Carini, Marco

Mantella, Annalisa

Masieri, Lorenzo

Minervini, Andrea

Saleh, Omar

Salvi, Matteo

Sebastianelli, Arcangelo

Serni, Sergio

Siena, Giampaolo

Tuccio, Agostino

Vittori, Gianni

English

Florence Research

need for prolonged catheterization and blood transfusion. Robot-as-sisted simple prostatectomy has been shown to mitigate these se-quelae albeit in relatively small case series.METHODS: Our patient was a 66 year-old male who presentedwith a history of bothersome lower urinary tract symptoms. His preop-erative IPSS was 22 and uroflowmetry demonstrated a peak flow of8ml/sec. 12-core transrectal ultrasound guided biopsy was negativeand ultrasound estimated volume was 138mL. The technique demon-strated is a transperitoneal hybrid approach of urethrovesical anasto-mosis with the posterior urethral plate reapproximated to the posteriorbladder neck, coapting much of the prostatic fossa.RESULTS: Operative time was 3hr 17min. The final specimenwas 154 grams. Estimated operative blood loss was 110mL and thepatient’s post-operative hemoglobin dropped 1.3 g/dL. The patient wasdischarged from the hospital postoperative day 2 and transurethralcatheter was removed after 7 days. At 4 months, the patient was foundto have had a 12-point decrease in IPSS. He is doing well, with no signof recurrent flow obstruction at 8 months of follow-up.CONCLUSIONS: Robot-assisted simple prostatectomy is tech-nically feasible and represents an alternative to open simple prostatec-tomy or endourologic approaches, especially for large adenomas.Source of Funding: NoneV1028ROBOTIC SUPRAPUBIC PROSTATECTOMY FOR SEVEREBENIGN PROSTATIC HYPERPLASIAWesley White, James Bienvenu*, Knoxville, TN; Eric Brewer,Birmingham, AL; W Bedford Waters, Frederick Klein, Knoxville, TNINTRODUCTION AND OBJECTIVES: Conventional treatmentof BPH includes -1 adrenergic antagonists, 5  reductase inhibitors,and minimally invasive procedures including TUMT and TUNA. Menwith urinary retention, recurrent UTIs, prostate hemorrhage, bladdercalculi, renal insufficiency, and/or symptoms unresponsive to medicaltherapy may be appropriate candidates for TURP or open prostatec-tomy. Compared to TURP, open prostatectomy offers a lower retreat-ment rate, more complete removal of the prostatic adenoma underdirect vision, and avoids the potential for TURP syndrome. However,open prostatectomy is associated with an increased risk of periopera-tive hemorrhage and the need for a longer hospitalization and conva-lescence. Many of the aforementioned disadvantages with open pros-tatectomy were likewise common with radical retropubic prostatectomybefore the advent of robotics. We present our experience with roboticsuprapubic prostatectomy for the treatment of severe BPH.METHODS: A 66 year old male presented with BPH refractoryto medical therapy. Preoperative AUA symptom score was 26 andpostvoid residual volume was 375cc. Maximum voiding flow rate pre-operatively was 7.2mL/sec. The patient underwent transrectal ultra-sound with a calculated volume of 175g. Treatment options werediscussed with the patient in detail. Following informed consent, roboticsuprapubic prostatectomy was performed. With the patient in the litho-tomy position, a conventional 5 port configuration was employed. Thebladder was dropped and the space of Retzius developed. The bladderwas filled and a cystotomy created. The adenoma was circumferentiallyenucleated using blunt and sharp dissection. The enucleation bed wasrendered hemostatic with pinpoint cautery. The incised mucosa of theposterior bladder neck was tacked to the prostate capsule using arunning 3-0 Vicryl suture. The cystotomy was closed in multiple layersusing absorbable suture.RESULTS: Operative time was 123 minutes. Estimated bloodloss was 50cc. There were no acute intraoperative or postoperativecomplications. Postoperative postvoid residual volume was 23cc. Post-operative AUA symptom score was 3.CONCLUSIONS: Based on our experience, robotic simpleprostatectomy is safe, effective, and minimizes many of the disadvan-tages traditionally associated with the open approach. The decision toapproach the prostate through a suprapubic or retropubic approach ispredicated on patient factors and the discretion of the operating sur-geon. Further study is needed to determine the appropriate patientselection, efficacy and/or superiority as compared to TURP.Source of Funding: NoneV1029INTRAOPERATIVE VASCULAR INJURIES: INADVERTENT ANDPREVENTABLE!Rajesh Ahlawat*, Gurgaon, NCR, IndiaINTRODUCTION AND OBJECTIVES: Intraoperative vascularinjuries are reported in approximately 1.5% of major urological laparo-scopic procedures and may need conversion. Although some of theseare accidental, others happen due to improper or poor knowledge ofinstrumentation and technique, and are thus preventable. We presenttwo such vascular injuries.METHODS: In the first instance, during left renal hilar dissec-tion for a partial nephrectomy, the surgeon tried to dissect behind therenal vein by holding and retracting an already applied Weck® clip ona lumbar vein. The pull on the clip resulted in avulsion of the lumbarvein from renal vein. The resulting hole was difficult to hold due to itsposterior location. An additional port was used to temporarily clamp anaccessory and main renal artery. The defect in thus collapsed renal veincould then be grasped and repaired with prolene 5-0 suture. The proce-dure could be completed without the need for conversion. In the secondprocedure, the surgeon created a hole at the junction of the renal arteryand aorta during laparoscopic donor nephrectomy while trying to cut aflimsy attachment of the renal vein with the harmonic scalpel (HS). He wastrying to release the broad renal vein to enable its rotation to reach alumbar vein coursing posteriorly across renal artery. Harmonic ACE® wasused at a setting of 5 for five seconds. With bleeding kept in control undervision with a surgicel pack and pressure, the procedure was converted toopen for safe completion.RESULTS: Self locking ligature clip from Weck (Hem-o-lock)holds the vessel firmly with its teeth and is unlikely to slip. Any attemptat holding an applied clip to retract may result in avulsion of the heldvessel . HS, with its ability to coagulate and dissect close to vitalorgans, is extensively used without the risk of electrical injury. It hasbeen described to achieve its surgical effect by providing temperaturesbelow 100°. However, heat generation depends on many factors, likepower setting and application time, apart from the amount of tissue heldbetween blades. Little or no tissue between blades may generate veryhigh blade temperatures (called the abuse mode). Continuing to fire HSwhile little or no tissue between distal part of the blades, despite a smallamount of tissue still held by the proximal end, may also result in abusemode. Temperatures 200°C have been recorded using harmonicACE, high enough to cause injury to organs in direct touch of the tip.CONCLUSIONS: Ligature clips and HS are safe and commonlyused. One needs to know the proper technique and basics of technol-ogies to enable their safe use.Source of Funding: NoneV1030LAPAROSCOPIC TRANSPERITONEAL ANDERSON-HYNESPYELOPLASTY: TECHNICAL NOTES AND RESULTS AFTER 100CASESAndrea Minervini*, Giampaolo Siena, Agostino Tuccio,Lorenzo Masieri, Matteo Salvi, Gianni Vittori, Annalisa Mantella,Arcangelo Sebastianelli, Omar Saleh, Sergio Serni, Marco Carini,Florence, ItalyINTRODUCTION AND OBJECTIVES: The laparoscopic Ander-son-Hynes pyeloplasty is the gold standard for the treatment of thepyeloureteral junction obstruction (PUJO). We described the surgicalsteps of laparoscopic Anderson-Hynes pyeloplasty with transperitoneale418 THE JOURNAL OF UROLOGY Vol. 187, No. 4S, Supplement, Monday, May 21, 2012approach and anterograde stent placement done using a personaltechnique. We reported the morphofunctional results after the first 100cases.METHODS: Between March 2005 and December 2010, 100patients, 47 males, 53 females (mean age 31, range 15-59) diagnosedwith incidental or symptomatic PUJO, underwent transperitoneal lapa-roscopic Anderson-Hynes pyeloplasty. In 11(11%) cases, a transme-socolic access to the PUJ was adopted. In all patients surgery wasperformed using 3 to 5 ports, a 12 mm umbilical/ paraumbilical port forHasson trocar and the remaining were all 5 mm ports. The placementof an anterograde double J ureteral stent was performed using apersonal technique after posterior anastomotic wall closure.The anas-tomosis was done with 5-0 Vicryl sutures.RESULTS: All operations were completed laparoscopically,and no open conversions were needed. The mean operative time was120 min (range 90-390). For the last 30 cases the operative time wasalways less than 120 minutes. Overall, 19 patients (19%) had anabnormal blood vessel that required a transposition in 15 (15/19, 79%).9 patients (9%) had kidney stones associated. The average time forureteral stenting was 5 min (range 3-22 min), and in 99 cases (99/100,99%) it was correctly positioned. The average postoperative hospital-ization stay was 4 days (range 3-10). 4 postoperative complicationsoccurred (4%): two patients required prolonged surgical drainage, onehad broncopneumonia, one had intrahepatic bleeding of an subcapsu-lar hemangioma, treated conservatively without blood transfusionneeding.At a mean follow-up of 36 months (range 1-72) we showed a97% success rate, documented as a morphofunctional improvement,with absence or reduction of hydronephrosis in asymptomatic patients.A persistent PUJO was detected in three patients and was treated byconservative endoscopic management or by performing an open/lapa-roscopic pyeloplasty.CONCLUSIONS: Our data confirm the antegrade procedure tobe an easy-to-learn and safe. it obviates the problem of having the stentin the renal pelvis during dissection and suturing and of repositioningthe patient onto the flank for the laparoscopic procedure.Our study confirms the effectiveness of the laparoscopic tech-nique, in terms of morphofunctional and clinical symptoms resolution,with a high overall success rate (97%).Source of Funding: NoneV1031ROBOTIC-ASSISTED LAPAROSCOPIC URETERALREIMPLANTATION WITH PSOAS HITCHJavier Estébanez*, Adolfo Cátedra, Gregorio Garmendia,Cristina Garrido, Itziar Crespo, Miguel Gutierrez, Ione Linazasoro,Jon Belloso, Enrique Artozki, Juan Sanz, San Sebastian-Donostia,SpainINTRODUCTION AND OBJECTIVES: We present our initialexperience in robotic-assisted laparoscopic ureteral reimplantation withpsoas hitch.METHODS: In this case-study, a 50 year old female patient hasbeen diagnosed with ureteral stenosis after having a hysterectomy. Weposition the patient supine with a slight trendelenubrg tilt. The cameraport is placed 2 cm superior to the umbilicus with two robotic trocarsplaced laterally. An assistant port is placed in the iliac fossa. We startthe procedure with an incision in the posterior parietal peritoneum. Welocate the ureter and dissect it at the point of the stenosis. The ureteris clipped and divided. We dissect the anterior and lateral walls of thebladder, ensuring that it can later be anchored to the psoas muscle.The ureter is spatulated. A double J stent is inserted into the ureterthrough the assistant trocar. We hitch the bladder to the psoas using 3polyglactin (teen) sutures. An incision is made in the muscular layer ofthe selected area of the bladder, sparing the mucosa. The superiorsutures must include all of the layers of the bladder and ureteral walls.The inferior and lateral sutures must only include the ureter and thebladder mucosa. We complete the reimplantation with several suturesin the bladder muscle, enclosing the ureter between the muscular layerand the mucosa. A drain tube is placed.RESULTS: In this case, surgical time was 100 minutes and thehospital stay 4 days. No intra or post-operative complication occurred.CONCLUSIONS: Robotic-assisted laparoscopic ureteral reim-plantation with psoas hitc is a feasible and reproducible procedure.Source of Funding: NoneV1032DOUBLE BUCCAL MUCOSA GRAFT-AUGMENTED PERINEALURETHROPLASTY IN TIGHT BULBAR URETHRAL STRICTURESSinasi Yavuz Onol, Fikret Onol*, Remzi Erdem, Cevper Ersoz,Tolga Akman, Abdullah Armagan, Istanbul, TurkeyINTRODUCTION AND OBJECTIVES: The optimal manage-ment of bulbar urethral strictures is controversial. Augmented urethro-plasty is a widely-used strategy due to the advantages of preserving theurethral plate and avoiding unnecessary urethral mobilization andtransection of spongiosum vascularity. Combined anteriorposteriordouble buccal mucosa grafting (dBMG) has been favored in particularlynarrow strictures since it offers the possibility of creating a wider-caliberurethral lumen. We present our technique and results with dBMG innarrow bulbar urethral strictures.METHODS: Fifteen patients (mean age: 37 years, range: 23-65) with bulbar urethral strictures were treated with dBMG-augmentedperineal urethroplasty between 2006 and 2011. All patients were cyto-stomized and had undergone at least one prior endoscopic treatments(mean: 3.8 times, range: 1-9) and multiple dilatations. The stricture wasevaluated with preoperative retrograde urethrogramantegrade cysto-gram, and intraoperative radiographic assessment of the defect be-tween the tips of 2 Benique sounds advanced through the cytostomytract and urethra. Mean stricture length was 3 cm. (range: 1.5-4 cm).The operation stages were: reverse Y incision, separation of bulbocav-ernous muscles, ventral sagittal urethrotomy and entry of stricturedurethra, midline incision of the dorsal urethra down to tunica albugineaand dissection of incision margins to provide bed for the BMG. The firstBMG was quilted to the corpus cavernosum as dorsal inlay and secondBMG was sutured to the margins of the ventral urethral incision asonlay, followed by approximation of bulbocavernous muscles over theurethra. A 16-18F catheter was left for 2 to 3 weeks. Retrogradeurethrograms were routinely obtained 4 weeks after catheter removal,and cystoscopy was performed in the presence of obstructive symp-toms. Failure was defined as any need for postoperative intervention,including urethrotomy or dilatation.RESULTS: With a mean follow-up of 28 months (range: 6-56),13 (86.6%) procedures were successful. Two patients required internalurethrotomy due to re-stricture of less than 1.5 cm. All patients werefree of their cytostomy at the last follow-up, and mean postoperativepeak urinary flow rate was 19.2 ml per second (range: 14-32).CONCLUSIONS: Combined dBMG urethroplasty is a viableoption for reconstructing tight bulbar urethral strictures in terms ofpreserving the urethral plate and its vasculature, and enabling theformation of a physiological, wide-caliber urethra.Source of Funding: NoneV1033ROBOT-ASSISTED RETROPERITONEAL LYMPH NODEDISSECTION: MODIFIED NERVE-SPARING LEFT SIDEDTEMPLATEKhurshid R Ghani*, Jay Jhaveri, Quoc-Dien Trinh, Emil Kheterpal,Jesse D Sammon, Wooju Jeong, Shyam Sukumar, Michael Ehlert,Mani Menon, Akshay Bhandari, Detroit, MIINTRODUCTION AND OBJECTIVES: Due to the inherent dif-ficulty with dissection, laparoscopic retroperitoneal lymph node dissec-tion (RPLND) is not considered standard treatment for patients withVol. 187, No. 4S, Supplement, Monday, May 21, 2012 THE JOURNAL OF UROLOGY e419

LAPAROSCOPIC TRANSPERITONEAL ANDERSON-HYNES

PYELOPLASTY: TECHNICAL NOTES AND RESULTS AFTER 100

CASES

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LAPAROSCOPIC TRANSPERITONEAL ANDERSON-HYNES PYELOPLASTY: TECHNICAL NOTES AND RESULTS AFTER 100 CASES

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