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V17 LAPAROSCOPIC DISMEMBERED PYELOPLASTY: TIPS AND TRICKS
Video Session 3 LAPAROSCOPY FOR THE KIDNEY Sunday, 20 March, 12.15-13.45, eURO Auditorium
V15
Microwaves laparoscopic-guided renal cancer ablation: Value on histopathology and haemostacy
Muto M.G.1, D'Urso D.L.1, Migliari M.R.1, Collura C.D.1, Giacobbe G.A.2, Coverlizza C.S.3, Demarchi D.A.3 1 St. Giovanni Bosco Hospital, Dept. of Urology, Turin, Italy, 2Mauriziano Hospital, Dept. of Urology, Turin, Italy, 3St. Giovanni Bosco Hospital, Dept. of Pathology, Turin, Italy Introduction & Objectives: The spread of ultrasound imaging has led to a dramatic increase of incidental small renal masses amenable to treatment. On the other hand, advancements in imaging has allowed the progressive expansion of minimally-invasive ablative techniques. Recently, Microwaves (MW) have been added to ablative armamentarium. MW’ termoablative effect causes cells death by inducing water’s molecules friction. Here we show the procedural steps and hystopathological results of MW’ laparoscopic-guided renal cancer ablation and tumor enucleation. Materials & Methods: Treatment of an emblematic case of a 46 YOM with a medical history of prior dorsal melanoma with ultrasound incidentally detected 3 cm renal mass was planned. This finding was confirmed by a staging CT-scan. Patient underwent laparoscopy-guided MW tumor ablation with MW’ antenna Evident ValleylabTM followed by tumor enucleation. Laparoscopy steps included preventive renal artery isolation, neoplasm deffatting and a pre-ablation trucut biopsy of tumor. MW antennas Evident ValleylabTM were applied from 1 to 3 times according to tumor volume and location in order to obtain the best ablative effect. After MW thermoablation, laparoscopic enucleation was performed with the purpose to evaluate MW hysto-pathologic effect and the haemostatic effect as well. Biopsy of the parenchyma surrounding the neoplasm was also performed. Results: Preablation pathology reported a Clear Cell Renal Carcinoma grading Fuhrman G1-2. Post-ablation pathology showed extensive coagulative necrosis without skipped tumor areas. Intra and postoperative complications were not reported, with particular regard to bleeding and anemia. Same results were obtained in a series of 10 patients. Conclusions: Laparoscopic MW thermoablation seems to be simple, rapid and effective allowing intraoperative monitoring of MW effect. MW make easier laparoscopic renal tumor enucleation providing an optimal haemostatic effect avoiding the need of stitching.
V16
Outcome of regional lymph node dissection in conjunction with laparoscopic nephroureterectomy for urothelial carcinoma of upper urinary tract
Sasaki H.S.1, Abe T.A.1, Harabayashi T.H.2, Shinohara N.S.1, Sazawa A.S.1, Maruyama S.M.1, Nonomura K.N.1 1 Hokkaido University Graduate School of Medicine, Dept. of Urology, Sapporo, Japan, 2Hokkaido Cancer Center, Dept. of Urology, Sapporo, Japan Introduction & Objectives: Focusing on accurate disease staging as well as potential therapeutic benefit, we routinely perform regional lymph node dissection (LND) in conjunction with laparoscopic nephroureterectomy (NU) in treatment of upper urinary tract (UUT) cancer. Our aim for the present study is to evaluate the ability of LND in laparoscopic NU. Materials & Methods: Thirty-nine patients undergoing laparoscopic NU with regional LND were included in the present study. We evaluated the number of lymph nodes resected, pathological node status, adverse event and the survival data. As for node count, we compared it with that of the 41 patients who underwent open NU between 1990 and 2008. Results: The median number of LNs removed was 10 (range, 2-59) for laparoscopic NU group, while 10 (range, 1-65) for open NU group (Mann-Whitney U test, p=0.82). Pathological examination revealed positive LNs in 4 patients (10.3%) and three of the four received adjuvant chemotherapy. Although chylous drain discharge was detected just after starting dietary intake in eight patients, it resolved without significant problem. Five-year overall survival by stage was 100% for pt2> disease, 55% for pT3 disease and 0% for pt4 disease. Conclusions: LND can be performed safely and effectively in laparoscopic nephroureterectmy. Accurate node staging is mandatory for postoperative management.
V17
Laparoscopic dismembered pyeloplasty: Tips and tricks
Bagheri F.1, Domján Zs.2, Buzogány I.2, Pusztai Cs.3, Farkas L.3 1 Dubai Health Authority, Dubai Hospital, Dept. of Urology, Dubai, United Arab
Eur Urol Suppl 2011;10(2):348
Emirates, 2Péterfy Street Hospital, Dept. of Urology, Budapest, Hungary, 3University of Pécs Medical School, Dept. of Urology, Pécs, Hungary Introduction & Objectives: Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by either extrinsic or intrinsic pathology of this segment. The introduction of laparoscopy has allowed minimally invasive reconstructive surgery that can mimic open surgical techniques. However, in laparoscopic approach, some difficulties exist which makes the operation more challenging. Upon our experience and based on the literature review, we highlight some tips and tricks how to excise the UPJ segment, spatulate the ureter, perform precise anastomosis and stent the ureter. Materials & Methods: Between May 2004 and October 2010, 140 patients with symptomatic UPJ obstruction underwent laparoscopic repair in our departments. All patients were approached transperitoneally. In 128 cases, dismembered pyeloplasty with intracorporeal ureteropelvic anastomosis were performed with either interrupted or continuous sutures. In all of these cases ureteric stent was applied. At the beginning of our practice, retrograde stenting was used, which was replaced by a new method of antegrade stenting. Gradually, we modified and developed our technique. Results: Mean operative time was 120 minutes (80-240). Mean hospital stay was 3.7 days. We had 3 cases of conversion to open surgery because of inability of anastomosis due to chronic inflammation of the pyelon and tearing of the tissues. We had two postoperative complications. With a mean follow up period of 2.5 years, we have had 98% success rate in patients operated with dismembered pyeloplasty. Conclusions: Laparoscopic pyeloplasty in the hand of an experienced laparoscopic surgeon is safe and feasible. It has the advantages of minimal invasiveness; meanwhile, it is proved to have comparable results as the conventional open procedure. For the sake of time and better outcomes, establishment of a routine technique with precise manipulation and good technique of ureteral stenting is necessary.
V18
Transperitoneal laparoscopic dismembered pyeloplasty using 3mm instruments
Falsaperla M., Puglisi M., Lanza C., Saita A., Motta M. Polyclinic-Vittorio Emanuele Hospital, University of Catania, Dept. of Urology, Catania, Italy Introduction & Objectives: Our video shows a case of a female 15 years old patient affected by Pyeloureteral junction stenosis, treated by dismembered pyeloplasty performed by transperitoneal laparoscopic technique using minilaparoscopic 3mm Storz(R) instruments which came under our observation for symptomatic giant hydronephrosis as documented by uro-CT scan. Materials & Methods: The technique had been performed by placing an optical balloon trocar through the umbilicus, and two working 3mm trocars placed in the left pararectal line. The initial phase of the intervention was represented by the mobilization of the descending colon accessing the retroperitoneal space by using a laparoscopic hook defining the anatomical layers and the dissection of the voluminous renal pelvis and ureter from the surrounding tissues. Once an optimal dissection of the ureteropelvic junction had been achieved, we made a cold-knife incision on it, which had been also spatulated using a Ranfac needle in order to hang it and to remove its redundant part. We then made anastomosis between pelvis and ureter using four semi-continuous sutures. The rear wall suture was first applied, then we sutured the front wall. After that, we completed the pieloplasty after double-J stenting along a guide wire previously inserted by retrograde way. Results: We did not have neither intraoperative bleeding nor urinary leakage so the surgery ended without any drain placement. Conclusions: The use of the 3mm instruments made the procedure, especially for sutures, particularly easy since the ergonomic instruments allows to comfortably manage the 17 mm needle. The most important advantage is in aesthetic outcomes since we had not need to use stitches on the skin but adhesive strips. The umbilical optical port (10 mm) is useful to remove resected tissues.
V19
Robot assisted dismembered pyeloplasty: Multi-institutional outcomes
Sivaraman, A.1, Chauhan, S.1, Coelho, R.F.1, Palmer, K.J.1, Orvieto, M.1, Patel, V.R.1, Munver, R.2, Levilee, R.3, Rocco, B.4, Byrd, V.3 1 Global Robotics Institute, Dept. of Urology, Celebration, United States of America, 2 Hachensack University Medical Center, Dept. of Urology, Hackensack, United States of America, 3University of Miami, Dept. of Urology, Miami, United States of America, 4European Institute of Oncology, Dept. of Urology, Milan, Italy Introduction & Objectives: The video presents our technique of Robotic-Assisted Laparoscopic Dismembered Pyeloplasty (RALDP) for primary and secondary repair of UPJO. Materials & Methods: These have been dicussed in the video. Results: These have been discussed in the video. Conclusions: RALDP is a safe, efficacious and viable option for either primary or secondary repair of UPJO with excellent outcomes, high success rate, and a low incidence of complications.
V15
Microwaves laparoscopic-guided renal cancer ablation: Value on histopathology and haemostacy
Muto M.G.1, D'Urso D.L.1, Migliari M.R.1, Collura C.D.1, Giacobbe G.A.2, Coverlizza C.S.3, Demarchi D.A.3 1 St. Giovanni Bosco Hospital, Dept. of Urology, Turin, Italy, 2Mauriziano Hospital, Dept. of Urology, Turin, Italy, 3St. Giovanni Bosco Hospital, Dept. of Pathology, Turin, Italy Introduction & Objectives: The spread of ultrasound imaging has led to a dramatic increase of incidental small renal masses amenable to treatment. On the other hand, advancements in imaging has allowed the progressive expansion of minimally-invasive ablative techniques. Recently, Microwaves (MW) have been added to ablative armamentarium. MW’ termoablative effect causes cells death by inducing water’s molecules friction. Here we show the procedural steps and hystopathological results of MW’ laparoscopic-guided renal cancer ablation and tumor enucleation. Materials & Methods: Treatment of an emblematic case of a 46 YOM with a medical history of prior dorsal melanoma with ultrasound incidentally detected 3 cm renal mass was planned. This finding was confirmed by a staging CT-scan. Patient underwent laparoscopy-guided MW tumor ablation with MW’ antenna Evident ValleylabTM followed by tumor enucleation. Laparoscopy steps included preventive renal artery isolation, neoplasm deffatting and a pre-ablation trucut biopsy of tumor. MW antennas Evident ValleylabTM were applied from 1 to 3 times according to tumor volume and location in order to obtain the best ablative effect. After MW thermoablation, laparoscopic enucleation was performed with the purpose to evaluate MW hysto-pathologic effect and the haemostatic effect as well. Biopsy of the parenchyma surrounding the neoplasm was also performed. Results: Preablation pathology reported a Clear Cell Renal Carcinoma grading Fuhrman G1-2. Post-ablation pathology showed extensive coagulative necrosis without skipped tumor areas. Intra and postoperative complications were not reported, with particular regard to bleeding and anemia. Same results were obtained in a series of 10 patients. Conclusions: Laparoscopic MW thermoablation seems to be simple, rapid and effective allowing intraoperative monitoring of MW effect. MW make easier laparoscopic renal tumor enucleation providing an optimal haemostatic effect avoiding the need of stitching.
V16
Outcome of regional lymph node dissection in conjunction with laparoscopic nephroureterectomy for urothelial carcinoma of upper urinary tract
Sasaki H.S.1, Abe T.A.1, Harabayashi T.H.2, Shinohara N.S.1, Sazawa A.S.1, Maruyama S.M.1, Nonomura K.N.1 1 Hokkaido University Graduate School of Medicine, Dept. of Urology, Sapporo, Japan, 2Hokkaido Cancer Center, Dept. of Urology, Sapporo, Japan Introduction & Objectives: Focusing on accurate disease staging as well as potential therapeutic benefit, we routinely perform regional lymph node dissection (LND) in conjunction with laparoscopic nephroureterectomy (NU) in treatment of upper urinary tract (UUT) cancer. Our aim for the present study is to evaluate the ability of LND in laparoscopic NU. Materials & Methods: Thirty-nine patients undergoing laparoscopic NU with regional LND were included in the present study. We evaluated the number of lymph nodes resected, pathological node status, adverse event and the survival data. As for node count, we compared it with that of the 41 patients who underwent open NU between 1990 and 2008. Results: The median number of LNs removed was 10 (range, 2-59) for laparoscopic NU group, while 10 (range, 1-65) for open NU group (Mann-Whitney U test, p=0.82). Pathological examination revealed positive LNs in 4 patients (10.3%) and three of the four received adjuvant chemotherapy. Although chylous drain discharge was detected just after starting dietary intake in eight patients, it resolved without significant problem. Five-year overall survival by stage was 100% for pt2> disease, 55% for pT3 disease and 0% for pt4 disease. Conclusions: LND can be performed safely and effectively in laparoscopic nephroureterectmy. Accurate node staging is mandatory for postoperative management.
V17
Laparoscopic dismembered pyeloplasty: Tips and tricks
Bagheri F.1, Domján Zs.2, Buzogány I.2, Pusztai Cs.3, Farkas L.3 1 Dubai Health Authority, Dubai Hospital, Dept. of Urology, Dubai, United Arab
Eur Urol Suppl 2011;10(2):348
Emirates, 2Péterfy Street Hospital, Dept. of Urology, Budapest, Hungary, 3University of Pécs Medical School, Dept. of Urology, Pécs, Hungary Introduction & Objectives: Ureteropelvic junction (UPJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by either extrinsic or intrinsic pathology of this segment. The introduction of laparoscopy has allowed minimally invasive reconstructive surgery that can mimic open surgical techniques. However, in laparoscopic approach, some difficulties exist which makes the operation more challenging. Upon our experience and based on the literature review, we highlight some tips and tricks how to excise the UPJ segment, spatulate the ureter, perform precise anastomosis and stent the ureter. Materials & Methods: Between May 2004 and October 2010, 140 patients with symptomatic UPJ obstruction underwent laparoscopic repair in our departments. All patients were approached transperitoneally. In 128 cases, dismembered pyeloplasty with intracorporeal ureteropelvic anastomosis were performed with either interrupted or continuous sutures. In all of these cases ureteric stent was applied. At the beginning of our practice, retrograde stenting was used, which was replaced by a new method of antegrade stenting. Gradually, we modified and developed our technique. Results: Mean operative time was 120 minutes (80-240). Mean hospital stay was 3.7 days. We had 3 cases of conversion to open surgery because of inability of anastomosis due to chronic inflammation of the pyelon and tearing of the tissues. We had two postoperative complications. With a mean follow up period of 2.5 years, we have had 98% success rate in patients operated with dismembered pyeloplasty. Conclusions: Laparoscopic pyeloplasty in the hand of an experienced laparoscopic surgeon is safe and feasible. It has the advantages of minimal invasiveness; meanwhile, it is proved to have comparable results as the conventional open procedure. For the sake of time and better outcomes, establishment of a routine technique with precise manipulation and good technique of ureteral stenting is necessary.
V18
Transperitoneal laparoscopic dismembered pyeloplasty using 3mm instruments
Falsaperla M., Puglisi M., Lanza C., Saita A., Motta M. Polyclinic-Vittorio Emanuele Hospital, University of Catania, Dept. of Urology, Catania, Italy Introduction & Objectives: Our video shows a case of a female 15 years old patient affected by Pyeloureteral junction stenosis, treated by dismembered pyeloplasty performed by transperitoneal laparoscopic technique using minilaparoscopic 3mm Storz(R) instruments which came under our observation for symptomatic giant hydronephrosis as documented by uro-CT scan. Materials & Methods: The technique had been performed by placing an optical balloon trocar through the umbilicus, and two working 3mm trocars placed in the left pararectal line. The initial phase of the intervention was represented by the mobilization of the descending colon accessing the retroperitoneal space by using a laparoscopic hook defining the anatomical layers and the dissection of the voluminous renal pelvis and ureter from the surrounding tissues. Once an optimal dissection of the ureteropelvic junction had been achieved, we made a cold-knife incision on it, which had been also spatulated using a Ranfac needle in order to hang it and to remove its redundant part. We then made anastomosis between pelvis and ureter using four semi-continuous sutures. The rear wall suture was first applied, then we sutured the front wall. After that, we completed the pieloplasty after double-J stenting along a guide wire previously inserted by retrograde way. Results: We did not have neither intraoperative bleeding nor urinary leakage so the surgery ended without any drain placement. Conclusions: The use of the 3mm instruments made the procedure, especially for sutures, particularly easy since the ergonomic instruments allows to comfortably manage the 17 mm needle. The most important advantage is in aesthetic outcomes since we had not need to use stitches on the skin but adhesive strips. The umbilical optical port (10 mm) is useful to remove resected tissues.
V19
Robot assisted dismembered pyeloplasty: Multi-institutional outcomes
Sivaraman, A.1, Chauhan, S.1, Coelho, R.F.1, Palmer, K.J.1, Orvieto, M.1, Patel, V.R.1, Munver, R.2, Levilee, R.3, Rocco, B.4, Byrd, V.3 1 Global Robotics Institute, Dept. of Urology, Celebration, United States of America, 2 Hachensack University Medical Center, Dept. of Urology, Hackensack, United States of America, 3University of Miami, Dept. of Urology, Miami, United States of America, 4European Institute of Oncology, Dept. of Urology, Milan, Italy Introduction & Objectives: The video presents our technique of Robotic-Assisted Laparoscopic Dismembered Pyeloplasty (RALDP) for primary and secondary repair of UPJO. Materials & Methods: These have been dicussed in the video. Results: These have been discussed in the video. Conclusions: RALDP is a safe, efficacious and viable option for either primary or secondary repair of UPJO with excellent outcomes, high success rate, and a low incidence of complications.