Résumé
ABSTRACT Background: The ectopic pelvic kidney, a common renal anomaly, is often smaller and malformed, with a shorter and sometimes tortuous ureter (1). Muscle-invasive bladder cancer (MIBC), constituting 15-25% of bladder cancer cases (2), mandates radical cystectomy with a 50% 5-year survival rate (2). Despite the growing use of robot-assisted radical cystectomy (RARC) (3, 4), there is limited data on its application in ectopic kidneys. Only one RARC case has been reported (5), in contrast to numerous open radical cystectomies (1, 6) involving an ectopic kidney. Patient and methods: After being diagnosed with T2 high-grade urothelial carcinoma, the 66-year-old patient, previously treated with multiple transurethral resections and adjuvant BCG therapy, received neoadjuvant chemotherapy. Preoperative staging CT revealed a 2.6 x 2.2 cm bladder neoformation and an ectopic right pelvic kidney. Results: Using the da Vinci Surgical System, radical cystectomy with ileal conduit (sec Wallace II) and lymphadenectomy were performed. During the demolition phase, the shorter right ureter was dissected with care to avoid damage to the renal pedicle. The reconstructive phase included intracorporeal urinary diversion (ICUD) and uretero-ileal anastomosis, facilitated by the favorable position of the kidney. The 8-hour console surgery resulted in minimal blood loss. Discharged on day 16 due to COVID-19, the patient exhibited positive outcomes. A 2-month CT follow-up revealed no cancer recurrence, metastasis, hydronephrosis, and complete regression of the lymphocele. Imaging follow-up continues without postoperative adjuvant chemotherapy. Conclusion: Robotic surgery with intracorporeal urinary diversion holds potential for right-sided pelvic kidney cases, but additional studies are necessary for validation.
Résumé
ABSTRACT Objective: Robotic intracorporeal neobladder reconstruction is a complex procedure in which the approximation of the reservoir to the urethral stump can be a demanding step. The aim of the study is to evaluate the reproducibility of a modified posterior reconstruction (PR) during the reconfiguration of intracorporeal neobladder after robot assisted radical cystectomy (RARC). Materials and Methods: From July 2021 to July 2022, 35 RARC were performed, and 17 patients underwent intracorporeal neobladder reconstruction. A PR was planned in males (14). Intra- and peri-operative data were collected. Surgical technique: RARC and node dissection are performed. Afterwards, 40-cm ileal segment is isolated; the portion with the more adequate mesenteric length is brought down to the pelvis. A modified PR is performed with a double-armed barbed suture: a first layer connects the Denonvillier's fascia to the rhabdosphincter in a running fashion; the second layer is created with the other arm and approximates the posterior side of the ileal segment towards the urethral stump. In the anterior caudal part of the ileum, a 1.5-cm incision is made to realize the neobladder neck; the neovesical-urethral anastomosis is performed with a second bidirectional suture. Results: Anastomotic and PR time were 14 (range 7-20) and 5 minutes (4-8), respectively. A single Clavien IIIa complication was recorded in a patient who underwent NAC and had a C. albicans superinfection in the post-operative course. All patients were discharged with complete or acceptable bladder voiding. Twelve patients with follow-up >90-days reported a satisfying daytime continence. Conclusions: PR represents a simple technical refinement that improves neobladder-urethral anastomosis by favoring ileal approximation to the urethral stump and decreasing anastomotic tension.
Résumé
ABSTRACT Introduction and Objectives: Treatment of bulky lithiasis in continent and non-continent urine storage reservoirs has been widely described and debated (1). Less is known about the optimal treatment in patients with a Mitrofanoff conduit. If voiding in these patients is incomplete, leading to recurrent symptomatic bacteriuria, formation of large lithiasis can be a common long-term complication (2, 3). Materials and Methods: This video describes a 19-year-old woman who underwent major open surgery at the age of six, with the configuration of a continent intestinal reservoir with a Mitrofanoff conduit. In 2020, she was referred to our center with a large stone in the reservoir and a minor stone in the inferior left renal calyx. We decided to proceed using a percutaneous approach with an "endovision technique" puncture for the bladder stone, combined with a retrograde intrarenal surgery for the renal stone. The MIP System "M size" was used to perform the percutaneous procedure, thus allowing a single-step dilation. The puncture and the dilation were followed endoscopically with a flexible ureterorenoscope avoiding the use of x-rays. The procedure was carried out as follows. The first step consisted in the insertion of a hydrophilic guidewire through the Mitrofanoff conduit. A flexible ureterorenoscope was then inserted coaxial to the guidewire. The percutaneous puncture, using an 80G needle, was followed endoscopically. Two guidewires were inserted, the first as a safety guidewire and the second for the tract dilation. The "single-step" dilation technique using the MIP system was performed and followed endoscopically. For the bladder lithotripsy, a dual-action lithotripter that combines ultrasonic and mechanical energy was used. Finally, a flexible ureterorenoscope and a basket for the retrieval of a single inferior caliceal stone were used. The procedure ended after positioning a single J stent in the left kidney and a nephrostomy tube in the reservoir. Results: The operative time was 80 minutes and the fluoroscopy time was 6 seconds. Hemoglobin and creatinine serum levels remained stable after the procedure and the patient was discharged on the third post-operative day, after removing both the single J and the nephrostomy tube. Follow-up lasted 12 months, with no bladder or renal stone recurrence, maintaining good continence of the Mitrofanoff conduit. Conclusion: In patients who have undergone several major surgeries a mini-invasive approach is advisable, not only for the morbidity of an open approach, but also for the increased risk of complications while handling an intestinal reservoir. Regarding a pure endoscopic approach, the passage of a nephroscope or a cystoscope through the Mitrofanoff conduit, combined with the continuous traction during the lithotripsy, could damage and compromise its continence. For this reason, the percutaneous approach is the most suitable method in these specific and rare cases.