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V2-12 ROBOT-ASSISTED INTRACORPOREAL ILEAL NEOBLADDER: SIMPLIFIED STEP-BY-STEP TECHNIQUE AND SURGICAL OUTCOMES
THE JOURNAL OF UROLOGYâ
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
have described our experience with intracorporeal urinary diversions, including orthotopic ileal neobladder and ileal conduit. Intracorporeal urinary diversion remains an advanced technique focused in centers of excellence. To our knowledge, there have been no previous reports of robotic intracorporeal continent cutaneous diversion. Herein, we provide the first description of our technique of robotic intracorporeal continent cutaneous urinary diversion (Indiana pouch) following robotic cystectomy, including the results of our initial experience. METHODS: We perform a robotic cystoprostatectomy using a standard 6-port transperitoneal technique, as previously described. We provide a step-by-step illustration of our intracorporeal approach to right colonic mobilization, bowel segmentation, ileocolonic anastomosis, ureterocolonic anastomoses, and creation of a hand-sewn Indiana pouch continent cutaneous urinary diversion. We describe optimization of port utilization and technique for robot positioning. Tapering of the catheterization channel and reinforcement of ileocecal valve are performed via the standard extraction incision. RESULTS: Robotic intracorporeal Indiana pouch was successfully performed following robotic cystoprostatectomy. Only 2 additional port incisions were necessary to complete the diversion. Operative time for intracorporeal diversion was 180 minutes, with negligible blood loss, and without any intra-operative complications. Post-operative care followed a standardized clinical care pathway. Length of stay was 7 days. There were no major (Clavien 3-5) 90-day complications observed. Externalized ureteral stents are removed at 2 weeks. At 3 weeks post-operatively, a pouchgram is performed. The malecot drain is capped, and the patient begins catheterizing via the cutaneous stoma. The malecot is subsequently removed. CONCLUSIONS: We demonstrate robotic intracorporeal continent cutaneous urinary diversion following robotic cystectomy is technically feasible and safe. Early functional results are promising. To our knowledge, this is the first description of completely intracorporeal continent cutaneous diversion. Source of Funding: none
V2-12 ROBOT-ASSISTED INTRACORPOREAL ILEAL NEOBLADDER: SIMPLIFIED STEP-BY-STEP TECHNIQUE AND SURGICAL OUTCOMES Idir Ouzaid*, Riccardo Autorino, Dinesh Samarasekera, Vishnuvardhan Ganesan, Jayram Krishnan, Georges-Pascal Haber, Cleveland, OH INTRODUCTION AND OBJECTIVES: To detail our simplified technique for robotic intracorporeal ileal neobladder (NB) after robot assisted radical cystectomy (RARC). METHODS: Between January 2012 and July 2013, 12 consecutive RARC with intracorporeal NB were performed. A transperitoneal five-port approach using a 4-arm da Vinciâ robot (Intuitive Surgical, Sunnyvale, CA, USA) and one patient-side assistant was employed. Outcomes as well as surgical technique are reported. The enclosed video details the steps of the procedure including the bowel segment selection and anastomosis, the ileourethral anastomosis, the detubularization and neobladder reconstruction, and finally the ureteroileal anastomoses. RESULTS: All procedures were successfully completed. Main surgical parameters were as follows: average operative time 44257 min, estimated blood loss 420213 ml, and hospital stay 8.42.8 days. Complications occurred in 66.6% of the cases of which, 58.3 % were postoperative with 41.6% and 16.7% of the patients experiencing minor (grade 1-2) and major (grade 3-5) complications respectively. Readmission and secondary procedure were 25% and 16.7% respectively. CONCLUSIONS: Robotic intracorporeal NB represents a challenging surgical task. A simplified step-by-step approach allows a practical standardization of the procedure and ultimately facilitates its safe implementation. Source of Funding: None
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V2-13 DORSAL INLAY BUCCAL MUCOSAL GRAFT (BMG) URETHROPLASTY IN THE SINGLE-STAGE MANAGEMENT OF LONG ANTERIOR URETHRAL STRICTURES Fikret Onol*, Cem Basatac, Ahmet Tahra, Rasim Guzel, Ugur Boylu, Sinasi Yavuz Onol, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: The management of long anterior urethral strictures (extending from the meatus to the bulbar urethra) is challenging. Selected cases with an adequate urethral plate may benefit from single-stage reconstruction. In this study, we present our technique and results of dorsal inlay BMG urethroplasty for long anterior urethral strictures. METHODS: Between 2010 and 2012, 13 patients (mean age: 43.7 years) underwent dorsal inlay BMG urethroplasty for long anterior urethral strictures. All except 3 patients had a history of previous urethral dilatations and/or internal urethrotomy. The cause of stricture was lichen sclerosus in 8 and inflammatory/idiopathic in 5. Preoperative evaluation included subjective assessment of the severity of symptoms with the AUA symptom score, uroflowmetry with residual urine volume determination, combined retrograde urethrography (RU) and voiding cystourethrography (VCUG), and urethrocystoscopy by using a pediatric ureterorenoscope. Dorsal inlay BMG technique was used in all cases: the urethra was split along the stricture both ventrally and dorsally without mobilizing it from its bed, and the BMG was secured in the dorsal urethral defect. The urethra was then retubularized in one stage. Patients were followed with AUA symptom questionnaire and uroflowmetry at 3 monthly intervals in the first year and annually thereafter. Cure was defined as patient satisfaction associated with a normal-appearing flow curve at the last postoperative visit and the absence of any restenosis requiring additional intervention. RESULTS: The mean stricture length was 13 cm (range: 10-15 cm) and the mean BMG length was 14.5 cm (range: 11-17 cm). The mean operation time was 170 min (130-240 min.). Average hospital stay was 2.3 days (1-7). Cure was achieved in 11 of 13 men (84.6%) during a median follow-up of 24 (range: 6-36) months. Two patients had a stricture at the proximal part of the graft and were managed by visual internal urethrotomy. Qmax values at the last follow-up were significantly improved as compared to preoperative measurements (mean 22.79.3 ml/s versus 6.45.9 ml/sec, p¼0.001). The mean AUA symptom scores were also significantly improved (26.35.2 preoperatively vs. 6.22.8 postoperatively, p<0.001). CONCLUSIONS: Dorsal inlay BMG urethroplasty seems as an effective method for the management of long anterior urethral strictures. In this technique, the procedure is simplified by not mobilizing or dissecting the urethra, which potentially preserves its blood supply coming from both circumflex and perforating vessels. Source of Funding: none
V2-14 LAPAROSCOPIC HEMINEPHRECTOMY FOR A NON-FUNCTIONING LOWER MOIETY Mahmoud Shalaby*, Assiut, Egypt; Ahmed Shoma, Mansoura, Egypt; Adel Hajeb, Mohamed Shalaby, Assiut, Egypt INTRODUCTION AND OBJECTIVES: Magnification and delicate handling gave laparoscopy a good share in management of pathologies related to renal duplicity because such qualities aid in preservation of the blood supply to the intact moiety together with its ureter. This video demonstrates the technique of transperitoneal laparoscopic heminephrectomy for a hydronephrotic non-functioning lower moiety of a duplex Lt kidney. METHODS: Thirty-three years old male patient, presented with loin pain, hematuria and fever one month after blunt trauma to the left loin. Multidetector CT showed a hugely dilated lower moiety of the left kidney with turbid content and a stone in its draining ureter. Retrograde uretero-pyelography showed incomplete duplication of the ureter.
Vol. 191, No. 4S, Supplement, Sunday, May 18, 2014
have described our experience with intracorporeal urinary diversions, including orthotopic ileal neobladder and ileal conduit. Intracorporeal urinary diversion remains an advanced technique focused in centers of excellence. To our knowledge, there have been no previous reports of robotic intracorporeal continent cutaneous diversion. Herein, we provide the first description of our technique of robotic intracorporeal continent cutaneous urinary diversion (Indiana pouch) following robotic cystectomy, including the results of our initial experience. METHODS: We perform a robotic cystoprostatectomy using a standard 6-port transperitoneal technique, as previously described. We provide a step-by-step illustration of our intracorporeal approach to right colonic mobilization, bowel segmentation, ileocolonic anastomosis, ureterocolonic anastomoses, and creation of a hand-sewn Indiana pouch continent cutaneous urinary diversion. We describe optimization of port utilization and technique for robot positioning. Tapering of the catheterization channel and reinforcement of ileocecal valve are performed via the standard extraction incision. RESULTS: Robotic intracorporeal Indiana pouch was successfully performed following robotic cystoprostatectomy. Only 2 additional port incisions were necessary to complete the diversion. Operative time for intracorporeal diversion was 180 minutes, with negligible blood loss, and without any intra-operative complications. Post-operative care followed a standardized clinical care pathway. Length of stay was 7 days. There were no major (Clavien 3-5) 90-day complications observed. Externalized ureteral stents are removed at 2 weeks. At 3 weeks post-operatively, a pouchgram is performed. The malecot drain is capped, and the patient begins catheterizing via the cutaneous stoma. The malecot is subsequently removed. CONCLUSIONS: We demonstrate robotic intracorporeal continent cutaneous urinary diversion following robotic cystectomy is technically feasible and safe. Early functional results are promising. To our knowledge, this is the first description of completely intracorporeal continent cutaneous diversion. Source of Funding: none
V2-12 ROBOT-ASSISTED INTRACORPOREAL ILEAL NEOBLADDER: SIMPLIFIED STEP-BY-STEP TECHNIQUE AND SURGICAL OUTCOMES Idir Ouzaid*, Riccardo Autorino, Dinesh Samarasekera, Vishnuvardhan Ganesan, Jayram Krishnan, Georges-Pascal Haber, Cleveland, OH INTRODUCTION AND OBJECTIVES: To detail our simplified technique for robotic intracorporeal ileal neobladder (NB) after robot assisted radical cystectomy (RARC). METHODS: Between January 2012 and July 2013, 12 consecutive RARC with intracorporeal NB were performed. A transperitoneal five-port approach using a 4-arm da Vinciâ robot (Intuitive Surgical, Sunnyvale, CA, USA) and one patient-side assistant was employed. Outcomes as well as surgical technique are reported. The enclosed video details the steps of the procedure including the bowel segment selection and anastomosis, the ileourethral anastomosis, the detubularization and neobladder reconstruction, and finally the ureteroileal anastomoses. RESULTS: All procedures were successfully completed. Main surgical parameters were as follows: average operative time 44257 min, estimated blood loss 420213 ml, and hospital stay 8.42.8 days. Complications occurred in 66.6% of the cases of which, 58.3 % were postoperative with 41.6% and 16.7% of the patients experiencing minor (grade 1-2) and major (grade 3-5) complications respectively. Readmission and secondary procedure were 25% and 16.7% respectively. CONCLUSIONS: Robotic intracorporeal NB represents a challenging surgical task. A simplified step-by-step approach allows a practical standardization of the procedure and ultimately facilitates its safe implementation. Source of Funding: None
e361
V2-13 DORSAL INLAY BUCCAL MUCOSAL GRAFT (BMG) URETHROPLASTY IN THE SINGLE-STAGE MANAGEMENT OF LONG ANTERIOR URETHRAL STRICTURES Fikret Onol*, Cem Basatac, Ahmet Tahra, Rasim Guzel, Ugur Boylu, Sinasi Yavuz Onol, Istanbul, Turkey INTRODUCTION AND OBJECTIVES: The management of long anterior urethral strictures (extending from the meatus to the bulbar urethra) is challenging. Selected cases with an adequate urethral plate may benefit from single-stage reconstruction. In this study, we present our technique and results of dorsal inlay BMG urethroplasty for long anterior urethral strictures. METHODS: Between 2010 and 2012, 13 patients (mean age: 43.7 years) underwent dorsal inlay BMG urethroplasty for long anterior urethral strictures. All except 3 patients had a history of previous urethral dilatations and/or internal urethrotomy. The cause of stricture was lichen sclerosus in 8 and inflammatory/idiopathic in 5. Preoperative evaluation included subjective assessment of the severity of symptoms with the AUA symptom score, uroflowmetry with residual urine volume determination, combined retrograde urethrography (RU) and voiding cystourethrography (VCUG), and urethrocystoscopy by using a pediatric ureterorenoscope. Dorsal inlay BMG technique was used in all cases: the urethra was split along the stricture both ventrally and dorsally without mobilizing it from its bed, and the BMG was secured in the dorsal urethral defect. The urethra was then retubularized in one stage. Patients were followed with AUA symptom questionnaire and uroflowmetry at 3 monthly intervals in the first year and annually thereafter. Cure was defined as patient satisfaction associated with a normal-appearing flow curve at the last postoperative visit and the absence of any restenosis requiring additional intervention. RESULTS: The mean stricture length was 13 cm (range: 10-15 cm) and the mean BMG length was 14.5 cm (range: 11-17 cm). The mean operation time was 170 min (130-240 min.). Average hospital stay was 2.3 days (1-7). Cure was achieved in 11 of 13 men (84.6%) during a median follow-up of 24 (range: 6-36) months. Two patients had a stricture at the proximal part of the graft and were managed by visual internal urethrotomy. Qmax values at the last follow-up were significantly improved as compared to preoperative measurements (mean 22.79.3 ml/s versus 6.45.9 ml/sec, p¼0.001). The mean AUA symptom scores were also significantly improved (26.35.2 preoperatively vs. 6.22.8 postoperatively, p<0.001). CONCLUSIONS: Dorsal inlay BMG urethroplasty seems as an effective method for the management of long anterior urethral strictures. In this technique, the procedure is simplified by not mobilizing or dissecting the urethra, which potentially preserves its blood supply coming from both circumflex and perforating vessels. Source of Funding: none
V2-14 LAPAROSCOPIC HEMINEPHRECTOMY FOR A NON-FUNCTIONING LOWER MOIETY Mahmoud Shalaby*, Assiut, Egypt; Ahmed Shoma, Mansoura, Egypt; Adel Hajeb, Mohamed Shalaby, Assiut, Egypt INTRODUCTION AND OBJECTIVES: Magnification and delicate handling gave laparoscopy a good share in management of pathologies related to renal duplicity because such qualities aid in preservation of the blood supply to the intact moiety together with its ureter. This video demonstrates the technique of transperitoneal laparoscopic heminephrectomy for a hydronephrotic non-functioning lower moiety of a duplex Lt kidney. METHODS: Thirty-three years old male patient, presented with loin pain, hematuria and fever one month after blunt trauma to the left loin. Multidetector CT showed a hugely dilated lower moiety of the left kidney with turbid content and a stone in its draining ureter. Retrograde uretero-pyelography showed incomplete duplication of the ureter.