERIAL
RESULTS: All steps of robotic-assisted Anderson-Hynes and non-dismembered pyeloplasties were successfully performed. Optimal robotic function required careful positioning and alignment taking into account individual variations at the UPJO. The scrubbed assistant surgeon was also critical to the success of the robotic-assisted procedure. The mean operative times for Anderson-Hynes and non-dismembered pyeloplasty were 142 minutes (range 90-270 minutes) and 105 minutes (range 70-200 minutes), respectively. The mean lengths of stay for Anderson-Hynes and nondismembered pyeloplasty were 4.5 days (range 3-7) and 4.2 days (range 3-6), respectively. Estimated blood loss was < 50 cc in all cases. No intraoperative complications were observed related to the robotic device. In one case stent placement was not possible, therefore conversion was performed. One access-related bowel injury in the non-dismembered cohort required open conversion and repair. Postoperatively, open exploration was required in one patient in the Anderson-Hynes cohort to repair a defect in the renal pelvis. At a mean follow-up of 18 months (range 3 - 27 months), the overall objective success rate was 100%.
A coordinated approach by the surgeon and scrubbed assistant is required for optimal function of the robotic device. The initial clinical results for robotic-assisted Anderson-Hynes and non-dismembered pyeloplasty appear encouraging but long-term follow-up is yet missing.
CONCLUSIONS:
333 USE OF SINGLE-LAYER SMALL INTESTINAL LONGSEGMENT URETERAL REPLACEMENT: Assmv A., Hafez Bazeed M. Urology
A., El-Sherbiny
M., Abd
SUBMUCOSA A PILOT
El-Hamid
(SIS) STUDY
M., Mohsen
FOR
T., Nour
E.,
TRANSVERSELY SEGMENTAL Ozkan -1
B. Demirkesen
University Istanbul,
& Nephrology
Centre,
Department
of Urology,
Mansoura,
Egypt
INTRODUCTION & OBJECTIVES: Previous studies have demonstrated successful use of SIS as a tube for replacement of short segment (11-mm) midureteral defects. However, such small segment ureteral defects could be managed by resection re-anastomosis. This study aims at evaluation of the use of singlelayer SIS as a tube in replacement of long-segment ureteral defects. MATERIAL & METHODS: The ureters of five female mongrel dogs were accessed through a median laparotomy incision. A segment of 4-cm midureter was resected on the right side. The right ureteral segments were replaced by tubularised SIS segments using 610 PDS interrupted sutures. Internal pigtail stents were left for 6 weeks. All animals were sacrificed at 12 weeks. The patency of the ureters was assessed by intravenous urography (IVU) and magnetic resonance urography (MRU) at 7 and 12 weeks from the initial procedures, while inflammation and regeneration were assessed grossly and histologically. RESULTS: At 12 weeks, all the ureters on the experimental side were completely occluded with significant hydroureteronephrosis with subsequent deterioration of kidney function, At autopsy, there was failure to calibrate any of the experimental ureters with a 3F catheter. Although histologically, urothelium and muscular cells had proliferated over the graft, they were embedded in an intense fibrotic and inflammatory process. CONCLUSIONS: Technically, single-layer SIS was easily modelled, providing conditions for a watertight anastomosis. Regeneration of urothelium and muscle were induced and supported by the graft. However; functional replacement was not successful. Single-layer SIS is not a suitable material for replacement of longsegment (4-cm) ureteral defects.
AND
of Istanbul, Turkey
RETUBULARISED TOTAL URETERAL
BOWEL REPLACEMENT
O., Cetinel
S., Ataus
S., Cetinel
Cerrahpasa
School
of Medicine,
SEGMENT IN PIGS
B. Department
of Urology,
INTRODUCTION & OBJECTIVES: The aim of the present study is to evaluate the results of transversely retubularised bowel segment (TRBS) that was described by Yang and Monti in 1997, for segmental and total ureteral replacement in pigs. MATERIAL & METHODS: We have performed segmental ureteral replacement in eight pigs by using one ileal TRBS tube (Group 1) and total ureteral replacement in six pigs by using two ileal TRBS tubes (Group 2). Right ureters were left untouched and used as controls. Pigs were evaluated by excretory urography approximately 3 months after surgery and then sacrified thereafter, harvesting the kidneys, ureters and the bladders en bloc for macroscopic and histologic examination by light and electron microscopes. RESULTS: Three pigs died in the early postoperative period in Group 1 and two pigs in Group 2. The remaining five pigs in Group 1 and four pigs in Group 2 were followed for 82 to 112 days and 70 to 80 days, respectively. In Group 1, postoperative excretory urograms revealed moderate ureterohydronephrosis in two, mild ureteral dilatation in one and normal upper tracts in two. Two pigs with moderate ureterohydronephrosis had had midline incisions and exploration at the scarification session of these pigs revealed many intestinal adhesions to the anastomotic region. Catheterisations were easy through ileal TRBS tubes and histologic examination thereafter demonstrated all ileal ureteral segments including anastomotic sites were patent. In Group 2, postoperative excretory urograms revealed moderate-severe ureterohydronephrosis and delayed excretion of contrast material. Stenosis was detected at the anastomosis regions between the two TRBS tubes. The other sites of anastomoses were patent. In the histologic evaluation, at the anastomosis sites between the two ileal tubes and in the surrounding connective tissue, moderate to marked fibrosis was seen consistent with stenosis. CONCLUSIONS: Ureteral replacement by TRBS technique seems to be a safe and effective surgical treatment option in segmental ureteral defects, while it was unsuccessful in total ureteral replacement according to the results in the current study. Further animal studies should be done in order to clarify this subject.
335 LAPAROSCOPIC TRANSPERITONEAL A REMOTE-CONTROLLED ROBOTIC (DA VINCI@). 37 CASES
PYELOPLASTY SURGICAL
USING SYSTEM
336 ROBOTIC-ASSISTED RESULTS Peschel R. I, Neururer
Hubert CHU
J., Feuillu Nancy
B., Mourey
- Brabois,
E., Ferchaud
Department
J., Prevot
of Urology,
Nancy,
L., Mangin France
MATERIAL & METHODS: From November 2001 to September 2003 we performed 37 transperitoneal laparoscopic pyeloplasties for UPJ obstruction with a remote-controlled robotic surgical system (Da Vinci@). 4 ports were used: 3 for the robotic arms and 1 for the assistant. Suture was completed with 6/O running sutures and a ureteral JJ stent was introduced preoperatively and left indwelling for 4 weeks. Mean patient age: 37 years (17.81), sex ratio: 12 men and 25 women. Control IVU was performed 3 months after surgery RESULTS: 36 pyeloplasties (12 left, 24 right) were completed laparoscopically with the robot. There was 1 open conversion related to difficulties of ureteropelvic dissection on a large inflammatory left kidney. An inferior polar pedicle had to be uncrossed in 22 cases. Mean operative time was 135 min (80-210). Mean suturing time was 38 min (l&60), including JJ stent placement. Mean hospital stay was 6.5 days (5-11). Bladder catheter was removed at day 3 (2-9). There were 3 post-operative urinary infections which resolved with antibiotic treatment. At 3 months follow-up, all the patients were clinically improved. Of the 24 available IVU’s there was a good ureteral excretion at 10 minutes in 23 patients (one patient was slightly improved). CONCLUSIONS: Robotics offers many undeniable advantages: 3-dimensional vision, image magnification, precision of movements, ergonomic surgeon position. It allows the open surgeon to transfer his surgical skill to the laparoscopic approach. Laparoscopic robotic pyeloplasty is performed with anatomical results comparable to those obtained in open surgery with magnification glasses, and with a now equivalent operative time. Robotic surgery will probably have an outstanding impact in the treatment of UPJ syndrome. Urology
Supplements
3 (2004)
No. 2, pp. 86
LAPAROSCOPIC R.i, Bartsch
PYELOPLASTY:
G.‘, Chow G.2, Gettman
CLINICAL
M.2
P.
INTRODUCTION & OBJECTIVES: Dismembered pyeloplasty is the gold standard treatment for uretero-pelvic junction (UPJ) syndrome. Laparoscopic dismembered pyeloplasty has been developed for few years but is a challenging procedure. Recent developments in robotic assisted remote laparoscopy offer the surgeon a real benefit in this type of surgery. Objective: To evaluate the feasibility and results of laparoscopic robotic pyeloplasty.
European
FOR
iuniversity Hospital Innsbruck, Department of Urology, Clinic, Department of Urology, Rochester, United States
Innsbruck,
Austria,
*Mayo
& OBJECTIVES: The Da Vinci robotic system has been introduced with a goal of simplifying complex laparoscopic tasks like intracorporeal suturing. Laparoscopic pyeloplasty is an effective treatment modality for ureteropelvic junction obstruction, but intracorporeal suturing may limit clinical applicability. We reviewed our clinical results with Da Vinci-assisted laparoscopic pyeloplasty. INTRODUCTION
& METHODS: From June, 2001 through August, 2003,45 patients with symptomatic ureteropelvic junction obstruction (UPJO) underwent Da Vinci-assisted laparoscopic pyeloplasty using a 4-port transperitoneal approach. Anderson-Hynes and non-dismembered pyeloplasty were performed in 35 and 10 patients, respectively. All steps of laparoscopic pyeloplasty were performed by the surgeon from a remote control unit and a scrubbed assistant surgeon. Perioperative results and radiographic follow-up data were retrospectively reviewed.
MATERIAL
RESULTS: All steps of robotic-assisted Anderson-Hynes and non-dismembered pyeloplasties were successfully performed. Optimal robotic function required careful positioning and alignment taking into account individual variations at the UPJO. The scrubbed assistant surgeon was also critical to the success of the robotic-assisted procedure. The mean operative times for Anderson-Hynes and non-dismembered pyeloplasty were 142 minutes (range 90-270 minutes) and 105 minutes (range 70-200 minutes), respectively. The mean lengths of stay for Anderson-Hynes and nondismembered pyeloplasty were 4.5 days (range 3-7) and 4.2 days (range 3-6), respectively. Estimated blood loss was < 50 cc in all cases. No intraoperative complications were observed related to the robotic device. In one case stent placement was not possible, therefore conversion was performed. One access-related bowel injury in the non-dismembered cohort required open conversion and repair. Postoperatively, open exploration was required in one patient in the Anderson-Hynes cohort to repair a defect in the renal pelvis. At a mean follow-up of 18 months (range 3 - 27 months), the overall objective success rate was 100%.
A coordinated approach by the surgeon and scrubbed assistant is required for optimal function of the robotic device. The initial clinical results for robotic-assisted Anderson-Hynes and non-dismembered pyeloplasty appear encouraging but long-term follow-up is yet missing.
CONCLUSIONS: