V1110 ROBOTIC DIVERTICULECTOMY IN A PEDIATRIC PATIENT

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interrupted 4-0 chromic sutures to achieve 360 degree coverage of the entire neovaginal area. A spongy vaginal mold is left in-situ for 5-7 days. CONCLUSIONS: Buccal mucosa generates a moist, hairless, nonkeratinized neovaginal mucosa with excellent color and texture matching the genital/vaginal skin. It leaves no visible surgical scars, avoids abdominal bowel surgery and has no excess mucous production. It is an ideal replacement material for primary or secondary vaginoplasty with excellent early results. Source of Funding: None

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performed through a limited laminectomy. The following video shows the key steps of the procedure including: Laminectomy, identification of the lumbar and sacral nerve roots, separation of the dorsal and ventral roots, splitting of the donor L5 nerve root and the anastomosis of the donor L5 nerve root to the recipient S3 nerve root. RESULTS: This technical video does not discuss the clinical outcomes of the nerve rerouting procedure. CONCLUSIONS: This video demonstrates some of the key surgical steps in the lumbar to sacral nerve rerouting procedure to restore bladder and bowel function in spina bifida patients. Source of Funding: Ministrelli Program for Urology Research and Education

V1107 MAKING THE MOST OF WHAT YOU HAVE: SPLIT APPENDIX TECHNIQUE FOR SIMULTANEOUS CREATION OF APPENDICOVESICOSTOMY & APPENDICOCECOSTOMY Brian A. VanderBrink*, Fishers, IN; Mark P. Cain, Martin Kaefer, Kirstan K. Meldrum, Rosalia Misseri, Richard C. Rink, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Urinary and fecal incontinence can coexist in pediatric neurologic conditions causing significant distress to patients and their families. When medical treatment fails, surgical intervention in form of appendicocecostomy (AC) and appendicovesicostomy (AV) has high success rates in achieving continence. Usually the appendix must be utilized for a single channel requiring the other channel typically being constructed from a piece of resected bowel. We describe our spilt-appendix technique for simultaneous creation of AC and AV. METHODS: This video highlights some of the technical aspects of the split appendic technique. Our technique was when appendiceal vascular supply and length permitted; the appendix was divided into two. The proximal end was kept in continuity with the cecum for an in situ AC while the distal end was utilized for AV. The appendiceal length, utilization of stapler to perform appendicocecal extension as described by Curtis Sheldon et al, continence status, and subsequent need for surgical revision, if necessary, was recorded. RESULTS: Of 394 children that underwent surgery, 43 patients (11%) were identified that used the split appendix technique. Mean appendiceal length was 10 ⫾ 2 cm. The appendix was approximately divided in half in 34 patients while asymmetrical separation with TA cecal extension technique utilized in 9 patients. Mean length of appendix used for AV and AC was 6 cm and 4 cm, respectively. All AC and 41/43 AV were continent. With a mean follow-up of 40 months, 16/86 (19%) channels created required surgical revision. AC and AV revisions occurred in 6 patients each, while 2 patients required surgical revision of both channels. Use of the TA stapler did not result in increased need for AC revision. CONCLUSIONS: AC and AV created from split appendix have durable short-term outcomes and comparable revision rates to other described techniques. The split appendix technique is applicable to a minority of children undergoing continent reconstruction, however has the benefit of avoiding a bowel resection and its accompanying risks. Source of Funding: None

V1109 LAPAROENDOSCOPIC SINGLE SITE (LESS) NEPHRECTOMY IN CHILDREN: FROM INFANTS TO ADOLESCENTS Chester Koh, Manuel Eisenberg*, Andre Berger, Ricardo Brandina, Ryan Dorin, Roger De Filippo, Andy Chang, Brian Hardy, Matthew Dunn, Monish Aron, Inderbir Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: We present our technique and initial experience with LESS nephrectomy for non-functioning kidneys in 8 pediatric patients. METHODS: In this video we present a 5 week old male with a weight of 5.1 kg who was found to have a large hydronephrotic non-functioning left kidney diagnosed on prenatal ultrasound and confirmed with computerized tomography. A laparoscopic left nephrectomy was performed exclusively with a single site technique through a multi-channel single port (TriPort, Advanced Surgical Concepts/Olympus) and a 12 mm umbilical incision. The procedure began with medial retraction of the left colon and the identification and initial dissection of the kidney. Once identified, the renal pelvis was incised and drained. The left ureter was completely mobilized, divided, and used for retraction. The renal hilum was then dissected and divided between metal clips. The remaining attachments were dissected free. The kidney was placed in an Endo Catch bag (Covidien) and extracted via the single port incisional site. RESULTS: Operative time was 133 minutes and estimated blood loss (EBL) was minimal. Hospital stay was 1.4 days and uneventful. Virtually no scar was noted at the 5 week mark following the LESS nephrectomy. Our current experience is comprised of 8 pediatric LESS nephrectomies (7 left, 1 right) performed in 5 female and 3 male patients with mean age of 6 years (range: 1 month - 15.6 years) with weights ranging from 5.1 kg to 58 kg and a mean BMI of 17.3 (range: 13.3 - 24.8). Mean operative time was 132 minutes (range: 85 - 176 minutes), mean incision length was 16 mm (range 12 - 25mm), mean EBL ⬍5 cc’s, and mean hospital stay 1.5 days (range: 1.0 - 2.1 days). In 5 cases a 3mm accessory miniport was utilized. Postoperative hydrocele was observed in 2 cases. CONCLUSIONS: To our knowledge this is the youngest and smallest patient in which a LESS procedure has been performed to date. LESS nephrectomy for benign conditions can be safely performed in selected pediatric patients, providing virtually scarless results. Source of Funding: None

V1108 THE TECHNIQUE OF LUMBAR TO SACRAL NERVE REROUTING FOR VOIDING FUNCTION

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Kevin Feber*, Huntington Woods, MI; Holly Gilmer, Kenneth Peters, Royal Oak, MI

Michael Erhard, Ponte Vedra Beach, FL; Ngoc-Bich Le*, Gainesville, FL

INTRODUCTION AND OBJECTIVES: Lumbar to sacral nerve rerouting has a reported 87% success of restoring bladder and bowel function in spina bifida patients by the creation of a skin-CNS-bladder reflex arc. This video shows some of the technical aspects of this novel procedure. METHODS: Nine patients with a median age of 8 years underwent the procedure. Intradural lumbar to sacral nerve rerouting was

INTRODUCTION AND OBJECTIVES: Bladder diverticula are uncommon in children and can be congenital, acquired, or genetic in origin. Laparoscopic diverticulectomy has been described in children, but the surgery is technically difficult due to intracorporeal suturing and limited work space. For these reasons, we recently performed a robotic-assisted laparoscopic diverticulectomy. Herein, we present this novel approach for performing a diverticulectomy in a pediatric patient.

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METHODS: The patient first underwent cystoscopy and the opening of the diverticulum was noted to be just superomedial to the right ureteral orifice. Due to the diverticulum’s close proximity to the right ureteral orifice, a stent was placed in order to prevent unrecognized injury. We performed the robotic diverticulectomy with the 3-arm technique using the Intuitive Surgical Da Vinci S System. The 12mm camera port was placed in a supraumbilical incision, the 8mm ports were in bilateral upper quadrants of the abdomen, and the 5mm assistant port was placed in the left lower quadrant. The bladder was retracted anteriorly and we easily identified the diverticulum, right ureter, and vas deferens. The peritoneum was reflected off of the bladder. We dissected the diverticulum down to the level of the mucosa without compromising the adjacent ureter. Once the neck of the diverticulum was skeletonized, we only incised the anterior portion, leaving the posterior lip intact. This allowed us to use the attached diverticulum as a handle for tissue manipulation. We then closed the mucosal layer of the bladder with a 4-0 Monocryl suture with interlocking stitches. Once the first layer was closed, we amputated the diverticulum and passed it off for pathology through an 8mm port. The seromuscular layer was closed and then we placed imbricating sutures. After all 3 layers of closure were completed, we filled the bladder to verify that it was watertight. Finally, we closed the peritoneal defect RESULTS: Total operative time, from incision to closure, was 1hr and 49 minutes. Estimated blood loss was less than 10ml. Our patient experienced no complications and was discharged the following day after overnight observation. CONCLUSIONS: With robotic assistance, a surgeon can perform a diverticulectomy on a child through a small incision without sacrificing articular motion or ergonomics. The robot affords the surgeon the dexterity to place intracorporeal sutures deep in the pelvis with ease and precision. Placement of the ureteral catheter is strongly recommended if the diverticulum lies adjacent to the ureteral orifice. This will aid in the safe dissection and excision of the diverticulum Source of Funding: None

V1111 TRANSPERITONEAL LAPAROSCOPIC RETROCAVAL URETER CORRECTION Franco Gaboardi*, Francesco Scieri, Francesco Pietrantuono, Andrea Gregori, Antonio Granata, Ai Ling Romano’, Antonio Salvaggio, Giacomo Piero Incarbone, Milano, Italy INTRODUCTION AND OBJECTIVES: The retrocaval ureter is a congenital abnormality in which the right ureter passes behind the inferior vena cava, leading to varying degrees of ureteral compression. Surgery is required for the treatment of the hydronephrosis or related symptoms. The video shows “step by step” a transperitoneal laparoscopic transection of a retrocaval ureter with transposition and reanastomosis. METHODS: A 14 years-old girl presented to our institution with right lumbar pain and hydronephrosis. The CT showed a retrocaval ureter. We performed a transperitoneal laparoscopic transection of the retrocaval ureter with transposition and reanastomosis with 2 uninterrupted absorbable sutures (Vicryl 3.0). A mono-J ureteral stent (Contour VL™ Variable Length Percuflex®, Boston Scientific) is placed just before starting the laparoscopic approach. RESULTS: Operative time was 260 minutes, blood losses were negligible; on postoperative day 3 after a retrograde pyelography excluded contrast medium extravasation and the Contour stent was converted in a double J stent. Bladder catheter and the drain were respectively removed on postoperative day IV and V. The patient had no perioperative complications and was discharged on postoperative day IX. The ureteral stent was removed 28 days after surgery. The urography at 3 months showed regular patency of the anastomosis. CONCLUSIONS: The transperitoneal laparoscopic correction of the right retrocaval ureter is a feasible and minimally invasive. Source of Funding: None

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V1112 ROBOTIC-ASSISTED LAPAROSCOPIC EXCISION OF FIBROEPITHELIAL POLYPS CAUSING URETEROPELVIC JUNCTION OBSTRUCTION IN CHILDREN Candace Granberg*, Ty Higuchi, Janelle Fox, Rochester, MN; Yuri Reinberg, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Fibroepithelial polyps (FEP) causing obstruction of the ureteropelvic junction (UPJ) are uncommon in children. Complete excision of the polyp with concomitant dismembered pyeloplasty is curative. Here, we present a novel approach to management of UPJ obstruction secondary to FEP: roboticassisted laparoscopic Anderson-Hynes dismembered pyeloplasty with removal of the FEP. METHODS: From 2008 to 2009, 17 patients age 1-19 years underwent robotic-assisted laparoscopic dismembered pyeloplasty for UPJ obstruction. Three patients were found intraoperatively to have FEP at the UPJ. We retrospectively reviewed clinical patient demographics, pre-operative imaging, pathological evaluation, and follow-up data. RESULTS: Three of 17 patients (17.6%) were found to have FEP as the cause of UPJ obstruction at the time of robotic-assisted laparoscopic dismembered pyeloplasty. All 3 patients were male, and age at time of surgery was 7, 9, and 11 years. All presented with intermittent flank pain, nausea, and vomiting. Two patients were diagnosed with UPJ obstruction on the right and one on the left. Only one patient had suggestion of a FEP at the UPJ on pre-operative ultrasound. One patient had a filling defect at the UPJ on pre-operative retrograde pyelogram suggestive of a polyp. All patients underwent standard 4-port robotic-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty without complication. Polyps originated from the UPJ in all 3 patients, and were readily visible upon entering the renal pelvis. All polyps were removed in their entirety and pathologic examination confirmed that they were FEP. On follow-up imaging, all patients were asymptomatic with no obstruction on Lasix renogram. CONCLUSIONS: UPJ obstruction secondary to FEP can be treated safely and effectively with a robotic-assisted approach. With increased magnification and meticulous surgical technique, FEP can be completely excised with this method. Surgeons should be prepared for complete excision of FEP if suspected pre-operatively, and this finding should not preclude proceeding robotically. Source of Funding: None

V1113 SIMPLIFIED TECHNIQUE FOR ROBOTIC-ASSISTED LAPAROSCOPIC EXTRAVESICAL URETERAL REIMPLANTATION IN CHILDREN Philip H. Kim*, Mukul B. Patil, Justin H. Lee, Roger E. DeFilippo, Andy Y. Chang, Los Angeles, CA; Craig A. Peters, Charlottesville, VA; Brian E. Hardy, Chester J. Koh, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic ureteral reimplantation is an alternative to open surgery for reflux correction in pediatric patients. We describe a simplified, extravesical technique for robotic ureteral reimplantation that incorporates the principles of open anti-reflux surgery. METHODS: Robotic extravesical ureteral reimplantation was performed in 25 male and female pediatric patients (22 unilateral, 3 bilateral). Intraoperative videos were reviewed to describe methods for patient positioning, port placement, and surgical technique. Follow-up voiding cystourethrogram (VCUG) results were available for 12 patients (10 unilateral, 2 bilateral). RESULTS: Patients were secured in the supine, steep Trendelenburg position. An 8.5 mm camera port was placed at the umbilicus, two 5 mm instrument ports bilaterally, and a 5 mm assistant port in the upper quadrant contralateral to the affected ureter. Upon abdominal entry, the bladder and ureter were identified, along with the uterus, fallopian tube, and ovary in females and the vas deferens in males.