Judy M. Choi

Comparison of laparoendoscopic single site (LESS) and conventional laparoscopic donor nephrectomy at a single institution

Most transplant centres harvest living donor kidneys via a conventional laparoscopic surgical approach. Laparoendoscopic single‐site donor nephrectomy (LESS‐DN) is a relatively novel minimally invasive approach that allows the surgery to be performed via a single incision. This technique may be advantageous in decreasing surgical morbidity and improving cosmetic outcomes, thus plausibly reducing the barriers to kidney donation. The study demonstrates the safety and feasibility of LESS‐DN in a large consecutive series of kidney donors. Comparative analysis between LDN and LESS‐DN showed that there was a significant decrease in intra‐operative blood loss and allograft warm ischaemia time in the LESS‐DN group, but also a significant increase in operating time. Other peri‐operative outcomes were similar between the two approaches. Evaluation of the LESS‐DN cases alone revealed that, the operating times did not significantly change through the course of the series. Using this outcome as a surrogate for technical difficulty suggests a relatively shallow learning curve for LESS‐DN.

Defining predictors of response to intralesional verapamil injection therapy for Peyronie’s disease

Study Type – Therapy (case series)

Complex rectovaginal fistulas after pelvic organ prolapse repair with synthetic mesh: a multidisciplinary approach to evaluation and management.

Objectives The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management. Methods Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution. Results Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain. Conclusions This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

Objectives Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). Methods Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. Results One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. Conclusions In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

A Single-Center Experience with Prone Retroperitoneoscopic Versus Open Renal Surgery in Children: An Age- and Procedure-Matched Comparison

PURPOSE We determined how surgical outcomes differ among children undergoing prone retroperitoneoscopic (RP) and open total and partial nephrectomies for benign renal disease. PATIENTS AND METHODS A retrospective analysis was performed, using medical records of children who were undergoing benign renal surgery at a single institution from 2001 to 2010. Patients were divided into open or RP cohorts, then subdivided into those who were undergoing total or partial nephrectomies. A further breakdown by age (<3 years and ≥3 years) was performed. Bilateral nephrectomies were separately evaluated. Surgical outcomes were compared across groups. RESULTS There were 308 (333 renal units) children who underwent RP (n=154) or open (n=154) total or partial nephrectomies, 25 of which were bilateral (20 RP, 5 open); 199 patients underwent total nephrectomies (RP n=118, open n=81), and 109 underwent partial nephrectomies (RP n=36, open n=73). After controlling for age and concomitant procedures, operative times were similar for the RP total and bilateral nephrectomy groups, but longer for the RP partial nephrectomy group, compared with their open counterparts. In both total and partial nephrectomies, the RP group had a shorter hospital stay. There were no open conversions in any of the RP groups and no differences in complications in the total, partial, and bilateral analyses. There were 13 patients who previously received peritoneal dialysis (8 bilateral RP, 3 unilateral RP, and 2 unilateral open), all of whom resumed dialysis in a mean of 1.11 days. CONCLUSIONS This is the largest series to date that compares RP and open renal surgeries in children. The RP and open approaches were comparably safe and efficacious. Hospital stays were significantly shorter in the RP total and partial groups, although operative times were significantly longer in the RP partial nephrectomy group. Prone retroperitoneoscopic surgery should be considered a viable option for renal surgery at any age.

1670 THE FATE OF PATIENTS DEVELOPING ERECTILE DYSFUNCTION AFTER PLAQUE INCISION AND GRAFTING FOR PEYRONIE'S DISEASE

required during inflatable penile prosthesis (IPP) insertion to ensure that the penis will be straight enough for penetrative intercourse. The aim of this study was to compare the outcomes of men undergoing SM employed during IPP insertion compared to those wherein these maneuvers were not required. METHODS: A retrospective review of 391 patients undergoing IPP insertion at the Johns Hopkins Hospital from January 2000-December 2011 was performed. Patients in whom some SM was employed (SM, n 93, 23.9% of the overall cohort) were compared to those for whom SM was not required (IPP group, n 297). Comparisons between groups were performed using Chi-square tests for categorical data; the means of continuous data were compared by using the t test and non-parametric alternate if the distribution could not be normalized or the variance was not equal. P-values 0.05 were considered statistically significant. RESULTS: Patients in whom a SM was used were younger (55.4 vs. 62.3 years) and more likely to have Peyronie’s disease, and less likely to have prostate cancer, radical prostatectomy or to have previously used erectile aids (all P 0.05). Mean surgical time in the SM group was longer (173.8 vs. 152.9 minutes, P 0.003). Within the SM group, modeling was performed in 40 (43%), tunical relaxing incisions in 37 (39.8%), and tunical reconstruction in 16 (17.2%) (most commonly using allograft dermis or pericardium, or synthetic gore-tex grafts) patients. There were no significant differences in terms of device infection (P 0.807), mechanical failure (P 0.212) or cylinder erosion (P 0.051). A significantly higher overall rate of tubing or pump erosion (defined as a visible penetration through the skin) was noted in the SM (10/93, 10.8%) vs. the IPP groups (13/297, 4.4%), P 0.022. The median time to device explantation or revision was 463 days (range 2-1908). CONCLUSIONS: IPP insertion in men with penile deformity requiring complex reconstruction to achieve straightening may be done proficiently. While straightening maneuvers may carry elevated risk, they can nevertheless achieve good results with an overall high safety profile.