- Email: [email protected]
REPAIR OF GLANDULAR EPISPADIAS
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
inserted into the seminal vesicle and remnant ureter endoscopically. Seminal vesicle cysts were excised by laparoscopic surgery with transperitoneal approach. One patient also had a laparoscopic ureterectomy for remnant ureter. RESULTS: The mean operative time was 128.3 minutes. The mean hospital stay was 6.3 days. There was no operative complication and transfusion. CONCLUSIONS: Seminal vesicles cysts may be found in patients with renal agenesis. Laparoscopy is considered a minimal invasive management of this combined anomalies, providing a good image and an easy approach. Source of Funding: None
THE JOURNAL OF UROLOGY®
305
harvested from dorsal penile skin. The urethral plate was reconstructed using buccal mucosa, quilted onto the tunica albuginea between urethral meatus and the tip of the glans. The dorsally-based fasciocutaneous ÀDSZDVEXWWRQKROHGYHQWUDOO\DQGVHZQWRWKHQHRXUHWKUDOSODWHLQ an ventral onlay fashion. The remaining penile skin was closed over the penis. RESULTS: Three months later good esthetic and functional results are achieved. The patient voids easily through the neourethra. Catheter placement reveals no stricture. CONCLUSIONS: Combined buccal mucosa graft and YDVFXODUL]HG SHQLOH VNLQ ÀDS UHSUHVHQW D JRRG FKRLFH IRU XUHWKUDO reconstruction, especially in cases of failed previous hypospadias repair. Source of Funding: None
V882 MEATAL MOBILIZATION (MEMO) TECHNIQUE FOR DISTAL HYPOSPADIAS REPAIR: HOW TO DO IT, RESULTS AND LONG TIME FOLLOW-UP Jorg Seibold*, Andreas Verger, Angela Bohmer, Axel S Merseburger, Karl-Dietrich Sievert, Arnulf Stenzl. Tuebingen, Germany. INTRODUCTION AND OBJECTIVE: A detailed description of an improved surgical technique for distal hypospadias repair is shown in WKLVYLGHR0HDWDOPRELOL]DWLRQ 0(02 DIWHUGLVWDOXUHWKUDOSUHSDUDWLRQ FDQEHXVHGIRUJODQGXODUFRURQDODQGVXEFRURQDOORFDOL]DWLRQRIWKH meatus, with or without chordee. Early results and long-time follow-up as well as complications are presented. METHODS: For early results 46 patients aged from 1.5 to 14 years underwent from May 2002 to June 2006, repair of glandular, FRURQDO DQG VXEFRURQDO K\SRVSDGLDV E\ WKH PHDWXV PRELOL]DWLRQ (MEMO) technique at the department of urology of the University of Tuebingen. RESULTS: For early results mean duration of surgery was 73 minutes. There were no intraoperative complications in any of the patients. The follow-up period was 28.5 months. Postoperatively, one patient developed a hematoma, which resolved without further treatment. There was neither recurrence nor any new episode of chordee or meatal VWHQRVLV1RQHRIWKHSDWLHQWVGHYHORSHGDXUHWKUDO¿VWXOD,QRQHSDWLHQW the meatus retracted but remained in the glans. For long-time follow-up QRDGGLWLRQDOXUHWKUDO¿VWXODRUVWHQRVLVRFFXUUHG,QRQHSDWLHQWDPLOG ventral penile deviation without need for correction was seen. CONCLUSIONS: With the MEMO technique of meatal PRELOL]DWLRQIRUFRUUHFWLRQRIPRVWRIGLVWDOK\SRVSDGLDVFRPSOLFDWLRQV are minimal and the cosmetic results excellent. In the long-time follow-up QRDGGLWLRQDO¿VWXODRUPHDWDOVWHQRVLVRFFXUUHGLQRQHSDWLHQWDPLOG ventral deviation was seen without need for correction. Source of Funding: None
V883 COMBINED BUCCAL MUCOSA GRAFT AND PENILE FLAP FOR URETHRAL RECONSTRUCTION IN FAILED HYPOSPADIAS REPAIR Miroslav L Djordjevic, Richard A Santucci*, Sava V Perovic. Belgrade, Serbia, and Detroit, MI. INTRODUCTION AND OBJECTIVE: Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 200 techniques for treating hypospadias, it LVRIWHQGLI¿FXOWWRUHSDLUWKHVHYHUHVWIRUPVXVLQJFRQYHQWLRQDOPHWKRGV We present a method of combining buccal mucosa and fasciocutaneous SHQLOHÀDSIRUXUHWKUDOUHFRQVWUXFWLRQIRUXVHHVSHFLDOO\LQSUHYLRXVO\ failed hypospadias. METHODS: 6 adult patients with persistent hypospadias despite childhood repair underwent repair using our technique of combined dorsal urethral plate formation with buccal grafts, and ventral RQOD\XUHWKURSODVW\XVLQJDIDVFLRFXWDQHRXVÀDS&DVHLQWKLVYLGHR $ 42 year old man underwent surgery due to failed hypospadias repair and lateral penile curvature. Surgery was performed in permanent erection induced by prostaglandin E1, which enables easier dissection, precise correction of curvature and precise determination of appropriate length RIJUDIWVDQGÀDSVSODQQHGIRUXUHWKUDOUHFRQVWUXFWLRQ5HPQDQWVRIWKH scarred urethra were completely removed. The penis was completely straightened using Yachia technique. A fasciocutaneous flap was
V884 REPAIR OF GLANDULAR EPISPADIAS Daniel G Da Justa*, Thomas G Mueller, John P Gearhart, Joseph G Barone. New Brunswick, NJ, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: Isolated glandular epispadias in males is a rare anomaly with reported incidence of 1 in 117,000. METHODS: We herein present a patient that was initially evaluated for repair of concealed penis at 3 months of age, who was found to have an epispadias just proximal to the coronal edge after IRUHVNLQZDVUHWUDFWHG ¿JXUH 7KHSURFHGXUHZDVDERUWHGDQGIXOO evaluation was performed which included a voiding cystogram, renal and bladder sonogram and urodynamic study all with normal results. RESULTS: Patient was given one dose testosterone IM and brought back to surgery at 22 months of age for the repair of the HSLVSDGLDV$0RGL¿HG&DQWZHOO5DQVOH\5HSDLUZDVSHUIRUPHGDQGLV shown on the video. Patient did well post operative and was discharged home the next day. CONCLUSIONS: Due to its rare incidence we believe this video provides a unique opportunity to see all the important steps of this particular technique used to repair an isolated glandular epispadias.
306
THE JOURNAL OF UROLOGY®
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
end. The graft mid-portion is secured with interrupted 4-0 chromic to the apex of the previously dissected vaginal vault. The meshed graft is then stretched and tacked into position with interrupted 4-0 chromic sutures to achieve 360 degree coverage of the entire neovaginal area. A spongy vaginal mold is left in-situ for 5-7 days. CONCLUSIONS: Buccal mucosa generates a moist, hairless, QRQNHUDWLQL]HG QHRYDJLQDO PXFRVD ZLWK H[FHOOHQW FRORU DQG WH[WXUH matching the genital/vaginal skin. It leaves no visible surgical scars, avoids abdominal bowel surgery and has no excess mucous production. It is an ideal replacement material for primary or secondary vaginoplasty with excellent early results. Source of Funding: None
V886
Source of Funding: None
V885 USE OF AUTOLOGOUS BUCCAL MUCOSA VAGINOPLASTY IN CHILDREN: SURGICAL TECHNIQUE Juan C Prieto, Nicol Corbin Bush*, Mindy L Samuelson, Ellen Wilson, Linda A Baker. Dallas, TX. INTRODUCTION AND OBJECTIVE: Vaginal replacement surgeries often require donor materials such as skin grafts, P\RFXWDQHRXV ÀDSV RU ERZHO HDFK ZLWK VLJQL¿FDQW GLVDGYDQWDJHV We describe our technique using autologous buccal mucosa grafting for partial or complete neovagina creation. METHODS: Our indications for buccal mucosa vaginoplasty have included primary repair of congenital defects such as vaginal agenesis (Mayer-Rokitansky syndrome), cloacal abnormalities, and intersex disorders as well as secondary repair of postsurgical vaginal defects like vaginal stenosis after vaginoplasty or pelvic extenteration. This video demonstrates our surgical technique in a Mayer-Rokitansky syndrome patient. RESULTS: A transverse incision is made over the mucosal prominence at the level of the expected location of the hymen. Blunt dissection and electrocautery are used to dissect between the urethra DQG DQRUHFWXP WR GHSWK FP DQG ZLGWK ¿QJHUEUHDGWKV %LODWHUDO buccal mucosa is harvested, prepared on the bench and sewn end to
SINGLE-PORT LAPAROSCOPIC SURGERY IN UROLOGY Jihad H Kaouk*, Georges-Pascal Haber, Raj K Goel, Mihir M Desai, Jeffrey S Palmer, Raymond R Rackley, Courtenay K Moore, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: Herein we present our initial experience in single-port laparoscopic urologic surgery using the Uni-X(TM) Single Port Access Laparoscopic System, a single port, multi-channel cannula, with specially designed curved laparoscopic instrumentation. METHODS: We performed single-port laparoscopic surgery (SPL) in 16 patients: retroperitoneal renal cryotherapy (n=2), transperitoneal renal cryotherapy (n=4), radical nephrectomy (n=1), simple nephrectomy (n=1) and abdominal sacrocolpopexy (n=5). Three pediatric varicocelectomies were also performed via SPL. For the transperitoneal approach, the multi-channel port was inserted WUDQVXPELOLFDOO\ IRUUHWURSHULWRQHRVFRS\WKHSRUWZDVLQVHUWHGDWWKHWLS of the 12th rib. All cases were completed exclusively with the single port excluding the radical nephrectomy where an additional 12 mm port was inserted through the pre-planned extraction Gibson incision. Free-hand intracoporeal suturing was performed for all SPL sacrocolpopexy. RESULTS: Since September 25, 2007 a total of 16 patients underwent SPL for various upper abdominal and pelvic pathologies. All cases were completed successfully without conversion to standard laparoscopic approach. Total operative time for various kidney procedures was 2.8 hours (range 2-3.2) and 2.5 hours (range 2-3) for sacrocolpopexy. Mean blood loss was 90cc. Hospital stay was 2.8 days (range, 1-8) for the kidney procedures and 2 days for sacrocolpopexy procedures. All pediatric (age 12-15 years) varicocelectomies were discharged same day of surgery. Complication (N=1) occurred in a cryoablation patient with baseline anemia and pulmonary comorbidity that required O2 mask ventilation and was transfused with 3 units of packed RBC post operatively. Her hospital discharge was delayed 1 week. CONCLUSIONS: Single-port laparoscopic surgery including kidney and pelvic surgery is feasible and effective in both the adult and pediatric population. Reconstructive surgery with intra-corporeal suturing is possible through the single port channel. Additional experience and continued investigation are warranted. Source of Funding: None
V887 NEURO-OCULAR METRICS AS AN OBJECTIVE MEASUREMENT OF SURGICAL COGNITOMOTOR SKILL: THE FUTURE OF CERTIFICATION? Lee Richstone, Casey A Seideman*, Ernesto Reggio, Brian A Vanderbrink, Zeph Okeke, Benjamin R Lee, Sandra Marshall, Louis R Kavoussi. New Hyde Park, NY, and San Diego, CA. INTRODUCTION AND OBJECTIVE: An objective PHDVXUHPHQW RI VXUJHRQ FRPSHWHQF\ LV QHFHVVDU\ WR RSWLPL]H RXWFRPHV1HXURRFXODUPHWULFVDUHDGLUHFWUHÀHFWLRQRIEUDLQDFWLYLW\ and have been correlated with cognitive function during completion of complex tasks. We investigated the construct validity of neuron-ocular metrics (NOM) as an objective measure of laparoscopic surgical skill. METHODS: The Eyelink II (SR Research, Canada) was used to record 7 NOM parameters including blink rate (L/R), saccades (L/R), pupil diameter (L/R) and convergence/divergence of the eyes during
inserted into the seminal vesicle and remnant ureter endoscopically. Seminal vesicle cysts were excised by laparoscopic surgery with transperitoneal approach. One patient also had a laparoscopic ureterectomy for remnant ureter. RESULTS: The mean operative time was 128.3 minutes. The mean hospital stay was 6.3 days. There was no operative complication and transfusion. CONCLUSIONS: Seminal vesicles cysts may be found in patients with renal agenesis. Laparoscopy is considered a minimal invasive management of this combined anomalies, providing a good image and an easy approach. Source of Funding: None
THE JOURNAL OF UROLOGY®
305
harvested from dorsal penile skin. The urethral plate was reconstructed using buccal mucosa, quilted onto the tunica albuginea between urethral meatus and the tip of the glans. The dorsally-based fasciocutaneous ÀDSZDVEXWWRQKROHGYHQWUDOO\DQGVHZQWRWKHQHRXUHWKUDOSODWHLQ an ventral onlay fashion. The remaining penile skin was closed over the penis. RESULTS: Three months later good esthetic and functional results are achieved. The patient voids easily through the neourethra. Catheter placement reveals no stricture. CONCLUSIONS: Combined buccal mucosa graft and YDVFXODUL]HG SHQLOH VNLQ ÀDS UHSUHVHQW D JRRG FKRLFH IRU XUHWKUDO reconstruction, especially in cases of failed previous hypospadias repair. Source of Funding: None
V882 MEATAL MOBILIZATION (MEMO) TECHNIQUE FOR DISTAL HYPOSPADIAS REPAIR: HOW TO DO IT, RESULTS AND LONG TIME FOLLOW-UP Jorg Seibold*, Andreas Verger, Angela Bohmer, Axel S Merseburger, Karl-Dietrich Sievert, Arnulf Stenzl. Tuebingen, Germany. INTRODUCTION AND OBJECTIVE: A detailed description of an improved surgical technique for distal hypospadias repair is shown in WKLVYLGHR0HDWDOPRELOL]DWLRQ 0(02 DIWHUGLVWDOXUHWKUDOSUHSDUDWLRQ FDQEHXVHGIRUJODQGXODUFRURQDODQGVXEFRURQDOORFDOL]DWLRQRIWKH meatus, with or without chordee. Early results and long-time follow-up as well as complications are presented. METHODS: For early results 46 patients aged from 1.5 to 14 years underwent from May 2002 to June 2006, repair of glandular, FRURQDO DQG VXEFRURQDO K\SRVSDGLDV E\ WKH PHDWXV PRELOL]DWLRQ (MEMO) technique at the department of urology of the University of Tuebingen. RESULTS: For early results mean duration of surgery was 73 minutes. There were no intraoperative complications in any of the patients. The follow-up period was 28.5 months. Postoperatively, one patient developed a hematoma, which resolved without further treatment. There was neither recurrence nor any new episode of chordee or meatal VWHQRVLV1RQHRIWKHSDWLHQWVGHYHORSHGDXUHWKUDO¿VWXOD,QRQHSDWLHQW the meatus retracted but remained in the glans. For long-time follow-up QRDGGLWLRQDOXUHWKUDO¿VWXODRUVWHQRVLVRFFXUUHG,QRQHSDWLHQWDPLOG ventral penile deviation without need for correction was seen. CONCLUSIONS: With the MEMO technique of meatal PRELOL]DWLRQIRUFRUUHFWLRQRIPRVWRIGLVWDOK\SRVSDGLDVFRPSOLFDWLRQV are minimal and the cosmetic results excellent. In the long-time follow-up QRDGGLWLRQDO¿VWXODRUPHDWDOVWHQRVLVRFFXUUHGLQRQHSDWLHQWDPLOG ventral deviation was seen without need for correction. Source of Funding: None
V883 COMBINED BUCCAL MUCOSA GRAFT AND PENILE FLAP FOR URETHRAL RECONSTRUCTION IN FAILED HYPOSPADIAS REPAIR Miroslav L Djordjevic, Richard A Santucci*, Sava V Perovic. Belgrade, Serbia, and Detroit, MI. INTRODUCTION AND OBJECTIVE: Hypospadias is one of the most common congenital deformities in the male urogenital system. Although there are more than 200 techniques for treating hypospadias, it LVRIWHQGLI¿FXOWWRUHSDLUWKHVHYHUHVWIRUPVXVLQJFRQYHQWLRQDOPHWKRGV We present a method of combining buccal mucosa and fasciocutaneous SHQLOHÀDSIRUXUHWKUDOUHFRQVWUXFWLRQIRUXVHHVSHFLDOO\LQSUHYLRXVO\ failed hypospadias. METHODS: 6 adult patients with persistent hypospadias despite childhood repair underwent repair using our technique of combined dorsal urethral plate formation with buccal grafts, and ventral RQOD\XUHWKURSODVW\XVLQJDIDVFLRFXWDQHRXVÀDS&DVHLQWKLVYLGHR $ 42 year old man underwent surgery due to failed hypospadias repair and lateral penile curvature. Surgery was performed in permanent erection induced by prostaglandin E1, which enables easier dissection, precise correction of curvature and precise determination of appropriate length RIJUDIWVDQGÀDSVSODQQHGIRUXUHWKUDOUHFRQVWUXFWLRQ5HPQDQWVRIWKH scarred urethra were completely removed. The penis was completely straightened using Yachia technique. A fasciocutaneous flap was
V884 REPAIR OF GLANDULAR EPISPADIAS Daniel G Da Justa*, Thomas G Mueller, John P Gearhart, Joseph G Barone. New Brunswick, NJ, and Baltimore, MD. INTRODUCTION AND OBJECTIVE: Isolated glandular epispadias in males is a rare anomaly with reported incidence of 1 in 117,000. METHODS: We herein present a patient that was initially evaluated for repair of concealed penis at 3 months of age, who was found to have an epispadias just proximal to the coronal edge after IRUHVNLQZDVUHWUDFWHG ¿JXUH 7KHSURFHGXUHZDVDERUWHGDQGIXOO evaluation was performed which included a voiding cystogram, renal and bladder sonogram and urodynamic study all with normal results. RESULTS: Patient was given one dose testosterone IM and brought back to surgery at 22 months of age for the repair of the HSLVSDGLDV$0RGL¿HG&DQWZHOO5DQVOH\5HSDLUZDVSHUIRUPHGDQGLV shown on the video. Patient did well post operative and was discharged home the next day. CONCLUSIONS: Due to its rare incidence we believe this video provides a unique opportunity to see all the important steps of this particular technique used to repair an isolated glandular epispadias.
306
THE JOURNAL OF UROLOGY®
Vol. 179, No. 4, Supplement, Monday, May 19, 2008
end. The graft mid-portion is secured with interrupted 4-0 chromic to the apex of the previously dissected vaginal vault. The meshed graft is then stretched and tacked into position with interrupted 4-0 chromic sutures to achieve 360 degree coverage of the entire neovaginal area. A spongy vaginal mold is left in-situ for 5-7 days. CONCLUSIONS: Buccal mucosa generates a moist, hairless, QRQNHUDWLQL]HG QHRYDJLQDO PXFRVD ZLWK H[FHOOHQW FRORU DQG WH[WXUH matching the genital/vaginal skin. It leaves no visible surgical scars, avoids abdominal bowel surgery and has no excess mucous production. It is an ideal replacement material for primary or secondary vaginoplasty with excellent early results. Source of Funding: None
V886
Source of Funding: None
V885 USE OF AUTOLOGOUS BUCCAL MUCOSA VAGINOPLASTY IN CHILDREN: SURGICAL TECHNIQUE Juan C Prieto, Nicol Corbin Bush*, Mindy L Samuelson, Ellen Wilson, Linda A Baker. Dallas, TX. INTRODUCTION AND OBJECTIVE: Vaginal replacement surgeries often require donor materials such as skin grafts, P\RFXWDQHRXV ÀDSV RU ERZHO HDFK ZLWK VLJQL¿FDQW GLVDGYDQWDJHV We describe our technique using autologous buccal mucosa grafting for partial or complete neovagina creation. METHODS: Our indications for buccal mucosa vaginoplasty have included primary repair of congenital defects such as vaginal agenesis (Mayer-Rokitansky syndrome), cloacal abnormalities, and intersex disorders as well as secondary repair of postsurgical vaginal defects like vaginal stenosis after vaginoplasty or pelvic extenteration. This video demonstrates our surgical technique in a Mayer-Rokitansky syndrome patient. RESULTS: A transverse incision is made over the mucosal prominence at the level of the expected location of the hymen. Blunt dissection and electrocautery are used to dissect between the urethra DQG DQRUHFWXP WR GHSWK FP DQG ZLGWK ¿QJHUEUHDGWKV %LODWHUDO buccal mucosa is harvested, prepared on the bench and sewn end to
SINGLE-PORT LAPAROSCOPIC SURGERY IN UROLOGY Jihad H Kaouk*, Georges-Pascal Haber, Raj K Goel, Mihir M Desai, Jeffrey S Palmer, Raymond R Rackley, Courtenay K Moore, Inderbir S Gill. Cleveland, OH. INTRODUCTION AND OBJECTIVE: Herein we present our initial experience in single-port laparoscopic urologic surgery using the Uni-X(TM) Single Port Access Laparoscopic System, a single port, multi-channel cannula, with specially designed curved laparoscopic instrumentation. METHODS: We performed single-port laparoscopic surgery (SPL) in 16 patients: retroperitoneal renal cryotherapy (n=2), transperitoneal renal cryotherapy (n=4), radical nephrectomy (n=1), simple nephrectomy (n=1) and abdominal sacrocolpopexy (n=5). Three pediatric varicocelectomies were also performed via SPL. For the transperitoneal approach, the multi-channel port was inserted WUDQVXPELOLFDOO\ IRUUHWURSHULWRQHRVFRS\WKHSRUWZDVLQVHUWHGDWWKHWLS of the 12th rib. All cases were completed exclusively with the single port excluding the radical nephrectomy where an additional 12 mm port was inserted through the pre-planned extraction Gibson incision. Free-hand intracoporeal suturing was performed for all SPL sacrocolpopexy. RESULTS: Since September 25, 2007 a total of 16 patients underwent SPL for various upper abdominal and pelvic pathologies. All cases were completed successfully without conversion to standard laparoscopic approach. Total operative time for various kidney procedures was 2.8 hours (range 2-3.2) and 2.5 hours (range 2-3) for sacrocolpopexy. Mean blood loss was 90cc. Hospital stay was 2.8 days (range, 1-8) for the kidney procedures and 2 days for sacrocolpopexy procedures. All pediatric (age 12-15 years) varicocelectomies were discharged same day of surgery. Complication (N=1) occurred in a cryoablation patient with baseline anemia and pulmonary comorbidity that required O2 mask ventilation and was transfused with 3 units of packed RBC post operatively. Her hospital discharge was delayed 1 week. CONCLUSIONS: Single-port laparoscopic surgery including kidney and pelvic surgery is feasible and effective in both the adult and pediatric population. Reconstructive surgery with intra-corporeal suturing is possible through the single port channel. Additional experience and continued investigation are warranted. Source of Funding: None
V887 NEURO-OCULAR METRICS AS AN OBJECTIVE MEASUREMENT OF SURGICAL COGNITOMOTOR SKILL: THE FUTURE OF CERTIFICATION? Lee Richstone, Casey A Seideman*, Ernesto Reggio, Brian A Vanderbrink, Zeph Okeke, Benjamin R Lee, Sandra Marshall, Louis R Kavoussi. New Hyde Park, NY, and San Diego, CA. INTRODUCTION AND OBJECTIVE: An objective PHDVXUHPHQW RI VXUJHRQ FRPSHWHQF\ LV QHFHVVDU\ WR RSWLPL]H RXWFRPHV1HXURRFXODUPHWULFVDUHDGLUHFWUHÀHFWLRQRIEUDLQDFWLYLW\ and have been correlated with cognitive function during completion of complex tasks. We investigated the construct validity of neuron-ocular metrics (NOM) as an objective measure of laparoscopic surgical skill. METHODS: The Eyelink II (SR Research, Canada) was used to record 7 NOM parameters including blink rate (L/R), saccades (L/R), pupil diameter (L/R) and convergence/divergence of the eyes during