V570 ROBOT-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION WITH EXCISIONAL TAILORING FOR REFLUXING MEGAURETER

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THE JOURNAL OF UROLOGY姞

pole ureter was found to enter the distal uretha. A robotic assisted laparoscopic ipsilateral ureteroureterostomy was performed. A ureteral stent was placed prior to the robotic portion of the procedure. Four ports were placed (three robotic ports and one assistant port). The ureters were identified as they coursed along the psoas muscle. They were dissected free from surrounding attachments. Traction sutures were placed within the upper pole ureter for manipulation. The upper pole ureter was divided and spatulated. A 2 cm ureterotomy was made in the lower pole ureter. The anastomosis was performed using 5-0 monocryl suture in the running fashion. The distal ectopic ureter was ligated at the level of the trigone and excised. A 7 mm round Jackson Pratt drain was left in place. RESULTS: The surgery was uncomplicated. The patient was discharged home on postoperative day 2 after an uneventful hospital stay. She was dry immediately after surgery. She continues to do well and is dry at 1 year of follow-up. CONCLUSIONS: Robotic surgical techniques can be successfully applied to management of ectopic ureter in a pediatric patient. Robotic assisted laparoscopic ipsilateral ureteroureterostomy is a minimally invasive surgery that has no need for bladder reconstruction, thus reducing post-operative bladder symptoms such as urge, frequency and spasms. Source of Funding: None

V570 ROBOT-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION WITH EXCISIONAL TAILORING FOR REFLUXING MEGAURETER Mark Faasse*, Bruce Lindgren, Edward Gong, Chicago, IL INTRODUCTION AND OBJECTIVES: In this video, we illustrate 3-port robot-assisted laparoscopic ureteral reimplantation with intracorporeal excisional tailoring of megaureter. Previously described minimally invasive techniques for this operation involved either extracorporeal ureteral tailoring or placement of additional laparoscopic ports. We also describe the use of CO2 laser for detrusorotomy during this procedure. METHODS: A 9 year-old boy was evaluated for primary enuresis and found to have right hydroureteronephrosis, Grade V vesicoureteral reflux, and 32% split function of the right kidney. Distally, the right ureteral diameter was 1.6 cm. The patientÆs family elected surgical intervention. Cystoscopy was performed, with insertion of a 6 Fr double-J right ureteral stent, and the patient was then taken out of lithotomy position and placed supine. Three laparoscopic ports were introduced. Unique features of our surgical technique include placement of ureteral stay sutures to permit freehand excision of redundant ureter without additional laparoscopic ports. The ureter was closed in a single layer, leaving the ureteral stent in place. CO2 laser (7W) was used for detrusorotomy. The distal ureter was anchored to adjacent detrusor muscle, and detrusorrhaphy was completed with absorbable sutures. RESULTS: Following ureteral stent removal, sonography demonstrated decreased hydroureteronephrosis, and VCUG confirmed resolution of vesicoureteral reflux. The patient is now asymptomatic. CONCLUSIONS: Minimally invasive approaches to ureteral reimplantation with excisional tailoring have previously been described, both using standard laparoscopy as well as robotic technology. To our knowledge, this is the first description of intracorporeal tailoring via just three laparoscopic ports. Use of fewer ports reduces risks associated with trocar introduction, port-site complications, and cosmetic impact. CO2 laser facilitates precise and hemostatic detrusorotomy; compared to electrocautery, we believe it reduces the risk of bladder mucosal injury and urine leak. Animal studies have demonstrated that it causes less collateral tissue damage. We routinely utilize supine position for robotic ureteral reimplantation, which has a lower risk of neurovascular complications than lithotomy. The technique described in this video is

Vol. 189, No. 4S, Supplement, Sunday, May 5, 2013

also applicable to reimplantation of obstructed megaureters, with the additional requirements of dismembering the ureter, excising the stenotic segment, and reanastomosis. Source of Funding: None

V571 PUMP IRRIGATION AS AN ADJUNCT TO ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX: A BETTER WAY TO A “HAPPY HIT” Brian T. Caldwell*, Jonathan J. Melquist, Kevin T. Gioia, Stony Brook, NY; Thomas J. Forest, Lafayette, LA; Robert J. Wasnick, Stony Brook, NY INTRODUCTION AND OBJECTIVES: Vesicoureteral reflux (VUR) affects up to 1% of children. While there is some controversy in regard to intervention, endoscopic submucosal intra-ureteric injection of Deflux™ (dextranomer/hyaluronic copolymer) has been shown to have high success rates and durable results. Modifications to initial STING (subureteric injection of Teflon) has led to better coaptation of the ureteral tunnel with the HIT (hydrodistention implantation technique) and the Double HIT procedures. We present a modification to hydrodistention that addresses some of the difficulties such as rapid bladder filling during HIT procedures. METHODS: Intermittent pump irrigation with the Single Action Pumping System (SAPS™, Boston Scientific, Natick, MA) was used to attain hydrodistention of the intramural ureter for HIT/Double HIT injection of Deflux™. RESULTS: Hydrodistention of the intramural ureter was obtained with this modality to facilitate visualization of the intramural ureter. This allowed visual identification of the optimal injection site of HIT/Double HIT in a controlled fashion. CONCLUSIONS: We present a modification to the hydrodistention aspect of HIT technique that addresses some of the challenges of continuous irrigation in patients with small bladder capacity. Intermittent pump irrigation provides greater control of ureteral hydrodistention while preventing bladder overdistention. This allows the ability to visually evaluate treatment progress of the intramural ureter throughout the injection process. Future studies could focus on the role of contrast infusion via pump irrigation with fluoroscopy to further evaluate efficacy at completion of endoscopic treatment of VUR. Source of Funding: None

V572 ROBOTIC NEPHROLITHOTOMY AND PYELOLITHOTOMY WITH UTILIZATION OF THE ROBOTIC ULTRASOUND PROBE Khurshid Ghani*, Quoc Dien-Trinh, Wooju Jeong, Ariella Friedman, Yegappan Lakshmanan, Jack Elder, Detroit, MI INTRODUCTION AND OBJECTIVES: The treatment of large renal stones in children can be difficult often requiring combination therapy and multiple procedures. Recent advances in robotic instrumentation have expanded the limits of robotic surgery. The aims of this study are to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. METHODS: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. RESULTS: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. The robotic ultrasound probe aided identification of calculi within the kidney. For nephrolithotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a