836 A VIDEO SIMULATOR ONLINE TO SHORTEN AND SECURE LAPAROSCOPIC LEARNING PERIOD

833



834

Valsalva Leak Point Pressure Predicts Result of Transobturator Suburethral Tape Implantation - Fact or Fiction ?

Three-year outcomes of the IRIS procedure for treatment of female stress urinary incontinence: Comparison with TVT procedure

Romancik M.1, Lutter I.1, Goncalves F.2, Obsitnik M.1, Weibl P.1, Havalda A.3

Jung H.C.1, Kim J.Y.1, Lim H.S.1, Yoon C.J.1, Park C.H.2, Kwon T.G.3, Yoo E.S.3, Park J.S.4, Kim D.Y.4, Lee K.S.5, Seo Y.J.5, Oh T.H.6

University Hospital Petrzalka, Department of Urology, Bratislava, Slovakia, University Hospital Kramare, Department of Urology, Bratislava, Slovakia, 3University Hospital Petrzalka, 1st Department of Obstetrics and Gynaecology, Bratislava, Slovakia 1

2

Introduction & Objectives: The aim of the study was to assess the influence of Valsalva leak point pressure (VLPP) on result of transobturator suburethral tape (TOT) implantation. Material & Methods: 65 female patients underwent surgery between March 2004 and November 2005. Their inclusion criterion was urodynamic stress urinary incontinence. The exclusion criteria were detrusor overactivity, detrusor underactivity, a significant post-void residuum and genital prolapse. The VLPP, amount of urine leakage (PWT) and urinary incontinence-specific quality of life (IQoL) were established before surgery. Patients were introduced into two groups according to the preoperative VLPP value: 1st group comprised patients with VLPP>60cm H2O, 2nd group comprised patients with VLPP≤60cm H2O. Six months after surgery the amount of urine leakage (PWT*) and urinary incontinence-specific quality of life (IQoL*) were reevaluated. Result of TOT implantation was assessed according to the following criteria: “cure” was defined as a PWT*≤2g, “improvement” a 2g< PWT*≤1/2PWT and “failure” a 2g< PWT*>1/2PWT. “Success” was considered as cure or improvement. “Objective improvement” was considered as the difference between postoperative leakage compared with preoperative leakage (∆PWT=PWT*-PWT). “Subjective improvement” was considered as the difference between postoperative urinary incontinence-specific quality of life compared with its preoperative value (∆IQoL=IQoL*-IQoL). Results: Mean age 51,5±9,9 years, mean parity 2,9±0,9, mean BMI 26,4±2,8 kgm-2, previous surgery: 9 pts (13,9%) underwent hysterectomy, 4 pts (6,2%) underwent another anti-incontinence procedure. 1st group included 41 pts, 2nd group included 24 pts. Cure rate and success rate in 1st versus 2nd group were 78% and 100% versus 25% and 87,50% respectively (p<0,005 and p<0,025 respectively). Objective improvement and subjective improvement in 1st versus 2nd group were -8,0±2,4g and 26,6±7,0 versus -12,0±4,4g and 28,9±8,1 respectively (p<0,005 and p>0,05 respectively). Postoperative leakage and postoperative urinary incontinence-specific quality of life in 1st versus 2nd group were 1,2±1,1g and 90,6±5,1 versus 4,6±3,1g and 84,0±5,6 respectively (p<0,005 and p<0,005 respectively). Conclusions: Cure and success rates were significantly higher in patients with higher VLPP values. In spite of the fact that patients with higher VLPP values achieved significantly lower postoperative leakage, urine leakage decreased significantly more in patients with lower VLPP values. Patients with higher VLPP values reached significantly higher postoperative urinary incontinence-specific quality of life, however no significant difference was found in subjective improvement between patients with higher and lower VLPP values.



835

Mid-term evaluation of the safety and efficacy of the Remeex re-adjustable sling for recurrent stress incontinence and intrinsic sphincteric deficiency Errando C., Baez C., Prados M., Gutierrez C., Arañó P., Villavicencio H. Fundacio Puigvert, Female Urology, Barcelona, Spain

Yeungnam University Hospital, Department of Urology, Daegu, South Korea, Kyemyung University Hospital, Department of Urology, Daegu, South Korea, Kyoungpook University Hospital, Department of Urology, Daegu, South Korea, 4Daegu Catholic University Hospital, Department of Urology, Daegu, South Korea, 5Dongguk University Hospital, Department of Urology, Kyoungju, South Korea, 6Sungkyungwan University Masan Samsung Hospital, Department of Urology, Masan, South Korea 1 2 3

Introduction & Objectives: IRIS (innovative replacement of incontinence surgery, B. Braun Korea & Dow Medics Co., Ltd, Seoul) is a polypropylene tape that’s placed beneath the mid-urethra to restore urinary continence. We evaluated the long-term efficacy and safety of the IRIS procedure and compared it with TVT (tension free vaginal tape) for the treatment of female stress urinary incontinence. Material & Methods: In this controlled, prospective, randomized study, 66 female patients were evaluated with history, physical examination, quality of life, and urodynamic studies (UDS). They were randomized to undergo IRIS(n=34) or TVT(n=32) between February 2002 and April 2003 and followed them up for at least 3 years postoperatively. The operative and postoperative morbidity, success rate demonstrated by stress test and subjective satisfaction rate assessed by questionnaire were analyzed. Results: The 3-year success rate was 94.1% for the IRIS and 93.8% for the TVT, and the satisfaction rates were 91.2% and 90.6%, respectively. Intraoperative complications for the IRIS group included 3 cases of bladder perforation, and there were 3 cases of bladder perforation for the TVT group. The postoperative complications for the IRIS group included 2 patients with de novo urgency and one patient with mesh erosion. Three patients with the TVT developed de novo urgency. One case of each group showed temporary voiding difficulty, which resolved within 3-5 days without release or resection of tape. Conclusions: On the basis of our results, the IRIS may be an effective and safe procedure as compared to the TVT, with a high success rate and a low complication rate.

A Video simulator Online to shorten and secure laparoscopic learning period

836

Messas A.1, Klifa D.1, Dubosq F.2, Bohin D.3, Beley S.4, Mongiat-Artus P.2, Delmas V.5, Teillac P.6, North Paris Hospital Network Max Fourestier, Urology, Nanterre, France, 2Saint Louis, Urology, Paris, France, Victor Dupuys, Urology, Argenteuil, France, 4Tenon Hospital, Urology, Argenteuil, France, 5Bichat, Urology, Nanterre, France, 6Saint Louis, Urology, Nanterre, France 1 3

Introduction & Objectives: Tension-free tapes are the first choice for treatment of stress incontinence (SUI) with hypermobile urethra. However, results are not as reliable in recurrent cases or in patients with intrinsic sphincter deficiency (ISD). We present our results with the Remeex re-adjustable sling system. The Remeex system consists of a 3 cm polypropylene sling with 2 prolene sutures that connect to a prosthesis (varitensor) placed over the rectus fascia. An adjustment arm (manipulator) exits the skin for 1-2 days allowing for tightening or loosening of the sling. The sling is placed tension free at surgery, the initial adjustment being performed the following day based on cough and pad testing. Once the tension is adjusted, the manipulator is withdrawn. The varitensor can be accessed in the long-term in an ambulatory setting under local anesthesia if subsequent adjustment (tighter or looser) is necessary. Material & Methods: 125 patients classified by clinical criteria Q-tip and urodynamics, into ISD (70 cases) and recurrent hyper-mobility SUI (55 cases) underwent the Remeex procedure. Outcome measures included urodynamic assessment of cure, and the King´s Health Questionnaire. Results: After a mean follow-up period of 32 months (range: 26-52), 109 patients (87.2%) are objectively cured of stress incontinence. Nine (7.2%) additional patients were satisfied and refused re-adjustment, and the remaining 7 (5.6%) patients are on the waiting list for re-adjustment. Nineteen patients (15.2%) showed some evidence of urge incontinence (9 with previous urodynamic mixed incontinence, and 10 with de-novo detrusor overactiviy incontinence). Twenty-one of the 109 successes (19.2%) required adjustment of the sling months after the initial procedure. The ability to adjust the sling enabled us to convert failures into cures. The tension was increased in 17 cases due to recurrence of SUI after a mean period of 12 months, and reduced in 4 cases due to obstruction. The varitensor was withdrawn in one case due to infection but continence was preserved. Bladder perforation during needle passage was seen in 15 patients. No other adverse events or complications were seen. Conclusions: The Remeex adjustable sling system provides a good cure rate for recurrent SUI and ISD with a low complication rate. The correct sling tension is easily achieved during the early postoperative period. When necessary, one is able to convert failures into cures. Increasing and decreasing the sling tension was successful in achieving clinical improvements. The problems of obstruction and recurrent incontinence during the follow up period were resolved successfully in every case.

Introduction & Objectives: Laparoscopic learning period is correlated with a higher morbidity risk, and longer operative time. Objectives: To create a video simulator to confront the beginners to difficulties and complications occurring during the learning period. Material & Methods: Between 1999 and 2006 we prospectively recorded laparoscopic procedures performed by 14 different surgeons in 6 different centers. The first procedure to be studied was laparoscopic sacral colpopexy. A retrospective step-by-step video analysis has been performed in order to identify difficult situation, mishaps, and ideal dissections. Each difficult surgical situation has been classified as Anatomical, Instrumental, Stategical, Technical or in relation with the first assistant. For each difficult situation, a second comparative video analysis was performed to discriminate a « good reaction » of the surgeon leading to a resolution of the difficulty or a « bad reaction » leading to complication or persistent difficulty. Results: 1800 hours of surgery have been recorded. Video analysis has been performed for 60 laparoscopic sacral colpopexy. We created short cuts corresponding to each difficulty, complication, good or bad reaction. A problem base learning model has been created: it is an interactive video course: 1. A video shows a difficult situation, 2. A multiple-choice question is asked offering different options for reaction, 3. A good answer leads to watch the nice dissection and the next step with another question, 4 a bad answer leads to watch the complication or difficulty resulting of an inappropriate reaction to the difficult situation and to watch another case at the same step of the procedure. A web site playing interactive video courses has been created. Conclusions: The online video Simulator is a problem base-learning model that can give safe and realistic experience of difficulties and complications occurring during the learning period. Further studies will evaluate its ability to shorten and secure the learning period in surgery.

Eur Urol Suppl 2007;6(2):231