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ARGUS MALE SLING SYSTEM- SURGICAL TECHNIQUE AND RESULTS
V8
VIDEO AWARD SESSION Friday, 28 March, 15.45-17.15, eURO Auditorium
V19
V43
ARGUS MALE SLING SYSTEM- SURGICAL TECHNIQUE AND RESULTS
LAPAROSCOPIC ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL URINARY DIVERSION
Hübner W., Gallistl H.
John H.1, Fehr J.1, Fischer B.1, Engel N.1:LNOXQG32
Humanis Clinic, Dept. of Urology, Korneuburg, Austria
1
.OLQLN +LUVODQGHQ &HQWUH RI 8URORJ\ =XULFK 6ZLW]HUODQG 2.DUROLQVND 8QLYHUVLW\ 'HSW RI 8URORJ\=XULFK6ZLW]HUODQG
Introduction & Objectives: 8QOLNH IHPDOH VOLQJV ZKHUH WKH WDSH FDQ EH SRVLWLRQHG tensionless to support the urethra, male slings have to permanently increase the urethral UHVLVWDQFHLQRUGHUWRDFKLHYHFRQWLQHQFHDQGFRUUHFWWKHLQWULQVLFVSKLQFWHUGHᚏFLHQF\,Q order to avoid overcorrection with concomitant obstruction; and have the ability to respond to future individual functional or anatomic changes, adjustable systems are preferable. :HSUHVHQWWKHVXUJLFDOWHFKQLTXHDQGRXUSUHOLPLQDU\UHVXOWVXVLQJWKH$UJXVPDOHVOLQJ system. Material & Methods: 7KH$UJXVVOLQJFRQVLVWVRIDWKLFNIRDPVLOLFRQHSDGᚏWWHGEHWZHHQ VLOLFRQHFROXPQV7KHFROXPQVDUHDGMXVWHGZLWKVLOLFRQHZDVKHUVWRUHJXODWHDQGNHHS WKHGHVLUHGWHQVLRQDJDLQVWWKHXUHWKUD7KHSDGDQGZDVKHUVDUHUDGLRRSDTXHZKLFK allows their position to be assessed during follow-up. Prior to implantation of the Argus VOLQJSDWLHQWVZHUHHYDOXDWHGXVLQJDPLQSDGWHVWDQG4XDOLW\RI/LIHTXHVWLRQQDLUH Patients were assessed periodically post operatively with any adverse events noted. Results: Since 2005, we have implanted the Argus Sling in 55 patients with post prostatectomy incontinence arising from radical prostatectomy (n=49) and TURP (n=6). The average age at implant was 66.4 years. Eighty one percent of patients had undergone previous anti incontinence procedures including BN incision, ProACT balloons, injectable EXONLQJDJHQWV$06,Q9DQFHDQG5HPHH[VOLQJV$GGLWLRQDOO\SDWLHQWVKDGSULRU pelvic irradiation. Operative time was 35(25-104) min including learning curve cases and WKRVH SHUIRUPHG GXULQJ ZRUNVKRSV $GMXVWPHQW ZDV UHTXLUHG LQ SDWLHQWV EHWZHHQ 1 to 240 days postoperatively. After a median follow-up of 17 months, pad weight was improved from 37g to 0.63g. Seventy four percent of patients were completely dry, VLJQLᚏFDQWO\LPSURYHGDQGZHUHXQFKDQJHG7KHV\VWHPZDVUHTXLUHGWREH explanted in 6 patients (11% of unchanged patients) for erosion and infection. Success was not associated with preoperative Stamey grading (grade I, II or grade III incontinence). The only intra operative complications was bladder perforations in 7% of patients. Conclusions: The Argus male sling is a straight forward approach and surgically easy to perform. Adjustment is easily achieved under local anaesthesia any time after the LPSODQWDWLRQ LI QHHGHG :H EHOLHYH WKH $UJXV VOLQJ V\VWHP WR EH DQ H[FHOOHQW ᚏUVW RU second line treatment option for males with Grade one to three urinary incontinence when less invasive systems are not indicated.
V44 THE ANTEGRADE INTER/INTRA/EXTRAFASCIAL DA VINCI PROSTATECTOMY AFTER TRANSRECTAL INJECTION 5HFNHU)6HLOHU'Werthemann P. .DQWRQVVSLWDO$DUDX8URORJ\$DUDX6ZLW]HUODQG Introduction & Objectives: We present the initial experience of s single surgeon converting from open to transperitoneal robotic prostatectomy in UHVSHFW WR WKH SUHSDUDWLRQ RI WKH GLᚎHUHQW IDVFLD DLGHG E\ SUHRSHUDWLYH instillation of the Denovilliers space. Material & Methods: Prior to radical, robotic-assisted Prostatectomy, 15-20 ml solution consisting of 0.4% Indigocarmin and 0.0003% Adrenaline were injected in the Denovilliers space under transrectal ultrasound guidance. Intra-, enter and extrafascial dissection were performed, depending on tumour status of the ipsilateral biopsy. The procedure was used in 30 consecutive patients. Results: The blue dye facilitated entering the Denovilliers Space via transperitoneal approach. Also, it helped to identify the ductus deferentes entering dorsolaterally. Corresponding to tumour stage, Intra/inter/ extrafascial dissection was possible. Conclusions: The preoperative transrectal dilatation with Indigocarmin and $GUHQDOLQHLVXVHIXOIRULGHQWLᚏFDWDWLRQXQGSUHSDUDWLRQRIWKH'HQRYLOOLHUV Space, especially for the surgeon beginning with radical robotic-assisted prostatectomy.
Eur Urol Suppl 2008;7(3):340
Introduction & Objectives: This video demonstrates the feasibility of a radical cystectomy, extended pelvic lymph node dissection and intracorporal reconstruction of the upper urinary tract with a 3-arm robotic system. Material & Methods: The patient is placed in a supine Trendelenburg position with the legs moderately abducted. The peri-umbilical camera trocar and the two 8mm robotic trocars are placed. In addition, two 12mm assistant trocars are introduced into the right hemi-abdomen and one 15mm trocar near the left iliac crest. The left peritoneal border near the iliac vessels is incised DQGWKHOHIWXUHWHUPRELOLVHG7ZR+HPRORFNFOLSVDUHSODFHGGLVWDOO\ZLWKD%LRV\QKROGLQJ VXWXUH7KHGLVWDOXUHWHUDOHQGLVVHQWIRUIUR]HQVHFWLRQ7KHULJKWXUHWHULVSUHSDUHGLQWKHVDPH way. The peritoneum is incised in the deep Douglas space and the seminal vesicles freed from WKH DQWHULRU UHFWDO ZDOO 7KH XSSHU DQG ORZHU EODGGHU SHGLFOHV DUH FXW ZLWK WKH /LJDVXUH PP GHYLFH 7KH HQGRSHOYLF IDVFLD LV RSHQHG DQG WKH SURVWDWH GLVVHFWHG LQ GHVFHQGLQJ WHFKQLTXH 7KH6DQWRULQLSOH[XVLVGLYLGHGDQGWKHXUHWKUDOVWXPSFXW$IWHUDIUR]HQVHFWLRQRIWKHGLVWDO urethral stump the urethra is closed with Biosyn 2-0. The specimen is placed in a large Endobag. The obturator and external and internal iliac lymph nodes are dissected. To reconstruct WKH XSSHU XULQDU\ WUDFW DQ LQWUDFRUSRUDO %ULFNHU FRQGXLW LV EXLOW $ &DGLHUH IRUFHSV LV EURXJKW through the mesosigma at the level of the promontory. The left ureter is transposed to the right. The caecum is mobilised in order that the ureteral stumps can be approximated. An Endo GIA 60mm is placed 20cm above the ileocaecal valve and an ileum segment of 20 cm is excluded. Small incisions are made into the oral end of the bowel in order to introduce the Endo GIA at the DQWLPHVHQWHULDOVLGH7KH%ULFNHUFRQGXLWLVWKHQᚏQLVKHGZLWKDWUDQVYHUVH(QGR*,$DSSOLFDWLRQ Both ureters are spatulated over 2-3cm to build a ureteral plate. The ureteral plate according to Wallace II is performed with Biosyn 4-0. The conduit is brought down, approximated to the ureteral plate and incised to the ureteral side. Two 3mm trocars are introduced at the preplanned stoma location and guidewires with 70cm ureteral stents are introduced in both ureters. The guide wires are removed and the ureteral plate sutured at the posterior and anterior border. The URERWLVGLVFRQQHFWHGWKH%ULFNHUFRQGXLWLVH[WUDFRUSRUDOL]HGZLWK$OLFHIRUFHSVDQGᚏ[HGDWWKH abdominal wall. The specimen is removed through the 15mm trocar site. Conclusions: /DSDURVFRSLF URERW DVVLVWHG UDGLFDO F\VWHFWRP\ ZLWK LQWUDFRUSRUDO XULQDU\ diversion is feasible. While the cystectomy itself and the extendend lymphadenectomy are routinely performed today, the intracorporal reconstruction of the upper urinary tract remains a WHFKQLFDOO\FKDOOHQJLQJDQGFOLQLFDOO\H[SHULPHQWDOWHFKQLTXH
VIDEO AWARD SESSION Friday, 28 March, 15.45-17.15, eURO Auditorium
V19
V43
ARGUS MALE SLING SYSTEM- SURGICAL TECHNIQUE AND RESULTS
LAPAROSCOPIC ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPORAL URINARY DIVERSION
Hübner W., Gallistl H.
John H.1, Fehr J.1, Fischer B.1, Engel N.1:LNOXQG32
Humanis Clinic, Dept. of Urology, Korneuburg, Austria
1
.OLQLN +LUVODQGHQ &HQWUH RI 8URORJ\ =XULFK 6ZLW]HUODQG 2.DUROLQVND 8QLYHUVLW\ 'HSW RI 8URORJ\=XULFK6ZLW]HUODQG
Introduction & Objectives: 8QOLNH IHPDOH VOLQJV ZKHUH WKH WDSH FDQ EH SRVLWLRQHG tensionless to support the urethra, male slings have to permanently increase the urethral UHVLVWDQFHLQRUGHUWRDFKLHYHFRQWLQHQFHDQGFRUUHFWWKHLQWULQVLFVSKLQFWHUGHᚏFLHQF\,Q order to avoid overcorrection with concomitant obstruction; and have the ability to respond to future individual functional or anatomic changes, adjustable systems are preferable. :HSUHVHQWWKHVXUJLFDOWHFKQLTXHDQGRXUSUHOLPLQDU\UHVXOWVXVLQJWKH$UJXVPDOHVOLQJ system. Material & Methods: 7KH$UJXVVOLQJFRQVLVWVRIDWKLFNIRDPVLOLFRQHSDGᚏWWHGEHWZHHQ VLOLFRQHFROXPQV7KHFROXPQVDUHDGMXVWHGZLWKVLOLFRQHZDVKHUVWRUHJXODWHDQGNHHS WKHGHVLUHGWHQVLRQDJDLQVWWKHXUHWKUD7KHSDGDQGZDVKHUVDUHUDGLRRSDTXHZKLFK allows their position to be assessed during follow-up. Prior to implantation of the Argus VOLQJSDWLHQWVZHUHHYDOXDWHGXVLQJDPLQSDGWHVWDQG4XDOLW\RI/LIHTXHVWLRQQDLUH Patients were assessed periodically post operatively with any adverse events noted. Results: Since 2005, we have implanted the Argus Sling in 55 patients with post prostatectomy incontinence arising from radical prostatectomy (n=49) and TURP (n=6). The average age at implant was 66.4 years. Eighty one percent of patients had undergone previous anti incontinence procedures including BN incision, ProACT balloons, injectable EXONLQJDJHQWV$06,Q9DQFHDQG5HPHH[VOLQJV$GGLWLRQDOO\SDWLHQWVKDGSULRU pelvic irradiation. Operative time was 35(25-104) min including learning curve cases and WKRVH SHUIRUPHG GXULQJ ZRUNVKRSV $GMXVWPHQW ZDV UHTXLUHG LQ SDWLHQWV EHWZHHQ 1 to 240 days postoperatively. After a median follow-up of 17 months, pad weight was improved from 37g to 0.63g. Seventy four percent of patients were completely dry, VLJQLᚏFDQWO\LPSURYHGDQGZHUHXQFKDQJHG7KHV\VWHPZDVUHTXLUHGWREH explanted in 6 patients (11% of unchanged patients) for erosion and infection. Success was not associated with preoperative Stamey grading (grade I, II or grade III incontinence). The only intra operative complications was bladder perforations in 7% of patients. Conclusions: The Argus male sling is a straight forward approach and surgically easy to perform. Adjustment is easily achieved under local anaesthesia any time after the LPSODQWDWLRQ LI QHHGHG :H EHOLHYH WKH $UJXV VOLQJ V\VWHP WR EH DQ H[FHOOHQW ᚏUVW RU second line treatment option for males with Grade one to three urinary incontinence when less invasive systems are not indicated.
V44 THE ANTEGRADE INTER/INTRA/EXTRAFASCIAL DA VINCI PROSTATECTOMY AFTER TRANSRECTAL INJECTION 5HFNHU)6HLOHU'Werthemann P. .DQWRQVVSLWDO$DUDX8URORJ\$DUDX6ZLW]HUODQG Introduction & Objectives: We present the initial experience of s single surgeon converting from open to transperitoneal robotic prostatectomy in UHVSHFW WR WKH SUHSDUDWLRQ RI WKH GLᚎHUHQW IDVFLD DLGHG E\ SUHRSHUDWLYH instillation of the Denovilliers space. Material & Methods: Prior to radical, robotic-assisted Prostatectomy, 15-20 ml solution consisting of 0.4% Indigocarmin and 0.0003% Adrenaline were injected in the Denovilliers space under transrectal ultrasound guidance. Intra-, enter and extrafascial dissection were performed, depending on tumour status of the ipsilateral biopsy. The procedure was used in 30 consecutive patients. Results: The blue dye facilitated entering the Denovilliers Space via transperitoneal approach. Also, it helped to identify the ductus deferentes entering dorsolaterally. Corresponding to tumour stage, Intra/inter/ extrafascial dissection was possible. Conclusions: The preoperative transrectal dilatation with Indigocarmin and $GUHQDOLQHLVXVHIXOIRULGHQWLᚏFDWDWLRQXQGSUHSDUDWLRQRIWKH'HQRYLOOLHUV Space, especially for the surgeon beginning with radical robotic-assisted prostatectomy.
Eur Urol Suppl 2008;7(3):340
Introduction & Objectives: This video demonstrates the feasibility of a radical cystectomy, extended pelvic lymph node dissection and intracorporal reconstruction of the upper urinary tract with a 3-arm robotic system. Material & Methods: The patient is placed in a supine Trendelenburg position with the legs moderately abducted. The peri-umbilical camera trocar and the two 8mm robotic trocars are placed. In addition, two 12mm assistant trocars are introduced into the right hemi-abdomen and one 15mm trocar near the left iliac crest. The left peritoneal border near the iliac vessels is incised DQGWKHOHIWXUHWHUPRELOLVHG7ZR+HPRORFNFOLSVDUHSODFHGGLVWDOO\ZLWKD%LRV\QKROGLQJ VXWXUH7KHGLVWDOXUHWHUDOHQGLVVHQWIRUIUR]HQVHFWLRQ7KHULJKWXUHWHULVSUHSDUHGLQWKHVDPH way. The peritoneum is incised in the deep Douglas space and the seminal vesicles freed from WKH DQWHULRU UHFWDO ZDOO 7KH XSSHU DQG ORZHU EODGGHU SHGLFOHV DUH FXW ZLWK WKH /LJDVXUH PP GHYLFH 7KH HQGRSHOYLF IDVFLD LV RSHQHG DQG WKH SURVWDWH GLVVHFWHG LQ GHVFHQGLQJ WHFKQLTXH 7KH6DQWRULQLSOH[XVLVGLYLGHGDQGWKHXUHWKUDOVWXPSFXW$IWHUDIUR]HQVHFWLRQRIWKHGLVWDO urethral stump the urethra is closed with Biosyn 2-0. The specimen is placed in a large Endobag. The obturator and external and internal iliac lymph nodes are dissected. To reconstruct WKH XSSHU XULQDU\ WUDFW DQ LQWUDFRUSRUDO %ULFNHU FRQGXLW LV EXLOW $ &DGLHUH IRUFHSV LV EURXJKW through the mesosigma at the level of the promontory. The left ureter is transposed to the right. The caecum is mobilised in order that the ureteral stumps can be approximated. An Endo GIA 60mm is placed 20cm above the ileocaecal valve and an ileum segment of 20 cm is excluded. Small incisions are made into the oral end of the bowel in order to introduce the Endo GIA at the DQWLPHVHQWHULDOVLGH7KH%ULFNHUFRQGXLWLVWKHQᚏQLVKHGZLWKDWUDQVYHUVH(QGR*,$DSSOLFDWLRQ Both ureters are spatulated over 2-3cm to build a ureteral plate. The ureteral plate according to Wallace II is performed with Biosyn 4-0. The conduit is brought down, approximated to the ureteral plate and incised to the ureteral side. Two 3mm trocars are introduced at the preplanned stoma location and guidewires with 70cm ureteral stents are introduced in both ureters. The guide wires are removed and the ureteral plate sutured at the posterior and anterior border. The URERWLVGLVFRQQHFWHGWKH%ULFNHUFRQGXLWLVH[WUDFRUSRUDOL]HGZLWK$OLFHIRUFHSVDQGᚏ[HGDWWKH abdominal wall. The specimen is removed through the 15mm trocar site. Conclusions: /DSDURVFRSLF URERW DVVLVWHG UDGLFDO F\VWHFWRP\ ZLWK LQWUDFRUSRUDO XULQDU\ diversion is feasible. While the cystectomy itself and the extendend lymphadenectomy are routinely performed today, the intracorporal reconstruction of the upper urinary tract remains a WHFKQLFDOO\FKDOOHQJLQJDQGFOLQLFDOO\H[SHULPHQWDOWHFKQLTXH