V1877 MANAGEMENT OF RECTOURINARY FISTULA: THE YORK MASON APPROACH

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concomitant reimplantation with a biological graft. Demographic, historical, and operative parameters were evaluated and surgical outcome recorded. RESULTS: Seventy-six of these patients were treated for polypropylene mesh complications following SUI (n ⫽ 55) or POP surgery (n ⫽ 21). The mean age was 57 years and mean follow-up was 15 months. Mesh complications involved the vagina (n⫽57), bladder (n⫽7), and urethra (n⫽12). Twenty-seven of 76 patients (36%) were initially managed as simple graft complications while 49 (64%) were managed as complex graft complications. Nine of 27 (33%) patients in the simple group compared to only 4 of the 49 (8%) patients in the complex group required further mesh excision. Postoperatively, 63 of 76 (83%) patients were dry and only 2 (3%) patients developed recurrent POP. CONCLUSIONS: Polypropylene mesh complications may require aggressive management depending on the severity of the graft complication. Our algorithm may help triage patients to simple excision versus a near total mesh explantation with washout and immediate re⫺implantation with biological material. The success of this algorithm is supported by the resolution of mesh extrusion/erosion while avoiding the need for further surgery to restore continence and pelvic floor support. Source of Funding: None

Bladder Oncology & Reconstruction Video 9 Tuesday, May 17, 2011

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V1875 LATISSIMUS DORSI DETRUSOR MYOPLASTY IN BLADDER ACONTRACTILITY Georgios Gakis*, Tuebingen, Germany; Milomir Ninkovic, Gustavo Sturtz, Munich, Germany; Christian Schwentner, Karl-Dietrich Sievert, Arnulf Stenzl, Tuebingen, Germany INTRODUCTION AND OBJECTIVES: To report the long-term results of the Latissimus Dorsi Detrusor Myoplasty (LDDM) procedure in patients with bladder acontractility caused by a lower motor neuron lesion. METHODS: From 06/2003 until 08/2009, a total of 14 patients (mean age: 38 years, range: 17– 63; 8 males, 6 females) underwent LDDM surgery. All patients required complete clean intermittent catheterization (CIC) 6 times per day (3–7) preoperatively with a mean postvoid residual urine volume (PVR) of 500 ml (250 – 800). Postoperative follow-up included videourodynamics after a median follow-up of 48 months (3–71 mo.). For statistical analysis, Student⬘s t-test method was used and p⬍0.05 was considered as level of significant difference. RESULTS: Complete spontaneous voiding was achieved in 11 of the 14 patients (79%) after a median time of 4 months postoperatively (1.2–16.3), with a mean PVR of 25 ml (0 – 80). The mean maximum vesical pressure increased from 15 cm H20 (0 – 40) preoperatively to 52 cm H20 (30 – 63) postoperatively (p⫽0.03). In these patients, the mean maximum flow rate was 29 ml/s (15– 46). In one male patient, the frequency of CIC was reduced from 6 times per day preoperatively to 3 times per day postoperatively, with a PVR of 180 ml (preop.: 500 ml) and a maximum flow rate of 10 ml/s. The maximum vesical pressure increased from 20 preoperatively to 45 cm H20 postoperatively. Two patients (1 male, 1 female) stil require CIC 4 – 6 times per day. In all patients, the mean bladder capacity was 470ml (360 – 600) and the bladder compliance ⬎70 ml/mbar. The mean number of recurrent urinary tract infections were 10 times per year preoperatively, but ceased in all 14 patients postoperatively. No postoperative vesicoureteral reflux was observed in any patient. In addition, no muscular deficit at the donor site was reported by any patient during the longterm follow-up period.

CONCLUSIONS: After LDDM surgery, complete spontaneous voiding was achieved in 11 of the 14 patients (79%). Urodynamically, there was a significant increase in the maximum vesical pressure without impaired bladder compliance. Recurrent urinary tract infections ceased postoperatively in all patients. Due to these results persistent over a long-term follow-up period LDDM can be regarded as an alternative treatment option to CIC in a selective group of patients with bladder acontractility. Source of Funding: Supported by an unrestricted grant of Karl Storz GmbH and Co.KG, Tuttlingen, Germany

V1876 GRACILIS MUSCLE FLAP TO REPAIR COMPLEX URINARY FISTULAS: SURGICAL HARVEST TECHNIQUE Lawrence Yeung*, Steven Brandes, Saint Louis, MO INTRODUCTION AND OBJECTIVES: The management and reconstruction of complex urinary fistulas that result from radiation therapy or energy sources such as cryotherapy or high intensity focused ultrasound are some of the most difficult problems to manage in urology. These fistula repairs frequently require the buttressing support that can be provided with a flap such as the gracilis muscle. METHODS: We describe the anatomy of the gracilis muscle flap and the harvest technique that we utilize. RESULTS: The gracilis is an expendable muscle that serves to adduct the thigh and flex the knee. It originates from the ischium and inferior pubic ramus and inserts distally on the medial tibial condyle and is about 6 cm wide proximally and 4 cm wide distally. Depending on the patient’s leg length, it can range from 24 –30 cm in length. It is innervated by the anterior branch of the obturator nerve. The gracilis has a consistent vascular anatomy that consists of a primary pedicle, which is a branch of the profunda femoral vessels and contains 1 artery and 2 veins, located 8 –12 cm distal to the inguinal crease. A minor secondary vascular pedicle located 10 cm distal to the primary pedicle can be routinely sacrificed. The primary vascular pedicle can be identified with Doppler ultrasound to aid in dissection of the muscle. Skin incisions for harvest are typically a 8 cm medial thigh and a small 2 cm counter incision at the knee. The distal tendon can be easily distinguished by its long length and insertion on the medial tibial tubercle. With the distal tendon transected, the muscle can be mobilized into the perineum though a hiatus that is created in the thigh to cover the fistula. A closed suction drain is placed in the thigh and a elastic bandage wrap placed to prevent hematoma and seroma formation. CONCLUSIONS: The gracilis muscle is an expendable muscle with a consistent vascular anatomy that allows for easy dissection by a Urologist. The resulting medial thigh scar is slightly posterior to the midline and inconspicuous. Its location adjacent to the perineum makes it an excellent choice for perineal and urethral reconstruction. Source of Funding: None

V1877 MANAGEMENT OF RECTOURINARY FISTULA: THE YORK MASON APPROACH Vincent Flamand, Lille, France; Rafael Sanchez-Salas*, Franc¸ois Rozet, Eric Barret, Xavier Cathelineau, Marc Galiano, Guy Vallancien, Paris, France INTRODUCTION AND OBJECTIVES: The York Mason parasacrococcygeal transsphinteric approach remains one of the most suitable techniques for the treatment of rectourinary fistulas. as it provides a maximum rate of success with limited morbidity. To report current experience with the York Mason approach. METHODS: 19 patients with rectourinary fistulas after radical prostatectomy (n⫽17) or HIFU (n⫽2) were treated with the York Mason operation from 1998 to 2010. All patients had a complete division of the anal sphincters and accurate suture of the divided muscle, achieving adequate restoration of the anatomical layers. The technique implied a

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resection of the fistula with minutely precise closure of the intestinal tract and urinary catheterization. Technique: Patient’s placed in a jack-knife fashion. A paracoccigeal incision is performed and matched paired sutures placed in anal sphincter before its incision. Fistula dissection and excision is performed, then anterior rectal wall closure is closed. Finally knotting of sphincter paired sutures is done and the skin is sutured. RESULTS: 19 patients have been treated with 20 months follow period and 80%, 95% and 100% rectourinary fistula resolution after 1 (n⫽16) , 2 (n⫽2) and 3 (n⫽1) York-Mason procedures, respectively, with 100% fecal continence. Median operative time was 70 minutes [56 –150] and median blood loss 110 ml [5– 600]. CONCLUSIONS: Parasacrococcygeal transsphinteric approach features a high rate of resolution for rectourinary fistulas surgical treatment. The York Mason operation holds a high rate of continence with low morbidity. Source of Funding: None

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We demonstrate in this video the problems with conventional endoscopic techniques; how tumour scatter can be minimised during resection by technical modifications using existing instruments; and how a newly designed endoscopic instrument might be utilised to perform en-bloc resection. METHODS: Suitable bladder tumours were managed by enbloc resection using the loop, Collins knife or a prototype instrument designed in conjunction with STORZ (Germany). The procedures were digitally recorded and a video library maintained. Patient demographics were recorded and a prospective database set up. RESULTS: 17 patients underwent en-bloc resection, mean age 61 (range 31– 87). All tumours were non muscle invasive, 46PUNLMP, 7 low grade pTa, 3 high grade pTa and one G2 pT1. Only one patient had a recurrence at 3 months, distant to site of original resection. There were no complications. CONCLUSIONS: En-bloc resection of non-muscle invasive tumours is feasible in some cases. The pilot study of the newly designed instrument shows its potential for safely dissecting through the normal bladder wall deep to the tumour base. En bloc resection is worthy of further study. Source of Funding: None

THE V-SHAPE HILAR STITCH (VHS) CLOSURE: A NOVEL ROBOTIC RENORRAPHY TECHNIQUE Shahab P. Hillyer*, Gregory Spana, Michael A. White, Riccardo Autorino, Bo Yang, Humberto Laydner, Fatih Altunrende, Georges P. Haber, Robert J. Stein, Jihad Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Renal parenchymal reconstruction during robotic partial nephrcetomy (RPN) can be challenging. The “Sliding-clip” technique has been introduced ad popularized to overcome this surgical step. A modification to the “Sliding-clip” technique, defined as “VHS” (V-shape, H-hilar, S-stitch) technique, is herein described to facilitate and improve renal reconstruction after excision of complex hilar tumors during RPN. METHODS: RPN in a patient with solitary kidney presenting with a complex (6.1 cm) hilar tumor is performed using the VHS technique. After tumor excision, a first set of inner 2-0 running Vicryl sutures (SH-1) is placed at tumor bed on each side of the renal hilum. Suture placement is performed to model the remaining renal parenchyma in order to obtain a “V-shape” figure, the edges of renal defect being each “arm” of the “V”. This facilitates the following step, the horizontal mattress renorrhaphy, which is undertaken using 0 Vicryl on a CT-1 needle. Branching vessels are clipped using hem-o-lock clips as they are encountered during tumor excision. RESULTS: Warm ischemia time and operative time were 29 and 158 minutes, respectively. Post-operative eGFR was 55 ml/min/m2 with a 16% decrease in eGFR and EBL was 350ml. A total of two inner sutures and four parenchymal sutures were used. Four were used during warm ischemia and 2 after bulldog clamps removed. The technique allowed complete closure of the renal defect when limited tissue was present for renorraphy. CONCLUSIONS: VHS allows for easier approximation of the renal defect when limited tissue is available for reconstruction in complex hilar tumors. Source of Funding: None

V1879 EN-BLOC (SAND WEDGE) BLADDER TUMOUR RESECTION Amit Patel*, Barnaby Chappell, Dan Wilby, Kay Thomas, Tim O’Brien, London, United Kingdom INTRODUCTION AND OBJECTIVES: Transurethral resection of a bladder tumour (TURBT) using a wire loop and diathermy is considered the gold standard treatment for endoscopic tumour removal and obtaining tissue for histological analysis. On closer inspection however ‘this gold standard procedure’ appears to break the ‘golden rule’ of oncological surgery, namely dissection through normal tissue with en bloc removal of a tumour as a single specimen.

V1880 OPTIMISING PHOTODYNAMIC DIAGNOSIS IN THE SURGICAL MANAGEMENT OF BLADDER CANCER Kay Thomas*, Tim O’Brien, London, United Kingdom INTRODUCTION AND OBJECTIVES: Photodynamic diagnosis (PDD) or ‘blue-light’ cystoscopy allows a more complete assessment of a bladder tumour than conventional ‘white light’ cystoscopy. The technique depends upon introducing a photosensitiser (Hexylaminolevulinate) into the bladder to improve the colour contrast between tumour tissue and normal tissue. PDD has given fresh insights into the pathological anatomy of bladder tumours so that both occult papillary disease and carcinoma in situ can be identified. Urologists can also be more confident of the margins of tumour excision. In 2010 PDD using Hexylaminolevulinate was approved for use in the United States by the FDA. The technique is straightforward to learn but understanding its possibilities and limitations will help urologists to use it appropriately. METHODS: Four studies of PDD were started in our unit in 2005. These assessed the use of PDD in 1. Multifocal recurrence 2. Post BCG 3. In patients with positive cytology but negative white light cystoscopy 4. A randomised trial of PDD ⫹ mitomycin versus white light cystoscopy ⫹ mitomycin in 250 patients with newly presenting bladder cancer. A video archive was created and now includes over 300 cases of PDD. This teaching video was created from that archive. RESULTS: The teaching video demonstrates the set-up; troubleshooting; detection of occult papillary disease and CIS; optimal resection including margins; and the problems of using PDD post BCG and in cases of early re-resection. The video also emphasises important aspects of bladder cancer endoscopic surgical technique which are not affected by PDD. Guidelines are offered for sensible incorporation of the technique of PDD into a bladder cancer practice. CONCLUSIONS: When used in appropriate cases, photodynamic diagnosis offers numerous exciting possibilities to improve bladder cancer surgery. Source of Funding: None

V1881 INITIAL EXPERIENCE WITH ROBOTIC-ASSISTED APPROACHES TO PARTIAL CYSTECTOMY Mathew Raynor*, Joshua Langston, Patrick Selph, Angela Smith, Matthew Nielsen, Eric Wallen, Raj Pruthi, Chapel Hill, NC INTRODUCTION AND OBJECTIVES: Robotic approaches to surgery appear to be particularly fitting for pelvic operations and those