240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY

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23% (7/30) and excision of the fistula and unhealthy tissue with primary urethral anastomosis in 27% (8/30). At a median follow-up of 10.4 months (range 1.3 - 44.6), 93% (28/30) of the patients achieved closure with 1 repair. Both failures were combined ablative fistulas. One recurred 1 mo after colostomy closure and had a successful second repair of the urethra with permanent colostomy. The second developed 1 mo after ileostomy closure and has closed with repeat fecal diversion. Overall, bowel diversion was closed in 80% (24/30) of patients with 3 awaiting closure, 1 not a candidate due to ongoing colitis and the two failed repairs. In patients who have completed their reconstruction, 2 patients required DVIU for recurrent stricture, 1 had a suprapubic tube for recalcitrant stricture, 5 had AUS of which 1 had multiple infections and eventually was managed with bladder neck closure and continent catheterizable stoma. CONCLUSIONS: Complex RUFs can be closed with a high success rate and restoration of orthotopic bowel and bladder function in the majority of patients. Long term studies are required to determine the durability of these repairs. Source of Funding: None

238 TRANSPERINEAL CLOSURE OF THE MALE URETHRA IN THE SETTING OF SUPRAPUBIC DIVERSION – AN ALTERNATIVE MANAGEMENT FOR URINARY INCONTINENCE. Ty Higuchi*, Yuka Yamaguchi, Hadley Wood, Kenneth Angermeier, Cleveland, OH INTRODUCTION AND OBJECTIVES: There are few reports of males undergoing transperineal closure of the urethra for persistent incontinence following suprapubic catheter or diversion. In females with this problem it is possible to perform transvaginal closure of the urethra with good success rates. We describe our technique and experience with urethral closure in males in this setting. METHODS: We retrospectively reviewed patients undergoing urethral closure to treat refractory incontinence from 2010 to 2011. Urethral closure was performed through a perineal incision and urethral dissection is carried to the perineal membrane. The spongiosum is cut at the proximal bulbar region and the urethra is transected more proximally near the bulbomembranous junction and closed. The area is reinforced by rotating a flap of preserved spongiosum forward over the urethral closure and the bulbospongiosus muscle serves as a final layer of reinforcement. We recorded patient demographics, etiology of incontinence, surgical outcomes and complications. RESULTS: Six patients met study criteria and the etiology of the incontinence was 3 neurogenic bladders (NGB) including 1 large urethrocutaneous fistula from a chronic foley catheter, 1 failed bladder neck closure for devastated urethra from chronic ISC and 1 with persistent incontinence after augmentation cystoplasty and catheterizable stoma. The remaining 3 had previously undergone therapy for prostate cancer. Two had experienced multiple AUS erosions resulting in an irreparable urethra and 1 developed a prostatic urethral stricture from XRT and failed multiple treatments. Five patients had suprapubic catheters and one had augmentation cystoplasty with continent stoma. Median age at the time of urethral closure was 73 years (range 60-82). The patient with urethrocutaneous fistula and NGB also underwent gracilis transfer and scrotal flap to cover the defect. The median length of surgery was 124.5 minutes (range 64-295), EBL was 40ml (range 5-200ml) and hospital stay was 1 day (range 1-17). Postoperatively, there were 2 superficial wound infections, 1 bleed requiring transfusion and 1 DVT. At a median of 1.45 months (range 1-18), 83% (5/6) of patients have had successful closure of their urethra with one procedure. The one patient who failed underwent previous XRT for prostate cancer and is awaiting revision. CONCLUSIONS: Transperineal closure of the male urethra following suprapubic diversion is a reasonable option for men with refractory incontinence. It avoids a major abdominal procedure and is well tolerated. Source of Funding: None

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239 ARTIFICIAL URINARY SPHINCTER PLACEMENT IN PATIENTS WITH ORTHOTOPIC NEOBLADDER URINARY DIVERSION AFTER RADICAL CYSTECTOMY: RETROSPECTIVE REVIEW OF CLINICAL OUTCOMES Michael Vainrib*, Vannita Simma-Chiang, Stuart Boyd, David Ginsberg, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. Our primary aim was to retrospectively review the outcomes and complications of patients who have elected to undergo artificial urinary sphincter (AUS), AMS-800 (American Medical Systems, Minnetonka, MN) placement for treatment of post-ONB SUI in a single institution. The secondary objective was to evaluate possible risk factors for AUS failure. METHODS: From 1994 - 2009, as part of IRB-approved Bladder Cancer Database, 64 patients (pts) who had undergone AUS placement after RC/ONB were identified. Comparative variables were analyzed using Fisher exact test. RESULTS: 36 male pts were eligible to review. Mean age at RC/ONB was 70 years (range 55-82) and at AUS placement 72 years (58-79). Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 3.2 years (0.5-10). TCC was the indication for RC in 94% of pts. Mean BMI was 28 kg/m2 and 19% of patients had diabetes. Pelvic floor physiotherapy was attempted in 17% of pts prior to undergoing AUS placement. Timing of incontinence in these patients included: complete (day and night) - 76%, daytime only - 10% and nighttime only - 14% pts. Post-AUS placement, 82% pts reported good (dry/social) continence. 11/36 received chemotherapy on average of 3.7 (1-10) years prior to AUS and 10/36 had radiation on average of 2.5 (0.5-10) years prior to AUS. There were no perioperative complications observed during AUS placement. Mean time to further surgical intervention was an average 2.6 (1-6) years after AUS placement and occurred due to: erosion - 9 patients, device malfunction - 5 patients, infection - 5 patients. There was no significant correlation between pathological stage of bladder cancer, presence of concomitant prostate cancer and degree of incontinence pre- or post-AUS. In addition, there was no correlation found between chemo- or radiotherapy and degree of incontinence or the need for AUS erosion or revision. CONCLUSIONS: With intermediate follow-up, patients undergoing AUS after RC/ONB were found to have an acceptable complication rate that is comparable to previous series. AUS is a safe, effective treatment for high risk patients after RC/ONB with severe SUI. Source of Funding: None

240 PARTICULAR ASPECTS OF ARTIFICIAL URINARY SPHINCTER IMPLANTATION AFTER URETHROPLASTY. Andre Cavalcanti*, Mauricio Rubinstein, Rio de Janeiro, Brazil INTRODUCTION AND OBJECTIVES: The artificial urinary sphincter(AUS) is the gold standard procedure to a definitive treatment of urinary incontinence associated with sphincter deficiency in male. The aim of this study is to describe our experience with the AUS implantation in a particular group: patients submitted to previously urethroplasties. METHODS: The charts of 22 patients submitted to a AUS implantation after a urethroplasty were observed. The mean follow-up was 23.3 months (range from 6 to 48 months) and the mean patients age was 63 years (range from 25 to 81 years). The majority of the patients were submitted to a urethroplasty to treat an anastomotic stricture after radical prostatectomy (16 patients). 4 patients were submitted to a urethroplasty to treat a posterior stricture after a BPH surgery and 2 to treat a posterior traumatic stricture. The AUS surgical approach was transcorporal in all patients. In 7 patiens we performed a

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modified transcorporal approach, from the original Webester‘s technique (using two lateral tunica albugı´nea flaps to cover the urethra and a pericardium bovine graft to close the corporal defect). RESULTS: In our initial 6 cases we used a early AUS implantation (3 months after the urethroplasty) and we observed a high urethral erosion rate (50%). In the other 16 cases we performed a late implantation (at least 6 months after the urethroplasty) and we observed an erosion rate decline to 6,2% (1 patient). 2/4 patients with AUS erosion were submitted to a suprapubic continent diversion and 2/4 patients were submitted to a AUS re-implantation with success. The final success rate of the AUS implantation (use of 1 pad per day or less), at least 6 months after the implantation was 75% (16/20 patients) with 65% complete dry (13/20). In 3/20 patients (15%) an improvement of the incontinence was observed with a reduction on the number of pads per day. 10/20 (50%) patients with AUS implanted were submitted to penile prosthesis implantation: 7 semirigid, 1 inflatable (3-pieces) e 2 inflatable (2-pieces). A delay cuff erosion was observed in all (2/2) patients after the implantation of a inflatable (2-pieces) penile prosthesis. CONCLUSIONS: The AUS implantation after an urethroplasty is possible with acceptable rates of success. In our opinion the delay transcorporal implantation and the correct penile prosthesis choice (when necessary) are the best approaches to prevent complications. Source of Funding: None

Female Voiding Dysfunction (Pelvic Reconstruction and Incontinence) Video Sunday, May 20, 2012

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V241 RECTUS SHEATH COLPOSUSPENSION WITH POLYPROPYLENE MESH FOR VAGINAL VAULT PROLAPSE REPAIR Marthinus L S De Kock, J Wilna Steenkamp, Kenneth Du Toit, Chris F Heyns*, Cape Town, South Africa INTRODUCTION AND OBJECTIVES: Vaginal vault prolapse after previous hysterectomy is a challenging form of pelvic organ prolapse since 75% of affected women have a concomitant cysto-, recto- and/or enterocele. This video demonstrates transabdominal vaginal vault prolapse repair with rectus sheath colposuspension using polypropylene mesh. METHODS: Vaginal examination and cystoscopy are performed to evaluate the extent of cysto-, recto- and enterocele. Three tissue clamps are applied to the vaginal vault. Through a transverse suprapubic incision the plane between the detrusor and the peritoneum is opened. The tissue clamps in the vagina are pushed upwards, identifying the vaginal vault for dissection. Three sutures of polypropylene zero are placed through the vaginal vault. Cystoscopy is performed to assess the extent of elevation. A sheet of polypropylene mesh 10 x 15 cm is folded double and tied to the three vaginal vault sutures. The free end of the mesh is split in two, each half is pulled through an incision in the rectus sheath on either side, folded down and sutured to itself, and the sheath is closed with polypropylene zero. RESULTS: We present the results at a minimum of 4 years followup in 40 women with vaginal vault prolapse after previous hysterectomy (mean patient age 60, range 42-82 years). Previous bladder suspension had been performed in 50% of the patients. Pre-operative symptoms included urinary incontinence in 55%, recurrent urinary tract infection in 38% and incomplete bladder emptying in 30%. Concomitant rectocele repair was performed in 30%, a midurethral sling was placed in 20% and Burch colpopexy was performed in 5%. The most common complication was occurrence of a secondary rectocele in 17.5% requiring subsequent posterior repair. Vaginal vault prolapse recurred in 5% and secondary stress incontinence occurred in 2.5% of cases.

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CONCLUSIONS: Rectus sheath colposuspension with polypropylene mesh using an open extraperitoneal approach is a simple and cost-effective surgical technique for the treatment of severe vaginal vault prolapse. The main advantage, compared to transperitoneal open or laparoscopic sacrocolposuspension, is that it is an extraperitoneal procedure, with consequently lower morbidity. Source of Funding: None

V242 ROBOT-ASSISTED REPAIR OF RECURRENT VESICOVAGINAL FISTULA Jay Jhaveri*, Quoc-Dien Trinh, Khurshid R Ghani, Carrie Fitzgerald, Jesse D Sammon, Wooju Jeong, Shyam Sukumar, Michael Ehlert, Ali Dabaja, Kandis Rivers, Craig G Rogers, Mani Menon, Detroit, MI INTRODUCTION AND OBJECTIVES: Vesicovaginal fistula (VVF) remains a challenge to surgeons and a burden on patients, especially when it is recurrent or associated with complications. While there is no consensus on the best approach, an abdominal approach is often preferred in patients with large or recurrent fistulas following transvaginal repair. We describe our technique of robot-assisted repair for recurrent VVF in two patients. METHODS: Patient 1 is a 59-year-old lady with a VVF after complicated total abdominal hysterectomy and bilateral salpingooopherectomy, rectosigmoid resection, peritonectomy and omentectomy for stage IV ovarian cancer. Patient 2 is a 52-year-old morbidly obese lady with a VVF after complicated hysterectomy for fibroid uterus. Both patients had unsuccessful vaginal repair of VVF. The technique of robot-assisted repair demonstrated is a 6-port transperitoneal technique for pelvic surgery, with patient in steep Trendelenburg. Cystotomy was performed to access the fistula. The fistula was excised and margins freshened to separate the bladder from vagina. The vaginal defect and cystotomy were closed using running 3-0 barbed suture (V-Loc, Covidien, Mansfield, MA). In order to prevent re-fistulization, suture lines were at opposing angles. In patient 2, a porcine dermal collagen matrix biomesh was used as an interpositional layer between bladder and vagina. RESULTS: Operative time was 135 minutes. Mean estimated blood loss was 100 mL. Both patients were discharged from hospital postoperative day 2. There were no complications. Cystogram performed at 14 days demonstrated no leak. Foley catheter was removed after 28 days in patient 1 and 21 days in patient 2. At 4 and 12 months respectively, both patients are dry with no evidence of VVF recurrence. CONCLUSIONS: Robot-assisted repair of recurrent VVF is technically feasible with an excellent success rate. Interposition with vascularized tissue is not essential for success; an alternative method for interposition is porcine dermal collagen biomesh. Advantages of the robotic repair are less pain, shorter hospital stay and lower morbidity, making it an attractive option for patients with recurrent VVF. Source of Funding: None

V243 TRANSVAGINAL SACROSPINOUS HYSTEROPEXY Alana Murphy*, Howard Goldman, Cleveland, OH INTRODUCTION AND OBJECTIVES: While a number of transvaginal hysteropexy techniques have been described over the years, the sacrospinous hysteropexy is the best studied technique and the literature reports favorable data regarding anatomic and functional outcomes. The sacrospinous hysteropexy is also a timely technique in an era of increasing interest in uterine preservation. Women who choose to forego a hysterectomy and elect a transvaginal repair benefit from decreased operative times and decreased morbidity in the form of less blood loss and reduced risk of lower genitourinary tract injury. Uterine sparing procedures do require careful patient selection. Spe-