Robotic-assisted native pyeloureterostomy with indocyanine green, after kidney transplantation.

INTRODUCTION: Postoperative ureteral strictures and vesicoureteral reflux after ureteroneocystostomy for kidney transplant can be managed by endoscopic procedures like balloon dilation and endoscopic injections. Complicated/recurrent cases, however, are usually managed by reconstructive surgery. We hereby highlight our technique of robotic-assisted native pyeloureterostomy with indocyanine green (ICG). MATERIALS AND SURGICAL TECHNIQUE: A 57-year-old woman, diagnosed with grade 4 vesicoureteral reflux on her transplanted kidney, was considered a candidate for ureteral reimplantation. After an endoscopic part, where the ICG is inserted into the renal pelvis, we proceed with the robotic native pyeloureterostomy. The renal pelvis of the transplanted kidney was identified with the help of the ICG in firefly mode. After the dissection of the graft pelvis, we performed a tension-free pyeloureterostomy using the native ureter. The postoperative course was uneventful and the patient was discharged on the third postoperative day. DISCUSSION: Robotic-assisted pyelo-ureterostomy appears as a safe and efficient technique for management of complicated urological complications postrenal transplantation using the native ureter. Intrapelvic ICG injection, not possible with open surgery, helps identifying the grafted pelvis thus reducing operative time and avoiding unnecessary dissection of the vascular hilum of the graft. Because of minimal dissection and the short operative time, abdominal drainage is unnecessary and the postoperative course is usually uneventful with a fast discharge from the hospital.

[Ipsilateral ureteroureterostomy. A safe alternative in complete duplicated collecting system with associated pathology]. / Uretero-ureteroanastomosis distal ipsilateral. Una alternativa segura en doble sistema renal completo con patología asociada.

In patients with complete double renal system with the involvement of only one system, there are several surgical alternatives for its resolution. Uretero-ureteral anastomosis has been presented as a good alternative, even in cases with atrophy of the affected system. OBJECTIVE: To report our experience in patients with complete double renal system with only one system affected, with the surgical technique of uretero-ureteral anastomosis. PATIENTS AND METHOD: Retrospective study of patients with double renal system with involvement of one of the systems, treated with uretero-ureteral anastomosis technique between January 2015 and May 2022. The variables of age, specific pathology of the affected system, preoperative study, days of hospitalization, postoperative complications (leakage, obstruction, infection), and follow-up time were evaluated. RESULTS: We analyzed 26 procedures in 25 patients, mean age 36.8 months (range: 8-80); 53.8% had ectopic ureter, 23% ureterocele, 11.5% sphincteric ureterocele, and 11.5% VUR of the lower system. All were studied preoperatively with urethrocystography and 65% with scintigraphy. 50% of the operated systems showed signs of renal atrophy. The average hospital stay was 2.2 days (range: 1-7). In an average follow-up of 26.5 months (range: 3-77), one patient presented leakage, no patient presented signs suggestive of obstruction, and one patient presented febrile urinary tract infection with persistent lower-grade reflux. CONCLUSION: In our experience, the uretero-ureteral anastomosis technique proved to be an easy and safe alternative to reproduce, with a success rate of 96%, 11% of grade I complications, and 4% of grade II complications according to the Clavien-Dindo classification.

Robotic-assisted radical cystectomy with cutaneous ureterostomies: a contemporary multicenter analysis.

BACKGROUND: Robotic-assisted radical cystectomy (RARC) offers decreased blood loss during surgery, shorter hospital length of stay, and lower risk for thromboembolic events without hindering oncological outcomes. Cutaneous ureterostomies (UCS) are a seldom utilized diversion that can be a suitable alternative for a selected group of patients with competing co-morbidities and limited life expectancy. OBJECTIVE: To describe operative and perioperative characteristics as well as oncological outcomes for patients that underwent RARC + UCS. METHODS: Patients that underwent RARC + UCS during 2013-2023 in 3 centers (EU = 2, US = 1) were identified in a prospectively maintained database. Baseline characteristics, pathological, and oncological outcomes were analyzed. Descriptive statistics and survival analysis were performed using R language version 4.3.1. RESULTS: Sixty-nine patients were included. The median age was 77 years (IQR 70-80) and the median follow-up time was 11 months (IQR 4-20). Ten patients were ASA 4 (14.5%). Nine patients underwent palliative cystectomy (13%). The median operation time was 241 min (IQR 202-290), and the median hospital stay was 8 days (IQR 6-11). The 30-day complication rate was 55.1% (grade ≥ 3a was 14.4%), and the 30-day readmission rate was 17.4%. Eleven patients developed metastatic recurrence (15.9%), and 14 patients (20.2%) died during the follow-up period. Overall survival at 6, 12, and 24 months was 84%, 81%, and 73%, respectively. CONCLUSIONS: RARC + UCS may offer lower complication and readmission rates without the need to perform enteric anastomosis, it can be considered in a selected group of patients with competing co-morbidities, or limited life expectancy. Larger prospective studies are necessary to validate these results.

Modified Tubeless Ureterocutaneostomy in High-Risk Patients After Radical Cystectomy and its Long-Term Clinical Outcomes.

OBJECTIVES: This work aimed to prevent stoma stenosis and achieve tubeless cutaneous ureterostomy in elderly and high-risk patients with our modified cutaneous ureterostomy. METHODS: We retrospectively analyzed 40 and 49 patients (176 renal units) who underwent Toyoda (group 1) and modified cutaneous ureterostomy (group 2) between 2012 and 2021. The average follow-up period was 44 months. The primary results of our study were the catheter-free rate and clinical outcomes, especially renal function and urinary diversion-related complications. Significant differences in catheter-free rate and urinary diversion-related complications were found between our modified method and the Toyoda technique. RESULTS: A total of 56 (71.8%) of 78 renal units in group 1 and 89 (90.8%) of 98 renal units in group 2 remained catheter free. Compared with group 1, group 2 had a higher catheter-free rate (P = .001). Multivariate analysis indicated that the surgical procedure (HR = 0.268; P = .001) and body mass index (HR = 3.127; P = .002) were the predictors independently associated with catheter insertion. During follow-up, renal deterioration was observed in 32 (36.0%) patients. Patients with catheter insertion were more likely to suffer from renal deterioration (P < .001), postoperative pyelonephritis (P < .001), and urolithiasis (P < .001) than their counterparts. CONCLUSION: Our modified cutaneous ureterostomy method may provide an effective and simple approach to tubeless cutaneous ureterostomy in elderly and high-risk patients.

Analysis of the efficacy of a single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy.

BACKGROUND: Radical cystectomy and urinary diversion are the standard surgical treatments for patients with muscle-invasive or high-risk, or recurrent non-muscle-invasive bladder cancer. Although this approach significantly prolongs patient survival, it can lead to postoperative complications. This study aims to compare the efficacy and complications of bilateral cutaneous ureterostomy with a single subumbilical stoma to those of cutaneous ureterostomy with two stomas and an ileal conduit as a means of urinary diversion after radical cystectomy. The findings of this study will provide valuable information for healthcare providers in selecting the appropriate urinary diversion method for their patients. METHODS: The clinical data for 108 patients who received bilateral cutaneous ureterostomy with a single subumbilical stoma (ureterostomy with a single stoma group), cutaneous ureterostomy with two stomas (ureterostomy with two stomas group), or an ileal conduit (ileal conduit group) after radical cystectomy were retrospectively analysed. The operative time, pathological stage, survival status, perioperative complication rate, rate of successful first extubation, rehospitalization rate at 6 months after surgery,ostomy-related medical costs,and postoperative quality of life were compared between the three groups of patients. RESULTS: A significant difference in the operative time was found between the three groups (P = 0.001). No significant differences in pathological stage, survival status, perioperative complication rate, rehospitalization rate at 6 months after surgery, or bladder cancer index (BCI) score were identified among the three groups. The difference in the successful first extubation rate between the three groups of patients was significant (P = 0.001). Significant differences in ostomy-related medical costs were observed among the three groups of patients (P = 0.006). CONCLUSION: A single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy may result in shorter surgery time, increased success rates for initial catheter removal, and lower medical expenses. However, to confirm these findings, further prospective randomized clinical trials are necessary.

Primary repair vs Delayed staged repair in infants with primary obstructive megaureters and their long term outcomes - A single centre experience.

BACKGROUND: There is paucity of literature in the management of infants with primary obstructive megaureters undergoing upfront primary repair with an extravesical technique of ureteral re implantation (with or without ureteral tailoring). OBJECTIVE: To compare 2 different approaches in the management of infants with unilateral primary obstructive megaureters. STUDY DESIGN: This was a retrospective analysis of a prospectively maintained data base between 2005 and 2021. Infants <1 year with unilateral primary obstructive megaureter were included. They were divided into 2 groups: those who underwent an upfront extravesical ureteric reimplantation with or without ureteral tailoring during infancy -Primary Repair (PR), and those who initially underwent a low end cutaneous ureterostomy during infancy followed by take down of ureterostomy and intravesical ureteric reimplantation after 1 year of age -Delayed staged repair (DSR). Children presenting with sepsis, in whom a diversion was imperative, were excluded. All children were followed up annually after their definitive repair with a renal ultrasound, diuretic renogram, estimated glomerular filtration rate and assessment of voiding dysfunction if present. The 1st year and 3rd year follow up details were collated and analysed. Failure was defined as persistent obstructive pattern on renogram with worsening differential renal function or presence of high grade reflux with recurrent breakthrough urinary tract infection; both of which necessitated a redo reimplantation following the definitive surgery. RESULTS: There were 18 infants in Primary repair and 16 infants in Delayed Staged Repair. Urinary tract infections was the commonest presenting symptom amongst both groups i.e. > 50%.The post operative complication rate was 11% in Primary repair and 31% in Delayed Staged Repair. One child in each of the groups (2 girls) required redo reimplantation (5.8%). At the end of the 3rd year follow up (from the definitive repair) there was significant reduction in the hydronephrosis, improvement in the differential renal function with no evidence of obstruction and improvement in the estimated glomerular filtration rate amongst all in both groups which was statistically significant i.e. p < 0.05. The success rate was 94.4% in Primary Repair and 93.75% in Delayed Staged Repair. The mean follow up was 9.7 years amongst those undergone Primary Repair and 9 years amongst those undergone Delayed Staged Repair. DISCUSSION AND CONCLUSION: Primary extravesical ureteral reimplantation may be considered as the preferred line of management of unilateral obstructed megaureters during infancy.

Bilateral Ureterovesical Junction Obstruction Resulting in Anuria in a 3-Week-Old Infant.

Bilateral megaureter with ureterovesical junction obstruction is exceedingly rare. We present a case of a 3-week-old boy who presented in acute renal failure and found to have bilateral megaureter. He was initially decompressed with bilateral percutaneous nephrostomy tubes and once stable underwent bilateral ureterostomy. At 6 months old, renal ultrasound showed stable mild right sided hydronephrosis.

Trends in ureteral surgery on an academic gynecologic oncology service.

OBJECTIVE: To describe the incidence, complications, and trends associated with ureteral surgeries on a gynecologic oncology service in the context of a fellowship training program over a 24-year period. METHODS: We conducted a retrospective cohort analysis of ureteral surgeries by gynecologic oncologists at either Moffitt Cancer Center or Tampa General Hospital from 1997 to 2020. Patient characteristics, predisposing factors, location and type of injury, repair method, postoperative management and complications were abstracted from the medical record. The recent cohort (2005-2020) was compared to our prior series (1997-2004). RESULTS: Eighty-eight cases were included. The average number of ureteral surgeries per year decreased from 5.75 (1997-2004) to 2.63 (2005-2020). Of 46 iatrogenic injuries, 45 were recognized and repaired intraoperatively. Ureteral transection was the most common type (85% [39 of 46]) and the distal 5 cm was the most common location of injury (63% [29 of 46]). Ureteroneocystostomy was the most common method of repair (83% [73 of 88]). Postoperative management, including stenting and imaging, has not changed significantly. Length of urinary catheter usage decreased in the recent cohort without associated complications. Five patients had major postoperative complications and 4 involved the urinary tract. Of those with follow-up, 96% (66 of 69) of ureteroneocystostomies and 75% (9 of 12) of ureteroureterostomies had radiologically normal urinary tracts. CONCLUSIONS: Ureteral surgery is necessary in the case of injury or involvement with invasive disease. There has been a decrease in number of procedures. Ureteroneocystostomy has remained the most common method of reconstruction for both injury and resection with acceptable postoperative complication rates.

Laparoscopic ureterolithotomy and retrograde flexible ureteroscopy-assisted transperitoneal laparoscopic ureteroureterostomy for a huge ureteropelvic junction stone and multiple small renal stones: A CARE-compliant case report.

RATIONALE: Concurrent kidney and ureteral stones are always complicated and a clinical challenge. Improvements in endoscopic equipment have led to the widespread adoption of retrograde intrarenal surgery, which has a good stone clearance rate. On the other hand, laparoscopic ureterolithotomy (LUL) has been reported to be non-inferior to retrograde flexible ureteroscopy in stone-free rate and the need for axillary procedures, and to have a significantly lower rate of post-operative sepsis compared to retrograde flexible ureteroscopy. We describe a case managed with LUL followed by laparoscope-assisted retrograde intrarenal surgery (LA-RIRS) in a single operation for a large upper ureteral stone and small renal stones, which is usually challenging and requires axillary procedures. PATIENT CONCERNS: The patient was a 66-year-old male with underlying hypertension and diabetes mellitus. He reported severe flank pain after receiving endoscopic management of concurrent right ureteropelvic junction stone and multiple renal stones about 1 month previously. DIAGNOSIS: The residual stones were reassessed using non-contrast computed tomography before surgery. A 2.8-cm residual ureteropelvic junction stone and multiple renal stones with a maximum length of 1 cm were found. A second operation was considered to be necessary due to the deterioration of his renal function and refractory flank pain. INTERVENTIONS: We performed LUL followed by LA-RIRS. Two surgeries were completed in a single operation. The Jackson-Pratt drain was removed 3 days after the operation. OUTCOMES: After the surgery, no high-grade complications were recorded according to the Clavien Dindo classification. A follow-up kidney, ureter, and bladder radiograph performed 2 months after the operation revealed no residual stones. Renal echo revealed no obstructive nephropathy 1 month after double-J catheter removal. CONCLUSION: LUL with LA-RIRS with a stone basket for renal stone extraction is a safe and feasible technique, and no step surgery or axillary procedures were needed in our case. If clinical cases with a huge stone burden over the ureter are indicated for LUL with concurrent small renal stones, LUL with LA-RIRS can be an alternative option.

Laparoscopic-assisted cutaneous ureterostomy in a canine patient with prostatic carcinoma.

A 9-year-old neutered male Dachshund dog was assessed for stranguria. An enlarged prostate was identified on physical examination, and a diagnosis of prostatic carcinoma confirmed by cytology. Due to a neoplastic lower urinary tract obstruction, palliative surgical urinary diversion treatment was performed with laparoscopic assisted cutaneous ureterostomy (LACU). The dog recovered well without any major complications. Adjuvant chemotherapy was maintained and continued for post-surgical medical therapy. This report describes a novel minimally invasive assisted technique in canine patients for palliative treatment of prostatic neoplasia.

[The role of open surgery in the treatment of patients with a history of extended and postinfectious ureteral stricture: a case report]. / La place de la chirurgie à ciel ouvert dans la reprise de la sténose urétérale étendue, ancienne et post infectieuse: à propos d'un cas.

The purpose of this study is to highlight the role of open surgery in the treatment of patients with a history of extended and postinfectious ureteral stricture as well as our experience with therapy. The study involved a 38-year old patient presenting at the urology service of the University Clinics of Lubumbashi with left lumbar pain, burning sensation during urination and fever. Clinical and paraclinical assessment showed extended ureteral stricture. Temporary urinary diversion (left ureterostomy) was performed followed by ureterectomy and left ureterovesical reimplantation. The postoperative course was simple. Three months after surgery the patient had no complaints, creatinine levels were normal, ultrasound and uroscan results were normal.

Hydronephrosis and Hydroureter Improvement Rates in Robotic-Assisted Laparoscopic Uretero-Ureterostomies: Does Anastomotic Site Matter?

OBJECTIVE: To compare improvement/change of hydronephrosis and hydroureter in patients with complete ureteral duplications that underwent upper and lower robotic-assisted laparoscopic uretero-ureterostomies. The hypothesis being that improvement of hydronephrosis and hydroureter between the two groups was similar. METHODS: 35 subjects met inclusion criteria and were reviewed retrospectively. 'Upper' anastomoses were defined as those being done below the lower pole of the kidney (Group 1), while 'lower' anastomoses were those done below the iliac vessels (Group 2). Primary variables analyzed were antero-posterior and diameter measurements of the renal pelvis and ureter, respectively, before and after surgery. Secondary variables included operative time, length of hospital stay, and complication rates. RESULTS: Group 1 consisted of 20 subjects while Group 2 consisted of 15 subjects. Presenting diagnoses were hydronephrosis in 31 subjects and incontinence in 4 subjects. Group 1 mean AP renal diameters decreased by 62.9% (P<.05), while Group 2 decreased by 65.4% (P<.05). Group 1 mean hydroureter diameter measurements decreased by 80.3% (P<.05), while Group 2 decreased by 83% (P<.05). The improvement in hydronephrosis and hydroureter between the two groups was not statistically different. Group 1 median operative time (271 minutes) was longer than Group 2 (201 minutes) (P<.05). There was no significant difference in hospital stay between the groups and there were no significant complications within the cohort. CONCLUSION: The improvement rate of hydronephrosis and hydroureter is similar in upper versus lower RAL UU. Operative time was significantly shorter in the lower anastomosis group.

Robot-assisted Transplant Ureteral Repair to Treat Transplant Ureteral Strictures in Patients after Robot-assisted Kidney Transplant: A Case Series.

OBJECTIVE: To describe the use of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in 3 patients who had undergone robot assisted kidney transplant (RAKT). METHOD: We reviewed the medical records of 3 patients who experienced TUS after RAKT and who underwent RATUR between 2017 and 2020. The patients' RAKT, post-transplant clinical course, endourological interventions, reoperation, and recovery were assessed. RESULTS: All patients diagnosed with TUS presented with deterioration of kidney function after RAKT. Method of diagnosis included ultrasound, antegrade ureterogram, and CT scan. All 3 patients had a short (<1 cm) area of TUS and underwent RATUR. For 2 patients, distal strictures were bypassed with modified Lich-Gregoir ureteroneocystostomy reimplantation. One patient was treated with pyelo-ureterostomy to the contralateral native ureter. No intraoperative complications, conversions to open surgery, or significant operative blood loss requiring blood transfusion for any patient were observed. Also, no patients had urine leaks in the immediate or late postoperative period. After RATUR, 2 patients developed Clavien grade II complications with rectus hematoma or urinary tract infection. CONCLUSION: RATUR is a technically feasible operation for kidney transplant patients with TUS after RAKT. This procedure may provide the same benefits of open operation without promoting certain comorbidities that may occur from open surgical procedures.

Paediatric bladder neurofibroma on bilateral ureterostomy: rare case report-strategic management.

Urogenital involvement in neurofibromatosis is extremely rare and thus is less documented. Herein, we discuss a 11-year-old boy who was referred with a diagnosis of neurofibroma bladder on bilateral flank ureterostomy with mild renal failure. A diagnosis of neurofibroma of the bladder with ureterohydronephrosis had been made and partial excision had been attempted, followed by bilateral ureterostomy because of increasing ureterohydronephrosis. He was 13 years and wanted to be dry as he wanted to go to school. With the plan of attaining dryness with stable upper tracts, he was posted for surgery. Near-total excision followed by a sigmoid conduit was performed. The biopsy was reported as plexiform neurofibroma and is on regular follow-up, dry on a stoma bag with stable renal parameters.

Modified Leadbetter-Politano Ureteroneocystostomy: A Safer Procedure.

PURPOSE: Open surgical reimplantation of ureters is a highly successful procedure, with reported correction rates of 95 to 99 percent regardless of the severity of vesicoureteral reflux (VUR). Leadbetter-Politano ureteroneocystostomy is one of the most preffered technique for open ureteroneocystostomy.  The authors report the modified Politano-Leadbetter technique with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Materials and Methods: Fifty-seven children with unilateral VUR, underwent modified Leadbetter-Politano ureteral reimplantation with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Persistence of VUR despite endoscopic correction, breakthrough infections, complications due to antibiotics, progressive renal scarring, reflux nephropathy, and parental preference were indications for open reimplantation. Operations were done by two full-time pediatric surgeons. Operation time and hospital stay of the patients, reflux persistency, voiding dysfunction and complications were recorded.  Results: No ipsilateral VUR was detected postoperatively. Mean operation time was 76.54 min (±8.76 min; range, 70-86 min) Mean duration of the hospital stay is 82.31 h (±9.78 h; range, 71-93 h). Postoperative gross hematuria was not seen in any patients. No voiding dysfunction and no late complications was encountered.  Conclusions: Modified Leadbetter-Politano technique is a good option to treat VUR with success rate up to 100% without any major complicatons such as viscus perforation and ureteral obstruction. It is a rather simple technique that require less operative time.

Robot-Assisted Pyeloureterostomy in the Treatment of the Lower Pole Ureteropelvic Junction Obstruction in an Incomplete Duplicated System.

PURPOSE: To describe the surgical treatment of a patient harboring a ureteropelvic junction obstruction in the lower unit of an incomplete duplicated collecting system. METHODS: A female patient with 32-year old presented a progressively increasing left lumbar pain for 1 year and urinary tract infections for the past 10 years. Computed tomography demonstrated a ureteropelvic junction obstruction in the lower unit of an incomplete duplicated urinary collecting system. RESULTS: The patient underwent a robot-assisted pyeloureterostomy. The surgical time was 118 minutes and there was no intraoperative complication. During surgery, anomalous vessels crossing to the lower pole of the kidney were identified. The bladder catheter and abdominal drain were removed at the first- and second postoperative days. The length of the hospital stay was 2 days and the postoperative course was uneventful. The double-J stent was retrieved 4 weeks after surgery. At 18 months of follow-up, the patient had complete pain resolution and no new episodes of urinary tract infections. The control image exam revealed minimal residual hydronephrosis. CONCLUSION: Robot-assisted pyeloureterostomy was an effective approach to the present case. Many times, the surgical strategy for patients with anatomic variants is determined intra-operatively. The surgeon must have a wide range of skills and be prepared for a timely decision.

Health-related quality of life in patients undergoing radical cystectomy with modified single stoma cutaneous ureterostomy, bilateral cutaneous ureterostomy and ileal conduit.

PURPOSE: To compare the clinical outcomes and patients' health-related quality of life (HR-QoL) with modified single stoma cutaneous ureterostomy (MCU), bilateral standard cutaneous ureterostomy (SCU) and ileal conduit (IC) using validated diversion-specific HR-QoL instrument. METHODS: The study included 70 patients who underwent open radical cystectomy with either MCU, SCU, or IC from May 2017 to May 2018. In total 23, 25 and 22 patients were included in each group, respectively, after applying the following exclusion criteria: female, pre- and postoperative radio and chemotherapy, palliative surgery. HR-QoL was evaluated using the European Association of Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC-QLQ-C30) and Functional Assessment of Cancer Therapy for patients undergoing radical cystectomy (FACT-Bl-Cys). RESULTS: Global health status per EORTC-QLQ-C30 was the only domain that was found to be statistically better in the IC group compared to MCU (p = 0.007). Higher scores in additional concerns (p = 0.008), functional health domains (p = 0.002), satisfaction from urinary diversion (p = 0.004), and total score (p = 0.027) per FACT-Bl-Cys questionnaire, global health status (p < 0.001), and symptom scale (p = 0.017) per EORTC-QLQ-C30 were observed in IC compered to SCU. Patients with MCU had better scores of functional health (p = 0.012), satisfaction from urinary diversion (p = 0.001), and global health status (p = 0.008) than SCU. CONCLUSION: IC is associated with better quality of life scores compared to SCU and similar scores compared to MCU. MCU possesses better scores of HR-QoL domains compared to SCU. Our results suggest that MCU should be preferred in patients requiring SCU and could be considered for patients requiring IC.

Robotic surgery in infants and children: an argument for smaller and fewer incisions.

PURPOSE: Robotic-assisted laparoscopic (RAL) surgery has gained momentum in pediatric urology. Technological adaptations such as the development of 5 mm instruments have led to robotic procedures being performed on younger children and those having smaller body habitus, with improved cosmesis. However, concerns have been raised regarding decreased intra-abdominal working space and the absence of monopolar curved scissors (hot endoshears®) when using 5 mm instruments. The aim of this study is to examine the overall experience at a single pediatric urology center using 5 mm instruments with no planned additional assistant ports during common robotic procedures. We hypothesized this approach is safe and feasible for a variety of pediatric urologic reconstructive procedures. METHODS: We retrospectively reviewed all major robotic procedures entered into an IRB approved data registry. The analysis was performed only for procedures in which 5 mm instruments were used exclusively with hook diathermy. Procedures that utilized 8 mm instrumentation were excluded from the study. Data were abstracted according to patient age, weight and robotic surgery performed. Outcomes included post-operative complications (Clavien-Dindo classification), operative time, operative blood loss, need for assistant port placement and conversion rates to open or pure laparoscopic surgery. RESULTS: From 2012 to 2016, 220 consecutive pediatric RAL urological surgical cases were performed on 201 patients. These comprised pyeloplasty (n = 102) 46.4%, ureteral reimplants (n = 84) 38.2% and ipsilateral ureteroureterostomy (n = 34) 15.5%. Median age at surgery was 4 years (3 months to 18 years). There were no conversions to open or laparoscopic surgery. Placement of an additional Assist port was documented in seven cases. Severe (Clavien grade 4) complications occurred in two patients requiring ICU admission: one for sepsis and one ventilator-dependent patient having increased work of breathing post-op. Intra-operative blood loss was minimal ( < 50 ml) in 97% of cases. Patients ≤ 1 year of age comprised 28.6% of the study population. Univariate analysis revealed no association between age and occurrence of complications (p = 0.957) CONCLUSIONS: This study represents one of the largest series of consecutive RAL surgery using 5 mm instruments in pediatric urology. Acceptable complication rates, OR times and blood loss were achieved using this technique. We conclude that the use of 5 mm instruments gives excellent operative outcomes in pediatric reconstructive procedures.

Laparoscopic retroperitoneal approach for retrocaval ureter in children.

PURPOSE: Retrocaval ureter (RCU) is a rare congenital anomaly and published data on pediatric laparoscopic management are poor. The aim of this study was to report our experience of retroperitoneal laparoscopic approach for management of RCU in children. METHODS: A retrospective review of data from patients treated for RCU between 2002 and 2018 in our institution was performed. All patients were positioned in a flank position and underwent a three-port (5-mm optical trocar and two 3-mm trocars) laparoscopic retroperitoneal ureteroureterostomy. Anastomosis was made by 6/0 absorbable sutures. A JJ stent was always inserted. RESULTS: Five patients with a median age of 94 months (5-152) were operated on and followed up for a median time of 103 months (46-201). Median operating time was 200 min (160-270). No conversion and no transfusion occurred. Median hospital stay was 2 days (1-4). Ureteral stent was removed after 52 days (47-82). Complications included pyelonephretis (N = 1). In all cases, hydronephrosis decreased postoperatively. CONCLUSIONS: Retroperitoneal laparoscopic approach for RCU is safe and effective in children. Our video demonstrates different patients with specific surgical details to show how to manage these children. The global vision of the upper tract by laparoscopy leads to optimal management of these children even if the anomaly was not detected preoperatively.

Evaluation of the residual prostate cancer rate on cystoprostatectomy specimen in patients treated with radiotherapy for prostate cancer.

PURPOSE: To evaluate the residual cancer rate after cystoprostatectomy (CPT) in patients with a history of radiation therapy for prostate cancer and the postoperative complication rates. MATERIAL AND METHODS: We conducted a retrospective study involving 21 patients who had a CPT over 7 years and who had a history of radiotherapy for prostate cancer. To compare results, two additional groups were created: a group of patients without a history of radiotherapy in whom a CPT was performed, and a group without a history of radiotherapy and in whom was accidentally discovered a prostate cancer after CPT on histology specimens. RESULTS: The median age at the time of radiotherapy was 69 years. The median age at the time of cystoprostatectomy was 78 years. The median PSA at the time of the intervention was 0.6 ng/ml in the group with a history of radiotherapy. The residual cancer rate was 24%. No patients had criteria for biological recurrence. There were no additional surgical complications in the radiotherapy group (p = 0.2). The rate of cutaneous ureterostomy was higher (p = 0.0006) due to increased surgical difficulties (p = 0.0009). CONCLUSION: The residual cancer rate was 24% after radiotherapy for prostate cancer. PSA alone does not appear to be sufficient to detect the persistence of residual prostate cancer after radiotherapy. There were no more surgical complications after prostate radiotherapy.