V857 OPTIMIZED TRANSGENDER SURGERY MALE TO FEMALE

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THE JOURNAL OF UROLOGY姞

EBL for the procedure was 200 ml. The patient was discharged on post-operative day one and her post-operative course was without complications or transfusions. CONCLUSIONS: This case represents the first reported laparoscopic adrenalectomy and IVC thrombectomy using robotic technology. Significant surgical experience is required prior to proceeding with such an operation. Patients undergoing this procedure may benefit from the minimally invasive approach. This procedure should only be performed robotically, however, if the surgeon can safely proceed without compromising sound oncologic surgical principles. Source of Funding: None

V856 ROBOT-ASSISTED LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA: THE NATIONAL CANCER INSTITUTE TECHNIQUE Kevin Asher*, Gopal Gupta, W. Marston Linehan, Peter Pinto, Gennady Bratslavsky, Bethesda, MD INTRODUCTION AND OBJECTIVES: Traditional treatment for pheochromocytoma has been total adrenalectomy because of concerns for malignancy, local recurrence, and surgical challenges associated with its central location. Because of numerous pathologic processes or certain hereditary syndromes that may threaten the contralateral adrenal, partial adrenalectomy has recently been advocated. We aim to describe our technique of robotic-assisted partial adrenalectomy and report the early functional and oncologic outcomes. METHODS: We identified 15 procedures performed in 12 consecutive patients with adrenal pheochromocytoma treated with robot⫺ assisted partial adrenalectomy. Using the robotic platform we performed resection via enucleation of pheochromocytomas in all patients by removing the tumor and associated medulla from the adjacent adrenal cortex. Perioperative outcomes and pathologic data were reviewed. The functional outcomes were assessed by steroid requirements while oncologic outcomes were measured by presence of local recurrence or development of metastatic disease. RESULTS: Among 15 procedures 4 were performed on a solitary adrenal gland. Additionally, 4 cases required resection of multiple tumors (up to six) with 2 performed in a solitary gland. The mean operative time was 163 minutes with the median EBL of 161mls. The median tumor size was 2.7 cm (0.5⫺5.5). There was one conversion to an open procedure on a patient requiring reoperation on a solitary adrenal gland due to severe adhesions. His course was complicated by a bile leak requiring temporary drainage. One other patient required postoperative steroid supplementation. At a median follow up of 9.5 months (0 –28.7), there were no recurrences or metastatic events. CONCLUSIONS: Robotic-assisted laparoscopic partial adrenalectomy for the treatment of pheochromocytoma is feasible, safe, and provides encouraging functional and oncologic outcomes. Even in patients with solitary adrenals or multiple lesions the procedure may offer an alternative to life⫺long steroid dependence. Longer follow up is necessary to better assess functional and oncologic outcomes. Source of Funding: None

V857 OPTIMIZED TRANSGENDER SURGERY MALE TO FEMALE Bastian Amend, Joerg Seibold, Arnulf Stenzl, Karl-Dietrich Sievert*, Tuebingen, Germany INTRODUCTION AND OBJECTIVES: Different techniques have been described for neovaginal and clitoral gender reassignment. Major problems after neovaginal reconstruction are vaginal stenosis and insufficient size resulting in patient dissatisfaction. Perovic et al. described the incorporation of an excessive penile urethra into the neovaginal circumference. We demonstrate our technique in regard to

Vol. 185, No. 4S, Supplement, Monday, May 16, 2011

optimized postoperative outcome and reduction of typical risks such as compartment syndrome, thrombosis and peroneal paralysis caused by prolonged lithotomy position. METHODS: From October 2006 to October 2010 26 patients underwent gender reassignment using the following technique: Dorsal position was used for penile disassembly and orchiectomy. After repositioning to lithotomy position with additional pneumatic stockings, both corpora cavernosa were resected and the neovagina was constructed using penile skin w/o foreskin including the penile urethra. Before the neovagina is inserted into the blunt-dissected rectoprostatic space and fixed to the sacrospinous ligament, the size-reduced vascularized and innervated glans is used to create the neoclitoris. The medial scrotal skin is used to form the labia majora and minora and the subcutaneous fat is rotated to shape the mons pubis. A unique approach to move the skin resulted in reduced skin incisions. RESULTS: 26 patients received transgender surgery with the described technique. One intraoperative complication (rectal injury with primary closure without colostomy) occurred without any consequences. No transfusions were needed. All patients reported satisfaction concerning neovaginal length and width. In addition to two urethral strictures treated by meatoplasty, no neovaginal strictures were reported. Patients were offered a second intervention for aesthetic aspects of the labia and mons pubis; it performed in two-thirds of the cases. 25 patients reported the possibility of clitoric orgasm and sensibility. CONCLUSIONS: The incorporation of vascularized distal urethra for the creation of neovagina results in an optimal functional size with regard to depth and width; in addition the glans was transformed into the neoclitoris. The two-step positioning of the patients reduced operating time and postoperative complications. Source of Funding: None.

V858 ROBOTIC VESICOVAGINA FISTULA REPAIR Aqsa Khan*, Claudia Sevilla, Jennifer Anger, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Robotic technology provides a minimally invasive abdominal approach to reconstructive pelvic surgery that can be performed by many pelvic surgeons, not just expert laparoscopists. Some might argue that the improved dexterity of the robot, precision of instruments, and the three-dimensional imaging of the robotic camera provides a technical advantage over open abdominal and vaginal approaches. The post-hysterectomy vesico-vaginal fistula (VVF) repair is an example of an operation that, in many instances, may benefit from robotic technology. METHODS: This video describes the surgical techniques of robotic-assisted VVF repair. RESULTS: To reduce inflammation after surgical injury, waiting up to three months before repair is optimal. Intra-operative ureteral stenting with open-ended stents can aid in intra-operative visualization of the ureteral orifices. Identification of planes is aided by manipulation of a vaginal stent and intra-operative filling of the bladder. Robotic assistance greatly aids in developing and extending the plane between the vagina and the bladder. The vagina and bladder are each closed in two layers. Interposition of omentum or bladder peritoneum is ideal, though other biologic material can be used when endogenous tissue is not available. Generally a foley catheter or suprapubic tube is left for three weeks, at which time a cystogram is performed and the catheter is removed. CONCLUSIONS: In proximal VVFs, particularly those where vaginal access is difficult, robotic-assisted VVF repair provides a durable result through a minimally invasive abdominal approach. Larger series are needed to compare outcomes to open abdominal and vaginal approaches. Source of Funding: None