Urology & Kidney Disease News - Cleveland Clinic

16 Urology & Kidney Disease News
Robotics and Laparoscopy
Laparoendoscopic Single Site Surgery: Retrocaval Ureter Repair
Robert J. Stein, MD, Riccardo Autorino, MD, Rakesh Khanna,
MD, Michael White, MD, Bo Yang, MD, Sylvain Forest,
MD, Fatih Altunrende, MD, Georges-Pascal Haber, MD, and
Jihad H. Kaouk, MD
Laparoendoscopic single site surgery (LESS) performed
through a small umbilical incision allows major urological
operations to be performed with a nearly scar-free result. To
date, our experience with these techniques numbers more
than 160 procedures, which includes more than 30 robotic
procedures. In terms of reconstructive procedures, a wide
spectrum of cases including pyeloplasty, ureteroneocystostomy,
and ileal interposition have been performed using both
standard and robotic techniques.
Recently, a 25-year-old woman presented with chronic intermittent
right flank pain. Preoperative imaging with proximal
hydroureteronephrosis suggested retrocaval ureter. A rightsided
retrograde pyelogram confirmed the diagnosis and a
double-J ureteral stent was placed (Figure 1). After creating
a small intraumbilical incision, a single-port device was
positioned and the ureter was dissected proximal and distal
to the inferior vena cava crossing (Figure 2).
At this point the ureter was transected posterior to the inferior
vena cava and the distal segment was transposed laterally
to a normal anatomic position. With the assistance of a separate
2-mm grasper, a uretero-ureterostomy was performed.
The patient was discharged 2 days postoperatively after her
transumbilical drain was removed (Figure 3).
Four weeks postoperatively the ureteral stent was removed,
and 4 weeks thereafter a radionuclide scan demonstrated a
post-diuretic T ½ of 1 minute. At a postoperative interval of 8
months the patient reports symptom resolution.
Since 2007, urologists have increasingly used LESS techniques.
The evident advantage of the surgery is the aesthetic
benefit, especially valued by younger patients, as in this case.
Theoretical benefits include decreased postoperative pain,
earlier convalescence, and less scarring with fewer incisions.
With preliminary retrospective comparisons thus far there
have been mixed results regarding any perioperative and
recovery benefits. With greater experience and more robust
comparative analyses, the true advantages of the LESS technique
will become clearer.
The largest hurdle for the LESS approach is the ergonomic
challenge of instrument clashing and loss of triangulation.
Endoscopes and instrumentation will require several modifications
that are under way to improve functionality for these
procedures. Adaptation of robotics is believed to perhaps be
a key development to make these procedures more practical
for many surgeons. With this goal, we embarked on the
initial experience using robotics in LESS and we are continuing
to refine these techniques. As procedures evolve and
experience grows, it will be necessary to thoroughly evaluate
outcomes of these increasingly less invasive procedures.
Key Point:
We recently performed a laparoendoscopic single site
surgery (LESS) for retrocaval ureter repair. Our experience
includes more than 160 LESS procedures, 30 of which were
robotic procedures. LESS has aesthetic benefits, but there
have been mixed results regarding any perioperative and
recovery benefits. With greater experience and more robust
comparative analyses, the true advantages of the LESS
technique will become clearer. Robotics may make these
procedures more practical for many surgeons.
Figure 1. Retrograde pyelogram demonstrating classical
appearance of retrocaval ureter
Figure 2. Single port platform and articulating instruments
used for the LESS procedure
Figure 3. Postoperative photograph demonstrating the
intraumbilical incision, transumbilical drain, and right lower
quadrant entry site of an ancillary 2mm grasper