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VID-09.04 Endoscopic Treatment of Fibroepithelial Polyp of the Ureter
VIDEO SESSIONS
Video Session 9 Adrenal, Kidney and Miscellaneous Wednesday, October 19 13:15-14:45 VID-09.01 Advantages of Single Optical Port in Laparoscopic Bilateral Adrenalectomy Cepeda Delgado M, Amón Sesmero J, Conde Redondo C, Rodríguez Tesedo V, Ruiz Serrano M, García Velandria F, Martínez-Sagarra J Hospital Universitario Rio Hortega, Valladolid, Spain Introduction and Objective: The removal of the adrenal gland under laparoscopy is the gold-standard treatment in benign tumor pathology, leaving the technical challenge in this regard limited to the size of the lesion, presence or absence of bilateral illness and skills of the surgeons. We show in this video a case of a obese female patient aged 46, with a clinical diagnosis of Cushing’s Syndrome, CT images of bilateral adrenal gland volume increase, who is operated in a bilateral laparoscopic approach as an option therapy with a single optical port. Materials and Methods: The beginning surgery carried out in right lateral decubitus by 4 laparoscopic ports, with the alternative 12mm optical port located midline upper umbilical scare in order to use the Endo-Eye® flexible laparoscope (Olympus), performing right adrenalectomy with operating time of 55 min. After turning the patient to the left lateral side, three additional ports are placed and surgery proceeds with the same performance on the left side, in a time of 63 minutes. Conclusions: The use of new instrumental devices such as vision Endo-Eye® flexible laparoscope (Olympus®) to optimize the surgical resection, improved aesthetics results by reducing the number of ports (only 7), maintaining the efficacy and safety in the procedure.
VID-09.02 Robotic Pyelolithotomy and Pyeloplasty in Horseshoe Kidneys D’Elia G, Emiliozzi P, Ortolani G, Iannello A, Tuffu G San Giovanni Hospital, Rome, Italy Introduction and Objective: One of the more challenging situations when consid-
S182
ering pyeloplasty and pyelolithotomy is the presence of a horseshoe kidney. We describe our technique of robotic pyelolithotomy and pyeloplasty in two patients with a horseshoe kidney. Materials and Methods: A 34-year-old woman with a 2cm pelvic stone and UPJ obstruction in the left hemisystem of a horseshoe kidney and a 58-year old male with two stones, respectively 5cm in the pelvis with ramification in the lower calyx and 3cm in the upper calyx of the left hemisystem of a horseshoe kidney. A transperitoneal four-port approach is used. In these cases we do not use the fourth arm. We identify and prepare the ureter up into the dilated renal pelvis. In a horseshoe kidney the left gonadal vein crosses the UPJ and is therefore divided. The renal pelvis is isolated and then opened. The stones are found and extracted. The redundant pelvis is excised. The ureter is spatulated on its posterior side. A running suture is performed for the posterior aspect of the pelvi-ureteric anastomosis. A 6 French JJ stent is introduced in an antegrade manner through the assistant port. The anterior aspect of the anastomosis is then completed with a running suture. Results: In both cases we did not consider necessary the division of the isthmus. We did not observe perioperative complications. Operative time was 148 and 105 minutes respectively, estimated blood loss was negligible and hospital stay was 3 days in both cases. The patients had durable clinical and radiographic success at 6 months. Conclusions: The indications for roboticassisted pyeloplasty and pyelolithotomy can be extended to anatomically challenging cases such as patients with horseshoe kidneys. Robotics allow surgeons to perform these complex procedures safely and effectively.
VID-09.03 Laparoscopic Exeresis of Large Ureterocele, Megaureter and Hydronephrotic Kidney Felip Santamaría N, Del Río Andreu M, Begara Morillas F, García Paños J, Madridgarcía F Dept. of Urology, Hospital Del Sureste, Madrid, Spain Introduction and Objective: We present a video of laparoscopic exeresis of a large ureterocele and a hydronephrotic kidney. Materials and Methods: We report the case of a 31-year-old patient with history
of right cryptorchidism surgery, consulting about right testicular pain and marked urinary frequency. The study detected hydronephrotic right kidney with megaureter associated with a large blind ureterocele that reaches the verumontanum along the prostatic urethra. We show a video about laparoscopic surgery of this case. At the fist part of the surgery the patient is placed in left lateral decubitus. After the nephrectomy we change the patient position and he is placed in supine. We continue opening parietal peritoneum and dissecting the ureterocele. We open the bladder mucosa adjacent to the ureterocele for controlling the left meatus and for helping during the dissection. Due to the size and arrangement of the ureterocele that reaches the area of the urethral sphincter, we decide to open the ureterocele and leave it open within the bladder. Results: Postoperative course was satisfactory and postoperative hospital stay was two days. Conclusions: The surgery of an ureterocele in adults is uncommon. There are few cases of laparoscopic exeresis of an ureterocele and we present our experience in one of them.
VID-09.04 Endoscopic Treatment of Fibroepithelial Polyp of the Ureter Garcia-Rojo D1, Tremps E1, Ramon M1, Ramirez C, Garcia-Artero N2, Moreno-Artero L3 1 Dept. of Urology, Hospital San Rafael, Barcelona, Spain; 2University of Granada, 3Escola Universitaria Blanquerna, Barcelona, Spain Introduction and Objectives: Fibroepithelial polyps are benign mesenchymal tumors with a morphology and clinical presentation very similar to transitional cell carcinomas, so that differential diagnosis is of paramount importance. Material and Methods: We present the case of a 72-year-old female patient, with history of breast cancer, which came to the office reporting urgency. Ultrasonography showed a bladder neoformation of about 1.7cm. Cystoscopy revealed a ureteral tumour, and that the polyp was moving forward and backward in the right ureteric orifice. Results: A right rigid ureteroscopy was performed and showed a neoformation, about 5cm long, originated in the pelvic ureter, with a pediculated base of insertion and ureteral stenosis. We decided to resect the pedicle and to perform a com-
UROLOGY 78 (Supplement 3A), September 2011
POSTER PRESENTATION
plete tumour extraction. The area resected was revised, a biopsy of implantation bed was performed, and a right double-J catheter was placed. The histopathological study confirmed the diagnostic suspicion of fibroepithelial polyp. An intravenous control urography was performed at two months after surgery with no repletion defects or areas of secondary stenosis found. After 10 years of followup, the patient was free of recurrence. Conclusions: Benign primitive non-epithelial tumours account for only 5% to 10% of urinary tract tumours, and the fibroepithelial polyp is the most frequent of them all. A differential diagnosis between fibroepithelial polyp and transitional cell carcinoma cannot be made with imaging tests alone. The suspicion must be established, and endoscopic exploration indicated, by means of ureterorenoscopy or percutaneous nephroureteroscopy, whatever is a better indication, with biopsy or definitive endoscopic treatment of the tumor.
VID-09.05 Minilaparoscopy for the Treatment of Pyeloureteral Junction Stenosis Falsaperla M, Puglisi M, Lanza C, Saita A, Motta M, Morgia G Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, Catania, Italy Introduction and Objectives: Our video shows a case of a female 15-year-old patient affected by pyeloureteral junction stenosis, treated by dismembered pyeloplasty performed by transperitoneal laparoscopic technique using minilaparoscopic 3mm Storz® instruments which came under our observation for symptomatic giant hydronephrosis as documented by uro-CT scan. Material and 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 pyeloplasty after double-J stenting along a guide wire previously inserted by retrograde way. Results: We had 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 allow to comfortably manage the 17mm needle. The most important advantage is in aesthetic outcomes since we had no need to use stitches on the skin but adhesive strips. The umbilical optical port (10mm) is useful to remove resected tissues.
VID-09.06 Laparoscopic Varicocelectomy Using Bipolar Cautery Versus Open Inguinal Technique: A Randomized Clinical Trial Karami H, Tabrizi A Urology Ward, Shahid Beheshti Tehran University Shohada Hospital, Tehran, Iran Introduction and Objective: The aim of this investigation was to compare laparoscopic management of varicocele using bipolar cautery with open inguinal technique. Materials and Methods: A total of 220 infertile men underwent laparoscopic and open inguinal technique varicocelectomy. To evaluate the clinical efficiency of the treatment, the patients were divided randomly into two groups. Laparoscopic varicocelectomy (LV) was performed on 100 patients, and open varicocelectomy (OV) was performed on 100 patients. In both groups, operating time, relapse rate, hydrocele formation, hospital stay, and pain control were evaluated. Results: Operative time was 17 minutes in LV versus 15 minutes; in OV (P ⫽ .00). Relapse rates were 6% in LV and 12% in OV (P ⬎ 0.05), hydrocele occurrence was 10%in LV versus 20% OV (P ⬎ 0.05), and hospital stay was an average of 6 hours in LV and12 hours in OV. Postoperative analgesic use was 2.5 ⫹/⫺ 0.4mg in LV versus 3.5 ⫹/⫺ 0.5mg in OV (P ⬎ 0.05). Conclusions: In comparison with open varicocelectomy, laparoscopy has better outcome, shorter hospital stay, lower pain, fewer relapses and hydrocele formation low pain.
UROLOGY 78 (Supplement 3A), September 2011
VID-09.07 Bipolar Plasma Vaporization of Secondary Bladder Neck Sclerosis Geavlete B, Multescu R, Stanescu F, Georgescu D, Jecu M, Moldoveanu C, Geavlete P “Saint John” Emergency Clinical Hospital, Bucharest, Romania Introduction and Objectives: This trial aimed to assess the therapeutic efficiency, overall safety and short-term postoperative results of bipolar plasma vaporization (BPV) in cases of secondary bladder neck sclerosis (BNS). A prospective, randomized comparison to the standard monopolar transurethral resection TUR was also performed. Materials and Methods: A total of 60 patients (mean age of 72) with BNS secondary to TURP (41 cases), to open surgery for BPH (open prostatectomy – 14 cases) and to radical prostatectomy for prostate cancer (5 cases) were enrolled in the trial. The inclusion criteria consisted of Qmax ⬍ 10 ml/s and IPSS ⬎19. All patients were evaluated preoperatively and at 1, 3 and 6 months after surgery by International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and post-voiding residual urinary volume (RV). Results: Similar preoperative parameters were determined for patients from both series. BPV and TUR were successfully performed in all cases (30 patients each). The mean operative time, catheterization period and hospital stay were significantly reduced in the BPV series (16.5 versus 27 minutes, 18 versus 46.5 hours and 34.5 versus 73 hours). Capsular perforation only occurred in 2 cases of the TUR study arm, while the rate of irritative symptoms was similar in the 2 series (13.3% versus 16.7%). The 1, 3 and 6 months’ follow-up emphasized superior parameters for the BPV group by comparison to the TUR group in terms of IPSS (3.4 versus 6.3, 3.6 versus 6.5 and 3.7 versus 6.8, respectively) and Qmax (23.8 versus 21.1 ml/s, 23.7 versus 20.6 ml/s and 23.0 versus 20.7 ml/s, respectively). At the same time intervals, QoL was also significantly improved in the BPV arm (1.2 versus 1.4, 1.4 versus 1.6 and 1.4 versus 1.7), while no significant differences were established in terms of RV between the 2 series. Only 2 patients of the TUR group required re-treatment during the follow-up period. Conclusions: BPV constitutes a valuable endoscopic treatment alternative for secondary BNS. In a randomized analysis, the method emphasized superior efficacy, a satisfactory safety profile and significantly improved short-term follow-up parameters by comparison to the standard TUR.
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Video Session 9 Adrenal, Kidney and Miscellaneous Wednesday, October 19 13:15-14:45 VID-09.01 Advantages of Single Optical Port in Laparoscopic Bilateral Adrenalectomy Cepeda Delgado M, Amón Sesmero J, Conde Redondo C, Rodríguez Tesedo V, Ruiz Serrano M, García Velandria F, Martínez-Sagarra J Hospital Universitario Rio Hortega, Valladolid, Spain Introduction and Objective: The removal of the adrenal gland under laparoscopy is the gold-standard treatment in benign tumor pathology, leaving the technical challenge in this regard limited to the size of the lesion, presence or absence of bilateral illness and skills of the surgeons. We show in this video a case of a obese female patient aged 46, with a clinical diagnosis of Cushing’s Syndrome, CT images of bilateral adrenal gland volume increase, who is operated in a bilateral laparoscopic approach as an option therapy with a single optical port. Materials and Methods: The beginning surgery carried out in right lateral decubitus by 4 laparoscopic ports, with the alternative 12mm optical port located midline upper umbilical scare in order to use the Endo-Eye® flexible laparoscope (Olympus), performing right adrenalectomy with operating time of 55 min. After turning the patient to the left lateral side, three additional ports are placed and surgery proceeds with the same performance on the left side, in a time of 63 minutes. Conclusions: The use of new instrumental devices such as vision Endo-Eye® flexible laparoscope (Olympus®) to optimize the surgical resection, improved aesthetics results by reducing the number of ports (only 7), maintaining the efficacy and safety in the procedure.
VID-09.02 Robotic Pyelolithotomy and Pyeloplasty in Horseshoe Kidneys D’Elia G, Emiliozzi P, Ortolani G, Iannello A, Tuffu G San Giovanni Hospital, Rome, Italy Introduction and Objective: One of the more challenging situations when consid-
S182
ering pyeloplasty and pyelolithotomy is the presence of a horseshoe kidney. We describe our technique of robotic pyelolithotomy and pyeloplasty in two patients with a horseshoe kidney. Materials and Methods: A 34-year-old woman with a 2cm pelvic stone and UPJ obstruction in the left hemisystem of a horseshoe kidney and a 58-year old male with two stones, respectively 5cm in the pelvis with ramification in the lower calyx and 3cm in the upper calyx of the left hemisystem of a horseshoe kidney. A transperitoneal four-port approach is used. In these cases we do not use the fourth arm. We identify and prepare the ureter up into the dilated renal pelvis. In a horseshoe kidney the left gonadal vein crosses the UPJ and is therefore divided. The renal pelvis is isolated and then opened. The stones are found and extracted. The redundant pelvis is excised. The ureter is spatulated on its posterior side. A running suture is performed for the posterior aspect of the pelvi-ureteric anastomosis. A 6 French JJ stent is introduced in an antegrade manner through the assistant port. The anterior aspect of the anastomosis is then completed with a running suture. Results: In both cases we did not consider necessary the division of the isthmus. We did not observe perioperative complications. Operative time was 148 and 105 minutes respectively, estimated blood loss was negligible and hospital stay was 3 days in both cases. The patients had durable clinical and radiographic success at 6 months. Conclusions: The indications for roboticassisted pyeloplasty and pyelolithotomy can be extended to anatomically challenging cases such as patients with horseshoe kidneys. Robotics allow surgeons to perform these complex procedures safely and effectively.
VID-09.03 Laparoscopic Exeresis of Large Ureterocele, Megaureter and Hydronephrotic Kidney Felip Santamaría N, Del Río Andreu M, Begara Morillas F, García Paños J, Madridgarcía F Dept. of Urology, Hospital Del Sureste, Madrid, Spain Introduction and Objective: We present a video of laparoscopic exeresis of a large ureterocele and a hydronephrotic kidney. Materials and Methods: We report the case of a 31-year-old patient with history
of right cryptorchidism surgery, consulting about right testicular pain and marked urinary frequency. The study detected hydronephrotic right kidney with megaureter associated with a large blind ureterocele that reaches the verumontanum along the prostatic urethra. We show a video about laparoscopic surgery of this case. At the fist part of the surgery the patient is placed in left lateral decubitus. After the nephrectomy we change the patient position and he is placed in supine. We continue opening parietal peritoneum and dissecting the ureterocele. We open the bladder mucosa adjacent to the ureterocele for controlling the left meatus and for helping during the dissection. Due to the size and arrangement of the ureterocele that reaches the area of the urethral sphincter, we decide to open the ureterocele and leave it open within the bladder. Results: Postoperative course was satisfactory and postoperative hospital stay was two days. Conclusions: The surgery of an ureterocele in adults is uncommon. There are few cases of laparoscopic exeresis of an ureterocele and we present our experience in one of them.
VID-09.04 Endoscopic Treatment of Fibroepithelial Polyp of the Ureter Garcia-Rojo D1, Tremps E1, Ramon M1, Ramirez C, Garcia-Artero N2, Moreno-Artero L3 1 Dept. of Urology, Hospital San Rafael, Barcelona, Spain; 2University of Granada, 3Escola Universitaria Blanquerna, Barcelona, Spain Introduction and Objectives: Fibroepithelial polyps are benign mesenchymal tumors with a morphology and clinical presentation very similar to transitional cell carcinomas, so that differential diagnosis is of paramount importance. Material and Methods: We present the case of a 72-year-old female patient, with history of breast cancer, which came to the office reporting urgency. Ultrasonography showed a bladder neoformation of about 1.7cm. Cystoscopy revealed a ureteral tumour, and that the polyp was moving forward and backward in the right ureteric orifice. Results: A right rigid ureteroscopy was performed and showed a neoformation, about 5cm long, originated in the pelvic ureter, with a pediculated base of insertion and ureteral stenosis. We decided to resect the pedicle and to perform a com-
UROLOGY 78 (Supplement 3A), September 2011
POSTER PRESENTATION
plete tumour extraction. The area resected was revised, a biopsy of implantation bed was performed, and a right double-J catheter was placed. The histopathological study confirmed the diagnostic suspicion of fibroepithelial polyp. An intravenous control urography was performed at two months after surgery with no repletion defects or areas of secondary stenosis found. After 10 years of followup, the patient was free of recurrence. Conclusions: Benign primitive non-epithelial tumours account for only 5% to 10% of urinary tract tumours, and the fibroepithelial polyp is the most frequent of them all. A differential diagnosis between fibroepithelial polyp and transitional cell carcinoma cannot be made with imaging tests alone. The suspicion must be established, and endoscopic exploration indicated, by means of ureterorenoscopy or percutaneous nephroureteroscopy, whatever is a better indication, with biopsy or definitive endoscopic treatment of the tumor.
VID-09.05 Minilaparoscopy for the Treatment of Pyeloureteral Junction Stenosis Falsaperla M, Puglisi M, Lanza C, Saita A, Motta M, Morgia G Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, Catania, Italy Introduction and Objectives: Our video shows a case of a female 15-year-old patient affected by pyeloureteral junction stenosis, treated by dismembered pyeloplasty performed by transperitoneal laparoscopic technique using minilaparoscopic 3mm Storz® instruments which came under our observation for symptomatic giant hydronephrosis as documented by uro-CT scan. Material and 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 pyeloplasty after double-J stenting along a guide wire previously inserted by retrograde way. Results: We had 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 allow to comfortably manage the 17mm needle. The most important advantage is in aesthetic outcomes since we had no need to use stitches on the skin but adhesive strips. The umbilical optical port (10mm) is useful to remove resected tissues.
VID-09.06 Laparoscopic Varicocelectomy Using Bipolar Cautery Versus Open Inguinal Technique: A Randomized Clinical Trial Karami H, Tabrizi A Urology Ward, Shahid Beheshti Tehran University Shohada Hospital, Tehran, Iran Introduction and Objective: The aim of this investigation was to compare laparoscopic management of varicocele using bipolar cautery with open inguinal technique. Materials and Methods: A total of 220 infertile men underwent laparoscopic and open inguinal technique varicocelectomy. To evaluate the clinical efficiency of the treatment, the patients were divided randomly into two groups. Laparoscopic varicocelectomy (LV) was performed on 100 patients, and open varicocelectomy (OV) was performed on 100 patients. In both groups, operating time, relapse rate, hydrocele formation, hospital stay, and pain control were evaluated. Results: Operative time was 17 minutes in LV versus 15 minutes; in OV (P ⫽ .00). Relapse rates were 6% in LV and 12% in OV (P ⬎ 0.05), hydrocele occurrence was 10%in LV versus 20% OV (P ⬎ 0.05), and hospital stay was an average of 6 hours in LV and12 hours in OV. Postoperative analgesic use was 2.5 ⫹/⫺ 0.4mg in LV versus 3.5 ⫹/⫺ 0.5mg in OV (P ⬎ 0.05). Conclusions: In comparison with open varicocelectomy, laparoscopy has better outcome, shorter hospital stay, lower pain, fewer relapses and hydrocele formation low pain.
UROLOGY 78 (Supplement 3A), September 2011
VID-09.07 Bipolar Plasma Vaporization of Secondary Bladder Neck Sclerosis Geavlete B, Multescu R, Stanescu F, Georgescu D, Jecu M, Moldoveanu C, Geavlete P “Saint John” Emergency Clinical Hospital, Bucharest, Romania Introduction and Objectives: This trial aimed to assess the therapeutic efficiency, overall safety and short-term postoperative results of bipolar plasma vaporization (BPV) in cases of secondary bladder neck sclerosis (BNS). A prospective, randomized comparison to the standard monopolar transurethral resection TUR was also performed. Materials and Methods: A total of 60 patients (mean age of 72) with BNS secondary to TURP (41 cases), to open surgery for BPH (open prostatectomy – 14 cases) and to radical prostatectomy for prostate cancer (5 cases) were enrolled in the trial. The inclusion criteria consisted of Qmax ⬍ 10 ml/s and IPSS ⬎19. All patients were evaluated preoperatively and at 1, 3 and 6 months after surgery by International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and post-voiding residual urinary volume (RV). Results: Similar preoperative parameters were determined for patients from both series. BPV and TUR were successfully performed in all cases (30 patients each). The mean operative time, catheterization period and hospital stay were significantly reduced in the BPV series (16.5 versus 27 minutes, 18 versus 46.5 hours and 34.5 versus 73 hours). Capsular perforation only occurred in 2 cases of the TUR study arm, while the rate of irritative symptoms was similar in the 2 series (13.3% versus 16.7%). The 1, 3 and 6 months’ follow-up emphasized superior parameters for the BPV group by comparison to the TUR group in terms of IPSS (3.4 versus 6.3, 3.6 versus 6.5 and 3.7 versus 6.8, respectively) and Qmax (23.8 versus 21.1 ml/s, 23.7 versus 20.6 ml/s and 23.0 versus 20.7 ml/s, respectively). At the same time intervals, QoL was also significantly improved in the BPV arm (1.2 versus 1.4, 1.4 versus 1.6 and 1.4 versus 1.7), while no significant differences were established in terms of RV between the 2 series. Only 2 patients of the TUR group required re-treatment during the follow-up period. Conclusions: BPV constitutes a valuable endoscopic treatment alternative for secondary BNS. In a randomized analysis, the method emphasized superior efficacy, a satisfactory safety profile and significantly improved short-term follow-up parameters by comparison to the standard TUR.
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