Robotic and Laparoscopic Reconstructive Surgery in Children and Adults (eBook)

Preface 6
Contents 7
Contributors 10
Part I Principles of Reconstructive Laparoscopy and Robotics in Urology 14
1 Laparoscopic and Robotic Instrumentation for Urologic Reconstructive Surgery in Adults 15
Laparoscopy vs. Robotics 15
Standard Laparoscopic Instrumentation 16
Graspers and Dissectors 16
Incision and Hemostasis 16
Suturing 19
Stapling/Clipping 20
Suction/Irrigation 20
Retraction 20
Vascular Clamps 21
Port-Site Closure 22
Robotic Instruments 22
Monopolar Cautery 23
Bipolar Cautery 25
Ultrasonic Energy 25
Scissors 25
Graspers 26
Needle Drivers 26
Clip Appliers 26
Five-Millimeter Instruments 26
References 27
2 Instrumentation During Pediatric Robotic Anastomoses and Reconstruction 28
Introduction 28
The Da Vinci Surgical System 29
Instruments 30
Robotic-Assisted Laparoscopic Pyeloplasty 32
Useful 5-mm Instruments 33
Robotic-Assisted Laparoscopic Renal Surgery 33
Useful 5-mm Instruments 34
Robotic-Assisted Laparoscopic Ureteral Reimplantation 34
Useful 5-mm Instruments 35
Robotic-Assisted Laparoscopic Bladder Surgeries 35
The Future 36
References 36
3 Instrumentation During Pediatric Laparoscopic Anastomoses and Reconstruction 39
Instrumentation for Visualization 39
Instrumentation for Insufflation/Insufflators 40
Instrumentation for Access 41
Trocars 41
Primary Access and Port Placement 42
Retroperitoneal Access 42
Transperitoneal Access 45
Instrumentation for Grasping and Blunt Dissection 45
Instrumentation for Incising and Hemostasis 45
Instrumentation for Suturing and Tissue Anastomosis 47
Instrumentation for Aspiration and Irrigation 48
Conclusions 49
Critical Operative Steps 49
Critical Instruments and Supplies 49
References 49
Part II Laparoscopic and Robotic Reconstructive Renal Surgery 51
4 Adult Laparoscopic Partial Nephrectomyfor Renal Cell Carcinoma 52
Epidemiology 52
Indications 52
Preoperative Preparation 54
Technique 54
Special Considerations 56
Hilar Control 56
Hemostasis 57
Dissectors 58
Outcomes 58
Positive Margins 58
Tumor Spillage and Port Site Metastasis 59
Recurrence and Survival 59
Complications 59
Future Directions 60
Summary 60
Critical Operative Steps 60
Critical Instruments and Supplies 60
References 61
5 Adult Robotic-Assisted Partial Nephrectomyfor Renal Cell Carcinoma 64
Historical Overview 64
Indications and Contraindications 65
Patient Preparation 65
Ureteral Catheter Placement and Patient Positioning 66
Access, Port Placement, Robot Docking 67
Bowel Mobilization and Hilar Dissection 69
Renal Mobilization, Tumor Identification, and Exposure 70
Hilar Control and Tumor Extirpation 71
Renorrhaphy, Specimen Retrieval, and Closure 72
Postoperative Course 74
Results 74
Conversions and Complications 76
Robotic Surgery for Complex Tumors and Future Directions 76
Summary and Conclusion 77
Critical Operative Steps 77
Critical Instruments and Supplies 78
References 78
6 Pediatric Laparoscopic and Robotic Upper Pole Nephrectomy for Nonfunctioning Moieties 81
Introduction 81
Indications 81
Preoperative Evaluation 81
Surgical Approach 83
Surgical TechniqueRobotic-Assisted Transperitoneal Approach 83
Surgical TechniqueRetroperitoneal Prone and Lateral 86
Complications 86
Critical Operative Steps 87
Critical Instruments and Supplies 87
References 87
Part III Laparoscopic and Robotic Reconstructive Renal Pelvis Surgery 90
7 Adult Laparoscopic and Robotic-Assisted Pyeloplasty for Ureteropelvic Junction Obstruction 91
Introduction 91
Indications 91
Contraindications 91
Preoperative Preparation and Positioning 92
Surgical Technique 93
Postoperative Care 94
Technical Considerations 94
Crossing Vessels 95
Secondary Pyeloplasties 95
Concomitant Pyelolithotomy 96
Horseshoe Kidney 96
Body Habitus 96
Bilateral UPJO 96
Outcomes 96
Complications 97
Conclusions 97
Critical Operative Steps 97
Critical Instruments and Supplies 97
References 98
8 Pediatric Laparoscopic (Infant, Pre-pubertal, and Teenager) Pyeloplasty for Ureteropelvic Junction Obstruction 99
Introduction 99
Etiology and Presentation of Ureteropelvic Junction Obstruction 99
Diagnostic Assessment 100
Ultrasonography 100
Computerized Tomography 101
Intravenous Pyelogram 101
Voiding Cystourethrogram 102
Diuretic Radionuclide Renography 102
Pressure Flow Study 102
Patient Management: Asymptomatic vs. Symptomatic 103
Surgical Management 104
Pre-operative Assessment 104
Instruments in Pediatric Laparoscopy 104
Transperitoneal Laparoscopic Pyeloplasty 105
Technique 105
Outcomes 107
Retroperitoneal Approach 107
Technique 108
Outcomes 108
Outcomes 109
Robotic-Assisted Laparoscopic Pyeloplasty 109
Robotic-Assisted Transperitoneal Approach 110
Robotic-Assisted Retroperitoneal Approach 110
Outcomes 110
Conclusion 111
Critical Operative Steps for Transperitoneal Laparoscopic Pyeloplasty 111
Critical Operative Steps for Retroperitoneal Laparoscopic Pyeloplasty 112
Critical Operative Steps for Retroperitoneal-Assisted Laparoscopic Pyeloplasty 112
Critical Operative Steps for Robotic-Assisted Transperitoneal Pyeloplasty 113
Critical Operative Steps for Robotic-Assisted Retroperitoneal Pyeloplasty 113
Critical Instruments 113
References 113
9 Pediatric Robotic (Infant, Pre-pubertal, and Teenager) Pyeloplasty for Ureteropelvic Junction Obstruction 115
Diagnosis 116
Indications 116
Instruments and Supplies 117
Surgical Technique 117
General Procedures 117
Approach: Transperitoneal or Retroperitoneal Approach 119
Access: Retrocolic or Transmesenteric Access 120
Technique: Dismembered or Non-dismembered Robotic Pyeloplasty 120
Postoperative Management and Follow-up 121
Postoperative Pain Management 121
Postoperative Care and Follow-up 121
Outcome 121
Procedure-Related Complications 122
Intraoperative Complications 122
Postoperative Complications 123
Robotic Procedures for Recurrent UPJO 123
Redo Robotic Pyeloplasty 123
Robotic Ureterocalicostomy 124
Conclusions 125
Critical Operative Steps 125
Critical Instruments and Supplies 125
References 126
Part IV Laparoscopic and Robotic Reconstructive Ureteral Surgery 128
10 Laparoscopic Ureteroureterostomy and Correction of Ureteral Defects 129
Introduction 129
Indications for Ureteral Surgery 129
Indications for Ureteroureterostomy of a Single Ureter to Itself 129
Indications for Ipsilateral Ureteroureterostomy 130
Indications for Transureteroureterostomy 131
Principles of the Traditional Open Surgical Approach 131
Principles of Open Ureteroureterostomy of a Single Ureter to Itself 131
Principles of Open Ipsilateral Ureteroureterostomy 133
Principles of Open Transureteroureterostomy 133
Laparoscopic Ureteral Surgery 134
Reports of Laparoscopic Ureteroureterostomy of a Single Ureter to Itself 134
Steps in Laparoscopic Ureteroureterostomy of a Single Ureter to Itself 135
Reports of Laparoscopic Ipsilateral Ureteroureterostomy 139
Steps in Laparoscopic Ipsilateral Ureteroureterostomy 139
Reports of Laparoscopic Transureteroureterostomy 140
Steps in Laparoscopic Transureteroureterostomy 140
Management of Complications 141
Conclusion 141
Critical Operative Steps 141
Critical Instruments and Supplies 141
References 142
11 Robotic Ureteroureterostomy and Correction of Ureteral Defects 144
Introduction 144
Indications 145
Surgical Technique 146
Pre-operative Preparation 146
Patient Positioning 146
Port Placement 147
Approach and Identification of the Ureteral Obstruction 148
Follow-up 150
Surgical Considerations 150
Operative Complications 150
Post-operative Complications 151
Conclusions 151
Critical Instruments and Supplies 151
Critical Operative Steps 151
References 152
Part V Laparoscopic and Robotic Reconstructive Bladder Surgery 154
12 Robotic Radical Cystectomy and Use of Intestinal Segments for Reconstruction in the Adult Patient 155
Introduction 155
Robotic-Assisted Radical Cystoprostatectomy 155
Indications and Contraindications 155
Operating Room Setup 156
Patient Preparation and Positioning 156
Port Placement 158
Identification and Transection of the Ureters 158
Division of the Anterior Pedicle 159
Development of the Posterior Plane 159
Division of the Posterior Bladder and Prostatic Pedicles 159
Anterior Bladder Release 159
Division of the Dorsal Venous Complex 159
Extended Pelvic Lymph Node Dissection 160
Transposition of the Left Ureter to the Right Side 160
Radical Cystectomy and Anterior Pelvic Exenteration 161
Urinary Diversion 161
Orthotopic Neobladder 161
Ileal Conduit Urinary Diversion 162
Continent Cutaneous Urinary Diversion 162
Outcomes 162
Minimally Invasive Partial Cystectomy 163
Indications 163
Positioning and Trocar Placement 163
Cystoscopy 164
Technique 164
Outcomes and Complications 165
Conclusion 165
Critical Operative Steps 165
Critical Instruments 166
References 166
13 Laparoscopic Bladder Augmentation and Creation of Continent-Catheterizable Stomas in the Pediatric Patient 168
Introduction 168
Indications 168
Contraindications 169
Surgical Technique 169
Pre-operative Considerations 169
Surgical Procedure 169
Introduction 169
Augmentation Enterocystoplasty 170
Access 170
Isolation of Bowel Segment 170
Bowel Anastomosis 171
Detubularization 172
Bladder Incision and Cystoplasty 172
Creation of Continent-Catheterizable Stoma 172
Introduction 172
Access 173
Isolation and Harvest of the Appendix 173
Appendicovesicostomy 173
Results 174
Complications 174
Post-operative Management 174
Critical Surgical Instruments 175
References 175
14 Laparoscopic Ureteral Reimplant Surgery to Correct Reflux Disease 176
Introduction 176
Historical Evolution 176
Surgical Techniques for Laparoscopic Treatment of VUR 177
Patient and Surgeon Position 177
Extravesical Procedure 177
Intravesical Procedures 178
Megaureter 179
Robotic-Assisted Ureteroneocystostomy 180
Outcomes and Discussion 180
Extravesical Techniques 180
Intravesical Techniques 181
Conclusion 182
Critical Operative Steps 182
Extravesical Reimplantation 182
Intravesical Reimplantation 184
Transtrigonal 184
Trigonoplasty 184
Critical Instruments and Supplies 184
Extravesical Technique 184
Intravesical Technique 184
Robotic Surgery 184
References 184
15 Robotic Ureteral Reimplant Surgery to Correct Reflux Disease 186
Introduction 186
Background 187
Indications for Intervention 187
Patient Selection 187
Anesthetic Risk and Pediatric Laparoscopy 187
Patient Preparation and Setup 187
Port Placement and Selection of Instruments 188
Specifics of the Robotic Approach 188
General Principles 188
Extravesical Ureteral Reimplantation 189
Positioning and Port Placement 189
Description of Robotic-Assisted Extravesical Technique 190
Results 191
Intravesical Ureteral Reimplantation 192
Positioning and Port Placement 192
Description of Robotic-Assisted Intravesical Technique 193
Results 194
Summary 195
Critical Instruments and Supplies: Robotic Intravesical and Extravesical Reimplantation 196
Critical Operative Steps: Extravesical Reimplantation 196
Critical Operative Steps: Intravesical Reimplantation 196
References 196
Part VI Laparoscopic Orchiopexy in Children 199
16 Laparoscopic and Robotic Orchiopexy for the Impalpable Undescended Testicle 200
Laparoscopic Orchiopexy 200
Introduction 200
Preoperative Assessment 200
Diagnostic Workup 200
Timing of Surgery 201
Open Surgical Management of the Non-palpable Testicle 201
Laparoscopic Management of the Non-palpable Testicle 201
Diagnostic Laparoscopy 201
Laparoscopic Orchiopexy 202
Laparoscopic Technique for the Non-palpable Testicle 203
Blind-Ending Testicular Vessels 205
Cord Structures Entering the Internal Ring 205
Intra-abdominal Testis 206
Primary Laparoscopic Orchiopexy 207
Establishing a Peritoneal Pedicle Flap 207
Creating a Neo-inguinal Hiatus and Testicular Delivery into the Scrotum 209
Gaining Additional Cord Length and Securing the Testicle 209
Closure and Exiting the Abdomen 209
Second-Stage FowlerStephens 210
Bilateral Non-palpable Testicles and Laparoscopic Orchiopexy 210
Laparoscopy in the Management of High-Palpable Undescended Testicle 212
Complications 212
Conclusions 213
References 214
Part VII Laparoscopic and Robotic Anastomoses for Radical Prostatectomy 217
17 Laparoscopic Anastomoses and Bladder Neck Reconstruction Following Radical Prostatectomy 218
Introduction 218
Position of the Patient and the Surgeon 218
Preparations for the Anastomosis 219
Interrupted Suture Technique 220
Running Suture Technique 221
Single-Knot Method 222
Discussion 227
Critical Operative Steps 229
Preparation of Anastomosis 229
Interrupted Suture 229
Running Suture 230
Van Velthoven Suture 230
Critical Instruments and Supplies 230
References 230
18 Robotic Anastomoses and Bladder Neck Reconstruction Following Radical Prostatectomy 232
Introduction 232
Operative Considerations 233
Indications and Contraindications 233
Preoperative Preparation 233
da Vinci Surgical System Components 234
Patient Positioning 234
Port Placement 235
Anesthesia Considerations 236
Transperitoneal RALP Technique 236
Bladder Mobilization 236
Exposure of the Prostatic Apex and Ligation of the Dorsal Venous Complex (DVC) 236
Bladder Neck Transection 237
Posterior Prostatic Dissection 238
Management of Rectal Injury 239
Retrovesical Dissection (Montsouris Technique) 239
Neurovascular Bundle Dissection and Controlling the Lateral Pedicles 240
Division of the Dorsal Venous Complex and the Posterior Urethra 241
Anatomic Restoration and the Urethrovesical Anastomosis 241
Lymph Node Dissection 244
Extraperitoneal Technique 244
Managing the Difficult Bladder Neck 245
Challenging Prostate Anatomy 245
Bladder Neck Reconstruction 246
Management of Ureteral Injury 247
Oncologic Outcomes 248
Functional Outcomes 249
Continence 249
Potency 249
Bladder Neck Contracture 250
Conclusions 250
Critical Operative Steps 251
Critical Instruments and Supplies 251
References 252
Part VIII NOTES and LESS - Future Directions in MIS Reconstructive Surgery 256
19 The Role of NOTES and LESS in Minimally Invasive Reconstructive Urological Surgery 257
Introduction 257
Potential Benefits of NOTESTM and LESS 257
Technical Challenges of NOTESTM and LESS 257
Laparoendoscopic Single-Site Surgery (LESS) 258
Nomenclature 258
Development of LESS 258
Equipment for LESS 259
Scope Innovations for LESS 259
Incisions for LESS 260
Natural Orifice Translumenal Endoscopic Surgery (NOTES) 261
Definition and Nomenclature 261
Development of NOTESTM 261
NOTESTM in Urology 262
Managing Coaxial Limitations 262
Scopes and Equipment 263
Conventional Scopes 263
New Scope and Platform Innovations for NOTESTM 263
Accesses 264
Transvaginal 264
Transgastric 264
Transvesical 265
Transcolonic/Transenteric 265
Pneumoperitoneum 265
Endoscopic Instruments 265
Internalized Instrumentation (NOTESTM and LESS) 266
Magnetic Instrumentation 267
Miniature Intracorporeal Robotics 267
Conclusions 267
References 267
Part IX Laparoscopy and Robotics in Incontinence and Pelvic Reconstructive Surgery 270
20 Laparoscopy and Robotics in Stress Urinary Incontinence and Pelvic Reconstructive Surgery 271
Introduction 271
Stress Urinary Incontinence 271
Laparoscopic Burch Colposuspension 272
Patient Evaluation 272
Surgical Technique 272
Outcomes 272
Robotic-Assisted Laparoscopic Colposuspension 273
Other Laparoscopic Procedures for SUI 273
Pelvic Organ Prolapse 274
Patient Evaluation Prior to POP Repair 274
Laparoscopic and Robotics for Anterior and Posterior Vaginal Wall Prolapse 275
Laparoscopic Cystocele Repair 275
Surgical Technique 275
Outcomes 275
Laparoscopic Rectocele Repair 275
Surgical Technique 275
Outcomes 275
Laparoscopic and Robotics for Repair of Apical Prolapse 276
Laparoscopic Uterosacral Ligament Fixation 276
Surgical Technique 276
Outcomes 276
Laparoscopic and Robotic Sacrocolpopexy 276
Surgical Technique 276
Outcome 279
Vesicovaginal Fistula 280
Laparoscopic and Robotic VVF Repair 281
Patient Evaluation 281
Surgical Technique 281
Outcomes 282
Augmentation Cystoplasty 282
Patient Evaluation 282
Surgical Procedure 282
Outcomes 283
Conclusions 283
References 284
Subject Index 287