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ROBOTIC ASSISTED LAPAROSCOPY FOR INGUINAL VASOVASOSTOMY AFTER BILATERAL HERNIORRHAPHY WITH MESH
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
383
V1069
V1071
ROBOTIC ASSISTED LAPAROSCOPY FOR INGUINAL VASOVASOSTOMY AFTER BILATERAL HERNIORRHAPHY WITH MESH
PURE NOTES TRANSVAGINAL NEPHRECTOMY IN THE PORCINE MODEL
Richard C Bennett*, Jon A Rumohr, Richard E Link, Larry I Lipshultz, Houston, TX INTRODUCTION AND OBJECTIVES: Vasal occlusion is a known complication of inguinal herniorrhaphy with mesh. The purpose of this video is to illustrate an operative technique for the reconstruction of inguinally obstructed vasa deferentia due to mesh herniorrhaphy. METHODS: A 39 year old male presented for evaluation of male factor infertility. He was found to have azoospermia on semen analysis. The patient had a history of laparoscopic bilateral mesh hernia repair 13 years prior to evaluation. His testicles were of normal size and consistency, and his FSH and testosterone levels were also normal. The patient underwent a testis biopsy and a vasogram. Normal spermatogenesis was found on biopsy, and an obstruction was identified at the level of the left groin. The site of obstruction coincided with the location of the previously placed mesh. In order to perform an inguinal vasovasostomy, intra-abdominal vas deferens must be mobilized. This video demonstrates the technique of robotic assisted laparoscopic intra-abdominal mobilization of the vasa deferentia and microscopic inguinal vasovasostomy. RESULTS: This bilateral procedure was completed in five hours. The patient was discharged from the hospital on postoperative day one, and his incisions have healed well. Six week following surgery the first semen analysis demonstrated 6.5 million total sperm in the ejaculate. It is normal for the first early postoperative semen analysis to start out low and progressively improve as intra-vasal edema subsides. CONCLUSIONS: This video demonstrates a novel technique for robotic assisted intra-abdominal mobilization of the vas deferens. Using this minimally invasive procedure sufficient healthy vas deferens is made available for an effective microscopic inguinal vasovasostomy. Source of Funding: None
Andre Berger*, Georges-Pascal Haber, Stacy Brethauer, Kazumi Kamoi, Patrick Gatmaitan, Sebastien Crouzet, Philippe Koenig, Monish Aron, David Canes, Raj K Goel, Robert J Stein, Ricardo Brandina, Jihad H Kaouk, Mihir M Desai, Inderbir S Gill, Cleveland, OH INTRODUCTION AND OBJECTIVES: To determine the feasibility, reproducibility and technical aspect of pure NOTES transvaginal nephrectomy. METHODS: We performed in 5 female pigs with a mean weight of 45 Kg, 5 right side radical nephrectomies. The animal is placed in lateral flank position, pneumoperitoneum was obtained using a Veress® needle. A needle/knife is introduced in the posterior fornix of the vagina, followed by balloon dilation and introduction of the gastroscope (single channel in initial 3 cases and dual channel in the remaining 2 cases). Kidney is localized we started by droping the colon. The ureter is individualized laterally and followed toward the hilum. Then, we introduced an XL articulated 60 cm endo-GIA to retract the ureter medially and start dissecting the posterior side of the kidney close to the psoas. The vessels are dissected until we identified the upper limit of the renal vein. The hilum is then clamped en bloc and endo-GIA is fired. Upper pole is freed followed by the lateral attachements. Once the dissection is finished, we replace the endo-GIA by a 15 cm endo-Catch to entrap the kidney and extract it. RESULTS: All procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean operative time was 113.2 min and estimated total blood loss was 50cc. No intraoperative complication was observed. CONCLUSIONS: Pure NOTES transvaginal nephrectomy is feasible and safe in the porcine model. It has the potential of a less morbid approach with scarless surgery. Further development of the instrumentation is necessary. Source of Funding: None
V1070
V1072
ROBOT-ASSISTED EXCISION OF A MULLERIAN CYST WITH ANASTOMOSIS OF THE VAS DEFERENS TO THE SEMINAL VESICLE
LESSONS LEARNED FROM A COMPARISON OF ADULT AND PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC PYELOPLASTIES
Rene J Sotelo*, Calkins Herrera, Juan C Astigueta, Oswaldo J Carmona, Robert J De Andrade, Otto Moreira, Caracas, Venezuela
Paul J Kokorowski*, Shahin T Chandrasoma, Matthew Dunn, Roger De Filippo, Andy Chang, Los Angeles, CA; Clayton S Lau, Duarte, CA; Chester J Koh, Los Angeles, CA
INTRODUCTION AND OBJECTIVES: Mullerian cyst of the vas deferens with ipsilateral renal agenesis is a rare condition. The choice of treatment depends on symptoms, which in turn are related to cyst size and location. Only two cases of robotic excision of seminal vesical cysts have been reported, with successful relief of symptoms and minimal morbidity. We report a case of symptomatic mullerian cyst of the vas deferens and ipsilateral renal agenesis that was successfully management by surgical excision. METHODS: A 19 year old man presented with lower urinary tract irritative symptoms. Ultrasonography and abdominopelvic magnetic resonance imaging (MRI) showed a 4 cm right pelvis cystic mass between the bladder and rectum that was associated with an absent right kidney. Semen analysis revealed oligospermia. We use 3 arms, and one aditional port succtiion, total 4 insicion. Transperitoneal approach right mullerian cyst of the vas deferens was resected. RESULTS: Operative time was 90 minutes. The procedure was technically accessible and minimal blood loss being less than 100cc and a drain was placed for 48 hours. The patient was discharged the next day and he is currently asymptomatic. CONCLUSIONS: Minimally invasive robotic-assisted excision of a mullerian cyst of the vas deferens is technically feasible, and should be considered for the treatment of this rare condition. Source of Funding: None
INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in adult and pediatric patients for the treatment of ureteropelvic junction obstruction (UPJO). This technique has been associated with smaller incisions, shorter hospital stays, and decreased medication usage. We compare the technical details of adult and pediatric robotic-assisted laparoscopic pyeloplasties and demonstrate our preferred technique. METHODS: Surgical videos of robotic-assisted laparoscopic pyeloplasty were reviewed with attention paid to positioning, port placement, type of UPJO (intrinsic vs.extrinsic), approach (retrocolic vs.transmesenteric), type of anastamosis, stenting, and use of postoperative drains. RESULTS: Pediatric patients were placed in the supine position with the ipsilateral side raised at a 45-degree angle, while adult patients were placed in the full flank position. Port placements in the pediatric patients were 1) umbilical, 2) midline below the xiphoid, and 3) lower ipsilateral quadrant in the mid-clavicular line, while the adult patients often had more lateral port placements. The majority of pediatric patients exhibited an intrinsic UPJO, while the adult patients presented with an extrinisic UPJO. For the left sided cases in pediatric patients, a transmesenteric dissection was possible due to the thin mesentery with immature vascularity. In adult cases as well as in right sided pediatric cases, a retrocolic dissection was preferred due to the thickness of the mesenteric fat and increased mesenteric vascularity. A 4-0 ‘hitch stitch’ was passed through the abdominal wall, renal pelvis, and back out of the abdomen adjacent to its entry point. This was done mainly in
Vol. 181, No. 4, Supplement, Monday, April 27, 2009
383
V1069
V1071
ROBOTIC ASSISTED LAPAROSCOPY FOR INGUINAL VASOVASOSTOMY AFTER BILATERAL HERNIORRHAPHY WITH MESH
PURE NOTES TRANSVAGINAL NEPHRECTOMY IN THE PORCINE MODEL
Richard C Bennett*, Jon A Rumohr, Richard E Link, Larry I Lipshultz, Houston, TX INTRODUCTION AND OBJECTIVES: Vasal occlusion is a known complication of inguinal herniorrhaphy with mesh. The purpose of this video is to illustrate an operative technique for the reconstruction of inguinally obstructed vasa deferentia due to mesh herniorrhaphy. METHODS: A 39 year old male presented for evaluation of male factor infertility. He was found to have azoospermia on semen analysis. The patient had a history of laparoscopic bilateral mesh hernia repair 13 years prior to evaluation. His testicles were of normal size and consistency, and his FSH and testosterone levels were also normal. The patient underwent a testis biopsy and a vasogram. Normal spermatogenesis was found on biopsy, and an obstruction was identified at the level of the left groin. The site of obstruction coincided with the location of the previously placed mesh. In order to perform an inguinal vasovasostomy, intra-abdominal vas deferens must be mobilized. This video demonstrates the technique of robotic assisted laparoscopic intra-abdominal mobilization of the vasa deferentia and microscopic inguinal vasovasostomy. RESULTS: This bilateral procedure was completed in five hours. The patient was discharged from the hospital on postoperative day one, and his incisions have healed well. Six week following surgery the first semen analysis demonstrated 6.5 million total sperm in the ejaculate. It is normal for the first early postoperative semen analysis to start out low and progressively improve as intra-vasal edema subsides. CONCLUSIONS: This video demonstrates a novel technique for robotic assisted intra-abdominal mobilization of the vas deferens. Using this minimally invasive procedure sufficient healthy vas deferens is made available for an effective microscopic inguinal vasovasostomy. Source of Funding: None
Andre Berger*, Georges-Pascal Haber, Stacy Brethauer, Kazumi Kamoi, Patrick Gatmaitan, Sebastien Crouzet, Philippe Koenig, Monish Aron, David Canes, Raj K Goel, Robert J Stein, Ricardo Brandina, Jihad H Kaouk, Mihir M Desai, Inderbir S Gill, Cleveland, OH INTRODUCTION AND OBJECTIVES: To determine the feasibility, reproducibility and technical aspect of pure NOTES transvaginal nephrectomy. METHODS: We performed in 5 female pigs with a mean weight of 45 Kg, 5 right side radical nephrectomies. The animal is placed in lateral flank position, pneumoperitoneum was obtained using a Veress® needle. A needle/knife is introduced in the posterior fornix of the vagina, followed by balloon dilation and introduction of the gastroscope (single channel in initial 3 cases and dual channel in the remaining 2 cases). Kidney is localized we started by droping the colon. The ureter is individualized laterally and followed toward the hilum. Then, we introduced an XL articulated 60 cm endo-GIA to retract the ureter medially and start dissecting the posterior side of the kidney close to the psoas. The vessels are dissected until we identified the upper limit of the renal vein. The hilum is then clamped en bloc and endo-GIA is fired. Upper pole is freed followed by the lateral attachements. Once the dissection is finished, we replace the endo-GIA by a 15 cm endo-Catch to entrap the kidney and extract it. RESULTS: All procedures were performed successfully without any addition of laparoscopic port or open conversion. Mean operative time was 113.2 min and estimated total blood loss was 50cc. No intraoperative complication was observed. CONCLUSIONS: Pure NOTES transvaginal nephrectomy is feasible and safe in the porcine model. It has the potential of a less morbid approach with scarless surgery. Further development of the instrumentation is necessary. Source of Funding: None
V1070
V1072
ROBOT-ASSISTED EXCISION OF A MULLERIAN CYST WITH ANASTOMOSIS OF THE VAS DEFERENS TO THE SEMINAL VESICLE
LESSONS LEARNED FROM A COMPARISON OF ADULT AND PEDIATRIC ROBOTIC-ASSISTED LAPAROSCOPIC PYELOPLASTIES
Rene J Sotelo*, Calkins Herrera, Juan C Astigueta, Oswaldo J Carmona, Robert J De Andrade, Otto Moreira, Caracas, Venezuela
Paul J Kokorowski*, Shahin T Chandrasoma, Matthew Dunn, Roger De Filippo, Andy Chang, Los Angeles, CA; Clayton S Lau, Duarte, CA; Chester J Koh, Los Angeles, CA
INTRODUCTION AND OBJECTIVES: Mullerian cyst of the vas deferens with ipsilateral renal agenesis is a rare condition. The choice of treatment depends on symptoms, which in turn are related to cyst size and location. Only two cases of robotic excision of seminal vesical cysts have been reported, with successful relief of symptoms and minimal morbidity. We report a case of symptomatic mullerian cyst of the vas deferens and ipsilateral renal agenesis that was successfully management by surgical excision. METHODS: A 19 year old man presented with lower urinary tract irritative symptoms. Ultrasonography and abdominopelvic magnetic resonance imaging (MRI) showed a 4 cm right pelvis cystic mass between the bladder and rectum that was associated with an absent right kidney. Semen analysis revealed oligospermia. We use 3 arms, and one aditional port succtiion, total 4 insicion. Transperitoneal approach right mullerian cyst of the vas deferens was resected. RESULTS: Operative time was 90 minutes. The procedure was technically accessible and minimal blood loss being less than 100cc and a drain was placed for 48 hours. The patient was discharged the next day and he is currently asymptomatic. CONCLUSIONS: Minimally invasive robotic-assisted excision of a mullerian cyst of the vas deferens is technically feasible, and should be considered for the treatment of this rare condition. Source of Funding: None
INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic pyeloplasty is an emerging, minimally invasive alternative to open pyeloplasty in adult and pediatric patients for the treatment of ureteropelvic junction obstruction (UPJO). This technique has been associated with smaller incisions, shorter hospital stays, and decreased medication usage. We compare the technical details of adult and pediatric robotic-assisted laparoscopic pyeloplasties and demonstrate our preferred technique. METHODS: Surgical videos of robotic-assisted laparoscopic pyeloplasty were reviewed with attention paid to positioning, port placement, type of UPJO (intrinsic vs.extrinsic), approach (retrocolic vs.transmesenteric), type of anastamosis, stenting, and use of postoperative drains. RESULTS: Pediatric patients were placed in the supine position with the ipsilateral side raised at a 45-degree angle, while adult patients were placed in the full flank position. Port placements in the pediatric patients were 1) umbilical, 2) midline below the xiphoid, and 3) lower ipsilateral quadrant in the mid-clavicular line, while the adult patients often had more lateral port placements. The majority of pediatric patients exhibited an intrinsic UPJO, while the adult patients presented with an extrinisic UPJO. For the left sided cases in pediatric patients, a transmesenteric dissection was possible due to the thin mesentery with immature vascularity. In adult cases as well as in right sided pediatric cases, a retrocolic dissection was preferred due to the thickness of the mesenteric fat and increased mesenteric vascularity. A 4-0 ‘hitch stitch’ was passed through the abdominal wall, renal pelvis, and back out of the abdomen adjacent to its entry point. This was done mainly in