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VE01: Robot-assisted ureteral reimplantation using the psoas hitch technique – important surgical steps
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O R A L P R E S E N T A T I O N S / E U R O P E A N U R O L O G Y S U P P L E M E N T S 13 (2014) 1—60
Material & Methods: Materials and Methods: 40 Patients with a Briganti nomogram-based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and SPECT-CT). In groups 1 and 2 intraoperatively SNs were pursued using a laparoscopic gamma probe (LGP) followed by fluorescence imaging (FI). In group 3 SNs were initially located via FI. Compared to group 1, in groups 2 and 3 a new tracer-formulation was introduced with a reduced total injected volume (2.0 mL vs. 3.2 mL), but increased particle concentration. For groups 1 and 2 the Tricam SL II + D-light C laparoscopic fluorescence imaging (LFI) system was used. In group 3 the LFI-system was upgraded to an Image 1 HUB HD + D-light P system. Results: Results: SPECT-CT images were taken as a starting point for SN biopsy. In group 1 we identified a mean of 50% of the SNs based on their fluorescent signature. Improvement of the hybrid tracer preparation and the injection technique resulted in a visualization rate of 64% in group 2. The introduction of the new fluorescence detection system increased the visualization rate to 93% in group 3. A KruskalWallis test showed a significant difference in the fluorescence visualization rate between the groups (p=0.004). Biochemical recurrence occurred in three patients in group 1 and 2 and in zero patients in group 3, suggesting that better nodal staging was achieved in group 3 with the optimized SN identification protocol. Conclusions: Conclusion: With different steps of improvement, the in vivo fluorescence detection in SNs during RARP + SN biopsy could be significantly enhanced. Although we showed a high fluorescence visualization rate in group 3, still SPECT-CT is used for the rough localization of the SNs in prostate cancer patients.
ERUS – Video abstracts VE01 Robot-assisted ureteral reimplantation using the psoas hitch technique – important surgical steps M. Musch, J.L. Hohenhorst, M. Janowski, A. Pailliart, M. Vanberg, D. Kroepfl. Kliniken Essen-Mitte, Dept. of Urology, Essen, Germany Introduction & Objectives: We present the most important steps of robot-assisted ureteral reimplantation using the psoas hitch technique (RAURI). In addition, the results of our RAURI series are described. Material & Methods: Between October 2009 and May 2013 RAURI was performed in 14 patients (in combination with a Boari flap in 5 patients) with benign or malign lesions of the distal part of the ureter. The patient and surgical data were collected prospectively. Follow-up was accomplished using standardized questionnaires that were sent to the patients. Results: Resection of the distal ureter was necessary due to urothelial carcinoma in 5 patients, ureteric stricture caused by advanced prostate cancer in 2 patients, ureteric stricture caused by an inflammatory conglomerate tumour of the adnexa in 1 patient, and iatrogenic ureteric stricture following gynecologic or urologic surgery in 6 patients. RAURI can be divided into the following important steps, which are illustrated in our video: 1) mobilization of the bladder, 2) preparation of the ureter, 3) fixation of the bladder on the psoas muscle, 4) opening of the bladder, 5) formation of a submucosal tunnel, 6) tension-free vesico-ureteric anastomosis and ureteric stenting, 7) closure of the bladder. The median operative duration (including docking and undocking of the robot) was 227.5 min. There were no intraoperative complications. Postoperative complications according to the Clavien-Dindo classification occurred in 10 patients within 90 days after surgery; 9 patients experienced minor complications (grade I–II), and 1 patient a major complication (grade IIIb). The median postoperative length of stay was 8 days. All patients re-
mained asymptomatic during a median follow-up of 13.42 months. In 1 patient an asymptomatic short stricture on the site of ureterovesical anastomosis was identified radiographically and subsequently underwent successful endoscopic incision. Conclusions: RAURI showed good surgical results in our patient population and thus seems to be a reliableminimal invasive alternative to open surgery. We feel that following the general principles of open surgery during important surgical steps of RAURI was a major factor for these successful outcomes. VE02 Robot-assisted en-bloc radical cystectomy with nephroureterectomy and intracorporal urinary diversion by seven patients with muscle-invasive bladder cancer and upper urinary tract urothelial cell carcinoma. Single-center experience J. Krude, A. Alexandrov, P. Lund, C. Hach, A. Goell. Alfried Krupp Krankenhaus, Dept. of Urology, Essen, Germany Introduction & Objectives: In this video we describe step-by-step our technique of robot-assisted en-bloc radical cystectomy with nephroureterectomy and intracorporal urinary diversion in seven patients with the diagnosis of muscle-invasive bladder cancer and synchronius upper urinary tract urothelial cell carcinoma. We also show important bench-marks of this procedure. This video shows in detail all steps of the procedure from port placement (seven-port transperitoneal approach) over the ablative steps (bladder and kidney resection and pelvic lymph node dissection) to the fully intracorporal robot-assisted reconstruction. Material & Methods: After informed consent, we assessed 7 patients undergoing an en-bloc radical cystectomy and nephroureterectomy at Alfried Krupp Hospital, Germany. All procedures were performed by one surgeon. We primarily assessed surgery and console duration, conversion rate, blood loss, intraoperative transfusion, and resection status. Secondary endpoints were postoperative transfusions as well as intra- and postoperative complications. Results: Three of the patients were male. Median age was 75.14 years (64–84), the mean BMI was 27.98 kg/m2 (22–34). Two of the patients were ASA 2, four ASA 3 and one ASA 4. The indication for an en-bloc radical cystectomy and nephroureterectomy was diagnosis of a simultaneous transitional cell cancer of the lower and upper urinary tract in three patients. The other four patients had a muscle-invasive bladder cancer and a functionless kidney. Urinary diversion was reconstructed as intracorporal ureterocutaneostomy in six and as extracorporal ileum conduit in one patient. Surgery lasted 296.85 min, thereof 199.71 min console time on average. There was no need of a conversion to open surgery. The mean blood loss was 238 ml and none of the patients required blood transfusions. Resection margins were tumor-free in six cases. In the patient with positive resection margins the tumor stage was pT4a. Postoperative complications occurred in two of the patients: paralytic Ileus (Clavien-Dindo class 1 (CDC 1) in one patient and port hernia (CDC 3b) in the other patient. Conclusions: Robot-assisted en-bloc radical cystectomy and nephroureterectomy could be performed with acceptable surgery durations with a high intraoperatively and postoperatively safety. Further surgeries have to be performed to evaluate functional and oncologic results. VE03 Robotic flexible ureteroscopy, safety, effectivity and a early results J. Rassweiler 1 , R. Saglam 2 , A.S. Kabakci 3 . 1 SLK-Kliniken Heilbronn GmbH, Dept. of Urology, Heilbronn, Germany; 2 Medicana International Ankara Hospital, Dept. of Urology, Ankara, Turkey; 3 Hacettepe University, Dept. of Bioengineering, Ankara, Turkey Introduction & Objectives: Flexible ureterorenoscopy (FURS) or retrograde intrarenal surgery are rapidly evolving in the last decade
O R A L P R E S E N T A T I O N S / E U R O P E A N U R O L O G Y S U P P L E M E N T S 13 (2014) 1—60
Material & Methods: Materials and Methods: 40 Patients with a Briganti nomogram-based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and SPECT-CT). In groups 1 and 2 intraoperatively SNs were pursued using a laparoscopic gamma probe (LGP) followed by fluorescence imaging (FI). In group 3 SNs were initially located via FI. Compared to group 1, in groups 2 and 3 a new tracer-formulation was introduced with a reduced total injected volume (2.0 mL vs. 3.2 mL), but increased particle concentration. For groups 1 and 2 the Tricam SL II + D-light C laparoscopic fluorescence imaging (LFI) system was used. In group 3 the LFI-system was upgraded to an Image 1 HUB HD + D-light P system. Results: Results: SPECT-CT images were taken as a starting point for SN biopsy. In group 1 we identified a mean of 50% of the SNs based on their fluorescent signature. Improvement of the hybrid tracer preparation and the injection technique resulted in a visualization rate of 64% in group 2. The introduction of the new fluorescence detection system increased the visualization rate to 93% in group 3. A KruskalWallis test showed a significant difference in the fluorescence visualization rate between the groups (p=0.004). Biochemical recurrence occurred in three patients in group 1 and 2 and in zero patients in group 3, suggesting that better nodal staging was achieved in group 3 with the optimized SN identification protocol. Conclusions: Conclusion: With different steps of improvement, the in vivo fluorescence detection in SNs during RARP + SN biopsy could be significantly enhanced. Although we showed a high fluorescence visualization rate in group 3, still SPECT-CT is used for the rough localization of the SNs in prostate cancer patients.
ERUS – Video abstracts VE01 Robot-assisted ureteral reimplantation using the psoas hitch technique – important surgical steps M. Musch, J.L. Hohenhorst, M. Janowski, A. Pailliart, M. Vanberg, D. Kroepfl. Kliniken Essen-Mitte, Dept. of Urology, Essen, Germany Introduction & Objectives: We present the most important steps of robot-assisted ureteral reimplantation using the psoas hitch technique (RAURI). In addition, the results of our RAURI series are described. Material & Methods: Between October 2009 and May 2013 RAURI was performed in 14 patients (in combination with a Boari flap in 5 patients) with benign or malign lesions of the distal part of the ureter. The patient and surgical data were collected prospectively. Follow-up was accomplished using standardized questionnaires that were sent to the patients. Results: Resection of the distal ureter was necessary due to urothelial carcinoma in 5 patients, ureteric stricture caused by advanced prostate cancer in 2 patients, ureteric stricture caused by an inflammatory conglomerate tumour of the adnexa in 1 patient, and iatrogenic ureteric stricture following gynecologic or urologic surgery in 6 patients. RAURI can be divided into the following important steps, which are illustrated in our video: 1) mobilization of the bladder, 2) preparation of the ureter, 3) fixation of the bladder on the psoas muscle, 4) opening of the bladder, 5) formation of a submucosal tunnel, 6) tension-free vesico-ureteric anastomosis and ureteric stenting, 7) closure of the bladder. The median operative duration (including docking and undocking of the robot) was 227.5 min. There were no intraoperative complications. Postoperative complications according to the Clavien-Dindo classification occurred in 10 patients within 90 days after surgery; 9 patients experienced minor complications (grade I–II), and 1 patient a major complication (grade IIIb). The median postoperative length of stay was 8 days. All patients re-
mained asymptomatic during a median follow-up of 13.42 months. In 1 patient an asymptomatic short stricture on the site of ureterovesical anastomosis was identified radiographically and subsequently underwent successful endoscopic incision. Conclusions: RAURI showed good surgical results in our patient population and thus seems to be a reliableminimal invasive alternative to open surgery. We feel that following the general principles of open surgery during important surgical steps of RAURI was a major factor for these successful outcomes. VE02 Robot-assisted en-bloc radical cystectomy with nephroureterectomy and intracorporal urinary diversion by seven patients with muscle-invasive bladder cancer and upper urinary tract urothelial cell carcinoma. Single-center experience J. Krude, A. Alexandrov, P. Lund, C. Hach, A. Goell. Alfried Krupp Krankenhaus, Dept. of Urology, Essen, Germany Introduction & Objectives: In this video we describe step-by-step our technique of robot-assisted en-bloc radical cystectomy with nephroureterectomy and intracorporal urinary diversion in seven patients with the diagnosis of muscle-invasive bladder cancer and synchronius upper urinary tract urothelial cell carcinoma. We also show important bench-marks of this procedure. This video shows in detail all steps of the procedure from port placement (seven-port transperitoneal approach) over the ablative steps (bladder and kidney resection and pelvic lymph node dissection) to the fully intracorporal robot-assisted reconstruction. Material & Methods: After informed consent, we assessed 7 patients undergoing an en-bloc radical cystectomy and nephroureterectomy at Alfried Krupp Hospital, Germany. All procedures were performed by one surgeon. We primarily assessed surgery and console duration, conversion rate, blood loss, intraoperative transfusion, and resection status. Secondary endpoints were postoperative transfusions as well as intra- and postoperative complications. Results: Three of the patients were male. Median age was 75.14 years (64–84), the mean BMI was 27.98 kg/m2 (22–34). Two of the patients were ASA 2, four ASA 3 and one ASA 4. The indication for an en-bloc radical cystectomy and nephroureterectomy was diagnosis of a simultaneous transitional cell cancer of the lower and upper urinary tract in three patients. The other four patients had a muscle-invasive bladder cancer and a functionless kidney. Urinary diversion was reconstructed as intracorporal ureterocutaneostomy in six and as extracorporal ileum conduit in one patient. Surgery lasted 296.85 min, thereof 199.71 min console time on average. There was no need of a conversion to open surgery. The mean blood loss was 238 ml and none of the patients required blood transfusions. Resection margins were tumor-free in six cases. In the patient with positive resection margins the tumor stage was pT4a. Postoperative complications occurred in two of the patients: paralytic Ileus (Clavien-Dindo class 1 (CDC 1) in one patient and port hernia (CDC 3b) in the other patient. Conclusions: Robot-assisted en-bloc radical cystectomy and nephroureterectomy could be performed with acceptable surgery durations with a high intraoperatively and postoperatively safety. Further surgeries have to be performed to evaluate functional and oncologic results. VE03 Robotic flexible ureteroscopy, safety, effectivity and a early results J. Rassweiler 1 , R. Saglam 2 , A.S. Kabakci 3 . 1 SLK-Kliniken Heilbronn GmbH, Dept. of Urology, Heilbronn, Germany; 2 Medicana International Ankara Hospital, Dept. of Urology, Ankara, Turkey; 3 Hacettepe University, Dept. of Bioengineering, Ankara, Turkey Introduction & Objectives: Flexible ureterorenoscopy (FURS) or retrograde intrarenal surgery are rapidly evolving in the last decade