Anatomic relationships of psoas muscle: clinical applications to psoas hitch ureteral reimplantation

Robot-assisted Boari flap and psoas hitch ureteric reimplantation: technique insight and outcomes of a case series with ≥1 year of follow-up

OBJECTIVE

To describe step-by-step surgical techniques and report outcomes of the largest single-centre series of patients with distal ureteric disease exclusively treated with robot-assisted ureteric reimplantation with Boari flap (RABFUR) and psoas hitch (RAPHUR), with a minimum follow-up of 1 year and complete postoperative data.

PATIENTS AND METHODS

A total of 37 patients with distal ureteric disease were treated between 2010 and 2018. Of these, 81% and 19% underwent RAPHUR and RABFUR, respectively. Intra-, peri- and postoperative outcomes were assessed. The 90-day postoperative complications were reported according to the standardised methodology proposed by the European Association of Urology Ad Hoc Panel. Functional outcomes (creatinine, estimated glomerular filtration rate [eGFR]) and postoperative symptoms (visual analogue pain scale) were assessed.

RESULTS

The median operating time and blood loss were 180 min and 100 mL, respectively. There were no conversions to open surgery and no intraoperative transfusions. The median length of stay, bladder catheter indwelling time and stent removal were 4, 7 and 30 days, respectively. The median follow-up was 24 months. Overall, 10 patients (27%) had postoperative complications and of these, eight (22%) and two (5.4%) were Clavien-Dindo Grade I-II and III, respectively. At the last follow-up, the median postoperative creatinine level and eGFR were 0.9 mg/dL and 73.5 mL/min/1.73 m² , respectively. At the last follow-up, five (13.5%) and three (8%) patients had Grade 1 hydronephrosis and mild urinary symptoms, respectively. The study limitations include its retrospective nature.

CONCLUSION

In the present study, we present our RABFUR and RAPHUR techniques. We confirm the feasibility and safety profile of both approaches in patients with distal ureteric disease relying on the largest single-centre series with ≥1 year of follow-up.

Robot-assisted segmental ureterectomy with psoas hitch ureteral reimplantation: Oncological, functional and perioperative outcomes of case series of a single centre

INTRODUCTION

According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR).

MATERIALS AND METHODS

11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes.

RESULTS

Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression.

CONCLUSIONS

In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings.

Robotic-assisted psoas hitch with ureteral reimplantation

OBJECTIVE

To demonstrate a robotic-assisted psoas hitch with ureteral reimplantation.

METHODS

We gleaned video footage from a robotic-assisted psoas hitch procedure performed for a patient with an isolated pelvic recurrence of ovarian cancer.

RESULTS

We demonstrate trocar placement and a robotic-arm docking strategy for pelvic recurrence of ovarian cancer. We also show surgical steps involved in a psoas hitch and reimplantation of a transected ureter into the bladder. Special emphasis is placed on guiding the surgeon using key robotic instruments and materials to optimize the robotic completion of this procedure. Key components of the procedure, including en bloc tumor excision and ureteral transection, are shown. The bladder is placed on traction using the fourth arm, and the avascular planes of dissection, including the space of Retzius and the paravesical spaces, are shown. The bladder is then backfilled to allow the surgeon to determine the ideal placement of the ureteral reimplantation to ensure the anastomosis is tension free. The surgeon then demonstrates where and how to place anchoring sutures from the bladder to the psoas muscle. The ureter is examined to determine where it can be implanted in the bladder with zero tension or angulation, which would compromise function and healing. The ureter is prepared for reimplantation, including trimming, tagging, and spatulation. An instrument tie technique is used to implant the ureter into the bladder and a ureteral stent is placed. Robotic-assisted psoas hitch with ureteral reimplantation has been described in the literature.1-4 CONCLUSIONS: Through the use of still photographs and video, we demonstrate the technique of robotic-assisted psoas hitch with ureteral reimplantation.

Endopelvic Approach for Iliac Crest Bone Harvesting

BACKGROUND

The anterior approach to lumbar spine surgery has grown in popularity in the past few years; spinal fusion of the last 2 lumbar levels is often required. Although alternatives to bone grafting are available, including recombinant human bone morphogenetic protein 2 or bone substitutes, only cancellous autologous bone has all the required factors for bone growth. To avoid the use of bone substitutes, remote iliac crest bone harvesting remains the gold standard. However, this technique may lead to some unfavorable outcomes.

CASE DESCRIPTION

The patient was a 46-year-old man with severe back and left leg pain. Magnetic resonance imaging showed an inflammatory discopathy of L5-S1 associated with a left posterior lateral herniated disc. Conservative treatment failed, and surgical treatment of the lumbar disk disease and the herniated disc was scheduled. A novel iliac crest bone harvesting method was performed during the retroperitoneal approach to the anterior lumbar interbody fusion. The patient's postoperative course was uneventful. There were no adverse outcomes related to the bone donor site.

CONCLUSIONS

This is the first in vivo report of endopelvic iliac crest bone harvesting. This technique allows bone graft harvesting to be performed with the same retroperitoneal approach used for anterior lumbar interbody fusion. It avoids many common complications associated with the remote approach to the iliac crest.