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LESS (LAPARO ENDOSCOPIC SINGLE-SITE) ROBOTIC SURGERY
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
551
Reconstruction and Trauma Video Session 5 Tuesday, April 28, 2009
10:30 am - 12:30 pm
V1540 E-NOTES MANAGEMENT OF PROXIMAL URETERAL PATHOLOGY-ILEAL INTERPOSITION Andre Berger, Robert J Stein, Marcelo Miranda, Neil S Patel, Monish Aron*, David Canes, Sebastien Crouzet, Georges-Pascal Haber, Kazumi Kamoi, John C Kefer, Brian H Irwin, Ricardo Brandina, Gauarang Shah, Jihad H Kaouk, Inderbir S Gill, Mihir M Desai, Cleveland, OH
Source of Funding: None
1539 HYSTERECTOMY DOES NOT IMPROVE APICAL VAGINAL RECONSTRUCTION: MODERATE TERM DATA ANALYSIS FOLLOWING UTEROSACRAL APICAL RECONSTRUCTION WITH AND WITHOUT HYSTERECTOMY. Renuka Tyagi*, Lauri Romanzi, New York, NY INTRODUCTION AND OBJECTIVES: Hysterectomy in the surgical management of the apex in pelvic reconstruction historically was obligatory. This view has recently been challenged in early-term papers of uterine-sparing apical reconstruction techniques. We report on moderate-term surgical outcomes for a continuous series of patients with upto 8 years of follow up for apical prolapse recurrence. METHODS: A retrospective chart review of patients with apical vaginal reconstruction using uterosacral fixation with or without hysterectomy was performed. All surgeries were performed between August 1999 to June 2008 at a single institution by one of two fellowship trained urogynecologist/female urologists. The charts were reviewed for age, prolapse, parity, medical co-morbidities, surgical procedure and postoperative prolapse. Patients who underwent total vaginal hysterectomy (VH) with mid pelvic uterosacral fixation or uterosacral hysteropexy (USH)with bilateral uterosacral fixation of the vaginal cuff and/or uterus were included for analysis. The uterine-sparing uterosacral hysteropexy technique has been previously reported by the authors. RESULTS: 160 patients were identified with 158 charts available for review. 99 patients underwent total vaginal hysterectomy with uterosacral fixation, 59 patients had uterosacral hysteropexy. There was no significant difference in preoperative parameters. Postoperative survival analysis evaluated for apical recurrence. 2-year recurrence free survival was found to be 97.9% (97 of 99 patients) for VH. Similarly 2-year recurrence free survival was found to be 98.2% (57 of 58 patients) for USH. There was no statistical difference between the groups. With the definition of recurrence expanded to prolapse at any compartment, 2-year recurrence free survival of for VH was 91.6%, and 2-year recurrence free survival for USH was 78.5%.10 of the 13 prolapse recurrences (76.9%) were noted at the anterior vaginal compartment (cystocele). CONCLUSIONS: In our population, with moderate-term follow up we have not found removal of the uterus to be protective for recurrence at the vaginal apex following uterosacral ligment fixation during pelvic reconstruction. Similar to other vaginal reconstruction reports we find the anterior vaginal wall continues to be the primary site for recurrent prolapse. Source of Funding: None
INTRODUCTION AND OBJECTIVES: Proximal ureteral pathology can be one of the most complicated Urologic dilemmas and ileal ureteral replacement one of the most difficult reconstructive procedures performed. E-NOTES (Embryonic Natural Orifice Transumbilical Endoscopic Surgery) allows this procedure to be performed through an extremely small incision compared to its open or even laparoscopic counterpart. METHODS: The patient is a 72 year old man who has developed 2 ureteral strictures from chronic stone impaction. Other forms of ureteral reconstruction including reimplantation or ureteroureterostomy were not feasible due to stricture location and length. Ileal interposition was performed through a novel multi-channel, transumbilical, single port (R-port, Advanced Surgical Concepts) with 2 additional 2mm needle ports. Initially the ureter is identified and dissected distally to the area of obstruction. The bladder is then completely mobilized. The umbilical incision is enlarged slightly in order to deliver the bowel for extracorporeal ileal harvest. A stent is secured within an isolated ileal segment and bowel continuity is reestablished. The bowel contents are returned to the abdomen and E-NOTES technique is used to create a 2 layer ileovesical anastomosis with the ileal segment in an iso-peristaltic configuration. The proximal portion of the ileal segment is led through the sigmoid mesentery and anastomosed in 2 layers to the dilated ureter cranial to the site of obstruction. RESULTS: Operative time was 5 hours and hospital stay was 2.5 days. The patient did not require any postoperative narcotic analgesics. Our initial experience includes 2 patients who underwent E-NOTES ileal ureter with symptomatic and radiographic relief of obstruction in both cases. CONCLUSIONS: E-NOTES ileal interposition allows for an especially complex procedure to be performed through a remarkably small incision. Source of Funding: None
V1541 LESS (LAPARO ENDOSCOPIC SINGLE-SITE) ROBOTIC SURGERY Sebastien Crouzet*, Raj K Goel, Georges-Pascal Haber, Wesley M White, Kazumi Kamoi, Robert J Stein, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Single port laparoscopy has expanded over the last year although technical constraints still hinder its routine application. Herein, we present our video illustrating single port robotic surgery METHODS: Through a multi-channel single port and using 5 mm robotic trocars, single port robotic surgery was performed for various urological pathologies. Patients are positioned in lithotomy and flank position for pelvic and renal procedures, respectively. The da Vinci-S robotic surgical platform was utilized for all procedures. The fourth arm was available but not employed RESULTS: Five single port robotic procedures were successfully completed without conversion or complication. No additional ports were utilized. Single port robotic surgeries included radical prostatectomy, partial nephrectomy, ureteral reimplantation, dismembered pyeloplasty and radical nephrectomy. Oncologically, negative margins were obtained for radical prostatectomy and both radical and partial nephrectomy. Nuclear renography following dismembered pyeloplasty and ureteral reimplantation demonstrated excellent drainage of the obstructed
THE JOURNAL OF UROLOGY®
552
system with no evidence of anastomotic leak CONCLUSIONS: Robotic LESS can provide a platform to further advance single port laparoscopy. Initial experience demonstrates safety, efficiency and acceptable oncological and functional outcomes. While early results are promising, long term evaluation of this approach is warranted Source of Funding: None
V1542 LAPARO-ENDOSCOPIC SINGLE SITE (LESS) SURGICAL PYELOPLASTY: THE UNIVERSITY OF TEXAS SOUTHWESTERN TECHNIQUE Tariq Hakky, Sarasota, FL; Chad R Tracy*, Dallas, TX; Jay D Raman, Hershey, PA; Jeffrey A Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: LESS is a novel technique for performing laparoscopic surgery through a single umbilical incision that may offer all of the benefits of standard laparoscopy with reduced post-operative pain, decreased morbidity and improved cosmesis. METHODS: We demonstrate our technique for performing this complex procedure, discuss what lessons we have learned, and update our early results. RESULTS: Single incision pyeloplasty is performed with the assistance of RealHand ® (Novare Surgical Systems) articulating instruments and a 5 mm endoscope introduced through three separate trocars in a single 25 mm incision. Antegrade stent placement is performed through an established trocar and the anastomosis is completed with either the Autosuture Endostitch ® device (US Surgical) or with free hand laparoscopy. To date, we have performed LESS pyeloplasty in 14 patients. Operative time averaged 202 minutes (range 178-240) with average estimated blood loss of 30 cc. Hospital stay averaged 76 hours (range 50-149). No intraoperative complications were encountered, though one patient, who had undergone previous endopyelotomy, required conversion to a standard laparoscopic approach. CONCLUSIONS: Pyeloplasty using LESS is technically feasible and can be performed by surgeons experienced in laparoscopy. Source of Funding: None
V1543 ROBOTIC-NOTES: VIDEO PRESENTATION IN RECONSTRUCTIVE UROLOGY Sebastien Crouzet*, Georges-Pascal Haber, Kazumi Kamoi, Andre Berger, Monish Aron, Raj K Goel, Wesley M White, Mihir M Desai, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: This video presents our initial experience using the da Vinci® surgical system to perform R-NOTES (Robotic Natural Orifice Transluminal Surgery) reconstructive urological procedures METHODS: In 10 female farm pigs we performed 10 pyeloplasties (right 5; Left 5), 10 partial nephrectomies (right 5; Left 5) and 10 radical nephrectomies (right 5; Left 5). The animal is placed in the lateral flank position and pneumoperitoneum is obtained using a Veress® needle. The scope and the 1st robotic arm are placed through a single 2 cm umbilical incision and the 2nd robotic arm is placed through the vagina. RESULTS: A total of 30 procedures were performed successfully without the addition of additional laparoscopic ports or open conversion. The mean incision size after closure was 2.6 cm (range 2.4 to 2.9 cm). Mean total operative time was 153.7min (range 140 to 187) and mean estimated total blood loss was 72.3 cc (range 55 to 100). Mean warm ischemia time in the partial nephrectomy group was 25.4 min (range 22 to 30). After completion of the procedure, autopsy was performed that demonstrated no visceral complications CONCLUSIONS: R-NOTES pyeloplasty, partial nephrectomy and radical nephrectomy are feasible and safe in the animal model. This approach may offer less morbidity and superior cosmesis. Further development of an R-NOTES vaginal port is ongoing Source of Funding: None
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
V1544 SINGLE-PORT, SINGLE-SURGEON ROBOTIC ASSISTED IN RECONSTRUCTIVE UROLOGY Sebastien Crouzet*, Georges-Pascal Haber, Wesley M White, Kazumi Kamoi, Andre Berger, Raj K Goel, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: We present our initial operative experience in which single port robotic-assisted reconstructive and extirpative urologic surgery was performed by a single surgeon METHODS: A pilot study was performed on male farm pigs to determine the feasibility and safety of single port, single-surgeon urologic surgery. All pigs were slept underwent general anesthesia and placed in the flank position. A 2cm umbilical incision was made through which a single port was placed and pneumoperitoneum achieved. An operative laparoscope was introduced and securely held employing a novel low profile robot under foot and/or voice control. Using articulating instruments, each pig underwent bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analyzed statistically to determine if outcomes improved with surgeon experience RESULTS: Five male farm pigs underwent bilateral pyeloplasty prior to undergoing completion bilateral radical nephrectomy. No intraoperative complications were encountered and there was no need for additional port placement. Mean operative times for pyeloplasty, and nephrectomy were 110 minutes (range 95-130 minutes), and 20 minutes (15-30 minutes), respectively. Mean estimated blood loss for all procedures was 130mL (range 70-180mL). When analyzed statistically, there was a trend towards improved outcomes with increasing surgeon experience (p = 0.08) CONCLUSIONS: Use of a low profile robot to clutch and manipulate the laparoscope affords the operating solitary surgeon flexibility and ease of movement during single port surgery and may constitute a revolutionary break-through within the field Source of Funding: None
V1545 ROBOTIC ASSISTED LAPAROSCOPIC POSTERIOR BLADDER DIVERTICULECTOMY Joseph E. Jamal*, Eric O. Kwon, Marc D. Danziger, Noel A. Armenakas, John A. Fracchia, R. Ernest Sosa, New York, NY INTRODUCTION AND OBJECTIVES: Bladder diverticulectomy can present significant difficulty if located on the posterior aspect of the bladder. We present a video of a novel approach to posterior bladder diverticulectomy using the DaVinci® robot. Methods: The patient was placed in the low-lithotomy position and a flexible cystoscopy was performed. The ipsilateral ureter was stented and a guide-wire was placed into the posterior bladder diverticulum. Laparoscopic ports were placed similar to robotic assisted laparoscopic radical prostatectomy with two 8mm robotic, 12mm right sided assistant and 5mm suction ports. The entire laparoscopic portion of the procedure was performed using the DaVinci® robot. Identification of the diverticulum was aided by illumination of the bladder and diverticulum using a flexible cystoscope. Sharp and blunt dissection was performed to circumscribe and dissect the diverticulum down to a narrow neck. An extravesical excision of the diverticulum was performed. The cystotomy was closed in 2 running layers of 2-0 Vicryl® suture. The bladder was drained with a urethral catheter at the end of the procedure. RESULTS: Total operative time was 122 minutes, console time was 52 minutes. There was minimal blood loss. The patient was discharged home on the following day with an urethral catheter. There were no complications. At 6 months follow-up, the patient has been voiding well with no urinary tract infections. CONCLUSIONS: Robotic assisted laparoscopic bladder diverticulectomy offers an ideal approach for posterior bladder diverticulectomy. Source of Funding: None
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
551
Reconstruction and Trauma Video Session 5 Tuesday, April 28, 2009
10:30 am - 12:30 pm
V1540 E-NOTES MANAGEMENT OF PROXIMAL URETERAL PATHOLOGY-ILEAL INTERPOSITION Andre Berger, Robert J Stein, Marcelo Miranda, Neil S Patel, Monish Aron*, David Canes, Sebastien Crouzet, Georges-Pascal Haber, Kazumi Kamoi, John C Kefer, Brian H Irwin, Ricardo Brandina, Gauarang Shah, Jihad H Kaouk, Inderbir S Gill, Mihir M Desai, Cleveland, OH
Source of Funding: None
1539 HYSTERECTOMY DOES NOT IMPROVE APICAL VAGINAL RECONSTRUCTION: MODERATE TERM DATA ANALYSIS FOLLOWING UTEROSACRAL APICAL RECONSTRUCTION WITH AND WITHOUT HYSTERECTOMY. Renuka Tyagi*, Lauri Romanzi, New York, NY INTRODUCTION AND OBJECTIVES: Hysterectomy in the surgical management of the apex in pelvic reconstruction historically was obligatory. This view has recently been challenged in early-term papers of uterine-sparing apical reconstruction techniques. We report on moderate-term surgical outcomes for a continuous series of patients with upto 8 years of follow up for apical prolapse recurrence. METHODS: A retrospective chart review of patients with apical vaginal reconstruction using uterosacral fixation with or without hysterectomy was performed. All surgeries were performed between August 1999 to June 2008 at a single institution by one of two fellowship trained urogynecologist/female urologists. The charts were reviewed for age, prolapse, parity, medical co-morbidities, surgical procedure and postoperative prolapse. Patients who underwent total vaginal hysterectomy (VH) with mid pelvic uterosacral fixation or uterosacral hysteropexy (USH)with bilateral uterosacral fixation of the vaginal cuff and/or uterus were included for analysis. The uterine-sparing uterosacral hysteropexy technique has been previously reported by the authors. RESULTS: 160 patients were identified with 158 charts available for review. 99 patients underwent total vaginal hysterectomy with uterosacral fixation, 59 patients had uterosacral hysteropexy. There was no significant difference in preoperative parameters. Postoperative survival analysis evaluated for apical recurrence. 2-year recurrence free survival was found to be 97.9% (97 of 99 patients) for VH. Similarly 2-year recurrence free survival was found to be 98.2% (57 of 58 patients) for USH. There was no statistical difference between the groups. With the definition of recurrence expanded to prolapse at any compartment, 2-year recurrence free survival of for VH was 91.6%, and 2-year recurrence free survival for USH was 78.5%.10 of the 13 prolapse recurrences (76.9%) were noted at the anterior vaginal compartment (cystocele). CONCLUSIONS: In our population, with moderate-term follow up we have not found removal of the uterus to be protective for recurrence at the vaginal apex following uterosacral ligment fixation during pelvic reconstruction. Similar to other vaginal reconstruction reports we find the anterior vaginal wall continues to be the primary site for recurrent prolapse. Source of Funding: None
INTRODUCTION AND OBJECTIVES: Proximal ureteral pathology can be one of the most complicated Urologic dilemmas and ileal ureteral replacement one of the most difficult reconstructive procedures performed. E-NOTES (Embryonic Natural Orifice Transumbilical Endoscopic Surgery) allows this procedure to be performed through an extremely small incision compared to its open or even laparoscopic counterpart. METHODS: The patient is a 72 year old man who has developed 2 ureteral strictures from chronic stone impaction. Other forms of ureteral reconstruction including reimplantation or ureteroureterostomy were not feasible due to stricture location and length. Ileal interposition was performed through a novel multi-channel, transumbilical, single port (R-port, Advanced Surgical Concepts) with 2 additional 2mm needle ports. Initially the ureter is identified and dissected distally to the area of obstruction. The bladder is then completely mobilized. The umbilical incision is enlarged slightly in order to deliver the bowel for extracorporeal ileal harvest. A stent is secured within an isolated ileal segment and bowel continuity is reestablished. The bowel contents are returned to the abdomen and E-NOTES technique is used to create a 2 layer ileovesical anastomosis with the ileal segment in an iso-peristaltic configuration. The proximal portion of the ileal segment is led through the sigmoid mesentery and anastomosed in 2 layers to the dilated ureter cranial to the site of obstruction. RESULTS: Operative time was 5 hours and hospital stay was 2.5 days. The patient did not require any postoperative narcotic analgesics. Our initial experience includes 2 patients who underwent E-NOTES ileal ureter with symptomatic and radiographic relief of obstruction in both cases. CONCLUSIONS: E-NOTES ileal interposition allows for an especially complex procedure to be performed through a remarkably small incision. Source of Funding: None
V1541 LESS (LAPARO ENDOSCOPIC SINGLE-SITE) ROBOTIC SURGERY Sebastien Crouzet*, Raj K Goel, Georges-Pascal Haber, Wesley M White, Kazumi Kamoi, Robert J Stein, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Single port laparoscopy has expanded over the last year although technical constraints still hinder its routine application. Herein, we present our video illustrating single port robotic surgery METHODS: Through a multi-channel single port and using 5 mm robotic trocars, single port robotic surgery was performed for various urological pathologies. Patients are positioned in lithotomy and flank position for pelvic and renal procedures, respectively. The da Vinci-S robotic surgical platform was utilized for all procedures. The fourth arm was available but not employed RESULTS: Five single port robotic procedures were successfully completed without conversion or complication. No additional ports were utilized. Single port robotic surgeries included radical prostatectomy, partial nephrectomy, ureteral reimplantation, dismembered pyeloplasty and radical nephrectomy. Oncologically, negative margins were obtained for radical prostatectomy and both radical and partial nephrectomy. Nuclear renography following dismembered pyeloplasty and ureteral reimplantation demonstrated excellent drainage of the obstructed
THE JOURNAL OF UROLOGY®
552
system with no evidence of anastomotic leak CONCLUSIONS: Robotic LESS can provide a platform to further advance single port laparoscopy. Initial experience demonstrates safety, efficiency and acceptable oncological and functional outcomes. While early results are promising, long term evaluation of this approach is warranted Source of Funding: None
V1542 LAPARO-ENDOSCOPIC SINGLE SITE (LESS) SURGICAL PYELOPLASTY: THE UNIVERSITY OF TEXAS SOUTHWESTERN TECHNIQUE Tariq Hakky, Sarasota, FL; Chad R Tracy*, Dallas, TX; Jay D Raman, Hershey, PA; Jeffrey A Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: LESS is a novel technique for performing laparoscopic surgery through a single umbilical incision that may offer all of the benefits of standard laparoscopy with reduced post-operative pain, decreased morbidity and improved cosmesis. METHODS: We demonstrate our technique for performing this complex procedure, discuss what lessons we have learned, and update our early results. RESULTS: Single incision pyeloplasty is performed with the assistance of RealHand ® (Novare Surgical Systems) articulating instruments and a 5 mm endoscope introduced through three separate trocars in a single 25 mm incision. Antegrade stent placement is performed through an established trocar and the anastomosis is completed with either the Autosuture Endostitch ® device (US Surgical) or with free hand laparoscopy. To date, we have performed LESS pyeloplasty in 14 patients. Operative time averaged 202 minutes (range 178-240) with average estimated blood loss of 30 cc. Hospital stay averaged 76 hours (range 50-149). No intraoperative complications were encountered, though one patient, who had undergone previous endopyelotomy, required conversion to a standard laparoscopic approach. CONCLUSIONS: Pyeloplasty using LESS is technically feasible and can be performed by surgeons experienced in laparoscopy. Source of Funding: None
V1543 ROBOTIC-NOTES: VIDEO PRESENTATION IN RECONSTRUCTIVE UROLOGY Sebastien Crouzet*, Georges-Pascal Haber, Kazumi Kamoi, Andre Berger, Monish Aron, Raj K Goel, Wesley M White, Mihir M Desai, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: This video presents our initial experience using the da Vinci® surgical system to perform R-NOTES (Robotic Natural Orifice Transluminal Surgery) reconstructive urological procedures METHODS: In 10 female farm pigs we performed 10 pyeloplasties (right 5; Left 5), 10 partial nephrectomies (right 5; Left 5) and 10 radical nephrectomies (right 5; Left 5). The animal is placed in the lateral flank position and pneumoperitoneum is obtained using a Veress® needle. The scope and the 1st robotic arm are placed through a single 2 cm umbilical incision and the 2nd robotic arm is placed through the vagina. RESULTS: A total of 30 procedures were performed successfully without the addition of additional laparoscopic ports or open conversion. The mean incision size after closure was 2.6 cm (range 2.4 to 2.9 cm). Mean total operative time was 153.7min (range 140 to 187) and mean estimated total blood loss was 72.3 cc (range 55 to 100). Mean warm ischemia time in the partial nephrectomy group was 25.4 min (range 22 to 30). After completion of the procedure, autopsy was performed that demonstrated no visceral complications CONCLUSIONS: R-NOTES pyeloplasty, partial nephrectomy and radical nephrectomy are feasible and safe in the animal model. This approach may offer less morbidity and superior cosmesis. Further development of an R-NOTES vaginal port is ongoing Source of Funding: None
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
V1544 SINGLE-PORT, SINGLE-SURGEON ROBOTIC ASSISTED IN RECONSTRUCTIVE UROLOGY Sebastien Crouzet*, Georges-Pascal Haber, Wesley M White, Kazumi Kamoi, Andre Berger, Raj K Goel, Inderbir S Gill, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: We present our initial operative experience in which single port robotic-assisted reconstructive and extirpative urologic surgery was performed by a single surgeon METHODS: A pilot study was performed on male farm pigs to determine the feasibility and safety of single port, single-surgeon urologic surgery. All pigs were slept underwent general anesthesia and placed in the flank position. A 2cm umbilical incision was made through which a single port was placed and pneumoperitoneum achieved. An operative laparoscope was introduced and securely held employing a novel low profile robot under foot and/or voice control. Using articulating instruments, each pig underwent bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analyzed statistically to determine if outcomes improved with surgeon experience RESULTS: Five male farm pigs underwent bilateral pyeloplasty prior to undergoing completion bilateral radical nephrectomy. No intraoperative complications were encountered and there was no need for additional port placement. Mean operative times for pyeloplasty, and nephrectomy were 110 minutes (range 95-130 minutes), and 20 minutes (15-30 minutes), respectively. Mean estimated blood loss for all procedures was 130mL (range 70-180mL). When analyzed statistically, there was a trend towards improved outcomes with increasing surgeon experience (p = 0.08) CONCLUSIONS: Use of a low profile robot to clutch and manipulate the laparoscope affords the operating solitary surgeon flexibility and ease of movement during single port surgery and may constitute a revolutionary break-through within the field Source of Funding: None
V1545 ROBOTIC ASSISTED LAPAROSCOPIC POSTERIOR BLADDER DIVERTICULECTOMY Joseph E. Jamal*, Eric O. Kwon, Marc D. Danziger, Noel A. Armenakas, John A. Fracchia, R. Ernest Sosa, New York, NY INTRODUCTION AND OBJECTIVES: Bladder diverticulectomy can present significant difficulty if located on the posterior aspect of the bladder. We present a video of a novel approach to posterior bladder diverticulectomy using the DaVinci® robot. Methods: The patient was placed in the low-lithotomy position and a flexible cystoscopy was performed. The ipsilateral ureter was stented and a guide-wire was placed into the posterior bladder diverticulum. Laparoscopic ports were placed similar to robotic assisted laparoscopic radical prostatectomy with two 8mm robotic, 12mm right sided assistant and 5mm suction ports. The entire laparoscopic portion of the procedure was performed using the DaVinci® robot. Identification of the diverticulum was aided by illumination of the bladder and diverticulum using a flexible cystoscope. Sharp and blunt dissection was performed to circumscribe and dissect the diverticulum down to a narrow neck. An extravesical excision of the diverticulum was performed. The cystotomy was closed in 2 running layers of 2-0 Vicryl® suture. The bladder was drained with a urethral catheter at the end of the procedure. RESULTS: Total operative time was 122 minutes, console time was 52 minutes. There was minimal blood loss. The patient was discharged home on the following day with an urethral catheter. There were no complications. At 6 months follow-up, the patient has been voiding well with no urinary tract infections. CONCLUSIONS: Robotic assisted laparoscopic bladder diverticulectomy offers an ideal approach for posterior bladder diverticulectomy. Source of Funding: None