Education and Training at the Minimally Invasive Urology Institute

This video showcases an operation performed by Dragan Golijanin, MD, at the Minimally Invasive Urology Institute at The Miriam Hospital in Providence, Rhode Island, a major teaching affiliate of The Warren Alpert Medical School of Brown University. The video was edited by Osama Al-Alao, MD.

A 50-year-old male, with a solitary kidney after a live kidney donation, developed two renal masses. After reviewing the risks and benefits of surgery, a possible nephrectomy, his GI portal hypertension, and a history of alcoholic liver cirrhosis, the patient agreed to the nephrectomy.

Procedure Details

The patient identified in the operating room, was placed in the left lateral decubitus position with the bed flexed, prepped and draped in a sterile manner. The procedural timeout was performed. Perioperative cefazolin was administered and a 12 mm incision was made approximately one and a half inches superior and to the right of the umbilicus with a number-15 blade scalpel.

A Veress needle was then placed through this incision into the intraperitoneal cavity and the peritoneal cavity was insufflated to 15 atmospheres of pressure. The Veress needle was removed and a 12 mm camera port was placed in the patient's intraperitoneal space under direct vision. Two 8 mm robotic ports were then placed, one at the right costal margin and the other at the right lower quadrant overlying McBurney's point through 8 mm incisions. Finally, a 12 mm assistant port was placed medial to the right lower quadrant incision and a 5 mm assistant port was placed at the xiphoid process to allow for a liver retractor to be placed.

The robot was then docked and a laparoscopy was performed with the above findings. Lysis of adhesion was performed and noted to expose the hepatic flexure appropriately. The liver was then retracted with a laparoscopic bowel forceps retractor through the 5 mm assistant port, with great care taken to avoid injury to the diaphragm. The hepatic flexure was then visualized by taking down the white line of Toldt and also this plane was further dissected to kocherize the duodenum. The urethral fascia was then entered at the lower pole and the perirenal fat was dissected from the kidney. The ureter was exposed and the dissection was then carried posterolaterally as well as superiorly. Finally, the hilar vessels were exposed and the surrounding fat was removed with a very careful dissection. The renal vessels were identified laterally and an intraoperative ultrasound was performed with the above findings.

The borders of these masses were then delineated with electrocautery and two straight clamps were then placed along the renal hilum. Indocyanine green was administered to the patient and Firefly showed an uptake of indocyanine green at the liver, but not at the kidney after placement of the bulldog clamps. Therefore, partial nephrectomy was performed by extirpation of the renal masses with a single nephrotomy and these were placed in separate EndoCatch bags.

The nephrotomy was then closed, first with a running 2-0 suture to reapproximate the cortical medullary junction. This was closed with two separate 2-0 V-Loc stitches and then 4-0 V-Loc stitches were used to close the renal cortex after placement of Tisseel and Surgicel SNoW into the nephrotomy before closure.

Nephropexy was then performed with a running 0 V-Loc. This was performed in order to provide a layer of Gerota as compartment assurance of venous bleed in case any significant bleeding were to occur, and also to prevent direct bowel adhesion to kidney. This nephropexy first inferiorly, then medially and laterally took approximately over 15 to 20 minutes of suturing during the procedure, Gerota's fascia that had previously been incised at the beginning of the procedure was completely restored leaving the kidney in proper position in a good compartment area. Hemostasis was verified prior to closure of the Gerota's fascia on 10 mm of mercury (mmHg) for an insufflation pressure. The robot was then undocked. The assistant incision was extended to 3 cm and the tumors were extracted. After appropriate hemostasis the incision was closed with a running 0 Vicryl stitch.

Prior to undocking the robot, a 19-French Blake drain was placed through the left robotic port and placed over Gerota's fascia, but under the liver, with the remaining robotic needle drivers. The liver retractor was then carefully removed under direct vision. There was no injury to the diaphragm noted intraoperatively and this was all prior to undocking the robot. The drain was then stitched into place with a 2-0 silk and again the fascia at the assistant port incision, which was extended for proper hemostasis additional 0 Vicryl stitch was placed for hemostasis. The skin was closed with staples, except at the drain port, and wounds were dressed with gauze and Tegaderm.

The patient tolerated the procedure well. He was brought to the post-anesthesia care unit (PACU) in good condition.

This video demonstrates a surgery performed by Gyan Pareek, MD, at the Minimally Invasive Urology Institute at The Miriam Hospital in Providence, Rhode Island, a major teaching affiliate of The Warren Alpert Medical School of Brown University. The video was edited by Osama Al-Alao, MD.

The patient was a 78-year-old male with a history of severe lower urinary tract symptoms and urge incontinence. His prostate size measured 150 grams by CT scan. After reviewing risks and benefits, as well as available options, the patient opted for the robot-assisted suprapubic simple prostatectomy procedure.

Procedure Details

The patient was taken to the main operating room, placed under general anesthesia, placed in the lithotomy position, prepped, and draped in a sterile manner. A procedural timeout was performed. Perioperative ancef was administered and the patient was tested in steep trendelenburg. It was noted that no aberration of his vital signs occurred. Padding for the robotic procedure was verified as adequate and the patient was placed back out of trendelenburg.

A vertical supraumbilical incision measuring approximately 12 mm was made with a Bovie cut. Two towel clamps were then placed on either side of the incision and used to lift the incision. A Veress needle was then placed through the incision into the abdomen and the abdomen was insufflated to 15 cm of water pressure.

The Veress needle was then removed and a 12 mm camera port was placed through the wound into the peritoneal cavity. The trocar was removed and the laparoscopy was performed without significant abnormalities. 

On the right, an 8 mm robotic port was placed approximately 8.5 cm from the supraumbilical incision aiming towards the right ASIS; 2 cm medial and superior to the right ASIS, a 12 mm assistant port was placed. A 5 mm assistant port was placed approximately 6 cm superior and 3 cm lateral to the supraumbilical port on the right and two 8 mm ports were placed on the left, one approximately 8.5 cm from the supraumbilical incision running towards the ASIS and the second approximately 2 cm medial and superior to the ASIS itself. 

The patient was then placed again into steep trendelenburg and the robot was docked. A monopolar scissors was used in the right hand, a Maryland or fenestrated bipolar was used on the left hand, and in the fourth arm, a ProGrasp was used.

During an inspection of the pelvis, the IPP reservoir was noticed in the right side, extraperitoneally and lateral to bladder. The pump was activated to initiate penile erection and to empty the reservoir to protect it from injury during dissection.

A cystotomy was then made longitudinally at the dome of the bladder, exposing the inner lumen of the bladder. This cystotomy measured approximately 6 cm.

A Keith needle was then placed through the abdomen on the right and then placed through the bladder from outside to in on the right-hand side, and then placed back through the abdominal wall to exteriorize it. This Keith needle was then cut and a suture it was on was placed to traction. This was repeated on the left side to get exposure.

The bladder was investigated. Both ureteral orifices were seen after injecting indigo carmine, as well as a large right lateral lobe. An incision was marked with cautery around the adenoma with great care taken to avoid injury to the ureteral orifices. A Vicryl traction stitch was then placed into the adenoma itself and the fourth arm was used to retract the adenoma superiorly. 

An incision was then made posteriorly, and the capsular space was entered. This was then dissected free from the surrounding capsule circumferentially and distally and including anteriorly. This was incised with scissors and this incision was also taken circumferentially and the adenoma was removed from the bladder.

Hemostasis was achieved with electrocautery and with FloSeal. Portions of the bladder mucosa were anastomosed to the urethral mucosa distal to the resected adenoma with 2-0 Vicryl at the 9 and 3 o'clock positions and also at the 6 o'clock position in a running fashion. A 22-French 3-way catheter was then placed in the patient's bladder through the ureter and 50 ml was instilled into the balloon.

A cystorrhaphy was then performed, first by reapproximating the muscularis mucosal layer with a running 2-0 Vicryl and second reapproximating the seromuscular layer with a running stitch using a 0 Vicryl. The bladder was then interrogated with 240 ml of saline and minimal leak was seen. So we had interrupted 0 Vicryl sutures to make sure there were no more leaks.

The Foley was then again placed to gravity. The instruments were then removed, and the robot was undocked. The patient was taken out of trendelenburg. The supraumbilical incision was extended to allow for removal of the specimen and the specimen was removed.

The fascia of the supraumbilical incision was closed using a running 0 Vicryl on a UR-6 and all incisions were closed at the skin using staples, aside from the left-most robotic port, through which a JP drain had been placed immediately prior to undocking the robot. This was stitched into place with a 2-0 silk and dressed with a drain sponge. All other wounds were dressed with Tegaderm and gauze.

The patient was awoken from anesthesia. He tolerated the procedure well. He was brought to the post-anesthesia care unit (PACU) in good condition.

This is a case worked on by Gyan Pareek, MD, at the Minimally Invasive Urology Institute at The Miriam Hospital in Providence, Rhode Island, a major teaching affiliate of The Warren Alpert Medical School of Brown University. The video was edited by Osama Al-Alao, MD.

The patient was a 79-year-old female with a history of ureteropelvic junction obstruction (UPJO), nephrolithiasis, and hydronephrosis managed with interval stent exchanges. After reviewing the risks, benefits, and available options, the patient opted for the robot-assisted pyeloplasty with pyelolithotomy.

Procedure Details

The patient was taken to the main operating room, placed under general anesthesia, placed in the left lateral decubitus position with the bed broken at the level of the flank, prepped and draped in a sterile manner. A procedural timeout was performed. A 16-French Foley catheter was placed in the patient's bladder and a 12 mm supraumbilical incision was made with a Bovie electrocautery.

A Veress needle was then placed into the intraperitoneal space. Water drop and air drop tests were successfully performed, and pneumoperitoneum was established to 15 cm of water. This yielded a pneumoperitoneum of 3.0 L. The Veress needle was then removed and a 12 mm camera trocar was placed in the patient's abdomen. The inner trocar was then removed and laparoscopy was performed which showed multiple adhesions at the right upper quadrant and no intra-abdominal injuries due to Veress needle placement.

Ports were then placed for the robotic arms, each 8 mm, one along the right costal margin in the right upper quadrant and the other in the right lower quadrant at approximately McBurney's point. A 12 mm assistant port was placed medial to the right lower quadrant robotic port and a 5 mm assistant port was placed at the xiphoid process. The adhesions were lysed laparoscopically in order to allow for port placement. The robot was then docked and a 30-degree scope was used for the procedure.

The white line of Toldt was incised with electrocautery and the colon was medialized from Gerota's fascia with sharp dissection and electrocautery. The retroperitoneum was then dissected inferior to the lower pole, where the ureter was discovered. The Gerota's fascia was then entered at the lower pole, showing the capsule of the kidney. Of note, this layer was significantly fibrotic diffusely near the hilum and at the lower pole.

The ureter was then dissected proximally to the level of the hilum and a Keith needle was used to introduce a 0 Prolene to retract the ureter towards the abdominal wall. The renal pelvis was then carefully dissected out using the incision in Gerota's fascia that was previously made, and this dissection was carried towards the UPJ.

The ureter was then transected approximately 1 cm distal to the UPJ. The stent was seen emanating from the proximal ureter. A flexible cystoscope was introduced via the 12 mm assistant port into the abdomen and was robotically guided into the renal pelvis. Stones were basketed and sent for analysis.

The ureter was spatulated as was the renal pelvis at the lateral side and a 3-0 Monocryl stitch was placed laterally at the apices of the spatulation. Another 3-0 Monocryl was then placed at the medial side of the anastomosis and the Prolene that had been used for traction was cut. 

The ureter was then flipped, exposing the posterior side, and a running 3-0 Monocryl was used for the posterior anastomosis. The ureter was then flipped back anteriorly. The stent coil was placed back into the renal pelvis and the anterior anastomosis was then performed using a running 3-0 Monocryl. 

Hemostasis was verified with pneumoperitoneum at 12 and the left robot arm was undocked. A Blake drain was placed through the 8 mm trocar in the right lower quadrant and this was placed over the anastomosis. The robot was then undocked completely and the trocars were removed and all ports were closed with staples.

The patient was awoken from anesthesia. She tolerated the procedure well. She was brought to the post-anesthesia care unit (PACU) in good condition.

Dr. Pareek was scrubbed and present for the entire duration of the case. 

This is a case worked on by Gyan Pareek, MD, at the Minimally Invasive Urology Institute at The Miriam Hospital in Providence, Rhode Island, a major teaching affiliate of The Warren Alpert Medical School of Brown University. The video was edited by Osama Al-Alao, MD.

The patient was a 59-year-old female with a history of a large left-sided renal cyst and chronic left flank pain. After reviewing the risks, benefits, and available options, the patient opted for the renal cyst decortication procedure.

Procedure Details

The patient was taken to the main operating room, placed under general anesthesia, placed in the right lateral decubitus position with the bed slightly broken, prepped and draped in a sterile manner. A procedural timeout was performed. Perioperative Ancef was administered and a 12 mm incision was made in the supraumbilical region with a #15 blade scalpel.

A Veress needle was then placed in the patient's intraabdominal cavity and a pneumoperitoneum was established to 15 mmHg. This established a pneumoperitoneum of 2 L. Under direct vision, a 12 mm trocar was then placed in the patient's intraperitoneal space without difficulty. Two 5 mm ports were then placed on either side of the 12 mm camera port and a Harmonic scalpel and Maryland were used for laparoscopic instruments.

The colon was reflected medially, immediately revealing the renal cyst. Gerota's fascia was entered and the cyst was cleaned off. The cyst was then drained with a needle and subsequently reroofed with the Harmonic scalpel. The underlying cyst wall remaining was burned with a Harmonic scalpel. The cyst wall was sent for pathology.

Hemostasis was verified. Instruments were removed, as well as the trocars, after the entire pneumoperitoneum was reduced. Ports were closed at the skin using subcuticular Monocryl stitches and DERMABOND.

The patient tolerated the procedure well. She was awoken from anesthesia and brought to the post-anesthesia care unit (PACU) in good condition.

Dr. Pareek was scrubbed and present for the entire duration of the case.