Viet Q. Tran

Management of Rectal Injuries Sustained During Laparoscopic Radical Prostatectomy

OBJECTIVES To report on a treatment algorithm for the management of rectal injures. Rectal injuries during laparoscopic radical prostatectomy (LRP) are rare. In the first 200 cases of LRP performed at our institution, 2 (1%) rectal injuries occurred. Our experience prompted collaboration with our colorectal surgery colleagues to develop a treatment algorithm for the management of such injuries. METHODS We report on the management of rectal injuries sustained during LRP at our institution. We describe the intraoperative laparoscopic repair of a rectal tear using a 2-layer interrupted closure with absorbable suture. The conservative, nonoperative, management of a rectourethral fistula in a patient who presented after LRP is also described. Collaboration with our colorectal surgery colleagues resulted in the formulation of a treatment algorithm for intraoperative and postoperative presentations of rectal injury during LRP. The algorithm is presented. RESULTS Of the first 200 cases of LRP at our institution 2 (1%) were complicated by rectal injury. Injuries recognized intraoperatively should be managed laparoscopically if the operating surgeon is adept at intracorporeal suturing. Small rectourethral fistulas can be managed conservatively with urinary catheterization or diversion and antibiotics as needed. Rarely, rectal injuries sustained during LRP will require fecal diversion; injuries that fail to heal despite fecal diversion require operative repair. CONCLUSIONS Rectal injuries incurred during LRP are rare but must be managed successfully to minimize morbidity. Rectal tears recognized intraoperatively can be managed laparoscopically. The development of a rectourethral fistula is a potential complication of LRP. Most fistulas can be managed conservatively with urinary catheterization or diversion. Rarely, rectal injuries that occur during LRP require fecal diversion or definitive operative repair.

Review of Intentionally Self-Inflicted, Accidental and Iatrogetic Foreign Objects in the Genitourinary Tract

Purpose: Retrospective evaluation of a series of patients presenting with genitourinary foreign objects. Patients and Methods: From 1997 to 2007, 11 men and 2 women were treated for a variety of foreign objects in the genitourinary tract. Medical records were reviewed for presentation, diagnosis, mental status, drug dependency, treatment, and follow-up. Results: 13 patients were seen for removal of the foreign objects or for treatment of the sequela. These objects were intentionally self-inflicted, accidentally introduced or iatrogenic in nature. Intentional objects included: safety pins, screwdriver, marbles, pen cap, pencils, straw, cocaine, stiff metal wire and part of a pizza mixer. Accidental objects included: magnets, female catheter, urinary incontinence devices and part of a Foley catheter. The iatrogenic object was a reservoir from an inflatable penile implant. Smaller noninjurious objects were retrieved cystoscopically or at the bedside; larger objects or objects associated with trauma to the urethra needed open and reconstructive operations. Conclusions: Generally thought to be self-inflicted for personal gratification, the source of genitourinary objects can also be accidental or iatrogenic. The most traumatic injuries are purposely self-inflicted and found in patients who remove the objects themselves. These patients are at higher risk of permanent urethral damage needing complex surgical treatment and follow-up.

Repair of Giant Vesicovaginal Fistulas

PURPOSE We evaluated the long-term success rate of an abdominovaginal approach using a rotational bladder flap to repair giant vesicovaginal fistula. MATERIALS AND METHODS A total of 35 patients were included in this study. Of these patients 28 had a large vesicovaginal fistula and 7 had complete loss of the urethral floor. Fistula etiology was secondary to obstructed labor in 25 patients, the result of iatrogenic surgical injuries in 5, sling erosion in 3 and pelvic irradiation in 2. Using combined abdominal and vaginal approaches the bladder was bisected sagittally, and a bladder flap was rotated downward and medially to fill the extensive fistula defect. An additional vascularized flap was interposed in 23 patients including gracilis muscle flap in 13, omental flap in 5, peritoneal flap in 2 and Martius flap in 3. RESULTS Fistulas were successfully repaired in 31 of 35 patients (88%). The remaining 4 patients underwent surgical correction with a second, more limited repair. This group included 2 patients with fistula from obstructed labor, 1 due to sling erosion and 1 due to irradiation. CONCLUSIONS A combined abdominovaginal approach with the use of a generous rotational bladder flap for repair of a complex vesicovaginal fistula allowed for excellent results. There was a high success rate on the first attempt due to the excellent exposure and healthy, well vascularized tissue used for repair.

Differences in Left and Right Laparoscopic Adrenalectomy

Although no difference was found in complications or conversion rates for either right or left laparoscopic adrenalectomy, the authors report that lower blood loss and decreased operative time were noted with laparoscopic right adrenalectomy.

Review of the Surgical Approaches for Peyronie's Disease: Corporeal Plication and Plaque Incision with Grafting

The understanding and management of Peyronies disease (PD) has improved but elucidating the exact etiology of the disease has yet to be achieved. In this paper, we review the historical and clinical aspects of PD. We focus on the evolution of surgical management for PD and review recent published articles that compare popular surgical techniques such as plication and plaque incision with vein graft. These two techniques have been reported to be equivalent with respect to patient satisfaction; however, each technique has its own advantages and disadvantages.

Penile corporeal reconstruction during difficult placement of a penile prosthesis.

For some patients with impotence and concomitant severe tunical/corporeal tissue fibrosis, insertion of a penile prosthesis is the only option to restore erectile function. Closing the tunica over an inflatable penile prosthesis in these patients can be challenging. We review our previous study which included 15 patients with severe corporeal or tunical fibrosis who underwent corporeal reconstruction with autologous rectus fascia to allow placement of an inflatable penile prosthesis. At a mean follow-up of 18 months (range 12 to 64), all patients had a prosthesis that was functioning properly without evidence of separation, herniation, or erosion of the graft. Sexual activity resumed at a mean time of 9 weeks (range 8 to 10). There were no adverse events related to the graft or its harvest. Use of rectus fascia graft for coverage of a tunical defect during a difficult penile prosthesis placement is surgically feasible, safe, and efficacious.

A Preliminary Report on Combined Penoscrotal and Perineal Approach for Placement of Penile Prosthesis with Corporal Fibrosis

Purpose. This paper aims at describing the combined penoscrotal and perineal approach for placement of penile prosthesis in cases of severe corporal fibrosis and scarring. Materials and methods. Three patients with extensive corporal fibrosis underwent penile prosthesis placement via combined penoscrotal and perineal approach from 1997 to 2006. Follow-up ranged from 15 to 129 months. Results. All patients underwent successful implantation of semirigid penile prosthesis. There were no short- or long-term complications. Conclusions. Results on combined penoscrotal and perineal approach to penile prosthetic surgery in this preliminary series of patients suggest that it is a safe technique and increases the chance of successful outcome in the surgical management of severe corporal fibrosis.

Resorbable Clip Migration Resulting in Ureteral Obstruction and Sepsis After Laparoscopic Pyeloplasty

We report a rare complication of Lapra-Ty clip migration into the ureter with resultant obstruction and sepsis after dismembered laparoscopic pyeloplasty.

Recurrent papillary renal cell carcinoma with concomitant ipsilateral upper urinary tract urothelial carcinoma and metachronous urothelial carcinoma of the bladder

Concomitant renal cell carcinoma (RCC) and ipsilateral upper urinary tract urothelial carcinoma (UTUC) is very uncommon, with only about 50 reported cases in the literature.1 Patients who developed synchronous, ipsilateral RCC and UTUC are on average 64.5-years-old, are 3-fold more likely to have disease in the left kidney and are more often men.2 Of these, 24% have a significant smoking history and 34% ultimately develop bladder malignancy. To our knowledge, there have been no reported cases of simultaneous UTUC with recurrent RCC in the same kidney. Here, we present a novel case of recurrent RCC in a 59-year-old male with synchronous, ipsilateral UTUC and metachronous urothelial carcinoma of the bladder and prostate. We illustrate an unusual clinical phenomenon and highlight novel predictive markers and prognosticators to aid in monitoring and managing similar disease presentations.

COMPLIANCE WITH OVERACTIVE BLADDER MEDICATIONS IN A MANAGED HEALTHCARE ORGANIZATION

399 COMPLIANCE WITH OVERACTIVE BLADDER MEDICATIONS IN A MANAGED HEALTHCARE ORGANIZATION Jocelyn Rieder*, Viet Tran, Karen Stern, Ashok Chopra, Sherif Aboseif. Los Angeles, CA. INTRODUCTION AND OBJECTIVE: Currently the main treatment of overactive bladder is anticholinergic medications. This treatment is limited by patients’ willingness to continue taking the medications. The purpose of this study is to evaluate the level of compliance with anticholinergic medication prescribed to treat overactive bladder disease in a managed healthcare population. METHODS: During a 12 month period in 2005 and 2006, 10,321 patients were newly prescribed an anticholiergic medication in the Southern California Kaiser Permanente Region. Medications included Tolteridine (Detrol), Tolteridine Extended Release (Detrol LA), Oxybutynin Immediate Release (IR), Oxybutynin Extended Release (ER), and Oxybutynin Patch (Oxytrol). Patients were followed for one year after