Completely intracorporeal robotic renal autotransplantation.

PURPOSE: We describe a technique of complete intracorporeal renal autotransplantation with donor nephrectomy and transplantation performed in a minimally invasive fashion without extracting the kidney. MATERIALS AND METHODS: We developed this technique of a completely intracorporeal robotic renal autotransplantation and determined the feasibility of this novel procedure. This includes a method of intracorporeal transarterial hypothermic renal perfusion using a perfusion catheter through a laparoscopic port. The procedure was successfully applied in a 56-year-old man with extensive left ureteral loss after failed ureteroscopy for ureterolithiasis. RESULTS: Robotic donor nephrectomy was performed with a warm ischemia time of 2.3 minutes. Subsequently cold ischemia was achieved by intracorporeal hypothermic renal perfusion for 95.5 minutes. Vascular anastomoses and ureteroureterostomy in the ipsilateral pelvis were completed after donor nephrectomy with a total overall surgeon console time of 334 minutes. Venous and arterial anastomosis times were 17.3 and 21.3 minutes, respectively. Estimated blood loss was less than 50 ml. There were no complications and the patient was discharged home on postoperative day 1 after normal Doppler transplant renal ultrasound. Postoperative renal scan at 6 weeks, intravenous urogram at 8 weeks and computerized tomography urography at 5 months revealed normal function and successful ureteral reconstruction. CONCLUSIONS: We report the feasibility of a technique of a completely intracorporeal robotic renal autotransplantation. This operation may be considered in select patients in the hands of experienced robotic surgeons. However, further refinement is required as this novel procedure is cautiously reproduced and adopted by others.

Optimization of near infrared fluorescence tumor localization during robotic partial nephrectomy.

PURPOSE: Near infrared fluorescence allows the differentiation of tumors and normal parenchyma during robotic partial nephrectomy. This may facilitate tumor excision but requires proper dosing of indocyanine green. Under dosing causes inadequate fluorescence of peritumor parenchyma. Overdosing causes tumors to fluoresce inappropriately. Currently there are no described dosing strategies to our knowledge to optimize near infrared fluorescence and reported doses vary widely. We devised a dosing strategy and assessed the reliability of near infrared fluorescence for differential fluorescence. MATERIALS AND METHODS: Robotic partial nephrectomy with near infrared fluorescence was performed for 79 tumors. Dosing strategy involved at minimum 2 indocyanine green doses, including the test dose and the calibrated dose before resection. The test dose was deliberately low to avoid confounding over-fluorescence. The second dose was calibrated depending on the extent of differential fluorescence achieved with the test doses. Intraoperative assessment of tumor fluorescence was recorded before pathological assessment. RESULTS: Mean tumor size was 3.5 cm (range 1.1 to 9.8) with a mean R.E.N.A.L. score of 8 (range 4 to 12). Median indocyanine green test dose and re-dose before clamping were 1.25 mg (range 0.625 to 2.5) and 1.875 mg (range 0.625 to 5), respectively. Differential fluorescence was achieved in 65 of 79 tumors (82%) that did not fluoresce. After 3 exclusions for the inability to assess fluorescence or indeterminate histology, 60 of 76 tumors were renal cell carcinoma. Of 60 renal cell carcinomas 55 behaved appropriately and did not fluoresce (92%). Overall 65 of 76 tumors behaved appropriately for an 86% agreement between histology and near infrared fluorescence behavior. CONCLUSIONS: With our dosing regimen near infrared fluorescence was highly reliable in achieving differential fluorescence of kidney and renal cell carcinomas. Standardized dosing is needed before deciding whether near infrared fluorescence improves robotic partial nephrectomy outcomes and additional studies may further improve reliability.

Health related quality of life for stone formers.

PURPOSE: Urolithiasis is a common urological condition that causes significant pain and suffering. Until recently few studies had been done to examine how quality of life is affected in stone formers. We hypothesized that patients with multiple recurrent episodes of urolithiasis have worse health related quality of life. Thus, we identified specific factors that impact health related quality of life in patients with urolithiasis. MATERIALS AND METHODS: In an institutional review board approved study we recruited 386 patients through mailings and through the outpatient clinic who were evaluated at our institution for urolithiasis in the last 5 years. Each patient was asked to answer questionnaires on stone disease, including SF-36®, a validated 36-item health care quality of life survey. RESULTS: Of the 386 patients recruited for study 115 responded to our inquiry. Variables such as surgical complications, time from last stone episode, number of emergency room visits and number of surgeries correlated with the SF-36 domains. CONCLUSIONS: Urolithiasis is associated with severe physical and psychological effects that lead to clinically significant impairment in quality of life. Our findings confirm and expand the findings of previous groups showing the many ways in which stone formation can affect patient quality of life. Appreciation of these effects in the acute and chronic treatment settings may change the way that the disease is approached.

WNK kinases regulate thiazide-sensitive Na-Cl cotransport.

Pseudohypoaldosteronism type II (PHAII) is an autosomal dominant disorder of hyperkalemia and hypertension. Mutations in two members of the WNK kinase family, WNK1 and WNK4, cause the disease. WNK1 mutations are believed to increase WNK1 expression; the effect of WNK4 mutations remains unknown. The clinical phenotype of PHAII is opposite to Gitelman syndrome, a disease caused by dysfunction of the thiazide-sensitive Na-Cl cotransporter. We tested the hypothesis that WNK kinases regulate the mammalian thiazide-sensitive Na-Cl cotransporter (NCC). Mouse WNK4 was cloned and expressed in Xenopus oocytes with or without NCC. Coexpression with WNK4 suppressed NCC activity by more than 85%. This effect did not result from defects in NCC synthesis or processing, but was associated with an 85% reduction in NCC abundance at the plasma membrane. Unlike WNK4, WNK1 did not affect NCC activity directly. WNK1, however, completely prevented WNK4 inhibition of NCC. Some WNK4 mutations that cause PHAII retained NCC-inhibiting activity, but the Q562E WNK4 demonstrated diminished activity, suggesting that some PHAII mutations lead to loss of NCC inhibition. Gain-of-function WNK1 mutations would be expected to inhibit WNK4 activity, thereby activating NCC, contributing to the PHAII phenotype. Together, these results identify WNK kinases as a previously unrecognized sodium regulatory pathway of the distal nephron. This pathway likely contributes to normal and pathological blood pressure homeostasis.

Evaluation of Absorbable Hemostatic Powder for Prevention of Lymphoceles Following Robotic Prostatectomy With Lymphadenectomy.

OBJECTIVE: To determine whether lymphoceles can be prevented after robotic prostatectomy with pelvic lymph node dissection (PLND), we performed a prospective randomized study using an absorbable hemostatic agent (Arista AH). The most common complications of PLND for prostate cancer are related to lymphocele formation, which occur in 30%-50% of patients according to studies that performed screening imaging. Although most are asymptomatic, when intervention is required the cost and morbidity are high. MATERIALS AND METHODS: Of 100 patients enrolled, 88 completed the study. Each patient served as his or her own control, with Arista AH placed over the field of PLND on only one side in a randomized fashion as revealed only after bilateral PLND was completed. All patients underwent screening pelvic computed tomography scan 3 months later, with radiologists blinded to the Arista AH treated side. A significant lymphocele was defined as a fluid collection 3 cm or greater in any plane. RESULTS: The mean lymph node yield was 8.1 nodes. Fourteen lymphoceles were identified. Five occurred on the side where Arista AH was used vs 9 on untreated sides (5.7% vs 10.2%, P = .248). When they occurred, there was no statistically significant difference in lymphocele size between treated and untreated sides (P = .441). No lymphoceles were symptomatic. CONCLUSION: Although the lymphocele rate with Arista AH was 5.7% compared with 10.2% without it, this was not a statistically significant difference potentially because the study was underpowered due to an unusually low baseline rate of lymphoceles. A larger study is warranted to determine whether using a hemostatic agent like Arista AH can prevent lymphoceles.

Outcomes of Robotic Nephrectomy Including Highest-complexity Cases: Largest Series to Date and Literature Review.

OBJECTIVE: To review the outcomes of robot-assisted laparoscopic nephrectomy (RALN) after 101 consecutive cases, the largest reported series to date. The benefit of adding robotic technology to laparoscopic nephrectomy is unclear and controversial. We used robotics for nephrectomy routinely, including for simpler cases rather than laparoscopy, as well as for the most complex nephrectomies rather than open surgery. METHODS: We reviewed a prospective database of 101 consecutive nephrectomy procedures by a single surgeon (R.A.). All were initiated as RALN regardless of complexity. Patient characteristics and outcomes were reviewed, including tumor complexity, conversion rate, transfusions, length of stay, and complications. RESULTS: Mean age was 60 years (19-86 years), and mean body mass index was 31 kg/m(2) (16-54 kg/m(2)). Ninety patients had tumors with mean size of 8.2 cm (2.2-25.8 cm). Eighty were malignant, including 31 pT3a tumors (39%), with 9 renal vein thrombi. Eight malignancies had caval tumor thrombi (10%). Local invasion required 1 bowel resection, 1 partial hepatectomy, and 1 distal pancreatectomy, all performed robotically with no conversions to open surgery. Ipsilateral retroperitoneal lymphadenectomy was performed in 40 patients removing 13.7 nodes (4-36). Mean operative time and blood loss were 172 minutes (57-411 minutes) and 67 mL (10-400 mL) with only 1 transfusion (1%). Mean length of stay was 1.1 days (0-7 days), with 94% discharged by postoperative day 1. Clavien grade III-IV complications occurred in 5% without deaths. CONCLUSION: Robotic nephrectomy allows for consistent outcomes regardless of procedure complexity. Completion of procedures without need for open conversion was possible even in the most complex procedures, including those with vascular and contiguous organ invasion.

Robotic partial nephrectomy for renal cell carcinomas with venous tumor thrombus.

OBJECTIVE: To describe the first report of robotic partial nephrectomies (RPNs) for renal cell carcinoma (RCC) with venous tumor thrombus (VTT). METHODS: Partial nephrectomy for RCC extending into the renal vein has been described in limited fashion, but such a complex procedure has not previously been reported in minimally-invasive fashion. We demonstrate the feasibility of robotic nephron-sparing surgery despite vein thrombi and the results of the initial four highly-selected patients to have undergone this novel procedure. Two patients underwent RPN for RCC with VTT involving intraparenchymal vein branches, and 2 others had VTT involving the main renal vein. Mean patient age was 65 years (range 50-74 years). Mean tumor size was 7.75 cm (range 4.3-12.8 cm) with mean RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score of 9.75 (range 8-12). RESULTS: Mean warm ischemia time was 24.2 minutes (range 19-27 minutes) and mean estimated blood loss was 168.8 mL (range 100-300 mL). No patients required transfusion, and there were no intraoperative complications. No patients required conversion to open or standard laparoscopic surgery. All 4 patients were discharged home on the first postoperative day. A single postoperative complication occurred in 1 patient who was readmitted with an ileus that resolved spontaneously. All patients had negative surgical margins. Two patients developed metastatic disease on surveillance imaging. CONCLUSION: RPN in patients with VTT is safe and feasible in selected patients. Given the risk of metastatic disease in patients with pathologic stage T3a RCC, the role of nephron sparing requires further evaluation such that radical nephrectomy remains the standard of care.

Contribution of laparoscopic training to robotic proficiency.

PURPOSE: Robotic surgical technology has been adopted by surgeons with and without previous standard laparoscopic experience. The necessity or benefit of prior training and experience in laparoscopic surgery is unknown. We hypothesized that laparoscopic training enhances performance in robotic surgery. MATERIALS AND METHODS: Fourteen medical students with no surgical experience were instructed to incise a spiral using the da Vinci(®) surgical robot with time to completion and errors recorded. Each student was then trained for 1 month in standard laparoscopy, but with no further robotic exposure. Training included a validated laparoscopic training program, including timed and scored parameters. After completion of the month-long training, the students repeated the cutting exercise using the da Vinci robot as well as with standard laparoscopic instruments and were scored within the same parameters. RESULTS: The mean time to completely incise the spiral robotically before training was 16.72 min with a mean of 6.21 errors. After 1 month of validated laparoscopic training, the mean robotic time fell to 9:03 min (p=0.0002) with 3.57 errors (p=0.02). Laparoscopic performance after 1 month of validated laparoscopic training was 13.95 min with 6.14 errors, which was no better than pretraining robotic performance (p=0.20) and worse than post-training robotic performance (p=0.01). CONCLUSIONS: Formal laparoscopic training improved the performance of a complex robotic task. The initial robotic performance without any robotic or laparoscopic training was equivalent to standard laparoscopic performance after extensive training. Additionally, after laparoscopic training, the robot allowed significantly superior speed and precision of the task. Laparoscopic training may improve the proficiency in operation of the robot. This may explain the perceived ease with which robotics is adopted by laparoscopically trained surgeons and may be important in training future robotic surgeons.

Breakage of Needle during Intracavernosal Injection and Use of Portable Ultrasound Guidance for Removal.

Purpose. Intracavernosal self-injection (ICI) was first described in 1982, and remains a viable therapy for erectile dysfunction. However, intracorporal needle breakage can be a rare complication of therapy. We report a rare complication of intracorporal needle breakage and a retention of a 30-gauge needle in a 42-year-old paraplegic man. We discuss our experience in using portable high-frequency ultrasound intraoperatively to visualize and guide removal of a retained ICI needle. Materials and Methods. Review of case and ultrasound technique are presented. Results. Using intraoperative ultrasound imaging, the retained intracorporal needle was successfully removed from the patient's penis without any complications. Follow-up ultrasonography and X-ray confirmed complete removal of the needle. Conclusions. We report on the successful implementation and use of a portable high-frequency ultrasound probe to visualize a retained intracorporal needle inside the penis and its use to guide removal. Given the rapid proliferation of portable ultrasound machines in the operating room and out in the field, we expect these imaging techniques to become routine, especially in urological emergencies.

Remote monitoring and supervision of urology residents utilizing integrated endourology suites-a prospective study of patients' opinions.

PURPOSE: To report on integrated endourology suites (IES), remote monitoring and supervision (RMS) of urology residents and to evaluate patients' opinions, acceptance, and satisfaction level with IES and RMS. PATIENTS AND METHODS: Patients undergoing flexible cystoscopy in the IES with RMS were surveyed using a questionnaire. All procedures were performed by junior urology residents (UR-1 level) using RMS. Patients were studied using a nine-question survey to evaluate their comfort level, acceptance, and level of satisfaction with RMS. Six questions used a scale of 1 to 10 (1=strongly disagree; 10=strongly agree), and the remaining three questions solicited a "yes" or "no" response. RESULTS: 100 patients were studied (59% Caucasians, 40% African Americans, and 1% Hispanic). Median age was 63 years. The highest level of education was middle school in 2% of patients, high school in 55%, undergraduate in 33%, and postgraduate in 10%. Patients scored a mean of 9.50/10 (highly satisfactory) regarding their comfort with RMS; 96% scored ≥ 7, 4% scored 5 to 6, and none scored <5. Patients were satisfied having a urology resident perform the procedure (9.48/10), other residents and medical students watch the procedure (9.41/10), a video camera in the room (9.40/10), and two-way sound communication (9.40/10). None perceived compromise to their privacy or quality of care. CONCLUSIONS: RMS in IES is highly acceptable to patients undergoing endoscopic procedures. RMS has the potential to positively impact residency training, efficiency, regulatory compliance, safety, and productivity.

Association of depression and urolithiasis.

OBJECTIVES: To study the hypothesis that patients with urolithiasis would have a higher prevalence of depression compared to the general population. Urolithiasis is associated with frequent recurrences. Patients with urolithiasis may develop a chronic condition associated with poor quality of life and depression. The frequency and severity of stones episodes would relate to depression. METHODS: In an institutional review board-approved study; we prospectively recruited 115 patients who were evaluated for urolithiasis. Patients completed an Emory stone questionnaire covering demographics and a validated CES-D depression questionnaire. Depression scores were compared with U.S. norms. Demographics and clinical variables were analyzed. RESULTS: On the CES-D depression questionnaire 30.4% of patients scored ≥ 16, a "significant level of physiological distress." The U.S. lifetime prevalence of depression was 16.5%. Determinants of depression included the following: family history of urolithiasis (OR = 3.49, CI = 1.51; 8.07), stone episode within the last 12 months (OR = 2.77, CI = 1.18; 6.53), and >1 emergency room visits for stone disease (OR = 2.61, CI = 1.14; 5.99). Patients with Charlson comorbidity indexes of ≤ 1 were more likely to be depressed than those scoring >1 (OR 2.89, CI = 1.20; 6.95). There were no significant associations with age at first stone, number of lifetime stones, number of surgeries, number of workdays missed, and need for dietary modifications or medications for stone prevention. CONCLUSIONS: The prevalence of depression in our patient cohort with urolithiasis was substantially greater than societal norms. Multiple stone-related factors were associated with significant psychological distress. Appreciation of this issue may allow better patient care.

Robotic management of benign mid and distal ureteral strictures and comparison with laparoscopic approaches at a single institution.

OBJECTIVE: To present our experience and outcomes with robotic mid and distal ureteral reconstruction and to compare these results with our previous laparoscopic series. METHODS: In an institutional review board-approved retrospective study, 16 patients underwent robotic mid and distal ureteral repair (13 ureteral reimplantations and 3 ureteroureterostomies) at our institution from August 2008 to September 2011. Proximal ureteral stricture, extrinsic obstruction, and ureteropelvic junction obstruction cases were excluded. The demographic, perioperative, and postoperative data were reviewed in the reimplantation and ureteroureterostomy robotic groups. These data were compared with the outcomes from our previously published series on laparoscopic ureteral reimplantation. RESULTS: The data from 16 robotic procedures were included in the present study, including 2 open conversions because of excessive scar tissue. A symptomatic bowel injury (Clavien grade IIIb) occurred in 1 case. In our previous series, 5 of the 6 laparoscopic procedures were performed completely laparoscopically with 1 open conversion for anastomosis completion. No major complications occurred. The mean robotic surgery time was 258.6 minutes (range 146-450) compared with 276.5 minutes (range 180-360) for the laparoscopic group. The mean robotic hospital stay was 2.5 days (range 1-8) compared with 2.7 days (range 2-5) for the laparoscopic group. The mean robotic estimated blood loss was 171 mL (range 30-500) compared with 150 mL (range 50-250) for the laparoscopic group. All cases were clinically and radiographically successful at the last follow-up examination. CONCLUSION: Although early in our experience, the robotic repair of mid and distal ureteral strictures appears to be an efficacious approach comparable to laparoscopy for such conditions.