SINGLE PORT TRANSUMBILICAL ROBOTIC SURGERY

THE JOURNAL OF UROLOGY®

Vol. 181, No. 4, Supplement, Monday, April 27, 2009

1198 OXYGEN PRODUCING MATERIALS FOR ENHANCING CELL SURVIVAL Catherine Ward*, Se Heang Oh, Anthony Atala, James J Yoo, Benjamin Harrison, Winston Salem, NC INTRODUCTION AND OBJECTIVES: Many times engineered tissue lacks a sufficient vascular supply to provide cells the needed oxygen to survive. This has been a critical limiting factor for developing functional tissues for human applications. We have developed a novel method to prolong cell survival until host neovascularization is achieved using in situ generation of oxygen. In this study we investigated the possibility of incorporating oxygen generating biomaterials into tissue engineered constructs to provide a sustained oxygen release over an extended period of time. We examined whether oxygen generating biomaterials are able to maintain cell viability while also maintaining structural integrity of a three-dimensional construct. METHODS: Poly(co-lactic-co-glycolic acid) PLGA was dissolved in dimethyl sulfoxide (DMSO, Aldrich). 5 wt% calcium peroxide (CPO) was added to the mixture and mixed well. The CPO suspended PLGA solution was then mixed with paraffin particles and then transferred to a silicone mold to fabricate scaffolds. To measure the amount of oxygen produced, the scaffolds were placed into media that had been equilibrated to 1% oxygen. Oxygen concentrations were measured using a blood gas analyzer and reported as a percentage of increase compared to average oxygen levels in normal media. To test the cell compatibility, 3T3 cells were seeded onto the scaffold and evaluated each day using an MTS assay. RESULTS: The scaffolds showed an overall average increase in oxygen levels over a ten day period. To evaluate the effect of CPO, cellseeded PLGA and PLGA/CPO scaffolds were cultured under normoxic conditions (21% O2, 5% CO2) for 3 days and the viable cell numbers in each scaffold were estimated using an MTS assay. The oxygen generating scaffolds showed at least equivalent cell numbers after three days compared to PLGA only scaffolds. At a concentration of 5 wt% CPO, no statistically significant decrease (p>0.05) in cell number was observed. CONCLUSIONS: Oxygen generating biomaterials produced a steady increase in oxygen concentration. These scaffolds are able to provide an adequate environment for cell survival and growth in hypoxic environments. The use of oxygen generating biomaterials may allow for increased cell survivability while neovascularization is being established after implantation. Source of Funding: Departmental

1199 INVESTIGATIONS ON THE BIOCOMPATIBILITY OF A NEW COLLAGEN-BASED MATRIX FOR HUMAN UROTHELIAL CELLS Gerhard Feil*, Sabine Maurer, Lothar Just, Jutta Krug, Konrad Kohler, Arnulf Stenzl, Karl-Dietrich Sievert, Tuebingen, Germany INTRODUCTION AND OBJECTIVES: In vitro engineering of lower urinary tract tissue equivalents suitable for reconstructive surgery might require biomaterials as cell carriers. Matrices have to be biocompatible, induce tissue regeneration, and must be subject to rapid degradation in vivo. The aim of the pilot study was to prove adherence, viability, and growth pattern of human urothelial cells (HUCs) seeded on a new factory-made bovine collagen I-based matrix. METHODS: Ureter tissue specimens were obtained from adult patients undergoing open tumor surgery according to the ethics committee approval. HUCs were isolated and labelled with the fluorescent cell linker PKH26, seeded onto the collagen matrix, and cultivated in serum-free medium. Cell adherence was indirectly ascertained by counting nonadherent cells in the culture supernatant. Growth behaviour was studied by phase contrast microscopy and cryosections of the populated matrix. Viability of HUCs seeded onto the collagen matrix was analysed with the WST-1 assay. RESULTS: HUCs grown on the collagen matrix were as homogeneously spread as HUCs seeded onto standard plastic surface. At day 1 after seeding the fraction of non-adherent HUCs was slightly

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increased (2.2%) compared to the controls (0.3%), whereas at day 3 both groups revealed similar rates (0.4% and 0.3%, respectively). Viability of HUCs growing on the matrix revealed 111% of the control group at day 3. The cell-matrix constructs could be easily detached from the culture dish and were manageable with surgical instruments. CONCLUSIONS: The data demonstrate a good in vitro biocompatibility of the new bovine collagen I-based matrix. We conclude that the matrix might be well suitable for construction of urothelial cellmatrix implants for reconstructive ureteral and urethral surgery. Further experiments with urothelial multilayers grown on the matrix will be performed in vitro as well as in vivo. Source of Funding: None

Technology & Instruments: Robotics/Laparoscopy (IV) Moderated Poster 40 Monday, April 27, 2009

3:30 pm - 5:30 pm

1200 VIDEO ENDOSCOPIC INGUINAL LYMPHADENECTOMY (VEIL): OUR INITIAL EXPERIENCE Yuvaraja B Thyavihally*, Hemant B Tongaonkar, Abhijit Bapat, Mumbai, India INTRODUCTION AND OBJECTIVES: Inguinal lymph node dissection in carcinoma of penis is associated with significant wound related complications like flap necrosis, infection etc. We present our initial experience with video endoscopic inguinal lymphadenectomy (VEIL), minimally invasive approach to avoid complications of open groin node dissection (GND). METHODS: From October 2007 to October 2008, 16 patients were operated for bilateral GND, one side standard GND and other side VEIL. VEIL was done for clinically N0 groin in 13 cases and for N1 in 3 cases (Right side in 4 and left in 12 patients). Selection criteria were absence of infective nodes, < 3cm nodes, non obese patient and N0 groin in high risk primary carcinoma of penis. Patient was positioned in low lithotomy with boot shaped leggings. Transverse incision up to the level of fascialata and finger dissection is done separating the flap from fascialata. Two working ports are placed under vision. Entire tissue along with fascialata is separated from muscle; sapheno-femoral junction is divided. RESULTS: Mean operative time for VEIL was slightly more with 150 minutes and for open GND was 110 (p=0.02). Numbers of Lymph nodes retrieved by VEIL were 8-16 nodes which were comparable to open GND (10-16 nodes). Flap necrosis occurred in 7 patients (one mild, two moderate and two severe) in open GND side and one in VEIL side. Six and 3 patients each in open and VEIL side had lymphocele which required repeated aspiration. With short follow up of 3-12 months, none of the patients had relapse. CONCLUSIONS: In selected cases of high risk carcinoma penis with negative groin or lymph node metastasis <3cm, non obese patient, VEIL has a definitive role in decreasing morbidity of inguinal nodal dissection without compromising boundaries of dissection and is safe. Source of Funding: None

1201 SINGLE PORT TRANSUMBILICAL ROBOTIC SURGERY Raj K Goel*, Wesley M White, Robert J Stein, Sebastien Crouzet, Georges Pascal-Haber, Jihad H Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: The technical constraints of single port laparoscopic surgery have generated concerns regarding its feasibility and pragmatism. Robotics has greatly facilitated the surgeon’s ability to complete complex extirpative and reconstructive procedures laparoscopically. We present our institution’s experience employing the robotic surgical platform during single port laparoscopic surgery.

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THE JOURNAL OF UROLOGY®

METHODS: A retrospective review of single port robotic surgery was performed. Patient demographics, peri-operative data, pain assessment and operative times were obtained. Single port robotic surgery was performed in patients suitable for standard laparoscopy. Exclusion criteria included patients with advanced malignancy, multiple abdominal or renal surgeries and those with a solitary kidney. Single port access was achieved via a commercially available multi-channel port. The daVinci-S® surgical platform using pediatric instruments were used. RESULTS: Nine single port robotic procedures were completed without complicatons or use of additional ports. Surgeries included radical prostatectomy (n = 1), radical nephrectomy (n = 1), ureteral reimplantation (n = 1), dismembered pyeloplasty (n = 2), partial nephrectomy (n = 2), sacrocolpopexy (n = 1), and nephroureterectomy (n = 1). Control of the renal artery and vein during radical nephrectomy was achieved using Hem-O-Lok clips. Suture ligation of the dorsal venous complex was completed intracorporeally. The urethral-vesical and uretero-pelvic anastamoses were completed without additional ports using a running suture technique. During partial nephrectomy under normal renal perfusion, renal tumor excision was performed using a Harmonic scalpel. Surgical margins for all cancer-related procedures were negative. No evidence of pelvic organ prolapse has been noted at 4 month followup. CONCLUSIONS: Application of the robotic platform during single port surgery may represent the next step in its evolution. The improved articulation offered by robotics may expand and disseminate the role and reproducibility of single port surgery. Source of Funding: None

1202 LAPROENDOSCOPIC SINGLE SITE(LESS) LIVE DONOR NEPHRECTOMY:A SINGLE CENTRE EXPERIENCE Arvind P Ganpule*, Abraham Kurien, Divya R Dhawan, Ravindra B Sabnis, Veeramani Muthu, Mahesh R Desai, Nadiad, India INTRODUCTION AND OBJECTIVES:We present our experience of 10 patients ,who underwent Laproendoscopic single site (LESS) live donor nephrectomy (LDN). We describe technical considerations and modifications . METHODS: Pneumoperitoneum was established via a 2 mm Veress needle port in 1 case and in rest by open technique. A single access tri/ quadri - lumen R-port (Advanced Medical concepts, Dublin, Ireland) was inserted through an umbilical incision. In all standard laparoscopic instruments were used. 9 cases had single and one had double vessel. Donor kidney was pre-positioned near the umbilical extraction site for easy retrieval by hand. RESULTS: Mean age was 46.11 + 17.71 yrs, BMI was 23.18 + 4.6 kg/m2 (range 17.9 - 29.78 kg/m2). Mean operating time was 240 + 19.67 min (range 90 - 240 min), blood loss was 144.44 + 85.87 cc (range 50 - 300 cc), Warm ischemia time was 6.94 + 1.88 minutes (range 4 - 10 min) and hospital stay was 5 + 1.99 days (range 3 - 5 days). Right LESS donor nephrectomy was done in one case. Mean length of renal artery was 3.71 cm (range 3 - 4.3 cm), renal vein 3.8 cm and ureter lenght was14.56 (range 13 - 16 cm). Mean retrieval incision length was 5.3 cm. Except for a small 3 mm upper polar tear in right LDN, no intraoperative complication was noticed. All allografts functioned immediately. Donor visual analog pain scores were 0/10 at 2 weeks. CONCLUSIONS: LESS donor nephrectomy is safe, efficient and feasible. Apart from enhanced cosmesis, LESS donor Nephrectomy offers the patient reduced pain. LESS LDN on right side and in donors with double vessels is technically feasible. Source of Funding: None

Vol. 181, No. 4, Supplement, Monday, April 27, 2009

1203 SINGLE INCISION TRANS - URETERAL (SITU) LAPAROSCOPIC NEPHRECTOMY Andrei Nadu*, Oscar Schatloff, Jacob Ramon, Tel Hashomer, Israel INTRODUCTION AND OBJECTIVES: NOTES (Natural Orifices Transluminal Endoscopic Surgery) and single incision surgery have been recently reported as feasible approaches to laparoscopic nephrectomy. We present a novel, hybrid technique that combines single incision laparoscopic nephrectomy with NOTES principles by using the ureteral stump as a natural orifice. METHODS: Six renal units were operated in a non survival study on female pigs by using a hybrid approach that combines a single umbilical incision with the natural orifice provided by the divided ipsilateral ureter. A transurethral 16 F Amplatz sleeve inserted in the ureter under cystoscopic guidance became a natural orifice port after transection of the ureter. Two adjacent ports (5 and 12 mm) were introduced through a single umbilical incision. The camera was placed in one of the umbilical ports and two operating instruments were introduced through the additional umbilical port and the “natural orifice port” respectively. Operative time, blood loss, complications were recorded. RESULTS: Right and left laparoscopic nephrectomy were successfully performed. No complications occurred except one case of a periureteral hematoma due to the dilation of the ureter. The hylar blood vessels were thoroughly dissected and controlled by either clips or vascular staplers. The blood loss was under 50 cc in all cases. The operative time decreased from 140 minutes in the first procedure to 70 minutes in the last (median 85 minutes). The learning curve was short as basic principles of laparoscopy like correct instrument angulation could be achieved through the inferior, natural orifice port. CONCLUSIONS: Laparoscopic nephrectomy combining a single umbilical incision with a natural orifice provided by the ipsilateral ureter is technically feasible. The divided ureter seems to provide a useful natural orifice. Further experience together with assessment of advantages over classic laparoscopic nephrectomy are needed. Source of Funding: None

1204 NOTES TRANS-GASTRIC PARTIAL CYSTECTOMY Irma J Lengu*, Matthew L Steinway, Mark D Sawyer, Joseph A Trunzo, Edward E Cherullo, Lee E Ponsky, Cleveland, OH INTRODUCTION AND OBJECTIVES: Partial cystectomy is indicated for solitary muscle invasive bladder tumors involving the dome or located in a bladder diverticulum, as well as non-invasive bladder tumors, which are not amendable to trans-urethral resection. We investigated the feasibility of performing trans-gastric partial cystectomy in a porcine model. METHODS: Peritoneum was accessed through a gastrotomy incision using an Olympus R Gastroscope. A bladder lesion was created in a trans-urethral fashion at the time of the operation. The bladder was accessed ultimately with a 22F Rigid cystoscope. A pre-marked 2cm flexible tip wire was used to make a 2x2cm lesion, using cautery with needle knife at 4 corners. It was observed transgastrically to avoid bowel injury. The same wire was used to make 2cm margins at each corner. At the margins, methylene blue was injected in the bladder wall, which was visualized transgastrically. An endoloop was applied through the gastroscope and secured slightly passed the marked margins. A second loop was placed distally to the first. A needle knife was used to cauterize between the two loops. Endoclips were applied in full thickness to close the cystotomy. The cystoscope was exchanged for Council-tip catheter. The closure was tested and observed transgastrically for a leak. If a leak was noted, additional clips were applied. The specimen was extracted with the gastrosope, using an endocatch bag. The gastrostomy was closed with clips. Bladder lesion size and margins were recorded. The swine were survived for 14 days. A cystogram was performed on day 14. Necropsy was performed. RESULTS: The procedure was performed successfully in 5 female