WHAT ARE THE DIFFERENCES BETWEEN ROBOTIC DISMEMBERED PYELOPLASTY FOR PRIMARY OR SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION?

Vol. 179, No. 4, Supplement, Monday, May 19, 2008

THE JOURNAL OF UROLOGY®

METHODS: Between May 2002 and November 2007, a single surgeon at our institution performed the following robotic urologic reconstructions (80 total renal units): dismembered pyeloplasty, dismembered pyeloplasty with concomitant stone extraction, ureteroureterostomy, ureterolysis with omental wrap, ureterocalycostomy, ureteral reimplant, upper pole nephroureterectomy, and partial cystectomy. We retrospectively compared demographic, preoperative, intra-operative, and post-operative data of patients undergoing these various procedures. 5(68/76 2XU UHVXOWV DUH VXPPDUL]HG LQ7DEOH $FURVV all cases, mean blood loss was 125 cc, mean operative time was 244.8 minutes, and mean length of stay was 2.8 days. Post-operative radiographic and symptomatic improvement were 97.3% and 100%, respectively. There were 6 major complications: 5 stent migrations and 1 gluteal compartment syndrome. Mean follow up for all robotic reconstructions was 24.3 months. CONCLUSIONS: Our data illustrates that robotics can be successfully and safely employed for virtually any type of urinary tract reconstruction. Robotic techniques are a viable option for reconstruction of the urinary tract with durable results. Table 1: Demographic, Pre-Operative, Operative, and Post-Operative Outcomes Pyeloplasty UreteroUreterolysis, UreteroUpper Pole Partial PyeloUreteral with Stone UreteroOmental CalycoNephroCystecplasty Reimplant Extraction stomy Wrap stomy Ureterectomy tomy Number Renal Units Age (mean years) BMI (mean

55

6

2

6

40.4

36.2

32.5

53.2

(13-74)

(25-68)

(31-34)

(48-58)

24.8

24.5

26.9

32.6

1

46

23.4

(16.3-42.4) (18.6-31.2)

(23.5-30.3) (22.9-38.4)

19%

33%

100%

0%

74.9

76.7

55

33.4

(10-600)

(10-200)

(10-100)

(10-52)

Time

239.4

271

218.5

254.4

(mean

(100-345)

(207-348)

(189-248)

(150-390)

2.9 (2-7)

3 (2-5)

2.5 (2-3)

2.6 (2-3)

3

6/2

0/0

0/0

0/0

83%

100%

100%

kg/m2) Previous Repair (%) EBL (mean cc) Operative

100%

450

Total

4

2

4

80

36.5

26

63

39.4

(29-44)

(21-31)

(36-77)

(13-74)

20.5

24.6

23.9

26.0

(18.6-22.5) (19.6-29.6)

(18.4-38.6) (16.3-42.5)

50%

0%

0%

50.3%

35

125

35

125

(20-50)

(100-150)

(20-50)

(10-450)

239.5

110.5

188.75

244.8

(215-264) (186-205)

(163-252)

(100-390)

3.5

2.5

2.75

2.8

(3-4)

(2-3)

(2-3)

(2-7)

0/0

0/0

0/0

0/0

6/2

100%

100%

100%

100%

N/A

98.3%

100%

100%

100%

100%

100%

100%

100%

21.5

22.4

32.3

13.5

16

24.3

(17-26)

(17-29)

(38-47)

(2-25)

(6-30)

(2-62)

355

minutes) Length of Stay (mean days) Complications Major/ Minor Radiographic Improve- 98% ment (%) Symptomatic Improve- 100% ment (%) Follow up (mean mos)

32.7 (2-62)

30.8 (14-41)

25

Source of Funding: None

1003 ROBOTIC ASSISTED RE-EXPLORATION FOR ACUTE POSTOPERATIVE COMPLICATIONS FOLLOWING ROBOTIC RADICAL PROSTATECTOMY Rajesh G Laungani*, Louis S Krane, Alok Shrivastava, Craig Rogers, James O Peabody, Mani Menon. Detroit, MI. INTRODUCTION AND OBJECTIVE: Acute post surgical hemorrhage and anastamotic disruption are serious complications of radical prostatectomy that may require re-operation and exploratory surgery. We report our technique as well as evaluate the feasibility, utility and patient outcomes after robotic assisted re-exploration for acute surgical complications after robotic radical prostatectomy. METHODS: A retrospective review of our robotic prostatectomy GDWDEDVHLGHQWL¿HGDOOSDWLHQWVZKRUHTXLUHGLPPHGLDWHSRVWRSHUDWLYH exploratory surgery using robotic techniques. We evaluated the reason for re-exploration, operative times, and associated increase in hospital VWD\UHODWHGWRURERWLFH[SORUDWRU\VXUJHU\,QWUDRSHUDWLYH¿QGLQJVZHUH also reviewed.

345

RESULTS: Of 3381 patients who underwent robotic radical SURVWDWHFWRP\    VXIIHUHG FRPSOLFDWLRQV ZLWKLQ WKH ¿UVW  hrs after surgery requiring emergent exploratory surgery. All patients underwent re-exploration using strictly robotic techniques. Placement of robotic and assistant ports as well as re-establishment of pneumoperitoneum was accomplished through the original port sites with no additional incisions. 3 patients were taken back due to evidence of acute hemorrhage. 2 of these were found to have large pelvic hematomas and 1 was found to have an abdominal wall bleeding vessel. All bleeding sites were controlled with a combination of electrocautery and robotic suturing techniques.4 patients were taken back due to poorly draining foley catheter and severe abdominal pain. These patients were found to have anastomotic disruption. Disruption was complete in 2 patients and partial in 2 patients. The anastomosis in each case was taken down and formally repaired with robotic suturing techniques. All patients who underwent robotic re-exploration were discharged within a mean of 4.6 days (1-11 days) after robotic re-exploratory surgery. Mean operative time was 92.4 min (59-148 min). CONCLUSIONS: Robotic techniques including port placement through original port sites as well as techniques for hemostasis and anastomotic repair are feasible in those patients who require exploratory surgery in the immediate post operative period, after robotic prostatectomy. Morbidity of large abdominal incision as well as bowel manipulation with traditional open exploratory laparotomy is avoided. 7RRXUNQRZOHGJHZHUHSRUWWKH¿UVWVHULHVRIH[SORUDWRU\VXUJHU\DIWHU URERWLFSURVWDWHFWRP\XWLOL]LQJSULPDULO\URERWLFWHFKQLTXHV Source of Funding: None

1004 WHAT ARE THE DIFFERENCES BETWEEN ROBOTIC DISMEMBERED PYELOPLASTY FOR PRIMARY OR SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION? Patrick W Mufarrij*, Aaron D Berger, Mark A Perlmutter, Michael E Lipkin, Ojas D Shah, Michael D Stifelman. New York, NY. INTRODUCTION AND OBJECTIVE: Performing surgery in D SUHYLRXVO\ RSHUDWHG ¿HOG FDQ EH FKDOOHQJLQJ VHFRQGDU\ WR PXOWLSOH IDFWRUVLQFOXGLQJ¿EURVLVDQGORVVRIWLVVXHSODQHV+HUHLQZHUHYLHZRXU experience with robotic pyeloplasty in patients who have failed previous attempts at repair, compared to those undergoing a primary repair. :H K\SRWKHVL]H WKDW URERWLF S\HORSODVW\ IRU VHFRQGDU\ XUHWHURSHOYLF junction obstruction (UPJO) may be associated with worse outcomes as compared to those with primary UPJO. METHODS: Between May 2002 and September 2007, a single surgeon at our institution performed 60 consecutive robotic dismembered pyeloplasties. An IRB-approved retrospective chart review obtained demographic, pre-operative, operative, and post-operative data. 14  ZHUHVHFRQGDU\UHSDLUVIRU83-2WKHUHPDLQLQJZHUHSULPDU\ repairs. All patients underwent a diuretic renal scan and symptom analysis pre- and post-surgery. Statistical analysis was performed with Pearson’s Correlation. RESULTS: Data is presented in table 1. There were no VWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVLQDQ\SDUDPHWHUVEHWZHHQSDWLHQWV undergoing a primary or secondary repair, at a mean follow up of 34.6 and 29.3 months, respectively. Both cohorts experienced increased JORPHUXODU¿OWUDWLRQUDWH*)5 DIWHUVXUJHU\ZLWKDWUHQGIRUDJUHDWHU increase in the secondary group (p = .09). A large majority of both secondary (86%) and primary (70%) patients had a crossing vessel etiology, which may explain why previous endoscopic procedures failed in the former. Two patients from each group demonstrated obstruction post-surgery. Both patients in the secondary cohort underwent successful repeat robotic pyeloplasties. One patient in the primary group underwent DVXFFHVVIXOUHWURJUDGHHQGRS\HORWRP\WKHRWKHUDQHSKUHFWRP\IRU a poorly functioning kidney. There were 6 major complications: 5 stent migrations and 1 gluteal compartment syndrome.

346

THE JOURNAL OF UROLOGY®

&21&/86,2165RERWLFS\HORSODVW\LVDVDIHHI¿FDFLRXV and viable option for either primary or secondary UPJO with excellent and durable outcomes. Table 1: Demographic, Pre-Operative, Operative, and Post-Operative Data Primary Secondary N 46 14 Age (mean years) 37.9 (13-74) 42.1 (18-72 Sex (F/M) 18 M, 28 F 6 M, 8 F Side 24 L, 22 R 9 L, 5 R Previous Repair 0 (0%) 14 (100%) OR Time (mean mins) 230.9 (100-348) 234.9 (172-345) EBL (mean cc) 72.2 (10-600) 85.4 (10-300) Transfusion Rate 0% 0% Intrinsic Etiology 14 (30%) 2 (14%) Crossing Vessel Etiology 32 (70%) 12 (86%) Stone(s) Present 4 2 Change GFR (mean ml/min) + 1.5 + 6.6 Length of Stay (mean days) 2.9 2.5 Symptom Improvement 100% 100% Radiographic Resolution of Obstruction 96% 86% Post-Op Need for Secondary Procedures 2 (4.3%) 2 (14%) Complications (Major/Minor) 6/2 0/0 Evidence of Obstruction at Last Follow Up 0% 0% Follow-up (mean months) 34.6 (11-56) 29.3 (4-65)

Source of Funding: None

Vol. 179, No. 4, Supplement, Monday, May 19, 2008

Table 1: Demographic, Pre-Operative, Operative, and Post-Operative Data Overall Primary Secondary No Stones Stones N 101 81 20 89 12 Age (mean years) 36.9 36.4 38.9 36.7 38.7 Sex (F/M) 62/39 49/32 13 F, 7 M 56 F, 33 M 6 F, 6 M Side 47 L, 54 R 36 L, 45 R 11 L, 9 R 40 L, 49 R 7 L, 5 R Previous Repair 20 (19.6%) 0 20 (100%) 16 (17.9%) 4 (31%) 233.1 234.1 228.9 232.4 232.3 OR Time (mean mins) (90-510) (90-510) (133-345) (90-500) (145-348) 63.2 61.2 72 62.8 641.7 EBL (mean cc) (10-600) (10-600) (10-300) (10-600) (10-200) Transfusion Rate 0 0 0 0 0 30% Intrinsic Etiology 38 (38%) 32 (40%) 6 (30%) 8 (66.7%)* (33.7)* 59% Crossing Vessel Etiology 63 (62%) 49 (60%) 14 (70%) 4 (33.3%)* (66.3)* Stone(s) present 12 (12.7%) 8 (10.9%) 4 (20%) 0 12 (100%) 2.15 2.15 Length of Stay (mean days) 2.15 (1-3) 2.18 (.75-7) 2 (1-5) (.75-7) (.75-7) Symptom Improvement 100% 100% 100% 100% 100% Radiographic Resolution of 97 (96%) 79 (97.5%) 18 (90%) 85 (95.5%) 12 (100%) Obstruction Post-Op Need for Secondary 4 (4.3%) 2 (2.5%) 2 (10%) 4 (4.5%) 0 (0%) Procedures Complications (Major/Minor) 8/3 8/3 0/0 8/3 0/0 Radiographic Resolution of Obstruction at last Follow- 100% 100% 100% 100% 100% Up 29.4 30.8 29.57 Follow–up (mean months) 23.7 (7-51) 27.2 (4-45) (2-63) (2-63) (2-63) * = p < 0.05

Source of Funding: None

1005 ROBOTIC DISMEMBERED PYELOPLASTY – A 5-YEAR, MULTIINSTITUTIONAL EXPERIENCE Patrick W Mufarrij*, Michael Woods, Ojas D Shah, Aaron D Berger, Raju Thomas, Michael D Stifelman. New York, NY, Maywood, IL, and New Orleans, LA. INTRODUCTION AND OBJECTIVE: Robotic pyeloplasty is the second most common urologic procedure performed with the da Vinci robot. Herein, we review our multi-institutional experience with robotic dismembered pyeloplasty for primary repair, secondary repair, and for concomitant stones. METHODS: Two surgeons at two university medical centers performed 101 robotic dismembered pyeloplasties between May 2002 and November 2007. An IRB-approved retrospective chart review was used to collect demographic, pre-operative, operative, and postoperative data. All patients underwent a diuretic renal scan or diuretic intravenous pyelogram and symptom analysis pre- and post-surgery. The procedure was executed with similar technique, except one surgeon performed antegrade stent placement via pyelotomy, while the other preferred cystoscopic retrograde stent placement. Statistical analysis was performed using Pearson’s Correlation. 5(68/76'DWDLVVXPPDUL]HGLQWDEOHZLWKDPHDQIROORZ XSRIPRQWKV7KHUHZHUHQRVWDWLVWLFDOO\VLJQL¿FDQWGLIIHUHQFHVLQ any parameters between patients undergoing a primary or secondary repair. Patients with stone disease were statistically more likely (p = 0.02) to have an intrinsic etiology for UPJO (66.7%) than a crossing vessel (33.3%). With regards to the 4 patients demonstrating obstruction postRSHUDWLYHO\WZRXQGHUZHQWVXFFHVVIXOUHSHDWURERWLFS\HORSODVW\RQH VXFFHVVIXO UHWURJUDGH HQGRS\HORWRP\ DQG RQH QHSKUHFWRP\ 7KHUH were 8 major complications: 6 stent migrations, 1 gluteal compartment syndrome, and 1 blood clot obstructing the renal pelvis. Of the 6 migrated stents, 5 occurred with the antegrade approach and 1 via the retrograde technique (p = 0.2). CONCLUSIONS: To our knowledge, this represents the largest review with the longest follow-up on robotic dismembered pyeloplasty. We describe excellent and durable outcomes with this technique for patients with primary or secondary UPJO, and for those with concomitant stones.

1006 DEVELOPMENT OF POLARIZED IMAGING FOR IMPROVED DIFFERENTIATION OF NERVE, BLADDER, AND PROSTATE TISSUE DURING ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY William K Johnston, III* Jihoon Kim, Raheel John, Paul Wu, Joseph T Walsh, Jr. Evanston, IL. INTRODUCTION AND OBJECTIVE: Few advances have been made in the visual and near infrared imaging that would improve LQWUDRSHUDWLYHUHDOWLPHYLVXDOL]DWLRQ6WRNHVSRODULPHWU\LPDJLQJ63,  KDVEHHQUHSRUWHGWRKHOSGLVFULPLQDWH¿EHURULHQWDWLRQDQGGLIIHUHQWLDWH tissue types. We sought to build an imaging camera that used the principle of SPI to help differentiate nerve tissue, bladder tissue and prostate tissue and to develop a laparoscopic camera that could be used during robotic-assisted laparoscopic prostatectomy. METHODS: We developed a SPI camera and laparoscope V\VWHP WKDW LOOXPLQDWHV ZLWK OLQHDUO\ SRODUL]HG OLJKW ZKRVH DQJOH RI SRODUL]DWLRQLVFRQWUROOHGDQGYDULHGURWDWHG XVLQJDFRPSXWHUFRQWUROOHG rotator. A xenon light-source provides light for illumination. Light traverses DPP¿EHURSWLFOLJKWJXLGHDQGSDVVHGWKURXJKYDULRXV¿OWHUV)LOWHUHG OLJKWWKHQSDVVHVDOLQHDUSRODUL]HUWKDWLVPRXQWHGWRDPRWRUL]HGURWDWLRQ VWDJH5RWDWLRQRIWKHOLQHDUSRODUL]HUFDQVHOHFWLYHO\SRODUL]HWKHLQFLGHQW OLJKWRYHUDUDQJHRIWRGHJUHHVRILQFLGHQWOLQHDUSRODUL]DWLRQDQJOHV (IPA). The remitted light was collected via a laparoscope onto the internal optics assembly. Initial studies were conducted (using the camera on animal nerve, bladder and prostate tissue and the laparoscope on a humanprostate) and images compared to standard imaging. 5(68/768VLQJWKH&3,LPDJLQJV\VWHPSRODUL]HGLPDJHV of a rat’s genitalfemoral nerve hidden within fatty tissue were obtained. :KHQFRPSDUHGWRVWDQGDUGLPDJLQJSRODUL]HGLPDJHVLOOXPLQDWHGWKH QHUYHDQGDOORZHGYLVXDOL]DWLRQWKURXJKWKHIDW63,LPDJHVREWDLQHG from a dog’s cystoprostectomy improved distinction between bladder ¿EHUV DQG SURVWDWH DW WKH EODGGHU QHFN FRPSDUHG WR VWDQGDUG OLJKW LPDJHV3RODUL]HGLPDJHVRIWKHSURVWDWHGHPRQVWUDWHGWKHRULHQWDWLRQRI WKHSURVWDWHFDSVXODU¿EHUVXQLTXHWRDGMDFHQWEODGGHUDQGSHULSURVWDWLF tissue. Lastly, the laparoscopic camera was used to image a human SURVWDWHVSHFLPHQSRVWH[WUDFWLRQ6LPLODU¿EHURULHQWDWLRQZDVGLVSOD\HG XQGHUSRODUL]DWLRQ &21&/86,216 :H GHYHORSHG D SRODUL]HG FDPHUD DQG laparoscope to enhance differentiation of biologic tissues (nerve, fat, muscle) and organs (bladder, prostate). While the current study describes tissue encountered during open and robotic prostatectomy, the system could have broader applications in other surgical and dermalogic procedure. Further in vivo testing in needed. Source of Funding: Evanston Northwestern Healthcare Grant.