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Video Surgi Session 2 11:00Am - 1:00Pm Thursday, 29Th October, 2020

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Video Surgi Session 2 11:00Am - 1:00Pm Thursday, 29Th October, 2020 Video Surgi Session 2 11:00am - 1:00pm Thursday, 29th October, 2020 41 Holmium Laser Ureterocele Excision with Transurethral Incision of the Prostate Grant R. Pollock MD1, Kalpesh Patel MD2, Joel Funk MD1 1University of Arizona, Department of Urology, Tucson, AZ, USA. 2Arizona Institute of Urology, Tucson, AZ, USA Abstract Objectives: Ureteroceles present a diagnostic and treatment challenge in adults. With an estimated prevalence of 1/500 to 1/4000, it is not uncommon for any urologist to encounter a ureterocele in clinical practice. We present an interesting case of a 53-year-old male with a 20-year history of obstructive voiding symptoms who presented to clinic with urinary retention that was found to be secondary to an orthotopic ureterocele that was prolapsed into the prostatic urethra. The patient underwent holmium laser ureterocele excision with transurethral incision of the prostate with a successful outcome. We present a video demonstrating the technique. Materials and Methods: Preoperative evaluation included a transrectal ultrasound of the prostate which revealed a prostate volume of 20cc. Urodynamics was also performed and pressure flow studies revealed a high-pressure, low flow voiding pattern with a functional detrusor muscle. Cystourethroscopy was performed revealing that an orthotopic ureterocele on the left side was prolapsed into the prostatic urethra and the bladder neck was mildly elevated. Using MOSES technology and laser settings of 30 Hz and 1.5 J, the ureterocele was completely excised and a transurethral incision of the prostate was performed. Results: The patient was discharged home on the day of surgery in stable condition with a Foley catheter in place. On post-operative day 1 he returned to clinic and he successfully passed a voiding trial with a post-void residual volume of 25cc. Renal ultrasonography was performed 3 months postoperatively and revealed no hydronephrosis. His postoperative International Prostate Symptom Score of 2 (lifestyle 0) was improved compared to his preoperative score (overall 34, lifestyle 6). Conclusions: Holmium laser ureterocele excision with a transurethral incision of the prostate is an effective treatment modality in the management of a prolapsed orthotopic ureterocele causing bladder outlet obstruction in a male patient. Source of Funding: None 45 Boari flap. Laparoscopic technique step by step Alexander Kheifets MD, Ben Valery Sionov MD, Abraham Ami Sidi MD, Alexander Tsivian MD The E. Wolfson Medical Center, Holon, N/A, Israel Abstract Boari flap. Laparoscopic technique step by step Alexander Kheifets, Ben Valery Sionov, A. Ami Sdi, Alexander Tsivian. Department of Urologic Surgery, The E. Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Israel (Presentation to be made by Dr Alexander Kheifets) Introduction Ureteral injury is one of the most serious complications of gynaecologic surgery Ureteral injury following gynecologic surgery is quite rare occurring in approximately 1% of cases. Consequently, the need for ureteral reconstruction by Boari flap is not common. In this video we present step-by-step laparoscopic technique of Boari flap ureteral reconstruction. Patients and methods The Patient is placed in the reverse Trendelenburg position. Once a pneumoperitoneum is established, 4 trocars are placed in an arch form. Via trans-peritoneal approach, inspection and adhesiolysis are carried out and the ureteral injury site is exposed about 2 cm cranial to the crossing of the common iliac vessels. The ureter is divided proximal to the level of the injury and spatulated. The bladder is mobilized by peritoneal incision, but the gap is deemed too wide for a safe primary re-implantation. An anterior bladder wall flap is created. The apex of the flap is approximately 3 cm wide, and the base is approximately 5 cm. The cut end of the ureter is pulled through the bladder flap. The spatulated ureter is then anastomosed to the upper portion of the flap over a 7FR ureteral stent. The flap is tubularized and closed with absorbable running sutures and fixed to the psoas muscle. A Foley catheter is left for 7 days and removed after a cystogram. A ureteral stent is left for 4 weeks. During the period 01/2000 - 09/2018, 66 patients with an age range of 14-75 years underwent a middle or lower ureteral reconstructive surgery. In 5 of them reconstruction using a Boari flap was performed. Results: During 10 months’ follow-up the patient was asymptomatic, with a normal imaging and laboratory findings. Conclusions: Laparoscopic Boari flap reconstruction is feasible and effective treatment, conferring the advantages of minimally invasive approach to these patients. 46 Robotic-assisted Laparoscopic High Uterosacral Ligament Suspension and Burch Urethropexy Archana Rajender MD, Gamal Ghoniem MD University of California Irvine, Orange, CA, USA Abstract Introduction: Pelvic organ prolapse can include the anterior, posterior, or apical compartments, individually or in combination. When apical suspension is planned for pelvic organ prolapse repair, the surgeon and patient must decide if hysterectomy should be performed simultaneously. Recent literature suggests that 36-60% of women would choose uterine preservation with prolapse repair, if the option was of equivalent efficacy. Interestingly, 21% of women would still choose uterine preservation even if the prolapse repair had lower success rates. There are a variety of techniques for apical suspension with uterine preservation, one of which includes uterosacral ligament suspension, either transvaginal or transabdominal. The risk of ureteral injury during high uterosacral ligament suspension is 1-11%. The main advantage of the laparoscopic approach is appropriate visualization of the ureters in a minimally invasive fashion and ability to perform other concomitant abdominal procedures. In this video, we demonstrate a robotic-assisted laparoscopic approach to high uterosacral ligament suspension with uterine preservation, and Burch urethropexy. Patient details: The patient presented is a 51-year-old woman, G2P2, who presented to the clinic for evaluation of a vaginal bulge and stress urinary incontinence. She reported frequent urination, nocturia, and stress urinary incontinence for the past 20 years. She reported use of 10 pads per day which were soaked at time of change. More recently she noticed a progressive vaginal heaviness. Pelvic examination demonstrated a 7cm total vaginal length, 3cm apical descent with Valsalva, stage 1 anterior wall prolapse, and urethral hypermobility. Urodynamic testing showed no detrusor overactivity, a VLPP 106cmH20 and CLPP of 128cmH20 at a volume of 250mL. After discussion of various treatment options, she stated the importance of uterine preservation. Therefore, she was counseled on proceeding with robotic-assisted laparoscopic high uterosacral ligament suspension and Burch urethropexy. Video information: The procedure is detailed in the video in two parts, (1) Uterosacral ligament suspension and (2) Burch urethropexy. Relevant anatomy is elucidated throughout. 47 Excision of Eroded Intravesical Mesh after Mid-urethral Sling Archana Rajender MD, Gamal Ghoniem MD University of California Irvine, Orange, CA, USA Abstract Introduction: Synthetic mesh complications after mid-urethral sling (MUS) for female stress urinary incontinence include bleeding, infection, voiding dysfunction, mesh exposure, pelvic pain and organ perforation. Intravesical mesh erosion is an uncommon complication with an unknown incidence after MUS placement. Presenting symptoms of bladder mesh erosion often include irritative voiding symptoms, recurrent urinary tract infections, hematuria, and bladder stones. Intravesical erosion of mesh is diagnosed on cystoscopy. The etiology includes unrecognized bladder injury at the time of sling placement, or, submucosal placement of mesh with delayed secondary erosion through the bladder. In this video, we demonstrate cystoscopic-guided excision of eroded bladder mesh with the aid of a 5mm suprapubic laparoscopic port. Patient details: The patient in the video is a 43-year-old woman who underwent MUS placement at an outside hospital, five years prior to presentation. Her symptoms included irritative voiding symptoms, hematuria and recurrent urinary tract infections. Diagnostic office cystoscopy demonstrated eroded mesh entrapped by a linear, 4cm stone on the right lateral wall of the bladder. She was counseled on proceeding with endoscopic removal of the eroded bladder mesh with the aid of a 5mm laparoscopic port. Video information: We present this video in the following segments (1) Cystoscopy and cystolitholapaxy, (2) Suprapubic port placement, and (3) Mesh excision. 74 Mini-Percutaneous Nephrolithotomy: Surgical Technique Michael C Phung MD, Nishant D Patel MD UCLA Health, Los Angeles, CA, USA Abstract Large stone burdens have traditionally been treated with percutaneous nephrolithotomy with sheath sizes ranging from 24-30Fr. Mini-percutaneous nephrolithotomy (mini-PCNL) allows for efficacious treatment of similar stone burdens but using sheath sizes 20Fr or smaller. This may allow for less bleeding, less pain, and quicker recovery for patients. The purpose of this video is to demonstrate an endoscopic assisted surgical technique in performing mini-PCNL, as well as the use of the Clear Petra sheath which allows for continuous suction of stone fragments and may increase the efficiency of the procedure. 161 The Use of Intraoperative MRI (iMRI) at the Time of Cystovaginoscopy
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