Robotic Local Fat Extirpation and Ureteric Reimplantation for Pelvic Lipomatosis with Ureteric Obstruction: Technical Considerations.

BACKGROUND: Ureteric reimplantation is the treatment of choice for pelvic lipomatosis with ureteric obstruction. Pelvic adherent fat poses a technical challenge during this surgery. DESCRIPTION OF TECHNIQUE: We describe the robotic approach to facilitate the precise dissection of the ureter and bladder in adherent fat. After creating pneumoperitoneum and port placement, the ureter is exposed at the iliac crossing and dissected distally. Perivesical fat at the intended site of ureteric reimplantation is excised and cystotomy is done. Ureterovesical anastomosis is performed over a stent. PATIENTS AND METHODS: Two patients with pelvic lipomatosis causing ureteric obstruction and renal function impairment underwent robotic ureteric reimplantation at our institute. Technical aspects and outcomes are discussed here. RESULTS: Blood loss was minimal. No intra-operative or post-operative complication was noted. Renal function improved for both patients. CONCLUSION: Robotic approach helps to overcome the technical difficulties posed by adherent fat during ureteric reimplantation in pelvic lipomatosis.

Role of Retrograde Intrarenal Surgery in the Management of Diabetic Renal Papillary Necrosis.

Introduction: It is challenging to diagnose diabetic renal papillary necrosis (RPN) radiologically due to the limitation in performing a contrast study in patients with compromised renal function. Endoscopic management by Double 'J' (DJ) stenting or percutaneous nephrostomy is the preferred treatment. The aim of our study was to analyze the role of retrograde intrarenal surgery (RIRS) in the management of RPN by retrieving necrosed papillae. Methods: This retrospective study included diabetic patients who presented with acute pyelonephritis or urosepsis at our institute. After evaluating with appropriate laboratory and radiological investigations, retrograde pyelography (RGP) and DJ stenting were performed in those who did not respond to intravenous antibiotic therapy. The RIRS was performed in patients who had filling defects in the pelvicaliceal system (PCS) on RGP after 3 weeks at the time of DJ stent removal. Patients with a minimum follow-up period of 6 months were included. Results: A total of 187 patients (81 female, 106 male) with diabetes with a mean age of 58.3 years were enrolled in this study. The mean serum creatinine was 2.7 mg/dL and mean estimated glomerular filtration rate was 32.8 mL/min/1.73 m2. One hundred twenty-six patients (67.3%) had hydroureteronephrosis (HUN), out of whom 74 (58.7%) had necrosed papillae in the PCS. In 61 (32.6%) patients, there was no HUN; however, 25 (41%) of these patients had necrosed papillae in PCS. Necrosed renal papillae were retrieved in 83 patients (46.1%) by RIRS. All the patients were followed up for a minimum period of 6 months; seven patients (3.8%) had recurrent pyelonephritis. Conclusions: The RIRS plays a significant role in the management of diabetic RPN. Retrieving necrosed papillae from the PCS after confirming their presence by RGP prevents ureteric obstruction, which leads to urosepsis, and presumptively prevents or delays future episodes of pyelonephritis.

Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

ABSTRACT Introduction: The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1, 2). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1, 3, 4). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance. Material and methods: A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed. Result: Patient's postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section. Conclusion: We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.