Robotic-assisted repair of colovesical anastomosis after Hartmann's reversal procedure

ABSTRACT Purpose Hartmann's procedure is the resection of the rectosigmoid colon with an end colostomy formation and closure of the anorectal stump (1). Its reversal has a morbidity rate up to 58% (2, 3) with an incidence of fistulae formation of 4.08% (1). Herein, we present a robotic-assisted repair of a complex fistula that occurred as complication of Hartmann's reversal when the stapler was introduced inadvertently through the vaginal canal. Patient and methods Eighty-three-year-old female with past medical history of hysterectomy and ischemic colitis that required colectomy and colostomy placement in December 2020. In March 2022, the patient underwent a colostomy takedown, after which she reported fecaluria, urine leakage per vagina, and recurrent urinary tract infections. Cystoscopy and vaginoscopy revealed a large colovesical fistula, a staple in the bladder trigone, and several staples in the anterior vaginal wall. Robotically, extensive adhesiolysis was performed, the sigmoid was separated from the bladder, and the intact rectal stump was dissected free. The staple from the bladder trigone was removed. Bladder was closed in two layers with 3-0 V-Loc. Colorectal anastomosis was not feasible due to the short length of both ends. Therefore, a permanent colostomy was placed. Results Operative time was 454min., and estimated blood loss was 100cc. Discharged on postoperative day 4 with a JP drain and a 20Fr Foley catheter. Drain, and Foley were removed on postoperative days 9 and 23, respectively. No postoperative complications were reported. Conclusion Robotic-assisted repair represents an effective approach for the management of colovesical fistulae after Hartmann's reversal.

Robotic-assisted Simple Prostatectomy: An Intrafascial Approach for a Prostate of 470 g.

BACKGROUND: Simple prostatectomy has been established as a management option for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with glands larger than 80 cc.1 Robotic-assisted simple prostatectomy (RASP) has been established as a safe and effective management option. This has been reported in multiple studies comparing it with the open approach where no statistically significant differences in complication rates have been found.2 The intrafascial approach is intended to add multiple benefits, such as not requiring continuous bladder irrigation and resection of a larger percentage of the adenoma, potentially leading to a lower reoperation rate and diagnosis of prostate cancer in patients in which this was missed preoperatively.3 OBJECTIVE: To present the resection of a very large prostate can lead to significant intraoperative challenges. Therefore, we demosntrate our intrafascial robotic management of a 470g prostate. MATERIALS AND METHODS: A 56-year-old with LUTS (IPSS: 34) for over 6 years, complicated with multiple episodes of urinary retention. PSA: 20.6 ng/mL. MRI reported a 463 cc prostate volume without focal lesions. First, the retropubic space was developed. Cystotomy was performed at the anterior bladder neck. A plane between the prostatic capsule and the surrounding fascia was dissected while carefully preserving the neurovascular bundles. Due to its large size, the prostate was divided into segments to facilitate its extraction. Hemostatic control and vesicourethral anastomosis were performed. RESULTS: Discharged on postoperative day 1 with a Jackson-Pratt drain and Foley catheter removed on days 6 and 9, respectively. Pathology was negative for malignancy. Patient-reported improvement of LUTS (IPSS: 3) and preservation of erectile function (SHIM: 23) at the 3-month follow-up. CONCLUSION: The intrafascial technique can be useful in cases where a large-sized prostate hinders a transvesical approach. Additionally, it allows for an easier piecemeal of the gland. A larger series is needed to determine its potential benefits.

Robotic Simultaneous Repair of Rectovesical Fistula With Vesicourethral Anastomotic Stricture after Radical Prostatectomy: Step-by-Step Technique and Outcomes.

OBJECTIVE: To report our experience and outcomes using a novel robotic technique for the simultaneous repair of rectovesical fistula (RVF) with vesicourethral anastomotic stricture (VUAS) after radical prostatectomy (RP). METHODS: Between 2019 and 2021, four consecutive patients who underwent robotic-assisted simultaneous repair of RVF with concurrent VUAS after RP were retrospectively reviewed. Baseline characteristics and perioperative outcomes were examined and reported. Complications were graded using the modified Clavien-Dindo classification system and the European Association of Urology Complications Panel Assessment and Recommendations. RESULTS: Four cases with a median age of 68.5 (63.3-72.3) years were treated. Interposition omentum flaps were used in all our cases. One case had perineal urethral mobilization to reach healthy urethral margins and tension-free vesicourethral anastomosis. Surgeries were uneventful, with no intraoperative complications reported. Median operative time, estimated blood loss, and length of hospital stay were 370 (291.3-453) minutes, 255 (175-262.5) mL, and 2.5 (2-3) days, respectively. Median Jackson-Pratt drains, Double-J stents and Foley catheter removal days were 6 (6-10), 38 (32-43), and 30 (27-41) days, respectively. No postoperative complications were reported. The median follow-up time was 16.25 (12-26) months, and no fistula recurrence was shown. CONCLUSION: Robotic-assisted laparoscopic repair could represent an effective approach for the simultaneous repair of RVF with concomitant VUAS. More studies and management standardization are needed to assess the role of the robotic platform in the simultaneous repair of RVF with VUAS after radical prostatectomy.

Cowper's gland syringocele in an adult: The great imitator.

Cowper's gland syringocele (CGS) is the cystic dilation of its duct. It is an uncommon urological condition and is thought to be more commonly encountered in pediatric urology. However, it is in adults that CGS poses a diagnostic challenge because of its "chameleon-like" clinical presentation that may masquerade multiple urological etiologies. In this population, where urological conditions are more prevalent, CGS may present as bladder outlet obstruction, recurrent urinary tract infections, gross hematuria, urinary retention, perineal pain, or abscess.

Superior Mesenteric Artery Injury during Robotic Radical Nephrectomy: Scenarios and Management Strategies.

Injury to the superior mesenteric artery (SMA) is a rare, underreported, and potentially devastating complication. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. Three different instances of intraoperative injury to the SMA are described in an accompanying video. All three occurred when the SMA was misidentified as the left renal artery during left robotic radical nephrectomy. In the first case, the SMA was mistakenly identified as the renal artery, but after further dissection, the real renal artery was identified and SMA injury was prevented. In the second case, the SMA was clipped and the real left renal artery was subsequently identified, requiring clip removal. In the third case, the SMA was clipped and completely transected, requiring prompt repair by vascular surgery with a successful outcome. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. The proper anatomic recognition of the SMA may prevent its injury. Intraoperative SMA injury should be promptly identified and repaired to avoid its devastating consequences.

Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies.

BACKGROUND: Obturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). OBJECTIVE: To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. SURGICAL PROCEDURE: ONI was identified during PLND and managed according to the type of nerve injury. RESULTS AND LIMITATIONS: The management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. CONCLUSIONS: ONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. PATIENT SUMMARY: We describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.

Robotic-assisted repair of colovesical anastomosis after Hartmann's reversal procedure.

PURPOSE: Hartmann's procedure is the resection of the rectosigmoid colon with an end colostomy formation and closure of the anorectal stump (1). Its reversal has a morbidity rate up to 58% (2, 3) with an incidence of fistulae formation of 4.08% (1). Herein, we present a robotic-assisted repair of a complex fistula that occurred as complication of Hartmann's reversal when the stapler was introduced inadvertently through the vaginal canal. PATIENT AND METHODS: Eighty-three-year-old female with past medical history of hysterectomy and ischemic colitis that required colectomy and colostomy placement in December 2020. In March 2022, the patient underwent a colostomy takedown, after which she reported fecaluria, urine leakage per vagina, and recurrent urinary tract infections. Cystoscopy and vaginoscopy revealed a large colovesical fistula, a staple in the bladder trigone, and several staples in the anterior vaginal wall. Robotically, extensive adhesiolysis was performed, the sigmoid was separated from the bladder, and the intact rectal stump was dissected free. The staple from the bladder trigone was removed. Bladder was closed in two layers with 3-0 V-Loc. Colorectal anastomosis was not feasible due to the short length of both ends. Therefore, a permanent colostomy was placed. RESULTS: Operative time was 454min., and estimated blood loss was 100cc. Discharged on postoperative day 4 with a JP drain and a 20Fr Foley catheter. Drain, and Foley were removed on postoperative days 9 and 23, respectively. No postoperative complications were reported. CONCLUSION: Robotic-assisted repair represents an effective approach for the management of colovesical fistulae after Hartmann's reversal.