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Techniques for Laparoscopic and Robotic Localization of Intraluminal Ureteral Pathology
Laparoscopy and Robotics Techniques for Laparoscopic and Robotic Localization of Intraluminal Ureteral Pathology Ronney Abaza and Saleem S. Zafar OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
Improvements in endoscopic technology have made open ureteral surgery uncommon. There remain cases of ureteral disease not amenable to ureteroscopic treatment, but laparoscopy allows even these complicated cases to be treated in a minimally invasive fashion. Laparoscopic and robotic surgical treatment of the ureter requires the ability to localize the diseased segment laparoscopically, even when the defect is within the lumen and cannot be seen externally or palpated as in open surgery. We describe 3 techniques to localize the disease within the ureter during laparoscopy and robotic surgery and the benefits and limitations of each technique. Three cases of laparoscopic and robotic ureteral surgery illustrate 3 different techniques used to localize disease within the ureteral lumen. The first case illustrates a ureteral occlusion balloon catheter used to identify a stricture by distending the collecting system proximal to the obstruction and cinching the balloon against the stricture. The second case illustrates a flexible ureteroscope introduced through a 5-mm port and into the incised ureter to guide excision of extensive polyposis. The third case, involving a polyp and stricture, illustrates a technique involving retrograde ureteroscopy with “cutting to the light” laparoscopically. Three techniques are demonstrated to successfully localize intraluminal ureteral disease that could not be identified visually by laparoscopic inspection alone. These techniques also can minimize the extent of ureteral dissection to preserve blood supply. Laparoscopy and robotic surgery can be successfully applied to benign ureteral disease not amenable to ureteroscopic treatment. Three cases are presented to illustrate 3 techniques for laparoscopic or robotic localization of intraluminal ureteral disease. UROLOGY 73: 582–585, 2009. © 2009 Elsevier Inc.
M
inimally invasive techniques have become the preferred method for managing benign ureteral disease with most conditions amenable to endoscopic treatment.1 Occasionally, patients who have already failed endoscopic intervention or those with extensive or complicated lesions cannot be managed endoscopically, and either open or laparoscopic surgery is necessary. Although laparoscopy and robotic surgery offer the benefits of a minimally invasive procedure, a limitation as compared with open surgery is decreased tactile sensation, which is often used to localize the intraluminal disease. Methods other than tactile sensation are therefore necessary for localizing these lesions, but published reports regarding laparoscopic or robotic ureteral surgery are limited to relatively small series and case reports with
From Robotic Urologic Surgery, Ohio State University Medical Center, James Cancer Hospital, Columbus, and the Department of Urology, University of Toledo College of Medicine, Toledo, Ohio Reprint requests: Ronney Abaza, M.D., 503 Doan Hall, 410 W 10th Ave, Columbus, OH 43210. E-mail: [email protected] Submitted: July 7, 2008, accepted (with revisions): August 21, 2008
582
© 2009 Elsevier Inc. All Rights Reserved
systematic descriptions of localization techniques to this point absent in the literature.2-6 We present 3 cases that illustrate different techniques for localization of intralumenal ureteral disease along with their advantages and limitations.
MATERIAL AND METHODS Technique 1: Cut to the Light With Ureteroscopy A patient with intermittent right flank pain and a midureteral stricture on intravenous pyelogram failed ureteroscopic treatment and elected for robotic reconstruction (Fig. 1). The patient was positioned with legs in stirrups and the right flank elevated with padding to 20 degrees. The operating table was then rotated to further elevate the right side to approximately 45 degrees. The colon was reflected robotically until the general vicinity of the ureter was identified. Because of the presence of a relatively short stricture with the need to resect only a short segment of ureter, the ureteroscopy technique was chosen to identify precisely the location of the stricture and to minimize the need for circumferential dissection of a long segment of ureter. This technique to localize the lesion with minimal ureteral dissection, so as to preserve blood supply to the repair, involved placing a flexible ureteroscope 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.08.486
Figure 1. Cutting-to-light technique with (A) ureteroscopic view of stricture, (B) preoperative view of the stricture on intravenous pyelogram, (C) view of ureteroscope light at site of the stricture with laparoscope light source turned off, and (D) corresponding view with light on before extensive robotic mobilization of the ureter. that was passed transurethrally into the ureter to the level of the stricture that was visualized ureteroscopically. The robotic scope’s light source was dimmed until the light from the ureteroscope transilluminated the ureter at the site of the stricture. The ureter was mobilized proximally and distally no more than necessary for excision of the diseased segment, and primary ureteroureterostomy was performed with a double-J stent in place. The patient was discharged on the second postoperative day, and the stent was removed 4 weeks later with successful resolution of the stricture on follow-up radiologic studies.
Technique 2: Ureteral Occlusion Balloon Catheter A patient with intermittent right flank pain underwent retrograde pyelography, which demonstrated a kinked ureter and an associated stricture. The patient elected for laparoscopic repair. The patient was initially positioned in lithotomy, and the lesion was localized with fluoroscopy by passing a 6-F ureteral occlusion balloon catheter (Boston Scientific, Natick, MA) in a retrograde fashion and injecting radiographic contrast. The injection of saline solution was performed through the catheter to distend the ureter proximal to the stricture, and the balloon was then minimally inflated and pulled back to cinch it against the stricture (Fig. 2). This technique was chosen because the proximal kinked segment would also require excision and its extent was better delineated by the injection of saline solution through the catheter proximal to the balloon to make the kinking more prominent. UROLOGY 73 (3), 2009
Figure 2. Illustration of occlusion balloon catheter across the stricture with the balloon cinched against the stricture and the ability to distend ureter proximal to the balloon if needed by injection of saline solution through the catheter.
Once the lesion was localized with this technique, the patient was repositioned with the right side raised to 45 degrees and the table rotated to elevate the right side further. Transperitoneal laparoscopic exposure was obtained, the right colon 583
Figure 3. Ureteroscopic localization of the disease transabdominally (A) before excision of polyps and (B) after polyps are excised to determine the extent of ureteral involvement.
was reflected medially, and the diseased segment of the ureter was easily located by visual identification of the balloon and confirmed by laparoscopic palpation of the balloon. Minimal dissection of the ureter was carried out to preserve vascularity, and the kinked segment along with the associated stricture was excised. A primary ureteroureterostomy was performed with a double-J stent in place. The patient was discharged on the first postoperative day, and the stent was removed 4 weeks later, at which time a retrograde pyelogram demonstrated a successful reconstruction.
Technique 3: Laparoscopic Ureteroscopy A patient with right flank pain underwent retrograde pyelography, which demonstrated diffuse ureteral fibroepithelial polyposis of the proximal and mid ureter. Ureteroscopy was performed, but the polyposis was too extensive to treat each polyp endoscopically. The patient elected for laparoscopic ureteral polypectomy. The patient was positioned obliquely with the right side raised to 45 degrees. Transperitoneal laparoscopic exposure was obtained, and the right colon was reflected. To localize the extent of the polyps, a ureterotomy was made in the mid ureter. A flexible ureteroscope was then passed through a 5-mm port, directed into the ureter, and passed proximally and distally to assess the extent of polyposis (Fig. 3), which took advantage of the open system and allowed easier access and visualization than retrograde ureteroscopy. The ureterotomy was then extended cephelad and caudad until the most proximal and distal polyps were identified. The polyps were then excised, and the ureter was closed with a running absorbable suture over a double-J stent. The stent was removed 6 weeks later with no evidence of residual polyp disease on retrograde pyelography.
COMMENTS Ureteral disease has been treated by endoscopic techniques as well as with open surgery and laparoscopy. One of the challenges in the laparoscopic or robotic management of benign ureteral disease is localization of the disease. Often, the surgeon’s general perception of the location of the stricture, based on preoperative imaging, will guide dissection and reveal a visible transition point. In other cases, identification of the ureteral disease is not straightforward. 584
In a previously described technique, intraoperative ultrasound was used to identify a ureteral catheter placed preoperatively at the level of the stricture and secured to a Foley catheter.1 Although reportedly effective, a potential disadvantage of this technique was the possibility of migration of the ureteral catheter, particularly during repositioning. Others have described their series of laparoscopic or robotic ureteral reconstruction without the mention of intraoperative localization techniques.2-6 To our knowledge, the techniques for the localization of ureteral disease presented here have not been previously described in the literature. Each method has advantages and disadvantages and offers the laparoscopic surgeon means beyond visual cues alone for localizing ureteral disease. The “cut to the light” method that uses a flexible ureteroscope passed retrograde to the site of the disease allows for precise localization under direct vision. Also, devascularization can be reduced by minimizing circumferential ureteral dissection. Disadvantages include the need for intraoperative access to the urethra, which can be particularly cumbersome in a woman because of the need for stirrups, thereby limiting the lateral positioning of the patient and prohibiting the use of a full flank position. Also, a second surgeon is required to perform flexible ureteroscopy. The ureteral occlusion balloon catheter technique offers localization that requires neither repositioning nor fluoroscopy during the laparoscopic portion of the procedure. Also, a single surgeon can perform both the localization and the repair. This technique, however, is not as reliable as other techniques because the ureteral catheter can migrate proximally when the patient is repositioned for laparoscopy. Nevertheless, although proximal migration of the balloon catheter is possible, distal migration is prevented by the stricture unlike with a simple ureteral catheter. Therefore, the balloon can be cinched again against the stricture if there is suspicion of proximal migration. Fortunately, even when the position of the balloon catheter is completely in doubt, the injection of fluid through the catheter can be used to distend the UROLOGY 73 (3), 2009
ureter proximal to the obstruction potentially allowing easier identification of the transition point visually. The final technique of transperitoneal ureteroscopy avoids the need for preoperative or intraoperative cystoscopy. Also, the patient position does not affect the ability to localize the disease. The primary disadvantage of this method is that the surgeon’s estimate of the disease and therefore where to make the ureterotomy may be inaccurate, thereby necessitating either an extension of the ureteral incision or the creation of another ureterotomy with potential for stricturing. Surprisingly, leakage of irrigant into the peritoneal cavity during ureteroscopy, although the potential exists, is not typically problematic.
CONCLUSIONS Although none of the described ureteral localization techniques is universally applicable, these methods offer the laparoscopic and robotic surgeon options for localiz-
UROLOGY 73 (3), 2009
ing ureteral disease. Most ureteral disease will be adequately localized with 1 of these 3 methods. The techniques each offer advantages and disadvantages and should be tailored to the individual patient. References 1. Muslumanoglu AY, Karadag MA, Tefekli AH, et al. When is open ureterolithotomy indicated for the treatment of ureteral stones? Int J Urology. 2006;13(11):1385-1388. 2. Mufarrij PW, Shah OD, Berger AD, Stifelman MD. Robotic reconstruction of the upper urinary tract. J Urol. 2007;178:2002-2005. 3. Fugita OE, Dinlence C, Kavoussi L. The laparoscopic boari flap. J Urol. 2001;166:51-53. 4. Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol. 1994;152:2057-2059. 5. Nezhat CH, Nezhat F, Seidman D, et al. Laparoscopic ureteroureterostomy: a prospective follow-up of 9 patients. Prim Care Update Ob Gyns. 1998;5:200. 6. Passerotti CC, Diamond DA, Borer JG, et al. Robot-assisted laparoscopic ureteroureterostomy: description of technique. J Endourol. 2008;22(4):581-586.
585
METHODS
RESULTS
CONCLUSIONS
Improvements in endoscopic technology have made open ureteral surgery uncommon. There remain cases of ureteral disease not amenable to ureteroscopic treatment, but laparoscopy allows even these complicated cases to be treated in a minimally invasive fashion. Laparoscopic and robotic surgical treatment of the ureter requires the ability to localize the diseased segment laparoscopically, even when the defect is within the lumen and cannot be seen externally or palpated as in open surgery. We describe 3 techniques to localize the disease within the ureter during laparoscopy and robotic surgery and the benefits and limitations of each technique. Three cases of laparoscopic and robotic ureteral surgery illustrate 3 different techniques used to localize disease within the ureteral lumen. The first case illustrates a ureteral occlusion balloon catheter used to identify a stricture by distending the collecting system proximal to the obstruction and cinching the balloon against the stricture. The second case illustrates a flexible ureteroscope introduced through a 5-mm port and into the incised ureter to guide excision of extensive polyposis. The third case, involving a polyp and stricture, illustrates a technique involving retrograde ureteroscopy with “cutting to the light” laparoscopically. Three techniques are demonstrated to successfully localize intraluminal ureteral disease that could not be identified visually by laparoscopic inspection alone. These techniques also can minimize the extent of ureteral dissection to preserve blood supply. Laparoscopy and robotic surgery can be successfully applied to benign ureteral disease not amenable to ureteroscopic treatment. Three cases are presented to illustrate 3 techniques for laparoscopic or robotic localization of intraluminal ureteral disease. UROLOGY 73: 582–585, 2009. © 2009 Elsevier Inc.
M
inimally invasive techniques have become the preferred method for managing benign ureteral disease with most conditions amenable to endoscopic treatment.1 Occasionally, patients who have already failed endoscopic intervention or those with extensive or complicated lesions cannot be managed endoscopically, and either open or laparoscopic surgery is necessary. Although laparoscopy and robotic surgery offer the benefits of a minimally invasive procedure, a limitation as compared with open surgery is decreased tactile sensation, which is often used to localize the intraluminal disease. Methods other than tactile sensation are therefore necessary for localizing these lesions, but published reports regarding laparoscopic or robotic ureteral surgery are limited to relatively small series and case reports with
From Robotic Urologic Surgery, Ohio State University Medical Center, James Cancer Hospital, Columbus, and the Department of Urology, University of Toledo College of Medicine, Toledo, Ohio Reprint requests: Ronney Abaza, M.D., 503 Doan Hall, 410 W 10th Ave, Columbus, OH 43210. E-mail: [email protected] Submitted: July 7, 2008, accepted (with revisions): August 21, 2008
582
© 2009 Elsevier Inc. All Rights Reserved
systematic descriptions of localization techniques to this point absent in the literature.2-6 We present 3 cases that illustrate different techniques for localization of intralumenal ureteral disease along with their advantages and limitations.
MATERIAL AND METHODS Technique 1: Cut to the Light With Ureteroscopy A patient with intermittent right flank pain and a midureteral stricture on intravenous pyelogram failed ureteroscopic treatment and elected for robotic reconstruction (Fig. 1). The patient was positioned with legs in stirrups and the right flank elevated with padding to 20 degrees. The operating table was then rotated to further elevate the right side to approximately 45 degrees. The colon was reflected robotically until the general vicinity of the ureter was identified. Because of the presence of a relatively short stricture with the need to resect only a short segment of ureter, the ureteroscopy technique was chosen to identify precisely the location of the stricture and to minimize the need for circumferential dissection of a long segment of ureter. This technique to localize the lesion with minimal ureteral dissection, so as to preserve blood supply to the repair, involved placing a flexible ureteroscope 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.08.486
Figure 1. Cutting-to-light technique with (A) ureteroscopic view of stricture, (B) preoperative view of the stricture on intravenous pyelogram, (C) view of ureteroscope light at site of the stricture with laparoscope light source turned off, and (D) corresponding view with light on before extensive robotic mobilization of the ureter. that was passed transurethrally into the ureter to the level of the stricture that was visualized ureteroscopically. The robotic scope’s light source was dimmed until the light from the ureteroscope transilluminated the ureter at the site of the stricture. The ureter was mobilized proximally and distally no more than necessary for excision of the diseased segment, and primary ureteroureterostomy was performed with a double-J stent in place. The patient was discharged on the second postoperative day, and the stent was removed 4 weeks later with successful resolution of the stricture on follow-up radiologic studies.
Technique 2: Ureteral Occlusion Balloon Catheter A patient with intermittent right flank pain underwent retrograde pyelography, which demonstrated a kinked ureter and an associated stricture. The patient elected for laparoscopic repair. The patient was initially positioned in lithotomy, and the lesion was localized with fluoroscopy by passing a 6-F ureteral occlusion balloon catheter (Boston Scientific, Natick, MA) in a retrograde fashion and injecting radiographic contrast. The injection of saline solution was performed through the catheter to distend the ureter proximal to the stricture, and the balloon was then minimally inflated and pulled back to cinch it against the stricture (Fig. 2). This technique was chosen because the proximal kinked segment would also require excision and its extent was better delineated by the injection of saline solution through the catheter proximal to the balloon to make the kinking more prominent. UROLOGY 73 (3), 2009
Figure 2. Illustration of occlusion balloon catheter across the stricture with the balloon cinched against the stricture and the ability to distend ureter proximal to the balloon if needed by injection of saline solution through the catheter.
Once the lesion was localized with this technique, the patient was repositioned with the right side raised to 45 degrees and the table rotated to elevate the right side further. Transperitoneal laparoscopic exposure was obtained, the right colon 583
Figure 3. Ureteroscopic localization of the disease transabdominally (A) before excision of polyps and (B) after polyps are excised to determine the extent of ureteral involvement.
was reflected medially, and the diseased segment of the ureter was easily located by visual identification of the balloon and confirmed by laparoscopic palpation of the balloon. Minimal dissection of the ureter was carried out to preserve vascularity, and the kinked segment along with the associated stricture was excised. A primary ureteroureterostomy was performed with a double-J stent in place. The patient was discharged on the first postoperative day, and the stent was removed 4 weeks later, at which time a retrograde pyelogram demonstrated a successful reconstruction.
Technique 3: Laparoscopic Ureteroscopy A patient with right flank pain underwent retrograde pyelography, which demonstrated diffuse ureteral fibroepithelial polyposis of the proximal and mid ureter. Ureteroscopy was performed, but the polyposis was too extensive to treat each polyp endoscopically. The patient elected for laparoscopic ureteral polypectomy. The patient was positioned obliquely with the right side raised to 45 degrees. Transperitoneal laparoscopic exposure was obtained, and the right colon was reflected. To localize the extent of the polyps, a ureterotomy was made in the mid ureter. A flexible ureteroscope was then passed through a 5-mm port, directed into the ureter, and passed proximally and distally to assess the extent of polyposis (Fig. 3), which took advantage of the open system and allowed easier access and visualization than retrograde ureteroscopy. The ureterotomy was then extended cephelad and caudad until the most proximal and distal polyps were identified. The polyps were then excised, and the ureter was closed with a running absorbable suture over a double-J stent. The stent was removed 6 weeks later with no evidence of residual polyp disease on retrograde pyelography.
COMMENTS Ureteral disease has been treated by endoscopic techniques as well as with open surgery and laparoscopy. One of the challenges in the laparoscopic or robotic management of benign ureteral disease is localization of the disease. Often, the surgeon’s general perception of the location of the stricture, based on preoperative imaging, will guide dissection and reveal a visible transition point. In other cases, identification of the ureteral disease is not straightforward. 584
In a previously described technique, intraoperative ultrasound was used to identify a ureteral catheter placed preoperatively at the level of the stricture and secured to a Foley catheter.1 Although reportedly effective, a potential disadvantage of this technique was the possibility of migration of the ureteral catheter, particularly during repositioning. Others have described their series of laparoscopic or robotic ureteral reconstruction without the mention of intraoperative localization techniques.2-6 To our knowledge, the techniques for the localization of ureteral disease presented here have not been previously described in the literature. Each method has advantages and disadvantages and offers the laparoscopic surgeon means beyond visual cues alone for localizing ureteral disease. The “cut to the light” method that uses a flexible ureteroscope passed retrograde to the site of the disease allows for precise localization under direct vision. Also, devascularization can be reduced by minimizing circumferential ureteral dissection. Disadvantages include the need for intraoperative access to the urethra, which can be particularly cumbersome in a woman because of the need for stirrups, thereby limiting the lateral positioning of the patient and prohibiting the use of a full flank position. Also, a second surgeon is required to perform flexible ureteroscopy. The ureteral occlusion balloon catheter technique offers localization that requires neither repositioning nor fluoroscopy during the laparoscopic portion of the procedure. Also, a single surgeon can perform both the localization and the repair. This technique, however, is not as reliable as other techniques because the ureteral catheter can migrate proximally when the patient is repositioned for laparoscopy. Nevertheless, although proximal migration of the balloon catheter is possible, distal migration is prevented by the stricture unlike with a simple ureteral catheter. Therefore, the balloon can be cinched again against the stricture if there is suspicion of proximal migration. Fortunately, even when the position of the balloon catheter is completely in doubt, the injection of fluid through the catheter can be used to distend the UROLOGY 73 (3), 2009
ureter proximal to the obstruction potentially allowing easier identification of the transition point visually. The final technique of transperitoneal ureteroscopy avoids the need for preoperative or intraoperative cystoscopy. Also, the patient position does not affect the ability to localize the disease. The primary disadvantage of this method is that the surgeon’s estimate of the disease and therefore where to make the ureterotomy may be inaccurate, thereby necessitating either an extension of the ureteral incision or the creation of another ureterotomy with potential for stricturing. Surprisingly, leakage of irrigant into the peritoneal cavity during ureteroscopy, although the potential exists, is not typically problematic.
CONCLUSIONS Although none of the described ureteral localization techniques is universally applicable, these methods offer the laparoscopic and robotic surgeon options for localiz-
UROLOGY 73 (3), 2009
ing ureteral disease. Most ureteral disease will be adequately localized with 1 of these 3 methods. The techniques each offer advantages and disadvantages and should be tailored to the individual patient. References 1. Muslumanoglu AY, Karadag MA, Tefekli AH, et al. When is open ureterolithotomy indicated for the treatment of ureteral stones? Int J Urology. 2006;13(11):1385-1388. 2. Mufarrij PW, Shah OD, Berger AD, Stifelman MD. Robotic reconstruction of the upper urinary tract. J Urol. 2007;178:2002-2005. 3. Fugita OE, Dinlence C, Kavoussi L. The laparoscopic boari flap. J Urol. 2001;166:51-53. 4. Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol. 1994;152:2057-2059. 5. Nezhat CH, Nezhat F, Seidman D, et al. Laparoscopic ureteroureterostomy: a prospective follow-up of 9 patients. Prim Care Update Ob Gyns. 1998;5:200. 6. Passerotti CC, Diamond DA, Borer JG, et al. Robot-assisted laparoscopic ureteroureterostomy: description of technique. J Endourol. 2008;22(4):581-586.
585