W. Stuart Reynolds

Pediatric Robotic-assisted Laparoscopic Augmentation Ileocystoplasty and Mitrofanoff Appendicovesicostomy: Complete Intracorporeal—Initial Case Report

INTRODUCTION To the best of our knowledge, we report the first case of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric patient, outlining the surgical technique and short-term results. TECHNICAL CONSIDERATIONS The operative steps of the open procedure were replicated laparoscopically using robotic-assistance. In brief, 5 transperitoneal laparoscopic ports were placed before docking the da Vinci S robotic system. A 20-cm ileal segment was isolated, and the gastrointestinal anastomosis was performed in an end-to-end fashion using intracorporeal suturing. The appendix was anastomosed to the right posterior wall of the bladder over an 8F feeding tube in an extravesical fashion. The bladder was incised in a coronal plane, and the simple ileal on-lay patch was anastomosed to the posterior and anterior walls of the bladder. A suprapubic catheter and pelvic drain were placed, and the Mitrofanoff stoma was then fashioned. Cystography was performed at 4 weeks postoperatively. CONCLUSIONS This preliminary first successful report suggests that robotic-assisted ileocystoplasty and appendicovesicostomy is feasible. A reasonable outcome with early recovery, resumption of normal activities, and excellent cosmesis can be achieved in selected patients. However, whether a robotic-assisted approach provides any significant advantages over conventional open procedures is yet to be determined with a large case series.

Epidemiology of Stress Urinary Incontinence in Women

Stress urinary incontinence is common and affects many women globally. About 50% of women with urinary incontinence report symptoms of stress incontinence, but estimates of the prevalence and incidence are limited by inconsistent methods of measurement between epidemiologic studies in different populations. Estimates also are affected by underlying differences in the age and ethnicity of study populations. Longitudinal studies assessing the incidence and natural history of stress incontinence estimate an annual incidence of 4% to 10%. While remission does occur, data on this remains sparse. Multiple risk factors have been associated with stress incontinence and may to contribute to the development of the condition. Recent epidemiologic studies have focused on defining additional lower urinary tract symptoms besides mixed or urge incontinence that may be associated with stress incontinence, but the significance of this is not yet known.

Further Experience With the Vascular Hitch (Laparoscopic Transposition of Lower Pole Crossing Vessels): An Alternate Treatment for Pediatric Ureterovascular Ureteropelvic Junction Obstruction

PURPOSE Standard treatment for ureterovascular ureteropelvic junction obstruction has been dismembered pyeloplasty. We previously reported the alternative technique of laparoscopic transposition of lower pole vessels (the vascular hitch) in pediatric patients. This report is an update of this select group of pediatric patients with intermediate followup. MATERIALS AND METHODS Patients underwent diagnostic renal sonography and (99m)technetium-mercaptoacetyltriglycine diuretic renography with additional magnetic resonance angiography in candidate patients. Radiographic criteria included moderate hydronephrosis with no caliceal dilatation and a well preserved cortex, poor renal drainage with preserved split function and lower pole crossing vessels. Intraoperative criteria included a normal ureter and ureteropelvic junction with peristalsis. Postoperatively patients were followed clinically, and with renal sonography and (99m)technetium-mercaptoacetyltriglycine renography at 1 and 2 months, respectively. Success was defined as symptom resolution with radiographic improvement in hydronephrosis and drainage with preserved renal function. RESULTS Nine boys and 11 girls 7 to 16 years old (mean age 12.5) underwent laparoscopic transposition of crossing vessels, including 3 with da Vinci robot assistance. Mean operative time was 90 minutes (range 47 to 140). Median hospital stay was 24 hours. No ureteral stents or urethral catheters were placed intraoperatively. At a mean followup of 22 months (range 12 to 42) 19 of 20 patients (95%) had been successfully treated. One patient who had recurrent pain underwent successful laparoscopic pyeloplasty. CONCLUSIONS At intermediate followup the laparoscopic vascular hitch procedure has been successful in treating patients with ureterovascular ureteropelvic junction obstruction. In these select patients this technique offers a feasible and durable alternative to standard dismembered pyeloplasty. Ongoing evaluation continues to ensure that the promising results endure.

Open Surgical Repair of Ureteral Strictures and Fistulas Following Radical Cystectomy and Urinary Diversion

PURPOSE Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary diversion-enteric fistula and ureteral strictures in patients undergoing radical cystectomy, and discuss the diagnosis and management of these complications, including our surgical approach to these patients. MATERIALS AND METHODS We preformed a retrospective review of 553 patients undergoing radical cystectomy and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral stricture or fistula developed were identified by serial laboratory and imaging evaluations. A chart review was preformed to identify symptoms, time to stricture or fistula development, radiological findings, type of diversion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were assessed. RESULTS Of 553 patients reviewed ureteral stricture developed in 41 (7.4%) with a mean followup of 20.2 months (range 1 to 98). Strictures developed in 11% (31 of 272) of the orthotopic ileal neobladder, 2.5% (6 of 236) of ileal conduit and 8% (4 of 45) of Indiana pouch cases. Open repair led to an overall success rate of 87%. Urinary diversion-enteric fistula developed in 12 (2.2%) of the 553 patients with a mean followup of 28.4 months (range 3 to 94), all of whom had undergone orthotopic neobladder diversion. No patient had recurrence after surgical repair of the fistula. CONCLUSIONS Open revision remains the gold standard management for ureteral strictures and urinary diversion-enteric fistulas occurring after radical cystectomy. The addition of the chimney modification to the orthotopic neobladder facilitates surgical repair.

Surgical technique using AdVance™ Sling placement in the treatment of post-prostatectomy urinary incontinence

OBJECTIVES To describe and illustrate a new minimally invasive approach to the treatment of male stress urinary incontinence following prostatectomy. SURGICAL TECHNIQUE Our initial experience consisted of four patients treated with the Advance sling for post-prostatectomy urinary incontinence. Sling placement involves the following steps: 1. Urethral dissection and mobilization, 2. Identification of surgical landmarks, 3. Placement of needle passers through the obturator foramen, 4. Mesh advancement, 5. Mesh tensioning and fixation, 6. Incision closure. COMMENTS Based on our initial experience, we believe that the Advance Male Sling System may be a safe technique for the treatment of male stress urinary incontinence. This technique is easy to perform and may offer a reproducible, transobturator approach. Further patient accrual is ongoing to assess the safety and reproducibility of this technique. Also, additional study will focus on efficacy standards and complication rates.

Immediate effects of the initial FDA notification on the use of surgical mesh for pelvic organ prolapse surgery in medicare beneficiaries

Prompted by increased reports of complications with the use of mesh for pelvic organ prolapse (POP) surgery, the FDA issued an initial public health notification (PHN) in 2008. We proposed to determine if the numbers of POP cases augmented with surgical mesh performed in U.S. Medicare beneficiaries changed relative to this PHN.

Urinary retention rates after intravesical onabotulinumtoxinA injection for idiopathic overactive bladder in clinical practice and predictors of this outcome

The purpose of this study was to find the rate of urinary retention in clinical practice after treatment with onabotulinumtoxinA (BTN/A) for refractory overactive bladder (OAB) symptoms and determine factors that predict this outcome.

Cystectomy With Urinary Diversion for Benign Disease: Indications and Outcomes

OBJECTIVE To analyze what factors contribute to a worse outcome after cystectomy and urinary diversion for benign disease as measured by the frequency of severe complications. METHODS A retrospective review was performed of consecutive patients who underwent a cystectomy for benign disease. The primary outcome was the type and severity of complications, according to Clavien-Dindo scale. RESULTS A total of 139 patients underwent cystectomy with diversion for benign diseases over the study period. The most common indications for surgery were spinal cord injury (32%) and radiation damage to the bladder (18%). The average preoperative age-adjusted Charlson comorbidity index was 4.6. Seventy-four patients (53%) underwent supratrigonal cystectomy. Mean surgery duration was 344±103 minutes, and the mean estimated blood loss was 476±379 mL. The most common complications were perioperative blood transfusion, prolonged ileus, and pyelonephritis. Seventy-nine patients (57%) had a complication grade≥II on the Clavien-Dindo scale. This did not differ based on indication for surgery, age, gender, body mass index, age-adjusted Charlson comorbidity index, estimated blood loss, or type of cystectomy. After adjustment, only duration of surgery in 10-minute increments (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P=.007) was associated with an increased incidence of serious complication. CONCLUSION Most of the patients experience some complication after cystectomy and urinary diversion for benign indications. Duration of surgery is an important variable that can affect outcome.

Obturator foramen dissection for excision of symptomatic transobturator mesh.

PURPOSE Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision. MATERIALS AND METHODS The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery. RESULTS Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12). CONCLUSIONS Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

Analysis of Continence Rates Following Robot-assisted Radical Prostatectomy: Strict Leak-free and Pad-free Continence

OBJECTIVES To propose a strict and specific definition of continence (leak-free and pad-free [LFPF]) and apply it to robot-assisted radical prostatectomy (RARP) outcomes on the basis of University of California-Los Angeles-Prostate Cancer Index (UCLA-PCI), as postprostatectomy incontinence is not well defined. METHODS A single-institution RARP database was reviewed concerning continence variables prospectively recorded by the UCLA-PCI. Specific responses to urinary function and continence items were reviewed at baseline and 1, 3, 6, 12, and 24 months after surgery. RESULTS From February 2003 to September 2007, a total of 1005 of 1500 RARP patients had data available for review. At baseline, only 73% of these patients were LFPF. This decreased to 4%, 9%, 17%, 24%, and 28% at 1, 3, 6, 12, and 24 months after surgery, respectively. Applying less strict definitions, at 24 months, 68% of patients reported no pad use and 90% of patients reported no pad use or the use of a security pad. When stratified by baseline LFPF status, patients not LFPF at baseline had higher baseline international prostate symptom score scores, lower urinary function scores, lower urinary bother scores, and larger prostate weights. Patients LFPF at baseline disproportionately regained LFPF continence starting 6 months after surgery compared with those not LFPF at baseline: 20% vs 9% (P = .005), 27% vs 15% (P = .0009), and 33% vs 15% (P = .0146) at 6, 12, and 24 months, respectively. CONCLUSIONS A strict definition of urinary continence results in more conservative postoperative outcomes. Preoperative LFPF status can be predictive of postoperative LFPF continence. However, only one-third of patients LFPF at baseline returned to LFPF at 24 months.