Repositioning of Ureteropelvic Junction in Robot-assisted Laparoscopic Pyeloplasty.

OBJECTIVE: To describe the technique of ureteropelvic junction (UPJ) repositioning in robot-assisted dismembered pyeloplasty as a modified approach during which the UPJ is brought to a new location to facilitate the anastomosis. MATERIALS AND METHODS: Retrospective review of pediatric and adult cases of robot-assisted laparoscopic pyeloplasty performed between the years 2016 and 2022. In a select group of patients, repositioning of the UPJ was performed. Demographic data, surgical and post-surgical outcomes were compared to a group that underwent classical Anderson-Hynes (AH) dismembered pyeloplasty. RESULTS: Overall, 70 patients underwent robot-assisted laparoscopic dismembered pyeloplasty and were included in the study, with 15 in the repositioning group and 55 in the AH group. The median age of patients included was 26 months (interquartile range (IQR) 7-203). Median operative time was 140 minutes (IQR 129-192) and 170 minutes (IQR 135-207) for the repositioning and AH group, respectively. The indications for UPJ repositioning were high UPJ insertion (n = 8), crossing vessel (n = 5), and renal malformations (n = 2). Clinical significance was shown in the Society of Fetal Urology classification and split renal function postoperatively, respectively (P <.001; P <.01). Postoperatively, both groups showed improvement in anterior posterior diameter (APD) and diuretic T1/2 (P = 0.48). There was 1 case of surgical failure requiring revisional surgery in the repositioning group (6.6%) and 3 in the AH group (5.5%) (P >.05). Overall, there were 3 cases of Clavien-Dindo Grade 3 complications, all in the AH group (2 cases of urine leak from anastomosis, 1 case of port side hernia). CONCLUSION: Repositioning of the UPJ is optional in cases when the obstructed UPJ is in a suboptimal anatomical position.

Transvaginal surgical repair of large urethral diverticula with bipedicle double-opposing flaps of the periurethral fascia.

PURPOSE: The aims of this study were to describe a novel technique for transvaginal repair of large (> 4 cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up. METHODS: The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4 cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture. RESULTS: All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4 years yielded no recurrence and no other late complications. CONCLUSION: Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

Interobserver Agreement of the Estimated Contact Surface Area System for Renal Masses.

BACKGROUND: Nephrometry scores have been designed to assist in standardization of renal masses before nephron-sparing surgery. Estimated contact surface area (eCSA) has been recently described. However, its reproducibility between raters has not been rigorously explored. Our aim was to examine the reproducibility of eCSA and Radius, Exophytic, Nearness, Anterior, Line (RENAL) score (RS) nephrometry systems for renal masses by studying the interobserver agreement between 4 raters. MATERIALS AND METHODS: We reviewed the cross-sectional images (computed tomography, magnetic resonance imaging) of patients who underwent nephron-sparing surgery (open, laparoscopic, and robotic). Four urologists independently scored the renal tumors according to the eCSA and RS systems. Scoring was done separately for each nephrometry system. Interobserver agreement was assessed for total scores and separate components of each system by calculating the intraclass correlation coefficient (ICC). RESULTS: Ninety patients were scored to achieve power of 83% with α = 0.05. eCSA and RS demonstrated excellent interobserver agreement (ICC = 0.89 for both). The radius component of eCSA and RS had the highest ICC (0.97 and 0.9, respectively) compared with the other components. Location and anterior/posterior components of RS showed poor interobserver correlation (ICC = 0.69 and 0.50, respectively). Maximal difference in RS complexity group assignment was 1 of 43 (47.8%) of cases. CONCLUSION: eCSA has excellent interobserver agreement, similar to RS. Directly measurable anatomic variables have better interobserver correlation compared with qualitative variables. These results strengthen the applicability of eCSA as a surgical complexity metric for renal surgery.

Thromboembolic events in patients with severe inherited fibrinogen deficiency.

Inherited afibrinogenemia and hypofibrinogenemia are rare bleeding disorders characterized by markedly reduced levels of fibrinogen in blood. Thrombotic complications in these disorders have been rarely described. We performed a multicenter retrospective study and reviewed the occurrence of thrombotic complications among patients with inherited fibrinogen deficiency. Cases were identified during a review of medical records of all patients with inherited fibrinogen deficiency followed at three different university hospitals in Israel. Nine patients were included in this study: five were afibrinogenemic and four hypofibrinogenemic. There were seven thrombotic events, mostly venous, that occurred in four out of nine patients (44 %). All thrombotic events occurred in afibrinogenemic patients. Mean age at the time of thrombosis was 45 (range 28-61) years. Thrombophilic evaluation performed was negative in all cases. At the time of thrombosis in five out of seven (71.4 %) events, fibrinogen replacement therapy was concurrently given. Therapeutic approach was different among patients ranging from supportive therapy alone, antiplatelet agents and anticoagulant therapy with the concurrent administration of fibrinogen replacement therapy. This study discloses a high rate of thrombosis in patients with afibrinogenemia. Events were both venous and arterial and may be recurrent. Management is highly problematic due to the precarious balance between bleeding and thrombotic risk in these patients. Fibrinogen replacement therapy should be cautiously used in these patients as most thrombotic events followed the administration of fibrinogen replacement therapy. Larger cohorts are warranted to better characterize the best management strategy in these paradoxical events.