Two-stage urethroplasty using buccal mucosa graft in patient with penile stricture and Lichen sclerosus

==inizio objective==

Lichen sclerosus (LS) is a disease of unknown etiology that affects the penile organ.
It is more common in young adults, but can affect any age.
It is characterized by atrophy of the epidermis.
LS affects especially the genital mucosa.
The disease can give: itching of the glans and penis, trauma during intercourse, difficulty in preputial mobility, erectile dysfunction, phimosis and paraphimosis and furthermore can lead to urethral stricture [1].

==fine objective==

==inizio methodsresults==

From January 2015 to February 2016 10 patients (pts) with LS and urethral stricture were enrolled for this study. Patient mean was age 45 years.
All of the patients underwent physical examination, uroflowmetry, retrograde and voiding urethrography in order to evaluate the stricture. The mean Qmax was 7 ml/sec. Mean stricture length was 3.7 cm.
All pts underwent two-stage urethroplasty with buccal/labial mucosa graft.
When the stricture affected the navicular urethra it was used a labial graft for its minor thickness.
A midline longitudinal incision was made along the penile skin ventrally. The penile urethra was exposed with minimal dissection. The urethra was opened along its ventral surface under the guidance of the guide wire, previously inserted. The urethra is spatulated up to 3 cm into normal caliber and pink urethral mucosa. The entire urethral plate affected by the LS was removed. Then the buccal mucosa graft was suteured on the urethral plate with two lateral running sutures and many single stiches on the whole graft in 5.0 Vicryl suture.
Second-stage procedure was carried out at 6 months from the first procedures in order to have a soft urethra and relaxed scar tissues. The neo-urethra is incised laterally and tubularized with 5.0 Vicryl suture.
The glans was reconstruct on the tubularized urethra. Dartos fascia and skin were closed. A sovrapubic catheter and a 10 Fr urethral stent were inserted and left for two weeks post-operatively.
Pts were discharged from the clinic 2 days after surgery. Pts were suggested to use anti-scar and moisturizing creams 3 times/day until the second-stage surgery.

==fine methodsresults==

==inizio results==

At 3 months follow-up after the second stage all pts underwent uroflowmetry in order to assess the voiding.
Two pts needed calibration with Nelaton catheter 16 Fr. One patient underwent surgery with buccal mucosa graft.
Mean Qmax was 21 ml/sec. All Pts were satisfied with the result of the surgery.

==fine results==

==inizio discussions==

In pts with penile strictures caused by LS, the penis is fully involved in the disease : glans, meatus, skin, fibrotic dartos. For these pts one-stage repair would be risky, having a poor chance of success. For this reason it is recommended the two-stage repair [2]. At moment buccal mucosa graft is the best tissue to replace the urethra

==fine discussions==

==inizio conclusion==

Penile urethroplasty is a complex procedure with high risk of insuccess so it should be perfomed only by surgeon specialized in genital reconstructive surgery. This procedure is the only technique that can treat LS and penile strictures.

==fine conclusion==

==inizio reference==

1) Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of Panurethral Stricture. Urol Clin North Am. 2017 Feb;44(1):67-75

2) Angulo JC, Arance I, Esquinas C, Nikolavsky D, Martins N, Martins F. Treatment of long anterior urethral stricture associated to lichen sclerosus. Actas Urol Esp. 2016 Nov 2. pii: S0210-4806(16)30131-0.

==fine reference==

Martius flap like approach for neobladder -vaginal fisulae after orthotopic urinary diversion in woman.

==inizio objective==

Vescico-vaginal fistulae (VVF) is uncommon and difficult pathology to manage especially because they occours in patients with previously surgery (trans abdominal hysterectomy 70%, trans vaginal hysterectomy 20%), radiotherapy exposition (6/10%) or in case of pelvic floor tissue ischemia (long labor time 10%) (1,2,3,4,5). Another clinic condition that can be at risk for vaginal fistula is in case of neoblabber replacement after radical cystectomy and occurring in 0–10% (6,7,8,9,10). Several risk factors have been identified in poorly vascularized tissue between the urethra neobladder anastomosis and anterior vaginal wall on the suture line proximity and in the damage to the anterior vaginal wall during dissection The technique that we are going to describe was introduced by Dr Heinrich Martius in 1928 in African women with vescico-urethral-fistula caused of a long labor time after recurrence with poor functional outcomes. This kind of flap has been used for urogyncological fistulae and less frequently for rectovaginal fistulae (11). Generally, the surgical approach, depending on the complexity of the cause and the localization of the fistulae. There are various techniques repair that can be considered like gracile muscle flaps, trans abdominal omentum flap, transperineal and transvaginal approaches or fistula plugs (12,13) and can be performed opening, lapharoscopy or Robot assisted. Healthy tissue transfer is important more that the tecnique for a good outcome of complex fistulae especially for clinical patients history. For low fistulae, when rectal, perineal or vaginal approach is planned, Martius flap become an excellent choice being in close proximity of the operation field (14).

==fine objective==

==inizio methodsresults==

We report a small collection of 2 patients with VVF after orthotopic urinary diversion. The first one is a patient 66 years old who received the Martius flap after previously transvaginal approach for anterior vaginal wall fistula with neo-bladder urethra anastomosis with a double wall layer repair. The recurrence occurred after 3 months and in the same side and the fistula size was 1.5cm. The second is a patient 62 years old received a Martius flap like first step for laterally vagina fistula wall with neo-bladder urethral anastomosis with size of 1cm. In both cases anterior vagina wall was sacrificed during radical open cystectomy and the posterior wall was folded anteriorly and anastomosed to the margin of vagina resection.

==fine methodsresults==

==inizio results==

The patients independently of previously transvaginal surgical approach were dry after removal catheter in 15th day. A cystoscopy and cystography performed after two months were without evidence of recurrence. At an average of 20.5 months (24, 17 months) both the patient are dry.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

We think that anterior approach of the neo-bladder vagina fistula using the Martius flap represents the less invasive and feasible technique that can be employed with minimally morbidity especially compared to gracile muscle flap or abdominal approach. We suggest this technique before to plane ad abdominal approach. Particular indication can be considered in all patients with poor outcome or actinic tissue damage because the bulbocavernosus muscle provides with a good drainage of the local secretion and in same time supplied an appropriate blood and lymphatic support .

==fine conclusion==

==inizio reference==

1. El-Gazzaz G, Hull T, Mignanelli E et al.: Analysis of function and predictors of failure in women undergoing repair of Crohn’s related rectovaginal fistula. J Gastrointest Surg 2010; 14: 824-29.
2. Athanasiadis S, Yazigi R, Kohler A, Helmes C: Recovery rates and functional results after repair for rectovaginal fistula in Crohn’s disease: a comparison of different techniques. Int J Colorectal Dis 2007; 22: 1051-60.
3. Pinto RA, Peterson TV, Shawki S et al.: Are there predictors of outcome following rectovaginal fistula repair? Dis Colon Rectum 2010; 53: 1240-47.
4. Boronow RC: Repair of radiation-induced rectovaginal fistula utilizing the Martius technique. World J Surg 1986; 10: 237-48.
5. White AJ, Buchsbaum HJ, Blythe JG, Lifshitz S: Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced rectovaginal fistulas. Obstet Gynecol 1982; 60: 114-18.
6. Tscholl R, Leisinger HJ, Hauri D. The ileal S-pouch for bladder replacement after cystectomy: preliminary re¬port of 7 cases. J Urol 1987; 138:344.
7. Ali-el-Dein B, el-Sobky E, Hohenfellner M et al. Or¬thotopic bladder substitution in women: functional eva¬luation. J Urol 1999; 161:1875.
8. Tunuguntla HS, Manoharan M, Gousse AE. Manage¬ment of neobladder-vaginal fistula and stress inconti¬nence following radical cystectomy in women: a re¬view. World J Urol 2005; 23:231.
9. Stein JP, Grossfeld GD, Freeman JA et al. Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 34 pa¬tients. J Urol 1997; 158:400.
10. Rapp DE, O’connor RC, Katz EE et al. Neobladder-va¬ginal fistula after cystectomy and orthotopic neobladder construction. BJU Int 2004; 94:1092.
11. Raugnekar NP, Judad Ali N, Kaul SA , Pathak HR: Role of the martius procedure in the management of urinary-vaginal fistulas. J Am Coll Surg 2000; 191: 259-63.
12. Chang SS, Cole E, Cookson MS et al. Preservation of the anterior vaginal wall during female radical cystec¬tomy with orthotopic urinary diversion: technique and results. J Urol 2002; 168:1442.
13. Juan E. Bestard Vallejo, Anna Orsola de los Santos, Carles X. Raventós Busquets, Jacques Planas Morin and Juan Morote Robles. Closure of neobladder-vaginal fistula in patient with Studer neobladder using vaginal approach and interposition of Martius flap. Urology Service. Hospital Vall d’Hebron. UAB. Barcelona. Spain. Arch. Esp. Urol. 2009; 62 (1): 56-59
14. Maude E. Carmel,1* Howard B. Goldman,2 Courtenay K. Moore,2 Raymond R. Rackley,2 and Sandip P. Vasavada2. Transvaginal Neobladder Vaginal Fistula Repair After Radical Cystectomy With Orthotopic Urinary Diversion in Women Neurourology and Urodynamics 35:90–94 (2016). 1 UT Southwestern Medical Center, Dallas, Texas. 2 Cleveland Clinic, Cleveland, Ohio.

==fine reference==

Robotic ureteral reimplantation for uretero-enteric anastomotic strictures in different urinary diversions

==inizio abstract==

In this video we describe the techniques and outcomes of robotic ureteral reimplantation for ureteroenteric anastomotic strictures in different UDs.
From April 2013 to July 2016 12 patients underwent robotic ureteral reimplantation in three tertiary referral centers.
Out of 12 patients, 7 had orthotopic neobladder, 4 ileal conduit and 1 Indiana pouch. All patients had prior robot assisted radical cystectomy and all but one had intracorporeal UD.
Surgical steps include a careful ureteral dissection on the surface of the ureter/s to avoid injurying the iliac vessels, spatulation of the ureters, JJ stent insertion and finally uretero-ileal anastomosis.
Three cases (one ileal conduit, one neobladder and one Indiana Pouch) are demonstrated in the video.
Baseline, perioperative and functional outcomes data are reported.
Mean stricture length was 2 cm (range 0.5-3), median operative time was 201 minutes (83-310) and median length of stay was 2 days (2-12).
Intraoperative blood loss was negligible. Four patients experienced a Clavien grade 2 complication (urinary tract infection requiring antibiotics). At a mean follow-up of 1-yr no patient developed recurrence.
The suboptimal success rate of endoscopic treatment, the minimally invasiveness of robotic surgery and the high success rate of robotic repair may contribute to an increased adoption of this surgical option in the near future.

==fine abstract==

Pieloplastica videolaparoscopica robot-assistita sinistra. Iniziale esperienza

==inizio abstract==

Il video mostra uno dei nostri primi interventi chirurgici di correzione della stenosi del giunto pielo-ureterale effettuato con l’ausilio del robot da Vinci XI. il paziente viene posizionato in decubito laterale, con una spezzatura del bacino di circa 10 gradi. -Viene effettuato un accesso open all’incrocio tra la linea ombelicale trasversa e la pararettale. Introdotto il primo trocar robotico da 8mm per l’ottica, si posizionano in visione sulla linea pararettale alta e bassa e a circa 7-8 cm dal primo, altri due trocar per l’operatività robotica. Il trocar per il sistema AerSeal da 8mm viene posizionato tra il trocar dell’ottica e il trocar posizionato sulla pararettale bassa, quasi a ridosso della linea xifopubica. Quando possibile preferiamo effettuare un isolamento “in situ” del giunto; in questo caso clinico specifico, il paziente presentava una pelvi anteriorizzata e l’uretere decorreva a ridosso del polo inferiore del rene. Per cui, prima di procedere alla pieloplastica, è stato effettuato anche l’isolamento del polo inferiore del rene. Viene ricostruito prima il piatto posteriore in Vicryl 5-0, successivamente lo stent viene posizionato per via retrograda e viene conclusa la pieloplastica con la ricostruzione del piatto anteriore in Vicryl 5-0.

==fine abstract==

Ureterocistoneostomia laparoscopica destra con lembo di Boari per stenosi uretrale > 8 cm

==inizio abstract==

Il video descrive il trattamento laparoscopico di una stenosi ureterale destra in una donna di 65 anni.
La stenosi dell’uretere, secondaria ad intervento chirurgico di sigmoidectomia , appendicectomia, linfoadenectomia lomboaortica e pelvica effettuato nel Gennaio 2016 per recidiva di carcinoma ovarico, è’ stata valutata mediante TC addome completo e pielografia ascendente e transnefrostomica, con misurazione di soluzione di continuo ureterale destra > 8 cm.
E’ stata posta indicazione al trattamento laparoscopico mediante ureteroneocistostomia con lembo vescicale, dopo tentativi infruttuosi di posizionamento stent ureterale dx.
Il video descrive l’isolamento dell’ uretere e la mobilizzazione della vescica. Per la soluzione di continuo rilevata, è stato necessario psoizzare la vescica. Si descrive l’incisione di lembo vescicale, l’anastomosi ureterovescicale del piatto posteriore, lo stenting retrogrado intracorporeo, la tubularizzazione del lembo e la prova di tenuta.
I tempi operatori sono stati 150 min, le perdite ematiche intraoperatorie 100ml.
In IV giornata è stata eseguita cistografia ed è stato rimosso il catetere vescicale.
La paziente è stata dimessa in VI giornata postoperatoria dopo rimozione del drenaggio.
Lo stent ureterale è stato rimosso in XXVIII giornata postoperatoria.
La contrastografia mostra la riconfigurazione vescicale e l’integrità delle alte vie escretrici, in paziente asintomatica.

==fine abstract==

Reimpianto ureterale robotico. Iniziale esperienza in un centro di alta specialità laparoscopica

==inizio abstract==

Il video mostra il caso di una stenosi ureterale da danno iatrogeno dell’uretere pelvico in una giovane donna. La paziente viene posizionata in posizione supina, con un Trendelemburg di circa 20°. Viene effettuato un primo accesso open per un trocar robotico sulla linea mediana a 2cm dall’ombelico verso l’appendice xifoidea. Sulla linea trasversale passante per il primo trocar vengono posizionati altri 2 trocar da 8 mm robotici (uno a destra e uno a sinistra). Viene posizionato un trocar ausiliario robotico a due centimetri dalla SIAS sinistra lungo una linea che congiunge la SIAS al trocar centrale. Viene posizionato un trocar airseal da 8 mm a due centimetri dalla SIAS destra lungo una linea che congiunge la SIAS al trocar centrale. Dopo aver liberato il sigma dalle sue aderenze con l’ovaio, il mesosigma viene inciso fino a raggiungere la regione in cui l’uretere incrocia i vasi iliaci. Si procede ad isolamento dell’uretere e si incide a tutto spessore la regione cupolare vescicale dove si effettuerà il reimpianto in Vicryl 5-0, su stent doppio J. La sutura in due emicontinue viene effettuata a tutto spessore, comprendendo anche la mucosa vescicale ed alcuni punti di rinforzo vengono posizionati al termine della procedura.

==fine abstract==

Ricostruzione Estetica del Pene in paziente adulto con Ipospadia Complicata

==inizio abstract==

Il Video mostra i concetti di riparazione uretrale ed estetica del pene in un paziente adulto con riparazione fallita di ipospadia nell’infanzia.
Al momento dell’intervento il paziente presentava un meato ipospadico residuo ed un piatto uretrale distale ampio dopo innesto di cute prepuziale avvenuto durante un precedente intervento.
Il nostro intervento mostra la ricostruzione dell’uretra distale impiegando un lembo cutaneo secondo Mathieu.
Il Video inoltre mostra la creazione del neomeato e la preparazione delle ali glandari con lo scopo di ottenere quello che è il sogno di molti pazienti con Ipospadia fallita: la ricostruzione uretrale combinata ad una ricostruzione estetica del glande e del meato che si avvicini quanto più possibile ad un “pene normale”.

==fine abstract==

Robotic vesico-vaginal fistula repair with bovine Pericardial Patch interposition

==inizio abstract==

A vesico-vaginal fistula (VVF) is a fistulous tract that connects bladder and vagina, causing
urine leakage via the vagina. Iatrogenic postoperative VVF is the most common case.
Classically, when treating a VVF via the abdominal route, an abdominal flap is mobilized and interposed between the bladder and the vagina. In our video, we describe a robotic VVF repair technique with bovine Pericardial Patch interposition instead of omental flap for a vaginal vault-located fistula. Duration of surgery was 115 min, estimated blood loss was <50 ml. The postoperative course was uneventful. At 40 days follow-up, which included clinical and cystographic examinations, the patient had not experienced any recurrence. In our opinion bovine Pericardial Patch interposition after a V-lock suturing technique using continuous sutures for vaginal closure and for perpendicular bladder closure is a safety procedure alternative to omental flap, reducing operating time and possible complications related to accidental peritoneal injuries. ==fine abstract==

Ventral-lateral onlay urethroplasty using buccal mucosa graft

==inizio abstract==

In questo video mostreremo un intervento di uretroplastica con innesto ventrale e laterale di mucosa buccale in un paziente con stenosi recidivante dell’uretra bulbare.
Il paziente era già stato sottoposto in altri centri a tre interventi di uretrotomia secondo Sachse e diversi tentativi di dilatazioni uretrali. Si pratica un primo tempo endoscopico per visualizzare la stenosi utilizzando un ureteroscopio e si inserisce un filo guida per facilitare il ritrovamento del lume uretrale stenotico una volta inciso il piatto uretrale.
L’incisione viene effettuata a livello perineale. Si procede all’apertura della fascia di Colles e si incide medialmente il muscolo bulbo-spongioso. Viene così esposta l’uretra bulbare. Si pratica un’incisione ventrale fino a repertare il filo guida.
L’incisione effettuata è di circa 5 cm fino al raggiungimento di mucosa uretrale sana. Si procede a prelevare un graft di mucosa buccale dalla guancia sinistra del paziente. Il difetto viene chiuso in sutura continua in Vicryl 5.0.
Si appone un catetere Foley Ch 16 in silicone che verrà tenuto per due settimane. Si sutura il graft lateralmente e ventralmente con due suture continue in Vicryl 6.0.
Il corpo spongioso dell’uretra viene richiuso sul graft. Chiusura del muscolo bulbo-spongioso, della fascia di Colles e del tessuto grasso sottocutaneo. Cute suturata in punti staccati Vicyil 5.0.

==fine abstract==

Cost Analysis of conventional Laparoscopic pyeloplasty (CLP) versus Robotic assisted laparoscopic pyeloplasty (RALP) at a single center study

==inizio objective==

Laparoscopic pyeloplasty is the standard of care for the ureteropelvic junction obstruction (UPJO) correction in several hospital (1).
Several cost analysis, in which common robot-assisted procedures such as radical prostatectomy, partial nephrectomy and radical cystectomy were analysed, revealed higher costs with robotic procedures (2-3).
The aim of this study was to compare the costs of conventional laparoscopic pyeloplasty (CLPP) and robotic-assisted laparoscopic pyeloplasty (RALPP) (4), which are both used for correction of UPJO at our institution from January 2016.

==fine objective==

==inizio methodsresults==

We retrospectively identified 11 consecutive RALPP (Group A) and 19 consecutive CLPP (Group B) performed at our institution between January 2016 and December 2016. 2 out of the 19 CLPP patients underwent laparoscopic redo pyeloplasty for recurrent UPJO. All procedures were performed by a single surgical team with a transperitoneal approach.
The costs of each procedure include: 105.45€ for preospedalization phase, 307.23€ for each hour of use of operatory room (nursing and surgical team), 237.98€ for medical devices (surgical sutures, surgicl gloves, etc), 86.08€ for anesthetic drugs, 514.00€ for each day of hospitalization, 21.06€ for each postoperative blood sample, 56.80€ for stenting removal. The cost of the Robotic Da Vinci Xi system with the use of 3 robotics arms is 4.382,24€ and with 4 robotics arms is 5.159,38€.
Th costs related to the laparoscopic instruments for the CLPP is 301,08€.
The regional refund for this kind of surgical procedure is 8.530€ .

==fine methodsresults==

==inizio results==

The mean operating room operation time in the Group A was 126.36 minutes and in the Group B was 117.36 minutes. The mean length of hospital stay was 3.36 days in the Group A and 3.42 days in the Group B. The mean postoperative blood sample was 1.63 samples in the Group A and 1.73 samples in the Group B. In Group A, seven procedures were performed with four robotics arms and four procedures with three robotics arms. No intraoperative and postoperative complications that caused adjunctive costs occurred and no patients experienced early failure of the procedure.
As a consequence, the global cost of the eleven RALPPs at our department was 85486,1€ (mean 7.771,46€) and the global costs of the nineteen CLPPs in our hospital was 60.510,58€ (mean 3.184,74).

==fine results==

==inizio discussions==

In our experience there are greater costs for robotic instrumentation but not for medical and nurse surgical team. Moreover the mean operating room operation time and the mean length of hospital stay were similar in the two groups. The global profit related to RALPP was 8343.9€ and the profit related to CLPP was 101.559,42€.
Moreover, in this first prelimary experience we have not considered the costs related to robotic platform maintenance contracts (200.000€), because at our hospital the maintenance of the robotic platform has been free for the first year.
It is possible in the future to achieve a more profit in the RALPP considering a shorter operative times due to the improvement of our robotic learning curve and considering a shorter time of dismission.
In addition to the costs of the surgical procedure and perioperative care, the costs of long-term follow-up and care must be considered when comparing these 2 procedures. Long term followup data are not yet available.

==fine discussions==

==inizio conclusion==

Our preliminary single institutional analysis shows bigger costs for the robotic-assisted laparoscopic pyeloplasty and as a consequence a better profit for the conventional laparoscopic pyeloplasty. It remains the best cost-effective procedure in the treatment of UPJO.

==fine conclusion==

==inizio reference==

1- Fedelini P, Verze P, Meccariello C, Arcaniolo D, Taglialatela D, Mirone VG. Intraoperative and postoperative complications of laparoscopic pyeloplasty: a single surgical team experience with 236 cases. J Endourol. 2013 Oct;27(10):1224-9.
2- Lotan Y, Cadeddu JA and Gettman MT: The new economics of radical prostatectomy: cost comparison of open, laparoscopic and robot assisted techniques. J Urol 2004; 172: 1431.
3-. Mir SA, Cadeddu JA, Sleeper JP et al: Cost comparison of robotic, laparoscopic, and open partial nephrectomy. J Endourol 2011; 25: 447.
4- Yee DS, Shanberg AM, Duel BP et al: Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children. Urology 2006; 67: 599.

==fine reference==