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V2-09 ELECTROVAPORIZATION OF LARGE BLADDER DIVERTICULUM
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THE JOURNAL OF UROLOGYâ
V2-07 CYSTOSCOPIC FINDINGS OF PLACENTA PERCRETA WITH BLADDER INVOLVEMENT Ahmed Alghrouz*, Stephanie Tran, Satyan Shah, Albuquerque, NM INTRODUCTION AND OBJECTIVES: Placenta percreta is a rare obstetric complication that can be fatal secondary to uncontrolled hemorrhage. Urologists are often consulted late in this condition and may be unaware of its evaluation. In this video, we highlight key cystoscopic findings of placenta percreta involving the bladder. METHODS: Video clips from two multiparous women with placenta percreta invading the bladder are used to highlight cystoscopic findings of this condition: 1) Submucosally pulsating arterial vessels 2) Location of abnormal vessels predominantly in the dome and posterior wall 3) Absence of trigone involvement. RESULTS: Cystoscopy with bilateral ureteral stent placement was performed in both patients just prior to cesarean delivery. In the first case, cystoscopy helped guide the extent of en-bloc partial cystectomy during subsequent hysterectomy, since separation of the uterus away from bladder is contraindicated. Estimated blood loss (EBL) was 2500cc. In the second case, cystoscopy confirmed the diagnosis of bladder invasion after MRI images failed to show bladder involvement. Hysterectomy was delayed for 2 weeks after cesarean delivery in an effort to preserve the bladder, and the patient received methotrexate in the interim. Repeat cystoscopy before the hysterectomy confirmed regression of the placental vessels, making partial cystectomy unnecessary. EBL was 300cc. CONCLUSIONS: Knowledge of these cystoscopic findings can help urologists diagnose and manage placenta percreta involving the bladder. Source of Funding: None
V2-08 TRANSVAGINAL BLADDER NECK CLOSURE FOR THE DEVASTATED FEMALE URETHRA Gregory Murphy*, Farmington, CT; Richard Kershen, Hartford, CT INTRODUCTION AND OBJECTIVES: Management of female urinary retention or incontinence with a chronically indwelling urethral catheter inevitably leads to urethral destruction over time. Incontinence from an eroded or patulous urethra not only worsens quality of life but also may result in skin breakdown and non-healing decubitus ulcers particularly in neurologically injured patients. Management of the destroyed urethra is especially difficult as pubovaginal slings are rendered impossible and abdominal approaches to bladder neck closure can be morbid in the debilitated patient. Herein we present our video of transvaginal (TV) bladder neck closure with posterior urethral flap for treatment of the devastated female urethra as described by Rovner et al. (Urology 2011) METHODS: Our patient is a 63 year old, obese, diabetic, paraplegic female with chronic neurogenic bladder after a prior spinal cord stroke. She is unable to self catheterize and had been managed for years with an indwelling urethral foley. This eventually lead to destruction of her urethra, total urinary incontinence and chronic non-healing decubitus ulcers. Insertion of a suprapubic tube and three prior attempts at bladder neck closure were unsuccessful in resolving her leakage. She was referred to our institution where we performed a multi-layered TV bladder neck closure with Martius flap interposition. RESULTS: The operation was uneventful. Operative time was 3.5 hours. EBL was 650 cc. The patient had her vaginal packing and labial penrose drain removed on POD#1 prior to discharge. She was seen in follow up at 3 months and her SPT was draining well, she had no vaginal leakage and her decubuti were steadily healing.
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
CONCLUSIONS: TV bladder neck closure is an effective, minimally invasive means of resolving the difficulties presented by the devastated female urethra, avoiding the risks associated with a transabdominal approach especially in the neurologically injured patient. Utilization of a posteriorly based urethral flap mitigates the risk of ureteral injury, while allowing the closure line to lie high in the retropubic space minimizing the risk of fistula formation. Source of Funding: None
V2-09 ELECTROVAPORIZATION OF LARGE BLADDER DIVERTICULUM Ryan Chandhoke*, Bilal Farhan, Gamal Ghoniem, Orange, CA INTRODUCTION AND OBJECTIVES: A bladder diverticulum which causes urinary complications requires intervention. There are several options for treatment. This is a case where we used a minimally invasive transurethral technique with electrovaporization of the diverticular mucosa as the primary treatment for an acquired bladder diverticulum due to an obstructive pubovaginal sling in a female patient. METHODS: A 63-year-old female presented to our institution in 2013 with complaints of incomplete bladder emptying, difficulty of urination with voiding only in a bent-over position, pelvic pain, and recurrent urinary tract infection (UTI). Her past surgical history included vaginal hysterectomy, rectocele repair with perineoplasty, placement of a pubovaginal sling with autologous fascia, and cystocele repair at an outside institution in 2001. Pelvic examination was unremarkable. Flexible cystoscopy revealed a normal urethra and a large left lateral wall diverticulum. The mouth of the diverticulum was wide and showed no abnormalities. Fluorourodynamic images re-demonstrated the large diverticulum which balllooned during voiding. The bladder emptied to completion while the diverticulum retained the contrast. The diagnosis was that of bladder outlet obstruction at the mid-urethral level. Follow up residual urine measurements showed higher volumes of 400mL which could be attributed to the growing diverticulum. The patient underwent partial urethrolysis with excision of the fascial sling. Her urination became easier and did not require changing position. She continued, however, to have incomplete bladder emptying and recurrent UTI due to the diverticulum. Electrovaporization was performed of the entire diverticular mucosa utilizing a bipolar button vaporization electrode. Only the coagulation setting was used at a power of 160 watts. There was no evidence of bleeding or perforation during the operation. Total electrovaporization time lasted thirty minutes. An indwelling urethral catheter was placed at the end of the case and left in for a total of six weeks. RESULTS: The patient did well postoperatively. Voiding cystourethrogram at six weeks showed a significant reduction in diverticular size. The Foley catheter was removed and the patient was able to void without difficulty with minimal residual urine and no urinary tract infections. CONCLUSIONS: Electrovaproization of a bladder diverticulum is a minimally invasive technique with similar clinical outcome to open and laparoscopic diverticulectomy. Its ease of surgery with a faster operating and recovery time exemplifies its usefulness in the clinical setting. Source of Funding: none
V2-10 VAGINAL APPROACH TO VESICOUTERINE FISTULA ~ o Jr*, Lucas Gon, Raphael Pioli, Cassio Riccetto, Eder Braza Paulo Palma, Campinas, Brazil INTRODUCTION AND OBJECTIVES: Vesicouterine fistula is a rare cause of genitourinary fistulas. Close relation between bladder
THE JOURNAL OF UROLOGYâ
V2-07 CYSTOSCOPIC FINDINGS OF PLACENTA PERCRETA WITH BLADDER INVOLVEMENT Ahmed Alghrouz*, Stephanie Tran, Satyan Shah, Albuquerque, NM INTRODUCTION AND OBJECTIVES: Placenta percreta is a rare obstetric complication that can be fatal secondary to uncontrolled hemorrhage. Urologists are often consulted late in this condition and may be unaware of its evaluation. In this video, we highlight key cystoscopic findings of placenta percreta involving the bladder. METHODS: Video clips from two multiparous women with placenta percreta invading the bladder are used to highlight cystoscopic findings of this condition: 1) Submucosally pulsating arterial vessels 2) Location of abnormal vessels predominantly in the dome and posterior wall 3) Absence of trigone involvement. RESULTS: Cystoscopy with bilateral ureteral stent placement was performed in both patients just prior to cesarean delivery. In the first case, cystoscopy helped guide the extent of en-bloc partial cystectomy during subsequent hysterectomy, since separation of the uterus away from bladder is contraindicated. Estimated blood loss (EBL) was 2500cc. In the second case, cystoscopy confirmed the diagnosis of bladder invasion after MRI images failed to show bladder involvement. Hysterectomy was delayed for 2 weeks after cesarean delivery in an effort to preserve the bladder, and the patient received methotrexate in the interim. Repeat cystoscopy before the hysterectomy confirmed regression of the placental vessels, making partial cystectomy unnecessary. EBL was 300cc. CONCLUSIONS: Knowledge of these cystoscopic findings can help urologists diagnose and manage placenta percreta involving the bladder. Source of Funding: None
V2-08 TRANSVAGINAL BLADDER NECK CLOSURE FOR THE DEVASTATED FEMALE URETHRA Gregory Murphy*, Farmington, CT; Richard Kershen, Hartford, CT INTRODUCTION AND OBJECTIVES: Management of female urinary retention or incontinence with a chronically indwelling urethral catheter inevitably leads to urethral destruction over time. Incontinence from an eroded or patulous urethra not only worsens quality of life but also may result in skin breakdown and non-healing decubitus ulcers particularly in neurologically injured patients. Management of the destroyed urethra is especially difficult as pubovaginal slings are rendered impossible and abdominal approaches to bladder neck closure can be morbid in the debilitated patient. Herein we present our video of transvaginal (TV) bladder neck closure with posterior urethral flap for treatment of the devastated female urethra as described by Rovner et al. (Urology 2011) METHODS: Our patient is a 63 year old, obese, diabetic, paraplegic female with chronic neurogenic bladder after a prior spinal cord stroke. She is unable to self catheterize and had been managed for years with an indwelling urethral foley. This eventually lead to destruction of her urethra, total urinary incontinence and chronic non-healing decubitus ulcers. Insertion of a suprapubic tube and three prior attempts at bladder neck closure were unsuccessful in resolving her leakage. She was referred to our institution where we performed a multi-layered TV bladder neck closure with Martius flap interposition. RESULTS: The operation was uneventful. Operative time was 3.5 hours. EBL was 650 cc. The patient had her vaginal packing and labial penrose drain removed on POD#1 prior to discharge. She was seen in follow up at 3 months and her SPT was draining well, she had no vaginal leakage and her decubuti were steadily healing.
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
CONCLUSIONS: TV bladder neck closure is an effective, minimally invasive means of resolving the difficulties presented by the devastated female urethra, avoiding the risks associated with a transabdominal approach especially in the neurologically injured patient. Utilization of a posteriorly based urethral flap mitigates the risk of ureteral injury, while allowing the closure line to lie high in the retropubic space minimizing the risk of fistula formation. Source of Funding: None
V2-09 ELECTROVAPORIZATION OF LARGE BLADDER DIVERTICULUM Ryan Chandhoke*, Bilal Farhan, Gamal Ghoniem, Orange, CA INTRODUCTION AND OBJECTIVES: A bladder diverticulum which causes urinary complications requires intervention. There are several options for treatment. This is a case where we used a minimally invasive transurethral technique with electrovaporization of the diverticular mucosa as the primary treatment for an acquired bladder diverticulum due to an obstructive pubovaginal sling in a female patient. METHODS: A 63-year-old female presented to our institution in 2013 with complaints of incomplete bladder emptying, difficulty of urination with voiding only in a bent-over position, pelvic pain, and recurrent urinary tract infection (UTI). Her past surgical history included vaginal hysterectomy, rectocele repair with perineoplasty, placement of a pubovaginal sling with autologous fascia, and cystocele repair at an outside institution in 2001. Pelvic examination was unremarkable. Flexible cystoscopy revealed a normal urethra and a large left lateral wall diverticulum. The mouth of the diverticulum was wide and showed no abnormalities. Fluorourodynamic images re-demonstrated the large diverticulum which balllooned during voiding. The bladder emptied to completion while the diverticulum retained the contrast. The diagnosis was that of bladder outlet obstruction at the mid-urethral level. Follow up residual urine measurements showed higher volumes of 400mL which could be attributed to the growing diverticulum. The patient underwent partial urethrolysis with excision of the fascial sling. Her urination became easier and did not require changing position. She continued, however, to have incomplete bladder emptying and recurrent UTI due to the diverticulum. Electrovaporization was performed of the entire diverticular mucosa utilizing a bipolar button vaporization electrode. Only the coagulation setting was used at a power of 160 watts. There was no evidence of bleeding or perforation during the operation. Total electrovaporization time lasted thirty minutes. An indwelling urethral catheter was placed at the end of the case and left in for a total of six weeks. RESULTS: The patient did well postoperatively. Voiding cystourethrogram at six weeks showed a significant reduction in diverticular size. The Foley catheter was removed and the patient was able to void without difficulty with minimal residual urine and no urinary tract infections. CONCLUSIONS: Electrovaproization of a bladder diverticulum is a minimally invasive technique with similar clinical outcome to open and laparoscopic diverticulectomy. Its ease of surgery with a faster operating and recovery time exemplifies its usefulness in the clinical setting. Source of Funding: none
V2-10 VAGINAL APPROACH TO VESICOUTERINE FISTULA ~ o Jr*, Lucas Gon, Raphael Pioli, Cassio Riccetto, Eder Braza Paulo Palma, Campinas, Brazil INTRODUCTION AND OBJECTIVES: Vesicouterine fistula is a rare cause of genitourinary fistulas. Close relation between bladder