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VID-02.03: Xenograft interposition in female urethral diverticulum surgery
VIDEO POSTER SESSIONS
VID-02.03 Xenograft interposition in female urethral diverticulum surgery Robles JE, Rioja JP, Saiz A, Brugarolas X, Rinco ´ n A, Tolosa E, Rosell D, Zudaire JJ, Berian JM Department of Urology, Clinica Universitaria, University of Navarra, Pamplona, Spain Introduction: Female urethral diverticulum (UD) is an uncommon surgical entity. Currently, complete excision via a transvaginal approach is the most common surgical procedure for its treatment. After a simple diverticulectomy, we describe the insertion of a biological mesh as a flap between the periurethral fascial closure and the vaginal wall to prevent fistula formation. Methods: A 34-year-old multiparous woman complaining of recurrent UTI over the past 8 years was studied. On physical examination, an anterior vaginal mass was palpable and purulent material could be extruded from the urethral meatus when the urethra was compressed. U-shaped UD, measuring 3.2⫻2.1⫻1.5 cm., was demonstrated on MRI. Surgical technique: An inverted U-shape incision was made on the anterior vaginal wall over the UD. This anterior vaginal wall flap was dissected inferiorly and laterally up to the level of the bladder neck to expose the periurethral fascia. A transverse incision was made into the periurethral fascia overlying the UD. The diverticular sac was dissected, mobilized off the periurethral fascia, and completely excised. A three-layer closure consisting of the urethral wall, the periurethral fascia, and the anterior vaginal wall was made using nonoverlapping sutures. Once the urethral defect was closed, horizontal sutures were placed to close the potential dead space alongside the urethra to prevent fistula formation. After closing the periurethral fascia, the porcine dermal collagen xenograft (Pelvicol娀, Bard) was put in place before closure of the vaginal skin. Results: The postoperative course was uneventful and no complications were encountered. The patient was followed up at 3, 6 and 12 months postoperatively with clinical examinations, urinalysis plus urine culture, and pelvic MRI. She was markedly improved, her symptoms had resolved and she denied dyspareunia. Conclusion: (1) To achieve satisfactory results, meticulous dissection to define the extent of the UD, complete excision of the diverticular sac and its communica-
tion to the urethra, and closure of urethral defects in layers without overlapping sutures or tension, are essential. (2) The use of Pelvicol xenograft interposition to repair and reinforce the periurethral fascia, gives extra scaffolding for tissue regeneration without the need to mobilise adjacent tissue flaps with excellent outcomes. VID-02.04 Uterus sparing procedure in total urogenital prolapse Palma P, Riccetto C, Fraga R, Herrmann V, Netto N University Of Campinas-UNICAMP, Sao Paulo, Brazil Introduction & Objective: Pericervical ring is the Key stone of the genital support, when an apical defect is present, prolapse may occur in anterior and posterior compartments. Methods: This video shows a patient with a complete urogenital prolapse. The correction was made using a polypropylene mesh sparing the uterus. A midline vaginal incision is made from the miduretrha to the cervix. Sharped and blunt dissection is used in the anterior compartment. The dissection is cared out all the way down to the uterine cervix. Two suprapubic punctures are made 2 cm apart above the pubic bone. A prepubic needle is inserted and moved toward the previous made suprapubic incision, the same maneuvers are repeated in the other side. A polypropylene mesh is used to treat central and lateral defect and uretrhal hypermobility at the same time. The arm tips are connected to the needle and brought to the suprapubic region. The TO incision is made 2 cm lateral and 3 cm inferior regarding TO slings. Guided by the index finger the helical needle tip is inserted in the previous incision with the axis parallel to the ischiopubic ramous. The needle exits close and under to the white line. The TO arm tips are connected to the needle and brought to the perineum region. Finally steechs are placed in the distal body of the mesh and sutured to the pericervical ring. The vaginal wall is close using overlap technique to avoid contact with the mesh and suture line.Next, the posterior compartment is addressed and dissection is carried out from the perineal body to the apex. The isquiorectal fossa is bluntly dissected and the ischial spine is identified as well the sacrospinal ligament. The posterior landmarks for the skin punction are 3cm lateral and inferior to the center of the anus. The needle is inserted and guided by the index finger perforating the sacrospinal ligament at the midportion. The tip of the needle is not
UROLOGY 70 (Supplment 3A), September 2007
brought outside the vagina to avoid ligament damage. The arm tip of the posterior mesh is introduced using a right angle clamp coneceted to the needle, and brought outside. The mesh is sutured over the enterocele with no site specific correction. The arm tips are pulled out correcting the posterior prolapse. Vaginal wall was closed, the exceeding mesh is treamed off. Two stabilizing sutures are placed.Next, level three corrections are performed at the perineal body. Results: The patient has been followed by 6 months without recurrence of prolapse and continent. Conclusions: In total genital prolapses the uterus must be sparing with excellent functional result by reestablishment of normal anatomy. VID-02.05 46-XY complete gonadal dysgenesis Mehraban D, Sedighi-Gilani MA Tehran University of Medical Sciences, Tehran, Iran Introduction: This video presentation features the laparoscopic diagnosis and treatment of a a young female with a diagnosis of 46-XY complete gonadal dysgenesis. Methods: Fifteen-year-old female patient presents with primary amenorrhea and absence of breast development. Her older sister with a similar problem, underwent gonadectomy and is married. A trial of progesterone fails and the patient is referred for management. Her height is 168 cm, weighs 50 Kg with phenotypically normal, infantile female secondary sex characteristics. On U/S the presence of a small atrophic uterus and bilateral streak gonads. Results: Laparoscopic diagnosis and gonadectomy is performed with success through an umbilical 10-mm trocar and two 5-mm lower quadrant trocars. Conclusions: Laparoscopy allows the straitforward identification and removal of gonads. VID-02.06 Bolstering up the urethra in male urinary ıncontinence with folded polypropylene mesh Kilinc M Selcuk Univesity Meram Medical School, Konya, Turkey Objective: The description and the results of a new technique. Bolstering up the urethra with folded mesh for the treatment of male stress urinary incontinence after prostate surgery. Methods: 12 patients (median age 70) underwent this new procedure. The patients were evaluated from October 2004 to May
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VID-02.03 Xenograft interposition in female urethral diverticulum surgery Robles JE, Rioja JP, Saiz A, Brugarolas X, Rinco ´ n A, Tolosa E, Rosell D, Zudaire JJ, Berian JM Department of Urology, Clinica Universitaria, University of Navarra, Pamplona, Spain Introduction: Female urethral diverticulum (UD) is an uncommon surgical entity. Currently, complete excision via a transvaginal approach is the most common surgical procedure for its treatment. After a simple diverticulectomy, we describe the insertion of a biological mesh as a flap between the periurethral fascial closure and the vaginal wall to prevent fistula formation. Methods: A 34-year-old multiparous woman complaining of recurrent UTI over the past 8 years was studied. On physical examination, an anterior vaginal mass was palpable and purulent material could be extruded from the urethral meatus when the urethra was compressed. U-shaped UD, measuring 3.2⫻2.1⫻1.5 cm., was demonstrated on MRI. Surgical technique: An inverted U-shape incision was made on the anterior vaginal wall over the UD. This anterior vaginal wall flap was dissected inferiorly and laterally up to the level of the bladder neck to expose the periurethral fascia. A transverse incision was made into the periurethral fascia overlying the UD. The diverticular sac was dissected, mobilized off the periurethral fascia, and completely excised. A three-layer closure consisting of the urethral wall, the periurethral fascia, and the anterior vaginal wall was made using nonoverlapping sutures. Once the urethral defect was closed, horizontal sutures were placed to close the potential dead space alongside the urethra to prevent fistula formation. After closing the periurethral fascia, the porcine dermal collagen xenograft (Pelvicol娀, Bard) was put in place before closure of the vaginal skin. Results: The postoperative course was uneventful and no complications were encountered. The patient was followed up at 3, 6 and 12 months postoperatively with clinical examinations, urinalysis plus urine culture, and pelvic MRI. She was markedly improved, her symptoms had resolved and she denied dyspareunia. Conclusion: (1) To achieve satisfactory results, meticulous dissection to define the extent of the UD, complete excision of the diverticular sac and its communica-
tion to the urethra, and closure of urethral defects in layers without overlapping sutures or tension, are essential. (2) The use of Pelvicol xenograft interposition to repair and reinforce the periurethral fascia, gives extra scaffolding for tissue regeneration without the need to mobilise adjacent tissue flaps with excellent outcomes. VID-02.04 Uterus sparing procedure in total urogenital prolapse Palma P, Riccetto C, Fraga R, Herrmann V, Netto N University Of Campinas-UNICAMP, Sao Paulo, Brazil Introduction & Objective: Pericervical ring is the Key stone of the genital support, when an apical defect is present, prolapse may occur in anterior and posterior compartments. Methods: This video shows a patient with a complete urogenital prolapse. The correction was made using a polypropylene mesh sparing the uterus. A midline vaginal incision is made from the miduretrha to the cervix. Sharped and blunt dissection is used in the anterior compartment. The dissection is cared out all the way down to the uterine cervix. Two suprapubic punctures are made 2 cm apart above the pubic bone. A prepubic needle is inserted and moved toward the previous made suprapubic incision, the same maneuvers are repeated in the other side. A polypropylene mesh is used to treat central and lateral defect and uretrhal hypermobility at the same time. The arm tips are connected to the needle and brought to the suprapubic region. The TO incision is made 2 cm lateral and 3 cm inferior regarding TO slings. Guided by the index finger the helical needle tip is inserted in the previous incision with the axis parallel to the ischiopubic ramous. The needle exits close and under to the white line. The TO arm tips are connected to the needle and brought to the perineum region. Finally steechs are placed in the distal body of the mesh and sutured to the pericervical ring. The vaginal wall is close using overlap technique to avoid contact with the mesh and suture line.Next, the posterior compartment is addressed and dissection is carried out from the perineal body to the apex. The isquiorectal fossa is bluntly dissected and the ischial spine is identified as well the sacrospinal ligament. The posterior landmarks for the skin punction are 3cm lateral and inferior to the center of the anus. The needle is inserted and guided by the index finger perforating the sacrospinal ligament at the midportion. The tip of the needle is not
UROLOGY 70 (Supplment 3A), September 2007
brought outside the vagina to avoid ligament damage. The arm tip of the posterior mesh is introduced using a right angle clamp coneceted to the needle, and brought outside. The mesh is sutured over the enterocele with no site specific correction. The arm tips are pulled out correcting the posterior prolapse. Vaginal wall was closed, the exceeding mesh is treamed off. Two stabilizing sutures are placed.Next, level three corrections are performed at the perineal body. Results: The patient has been followed by 6 months without recurrence of prolapse and continent. Conclusions: In total genital prolapses the uterus must be sparing with excellent functional result by reestablishment of normal anatomy. VID-02.05 46-XY complete gonadal dysgenesis Mehraban D, Sedighi-Gilani MA Tehran University of Medical Sciences, Tehran, Iran Introduction: This video presentation features the laparoscopic diagnosis and treatment of a a young female with a diagnosis of 46-XY complete gonadal dysgenesis. Methods: Fifteen-year-old female patient presents with primary amenorrhea and absence of breast development. Her older sister with a similar problem, underwent gonadectomy and is married. A trial of progesterone fails and the patient is referred for management. Her height is 168 cm, weighs 50 Kg with phenotypically normal, infantile female secondary sex characteristics. On U/S the presence of a small atrophic uterus and bilateral streak gonads. Results: Laparoscopic diagnosis and gonadectomy is performed with success through an umbilical 10-mm trocar and two 5-mm lower quadrant trocars. Conclusions: Laparoscopy allows the straitforward identification and removal of gonads. VID-02.06 Bolstering up the urethra in male urinary ıncontinence with folded polypropylene mesh Kilinc M Selcuk Univesity Meram Medical School, Konya, Turkey Objective: The description and the results of a new technique. Bolstering up the urethra with folded mesh for the treatment of male stress urinary incontinence after prostate surgery. Methods: 12 patients (median age 70) underwent this new procedure. The patients were evaluated from October 2004 to May
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