Robotic versus open distal ureteral reconstruction and reimplantation for benign stricture disease.

Four neocystostomies, four psoas hitches, and two Boari flaps were performed in the RAUR group. Estimated blood loss 30.6 vs 327.5 mL, P=0.001 and length of hospital stay 2.4 vs 5.1 d, P=0.01 were significantly reduced in the robotic group. Median BMI 29.4±5.3 vs 26.5±5.2, P=0.130 and operative time in minutes 306.6 vs 270.0 min, P=0.316 were higher in the robotic group, although these were not statistically significant.

via Robotic versus open distal ureteral reconstruction and reimplantation for benign stricture disease.

This article reports on 10 robotic ureteral reimplants.  I have performed several of these with similar results.  Patients tend to recover faster and go home from the hospital sooner.  The connection between the ureter and bladder is magnified, so the robotic approach is easier than the open approach for this part.

I have performed this operation for ureteral cancer in the distal ureter as well.

UroToday – Laparoscopic mesh herniorrhaphy: Impact on outcomes associated with radical retropubic prostatectomy

Source: Urotoday

Eighteen patients with a prior LMH underwent RRP. Five of the 18 had bilateral LMH, with unilateral LMH in the remainder. Outcomes in this group were compared with 38 patients without prior LMH. There was no difference between the groups in terms of age, preoperative PSA, prostate size, preoperative Gleason score, or body mass index, and RRP was successfully performed in all 18 LMH patients. One of 18 patients had a postoperative complication (persistent JP drainage). Compared with the control group, differences in operative time and blood loss bordered on statistical significance.

Prior LMH is not a contraindication to RRP. While resulting in slightly longer operating times and higher blood loss, our experience suggests that RRP can be safely performed in these patients.

This study from the Medical College of Wisconsin showed how radical prostatectomy can be performed safely after laparoscopic hernia surgery with mesh. My experience with robotic surgery has been similar. Robotic prostatectomy after laparoscopic hernia surgery takes a little more time, but is not too much of a problem.

The first step where the bladder is moved out of the way is more complicated and performing a pelvic lymph node dissection is more complicated as well. Patients of mine who are at risk of developing prostate cancer sometimes develop inguinal hernias. If they are considering undergoing laparoscopic hernia surgery with mesh, I am comfortable with given them the OK.

Robotic Donor Nephrectomy for donating a kidney for transplant

UroToday – AUA 2007 – Experience with Robotic-Assisted Laparoscopic Living Donor Nephrectomy

This series demonstrates that robotic-assisted laparoscopic donor nephrectomy can be performed safely with low complication rates and outcomes similar to standard laparoscopic living donor nephrectomy.

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Surgery for Xanthogranulomatous Pyelonephritis

UroToday – Laparoscopic Versus Open Radical Nephrectomy for Xanthogranulomatous Pyelonephritis: Contemporary Outcomes Analysis

beige_quote.bmpBERKELEY, CA ( – It was not until 9 years after the initial laparoscopic nephrectomy, that the first report on using this technique for xanthogranulomatous pyelonephritis (XGP) emerged from Washington University.
At that time, we noted the procedures were much longer than the open, with no benefits in pain control or hospital stay, and were associated with a high rate of complications. Over the years, has the laparoscopic approach to this condition improved? The answer is “a bit” but only “a bit”. In this sobering report the authors compare 6 laparoscopic to 6 open nephrectomies for XGP. The procedure time was 2 hours longer in the laparoscopic group (p = 0.03). One of the 6 laparoscopic patients was converted to open and 2 cases were converted to hand-assist. Complications were higher in the laparoscopic group (3 vs. 2).

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Are da Vinci Pyeloplasties "Experimental"

I recently had an encounter with United Healthcare that initially resulted in a denial of a request to treat one of their patients with UPJ stenosis (partial obstruction of the drainage leading from the kidney to the bladder) with a robotic repair of the condition. The denial was initially based on the perception that such surgery was “experimental” and not a generally accepted form of treatment. After nearly two months of back and forth, I have approval to do the procedure and I believe I have convinced United Health to accept the procedure generally for all its subscribers. I have posted below several references to articles that I forwarded to the medical director in the course of our discussions. Most pyeloplasties are done in children and you can see that the articles reflect that, although my patient was an adult. Perhaps they will be of help to someone else in a similar situation.

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Port placement in robotic renal surgery from Henry Ford and Kuala Lumpur

A structured process for achieving optimal port placement for robotic transperitoneal renal surgery
From the World Congress of Endourology
Source: UroToday

M.J. Fumo1, K.K. Badani
, S. Kaul , A. Shrivastava , S. Dusik-Fenton , F. Ogunfitidimi , S. Murali
, N. Ashani , K. Arumunga , R.H Littleton , J.O. Peabody , R.M. Sahabudin
, A.K. Hemal ,M. Menon

1Vattikuti Urology

Institute of
Urology and
Nephrology, 2
Hospital Kuala Lumpur


The DaVinci robotic
system has the advantages of 3D imaging, magnification, and precise
movements with many degrees freedom; however, it is hampered by size
making optimal port placement essential to prevent loss of range of motion
from robotic arms colliding with each other or the patient’s body. We seek
to clarify optimal port placement for transperitoneal renal surgery.

port placement for renal surgery can be optimized to eliminate loss of
range of motion. Placing the camera port laterally and robotic ports
antero-medially resulted in considerable flexibility of robotic movement.

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Previous Laparoscopic Hernia Repair with mesh in prostate cancer patients

This past month 2 patients of mine with prior laparoscopic hernia repairs with mesh had successful dvPs. I have done several of these now and do not get overly concerned with this finding in a patient. One of the patient’s was from Florida and was advised against robotic prostatectomy from 2 urologists that performed robotics locally due to his prior hernia surgery. This patient actually had recurrent inguinal hernias that we fixed at the same time of his robotic prostatectomy.

I think the open approach will be much more difficult in patients with prior lap hernias and would advise against open prostate surgery, but I do not feel it is a problem for myself while performing robotics. Operative reports from the original lap hernia operation are helpful. If the lining of the abdomen (peritoneum) is not covered over the mesh, this would make the dvP much harder as bowel would likely be adhered to the mesh. If the lap hernia was done extraperitoneal (this is usually the case) or the peritoneum covers the mesh, it should not be a problem.

Lymph node dissections are much more difficult with prior hernia repairs, especially lap hernias and I performed my first of these for lap hernias this past week and found it to be safe even though the mesh was placed lower than usual and partly covered the vein. I inform patients with prior surgery in this area that I may not be able to remove the lymph nodes if the reaction is too severe and I don’t feel its safe. The lymph nodes are more useful for staging and giving the patient their prognosis, but not for helping the cure rate. Fortunately I have always been able to remove the lymph nodes when I wanted to so far.

Adrenal surgery: right vs left

I have performed several robotic adrenalectomies and about a dozen laparoscopic adrenalectomies. I have had excellent results with robotic and lap, and have not had any trouble with either the right of the left side.
There is a study from China that concludes that right or left laparoscopic adrenalectomies are similar in outcomes.
I have several issues with this. I am fairly certain that the surgeons were experienced based on the results. Looking at retrospective data on this can lead to a false conclusion. The right side should be quicker since there is less tissue to mobilize, but often takes me the same time due to the extra care in isolating and controlling the right adrenal vein. I feel the right side are more difficult. I am still performing most of these laparoscopically because the endocrinologists that refer them only have privileges at a non-robotic hospital.
I especially like doing these robotically, as the robotic arms give you more flexibility with the enodwristed instruments.

New Robotic Surgical Procedure: Robotic Bladder Diverticulectomy

Today, Dr. Marc Greenstein and I performed the first robotic diverticulectomy at our hospital, and likely among one of the first on the country.
This procedure was done for recurrent bladder infections, but can also be done for bladder cancer.
The operation went extremely well and much better than the typical open version of the operation. Our robotic time was under 1 hour and there was almost no blood loss, and should cut the patient’s hospital stay from 4-5 days to overnight. The expected pain and bladder discomfort should be much less as well.
I will need to update my website and add some video when I get the chance, as well as submit a paper for publishing.

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