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V12-09 COMPLEX ROBOTIC URETEROPLASTY USING BUCCAL MUCOSAL ONLAY GRAFT FOR TREATMENT OF 3CM PROXIMAL URETERAL STRICTURE
THE JOURNAL OF UROLOGYâ
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
V12-08 EXTRAPERITONEAL ROBOT-ASSISTED REPAIR OF A PELVIC FRACTURE ASSOCIATED URETHRAL INJURY Vineet Agrawal, Helen R. Levey*, Robert Davis, Jean Joseph, Rochester, NY INTRODUCTION AND OBJECTIVES: The gold standard for management of posterior urethral injuries has been a topic of debate. In this video, we demonstrate to our knowledge, the first case of successful management of a pelvic fracture associated urethral injury in a young male, with utilization of robot-assisted surgery. METHODS: Twenty-four hours following pelvic injury, a 25year-old man underwent an extraperitoneal robotic bladder and urethral repair. Primary repair of the membranous urethra was performed with a concomitant extraperitoneal bladder injury repair. A suprapubic tube, Foley catheter and Blake drain were left in place. RESULTS: Follow-up cystogram and peri-catheter urethrogram three weeks later showed no contrast extravasation. The suprapubic and urethral catheters were removed at 3 weeks and 5 weeks post-op respectively. Flexible cystoscopy demonstrated a well-healed anastomosis. At the 3 and 6 months follow-up, the patients reports normal voiding and erectile function. CONCLUSIONS: We present to our knowledge the first case of immediate management of a pelvic fracture associated urethral injury using robot-assistance. This contrasts with the traditional practice of immediate SP tube diversion and delayed urethroplasty 3- 6 months following injury. Immediate repair using a robot-assisted approach is worth considering as we seek to shorten the convalescence of our affected patients, with no long-term sequelae. Source of Funding: None
V12-09 COMPLEX ROBOTIC URETEROPLASTY USING BUCCAL MUCOSAL ONLAY GRAFT FOR TREATMENT OF 3CM PROXIMAL URETERAL STRICTURE Carrie Stewart*, Michael Maddox, Michael Ellis, Benjamin Lee, New Orleans, LA INTRODUCTION AND OBJECTIVES: Ureteral strictures of the proximal ureter >2cm pose a difficult management dilemma. Options for repair include ileal ureter bowel interposition, autotransplantation, transureteroureterostomy in situations where the distance can not be bridged by pyeloplasty þ/- nephropexy. In this video we present a stepby-step alternative technique for successful use of buccal mucosa for repair of a ureteral stricture. METHODS: A 28-year-old male was referred with an iatrogenic ureteral stricture 3cm and left flank pain. He had undergone multiple prior ureteroscopy for stone disease, the suspected cause of his stricture disease, and two prior endopyelotomies. Cystoscopy and retrograde pyelogram demonstrated a 3 cm stricture at the proximal ureter with a small renal pelvis. The distance from the renal pelvis was too large to have a tension free pyeloplasty. Relative functional decrease from 45% to 40% on the symptomatic side was seen on his nuclear medicine renal scan. The patient was consented for robotic assisted laparoscopic buccal mucosa ureteroplasty. RESULTS: Buccal mucosa was harvested by otolaryngology and utilized for ureteral reconstruction. Technical steps, emphasized in the video, include the following: 1) Buccal mucosa harvested using Xylocaine with epinephrine; 2) Buccal mucosa fat debrided; 3) Colorenal ligaments divided to reflect bowel medially to expose ureter 4) Vessel loop used as a temporary hitch stitch to elevate, isolate and stabilize ureter; 5) With the robotic camera light dimmed, ureteroscopy is performed to identify the level of the stricture; 6) Stricture incised by making a ventral ureterotomy; 7) Using a running 4-0 Vicryl suture the buccal graft was secured to the ureterotomy as an onlay graft; 8)
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A double J ureteral stent is placed; 9) An omental wrap around the graft is performed. After minimal drain output, the patient was discharged the next morning. The ureteral stent was maintained for 6 weeks. Subsequent ureteroscopy performed at time of removal confirmed resolution of stricture and healthy, well-perfused graft tissue. CONCLUSIONS: This video demonstrates the key steps to perform a successful buccal mucosa onlay graft for treatment of a complex, 3 cm proximal ureteral stricture. Source of Funding: None
V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY Travis Pagliara*, Daniel Liberman, Sean Elliott, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Continent cutaneous ileal cecocystoplasty (CCIC) offers an effective treatment option for patients with a thick-walled neurogenic bladder. To achieve a tensionfree ileo-colic anastomosis, the right colon must be mobilized past the hepatic flexure via an extended laparotomy. We introduce hand-assisted laparoscopic right colon mobilization to allow for a tension-free bowel anastomosis through a Pfannenstiel incision. METHODS: A 10cm Pfannenstiel incision is used to begin mobilization of the cecum along the line of Toldt. A gel hand port is inserted and pneumoperitoneum is achieved. A 12mm camera port is inserted through the umbilicus under direct vision. A 5mm midline trocar is placed one handbreadth cephalad to the umbilicus. The right colon is grasped through the hand port and is mobilized past the hepatic flexure, using electro-dissection via the 5 mm port. A Kocher maneuver is continued until the inferior vena cava and duodenum are well exposed. The stapled ileo-colic anastomosis, staple-tapering of ileum, and bladder augmentation are performed in the usual open fashion. The stoma is matured through the umbilical port site. RESULTS: The hand-assisted laparoscopic modification of the CCIC has been performed on 20 patients at our institution with an average operative time of 4 hours. One case was aborted before bowel harvest when it was apparent that severe morbid obesity (body mass index of 60) and tight mesentery would preclude a tension-free anastomosis. There have been no bowel injuries or ileo-colic anastomotic leaks. CONCLUSIONS: CCIC using a hand-assisted laparoscopic mobilization of the right colon allows for a less invasive and more efficient bladder reconstructive procedure. Future research will explore whether there is a difference in hernia rates, wound complications or length of stay. Multiple Choice Question: Q: How far should the right colon be mobilized to ensure a tension-free ileo-colic anastomosis during continent cutaneous ileal cecocystoplasty A) not at all B) to the ileo-colic artery C) to the hepatic flexure D) past the hepatic flexure until the inferior vena cava E) past the gastrocolic ligament Explanation: To allow for a tension-free ileo-colic anastomosis during bladder augmentation surgery it is important mobilize the right colon past the hepatic flexure until the inferior vena cava. This allows for the bowel anastomosis to be done through a pfannenstiel incision without tension and injury to the mesentery. Source of Funding: None
Vol. 193, No. 4S, Supplement, Monday, May 18, 2015
V12-08 EXTRAPERITONEAL ROBOT-ASSISTED REPAIR OF A PELVIC FRACTURE ASSOCIATED URETHRAL INJURY Vineet Agrawal, Helen R. Levey*, Robert Davis, Jean Joseph, Rochester, NY INTRODUCTION AND OBJECTIVES: The gold standard for management of posterior urethral injuries has been a topic of debate. In this video, we demonstrate to our knowledge, the first case of successful management of a pelvic fracture associated urethral injury in a young male, with utilization of robot-assisted surgery. METHODS: Twenty-four hours following pelvic injury, a 25year-old man underwent an extraperitoneal robotic bladder and urethral repair. Primary repair of the membranous urethra was performed with a concomitant extraperitoneal bladder injury repair. A suprapubic tube, Foley catheter and Blake drain were left in place. RESULTS: Follow-up cystogram and peri-catheter urethrogram three weeks later showed no contrast extravasation. The suprapubic and urethral catheters were removed at 3 weeks and 5 weeks post-op respectively. Flexible cystoscopy demonstrated a well-healed anastomosis. At the 3 and 6 months follow-up, the patients reports normal voiding and erectile function. CONCLUSIONS: We present to our knowledge the first case of immediate management of a pelvic fracture associated urethral injury using robot-assistance. This contrasts with the traditional practice of immediate SP tube diversion and delayed urethroplasty 3- 6 months following injury. Immediate repair using a robot-assisted approach is worth considering as we seek to shorten the convalescence of our affected patients, with no long-term sequelae. Source of Funding: None
V12-09 COMPLEX ROBOTIC URETEROPLASTY USING BUCCAL MUCOSAL ONLAY GRAFT FOR TREATMENT OF 3CM PROXIMAL URETERAL STRICTURE Carrie Stewart*, Michael Maddox, Michael Ellis, Benjamin Lee, New Orleans, LA INTRODUCTION AND OBJECTIVES: Ureteral strictures of the proximal ureter >2cm pose a difficult management dilemma. Options for repair include ileal ureter bowel interposition, autotransplantation, transureteroureterostomy in situations where the distance can not be bridged by pyeloplasty þ/- nephropexy. In this video we present a stepby-step alternative technique for successful use of buccal mucosa for repair of a ureteral stricture. METHODS: A 28-year-old male was referred with an iatrogenic ureteral stricture 3cm and left flank pain. He had undergone multiple prior ureteroscopy for stone disease, the suspected cause of his stricture disease, and two prior endopyelotomies. Cystoscopy and retrograde pyelogram demonstrated a 3 cm stricture at the proximal ureter with a small renal pelvis. The distance from the renal pelvis was too large to have a tension free pyeloplasty. Relative functional decrease from 45% to 40% on the symptomatic side was seen on his nuclear medicine renal scan. The patient was consented for robotic assisted laparoscopic buccal mucosa ureteroplasty. RESULTS: Buccal mucosa was harvested by otolaryngology and utilized for ureteral reconstruction. Technical steps, emphasized in the video, include the following: 1) Buccal mucosa harvested using Xylocaine with epinephrine; 2) Buccal mucosa fat debrided; 3) Colorenal ligaments divided to reflect bowel medially to expose ureter 4) Vessel loop used as a temporary hitch stitch to elevate, isolate and stabilize ureter; 5) With the robotic camera light dimmed, ureteroscopy is performed to identify the level of the stricture; 6) Stricture incised by making a ventral ureterotomy; 7) Using a running 4-0 Vicryl suture the buccal graft was secured to the ureterotomy as an onlay graft; 8)
e979
A double J ureteral stent is placed; 9) An omental wrap around the graft is performed. After minimal drain output, the patient was discharged the next morning. The ureteral stent was maintained for 6 weeks. Subsequent ureteroscopy performed at time of removal confirmed resolution of stricture and healthy, well-perfused graft tissue. CONCLUSIONS: This video demonstrates the key steps to perform a successful buccal mucosa onlay graft for treatment of a complex, 3 cm proximal ureteral stricture. Source of Funding: None
V12-10 HAND-ASSISTED LAPAROSCOPIC RIGHT COLON MOBILIZATION FOR CONTINENT CUTANEOUS ILEAL CECOCYSTOPLASTY Travis Pagliara*, Daniel Liberman, Sean Elliott, Minneapolis, MN INTRODUCTION AND OBJECTIVES: Continent cutaneous ileal cecocystoplasty (CCIC) offers an effective treatment option for patients with a thick-walled neurogenic bladder. To achieve a tensionfree ileo-colic anastomosis, the right colon must be mobilized past the hepatic flexure via an extended laparotomy. We introduce hand-assisted laparoscopic right colon mobilization to allow for a tension-free bowel anastomosis through a Pfannenstiel incision. METHODS: A 10cm Pfannenstiel incision is used to begin mobilization of the cecum along the line of Toldt. A gel hand port is inserted and pneumoperitoneum is achieved. A 12mm camera port is inserted through the umbilicus under direct vision. A 5mm midline trocar is placed one handbreadth cephalad to the umbilicus. The right colon is grasped through the hand port and is mobilized past the hepatic flexure, using electro-dissection via the 5 mm port. A Kocher maneuver is continued until the inferior vena cava and duodenum are well exposed. The stapled ileo-colic anastomosis, staple-tapering of ileum, and bladder augmentation are performed in the usual open fashion. The stoma is matured through the umbilical port site. RESULTS: The hand-assisted laparoscopic modification of the CCIC has been performed on 20 patients at our institution with an average operative time of 4 hours. One case was aborted before bowel harvest when it was apparent that severe morbid obesity (body mass index of 60) and tight mesentery would preclude a tension-free anastomosis. There have been no bowel injuries or ileo-colic anastomotic leaks. CONCLUSIONS: CCIC using a hand-assisted laparoscopic mobilization of the right colon allows for a less invasive and more efficient bladder reconstructive procedure. Future research will explore whether there is a difference in hernia rates, wound complications or length of stay. Multiple Choice Question: Q: How far should the right colon be mobilized to ensure a tension-free ileo-colic anastomosis during continent cutaneous ileal cecocystoplasty A) not at all B) to the ileo-colic artery C) to the hepatic flexure D) past the hepatic flexure until the inferior vena cava E) past the gastrocolic ligament Explanation: To allow for a tension-free ileo-colic anastomosis during bladder augmentation surgery it is important mobilize the right colon past the hepatic flexure until the inferior vena cava. This allows for the bowel anastomosis to be done through a pfannenstiel incision without tension and injury to the mesentery. Source of Funding: None