V681 UTERINE PRESERVATION: BILATERAL SACROSPINOUS SUSPENSION USING MESH (UPHOLD ®)

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of pelvic organ prolapse using a mesh kit. To our knowledge, this the first reported purely transvaginal approach to the management of mesh complications involving the lower urinary tract. METHODS: Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit was performed. A reverse C-shaped incision was made in the anterior vaginal wall, mesh arms were identified laterally, divided and then dissected from the bladder. The bladder was closed in 3 layers transvaginally, followed by closure of the vaginal wall as a fourth layer. RESULTS: Removal of eroded mesh within the bladder was completed with all operative steps performed transvaginally. The patient was discharged home within 23 hours. There were no postoperative complications. CONCLUSIONS: Transvaginal removal of mesh erosion involving the bladder is safe, technically feasible, and allows for rapid return to normal function. Source of Funding: None

V678 LAPARO-ENDOSCOPIC SINGLE-SITE (LESS) EXTRAVESICAL REPAIR OF VESICOVAGINAL FISTULA Aly Abdel-Karim*, Ahmed Moussa, Salah Elsalmy, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: In this video we describe for the first time the technique of laparo-endoscopic single-site (LESS) extravesical repair of vesicovaginal fistula (VVF). METHODS: The case that we present in this video is a 52 years old female that presented with persistent urinary leakage per vagina following abdominal hysterectomy. Computed tomography (CT) of the abdomen and pelvis and cystoscopy revealed a supratrigonal vesicovaginal fistula. The fistula was repaired through extravesical LESS surgery using the R-port and curved instruments. The fistulas tract was identified and completely excised extravesically using sharp dissection. The edge of the bladder was trimmed at the site of fistulas tract. The vagina was closed in one layer with continuous 3/0 vicryl sutures, while urinary bladder was closed in 2 layers using 3/0 vicryl suture. An additional 5-mm extraport was added at time of suturing to allow triangulation and hand-free intracoprporeal suturing. An omental flap was interposed between the bladder and vagina. The urinary bladder was drained by an indwelling urethral catheter for 3 weeks. RESULTS: The operative time was 240 minutes. Blood loss was 90c.c. There were no intraoperative or postoperative complications. Postoperative hospital stay was 2 days. There was no postoperative urinary leakage. Follow up of the patient for 10 months showed complete continence and no recurrence of VVF. CONCLUSIONS: LESS extravesical repair of VVF is technically feasible and effective procedure that adheres to the principles of transabdominal open surgical repair. However, the technique requires advanced laparoscopic skills. Source of Funding: None

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tion, repair of fistula, flap placement, and post-operative care for the extra-vesicle approach to vesico-vaginal fistula repair are demonstrated in this video. RESULTS: Successful completion of robotic extravesicle repair of vesico-vaginal fistula is demonstrated in this video. CONCLUSIONS: Vesico vaginal fistula can be repaired robotically and utilizing the extra-vesicle approach utilizing the techniques demonstrated in this video. Source of Funding: None

V680 THE ELEVATE SYSTEM FOR ANTERIOR & APICAL VAGINAL PROLAPSE Larry T. Sirls, Dmitriy Nikolavsky*, Royal Oak, MI INTRODUCTION AND OBJECTIVES: The Elevate® polypropylene mesh system corrects pelvic organ prolapse (POP). Direct insertion of tined tipped mesh anchors into the sacrospinous ligament and pubococcygeus muscle avoid groin/perineal incisions and blind trocar passage. We report the Elevate® systems operative time, blood loss, post-operative pain, length of stay and peri-operative complications. METHODS: Retrospective review of inpatient/computerized records provided baseline, operative, and post-operative data. Operative data included compartment repaired, concurrent vaginal hysterectomy, operative time (OT), estimated blood loss (EBL), and adjacent organ injury. Post-operative data included changes in hemoglobin and hematocrit, blood transfusion, self reported pain scale, length of stay (LOS) and complications. Data were analyzed for each procedure type (anterior, posterior or total Elevate®) and separately for those having concurrent hysterectomy. RESULTS: Elevate® was used in 43 women between August 2009 and August 2010. Mean age was 68.4 ⫾ 10.2 years and body mass index (BMI) was 26.6 ⫾ 4.2. All patients had grade 3 or 4 prolapse. Anterior Elevate® was placed in 31, posterior Elevate® in 4, and 8 had a total Elevate®. Concurrent hysterectomy was done in 11 and these patients had anterior Elevate® only. Median OT for anterior, posterior, or total Elevate® without hysterectomy was 61, 57 and 101 minutes, median hemoglobin drop was 2.3, 2.6 and 2.3 gm respectively and LOS was 1, 1, 2 days respectively. Post-operative complications included 4 women requiring catheter reinsertion, 3 urinary tract infections (UTI), 1 hematoma and 1 pelvic abscess requiring drainage but not mesh removal. First 24 hour visual analog scale mean pain scores were 2.7, 2.8 and 0.6 on a 0-10 scale. Concurrent hysterectomy median OT was 148 minute and LOS was similar to the total mesh group at 2 days. Urethral catheter was reinserted in 4, 3 developed post op UTI. There were no adjacent organ injuries and no Elevate® patient required transfusion. CONCLUSIONS: POP repair with Elevate® avoids trocar passage, has short OT, minimal blood loss, and few complications. Patients have little pain and many are discharged home on the first post-operative day. Long-term observations are needed to assess Elevate mesh complications, failure rates and compare the outcomes with other mesh repair kits. Source of Funding: None

ROBOTIC-ASSISTED LAPAROSCOPIC VESICO-VAGINAL FISTULA REPAIR: THE EXTRA-VESICLE TECHNIQUE Alex Rogers, David Thiel*, Jacksonville, FL; Theodore Brisson, Charelston, SC; Steven Petrou, Jacksonville, FL INTRODUCTION AND OBJECTIVES: Vesico-vaginal fistulae are a known complication of hysterectomy. Open and vaginal repairs of vesico-vaginal fistulae have been described. All prior reports of laparoscopic and robotic vesico-vaginal fistula repair involve an intravesicle approach. We describe our extra-vesicle technique of robotic vesicovaginal fistula repair. METHODS: Pre-operative imaging, patient selection, patient positioning, fistula localization, port placement, intra-operative dissec-

V681 UTERINE PRESERVATION: BILATERAL SACROSPINOUS SUSPENSION USING MESH (UPHOLD ®) Gamal Ghoniem*, Melanie Crites, Bader Almosaieed, Weston, FL INTRODUCTION AND OBJECTIVES: Nowadays, many women desire to keep their uterus during pelvic prolapse repair. Sacrospinous suspension is generally highly effective and well tolerated surgical treatment for uterovaginal prolapse. Long term sup-

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port of the vaginal apex has been reported in 81–100% of cases after this procedure. We present our experience with using Uphold mesh for bilateral sacrospinous suspension without hysterectomy. METHODS: Detailed history and physical examination done (degree of prolapse and total vaginal length identified). The uterus screened for pathology by Pap smear and pelvic ultrasound. Questionnaire (UDI-6, IIQ-7, and QoL) were filled by all patients. After surgery, the patients were followed up in the clinic postoperatively after 4 – 6 weeks and evaluation included: physical examination to assess prolapse stage, presence of urinary retention, total vaginal length, presence of erosion, pain, and Visual analogue scale obtained and questionnaires redone. RESULTS: Six patients underwent vaginal sacrospinous suspension using Uphold mesh with uterine preservation at our centre. The average age of the patients was 70.3 years. Preoperatively stage 3 cystocele presented in 5 patients and stage 2 in one patient. Stage 1 rectocele presented in 5 patients and stage 0 in one patient. Stage 2 enterocele presented in 4 patients, stage one in one patient and stage 0 in another patient. All kinds of prolapses were down staged postoperatively to stage 0 in 3 patients and one in one patient at 6 weeks follow up visit with pending follow up in the other two patients. Follow up bladder scan, after 6 weeks, in 3 patients were 65, 117, and 14 cc. The average operative time was 88.4 minutes, average blood loss was 185 cc, and average hospital stay was 1.4 days. There was no wound infection, DVT, neither perforation nor erosion diagnosed for any patient postoperatively. There was no change in total vaginal length on follow up. CONCLUSIONS: Early experience with vaginal sacrospinous suspension using Uphold mesh with uterine preservation showed good outcome with short operative time, low blood loss, and low incidence of complications Source of Funding: None

V682 INTRACORPOREAL ROBOTIC-ASSISTED LAPAROSCOPIC ILEOVESICOSTOMY Lance Hampton, Adam Klausner, Blake Moore*, Richmond, VA INTRODUCTION AND OBJECTIVES: There are approximately 12 thousand new spinal cord injury (SCI) patients every year in the U.S. with an estimated prevalence of 260,000. These patients often have associated neurogenic bladder and may require treatment to reduce elevated bladder pressure and subsequent renal damage. Ileovesicostomy is a long-term surgical management option for patients who have failed medical or other conservative therapies. This video demonstrates the technique at our institution for intracorporeal robotic-assisted laparoscopic ileovesicostomy. METHODS: This video is a representation of our first 2 cases, a man and woman with prior SCI and associated neurogenic bladder. A 4-arm daVinci S system (Intuitive Surgical) was used with port placement similar to robotic prostatectomy including two assistant ports on the patient’s right. All bowel work was completed intracorporeally except for stoma maturation at the end of the procedure. RESULTS: The initial procedure was completed in 330 minutes including 205 minutes on the robot and 65 minutes for stoma maturation. The second case was completed in 244 minutes, 144 minutes on the robot and 43 minutes for stoma maturation. Length of stay was 6 and 8 days, respectively. Both cases were completed without intraoperative or postoperative complication. Both patients are currently managing their bladders successfully without intermittent/indwelling catheters. CONCLUSIONS: Intracorporeal robotic ileovesicostomy has been shown to be a safe and effective means for surgical management of neurogenic bladder in selected patients. Source of Funding: None

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V683 TRANSVAGINAL COLPOCLEISIS IN THE TREATMENT OF VAGINAL VAULT PROLAPSE IN THE ELDERLY FEMALE: SURGICAL TECHNIQUE Denise Chow*, Michelle Koski, Joanna Togami, Ralph Chesson, Ahmet Bedestani, J. Christian Winters, New Orleans, LA INTRODUCTION AND OBJECTIVES: Colpocleisis is an effective treatment for high grade pelvic organ prolapse. The colpocleisis procedure has traditionally been one that is underutilized by urologists. This is a video detailing the surgical technique of transvaginal colpocleisis. The essential steps of this technique will be highlighted. METHODS: The key components of the procedure include: 1) Delineation of the vaginal incision. 2) Full thickness vaginal dissection of the entire prolapse, from the bladder neck to proximity of the posterior fourchette and laterally to the levator musculature. 3) Excision of vaginal epithelium. 4) Sequential sutures to reduce the prolapse. 5) Perineorrhaphy including levator myorraphy. RESULTS: We have performed this procedure in over fifty patients for the treatment of vaginal vault prolapse with minimal complication and no recurrence. CONCLUSIONS: Colpocleisis is a safe and efficacious procedure for elderly females who are not sexually active and desire surgical correction of vaginal vault prolapse. In an aging patient population with expected increase in demand for pelvic floor reconstruction, colpocleisis is a useful approach for the urologist in well selected patients. Source of Funding: None

V684 INTRAOPERATIVE FLUOROSCOPIC MONITORING DURING TENSIONFREE VAGINAL MESH SURGERY: SAFER PROCEDURE EVEN FOR BEGINNERS Hideki Kobayashi*, Norihumi Sawada, Satoru Kira, Tatsuya Miyamoto, Yaburu Haneda, Hidenori Zakoji, Takayuki Tsuchida, Chuo-city, Japan; Isao Araki, Otsu-city, Japan; Masayuki Takeda, Chuo-city, Japan INTRODUCTION AND OBJECTIVES: TVM (Tension free Vaginal Mesh) surgery is a common and minimally invasive procedure for female pelvic organ prolapses. There are three kinds of modified procedures, and each is designed for each type of prolapse. Although less invasive, the shortcomings of this surgery is its groping approach by single surgeonxfs fingers without any monitoring. Inevitably, there are always risks for complications during surgery, including ureteral, bladder, bowel, vascular, and nerve injuries. In Japan, hands-on training using fresh cadaver is extremely difficult. Hence, we have developed intraoperative fluoroscopic monitoring during TVM surgery, which is safer surgery even for beginners. METHODS: Case: a 78-year-old woman with prolapse of bladder, who underwent TVM for anterior vaginal wall. Procedure: At first, we use a fluoroscopexfs c-arm to insert bilateral ureteral stents. We can confirm the position of ureter easily. This fluoroscopexfs c-arm is sometimes used during surgery. Urethral catheter was used for both means of urine drainage and injection of contrast medium. Shape of bladder is very important for safe performance of this surgery. Course for the ischial spine must be just bilateral of bladder. We must drive puncture needle through the obturate foramen toward the ATFP (Arcus Tendeneous Fasciae Pelvis). In all procedure, we can use fluoroscopic image whenever we want. RESULTS: We can confirm the prolapsed bladder and position of bilateral ureteral stents easily with fluoroscopic image. We can confirm the position of ischia spine beforehand. We can teach a technical point to young doctor with fluoroscopic image. We realized that the cervix is obviously distant from bilateral ureters in this case. We can confirm the head of needle with fluoroscopic image whenever we want. If the distance between first and second puncture of ATFP (Arcus Tendeneous Fasciae Pelvis) was short, we can retry for puncture. If