Video Surgi Session 2 11:00am - 1:00pm Thursday, 29th October, 2020

41 Holmium Laser Ureterocele Excision with Transurethral Incision of the Prostate

Grant R. Pollock MD1, Kalpesh Patel MD2, Joel Funk MD1 1University of Arizona, Department of , Tucson, AZ, USA. 2Arizona Institute of Urology, Tucson, AZ, USA

Abstract

Objectives: Ureteroceles present a diagnostic and treatment challenge in adults. With an estimated prevalence of 1/500 to 1/4000, it is not uncommon for any urologist to encounter a ureterocele in clinical practice. We present an interesting case of a 53-year-old male with a 20-year history of obstructive voiding symptoms who presented to clinic with that was found to be secondary to an orthotopic ureterocele that was prolapsed into the prostatic . The patient underwent holmium laser ureterocele excision with transurethral incision of the prostate with a successful outcome. We present a video demonstrating the technique. Materials and Methods: Preoperative evaluation included a transrectal ultrasound of the prostate which revealed a prostate volume of 20cc. Urodynamics was also performed and pressure flow studies revealed a high-pressure, low flow voiding pattern with a functional . Cystourethroscopy was performed revealing that an orthotopic ureterocele on the left side was prolapsed into the prostatic urethra and the bladder neck was mildly elevated. Using MOSES technology and laser settings of 30 Hz and 1.5 J, the ureterocele was completely excised and a transurethral incision of the prostate was performed. Results: The patient was discharged home on the day of surgery in stable condition with a Foley in place. On post-operative day 1 he returned to clinic and he successfully passed a voiding trial with a post-void residual volume of 25cc. Renal ultrasonography was performed 3 months postoperatively and revealed no hydronephrosis. His postoperative International Prostate Symptom Score of 2 (lifestyle 0) was improved compared to his preoperative score (overall 34, lifestyle 6). Conclusions: Holmium laser ureterocele excision with a transurethral incision of the prostate is an effective treatment modality in the management of a prolapsed orthotopic ureterocele causing bladder outlet obstruction in a male patient. Source of Funding: None 45 Boari flap. Laparoscopic technique step by step

Alexander Kheifets MD, Ben Valery Sionov MD, Abraham Ami Sidi MD, Alexander Tsivian MD The E. Wolfson Medical Center, Holon, N/A, Israel

Abstract

Boari flap. Laparoscopic technique step by step

Alexander Kheifets, Ben Valery Sionov, A. Ami Sdi, Alexander Tsivian. Department of Urologic Surgery, The E. Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel (Presentation to be made by Dr Alexander Kheifets)

Introduction Ureteral injury is one of the most serious complications of gynaecologic surgery Ureteral injury following gynecologic surgery is quite rare occurring in approximately 1% of cases. Consequently, the need for ureteral reconstruction by Boari flap is not common. In this video we present step-by-step laparoscopic technique of Boari flap ureteral reconstruction.

Patients and methods The Patient is placed in the reverse Trendelenburg position. Once a pneumoperitoneum is established, 4 trocars are placed in an arch form. Via trans-peritoneal approach, inspection and adhesiolysis are carried out and the ureteral injury site is exposed about 2 cm cranial to the crossing of the common iliac vessels. The is divided proximal to the level of the injury and spatulated. The bladder is mobilized by peritoneal incision, but the gap is deemed too wide for a safe primary re-implantation. An anterior bladder wall flap is created. The apex of the flap is approximately 3 cm wide, and the base is approximately 5 cm. The cut end of the ureter is pulled through the bladder flap. The spatulated ureter is then anastomosed to the upper portion of the flap over a 7FR ureteral stent. The flap is tubularized and closed with absorbable running sutures and fixed to the psoas muscle. A Foley catheter is left for 7 days and removed after a cystogram. A ureteral stent is left for 4 weeks. During the period 01/2000 - 09/2018, 66 patients with an age range of 14-75 years underwent a middle or lower ureteral reconstructive surgery. In 5 of them reconstruction using a Boari flap was performed. Results: During 10 months’ follow-up the patient was asymptomatic, with a normal imaging and laboratory findings.

Conclusions: Laparoscopic Boari flap reconstruction is feasible and effective treatment, conferring the advantages of minimally invasive approach to these patients. 46 Robotic-assisted Laparoscopic High Uterosacral Ligament Suspension and Burch

Archana Rajender MD, Gamal Ghoniem MD University of California Irvine, Orange, CA, USA

Abstract

Introduction: Pelvic organ prolapse can include the anterior, posterior, or apical compartments, individually or in combination. When apical suspension is planned for pelvic organ prolapse repair, the surgeon and patient must decide if hysterectomy should be performed simultaneously. Recent literature suggests that 36-60% of women would choose uterine preservation with prolapse repair, if the option was of equivalent efficacy. Interestingly, 21% of women would still choose uterine preservation even if the prolapse repair had lower success rates. There are a variety of techniques for apical suspension with uterine preservation, one of which includes uterosacral ligament suspension, either transvaginal or transabdominal. The risk of ureteral injury during high uterosacral ligament suspension is 1-11%. The main advantage of the laparoscopic approach is appropriate visualization of the in a minimally invasive fashion and ability to perform other concomitant abdominal procedures. In this video, we demonstrate a robotic-assisted laparoscopic approach to high uterosacral ligament suspension with uterine preservation, and Burch urethropexy.

Patient details: The patient presented is a 51-year-old woman, G2P2, who presented to the clinic for evaluation of a vaginal bulge and stress . She reported frequent , nocturia, and stress urinary incontinence for the past 20 years. She reported use of 10 pads per day which were soaked at time of change. More recently she noticed a progressive vaginal heaviness. Pelvic examination demonstrated a 7cm total vaginal length, 3cm apical descent with Valsalva, stage 1 anterior wall prolapse, and urethral hypermobility. showed no detrusor overactivity, a VLPP 106cmH20 and CLPP of 128cmH20 at a volume of 250mL. After discussion of various treatment options, she stated the importance of uterine preservation. Therefore, she was counseled on proceeding with robotic-assisted laparoscopic high uterosacral ligament suspension and Burch urethropexy.

Video information: The procedure is detailed in the video in two parts, (1) Uterosacral ligament suspension and (2) Burch urethropexy. Relevant anatomy is elucidated throughout. 47 Excision of Eroded Intravesical Mesh after Mid-urethral Sling

Archana Rajender MD, Gamal Ghoniem MD University of California Irvine, Orange, CA, USA

Abstract

Introduction: Synthetic mesh complications after mid-urethral sling (MUS) for female stress urinary incontinence include bleeding, infection, voiding dysfunction, mesh exposure, pelvic pain and organ perforation. Intravesical mesh erosion is an uncommon complication with an unknown incidence after MUS placement. Presenting symptoms of bladder mesh erosion often include irritative voiding symptoms, recurrent urinary tract infections, hematuria, and bladder stones. Intravesical erosion of mesh is diagnosed on . The etiology includes unrecognized bladder injury at the time of sling placement, or, submucosal placement of mesh with delayed secondary erosion through the bladder. In this video, we demonstrate cystoscopic-guided excision of eroded bladder mesh with the aid of a 5mm suprapubic laparoscopic port.

Patient details: The patient in the video is a 43-year-old woman who underwent MUS placement at an outside hospital, five years prior to presentation. Her symptoms included irritative voiding symptoms, hematuria and recurrent urinary tract infections. Diagnostic office cystoscopy demonstrated eroded mesh entrapped by a linear, 4cm stone on the right lateral wall of the bladder. She was counseled on proceeding with endoscopic removal of the eroded bladder mesh with the aid of a 5mm laparoscopic port.

Video information: We present this video in the following segments (1) Cystoscopy and cystolitholapaxy, (2) Suprapubic port placement, and (3) Mesh excision. 74 Mini-Percutaneous Nephrolithotomy: Surgical Technique

Michael C Phung MD, Nishant D Patel MD UCLA Health, Los Angeles, CA, USA

Abstract

Large stone burdens have traditionally been treated with percutaneous nephrolithotomy with sheath sizes ranging from 24-30Fr. Mini-percutaneous nephrolithotomy (mini-PCNL) allows for efficacious treatment of similar stone burdens but using sheath sizes 20Fr or smaller. This may allow for less bleeding, less pain, and quicker recovery for patients. The purpose of this video is to demonstrate an endoscopic assisted surgical technique in performing mini-PCNL, as well as the use of the Clear Petra sheath which allows for continuous suction of stone fragments and may increase the efficiency of the procedure. 161 The Use of Intraoperative MRI (iMRI) at the Time of Cystovaginoscopy for Patient with Cloacal Anomaly

Poone S. Shoureshi MD, J. Christopher Austin MD, Casey A. Seideman MD Oregon Health and Science University, Department of Pediatric Urology, Portland, OR, USA

Abstract

Objectives: Patients born with cloacal anomalies pose a significant reconstructive challenge to pediatric urologists. Preoperative workup with and imaging to assess the length of the confluence is vital to determining the proper surgical approach for treatment. MRI is increasingly being used to assess anorectal malformations as it provides a clear image without radiation exposure. We present a unique case of an exam under anesthesia with simultaneous multiparametric intraoperative MRI (iMRI) for preoperative assessment of cloacal anomaly.

Materials and Methods: Our patient is a 7-month-old female with cloacal anomaly, bilateral ectopic ureters, grade 5 vesicoureteral reflux bilaterally, caudal dysgenesis, left lower extremity abnormalities, and imperforate anus s/p colostomy. She was scheduled for cystoscopy, vaginoscopy and exam under anesthesia for preoperative evaluate. We elected to perform simultaneous, intraoperative pelvic and abdominal MRI to avoid multiple sedation procedures.

Results: Cystovaginoscopy demonstrated a normal appearing bladder, an incompetent bladder neck, bilateral ectopic ureters entering just distal to bladder neck, and two vaginal openings. Prior to performing the iMRI, a Foley catheter was placed in the right hemivagina, the bladder, and a pollack catheter in the left hemivagina. We instilled a total of 10cc gadolinium and performed the iMRI. The common channel measured 3.3 cm and the urethra 1.3 cm.

Conclusion: The novel use of iMRI simultaneously with cystovaginoscopy can further enhance the preoperative workup in patients with complex anomalies such as cloacal malformation, and avoids multiple sedation procedures.

If funding provided, type in source company / entity name(s):

None 170 Video: Percutaneous Nephrolithotomy with Rendezvous for Treatment of Extensive Uric Acid Nephrolithiasis

Alexandra Carolan MD, Jonathan Moore MD, Karen Stern MD Mayo Clinic, Phoenix, AZ, USA

Abstract

Objectives: To present management of extensive uric acid nephrolithiasis with prone percutaneous nephrolithotomy with rendezvous ureteroscopy and laser

Materials and Methods: Retrospective chart review, case report and technique presentation

Results: The patient is a 68-year-old female with a distant history of calcium oxalate nephrolithiasis, who was recently diagnosed with uterine leiomyosarcoma. She presented with abdominal pain, nausea and vomiting. She was found to have a chronically obstructing left distal ureteral stone—which was treated with and ureteral stent placement—and thousands of small uric acid stones filing the right renal collecting system and distal right ureter, past which a stent could not be placed. A temporizing percutaneous tube was attempted, but recurrent clogging with stone material and development of acute renal failure necessitated moving forward with treatment. She underwent prone percutaneous nephrolithotomy and “rendezvous ureteroscopy”—simultaneous antegrade and retrograde ureteroscopy, laser lithotripsy and stone extraction. Two teams working simultaneously allowed removal of approximately 90% of the stone burden over four hours. The patient then underwent robot-assisted hysterectomy for treatment of her uterine leiomyosarcoma. Lastly, she had a second-look procedure to clear remaining stones and was rendered stone free. Her creatinine normalized.

Conclusions: Prone percutaneous nephrolithotomy with rendezvous ureteroscopy and laser lithotripsy is feasible for the management of extensive ureteral and renal stone burden which would otherwise require significantly longer operative times 210 Endoscopic Management of Recurrent Hematospermia associated with Ejaculatory Duct Calculi

Garrick M. Greear MD, Daniel Holst MD, Tung-Chin Hsieh MD University of California – San Diego, La Jolla, CA, USA

Abstract

INTRODUCTION AND OBJECTIVE: Hematospermia is an uncommon urologic symptom with many potential etiologies. While most cases are benign and self- limited, recurrent or persistent hematospermia may be a source of significant anxiety for patients and warrants workup to exclude malignant or reversible etiologies. Calculi of the ejaculatory duct or seminal vesicle are recognized as one cause of bothersome recurrent hematospermia. Endoscopic treatment of an ejaculatory duct calculus is presented and relevant literature regarding this technique is summarized. METHODS: A tapered 4.5-6.5 Fr semi-rigid ureteroscope and Holmium laser fiber (200 micron) was used to fragment and extract a calculus of the ejaculatory duct, and endoscopy performed of the previously obstructed duct to the level of the seminal vesicle. A brief literature review was undertaken and summarized to understand the adoption of this technique and explore reported outcomes. RESULTS: Endoscopy of the ejaculatory duct with concurrent laser lithotripsy and stone extraction led to resolution of recurrent hematospermia in our patient with minimal morbidity. An emerging body of literature corroborates this result. CONCLUSIONS: Endoscopy is a promising therapeutic option for patients afflicted with bothersome hematospermia attributable to calculi of the ejaculatory duct or seminal vesicle, and is a novel application of the existing endoscopic skill set of most urologists. An evaluation for this pathology may warrant inclusion into guidance for the workup of hematospermia, as no widely accepted guideline currently exists.

If funding provided, type in source company / entity name(s):

None 237 Labia Minora Ring Flap Pars Fixa and Perineal Masculinization During Single Stage Phalloplasty

Mang L Chen MD1, Alex Kavanagh MD2, Bradley D Figler MD3 1G.U. Recon, San Francisco, CA, USA. 2University of British Columbia, Vancouver, British Columbia, Canada. 3UNC, Chapel Hill, NC, USA

Abstract

Labia minora ring flap pars fixa urethroplasty and perineal masculinization during single stage phalloplasty offers transmasculine individuals the ability void standing and have male external genitalia in one surgery. The microsurgeons create the neophallus and pars pendulans (PP) urethra. The reconstructive urologist performs the vaginectomy, modified labia minora ring flap harvest, ventral chordee release with pars fixa (PF) urethroplasty, clitoral denudation, dorsal nerve dissection, perineal reconstruction, and complex scrotoplasty using labia majora flaps. Urologic complications are minimized by using techniques that preserve blood flow and minimize tension on the urethral anastomoses. The ring flap technique specifically extends the pars fixa urethra as distally as possible, eliminating tension at the PF-PP urethral anastomosis. From October 2017 to March 2020, 95 single stage phalloplasties with ring flap PF urethroplasties were performed. Urethral revisions including fistula and/or stricture repair, were required in 23 patients (24%). Most strictures at the PF-PP urethral anastomosis were short and non-obliterative, allowing for simpler non-transecting urethroplasties. Substitution urethroplasties were rarely required but more often performed in strictures involving the PF urethra. 300 Congenital Ureteral Obstruction in a Pelvic

Johann P Ingimarsson MD1, Lawrence T Zhang BA1, Ithaar Derweesh MD2, Stephen T Ryan MD1 1Maine Medical Center, Portland, ME, USA. 2UCSD, San Diego, CA, USA

Abstract

We report the case of a 30-year-old woman with congenital ureteral obstruction in a pelvic kidney who presented with recurrent episodes of pyelonephritis. Here we present the findings and management. 319 Interactive Virtual Reality Assisted Pyeloplasty in a Horseshoe Kidney

Martin Hofmann MD, Lillian Xie BS, Greg Gin MD, Roshan Patel MD UC Irvine, Orange, CA, USA

Abstract

Interactive Virtual Reality Assisted Pyeloplasty in a Horseshoe Kidney Martin Hofmann M.D., Lillian Xie B.S., Greg Gin M.D., Roshan Patel M.D. (Presentation to be made by Dr. Martin Hofmann) Introduction Three-dimensional (3D) virtual reality (VR) models have been shown to be of some potential benefit in cases of partial . In this video we present the use of 3D VR modeling in complex upper urinary tract reconstruction. This is the case of a 38 year-old, otherwise-healthy male who was diagnosed with a horseshoe kidney and ureteropelvic obstruction after presenting to an outside emergency room with flank pain. Methods Routine preoperative assessment was performed with laboratory workup to assess overall renal function, contrast computed tomography (CT) to delineate anatomy and assess for a crossing vessel, retrograde pyelography, and nuclear medicine (NM) diuretic renal scan to determine differential renal function and confirm obstruction. A 3D VR model was created and an Oculus Rift platform with Leap motion controllers was used to interact with the model. Thereafter a robot-assisted laparoscopic dismembered left pyeloplasty was performed. The Foley was removed on post-operative day 1 and the stent was removed 4 weeks after surgery. A NM diuretic renal scan was performed 8 weeks after surgery to assess for obstruction. Results There were no complications during surgery and the patient was discharged home on post-operative day 1. He remained asymptomatic after stent removal and a NM renal scan performed 8 weeks after surgery revealed improvement in the diuretic T1/2 from no excretion preoperatively to 17 minutes postoperatively. Conclusion Interactive VR modeling may be useful in planning complex reconstructive cases. Source of Funding: None 333 Tips and Tricks for Ultrasound-Guided Access in Obese Patients during Percutaneous Nephrolithotomy (PCNL) in the Supine Position

Cameron J Hinkel MD1, Justin S Ahn MD2, Catherine Tsai MD3, Thomas Chi MD2, David T Tzou MD1 1University of Arizona College of Medicine, Tucson, AZ, USA. 2University of California San Francisco, San Francisco, CA, USA. 3University of California San Diego, San Diego, CA, USA

Abstract

Objective: Performing ultrasound (US) guided percutaneous nephrolithotomy (PCNL) in the supine position offers several advantages compared to prone. However, the additional challenges of performing US guided renal access in obese patients can dissuade urologists from adopting this technique. These include increased skin-to-stone distance and degraded image quality due to the pannus, as well as a greater difficulty with visualizing the access needle and failing to establish a safe tract into the target calyx. Here we aim to address these challenges and provide advanced tips and tricks we utilize to achieve ultrasound guided PCNL access in obese patients. Methods: Key landmarks to facilitate supine PCNL are more difficult to identify in obese patients as these can be obscured by the overlying pannus. With the patient in the Galdakao-modified Valdivia position, a bump under the ipsilateral hip exposes the midline of the back. The pannus is taken out of the operative field with 4- inch wide silk tape on the abdominal wall using the Diagonal Retraction Tape (DRT) technique. Using a 5-1 MHz convex abdominal ultrasound transducer (Arietta 70; Hitachi Aloka Medical America, Wallingford, CT), we orient the probe longitudinally with respect to the kidney, with the lower pole of the kidney on the right of the screen. Results: With DRT applied, the skin-to-stone distance is decreased, bowel is moved farther away from the intended trajectory, and the kidney is more clearly visualized. During the puncture process, a common complaint is losing track of the access needle in relation to the target calyx. To remedy this, we use a fanning technique with the ultrasound probe to find the needle and correct its trajectory back toward the target calyx. This results in needle alignment with the target and will facilitate success for ultrasound-guided access in the obese patient from the supine position. Conclusions: Performing US guided PCNL is feasible and effective in obese patients using the tips and tricks demonstrated. Care must be taken to position the patient properly. Retracting the pannus and fanning the ultrasound probe will help the operator align the needle with the target calyx in patients with complex anatomy. 162 The Effect of Vesicopexy on Urinary Continence Recovery Following Robotic-Assisted Radical Prostatectomy: Feasibility and Technique

Alireza Ghoreifi MD, Sameer Chopra MD, Kian Asanad MD, Marissa Maas BS, Anirban Mitra MD, Eli Thompson MD, Adit Shah MD, Guadalupe Gonzalez PA, Jamal Nabhani MD, Hooman Djaladat MD, MS University of Southern California, Los Angeles, CA, USA

Abstract

Objectives: Urinary incontinence (UI) is one of the most common complications following robotic-assisted radical prostatectomy, which is reported as high as 35%, 3-month after surgery. Different techniques with a focus on restoring lower urinary tract structures have been proposed to improve postoperative continence. However, UI is still a big challenge in postprostatectomy patients with a significant financial burden on both patients and the healthcare system. The aim of this video is to present a new technique of vesicopexy in patients undergoing RARP.

Material and Methods: In this technique, following confirmation of a watertight urethrovesical anastomosis, the bladder was pexed to the anterior abdominal wall. A 2-0 V-Loc™ barbed suture was used for bladder fixation in a running fashion. Following catheter removal, we recommended Kegel exercise (100 x 3/day) to all patients. Urinary continence was assessed in a 1-month and 3-month postoperative visit using a pictorial pad usage questionnaire. The illustrative case in the video is that of a 68-year-old male with prostate cancer, who underwent RARP plus vesicopexy using Xi robot. We also performed a pilot study on 43 patients to evaluate the feasibility of this technique.

Results: Unilateral nerve-sparing was performed for this patient. Operative time and estimated blood loss were 250 minutes and 100 cc, respectively. Surgery was uneventful with no need for perioperative blood transfusion. The patient was discharged on postoperative day 1. Pathology revealed prostate cancer, Gleason score 3+4 with negative margins. No complication was reported during the 90-day follow-up. The patient was continent (pad-free) at 1-month and 3-month follow-up visits. Among 43 patients included in the pilot study, 1- month and 3-month continence rates were 53% and 89%, respectively.

Conclusions: Vesicopxy is a safe and feasible technique that can lead to a satisfactory recovery of early continence in patients undergoing RARP.

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None