V12-07 ROBOTIC INTRACORPOREAL “PADUA ILEAL BLADDER”: SURGICAL TECHNIQUE, PERIOPERATIVE, ONCOLOGIC AND FUNCTIONAL OUTCOMES

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and median length of stay was 2 days (2-12). All cases were completed robotically. Intraoperative blood loss was negligible. Four patients experienced a Clavien grade II complication (urinary tract infection requiring antibiotics). At a median follow-up of 320 days (55-907) no recurrences occurred. CONCLUSIONS: Robotic ureteral reimplantation for ureteroenteric strictures is a safe and highly effective procedure. Given the suboptimal success rate of endoscopic treatment, robotic repair has become a first treatment option in our centers. Source of Funding: none

V12-04 ROBOT ASSISTED ORTHOTOPIC MODIFIED STUDER NEOBLADDER Hubert John*, Christian Padevit, Kevin Horton, Winterthur, Switzerland; Abolfazl Hosseini, Peter Wiklund, Karolinska Stockholm, Sweden INTRODUCTION AND OBJECTIVES: Robotic intracorporeal orthotopic neobladder after radical cystectomy and extended lymphadenectomy is a technically challenging procedure. So far, only a few centers worldwide have taken this procedure into routine. After over 1000 procedures and routinely performed intracorporeal Bricker urinary deviation, the swiss team started with the intracorporeal neobladder technique carefully. The video presents our standardized technique in 10 patients after one first proctored surgery by a mentoring team (AH/PW). METHODS: A daVinci SI-system with 4 arms and 6-port access was used. The left ureter is drawn unter the mesorectum to the right side. 50cm are needed for the pouch. The urethro-ileal anastomosis with a 3-0 barbed suture is performed after an approximation of rectoprostatic fascia and the ileal sling. A 60mm/45mm stapler ileo-ileostomy is established. Two holding sutures are placed 10cm proximal from the urethroileal anastomosis, marking the deepest point of the pouch. The ileum is opened at the antimesenteric side over 40cm and the posterior wall is closed using 3-0 barbed running suture. Than, the distal ventral pouch is closed. The distal ureters were incised and a Wallace plate was formed. The ureters are stented through the abdominal wall and the chimney with Ch8 mono-J catheters. The ileoureteral anastomosis is performed with a 3-0 double arm running suture. The last anterior segment of the pouch is closed and than proved for water tightness. RESULTS: Operative time (skin-skin) was 575(420-725) minutes, bleeding 600(200-1000)ml. 1 patient required invasive ventilaton more than 24h. Time to flatus was 2(1-5) days, to bowel movement 4(3-10) days. The in-hospital stay was 15(9-27) days. There were no reoperations within 30days and no 30d- mortality. There were no positive margins nor positive lymph nodes in 22(15-43) removed nodes. The indwelling catheters remained 26(17-40) days, all pouches voided subsequently without residual urine. CONCLUSIONS: Robotic intracorporeal urinary diversion with a modified orthotopic Studer neobladder is a technically demanding procedure. With a standardized setting, the procedure is feasable in experienced robotic teams with promising intraoperativ and early postoperative results. Still, long termin pouch function, metabolism and oncological follow-up have to be observed critically.

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technical complexity (abdominal adhesions and altered anatomy after cystectomy). We sought to describe our experience in robot-assisted (RA) reoperations following RARC. METHODS: We retrospectively review 406 RARCs performed by a single surgeon between 2005 and 2015. Data were reviewed for demographics, preoperative disease, and operative and perioperative outcomes. Surgical interventions for RARC-specific complications were identified and RA technique described. RESULTS: For ureteroileal complications: 12 RA versus 7 open. Both had comparable perioperative outcomes. Fistula repair: 5 RA versus 6 open. Although patients in the RA group had longer operative times, they had shorter hospital stay (4 versus 10 days) and none of them required further intervention (4 in the open group did). Bowel obstruction that failed conservative treatment: 4 RA versus 7 open. Further intervention was required in 2 patients in the RA. Parastomal hernia repair: 4 RA and 2 open (one failed). CONCLUSIONS: Our initial experience with RA management of RARC complications appears safe and feasible, although the decision to proceed is determined primarily by surgeon experience. Source of Funding: Roswell Park Alliance Foundation

V12-06 UTILIZATION OF INDOCYANINE GREEN FLUORESCENCE ANGIOGRAPHY DURING INTRACORPOREAL URETERO-ILEAL ANASTOMOSIS FOLLOWING ROBOTIC RADICAL CYSTECTOMY Daniel Melecchi Freitas*, Carlos Fay, Nariman Ahmadi, Andre Abreu, Toshitaka Shin, Inderbir Gill, Andre Berger, Mihir Desai, Monish Aron, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Indocyanine-green (ICG) is an exogenous tracer approved by he FDA and is currently used in several urological procedures such as partial nephrectomies to reveal vascular anatomy and tissue perfusion. METHODS: In this video we report our initial experience and proof-of-concept in 10 patients who underwent robotic-assisted radical cystectomy with intracorporeal diversion where ICG was utilized prior to perform uretero-ileal anastomosis to assess ureteric vascularity. RESULTS: In our cohort of 10 patients, 7 patients required resection of distal ureter in at least one ureter. Three patients required bilateral distal ureteral resection, three patients required left and one patient required right distal ureter resection. The median resected ureteral lenght was 2cm. The median operation time 510 minutes. Complications were found in 3 patients, fever in two and ileus in one (Clavien II). The median length of stay was 5.5 days and the median follow-up was 81 days. CONCLUSIONS: Intravenous injection of ICG before ureteroileal anastomosis is useful to evaluate distal ureteral vascularity. It helps to identify and excise the non-vascularized ureteral segment. Long term follow-up will be necessary to evaluate the benefits of ICGuse to prevent ureteroileal strictures. Source of Funding: none

Source of Funding: None

V12-07 V12-05 REVISITING THE ABDOMEN AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY: TIPS AND TRICKS FOR ROBOT-ASSISTED REPAIR Ahmed Hussein*, Justen Kozlowski, Youssef Ahmed, Khurshid Guru, Buffalo, NY INTRODUCTION AND OBJECTIVES: Reoperations following robot-assisted radical cystectomy (RARC) are challenging owing to

ROBOTIC INTRACORPOREAL “PADUA ILEAL BLADDER”: SURGICAL TECHNIQUE, PERIOPERATIVE, ONCOLOGIC AND FUNCTIONAL OUTCOMES Giuseppe Simone*, Rocco Papalia, Leonardo Misuraca, Gabriele Tuderti, Francesco Minisola, Mariaconsiglia Ferriero, Giulio Vallati, Salvatore Guaglianone, Michele Gallucci, Rome, Italy INTRODUCTION AND OBJECTIVES: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a

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challenging procedure. The need for surgical skills and long operative times have led to concern about its reproducibility. The aim of this video is to illustrate our technique for RARC and totally intracorporeal orthotopic “Padua Ileal Bladder”. METHODS: From August 2012 to February 2014, 45 patients underwent RARC, extended pelvic lymph node dissection and intracorporeal partly stapled neobladder at a single tertiary referral centre. Surgical steps are demonstrated in the accompanying video. Demographics, clinical and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS: Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305 minutes (IQR 282-345). Median estimated blood loss was 210 ml (IQR 50-250). Median hospital stay was 9 days (IQR7e12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8% and 77.8%, respectively, while severe complications occurred in 17.8%, 17.8% and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Twoyr disease free survival, cancer specific survival and overall survival rates were 72.5%, 82.3% and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS: Our experience supports the feasibility of totally intracorporeal neobladder following ?RARC. Operative times and perioperative complication rate are likely to be reduced with increasing experience. Source of Funding: none

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months after surgery it increased to 1.33 mg/dL. The CT scan showed the right kidney without any change, there was no limphnode or visceral metastasis, the left kidney had adequate contrast enhancement, and there was ureteral hydronephrosis till the implant in the Bricker, without patency for contrast. There was no sign of metastasis in the implant. With a follow-up of one year after the uretero-ileal bypass, patient is assimptomatic, serum creatinine decreased to 0,92 mg/dL, and image control shows total resolution of hydronephrosis. CONCLUSIONS: Latero-lateral ureteroenteric anastomosis is a feasible treatment option for benign anastomotic strictures. It can be performed either by open or minimally invasive approaches with good perioperative outcomes

Source of Funding: none

V12-09 ANATOMIC ROBOT ASSISTED RADICAL CYSTECTOMY IN FEMALE: STEP BY STEP TECHNIQUE

V12-08 URETEROILEAL BYPASS: A NEW ROBOTIC TECHNIC TO TREAT URETEROENTERERIC STRICTURES IN URINARY DIVERSION Guilherme Padovani*, Rubens Park, Marcos Mello, Rafael Coelho, Leonardo Borges, Adriano Nessralah, Miguel Srougi, William Nahas, ~o Paulo, Brazil Sa INTRODUCTION AND OBJECTIVES: Bladder cancer is the ninth most frequently cancer diagnosed worldwide. The standard definitive treatment for MIBC is radical cystectomy (RC) and urinary reconstruction. Complications of RC and diversion can appear after months or years of surgical treatment. Ureteroentereric strictures are a late complication after cystectomy and diversion that occur in 2% to 15% of patients. 4-6 Multiple treatment alternatives have been proposed to those strictures with variable success rates, ureteral reimplantation is still considered the gold standard surgical treatment 7. However, the surgical approach to the ureteroenteric anastomosis can be challenging due to fibrosis and adhesions. We propose herein a technical modification aiming to minimize ureteral dissection; the technique involves a latero-lateral anastomosis of the dilated ureter with the ileal conduit without detaching de ureter from the intestinal segment. Our experience with this technical modification is described. METHODS: We reported a patient submitted to uretero-ieal bypass to treat uretero-enteric stricture in Bricker implant. The technique was made robot-assisted, and it is shown in the figure. RESULTS: The case reported is a 70 years-old man, without any comorbities, diagnosed with muscle invasive bladder cancer after transuretral ressection. He was subbmited to RobotAssisted RC with intracorporeal Bricker diversion, without any major complications. The pathologic report of cistectomy was high grade urothelial carcinoma pT2 N0. With 3 months of follow-up, patient refered left flank pain, without any report of urinary infecction. Serum Creatinine before cistetomy was 0.8 mg/dL, and 3

Giuseppe Simone, Salvatore Guaglianone, Leonardo Misuraca*, Francesco Minisola, Gabriele Tuderti, Mariaconsiglia Ferriero, Giuseppe Romeo, Michele Gallucci, Rome, Italy INTRODUCTION AND OBJECTIVES: Robot assisted radical cystectomy in female for bladder cancer is a challenging urologic surgical procedure. We describe step by step surgical technique and present perioperative outcomes of a single patient who underwent a robot assisted radical cystectomy (RARC) with totally intracorporeal orthotopic neobladder (iON). METHODS: A 66 yr-old female patient with a cT1/N0/M0 high grade BCG refractory recurrent bladder cancer, underwent RARC and iON.?Key steps of surgery include: the ligation of gonadic pedicles, meticulous dissection of the umbilical and uterine artery and the ureter, dissection of the bladder pedicle, opening of the vagina and creation of the plane between vagina and bladder. Cut of the urethra and securing the Foley catheter with the entire specimen placed into an Endocatch bag to minimize any urine spillage. Removal of the specimen into an endocatch bag through the vagina. Extended pelvic lymph node dissection. Suture of the vagina and creation of a peritoneal flap as posterior neobladder support. RESULTS: The procedure was successfully completed. Operative time was 295 minutes, EBL was 250 mL, time to flatus was 3 days, time to bowel was 7 days. Hemoglobin and creatinine at discharge were 10.3 g/dL and 0.76 mg/dL, respectively. The hospital stay was 8 days. The pathologic stage was pT0 pN0. The number of nodes removed was 26. Postoperative course was uneventful. The patient recovered daytime continence 45 days after surgery. CONCLUSIONS: A meticulous dissection of vascular suppliers of the bladder, a natural orifice specimen retrieval and the ease of posterior neobladder support thanks to a perfect vision of the small pelvis anatomic structures may contribute to minimize invasiveness and to improve perioperative outcomes of radical cystectomy in female patients. Source of Funding: none