NARUS 2018: Utilizing Advanced Technology During Robotic Reconstruction

Las Vegas, NV (UroToday.com) Dr. Ketan Badani from Mount Sinai Hospital in New York discussed utilizing advanced technology during robotic surgery reconstruction cases. Dr. Badani started by noting that most robotic surgeons are not classically trained reconstructive surgeons, but highlights that at its most fundamental core, the robot is THE reconstructive tool. The fundamentals learned in robotic prostatectomy, partial nephrectomy and urinary diversion are easily translated into complex urinary repair. Dr. Badani notes the importance of indocyanine green (ICG) for reconstructive cases – after intravenous injection it will demonstrate perfusion of tissues, and if used for direct urinary tract infusion, can be used to demonstrate urinary anatomy.

Dr. Badani presented a case of a 60-year-old female with a proximal left ureteral calculus that was treated with stone basket and ureteral stenting. She then presented with recurrent symptomatic hydronephrosis and pain after the stent was removed. There was an attempted stent placement, which was unsuccessful, and she subsequently had a percutaneous nephrostomy tube placed. Dr. Badani then showed a video of proximal ureteral stricture repair using a 5cm buccal mucosal graft. There has been an uptake in this procedure, with a recently published multi-institutional experience of 19 patients undergoing robotic assisted buccal mucosa graft ureteroplasty for complex ureteral strictures with 90% success rate at a median 26 months of follow-up [1].

A second case presented by Dr. Badani was a 68-year-old with a history of Gleason 4+4 prostate cancer who underwent a robotic prostatectomy who also had a history of inguinal hernia repair treated four times. During his robotic prostatectomy, he had an extended pelvic lymphadenectomy and post-operatively was diagnosed with urine leak via high JP drain output. Two weeks post-operatively he presented to Dr. Badani with a Foley catheter, right percutaneous nephrostomy tube and JP drain still in place. To fix this ureteral injury, and secondary to the complex adhesions of the bladder to the pubic bone, Dr. Badani performed a Boari flap with successful reconstruction. 

Dr. Badani then presented a case of a 58-year-old male with a history of external beam radiotherapy for prostate cancer. He then developed bladder cancer and underwent a cystoprostatectomy with an Indiana pouch continent diversion. At initial consultation, he had left flank pain and hydronephrosis with no tubes in place; the stoma was fine and he was catheterizing without difficulty. Subsequently, imaging demonstrated severe left hydronephrosis down to the level of the pouch and a percutaneous nephrostomy tube was place. Dr. Badani then presented a video of ureteral revision, utilizing infusion of ICG down the percutaneous nephrostomy to assist with delineating the ureteral anatomy. 

Finally, Dr. Badani presented a case of a 55-year-old male with a history of prostate cancer treated with external beam radiotherapy. He subsequently underwent a transplant with a transplant ureter to native ureter anastomosis to avoid the radiation effect in the pelvis. This subsequently developed an anastamotic stricture and a percutaneous nephrostomy tube was placed in the transplant kidney. Dr. Badani then performed a transplant ureter revision, making use of the ICG to delineate the fibrotic area of ureteral stricture. 

Dr. Badani concluded with highlighting several advances in technology to facilitate robotic reconstruction. These included ICG, integrated imaging with Tilepro, the da Vinci Xi to allow multi-quadrant access and angles, as well as the robotic controlled stapler for bowel surgery. 

References: 

1. Zhao LC, Weinberg AC, Lee Z, et al. Robotic ureteral reconstruction using buccal mucosa grafts: A multi-institutional experience. Eur Urol 2017 Nov 24 [Epub ahead of print].

Speaker: Ketan Badani, Mount Sinai Hospital, New York, NY

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV