- Email: [email protected]
FACE, CONTENT, AND CONSTRUCT VALIDITY OF THE IDEAL ADULT URETEROSCOPY TRAINER: A HIGH-FIDELITY URETEROSCOPY AND RENOSCOPY SIMULATOR
792
THE JOURNAL OF UROLOGY®
residents obtaining “exceeds expectations” in 50% of evaluations in all domains of the 360 degree evaluations while junior residents score lower with 35% “exceeds expectations” on the initial labs. These evaluations improve with later labs to 67% and 46 % respectively (p < 0.017). Faculty score evaluations improve with subsequent labs as well with senior residents scoring “performed independently” in 73% of steps and junior residents scoring 53% on initial labs and improving to 92% and 67% on later labs respectively (p < 0.049). The initial times to complete a laparoscopic nephrectomy for senior and chief residents average 188 minutes and more junior residents 288 minutes. These times improved significantly to 125 minutes and 133 minutes on later labs respectively. All components of the operation take longer without a specific improvement in one section of the operation. CONCLUSIONS: Our data indicate that this intergraded simulation curriculum promotes significant resident skills progression. By incorporating the whole faculty and staff into the evaluation process we find that this comprehensive approach affords multiple opportunities for resident evaluation in all 6 domains of the core competencies. This also allows quantifiable and documentable progression of the trainee along the learning curve in a safe environment. Additionally, training residents with simulation may allow us to better understand how surgeons acquire skills and help us to more effectively train the next generation of surgeons. Source of Funding: Department of Clinical Investigations, Madigan Army Medical Center
2183 GENITOURINARY SKILLS TRAINING CURRICULUM FOR MEDICAL STUDENTS Adam G Kaplan*, Surendra B Kolla, Aldrin J R Gamboa, Michael L Louie, Ross M Moskowitz, Rosanne T Santos, Jennifer M Gan, Ralph V Clayman, Elspeth M McDougall, Orange, CA INTRODUCTION AND OBJECTIVE: Basic urology training in medical school is considered important for many medical and surgical disciplines. We developed an intensive genitourinary (GU) skills training curriculum for medical students beginning their clinical clerkship training years and evaluated the initial experience with this program. METHODS: A total of 94 third year medical students at UC, Irvine, participated in a 5.5 hour-long GU exam skills training program, the month preceding the commencement of their clinical clerkship training. The teaching course included 1.5 hours didactic lecture and video presentation with questions and answers, followed by four 1-hour stations including: male Foley catheter (MFC) placement, female Foley catheter (FFC) placement, testicular (TE) and digital rectal (DRE) examination training with a standardized patient (SP), virtual reality cystourethroscopy and a urologist lead tutorial of abnormal GU findings. The students completed a pre- and post-course questionnaire asking them to rate their comfort with each of the GU skills, and evaluate the effectiveness of the training curriculum. RESULTS: All 94 medical students completed the GU skills training course. Prior to the course < 10% of students reported comfort for the various GU skill tasks, including TE (5%), DRE (10%), and Foley catheterization (2%). After the course, the comfort level of the students improved significantly in all parameters, including DRE (100%), TE and Foley catheterization (98%) (p < 0.001). The students rated in order of most to least useful training: 1) TE and DRE teaching with SP, 2) MFC and FFC training, 3) didactic lecture, 4) tutorial of abnormal GU exam findings, and 5) VR cystourethroscopy. CONCLUSIONS: This intensive skills training curriculum significantly improved medical student comfort with, and knowledge of, the basic GU skills of testicular and rectal exam, and male and female Foley catheter placement Source of Funding: None
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
2184 VALIDATION OF THE DV-TRAINER ®, A NOVEL VIRTUAL REALITY SIMULATOR FOR ROBOTIC SURGERY Patrick A Kenney*, Matthew F Wszolek, Justin J Gould, John A Libertino, Alireza Moinzadeh, Burlington, MA INTRODUCTION AND OBJECTIVE: Simulation is an established component of laparoscopic training, and may prove to be a valuable tool in robotic surgery. The dv-Trainer ® (Mimic Technologies Inc, Seattle, WA) is a virtual reality simulator for the da Vinci ® Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) that is in beta development. We sought to assess the face, content and construct validity of the dv-Trainer. METHODS: Medical students, residents, and attending surgeons were enrolled in a prospective, IRB-approved study. All data was deidentified at study outset. Subjects were prospectively categorized as either novice (<10 robotic cases) or expert (q30 robotic cases). Following a standardized introduction and 10 minutes of practice time, each subject completed two endowrist modules and two needle driving modules in sequence. Performance was recorded using a built-in scoring algorithm. Each subject completed a questionnaire after finishing the modules. RESULTS: The novice group (n=19) was composed of 16% students, 58% residents, and 26% attending surgeons. Novices had operated an average of 1.3 ± 2.2 hours at the da Vinci console prior to using the simulator. On average, experts (n=7) had performed 140 ± 116 robotic cases. Expert robotic surgeons outperformed novices on the simulator in nearly all variables in a pooled data set (Table 1). All novices ranked the simulator as a realistic practice format. All experts ranked the simulator as useful for training residents and attendings, and agreed with incorporating the simulator into a residency curriculum. The haptic feedback, virtual reality and instrumentation all achieved acceptability. The needle driving modules did not exceed the acceptability threshold. CONCLUSIONS: The dv-Trainer has face, content and construct validity as a virtual reality simulator for the da Vinci Surgical System. Needle driving modules will need to be refined. Studies are underway to assess concurrent and predictive criterion validity. The dv-Trainer may become a valuable training simulator in robotic surgery. Table 1. Pooled data (Pick & Place, Pegboard, Dots & Numbers, Suture Sponge) Novice
Expert
P value
Total task time (sec)
269 ± 196
139 ± 56
<0.01
Total motion (mm)
2635 ± 1682
1674 ± 712
<0.01
Instrument Collisions
4.9 ± 7.8
0.9 ± 1.3
<0.01
Time out of view (sec)
21 ± 63
2±5
0.02
Time out of center (sec)
87 ± 104
32 ± 36
<0.01 0.07
Max Force
6.02 ± 13.52
2.71 ± 5.34
Successful targets
10.8 ± 4.7
12.6 ± 3.8
0.04
Unattempted targets
0.3 ± 3.5
0±0
<0.01
Dropped targets
0.3 ± 0.6
0±0
0.02
Source of Funding: None
2185 FACE, CONTENT, AND CONSTRUCT VALIDITY OF THE IDEAL ADULT URETEROSCOPY TRAINER: A HIGH-FIDELITY URETEROSCOPY AND RENOSCOPY SIMULATOR Michael A White*, Alex P DeHaan, Doyle D Stephens, Richard J Kahnoski, Grand Rapids, MI INTRODUCTION AND OBJECTIVE: Surgical simulation technology may efficiently train and accurately assess the acquisition of many skills. Surgical simulators often lack realism and can be very expensive, ranging in price from $3000 to more than $50,000. We assessed the face, content, and construct validity of a newly developed, anatomically accurate, and reasonably priced high-fidelity ureteroscopy and renoscopy trainer.
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
METHODS: 46 participants, including attending urologists, urology residents, medical students, and industry representatives assessed the face and content validity of the simulator using a standard questionnaire. In addition 10 experienced ureteroscopists (>30 procedures/year) and 10 novice ureteroscopists (0 procedures/year) were assessed on their ability to perform flexible ureteroscopy, renoscopy, and intrarenal basket extraction of a lower pole stone using the IDEAL adult ureteroscopy trainer. Subject performance was assessed by an experienced ureteroscopist using a checklist, global rating scale, and time to completion of task. RESULTS: Of the participants 100% rated the trainer as a realistic training format and easy to use. 100% felt that this was a good training tool and 98% saw this also as a good practice format. 96% would recommend this to urology trainees and 100% felt this should be used in residency programs. 96% would use this or would have used this in their residency. Only 37.5% of the experienced ureteroscopists compared to 100% of the novice ureteroscopists would use this to practice. 9% of participants foresaw a problem with the use of the trainer. Experienced ureteroscopists scored significantly higher on their global rating scale (33.1± 1.3 vs. 15.0± 2.7, p<0.0001), checklist (4.1±1.0 vs. 2.4±1.1, p=0.004) and required less time to complete the task (141.2±40.1 sec. vs. 447.2±301.7 sec., p=0.01) than novice ureteroscopists on the trainer. CONCLUSIONS: The IDEAL adult ureteroscopy trainer has face, content, and construct validity as a high-fidelity ureteroscopy and renoscopy trainer. Source of Funding: None
2186 VIRTUAL REALITY TRANSRECTAL ULTRASOUND GUIDED PROSTATIC BIOPSY SIMULATOR Venu Chalasani*, Derek W Cool, Shi Sherebrin, Aaron Fenster, Joseph L Chin, Jonathan I Izawa, London, ON, Canada INTRODUCTION AND OBJECTIVE: Numerous transrectal ultrasound guided prostatic biopsy (TRUS) schemes have been described in the literature since the original sextant biopsy plan was implemented. We present the design and content validity testing of a new virtual reality (VR) simulator for TRUS, which allows training doctors to perform multiple different biopsy schemes in either axial or sagittal views. METHODS: This system design uses a regular “end-firing” TRUS probe, which is standard throughout North America. The TRUS probe is held and manipulated directly by the trainee. Movements of the probe are tracked with a micro-magnetic sensor, to dynamically slice through a phantom patient’s 3D prostate volume to provide real-time continuous TRUS views. Transrectal ultrasound scans during prostate biopsy clinics were recorded. These cases form the database for the images viewed by the trainee on the simulator. Prostate phantom molds were designed to accurately replicate the haptic environment during a transrectal ultrasound guided biopsy, in which the user is looking at the ultrasound monitor whilst performing the biopsy. Each prostate was virtually embedded in a block of agar, which provides an access surface similar to the rectal wall. The entire mold was fixed in a box with a circular port access hole intended to mimic the anus. A content validity questionnaire (using Likert items) was administered to 11 high volume TRUS doctors to assess the simulator. RESULTS: Data from 50 patients attending for prostatic biopsy were successfully acquired, segmented and integrated into the VR TRUS simulator. Two prostate molds were successfully constructed and integrated into a box with an agar rectum. The completed VR TRUS simulator therefore uses real patient images, and is able to provide simulation for 50 cases, with a haptic interface that uses a standard TRUS probe and biopsy needle. All assessors (100%) found the simulation accurate, the interface easy to use, and felt that the simulator would be useful for training residents; 91% rated the range of motion as realistic; and 64% regarded the haptics as lifelike. CONCLUSIONS: A virtual reality TRUS simulator has successfully been created, with promising content validity. Further face and transfer validity studies are planned in order to develop this technology further.
793
Source of Funding: Canadian Institutes of Health Research (CIHR) and Prostate Cancer Research Foundation of Canada (PCRFC)
Female Urology and Pelvic Reconstruction Video Session 8 Wednesday, April 29, 2009
1:00 pm - 3:00 pm
V2187 URETHROVAGINAL FISTULA REPAIR WITH MARTIUS FLAP Ariana L Smith*, Ja-Hong Kim, Chad Baxter, Andrea Staack, Larissa Rodriguez, Shlomo Raz, Los Angeles, CA Introduction and Objective: Urethrovaginal fistulas (UVF) are rare complications of periurethral surgery. METHODS: Retrospective analysis of the last 4 years of cases by one surgeon (SR) identified 11 UVF repairs. Chart review revealed presenting symptoms, prior surgery and subsequent procedures performed. Technique: Indigo carmine is injected through the urethral catheter to visualize the fistula and a 10F catheter is inserted through the opening. An inverted U incision, incorporating the fistula tract, is made on the anterior vaginal wall. Dissection of the U flap proximally allows advancement over the fistula after repair. A horizontal incision is made in the periurethral fascia and flaps are dissected. The fistula tract is not excised, it is closed vertically. A second layer, taking deep bites of urothelium, produces a watertight closure. The periurethral fascia is closed horizontally. A Martius flap is used to cover the repair. The U flap is advanced for closure. RESULTS: 11 UVF repairs were performed in 10 patients over 4 years. In 100% of patients we identified either: multiple anti-incontinence procedures {n=5}, urethral diverticulectomy (UD) {n=3} or urethrolysis after obstructing sling {n=2} as the risk factor for UVF. In the UD group, fistula developed after simultaneous obstructing sling in 1, repeat UD in 1, and after initial repair in 1. All 10 patients were referred from outside institutions and 6 had undergone between 1 and 4 attempted UVF repairs prior to presentation. In our series there was 1 failure in a patient with obstructed voiding; concurrent urethrolysis was performed with the second successful repair. 5 patients underwent subsequent antiincontinence procedures. CONCLUSIONS: UVF is the result of iatrogenic injury to the urethra most commonly during repeat sling placement, UD or urethrolysis. Proper urethral anatomy must be understood to prevent this complication. Due to risk of recurrent fistula in the setting of obstruction, we recommend simultaneous urethrolysis when obstructive voiding is suspected and we do not recommend simultaneous anti-incontinence surgery. In addition, it can be difficult to determine preoperatively how much incontinence is due to stress and how much is due to the fistula; 50% of our patients did not require subsequent surgery for incontinence. We support the use of Martius flaps since the urethra is often attenuated from prior surgeries and lacks redundancy to incorporate into the closure. We believe that the technique used to repair this injury determines the success; we report a 90% primary success rate in our series using this technique. Source of Funding: None
V2188 LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA João L Amaro, Paulo R Kawano, Oscar E H Fugita*, Hamilto A Yamamoto, Aparecido D Agostinho, Rodrigo Guerra, Botucatu, Brazil INTRODUCTION AND OBJECTIVE: The primary etiology of vesicovaginal fistula (VVF) in developed countries is surgical trauma associate with gynecologic procedure. Abdominal hysterectomy has been shown to be the most common cause, with VVF occurring
THE JOURNAL OF UROLOGY®
residents obtaining “exceeds expectations” in 50% of evaluations in all domains of the 360 degree evaluations while junior residents score lower with 35% “exceeds expectations” on the initial labs. These evaluations improve with later labs to 67% and 46 % respectively (p < 0.017). Faculty score evaluations improve with subsequent labs as well with senior residents scoring “performed independently” in 73% of steps and junior residents scoring 53% on initial labs and improving to 92% and 67% on later labs respectively (p < 0.049). The initial times to complete a laparoscopic nephrectomy for senior and chief residents average 188 minutes and more junior residents 288 minutes. These times improved significantly to 125 minutes and 133 minutes on later labs respectively. All components of the operation take longer without a specific improvement in one section of the operation. CONCLUSIONS: Our data indicate that this intergraded simulation curriculum promotes significant resident skills progression. By incorporating the whole faculty and staff into the evaluation process we find that this comprehensive approach affords multiple opportunities for resident evaluation in all 6 domains of the core competencies. This also allows quantifiable and documentable progression of the trainee along the learning curve in a safe environment. Additionally, training residents with simulation may allow us to better understand how surgeons acquire skills and help us to more effectively train the next generation of surgeons. Source of Funding: Department of Clinical Investigations, Madigan Army Medical Center
2183 GENITOURINARY SKILLS TRAINING CURRICULUM FOR MEDICAL STUDENTS Adam G Kaplan*, Surendra B Kolla, Aldrin J R Gamboa, Michael L Louie, Ross M Moskowitz, Rosanne T Santos, Jennifer M Gan, Ralph V Clayman, Elspeth M McDougall, Orange, CA INTRODUCTION AND OBJECTIVE: Basic urology training in medical school is considered important for many medical and surgical disciplines. We developed an intensive genitourinary (GU) skills training curriculum for medical students beginning their clinical clerkship training years and evaluated the initial experience with this program. METHODS: A total of 94 third year medical students at UC, Irvine, participated in a 5.5 hour-long GU exam skills training program, the month preceding the commencement of their clinical clerkship training. The teaching course included 1.5 hours didactic lecture and video presentation with questions and answers, followed by four 1-hour stations including: male Foley catheter (MFC) placement, female Foley catheter (FFC) placement, testicular (TE) and digital rectal (DRE) examination training with a standardized patient (SP), virtual reality cystourethroscopy and a urologist lead tutorial of abnormal GU findings. The students completed a pre- and post-course questionnaire asking them to rate their comfort with each of the GU skills, and evaluate the effectiveness of the training curriculum. RESULTS: All 94 medical students completed the GU skills training course. Prior to the course < 10% of students reported comfort for the various GU skill tasks, including TE (5%), DRE (10%), and Foley catheterization (2%). After the course, the comfort level of the students improved significantly in all parameters, including DRE (100%), TE and Foley catheterization (98%) (p < 0.001). The students rated in order of most to least useful training: 1) TE and DRE teaching with SP, 2) MFC and FFC training, 3) didactic lecture, 4) tutorial of abnormal GU exam findings, and 5) VR cystourethroscopy. CONCLUSIONS: This intensive skills training curriculum significantly improved medical student comfort with, and knowledge of, the basic GU skills of testicular and rectal exam, and male and female Foley catheter placement Source of Funding: None
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
2184 VALIDATION OF THE DV-TRAINER ®, A NOVEL VIRTUAL REALITY SIMULATOR FOR ROBOTIC SURGERY Patrick A Kenney*, Matthew F Wszolek, Justin J Gould, John A Libertino, Alireza Moinzadeh, Burlington, MA INTRODUCTION AND OBJECTIVE: Simulation is an established component of laparoscopic training, and may prove to be a valuable tool in robotic surgery. The dv-Trainer ® (Mimic Technologies Inc, Seattle, WA) is a virtual reality simulator for the da Vinci ® Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) that is in beta development. We sought to assess the face, content and construct validity of the dv-Trainer. METHODS: Medical students, residents, and attending surgeons were enrolled in a prospective, IRB-approved study. All data was deidentified at study outset. Subjects were prospectively categorized as either novice (<10 robotic cases) or expert (q30 robotic cases). Following a standardized introduction and 10 minutes of practice time, each subject completed two endowrist modules and two needle driving modules in sequence. Performance was recorded using a built-in scoring algorithm. Each subject completed a questionnaire after finishing the modules. RESULTS: The novice group (n=19) was composed of 16% students, 58% residents, and 26% attending surgeons. Novices had operated an average of 1.3 ± 2.2 hours at the da Vinci console prior to using the simulator. On average, experts (n=7) had performed 140 ± 116 robotic cases. Expert robotic surgeons outperformed novices on the simulator in nearly all variables in a pooled data set (Table 1). All novices ranked the simulator as a realistic practice format. All experts ranked the simulator as useful for training residents and attendings, and agreed with incorporating the simulator into a residency curriculum. The haptic feedback, virtual reality and instrumentation all achieved acceptability. The needle driving modules did not exceed the acceptability threshold. CONCLUSIONS: The dv-Trainer has face, content and construct validity as a virtual reality simulator for the da Vinci Surgical System. Needle driving modules will need to be refined. Studies are underway to assess concurrent and predictive criterion validity. The dv-Trainer may become a valuable training simulator in robotic surgery. Table 1. Pooled data (Pick & Place, Pegboard, Dots & Numbers, Suture Sponge) Novice
Expert
P value
Total task time (sec)
269 ± 196
139 ± 56
<0.01
Total motion (mm)
2635 ± 1682
1674 ± 712
<0.01
Instrument Collisions
4.9 ± 7.8
0.9 ± 1.3
<0.01
Time out of view (sec)
21 ± 63
2±5
0.02
Time out of center (sec)
87 ± 104
32 ± 36
<0.01 0.07
Max Force
6.02 ± 13.52
2.71 ± 5.34
Successful targets
10.8 ± 4.7
12.6 ± 3.8
0.04
Unattempted targets
0.3 ± 3.5
0±0
<0.01
Dropped targets
0.3 ± 0.6
0±0
0.02
Source of Funding: None
2185 FACE, CONTENT, AND CONSTRUCT VALIDITY OF THE IDEAL ADULT URETEROSCOPY TRAINER: A HIGH-FIDELITY URETEROSCOPY AND RENOSCOPY SIMULATOR Michael A White*, Alex P DeHaan, Doyle D Stephens, Richard J Kahnoski, Grand Rapids, MI INTRODUCTION AND OBJECTIVE: Surgical simulation technology may efficiently train and accurately assess the acquisition of many skills. Surgical simulators often lack realism and can be very expensive, ranging in price from $3000 to more than $50,000. We assessed the face, content, and construct validity of a newly developed, anatomically accurate, and reasonably priced high-fidelity ureteroscopy and renoscopy trainer.
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Wednesday, April 29, 2009
METHODS: 46 participants, including attending urologists, urology residents, medical students, and industry representatives assessed the face and content validity of the simulator using a standard questionnaire. In addition 10 experienced ureteroscopists (>30 procedures/year) and 10 novice ureteroscopists (0 procedures/year) were assessed on their ability to perform flexible ureteroscopy, renoscopy, and intrarenal basket extraction of a lower pole stone using the IDEAL adult ureteroscopy trainer. Subject performance was assessed by an experienced ureteroscopist using a checklist, global rating scale, and time to completion of task. RESULTS: Of the participants 100% rated the trainer as a realistic training format and easy to use. 100% felt that this was a good training tool and 98% saw this also as a good practice format. 96% would recommend this to urology trainees and 100% felt this should be used in residency programs. 96% would use this or would have used this in their residency. Only 37.5% of the experienced ureteroscopists compared to 100% of the novice ureteroscopists would use this to practice. 9% of participants foresaw a problem with the use of the trainer. Experienced ureteroscopists scored significantly higher on their global rating scale (33.1± 1.3 vs. 15.0± 2.7, p<0.0001), checklist (4.1±1.0 vs. 2.4±1.1, p=0.004) and required less time to complete the task (141.2±40.1 sec. vs. 447.2±301.7 sec., p=0.01) than novice ureteroscopists on the trainer. CONCLUSIONS: The IDEAL adult ureteroscopy trainer has face, content, and construct validity as a high-fidelity ureteroscopy and renoscopy trainer. Source of Funding: None
2186 VIRTUAL REALITY TRANSRECTAL ULTRASOUND GUIDED PROSTATIC BIOPSY SIMULATOR Venu Chalasani*, Derek W Cool, Shi Sherebrin, Aaron Fenster, Joseph L Chin, Jonathan I Izawa, London, ON, Canada INTRODUCTION AND OBJECTIVE: Numerous transrectal ultrasound guided prostatic biopsy (TRUS) schemes have been described in the literature since the original sextant biopsy plan was implemented. We present the design and content validity testing of a new virtual reality (VR) simulator for TRUS, which allows training doctors to perform multiple different biopsy schemes in either axial or sagittal views. METHODS: This system design uses a regular “end-firing” TRUS probe, which is standard throughout North America. The TRUS probe is held and manipulated directly by the trainee. Movements of the probe are tracked with a micro-magnetic sensor, to dynamically slice through a phantom patient’s 3D prostate volume to provide real-time continuous TRUS views. Transrectal ultrasound scans during prostate biopsy clinics were recorded. These cases form the database for the images viewed by the trainee on the simulator. Prostate phantom molds were designed to accurately replicate the haptic environment during a transrectal ultrasound guided biopsy, in which the user is looking at the ultrasound monitor whilst performing the biopsy. Each prostate was virtually embedded in a block of agar, which provides an access surface similar to the rectal wall. The entire mold was fixed in a box with a circular port access hole intended to mimic the anus. A content validity questionnaire (using Likert items) was administered to 11 high volume TRUS doctors to assess the simulator. RESULTS: Data from 50 patients attending for prostatic biopsy were successfully acquired, segmented and integrated into the VR TRUS simulator. Two prostate molds were successfully constructed and integrated into a box with an agar rectum. The completed VR TRUS simulator therefore uses real patient images, and is able to provide simulation for 50 cases, with a haptic interface that uses a standard TRUS probe and biopsy needle. All assessors (100%) found the simulation accurate, the interface easy to use, and felt that the simulator would be useful for training residents; 91% rated the range of motion as realistic; and 64% regarded the haptics as lifelike. CONCLUSIONS: A virtual reality TRUS simulator has successfully been created, with promising content validity. Further face and transfer validity studies are planned in order to develop this technology further.
793
Source of Funding: Canadian Institutes of Health Research (CIHR) and Prostate Cancer Research Foundation of Canada (PCRFC)
Female Urology and Pelvic Reconstruction Video Session 8 Wednesday, April 29, 2009
1:00 pm - 3:00 pm
V2187 URETHROVAGINAL FISTULA REPAIR WITH MARTIUS FLAP Ariana L Smith*, Ja-Hong Kim, Chad Baxter, Andrea Staack, Larissa Rodriguez, Shlomo Raz, Los Angeles, CA Introduction and Objective: Urethrovaginal fistulas (UVF) are rare complications of periurethral surgery. METHODS: Retrospective analysis of the last 4 years of cases by one surgeon (SR) identified 11 UVF repairs. Chart review revealed presenting symptoms, prior surgery and subsequent procedures performed. Technique: Indigo carmine is injected through the urethral catheter to visualize the fistula and a 10F catheter is inserted through the opening. An inverted U incision, incorporating the fistula tract, is made on the anterior vaginal wall. Dissection of the U flap proximally allows advancement over the fistula after repair. A horizontal incision is made in the periurethral fascia and flaps are dissected. The fistula tract is not excised, it is closed vertically. A second layer, taking deep bites of urothelium, produces a watertight closure. The periurethral fascia is closed horizontally. A Martius flap is used to cover the repair. The U flap is advanced for closure. RESULTS: 11 UVF repairs were performed in 10 patients over 4 years. In 100% of patients we identified either: multiple anti-incontinence procedures {n=5}, urethral diverticulectomy (UD) {n=3} or urethrolysis after obstructing sling {n=2} as the risk factor for UVF. In the UD group, fistula developed after simultaneous obstructing sling in 1, repeat UD in 1, and after initial repair in 1. All 10 patients were referred from outside institutions and 6 had undergone between 1 and 4 attempted UVF repairs prior to presentation. In our series there was 1 failure in a patient with obstructed voiding; concurrent urethrolysis was performed with the second successful repair. 5 patients underwent subsequent antiincontinence procedures. CONCLUSIONS: UVF is the result of iatrogenic injury to the urethra most commonly during repeat sling placement, UD or urethrolysis. Proper urethral anatomy must be understood to prevent this complication. Due to risk of recurrent fistula in the setting of obstruction, we recommend simultaneous urethrolysis when obstructive voiding is suspected and we do not recommend simultaneous anti-incontinence surgery. In addition, it can be difficult to determine preoperatively how much incontinence is due to stress and how much is due to the fistula; 50% of our patients did not require subsequent surgery for incontinence. We support the use of Martius flaps since the urethra is often attenuated from prior surgeries and lacks redundancy to incorporate into the closure. We believe that the technique used to repair this injury determines the success; we report a 90% primary success rate in our series using this technique. Source of Funding: None
V2188 LAPAROSCOPIC REPAIR OF VESICOVAGINAL FISTULA João L Amaro, Paulo R Kawano, Oscar E H Fugita*, Hamilto A Yamamoto, Aparecido D Agostinho, Rodrigo Guerra, Botucatu, Brazil INTRODUCTION AND OBJECTIVE: The primary etiology of vesicovaginal fistula (VVF) in developed countries is surgical trauma associate with gynecologic procedure. Abdominal hysterectomy has been shown to be the most common cause, with VVF occurring