V9-06: ROBOTIC-ASSISTED MANAGEMENT OF SYMPTOMATIC INTRAPARENCHYMAL CALYCEAL DIVERTICULA

Video

Introductions and Objectives
Calyceal diverticula are uncommon urine-containing cavities within the renal parenchyma that communicate with the collecting system through a narrow channel. Although usually small and asymptomatic, large calyceal diverticula can lead to urine stasis, pain, infection, and stone formation. Management for symptomatic calyceal diverticula can be accomplished via percutaneous, open, or minimally invasive approaches. Diverticula that are located deep within renal parenchyma can be difficult to manage due to challenges in identifying the lesion at time of surgery, inability to locate the patent communication from the collecting system, or significant hemorrhage from surrounding parenchyma.

Methods
This video demonstrates a robot-assist laparoscopic calyceal diverticulectomy in a 17 year old male who presented with intractable right flank pain and nausea with vomiting and was subsequently found on CT urography to have an intraparenchymal calyceal diverticulum. Prior to flank positioning, a ureteral catheter was placed cystoscopically to allow irrigation-based localization of the diverticular communication to the renal collecting system. During the procedure, intraoperative renal ultrasonography was employed to identify the margins of dissection and a laparoscopic bulldog clamp was placed on the renal artery just prior to dissection to help minimize blood loss and maintain good operative visibility.

Results
The diverticulum was identified by renal ultrasonography, dissected and the small communicating channel to the renal collecting system was oversewn. Blood loss was 50cc and renal artery clamp time was 24 minutes. Operative time was 202 minutes. There were no intraoperative or post-operative complications. The patient was discharged on post-operative day 1. Post-operatively, the patient's presenting symptoms of flank pain and nausea with vomiting resolved. Follow-up imaging noted complete resolution.

Conclusions
In this video, we demonstrate a safe and reproducible way of managing a symptomatic intraparenchymal calyceal diverticulum. Essential technical components during this robotic-assisted approach include placement of a ureteral catheter prior to dissection, use of intraoperative renal ultrasonography, and temporary clamping of the renal artery.

Funding: none