V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL...
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METHODS: We evaluated 12 consecutive patients whom un- derwent to RRC after using neoadjuvant chemotherapy. Age, BMI, operative time, estimated blood loss, hospital stay, pathological stage and complications rate were prospective collected and evaluated. Media and standard deviation were used to describe the results. A video with the main steps of the technique and results were presented. RESULTS: All were finished successfully, no conversion to laparoscopy or open surgery were necessary, mean age, BMI, opera- tive time, hospital stay and blood loss were 63.35.6 years; 26.53.5; 26031.8 min; 16.27.6 days and 562.5262 cc respectively. Complications were presented in seven patients at 30 days and were classified as one patient Clavien 1, four patients clavien 2 and two patients clavien 3b. Most common pathological stage was pT3a. Down- grade was verified in 5 patients (41,6%). Also there were two patients pT1, one patient pT3b and one pT2a. Two patients had positive nodes (16,6%) and the average of lymph node was 16.54.6. CONCLUSIONS: Robotic radical cystectomy (RRC) is a feasi- ble and safe procedure that offers the advantages of minimally invasive surgery to these type of patients. Also, RRC has shown oncological results comparable with open cystectomy. Neoadjuvant chemotherapy can be deployed without adding complexity to the procedure while it offers potential protection against systemic disease. It is still an evolving procedure and long term results are ongoing. Source of Funding: None V1884 CUTANEOUS URETEROSTOMY FOR ADULTS AS AN ALTERNATIVE TO THE ILEAL CONDUIT: VIDEO OF THE SURGICAL TECHNIQUE Alejandro Rodriguez,R.*, Tariq Hakky, S., Jorge Lockhart, Tampa, FL INTRODUCTION AND OBJECTIVES: Here we present a video of the surgical modifications that improved the outcome of cutaneous ureterostomies in adults. METHODS: In this video we demonstrate the following modifi- cations: 1. Transposition of the left ureter above the inferior mesenteric artery 2. Mobilization of the ileocecal segment with repositioning above each terminal ureter 3. Abdominal wall hiatus fixation with 4 angle sutures and 4. YV plasty of the ureters with edge-to-edge anastomosis for stomal creation. 161 patients (59.1%) had Double J stents for less than 3 months (Group A) and 111 patients had stents for longer than 3 months (Group B). RESULTS: Of 272 patients with cutaneous ureterostomies, 36 (13.2%) developed ureteral obstruction. Ureteral obstruction was on the right side in 6 patients (2.2%) and on the left side in 29 (9.9%). Ureteral obstruction was treated with re-stenting in 20 cases (55.4%), stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%). In Group A, ureteral obstruction developed on the right side, left side, and bilaterally in 3.7%, 13.7%, and 1.82%, respectively. In Group B, ureteral obstruction developed on the right side, left side, and bilaterally in 0%, 4.5%, and 0%, respectively. Stenting time impacted only the left ureter with less obstruction in the group with longer stent placement (greater than 3 months) (p0.01). CONCLUSIONS: In this video we demonstrate the surgical modifications that have improved the outcomes of cutaneous ureteros- tomies in adult patients. Long-term stenting for greater than 3 months plays an important role. Source of Funding: None V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL INCISION Devendar katkoori, Ahmed Eldefrawy, Rajinikanth Ayyathurai, Murugesan Manoharan*, Miami, FL INTRODUCTION AND OBJECTIVES: Robotic assisted laparo- scopic radical cystectomy (RARC) is gaining popularity. A completely intracorporeal procedure is technically difficult and time consuming procedure. Most surgeons perform the diversion using small midline incision, which is also used for specimen retrieval. We report our technique of RARC with modified Pfannenstiel incision. METHODS: Cystectomy is performed using da Vinci robotic platform in a standard fashion. Bilateral pelvic lymph node dissection (BPLND) is done and the robot is undocked; 8-10 cm transverse curvilinear incision is made along pubic hairline centered over symphy- sis pubis. V-shaped incision (limbs of V at 30° angle, prevents inad- vertent entry into inguinal canal) is made in the anterior rectus sheath with midpoint 2 cm above symphysis pubis. Rectus sheath is reflected and V-incision is converted into Y-incision by vertical incision on the inferior leaflet of rectus sheath towards pubic symphysis. Rectus mus- cles are separated. Specimen is extracted, neobladder (NB) / ileal conduit (IC) is performed and diversion completed via the incision. RESULTS: 30 patients underwent RARC since April 2008. Median age was 65 yr (44-85). All had extracorporeal urinary diver- sions. Ratio of IC vs. NB was 6.5:3.5. The EBL was 275 (175-375ml), mean operating time was 50.8 hr. No intraoperative visceral injuries were noted. Two patients had positive surgical margins. Mean number of lymph nodes removed was 123. No incision hernia noted. CONCLUSIONS: RARC with modified Pfannenstiel incision is feasible, less time consuming, facilitates NB/IC reconstruction. The incision heals with a cosmetic scar and low risk of Incisional hernia. Source of Funding: None V1886 ROBOT ASSISTED PARTIAL CYSTECTOMY FOR UROTHELIAL CANCER WITHIN A BLADDER DIVERTICULUM Rosa Park, Mathew Oommen*, Benjamin Lee, New Orleans, LA INTRODUCTION AND OBJECTIVES: When a bladder diver- ticulum is present, it is important during the cystoscopic evaluation to directly visualize the diverticulum, as a urothelial carcinoma can be present. In the setting where no other histological evidence of tumor is present elsewhere in the bladder, bladder preservation is a feasible oncological option. We present a case of a 66 year old male with biopsy proven high-grade urothelial carcinoma in a bladder diverticulum, with negative bladder biopsies elsewhere. After options were discussed, a robot assisted partial cystectomy with bladder diverticulectomy was offered to the patient. METHODS: Initially, a 5-french open-ended catheter was in- serted to identify and delineate the ureter. A camera port, 3 robotic ports and 2 assistant ports were placed. The Space of Retzius was dissected down to the symphysis pubis, exposing the the diverticulum. A flexible cystoscope was then used to help delineate the neck of the diverticulum. Meticulous dissection was performed until the entire di- verticulum was mobilized. Purse string sutures were placed on the bladder side next to the neck of the diverticulum to prevent spillage when opening the bladder. The diverticulum was removed in its entirety and immediately placed in a laparoscopic retrieval sac. Bladder was closed in 2 layers. RESULTS: The patient tolerated the procedure well and was discharged on postoperative day one. Final pathology showed mixed type high-grade urothelial carcinoma, neuroendocrine carcimona, and adenocarcinoma, intestinal like with negative margins. CONCLUSIONS: Minimally invasive robotic bladder preserva- tion surgery is a safe and feasible approach in select patients with bladder carcinoma presenting within a bladder diverticulum. Patients should undergo surveillance cystoscopy post operatively. Source of Funding: None Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012 THE JOURNAL OF UROLOGY e761
Transcript of V1885 ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARY DIVERSION USING A MODIFIED PFANNENSTIEL...
METHODS: We evaluated 12 consecutive patients whom un-derwent to RRC after using neoadjuvant chemotherapy. Age, BMI,operative time, estimated blood loss, hospital stay, pathological stageand complications rate were prospective collected and evaluated.Media and standard deviation were used to describe the results. Avideo with the main steps of the technique and results were presented.
RESULTS: All were finished successfully, no conversion tolaparoscopy or open surgery were necessary, mean age, BMI, opera-tive time, hospital stay and blood loss were 63.3�5.6 years; 26.5�3.5;260�31.8 min; 16.2�7.6 days and 562.5�262 cc respectively.
Complications were presented in seven patients at 30 days andwere classified as one patient Clavien 1, four patients clavien 2 and twopatients clavien 3b. Most common pathological stage was pT3a. Down-grade was verified in 5 patients (41,6%). Also there were two patientspT1, one patient pT3b and one pT2a. Two patients had positive nodes(16,6%) and the average of lymph node was 16.5�4.6.
CONCLUSIONS: Robotic radical cystectomy (RRC) is a feasi-ble and safe procedure that offers the advantages of minimally invasivesurgery to these type of patients. Also, RRC has shown oncologicalresults comparable with open cystectomy.
Neoadjuvant chemotherapy can be deployed without addingcomplexity to the procedure while it offers potential protection againstsystemic disease. It is still an evolving procedure and long term resultsare ongoing.
Source of Funding: None
V1884CUTANEOUS URETEROSTOMY FOR ADULTS AS ANALTERNATIVE TO THE ILEAL CONDUIT: VIDEO OF THESURGICAL TECHNIQUE
Alejandro Rodriguez,R.*, Tariq Hakky, S., Jorge Lockhart, Tampa, FL
INTRODUCTION AND OBJECTIVES: Here we present a videoof the surgical modifications that improved the outcome of cutaneousureterostomies in adults.
METHODS: In this video we demonstrate the following modifi-cations: 1. Transposition of the left ureter above the inferior mesentericartery 2. Mobilization of the ileocecal segment with repositioning aboveeach terminal ureter 3. Abdominal wall hiatus fixation with 4 anglesutures and 4. YV plasty of the ureters with edge-to-edge anastomosisfor stomal creation. 161 patients (59.1%) had Double J stents for lessthan 3 months (Group A) and 111 patients had stents for longer than 3months (Group B).
RESULTS: Of 272 patients with cutaneous ureterostomies, 36(13.2%) developed ureteral obstruction. Ureteral obstruction was onthe right side in 6 patients (2.2%) and on the left side in 29 (9.9%).Ureteral obstruction was treated with re-stenting in 20 cases (55.4%),stomal revision in 12 (33.3%) and conversion to a conduit in 4 (11%).In Group A, ureteral obstruction developed on the right side, left side,and bilaterally in 3.7%, 13.7%, and 1.82%, respectively. In Group B,ureteral obstruction developed on the right side, left side, and bilaterallyin 0%, 4.5%, and 0%, respectively. Stenting time impacted only the leftureter with less obstruction in the group with longer stent placement(greater than 3 months) (p�0.01).
CONCLUSIONS: In this video we demonstrate the surgicalmodifications that have improved the outcomes of cutaneous ureteros-tomies in adult patients. Long-term stenting for greater than 3 monthsplays an important role.
Source of Funding: None
V1885ROBOTIC ASSISTED RADICAL CYSTECTOMY AND URINARYDIVERSION USING A MODIFIED PFANNENSTIEL INCISION
Devendar katkoori, Ahmed Eldefrawy, Rajinikanth Ayyathurai,Murugesan Manoharan*, Miami, FL
INTRODUCTION AND OBJECTIVES: Robotic assisted laparo-scopic radical cystectomy (RARC) is gaining popularity. A completely
intracorporeal procedure is technically difficult and time consumingprocedure. Most surgeons perform the diversion using small midlineincision, which is also used for specimen retrieval. We report ourtechnique of RARC with modified Pfannenstiel incision.
METHODS: Cystectomy is performed using da Vinci roboticplatform in a standard fashion. Bilateral pelvic lymph node dissection(BPLND) is done and the robot is undocked; 8-10 cm transversecurvilinear incision is made along pubic hairline centered over symphy-sis pubis. V-shaped incision (limbs of V at 30° angle, prevents inad-vertent entry into inguinal canal) is made in the anterior rectus sheathwith midpoint 2 cm above symphysis pubis. Rectus sheath is reflectedand V-incision is converted into Y-incision by vertical incision on theinferior leaflet of rectus sheath towards pubic symphysis. Rectus mus-cles are separated. Specimen is extracted, neobladder (NB) / ilealconduit (IC) is performed and diversion completed via the incision.
RESULTS: 30 patients underwent RARC since April 2008.Median age was 65 yr (44-85). All had extracorporeal urinary diver-sions. Ratio of IC vs. NB was 6.5:3.5. The EBL was 275 (175-375ml),mean operating time was 5�0.8 hr. No intraoperative visceral injurieswere noted. Two patients had positive surgical margins. Mean numberof lymph nodes removed was 12�3. No incision hernia noted.
CONCLUSIONS: RARC with modified Pfannenstiel incision isfeasible, less time consuming, facilitates NB/IC reconstruction. Theincision heals with a cosmetic scar and low risk of Incisional hernia.
Source of Funding: None
V1886ROBOT ASSISTED PARTIAL CYSTECTOMY FOR UROTHELIALCANCER WITHIN A BLADDER DIVERTICULUM
Rosa Park, Mathew Oommen*, Benjamin Lee, New Orleans, LA
INTRODUCTION AND OBJECTIVES: When a bladder diver-ticulum is present, it is important during the cystoscopic evaluation todirectly visualize the diverticulum, as a urothelial carcinoma can bepresent. In the setting where no other histological evidence of tumor ispresent elsewhere in the bladder, bladder preservation is a feasibleoncological option. We present a case of a 66 year old male with biopsyproven high-grade urothelial carcinoma in a bladder diverticulum, withnegative bladder biopsies elsewhere. After options were discussed, arobot assisted partial cystectomy with bladder diverticulectomy wasoffered to the patient.
METHODS: Initially, a 5-french open-ended catheter was in-serted to identify and delineate the ureter. A camera port, 3 roboticports and 2 assistant ports were placed. The Space of Retzius wasdissected down to the symphysis pubis, exposing the the diverticulum.A flexible cystoscope was then used to help delineate the neck of thediverticulum. Meticulous dissection was performed until the entire di-verticulum was mobilized. Purse string sutures were placed on thebladder side next to the neck of the diverticulum to prevent spillagewhen opening the bladder. The diverticulum was removed in its entiretyand immediately placed in a laparoscopic retrieval sac. Bladder wasclosed in 2 layers.
RESULTS: The patient tolerated the procedure well and wasdischarged on postoperative day one. Final pathology showed mixedtype high-grade urothelial carcinoma, neuroendocrine carcimona, andadenocarcinoma, intestinal like with negative margins.
CONCLUSIONS: Minimally invasive robotic bladder preserva-tion surgery is a safe and feasible approach in select patients withbladder carcinoma presenting within a bladder diverticulum. Patientsshould undergo surveillance cystoscopy post operatively.
Source of Funding: None
Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012 THE JOURNAL OF UROLOGY� e761
