- Email: [email protected]
HYPOTHERMIC ROBOT-ASSISTED RADICAL PROSTATECTOMY: IMPACT ON RECOVERY OF CONTINENCE
314
THE JOURNAL OF UROLOGY®
nonvoiding, usually have quiet pelvic floor and occasionally findings suggestive of abdominal voiding or straining; and Type 4. PBND prolonged EMG lag-time (> 6 seconds) and a right shifted, depressed uroflow curve with quite pelvic floor during voiding. Patients with DV received biofeedback +/- anticholinergics, LOAB and NLOAB received timed voiding and anticholinergics, UB received timed voiding, and PBND received alpha blockers. RESULTS: The breakdown by VD type, flow/EMG findings and results of therapy are listed in the table below. A history of UTI, usually afebrile, was present in 20%. Lag time appropriately increased in those with LOAB and decreased to normal range in those with PBND. CONCLUSIONS: Flow/EMG is useful in triaging patients into specific VD types for more efficient treatment. Without lag time, PBND could not have been diagnosed in 5 patients and OAB would not have been confirmed in 37. Also, without simultaneous EMG, 6 of 10 DV patients without staccato voiding would not have been diagnosed.
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
881 DYSFUNCTIONAL VOIDING: IS IT A SPECTRUM OF ABNORMALITIES WITH CORRESPONDING URODYNAMIC FINDINGS OR ONE DISTINCT DISEASE? Carlo C Passerotti*, Sao Paulo, Brazil; Hiep T Nguyen, Boston, MA; Miguel Srougi, Homero Bruschini, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Children with no obvious anatomic or neurological abnormalities who present with various urinary symptoms such as urgency, frequency, incontinence or urinary tract infection (UTI) are often diagnosed as having dysfunctional voiding. However, it is likely that dysfunction voiding represents a spectrum of abnormalities with different etiologies. The purpose of this study is to correlate the clinical presentation of children diagnosed with dysfunctional voiding with specific urodynamic findings, with the goal of defining the different etiologies of dysfunction voiding. METHODS: 84 children (mean age of 8.2 years, range 3 - 17) with urinary symptoms suggestive of dysfunctional voiding underwent clinical assessment and urodynamic evaluation. All the patients had a normal urogram, voiding cystogram and neurological evaluation. Urodynamic study including urethral pressure profile (UPP) was performed using a 7Fr, 4-channel membrane catheter in all patients. Urodynamic findings were then correlated with clinical presentation. Statistical analysis was performed using 95% confidence interval. RESULTS: Urodynamic Findings compared to linical Presentation Detrusor Low Urethral Overactive Sphincter Sphincter Compliance Normal Stenosis Bladder Overactivity Dyssynergia bladder
Source of Funding: None
880 DYSFUNCTIONAL MICTURITION AS A CAUSE OF IDIOPATHIC UREHTRAL STRICTURES Jordan Gitlin, Carolyn Chang, Edward Reda, Israel Franco*, Tarrytown, NY Introduction and Objective: The etiology of idiopathic urethral strictures remains a mystery with a paucity of information presented in the modern literature to explain the cause. As with bulbar urethritis (BU) numerous causes have been proposed but none has been able to be confirmed as the primary one. Our work on BU has led us to believe that it is due to abnormal flow dynamics from dyssynergic sphincter activity. It is our hypothesis that this same phenomena if present for an extended period of time and of sufficient force can lead to progressive scarring of the urethra and stricture formation. Methods: A computer search was performed of our records of all patients that underwent an internal urethrotomy or perineal urethroplasty over a 5 year period. 25 patients were identified that had either of these procedures and had been classified by the surgeon as idiopathic based on the history of no previous trauma or instrumentation. Results: A review of the records revealed the average age of the pts as 18 yo (median = 16 yo). No patient gave a history of trauma or instrumentation. There was a long term history of the following symptoms predating the presentation for evaluation; dysuria (21/25), hx of a slow stream (23/25) , bulbar urethritis (17/25) and hx of blood spotting (18/25). 20 pts had IU and 5 had perineal urethroplasties with end to end anastomosis. Post operatively 12/25 pts were treated with alpha blockers for bladder neck dysfunction. In all patients who had dysuria treatment of their symptoms with pelvic floor relaxation or alpha blockers resulted in complete rsolution of symptoms. Conclusions: Our findings in this review along with the fact that there is a markedly increased rate of urethral stricture formation in boys with BU especially if instrumented has lead us to conclude that most idiopathic urethral strictures in adolescents and young adults maybe due to dyssynergic voiding over a long period of time which leads to repetitive irritation of the urethral mucosa and the subsequent indolent development of urethral strictures. Source of Funding: None
Isolated 0 0 1 (50%) Enuresis Enuresis + Daytime 15 (30.6%) 3 (6.1%) 19 (38.8) Symptoms Urinary 2 (66.7%) 0 0 incontinence Non-febrile 2 (22.2%) 0 3 (33.3%) UTI Febrile UTI Total
5 (23.8%)
0
0 1 (2.0%) 0 0
11 (52.4%)
1 (4.8%)
24 (28.6%) 3 (6.1%) 34 (40.5%)
2 (2.4%)
0
1 (50%) 2 (2.4%)
8 (16.3%) 3 (6.1%) 1 (33.3%) 1 2 (22.2%) (22.2%) 2 1 (4.7%) (14.3%) 10 11 (13.1%) (11.9%) 0
Total
49 (58.3%) 3 (3.6%) 9 (10.7%) 21 (25.0%) 84 (100%)
Enuresis with daytime symptoms was the most common mode of presentation and was associated more commonly with urodynamic findings of detrusor sphincter dyssynergia, overactive bladder and low compliance bladder. Interestingly, children with dysfunctional voiding who presented with UTI had similar urodynamic findings. There was no correlation between UUP findings and clinical presentation or urodynamic findings. Similarly, there was no correlation between urodynamic findings and bowel function. CONCLUSIONS: Patients with dysfunctional voiding may have different clinical presentation but seem to demonstrate similar urodynamic findings. This suggest that dysfunctional voiding may be a discrete problem rather than a spectrum of diseases. Source of Funding: None
Technology & Instruments: Robotics/Laparoscopy (II) Podium 23 Monday, April 27, 2009
10:30 am - 12:30 pm
882 HYPOTHERMIC ROBOT-ASSISTED RADICAL PROSTATECTOMY: IMPACT ON RECOVERY OF CONTINENCE Thomas E Ahlering*, David S Finley, Orange, CA; Kathryn E Osann, Douglas K Skarecky, Irvine, CA INTRODUCTION AND OBJECTIVE: Surgical excision of the prostate during radical prostatectomy involves tissue dissection and the use of thermal energy which likely causes significant inflammatory damage to surrounding neuromuscular tissues (i.e. bladder, urethra,
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
cavernous nerves) which may contribute to urinary incontinence. We report the use of local hypothermia during Robot-assisted Laparoscopic Prostatectomy (hRLP) to attenuate inflammation. METHODS: Regional pelvic cooling was achieved utilizing cold intracorporeal irrigation and an endo-rectal cooling balloon (ECB, Figure 1.) cycled with 4oC saline. A prospective group of 81 men undergoing nerve-sparing hRLP (case #668-748) was compared to a standard RLP control group (case #1-667). Intracorporeal rectal and neurovascular bundle temperatures were measured using thermocouples. Continence was defined as the use of zero urinary pads. Kaplan-Meier analysis of time to zero pads and multivariate Cox Proportional Hazards Regression was used to examine group differences in continence after adjusting for baseline characteristics, learning curve and incorporation of the Rocco technique.
315
endopyelotomy failures, 1 laparoscopic and 8 open repair failures. RESULTS: Data is presented in table 1. There were no statistically significant differences in any parameters between pts undergoing a 1° or 2° repair, at a mean f/up of 20.1mos. Overall, 96.9% of pts showed improved T½ after repair w/ a mean decrease of 32.5min; 72.7% showed improved renal function w/ a mean increase of 4.5% in the affected renal unit. When examining changes in GFR, 86.2% showed either improvement or no change in GFR after surgery, w/ 51.7% showing a rise in GFR by a mean of 15.1 ml/min. Of the 4 pts w/ renal insufficiency (defined as GFR<60), 3 improved the GFR above 65 after surgery. There were 8 complications; more common was ileus & blood transfusion. With regards to the 4 pts demonstrating obstruction post-op, 2 underwent successful retrograde endopyelotomy; 2 underwent temporary stent placement for blood clot obx of the renal pelvis. CONCLUSIONS: RALDP is an efficacious and viable option for either 1° or 2° repair of UPJO w/ excellent outcomes, high success rates, and low incidence of complications. Pre-Operative, Operative and Post-Operative Outcomes of RALDP OVERALL PRIMARY SECONDARY Number of Patients (N) 168 147 21
RESULTS: 81 patients underwent hRLP; 5 were excluded (2 prior radiation,3 cooling failures). The median temperature achieved was 25.5oC (ECB+irrigation, range:19.4-34.0oC). 1, 2 and 3-month hRLP zero pad rates were 38%, 64% and 88% vs 31%, 49% and 66% for the controls (p=0.007). Return to continence was significantly faster for hRLP vs. controls: median time to zero pad use was 41 days (range:0110d) for hRLP (n=76) vs. 60days (range:1-720) for controls [n=591/665 (89%)] p=0.0066 (log-rank test). Multivariate analysis adjusting for AUA symptom score, nerve sparing surgery, learning curve, IIEF-5, age, and prostate weight, demonstrated a significantly faster return to continence (HR=1.50, 95%CI: 1.06-2.03). CONCLUSIONS: Local hypothermia induced by transrectal and intracorporeal cooling resulted in a statistically significant improvement in early post-operative zero-pad continence rates. Source of Funding: None
Mean Age (years)
37.6
37.8
36.0
Sex (F/M)
94/74
82/65
12/9
Side (R/L)
96/72
88/59
8/13
Mean OR Time (Minutes) Mean Estimated Blood Loss (ml) (EBL) Mean Hospital Length of Stay (days) (LOS) Intrinsic Etiology
134.87
125.95
190.4
48.67
42.92
86.2
1.48
1.45
1.7
Crossing Vessel Etiology Symptom Improvement T 1/2 Improvement Diuretic Renal Function Improvement GFR Improvement
93/168 (55.4%) 84/147 (57%)
9/21 (43%)
75/168 (44.6%) 63/147 (43%) 12/21 (57%) 138/143 159/164(96.9%) 21/21 (100%) (96.5%) 96.9% 96.5% 100% 72.7%
73.3%
67%
51.7%
48%
67%
Complications
8/168
6/147
2/21
Blood Transfusion
3
2
1
Ileus
4
3
1
Post-OP UTI
1
1
0
Need for Second Procedure
4
3
1
Source of Funding: None
883 ROBOTIC ASSISTED LAPAROSCOPIC DISMEMBERED PYELOPLASTY (RALDP) FOR PRIMARY AND SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION: A MULTIINSTITUTIONAL EXPERIENCE Manoj B Patel*, Celebration, FL; Ravi Munver, Hackensack, NJ; Jorge E Bracho, II, Charles R Moore, Miami, FL; Sanket Chauhan, Kenneth J Palmer, Geoffery D Coughlin, Celebration, FL; Vincent G Bird, Raymond J Leveilee, Miami, FL; Vipul R Patel, Celebration, FL INTRODUCTION AND OBJECTIVE: Historically, the standard treatment for ureteropelvic junction obstruction (UPJO) has been open pyeloplasty but over the past 15 years, the laparoscopic approach has shown substantial efficacy, challenging this standard. The introduction of robotic assistance into laparoscopy has not only enabled more surgeons to attempt the laparoscopic approach to pyeloplasty, but also to perform more difficult cases, of previously failed surgical repairs. Herein, we report, a multi-institutional experience w/ RALDP for primary (1°) & secondary (2°) repair of UPJO. METHODS: Between June 2002 and October 2008, from 3 institutions performing a high volume of robotic cases, 168 pts undergoing RALDP w/ stenting for UPJO were respectively reviewed. All pts underwent a diuretic renal scan & the glomerular filtration rate (GFR (ml/min)) was calculated pre- & post-surgery. Various endpoints were examined to compare outcomes between 1° & 2° repair. Of the 168 pts, 21 were in the 2° repair group; of which, 57% had a crossing vessel etiology, w/ 9 being initially treated w/ endopyelotomy. The 2° group consisted of 12
884 ROBOTIC-ASSISTED PELVIC FLOOR RECONSTRUCTION Sophia Drinis*, Daniel B Rukstalis, Danville, PA INTRODUCTION AND OBJECTIVE: Surgical options for stress urinary incontinence and pelvic floor prolapse are expanding. Transvaginal mid urethral slings and synthetic mesh kits are increasing in popularity. However, long-term data on safety and efficacy is lacking. Dyspareunia and erosion is a debilitating complication and perineal anatomy may preclude these approaches. The Burch colposuspension and sacral colpopexy enjoy long-term data demonstrating efficacy. Laparoscopy offers a minimally invasive alternative and robotic assistance may improve accuracy, visualization, suture placement and allows for additional reconstruction with synthetic grafts in a single procedure. We describe our initial experience with Robotic pelvic floor reconstruction (RPFR). METHODS: We retrospectively reviewed prospectively collected data from a de-identified quality improvement database on 27 consecutive women with stress urinary incontinence, urethral hypermobility and prolapse who underwent RPFR. A transperitoneal 4- 5 port configuration was used. Non-absorbable sutures affix periurethral tissue to Cooper’s ligament. Dissection extends from sacral promontory (SP) to perineal body (PB). A 25x3cm polypropylene mesh is secured to PB, posterior and apical vaginal wall, cervix and anterior spinous process of the SP. A 5x8cm mesh is placed within the vesicovaginal plane. Voiding trials
THE JOURNAL OF UROLOGY®
nonvoiding, usually have quiet pelvic floor and occasionally findings suggestive of abdominal voiding or straining; and Type 4. PBND prolonged EMG lag-time (> 6 seconds) and a right shifted, depressed uroflow curve with quite pelvic floor during voiding. Patients with DV received biofeedback +/- anticholinergics, LOAB and NLOAB received timed voiding and anticholinergics, UB received timed voiding, and PBND received alpha blockers. RESULTS: The breakdown by VD type, flow/EMG findings and results of therapy are listed in the table below. A history of UTI, usually afebrile, was present in 20%. Lag time appropriately increased in those with LOAB and decreased to normal range in those with PBND. CONCLUSIONS: Flow/EMG is useful in triaging patients into specific VD types for more efficient treatment. Without lag time, PBND could not have been diagnosed in 5 patients and OAB would not have been confirmed in 37. Also, without simultaneous EMG, 6 of 10 DV patients without staccato voiding would not have been diagnosed.
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
881 DYSFUNCTIONAL VOIDING: IS IT A SPECTRUM OF ABNORMALITIES WITH CORRESPONDING URODYNAMIC FINDINGS OR ONE DISTINCT DISEASE? Carlo C Passerotti*, Sao Paulo, Brazil; Hiep T Nguyen, Boston, MA; Miguel Srougi, Homero Bruschini, Sao Paulo, Brazil INTRODUCTION AND OBJECTIVE: Children with no obvious anatomic or neurological abnormalities who present with various urinary symptoms such as urgency, frequency, incontinence or urinary tract infection (UTI) are often diagnosed as having dysfunctional voiding. However, it is likely that dysfunction voiding represents a spectrum of abnormalities with different etiologies. The purpose of this study is to correlate the clinical presentation of children diagnosed with dysfunctional voiding with specific urodynamic findings, with the goal of defining the different etiologies of dysfunction voiding. METHODS: 84 children (mean age of 8.2 years, range 3 - 17) with urinary symptoms suggestive of dysfunctional voiding underwent clinical assessment and urodynamic evaluation. All the patients had a normal urogram, voiding cystogram and neurological evaluation. Urodynamic study including urethral pressure profile (UPP) was performed using a 7Fr, 4-channel membrane catheter in all patients. Urodynamic findings were then correlated with clinical presentation. Statistical analysis was performed using 95% confidence interval. RESULTS: Urodynamic Findings compared to linical Presentation Detrusor Low Urethral Overactive Sphincter Sphincter Compliance Normal Stenosis Bladder Overactivity Dyssynergia bladder
Source of Funding: None
880 DYSFUNCTIONAL MICTURITION AS A CAUSE OF IDIOPATHIC UREHTRAL STRICTURES Jordan Gitlin, Carolyn Chang, Edward Reda, Israel Franco*, Tarrytown, NY Introduction and Objective: The etiology of idiopathic urethral strictures remains a mystery with a paucity of information presented in the modern literature to explain the cause. As with bulbar urethritis (BU) numerous causes have been proposed but none has been able to be confirmed as the primary one. Our work on BU has led us to believe that it is due to abnormal flow dynamics from dyssynergic sphincter activity. It is our hypothesis that this same phenomena if present for an extended period of time and of sufficient force can lead to progressive scarring of the urethra and stricture formation. Methods: A computer search was performed of our records of all patients that underwent an internal urethrotomy or perineal urethroplasty over a 5 year period. 25 patients were identified that had either of these procedures and had been classified by the surgeon as idiopathic based on the history of no previous trauma or instrumentation. Results: A review of the records revealed the average age of the pts as 18 yo (median = 16 yo). No patient gave a history of trauma or instrumentation. There was a long term history of the following symptoms predating the presentation for evaluation; dysuria (21/25), hx of a slow stream (23/25) , bulbar urethritis (17/25) and hx of blood spotting (18/25). 20 pts had IU and 5 had perineal urethroplasties with end to end anastomosis. Post operatively 12/25 pts were treated with alpha blockers for bladder neck dysfunction. In all patients who had dysuria treatment of their symptoms with pelvic floor relaxation or alpha blockers resulted in complete rsolution of symptoms. Conclusions: Our findings in this review along with the fact that there is a markedly increased rate of urethral stricture formation in boys with BU especially if instrumented has lead us to conclude that most idiopathic urethral strictures in adolescents and young adults maybe due to dyssynergic voiding over a long period of time which leads to repetitive irritation of the urethral mucosa and the subsequent indolent development of urethral strictures. Source of Funding: None
Isolated 0 0 1 (50%) Enuresis Enuresis + Daytime 15 (30.6%) 3 (6.1%) 19 (38.8) Symptoms Urinary 2 (66.7%) 0 0 incontinence Non-febrile 2 (22.2%) 0 3 (33.3%) UTI Febrile UTI Total
5 (23.8%)
0
0 1 (2.0%) 0 0
11 (52.4%)
1 (4.8%)
24 (28.6%) 3 (6.1%) 34 (40.5%)
2 (2.4%)
0
1 (50%) 2 (2.4%)
8 (16.3%) 3 (6.1%) 1 (33.3%) 1 2 (22.2%) (22.2%) 2 1 (4.7%) (14.3%) 10 11 (13.1%) (11.9%) 0
Total
49 (58.3%) 3 (3.6%) 9 (10.7%) 21 (25.0%) 84 (100%)
Enuresis with daytime symptoms was the most common mode of presentation and was associated more commonly with urodynamic findings of detrusor sphincter dyssynergia, overactive bladder and low compliance bladder. Interestingly, children with dysfunctional voiding who presented with UTI had similar urodynamic findings. There was no correlation between UUP findings and clinical presentation or urodynamic findings. Similarly, there was no correlation between urodynamic findings and bowel function. CONCLUSIONS: Patients with dysfunctional voiding may have different clinical presentation but seem to demonstrate similar urodynamic findings. This suggest that dysfunctional voiding may be a discrete problem rather than a spectrum of diseases. Source of Funding: None
Technology & Instruments: Robotics/Laparoscopy (II) Podium 23 Monday, April 27, 2009
10:30 am - 12:30 pm
882 HYPOTHERMIC ROBOT-ASSISTED RADICAL PROSTATECTOMY: IMPACT ON RECOVERY OF CONTINENCE Thomas E Ahlering*, David S Finley, Orange, CA; Kathryn E Osann, Douglas K Skarecky, Irvine, CA INTRODUCTION AND OBJECTIVE: Surgical excision of the prostate during radical prostatectomy involves tissue dissection and the use of thermal energy which likely causes significant inflammatory damage to surrounding neuromuscular tissues (i.e. bladder, urethra,
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
cavernous nerves) which may contribute to urinary incontinence. We report the use of local hypothermia during Robot-assisted Laparoscopic Prostatectomy (hRLP) to attenuate inflammation. METHODS: Regional pelvic cooling was achieved utilizing cold intracorporeal irrigation and an endo-rectal cooling balloon (ECB, Figure 1.) cycled with 4oC saline. A prospective group of 81 men undergoing nerve-sparing hRLP (case #668-748) was compared to a standard RLP control group (case #1-667). Intracorporeal rectal and neurovascular bundle temperatures were measured using thermocouples. Continence was defined as the use of zero urinary pads. Kaplan-Meier analysis of time to zero pads and multivariate Cox Proportional Hazards Regression was used to examine group differences in continence after adjusting for baseline characteristics, learning curve and incorporation of the Rocco technique.
315
endopyelotomy failures, 1 laparoscopic and 8 open repair failures. RESULTS: Data is presented in table 1. There were no statistically significant differences in any parameters between pts undergoing a 1° or 2° repair, at a mean f/up of 20.1mos. Overall, 96.9% of pts showed improved T½ after repair w/ a mean decrease of 32.5min; 72.7% showed improved renal function w/ a mean increase of 4.5% in the affected renal unit. When examining changes in GFR, 86.2% showed either improvement or no change in GFR after surgery, w/ 51.7% showing a rise in GFR by a mean of 15.1 ml/min. Of the 4 pts w/ renal insufficiency (defined as GFR<60), 3 improved the GFR above 65 after surgery. There were 8 complications; more common was ileus & blood transfusion. With regards to the 4 pts demonstrating obstruction post-op, 2 underwent successful retrograde endopyelotomy; 2 underwent temporary stent placement for blood clot obx of the renal pelvis. CONCLUSIONS: RALDP is an efficacious and viable option for either 1° or 2° repair of UPJO w/ excellent outcomes, high success rates, and low incidence of complications. Pre-Operative, Operative and Post-Operative Outcomes of RALDP OVERALL PRIMARY SECONDARY Number of Patients (N) 168 147 21
RESULTS: 81 patients underwent hRLP; 5 were excluded (2 prior radiation,3 cooling failures). The median temperature achieved was 25.5oC (ECB+irrigation, range:19.4-34.0oC). 1, 2 and 3-month hRLP zero pad rates were 38%, 64% and 88% vs 31%, 49% and 66% for the controls (p=0.007). Return to continence was significantly faster for hRLP vs. controls: median time to zero pad use was 41 days (range:0110d) for hRLP (n=76) vs. 60days (range:1-720) for controls [n=591/665 (89%)] p=0.0066 (log-rank test). Multivariate analysis adjusting for AUA symptom score, nerve sparing surgery, learning curve, IIEF-5, age, and prostate weight, demonstrated a significantly faster return to continence (HR=1.50, 95%CI: 1.06-2.03). CONCLUSIONS: Local hypothermia induced by transrectal and intracorporeal cooling resulted in a statistically significant improvement in early post-operative zero-pad continence rates. Source of Funding: None
Mean Age (years)
37.6
37.8
36.0
Sex (F/M)
94/74
82/65
12/9
Side (R/L)
96/72
88/59
8/13
Mean OR Time (Minutes) Mean Estimated Blood Loss (ml) (EBL) Mean Hospital Length of Stay (days) (LOS) Intrinsic Etiology
134.87
125.95
190.4
48.67
42.92
86.2
1.48
1.45
1.7
Crossing Vessel Etiology Symptom Improvement T 1/2 Improvement Diuretic Renal Function Improvement GFR Improvement
93/168 (55.4%) 84/147 (57%)
9/21 (43%)
75/168 (44.6%) 63/147 (43%) 12/21 (57%) 138/143 159/164(96.9%) 21/21 (100%) (96.5%) 96.9% 96.5% 100% 72.7%
73.3%
67%
51.7%
48%
67%
Complications
8/168
6/147
2/21
Blood Transfusion
3
2
1
Ileus
4
3
1
Post-OP UTI
1
1
0
Need for Second Procedure
4
3
1
Source of Funding: None
883 ROBOTIC ASSISTED LAPAROSCOPIC DISMEMBERED PYELOPLASTY (RALDP) FOR PRIMARY AND SECONDARY URETEROPELVIC JUNCTION OBSTRUCTION: A MULTIINSTITUTIONAL EXPERIENCE Manoj B Patel*, Celebration, FL; Ravi Munver, Hackensack, NJ; Jorge E Bracho, II, Charles R Moore, Miami, FL; Sanket Chauhan, Kenneth J Palmer, Geoffery D Coughlin, Celebration, FL; Vincent G Bird, Raymond J Leveilee, Miami, FL; Vipul R Patel, Celebration, FL INTRODUCTION AND OBJECTIVE: Historically, the standard treatment for ureteropelvic junction obstruction (UPJO) has been open pyeloplasty but over the past 15 years, the laparoscopic approach has shown substantial efficacy, challenging this standard. The introduction of robotic assistance into laparoscopy has not only enabled more surgeons to attempt the laparoscopic approach to pyeloplasty, but also to perform more difficult cases, of previously failed surgical repairs. Herein, we report, a multi-institutional experience w/ RALDP for primary (1°) & secondary (2°) repair of UPJO. METHODS: Between June 2002 and October 2008, from 3 institutions performing a high volume of robotic cases, 168 pts undergoing RALDP w/ stenting for UPJO were respectively reviewed. All pts underwent a diuretic renal scan & the glomerular filtration rate (GFR (ml/min)) was calculated pre- & post-surgery. Various endpoints were examined to compare outcomes between 1° & 2° repair. Of the 168 pts, 21 were in the 2° repair group; of which, 57% had a crossing vessel etiology, w/ 9 being initially treated w/ endopyelotomy. The 2° group consisted of 12
884 ROBOTIC-ASSISTED PELVIC FLOOR RECONSTRUCTION Sophia Drinis*, Daniel B Rukstalis, Danville, PA INTRODUCTION AND OBJECTIVE: Surgical options for stress urinary incontinence and pelvic floor prolapse are expanding. Transvaginal mid urethral slings and synthetic mesh kits are increasing in popularity. However, long-term data on safety and efficacy is lacking. Dyspareunia and erosion is a debilitating complication and perineal anatomy may preclude these approaches. The Burch colposuspension and sacral colpopexy enjoy long-term data demonstrating efficacy. Laparoscopy offers a minimally invasive alternative and robotic assistance may improve accuracy, visualization, suture placement and allows for additional reconstruction with synthetic grafts in a single procedure. We describe our initial experience with Robotic pelvic floor reconstruction (RPFR). METHODS: We retrospectively reviewed prospectively collected data from a de-identified quality improvement database on 27 consecutive women with stress urinary incontinence, urethral hypermobility and prolapse who underwent RPFR. A transperitoneal 4- 5 port configuration was used. Non-absorbable sutures affix periurethral tissue to Cooper’s ligament. Dissection extends from sacral promontory (SP) to perineal body (PB). A 25x3cm polypropylene mesh is secured to PB, posterior and apical vaginal wall, cervix and anterior spinous process of the SP. A 5x8cm mesh is placed within the vesicovaginal plane. Voiding trials