ABSTRACT Introduction and Objectives: Management of recurrent ureteropelvic junction obstruction (UPJO) following pyeloplasty presents a challenging clinical problem. Failure of initial pyeloplasty is, in part, secondary to ureteral devascularization and subsequent fibrosis. In this video, we present a case of an anastomotic augmentation with cryopreserved placental tissue (CPT) to improve tissue healing and angiogenesis, and aid with the success of re-do robotic pyeloplasty. Materials and Methods: We present a 46-year-old female with history of recurrent left-sided UPJO treated by initial endopyelotomy and then open pyeloplasty. She underwent re-do robotic pyeloplasty (DaVinci Si™, Intuitive Surgical) with CPT. The patient was placed in the flank position; a 12mm camera port, three 8mm robotic ports, and a 12mm assistant port were used. The renal pelvis and upper ureter were mobilized to reveal a dense scar at the UPJ. A dismembered pyeloplasty was performed with barbed suture. After completion of the anastomosis, a section of CPT (Stravix™, Osiris Therapeutics) was wrapped around the anastomosis. CPT is composed of umbilical amnion and Wharton's jelly, which contains a mixture of extracellular matrix, and growth factors. The CPT is prepared and thawed on the bedside table, and placed into the peritoneum through the 12mm port in the correct orientation. The wrap is secured to the anastomosis with a fibrin sealant (EVICEL™, Johnson & Johnson). Results: The patient experienced resolution of flank pain. MAG3 renogram demonstrated resolution of obstruction at 6 months, with improvement of T½ time from 34 minutes to 7 minutes, with sustained improvement with repeat scan 18 months after surgery. Ureteroscopy demonstrated a patent UPJ. Strategies for successful robotic pyeloplasty after initial failed management include: (1) use of appropriate CPT agent to support the anastomosis - selection of thicker, more durable CPT to allow passage through laparoscopic port, (2) preparation on bedside table with enough time to allow thawing, (3) marking Wharton's jelly side of tissue for orientation, and (4) use of sealing agent to secure CPT to the anastomosis and prevent dislodgement. Conclusions: We demonstrate a novel approach to manage recurrent UPJ obstruction with robotic surgery using CPT. Placenta-derived products may have an increasing role in the performance of complex robotic urologic reconstructive surgery.

ABSTRACT Introduction: Dusting, use of high frequency and low pulse energy-is commonly performed during ureteroscopic holmium laser lithotripsy but reports on the ability of this method to treat large stones via percutaneous nephrolithotomy (PCNL) are limited. We report on the first clinical feasibility of a dusting technique during PCNL using a specially designed laser suction handpiece (LSHP). Materials and Methods: We performed PCNL on a patient with spinal cord injury, and recurrent urinary tract infection. Computed tomography demonstrated a left complete staghorn stone, 1000 Hounsfield units. Standard (30F) prone PCNL was performed via lower pole access and balloon dilatation. A 120-Watt holmium (P120H, Lumenis) was used to perform Dusting Utilizing a Suction Technique (D.U.S.T.) for PCNL with a 550um fiber in the LSHP which was connected to a suction pump in the P120H. The LSHP has a stainless steel cannula with inner lumen diameter of 3.25mm, with fiber positioned in a separate working channel on top of the cannula. Suction is activated via the LSHP, and fragments are sucked into a collection container. We used it in “automatic” mode where suction occurred only during laser activation. Results: We successfully performed DUST-PCNL to treat the staghorn stone using settings of 0.6Jx70Hz, and 1.0Jx60Hz, (long pulse width). Total operative time was 110 minutes; laser time 21.29 minutes, laser energy 47.68kJ. We did not encounter any difficulty with fragment aspiration or clogging of the cannula or suction tubing. Ancillary devices used included a basket to retrieve large fragments, and flexible nephroscopy to dust an upper pole branch of the staghorn stone. A nephrostogram on post-operative day POD 1 demonstrated a 4mm residual fragment. Patient was discharged on POD 2. There were no complications; stone analysis demonstrated a struvite stone. Conclusions: We confirmed initial clinical feasibility and safety of DUST-PCNL to perform simultaneous lithotripsy and aspiration for effective stone clearance. An advantage of this method is versatility in treating a stone with both rigid and flexible endoscopy using a single energy source. Further evaluation is needed to better understand the efficacy of this technique.

Introduction: The treatment of large renal stones in children can be challenging often requiring combination therapy and multiple procedures. The purpose of this video is to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. Materials and Methods: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. Results: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. Mean operative time, blood loss and hospital stay was 216 minutes, 37.5 mL and 2 days, respectively. The robotic ultrasound probe aided identification of calculi within the kidney in all cases. For nephrolithotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a combination of robotic Maryland forceps, fenestrated grasper or Prograsp. Antegrade nephroscopy introduced through a laparoscopic port was used in all patients for confirmation of residual stone status. Two patients did not require a ureteral stent in the post-operative period. One patient had a minor complication (Clavien Grade 2 - dislodged malecot catheter). All patients were stone free at last follow-up. Conclusions: Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe offers a one-stop solution for complex renal stones with excellent stone-free rates.

Objectives To examine the effect of surgical approach on perioperative morbidity and mortality after partial nephrectomy. Materials and Methods Within the Nationwide Inpatient Sample, patients who underwent RAPN or LPN between October 2008 and December 2009 were identified. Propensity-based matching was performed to adjust for potential baseline differences between the two groups. The rates of intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality, stratified according to RAPN vs. LPN, were compared. Results Overall, 851 (72.5%) patients underwent RAPN and 323 (27.5%) underwent LPN. For RAPN and LPN respectively, the following rates were recorded in the propensity-score matched cohort: blood transfusions, 4.5 vs. 6.8% (p = 0.223); intraoperative complications, 5.2 vs. 2.6% (p = 0.096); postoperative complications, 10.6 vs. 13.5% (p = 0.268); prolonged length of stay, 6.8 vs. 9.4% (p = 0.238); in-hospital mortality, 0.0 vs. 0.0%. Conclusions RAPN has supplanted LPN as the predominant minimally invasive surgical approach for renal masses. Perioperative outcomes after RAPN and LPN are comparable. Interpretation of these findings needs to take into account the lack of adjustment for case complexity and surgical expertise.