Objective To describe the surgical technique and evaluate the feasibility, safety, early functional outcomes and preliminary oncological results of the Total Urethral Length Preservation (TULP) technique, a urethra-preserving modification of the Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). Patients and Surgical Procedure Twenty consecutive patients underwent RS-RARP using the TULP technique. Eligible patients had a prostate volume ≤80 mL, predominantly peripheral-zone tumors without disease at the anterior apical midline or in the transition zone close to the urethra and without prior surgical treatment for benign prostatic hyperplasia. Perioperative, pathological and early functional and oncological outcomes were prospectively collected. This interim analysis includes the first 6 weeks of follow-up. Results Median preoperative PSA was 6.92 ng/mL (IQR 5.4–11.5). Median console time was 180 minutes (IQR 150–210), and median estimated blood loss was 250 mL (IQR 150–350). Intraoperative repair of a small urethral lesion was required in two patients. No postoperative complications of any Clavien–Dindo grade were observed. The transurethral catheter was removed within 24 hours in 18 patients; in the two patients requiring urethral repair, catheterization was maintained for one week. Immediate urinary continence was achieved in all patients, and no patient required postoperative pad use. Final pathology demonstrated pT2 disease in 17 patients, pT3a disease in 2 patients, and pT3b disease in 1 patient. Positive surgical margins were observed in 4 patients (20%), including 2 at the urethral resection zone. Conclusions The TULP technique appears feasible and safe in carefully selected patients, achieving complete immediate urinary continence in all patients with minimal duration of postoperative catheterization and with encouraging preliminary oncological outcomes.
Objective To describe the intraoperative use of indocyanine green (ICG) fluorescence imaging to assess testicular perfusion during the second stage of staged laparoscopic traction orchidopexy (Shehata technique) for an intra-abdominal testis. Patients and surgical procedure An 11-month-old boy with a non-palpable left intra-abdominal testis underwent a planned two-stage laparoscopic traction orchidopexy. During the first stage, the testis was mobilized and fixed to the contralateral abdominal wall to allow gradual elongation of the testicular vessels. Ten weeks later, intravenous ICG (0.8 mL, 2.5 mg/mL) was administered during the second stage, and near-infrared fluorescence imaging was used to evaluate real-time testicular perfusion before completing orchidopexy. Results ICG fluorescence demonstrated rapid and adequate perfusion from the testicular vessels to the testis, confirming vessel integrity after the traction period. Following confirmation of sufficient blood flow, the testis was mobilized into a subdartos pouch without tension. The postoperative course was uneventful. At one-year follow-up, the testis remained well positioned with no evidence of atrophy or recurrence. Conclusions ICG fluorescence imaging provides real-time confirmation of testicular perfusion during the Shehata technique and may enhance the safety of this vessel-preserving approach.
Introduction Robot-assisted radical prostatectomy (RARP) with nerve-sparing is technically demanding and requires mastery of different surgical approaches to preserve functional outcomes while maintaining oncological control. This video demonstrates the feasibility of performing three approaches—anterior, anterior with Hood technique, and posterior—using a high-fidelity inanimate pelvic model. Methods All procedures were performed on the Urotrainer® VP model with a da Vinci® robotic surgical system in a dry-lab environment. The model replicates prostate, bladder, seminal vesicles, urethra, neurovascular bundles and planes with life-like tissue properties. Each approach was demonstrated step-by-step, emphasizing dissection planes and nerve preservation. Vesicourethral anastomosis was also performed, allowing multiple repetitions of the reconstructive step. Results The model enabled realistic simulation of anterior, Hood, and posterior nerve-sparing approaches. Fascial planes and neurovascular bundles were consistently identified, and dissection could be performed with lifelike tactile feedback. While resection steps were limited to one per model, the anastomosis was repeatable, providing opportunities for additional practice. Conclusion This high-fidelity inanimate model facilitates demonstration and training of multiple nerve-sparing approaches in RARP. Its anatomical fidelity and capacity for reconstructive repetition highlight its value as an educational tool in robotic surgery training programs.
Objective: To report the technique for thulium fiber laser enucleation of the prostate, making emphasis on important tips and tricks to have success during the surgery and in the post-operative time. Patient: The case of a 63 year-old male with no comorbidities presented with a 5-year history of oLUTS. Evaluation revealed a severely symptomatic IPSS score and a 75cc prostate. ThuFLEP was considered given to the symptoms and prostate size. Surgical procedure: ThuFLEP was performed with the following approach: careful disinsertion of the prostatic apex, progression through posterior, lateral, and anterior planes, bladder neck fiber transection, mucosal bridge transection, endoscopic morcellation, and coagulation. Results: Enucleation and morcellation times were 35 and 12 min, respectively. Patient was discharged after 3 h of bladder irrigation, and the Foley catheter was removed on PO3. Immediate continence was achieved. The recovery went without complications. Discussion: Thulium fiber laser is a useful technology for prostate enucleation. Key technical tips to success during the procedure are maintaining a clear view, wide shoulder-to-shoulder movements, and transecting the vertical fibers at the bladder neck in the anterior plane. Creating an anterior flat at the level of the sphincter and preserving the semicircular fibers near the apex may promote early continence.
Introduction In this study we aim to introduce a novel and simple technique: Adjustable Tension Ligation with Anterior Suspension (ATLAS) Suture, to control the dorsal venous complex (DVC) during robotic-assisted laparoscopic radical prostatectomy (RARP) that allows for excellent hemostasis and visibility during apical prostatic dissection. Methods Between July 2023 and April 2024, 30 consecutive patients who underwent total extra-peritoneal (TEP) RARP with a standardized ATLAS suture of the DVC were included in this study. Inclusion criteria for patient selection include: (1) BMI ≤35 kg/m2, and (2) localised prostate cancer. The step-by-step ATLAS suture technique is as follows: (1) apical dissection of the prostate to reveal the “groove” between the DVC and urethra laterally; (2) a 3-O barbed suture with a CT1 needle is passed between the DVC and urethra with a foley catheter in-situ; (3) the barbed suture is looped three times around the DVC and tightened; (4) the suture is anchored onto the periosteum around the symphysis pubis to form a “pulley” mechanism for adjusting the tension of the suture around the DVC. Peri- and post-operative data including DVC ligation times, apical dissection times, estimated blood loss, technical failure rate, and histology of RARP specimen including positive margin rates, and post-operative complications were collected and analyzed. Results The mean dissection and ligation time was: 3.67 min (2.83–5.10) and the mean apical dissection time was 3.70 min (2.85–4.63). Mean blood loss was 38.3 ml. There was no technical failure in terms of suture breakage, slippage or inadvertent needling of the urethra. Post-operative histology results are as follows: Gleason 3 + 3 in 2 patients (8%), 3 + 4 in 10 patients (43%), 3 + 5 in 1 patient (4%), 4 + 3 in 8 patients (35%) and 4 + 5 in 2 patients (8%). All 30 patients had uninvolved apical margins. 3/30 patients had Clavien-Dindo grade I complications including 1 acute retention of urine post catheter removal, 1 superficial wound infection and 1 catheter blockage. Conclusion This study presents a novel, easy to perform and reproducible technique to control the DVC, allowing excellent hemostasis and visibility during apical prostate dissection.
Objective Steerable Ureteroscopic Renal Evacuation (SURE) using the CVAC 2nd Generation system allows for continuous irrigation with passive and active aspiration while enabling real-time evacuation of stone fragments during and after lithotripsy. This video highlights practical tips for use and provides visual demonstration of fragment clearance using CVAC in real-time. Patient and surgical procedure An 82-year-old male with multiple non-obstructing renal calculi and total linear stone burden of 2.1cm underwent retrograde ureteroscopy and laser lithotripsy using the CVAC system (11.9Fr ureteroscope) with a 12/14 access sheath and ureteral stent placement. A combination of dusting and popcorning techniques were used to break down stone fragments to <2mm for aspiration purposes. Results Total time to complete surgery was two hours. The ureteral stent was removed on post-operative day eight. Two and a half months later, the patient was doing well, and cross-sectional imaging at 6 weeks revealed two punctate renal stones (<1mm). Conclusions The video highlights a practice guide and troubleshooting tips to the CVAC system. To our knowledge it is the only ureteroscope with a working channel that enables laser lithotripsy as well separate aspiration and irrigation channels permitting continuous stone removal (during and after lithotripsy).
Introduction and objective MIST for BPH may be performed under various pain management methods including LA, monitored anaesthesia care, and general anaesthesia (GA). Given paucity of documented experience in our country surrounding MIST under LA, our institution has implemented a LA protocol for MIST. We have administered our LA protocol without sedation to 7 patients from our cohort of 62 MIST cases from 30 August 2021 to 31 January 2025. Our video showcases a patient’s prostatic urethral lift (PUL) experience under our institution’s LA protocol. Methods The PUL was conducted in the operating theatre with an anaesthetist on standby for possible conversion to monitored anaesthesia care. Our LA protocol comprises of the traditional prostate block augmented with the modified block described by J.R. Beahrs. The traditional block targets the “Mountain”, a hyperechoic region between the prostate and seminal vesicles where periprostatic neurovascular bundles traverse. Beahrs’ modification provides a pelvic plexus block, which infiltrates the hyperechoic “Clouds Above the Mountain” lateral to the seminal vesicles between the prostate and bladder neck where the inferior hypogastric nerve plexus lies. Our LA mixture (10 millilitres of 1% Lignocaine and 10 millilitres of 0.5% Bupivacaine) is given in four aliquots of 5 millilitres to the “Mountain” and “Clouds” bilaterally. Lignocaine gel is applied to the urethral meatus twice: in the induction room and prior to rigid cystoscopy during PUL. Results Our patient expressed a Visual Analogue Scale (VAS) score of 5, during LA administration and during PUL, and a score of 2 after PUL. Conclusions PUL could be safely performed with minimal discomfort under our LA protocol without sedation. MIST under LA may potentially be conducted as an office procedure, avoiding risks of GA and optimising resource allocation within the operating theatres.
Objective Robotic-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder reconstruction has emerged as a minimally invasive option for muscle-invasive bladder cancer, but ileourethral approximation remains a major technical challenge, especially in patients with a short or bulky mesentery. Achieving a tension-free anastomosis is crucial for both functional and oncological outcomes. We describe a novel posterior funnel-shaped flap (Faria’s flap) designed to overcome this limitation and facilitate safe, tension-free ileourethral anastomosis. Patient and surgical technique We report the case of a 63-year-old male with muscle-invasive urothelial carcinoma (cT3N0M0), treated with neoadjuvant chemotherapy followed by RARC and intracorporeal Y-shaped ileal neobladder reconstruction. During surgery, the ileal loop failed to reach the urethra. To address this, we developed a posterior funnel-shaped flap: a 10-cm longitudinal incision was created in the distal ileum, followed by posterior suturing that produced a funnel configuration, extending the ileal reach while preserving vascular integrity. The anastomosis was then performed without tension. Reconstruction was completed with a modified Y-shaped neobladder. Console time was 4 h 10 min, estimated blood loss 310 mL, and no intraoperative complications occurred. The patient was discharged on day 6, with catheter removal on day 16 and stent removal on week 3. At follow-up, he achieved complete daytime and nighttime continence, normal voiding, and no residual urine. Conclusion The posterior funnel-shaped flap represents a feasible modification to facilitate ileourethral anastomosis in robotic intracorporeal neobladder reconstruction. This technique provides additional reach while reducing anastomotic tension and supporting favorable functional outcomes. Although early results are encouraging, further studies with larger cohorts are required to validate its oncological and functional benefits.
Introduction Office-based targeted laser ablation (OTLA) is an innovative, minimally invasive treatment for prostate cancer that combines precision with functional preservation. Utilizing transrectal ultrasound (TRUS) with enhanced flow imaging, this video highlights the OTLA technique, its adaptability across National Comprehensive Cancer Network (NCCN) risk categories, and its outcomes in an outpatient setting. Methods Sixty-three OTLA procedures were performed using the Tranberg CLS laser system and TRUS guidance between May 2023 and October 2024. Patients underwent treatment under intravenous sedation with careful neurovascular preservation and real-time ablation zone monitoring. Post-procedural assessments included follow-up biopsies and functional outcomes. Results Early outcomes demonstrated PSA reductions across all risk groups and low recurrence rates in low- and intermediate-risk patients. Postoperative complications were minimal, with 8.3% reporting erectile dysfunction and no urinary incontinence observed. Conclusion OTLA offers a safe, effective, and accessible alternative to traditional prostate cancer therapies, positioning it as a promising outpatient option.
Retroperitoneal robot-assisted partial nephrectomy is feasible and safe in patients with T1 and T2a renal tumors who are candidates for nephron-sparing surgery. This video provides a step-by-step guide to performing retroperitoneal robot-assisted partial nephrectomy using the Hugo™ RAS system.
Objective To present our surgical technique for Robotic-Assisted Supine Retroperitoneal Lymph Node Dissection (RAS-RPLND) using the da Vinci robotic system. We emphasize a nerve-sparing approach and the mandatory preservation of the inferior mesenteric artery (IMA) in a high-risk patient with active Crohn’s disease. Introduction Post-chemotherapy RPLND is critical for managing Non-Seminomatous Germ Cell Tumors (NSGCTs) with residual masses >1 cm, as imaging cannot reliably differentiate teratoma from necrosis or viable tumor. While open RPLND carries significant morbidity and laparoscopic approaches present technical challenges, robotic assistance offers precision and reduced invasiveness. Preserving the IMA is typically elective; however, in patients with inflammatory bowel disease, it becomes critical. Clinical case and surgical procedure A 26-year-old male with active Crohn’s disease and Stage IIB NSGCT (post-BEP chemotherapy) underwent RAS-RPLND due to contraindications for additional chemotherapy. The procedure employed a supine position with the DaVinci Si system, using a port configuration adaptable to X/Xi systems. A bilateral template dissection was performed. Initial key steps included reflecting the bowel to expose the retroperitoneum, identifying the duodenum, and fixing the peritoneum with V-Loc sutures. The IMA was preserved to ensure collateral blood supply to the bowel, and sympathetic nerves were spared for ejaculatory function. The right spermatic cord was resected laparoscopically. The 38 mm paracaval mass was resected en bloc. Operative time was 210 min, with 150 mL blood loss and no complications. Pathology confirmed teratoma in 9/27 nodes. Discussion RAS-RPLND addresses the limitations of open and laparoscopic techniques. This case is distinct as it demonstrates the feasibility of IMA sparing not just as a technical exercise, but as a mandatory maneuver for a patient with Crohn’s disease. While the learning curve is steep, the robotic platform facilitates complex vascular and neural preservation. Conclusion RAS-RPLND is a promising approach for post-chemotherapy NSGCT. This case highlights its role in balancing oncologic control with functional preservation in patients with significant comorbidities.
Background Upper tract urothelial carcinoma (UTUC) is a rare malignancy that accounts for 5–10% of all urothelial tumors. Kidney-sparing surgery is a viable option for selected patients with low-risk disease. Case presentation We report the case of a 64-year-old male, former smoker, presenting with painless hematuria. Cystoscopy was unremarkable. A CT urogram demonstrated a 1.5 cm filling defect in the left proximal ureter with associated hydronephrosis. Diagnostic ureteroscopy performed at the beginning of the procedure confirmed a proximal ureteral lesion with no evidence of other lesions in the renal pelvis or calyces. Urinary cytology and biopsy were obtained, confirming urothelial carcinoma. Renal function was preserved. Surgical technique A transperitoneal robotic segmental ureterectomy with ureteropelvic anastomosis was performed. After mobilization of the left colon, the ureter was dissected proximally and distally to the lesion. Tumor location was confirmed intraoperatively, and the anticipated defect measured approximately 2 cm. The proximal ureter was transected, releasing obstructed urine. Due to an atypical distal ureteral appearance characterized by thickened and friable mucosa, resection was extended 1 cm distally. The specimen was retrieved in an endoscopic bag, and frozen-section analysis confirmed negative proximal and distal margins. Reconstruction was performed with a tension-free ureteropelvic anastomosis using running 4–0 PDS sutures, following placement of a 6 Fr × 26 cm double-J stent. A perirenal fat patch was applied over the anastomosis. Outcome Total operative time was 124 min, with an estimated blood loss of 45 mL. The patient had an uneventful recovery and was discharged on postoperative day 2. The ureteral stent was removed 4 weeks postoperatively. Final pathology demonstrated a 1.8 cm low-grade pT1 urothelial carcinoma within a 3 cm resected ureteral segment, with negative margins. At 3-year follow-up, the patient remained asymptomatic, with preserved renal function (creatinine 1.16 mg/dL), no hydronephrosis on CT urography, and no evidence of recurrence on cystoscopic surveillance. Conclusion Robotic segmental ureterectomy with ureteropelvic anastomosis is a feasible and effective kidney-sparing option in carefully selected patients with UTUC when negative margins and appropriate oncologic principles are maintained.
Vesicovaginal Fistulas (VVFs) are abnormal communications between the bladder and the vagina, commonly caused by obstetric or gynecologic injuryDifferent surgical approaches have been executed for VVF repair: Transvaginal, transabdominal, and transvesical approaches. Current VVF repair methods leave two over-lapping suture lines, which may be subject to breakdown and recurrence. The Preserve the Tract and Turn it Inside Out (PATIO) method for fistula repair in the management of urethrocutaneous (UC) fistulas has shown good success without interposition. In this technique the fistula is everted rather than excised preventing two overlapping suture lines which prevents the egress of urine through the fistula tract. In this report, we utilized the first report of a Preserve the Tract and Turn it Inside Out (PATIO) technique to repair a VVF. The case of a 33-year-old woman with a successful PATIO repair is shown. The PATIO technique is a novel approach to vesicovaginal fistula repair. Eversion of the fistula tract prevents the egress of urine and the creation of two abutting suture lines, which theoretically should limit complications and fistula recurrence.
Introduction: Vesicourethral anastomotic disruption is a rare complication following robot assisted radical prostatectomy (RARP). Traditional management for vesicourethral anastomotic leak (VUAL) includes prolonged catheterization and percutaneous abdominal drainage. Surgical intervention is often considered a last resort after failed conservative measures. This video aims to demonstrate the safety and feasibility of immediate robot assisted repair of a complete vesicourethral anastomotic disruption. Methods: Patient is a 54 year old male with cT1a Gleason 3 + 4 prostate cancer who underwent uneventful RARP with same day discharge. He passed voiding trial on post-operative day (POD) 7 and final pathology was T2 Gl 3 + 4 with negative margins. One week later, he presented to an outside hospital with abdominal pain and difficulty voiding. A foley catheter was placed in the emergency room with reported 600cc clear urine drainage. CT scan showed that the Foley was placed posterior to the bladder with an adjacent small fluid collection. The patient was transferred to our institution for further management. He was taken to the OR for cystoscopy, cystogram and catheter placement. Despite a reassuring intraoperative cystogram, postop CT showed the Foley was again posterior to the bladder. A suprapubic tube was placed by interventional radiology. After reviewing options, patient elected for immediate robot-assisted repair of VUAL. Port sites from prior RARP were reused. A midline cystotomy was made to access the anastomotic disruption. This also allowed clear identification of the ureteral orifices in respect to the anastomosis. The posterior bladder neck was reapproximated to periurethral tissue followed by a vesicourethral anastomosis with standard technique, running two 3–0 barbed absorbable suture circumferentially. Results: The case was successfully completed robotically. Operative time was 160 min with 50cc EBL. Patient was discharged on POD1. Drain was removed on POD 6 and urethral catheter at 4 weeks postop. SPT was removed after a negative CT cystogram at 8 weeks. Patient’s PSA remains undetectable, and he is completely continent with normal urinary stream. Conclusion: This case demonstrates that immediate robotic repair of a vesicourethral anastomotic leak is a safe and effective management option. Immediate repair for this patient led to improved quality of life, shortened duration of catheter, and excellent urinary outcomes. Further data is needed to establish the perceived benefits of immediate repair compared to conservative management.
Objective To report the described case of retrocaval ureter treated for the first time with robot-assisted ureteroplasty with Hugo RAS system. Patient and surgical procedure A 36-year-old man presented with acute right flank pain and underwent contrast-enhanced abdominal CT scan, which revealed right hydronephrosis due to retrocaval ureter in the lumbar region. The patient was counselled for robot-assisted ureteroplasty. Following the incision of the Told’s fascia, the colon was mobilized. The inferior vena cava (IVC) served as the anatomical landmark for identifying and dissecting the ureter, which was traced posterior to the IVC, revealing dilatation of the renal pelvis and proximal ureter. The retrocaval segment of the ureter was completely detached from the IVC and resected near the ureteropelvic junction. The distal ureter was preserved and translocated anteriorly to the IVC. Anastomosis was initiated on the posterior surface using a continuous 3/0 monofilament suture and completed over a double-J stent with a separate suture of the same type Results No intraoperative complications were recorded. Console time was 55 min. The estimated blood loss was <50 mL. The patient was discharged on the second postoperative day and the double-J stent was removed after four weeks. Conclusions This is the first reported case of robot-assisted ureteroplasty for a retrocaval right ureter treated using the Hugo RAS System. We detailed the proper trocar placement and provided a step-by-step description of this delicate surgery. Our experience may be of interest to centres utilizing novel robotic platforms to perform complex procedures for congenital ureteral anomalies.
Introduction The PISA (Pelvic and Inguinal Single Access) technique has emerged as a minimally invasive alternative to open lymphadenectomy for penile cancer, enabling simultaneous access to both inguinal and pelvic regions with reduced morbidity, faster recovery, and comparable oncological outcomes. Unlike the VEIL technique, PISA does not require trocar repositioning when a pelvic lymphadenectomy is indicated. Materials & methods We report the case of a 62-year-old male diagnosed with T3cN1M0 squamous cell penile carcinoma, previously treated with partial penectomy. Pelvic magnetic resonance imaging revealed superficial left inguinal lymph node involvement. A decision was made to perform an inguinal lymphadenectomy. The procedure was performed robotically using single inguinal incisions, allowing for an eventual pelvic approach through the same access when indicated by intraoperative findings. Results The surgery was completed without complications. Total time was 160 min, and hospital stay was 4 days. During the initial 90-day follow-up, no postoperative complications, readmissions, or reinterventions were recorded. Pathology revealed no metastatic involvement of superficial or deep inguinal or pelvic lymph nodes bilaterally. Conclusions The PISA technique allowed for robot-assisted inguinal lymphadenectomy without the need for trocar repositioning or increased invasiveness when a pelvic lymphadenectomy was required. In this case, it demonstrated technical feasibility and safety, with an uneventful postoperative course and absence of complications during early follow-up. This surgical approach represents a valid alternative to the conventional technique, optimizing operative time, reducing tissue trauma, and improving perioperative outcomes in patients with locally advanced penile cancer.
Introduction: Robotic video endoscopic inguinal lymphadenectomy (R-VEIL) is a minimally invasive alternative to open inguinal lymphadenectomy. The procedure reduce morbidity and maintains oncological efficacy. The integration of indocyanine green (ICG) fluorescence imaging may enhance the accuracy of lymphatic mapping and the identification of lymph nodes. Objective: To evaluate the impact of ICG fluorescence guidance on lymph node retrieval and postoperative outcomes in R-VEIL for penile cancer. Methods: Seven patients with clinical stage T1b-T3N0–1 squamous cell carcinoma of the penis underwent bilateral R-VEIL. ICG was injected subcutaneously at the penile shaft before the procedure beginning, and fluorescence imaging was used to visualize lymphatic drainage and to improve nodal identification. The number of lymph nodes retrieved and postoperative lymphatic complications were compared between ICG-guided and non-ICG procedures. Results: The mean number of lymph nodes removed was higher in the ICG group (10 vs. 8). The mean drainage removal time was shorter in the ICG group (5 vs. 8 days), suggesting a reduction in lymphatic leakage. Only one patient in the ICG group (14.3%) required puncture for symptomatic lymphocele, compared to two patients (28.6%) in the non-ICG group. Conclusion: ICG fluorescence guidance in R-VEIL enhances lymph node detection and may contribute to improved postoperative outcomes. Further studies with larger cohorts are needed to confirm these findings.
Introduction Scar tissue in patients with prior bladder operations can make sheath placement for percutaneous cystolithotomy (PCCL) challenging. We propose a technique that allows direct visualisation during port and sheath placement without the need of a larger incision. Patients and Methods Three patients underwent PCCL for bladder stones. The surgical technique was as follows: 14 G venflon and 0.035″ sensor guidewire were passed into the bladder. The tract was dilated using 7Fr and 9Fr but attempts at 30Fr Amplatz Nephromax Balloon failed. 11 mm optical trocar was inserted into the bladder under vision parallel to the guide wire and a 30Fr Amplatz sheath was placed. 24Fr nephroscope and Swiss lithoclast used to fragment and remove the stones. Results Median age was 7 years (9 months to 18 years) and bladder stones ranged from 15mm-36 mm in greatest diameter. All had previous ileocystoplasty and Mitrofanoff formation, of which two also had bladder neck closures. One was born with a myelomeningocele, another with cloaca, and the final had bladder exstrophy and prior Kelly procedure. Balloon tract dilatation failed in all due to scar but entry into the bladder was successful with the optical port. Stones were removed and were predominately calcium phosphate in one and magnesium ammonium phosphate in the remaining two patients. Conclusions Where ballon dilatation fails due to scar tissue and serial blind dilator may require excessive force, the use of an optical port allows for safe entry into the bladder sufficient for a 30Fr sheath.
Introduction and objectives: Nutcracker syndrome is an uncommon vascular condition involving compression of the left renal vein, resulting in flank pain, hematuria, pelvic congestion syndrome and gastrointestinal intolerance. While effective endovascular and surgical options exist, anatomic variations such as a retroaortic renal vein may complicate standard approaches. We present the first reported case, to our knowledge, of robotic-assisted inferior mesenteric vein (IMV) transposition to a retroaortic renal vein tributary in an adolescent female with dual venous compression. Patients and surgical procedure: An otherwise healthy 18-year-old female presented with intermittent hematuria and left flank pain worsened by increased fluid intake, consistent with nutcracker syndrome. Imaging showed dual compression of the left main renal vein between the superior mesenteric artery and aorta, as well as compression of a retroaortic renal vein tributary between the aorta and vertebral body. Intraoperatively, a large retroaortic tributary was identified medial to the gonadal vein ostium, measuring approximately 80% of the main renal vein diameter. To avoid clamping the main renal vein and preserve the pelvic venous system, an end-to-side anastomosis between this branch and the IMV was performed robotically. Results: Total operative time was 173 min, with minimal blood loss <50 ml and no intraoperative or postoperative complications. She was discharged on postoperative day two. At 6-month follow-up, she reports resolution of flank pain and gross hematuria, with resumption of normal oral intake and activity. Her renal function has remained within normal limits. Conclusions: Robotic-assisted IMV transposition to a retroaortic renal vein is a promising and effective surgical option for select patients with nutcracker syndrome and complex venous anatomy. This approach avoids manipulation of the main renal vein and preserves future surgical options such as renal autotransplantation. High-definition surgical video of this novel procedure is included to demonstrate key operative steps and anatomic landmarks.
Retrocaval ureter is a rare congenital anomaly caused by aberrant inferior vena cava development, resulting in posterior deviation and extrinsic compression of the right ureter that may lead to hydronephrosis and flank pain in adulthood. This video documents a robotic right ureteroureterostomy performed for a right retrocaval ureter in a 43-year-old gentleman with chronic intermittent right flank pain and imaging-confirmed hydroureteronephrosis. The patient underwent elective minimally invasive reconstruction with careful mobilization of the ureter from behind the inferior vena cava and tension-free ureteroureterostomy with internal stenting. The procedure was well tolerated, and postoperative imaging demonstrated improving hydronephrosis without obstruction. At two-year follow-up, the patient remained asymptomatic with preserved renal function. This case highlights the role of robotic ureteroureterostomy as a safe and durable treatment option for symptomatic retrocaval ureter.
