Continent vesicostomy after female urethrectomy

VI3 THE NERVE-SPARING

RADICAL

PERINEAL

PROSTATECTOMY

V3

IWALE UROLOGY Thursday,March 13, 15.30-17.00 hrs, eUR0 Auditorium

CONTINENT Frea,

Offenburg,

Urology, Offenburg,

INTRODUCTION minimally

and Paediadric

Urology,

Hof, Germany,

‘Klinikum

Germany

& OBJECTIVES:

invasive procedure

The radical perineal prostatectomy

is a

to treat localized prostate cancer. For the rate of

young and healthy patients with an early tumour stage increases a nerve-sparing procedure

is of major concern.

sparing is standardised

While with the retropubic

surgeons

believe

FEMALE

VI4 URETHRECTOMY

Kocjancic E.. Gontero P., Minocci D.. Monesi G., Sala M., Crivellaro

University

Hof, Urology

AFTER

S.,

Favro M., Baietto S.

Keller H.‘, Linder M.‘, Lamade F.’

‘Klinikum

VESICOSTOMY

approach

a nerve-

that for the perineal approach

it would

of Medicine

of Novara,Urological,

Novara, Italy

INTRODUCTION & OBJECTIVES: We present a case of urethrectomy followed by the creation of a continent vesicostomy in a 52 years old female patient presented with a recurrent Skene gland carcinoma. PERINEAL PART: The procedure starts with the dissection of the base of the lesion, which was previously removed on 2 occasions by the gynaecologist. Frozen section examination revealed the persistence of carcinoma. A wide circumcisional incision around the external urethral meatus is performed, cutting through the Colles fascia. The urethral wall dissection is conducted including all the ligaments connecting the urethra to the pubic bone and the lateral pelvic pavement. The pubo-urethral ligament is exposed. On the left end site, part of the cavernous body, which gives the appearance of cancerous infiltration, is excised leaving a margin of normal tissue. Posteriorly, the urethra is freed from the vaginal septum. The right urethro-pelvic ligament is isolated and transacted. The same is done on the left urethra-pelvic ligament, The urethra is finally completely isolated and the urethra-vesical junction is seen at the bottom of the wound.

be difficult or even not possible.

MATERIAL

Kc METHODS:

a self-retaining

We use a modified approach according to Young,

system, and magnifying

glasses, which we believe, are of major

importance.

RESULTS:

The video shows the preservation

of both neurovascular

bundles,

which can be achieved very well with the perineal approach.

CONCLUSIONS:

Thus

the

procedure,

nerve

sparing

in which

can be done with two surgeons

nerve-sparing is as easily

RPP possible

is

a minimally as retropubically,

invasive which

SUP&APUBIC PART: A Phamestiel incision is then performed. The anterior bladder wall is exposed in the Retzius space. The endopelvic portion of both pubourethral ligaments is dissected and the urethra is retrieved into the pelvis. The urethra is then dissected at the level of the bladder neck. Another Foley catheter is inserted through the bladder neck and the balloon inflated in order to allow the bladder to be tilled. A “u” shaped incision through the muscular layer of the bladder is conducted carefully isolating a detrusor flap from the mucosa. The mucosa is then incised in the same “U” shape of the detrusor flap. After removal of the Foley catheter the bladder neck is closed with an external and an internal suture layer. CONCLUSIONS: The mucosa flap is tubularised around a 16 F catheter with a running suture. The bladder is then closed underneath the tubularised flap with a running suture involving the mucosa. The tubularised mucosa is then pulled back to the closed mucosa layer. The detmsor is then sutured above the tubularised mucosa, leaving 1 cm of the distal tuhularised flap free. The bladder is secured to the rectus fascia with a stay suture. The vesicostomy is finally anastomosed to a skin flap obtained in the mid portion of the skin incision. The same surgical technique was used in 5 other female patients submitted to urethrectomy for gynaecological pathology (vulva carcinoma). The patients were studied with cystography and urodynamic evaluation. In all cases a complete to perform self-catheterization.

in less than 90 minutes.

continence

was achieved

and the patients were able

VI5 ACT: ADJUSTABLE CONTINENCE THERAPY: INVASIVE POST OPERATIVELY ADJUSTABLE FEMALE STRESS URINARY INCONTINENCE

A MINIMALLY THERAPY FOR

Kociancic E.‘, Sauter T', Mmocci D.‘, Monesi G.‘, Favro M.‘, Cerattt G.‘, Sala M.‘. Gontero P.‘, Gughelmetti S.‘, Crivellaro S.‘, Frea B.’ ‘University of Medicine of Novara, Urological, Benjamm Franklin, Ilrological, Berlin, Germany

Novara,

Italy, ‘University

VI6 SAFYRE: SLING

A VERSATILE

SELF-ANCHORING

RE-ADJUSTABLE

Palma P., Rtccetto C., Dambros M.. Thiel M.. Fraga R., Vilas-Boas C., Netto Jr.N Untversidade

Estadual de Campinas. IJrology. Campmab, Brazil

Hospttal

INTRODUCTION & OBJECTIVES: An entirely new concept for the treatment of female stress urinary mcontinence, named ACT (adjustable continence therapy) is presented. The device consist of an adjustable balloon, which is placed under the bladder neck, a sub cutaneously positioned titanium port and a two-lumen tube in between. MATERIAL & METHODS: A cough stress test is performed pre-operatively. Surgery is performed under local anaesthesia using a I to 3 mixture of bupivacain. 25% and lidocaine 1%. The skin incision is made between the labium majus and minus just above the meatus. Using scissors the space under the pubic symphysis is prepared in latero medial aspect. After the scissors reaches the pubic edge the tip is directed toward the bladder neck. RESULTS: When the scissors are removed the delivery trocar is passed using the same route while being twisted. The two blades of the tip of the internal stylet cause a cutting effect wile twisting the trocar, whtch enable guidance of the trocar under force control. When the tip of the trncar reaches the pubic bone, the fibrous tissue adjacent to the lateral vaginal wall is detached gently by control pressure and turning movements of the trocar. The final position of the trocar is achieved when the tip of the trocar reach the vesico urethral junction below the bladder neck. The correct direction of the deliver instrument is controlled under fluoroscopy. Once the correct position of the trocar is confirmed the internal stylet is removed. Prior to the implantation any air should be aspirated from the device using N” 23 non coring Huber needle The ACT device is then advanced trough the trocar sheath to the selected periurethral position using the push wire. The advance of the device is observed using X-rays and should be placed close to the bladder neck. Correctly the ACT’s balloon has to be located above the deep transverse perineal muscle and bellow to the endopelvic fascia. The balloon is inflated 1.5 cc with diluited contrast medium and the sheath of the trocar is then drown back to expose the balloon. The anterior vaginal wall palpation contirms the correct position of the balloon. The procedure is then repeated controlaterally. CONCLUSIONS: When both the devices are positioned a stress test is performed under fluoroscopy to verify the effect of the devices on the bladder neck and mid urethra. When the balloon remams in the correct position the push wire is removed. Implantation of the subcutaneous port is performed by creating a subcutaneous pocket in the labium majns in which the port is easily placed. This procedure facilitate the port palpation for post operatively adjubttnent in the future. The small incision is closed in two layer using absorbable suture. ‘The catheter is removed 12 hours post-operatively.

INTRODUCTION & OBJECTIVES: To shown the versattlity of a new self-anchoring readjustable sling: the suprapubtc, vaginal and transobturator approaches. MATERIAL & METHODS: The procedure may be performed under local anaesthesta and sedation. Anaesthetic injection is performed 5 cm apart, close to the pelvic brim. A 2 I Gauge spinal needle is used to inject the anaesthetic solution in the R&ins space. An Allis clamp IS placed 1 cm from the urethral meatus and a I,5 cm long longitudinal vaginal mcision IS made. Sharp and blunt dissection are used o create a tunnel to the ascending ramus of the ischium, on both sides, avoiding perforation of the endopelvic fascia. Next, using a scalpel, two suprapubic punctures are made at the previously anaesthetized sites. For vaginal approach, a metallic sound IS used for urethra and bladder displacement. The needle ts primed with the hook like end inside the handle. The needle’s tip is introduced in the previously made tunnel and the metallic sound is brought to the same side, displacmg the bladder away from the needle’s trajectory The surgeon’s index finger is used to guide the needle introduction. The handle is removed exposing the hooked tip. Cystoscopy is performed to rule out urethra and bladder perforations. Notice the normal urethra and bladder mucosa. The self-anchoring readjustable tail is hooked to the needle and brought to the suprapubic region. The same manoenvres are repeated on the other side. Intraoperative adjustment is performed at this point and time. For suprapubic approach, the needle is primed with the hooked end outside the handle. Both needles are passed as in the classical Stamey procedure and a single cystoscopy is performed, saving operative time. Transobturator approach is another way to provide urethral backboard support. The obturator foramen is palpated and a skin incision is made close to the medial border at the level of the urethral meatus, avoiding damage to the neurovascular bundle that runs laterally. The hooked needle 1s introduced vertically and the obturator fascia is perforated. Than, the needle is brought to the horizontal positton and mtroduced towards in vaginal incision, guided by the surgeon’s index finger. No cystoscopy IS necessary in this approach. The sling IS hooked and the needle removed, putting the sling in place. CONCLUSIONS: All approaches are safe to perform. easy to teach, providing very good initial results sling

Portoperative

readjustment

European

Urology

adds considerable

Supplements

advantage

2 (2003)

to this versatile

No. 1, pp. 207