video posters / european urology supplements 9 (2010) 519–530
renorrhaphy technique for RAPN. We present the ﬁrst examples of barbed suture for use in the renorrhaphy of human patients undergoing RAPN. Methods: The Quill™ SRS #0, on a CT-1, and the V-Loc™180 3–0, on an SH needle, were used in our RAPN procedures. In this video we demonstrate 4 applications of barbed suture for closure of the deep and capsular layers of renorrhaphy. The Quill™ and a constructed double-armed V-loc™ suture were each used to close both the resection bed followed by the renal capsule using a single suture. The Quill™ was used for horizontal mattress closure of the capsule during an “off-clamp” RAPN and the V-Loc™ was used to close the deep layer and perform ﬁgureof-eight vessel ligation in the setting of early unclamping. Summary of Results: Renorrhaphy was successfully completed in 6 RAPNs using barbed suture with a mean warm ischemia time of 13.8 min and with no urine leaks, hemorrhage, or other complications. The sliding hem-o-lok clip technique was used without the need for redundant clips to prevent slippage. Conclusions: Use of barbed suture for the renorrhaphy of RAPN simpliﬁes the technique and improves efﬁciency, potentially allowing for reduced warm ischemia times and tighter renal closures. 92 Robotic partial nephrectomy in the setting of renal insufﬁciency S. Kaul, F. Petros, J. Sammon, M. Menon, C. Rogers. Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA Objectives: Patients with pre-existing renal insufﬁciency undergoing minimally invasive partial nephrectomy comprise a high risk group. We evaluate our experience with minimally invasive robotic partial nephrectomy (RPN) in patients with compromised baseline renal function and evaluate perioperative outcomes. Methods: Of 92 patients undergoing RPN from August 2007 to February 2010, 22 (20%) had pre-existing renal insufﬁciency deﬁned as eGFR of <60 ml/min. Patients underwent one of 4 techniques designed to minimize warm ischemia: Off clamp resection, intra corporeal cooling, enucleoresection and renorrhaphy with a barbed suture. Demographic, operative parameters and peri-operative outcomes were evaluated. Post Operative GFR was assessed at 1 month and last follow up. Summary of Results: Successful RPN was performed in 20 patients with stage III CKD based on preoperative eGFR < 60. Mean tumor size-3.1 cm (1.1–6.6), mean warm ischemia time-14 min, mean EBL-163.8 ml, and mean preoperative eGFR-52 (32.4– 59.8). A total of 21 tumors were removed; with hilar clamping in 13 tumors (artery alone-3) and off-clamp in 8 tumors. Two patients had solitary kidney. Intracorporeal renal hypothermia was performed in 2 patients using iced saline irrigation with 2 suction devices for continuous installation and aspirating of ﬂuid after hilar clamping. Surgical margins were negative in all patients except one with a focal microscopic positive margin from enucleoresection of a papillary RCC in a solitary kidney. Patients were followed up to 19.3 months (mean 6.2). There were neither recurrences nor deaths due to RCC. Conclusions: RPN is feasible in the setting of compromised renal function. Off-clamp resection, enucleoresection, intracorporeal hypothermia and barbed suture use may be considered in these patients to minimize ischemic damage.
93 Assistantless urethrovesical anastomosis during Robotic Radical Prostatectomy (RRP) using unidirectional barbed wound closure device S. Kaul, J. Sammon, A. Bhandari, J.O. Peabody, H. Stricker, C. Rogers, M. Menon. Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA Objectives: Urethrovesical anastomoses (UVA) is a critical and technically demanding step during RRP. The commonly used Van Velthoven stitch has limitations relating to slippage of monoﬁlament suture. This necessitates constant traction by an assistant or repeated tightening of suture by the surgeon, prolonging UVA time. We present a novel technique of UVA utilizing unidirectional barbed suture to address these limitations. Methods: The bi-directional UVA suture is pre-prepared from two 6in. 3–0 polyglyconate barbed sutures secured end-to-end. This 12in composite suture is used to perform UVA without assistance and without tying knots. 51 consecutive patients undergoing RRP at our institution underwent a dual layer UVA using the barbed suture. Integrity of anastomosis was tested by instilling 240 ml of saline. Cystogram was performed at 7 days. Follow up was at least 1 month. Summary of Results: Median time for UVA was 11 minutes (45% performed under 10 minutes). Eight (16%) required anterior bladder neck reconstruction by extending the suture across in ﬁgure of eight pattern. No patients had cystogram detected urinary leaks, urinary retention or anastomotic strictures. Not having an assistant follow the suture minimizes instrument clashes and makes UVA faster and efﬁcient. Because of the barbs, each throw acts as an independent interrupted suture and holds itself in place, making knot tying unnecessary. Conclusions: We present a novel technique of UVA during RRP that is safe, efﬁcient and addresses limitations of current techniques. Utilizing barbed self locking suture obviates the need for assistance, prevents slippage and allows for knotless anastomosis. 94 Heminephrectomy in horseshoe kidney: Robotic assistance to optimize vascular control and renorrhaphy E. Kheterpal, S. Kaul, J. Sammon, A. Bhandari, N. Patil, N. Pokala, C. Rogers. Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA Objectives: Surgical management of tumors within a horseshoe kidney may present additional technical challenges, particularly with a minimally invasive approach. Previous groups have described laparoscopic and robotic management of tumors in horseshoe kidneys using a GIA stapler to divide the renal isthmus and renal arteries. In this video we describe the use of robotic assistance for vascular control and sutured renorrhaphy during heminephrectomy of a large tumor in a horseshoe kidney with aberrant vasculature and a prominent isthmus. Methods: A 60 yr old male was diagnosed with 4.6 cm heterogeneous enhancing mass involving the right moiety of a horseshoe kidney. A CT angiogram demonstrated abnormal renal vasculature with multiple arteries arising from the aorta, the inferior mesenteric artery, and the common iliac artery. The isthmus of the horseshoe kidney was too wide and thick to use a GIA stapler for transection so robotic assistance was used to help facilitate transection of the isthmus with sutured renorrhaphy. We demonstrate the steps involved in performing a robotic assisted heminephrectomy. Summary of Results: Robotic assisted right heminephrectomy was completed without the need for open conversion. Operative blood loss was 300 ml. There were no intraoperative complications. Patient had an uneventful recovery and was discharged home on the third post-operative day.