Perineal Dissection Research Articles

Evaluation of Perioperative Clinical Parameters and Quality of Life in Patients Undergoing Radical Perineal or Retropubic Prostatectomy: A Prospective Randomized Study

Objective: The objective of study is to investigate the effects of radical retropubic and perineal prostatectomy methods in addition to the effect of pelvic lymph node dissection on perioperative morbidities, oncological outcomes and 1-year quality of life in patients with clinically local stage prostate cancer. Material and methods: Patients admitted to our clinic between January 2013 and March 2015 and diagnosed with clinically localized stage prostate cancer were included. A total of 103 patients were randomized into 3 groups in which 38 patients received radical perineal prostatectomy(RPP), 31 had radical retropubic prostatectomy(RRP), and 34 RRP with pelvic lymph node dissection(PLND). Age, comorbidities, preoperative Gleason scores and serum prostate-specific antigen(PSA) data as well as the surgical parameters, clinical and pathological stages, and 1-year follow-up data were recorded for each patient.“Extended prostate cancer index composite (EPIC)” and “SF-12v2™ Health Survey(Version 2.0)” questionnaires were used for overall and disease-specific quality of life at month 0, 1, 6 and 12 visits. Results: No difference was found between the groups with regard to preoperative data such as age, serum PSA levels, clinical stage, biopsy Gleason score and Charlson comorbidity index while intraoperative data for the amount of bleeding and the average amount of transfusion were significantly lower in RPP group(RPP:645cc, RRP:960cc, RRP+PLND:890cc).1-year recurrencefree survivals for RPP, RRP, and RRP+PLND groups were 9.9 months, 11.2 months and 10.2 months, respectively, with no significant difference.Overall and prostate cancer-specific quality of life was similar for all 3 groups.No additional benefit with nerve-sparing surgery was shown in any of the groups in terms of incontinence and erectile functions. Conclusion: Perineal dissection is beneficial in terms of the amount of bleeding and blood transfusion while prolonged postoperative drainage and wound infection rates are higher compared to retropubic approach.All 3 groups were similar in urinary, sexual, gastrointestinal and hormonal functions as well as the quality of life.

Functional Anatomy of Urogenital Hiatus Closure: the Perineal Complex Triad Hypothesis.

Urogenital hiatus enlargement is a critical factor associated with prolapse and operative failure. This study of the perineal complex was performed to understand how interactions among its three structures: the levator ani, perineal membrane, and perineal body-united by the vaginal fascia-work to maintain urogenital hiatus closure. Magnetic resonance images from 30 healthy nulliparous women with 3D reconstruction of selected subjects were used to establish overall geometry. Connection points and lines of action were based on perineal dissection in 10 female cadavers (aged 22-86years), cross sections of 4 female cadavers (aged 14-35years), and histological sections (cadavers aged 16 and 21years). The perineal membrane originates laterally from the ventral two thirds of the ischiopubic rami and attaches medially to the perineal body and vaginal wall. The levator ani attaches to the perineal membrane's cranial surface, vaginal fascia, and the perineal body. The levator line of action in 3D reconstruction is oriented so that the levator pulls the medial perineal membrane cranio-ventrally. In cadavers, simulated levator contraction and relaxation along this vector changes the length of the membrane and the antero-posterior diameter of the urogenital hiatus. Loss of the connection of the left and right perineal membranes through the perineal body results in diastasis of the levator and a widened hiatus, as well as a downward rotation of the perineal membrane. Interconnections involving the levator ani muscles, perineal membrane, perineal body, and vaginal fascia form the perineal complex surrounding the urogenital hiatus in an arrangement that maintains hiatal closure.

Anatomical and histological investigation of the area anterior to the anorectum passing through the levator hiatus

Objective: To document the anatomical structure of the area anterior to the anorectum passing through the levator hiatus between the levator ani slings bilaterally. Methods: Three male hemipelvises were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University. (1) The anatomical assessment was performed in three ways; namely, by abdominal followed by perineal dissection, by examining serial cross-sections, and by examining median sagittal sections. (2) The series was stained with hematoxylin and eosin to enable identification of nerves, vessels, and smooth and striated muscles. Results: (1) It was found that the rectourethralis muscle is closest to the deep transverse perineal muscle where the longitudinal muscle of the rectum extends into the posteroinferior area of the membranous urethra. The communicating branches of the neurovascular bundle (NVB) were identified at the posterior edge of the rectourethralis muscle on both sides. The rectum was found to be fixed to the membranous urethra through the rectourethral muscle, contributing to the anorectal angle of the anterior rectal wall. (2) Serial cross-sections from the anal to the oral side were examined. At the level of the external anal sphincter, the longitudinal muscle of the rectum was found to extend caudally and divide into two muscle bundles on the oral side of the external anal sphincter. One of these muscle bundles angled dorsally and caudally, forming the conjoined longitudinal muscle, which was found to insert into the intersphincteric space (between the internal and external anal sphincters). The other muscle bundle angled ventrally and caudally, filling the gap between the external anal sphincter and the bulbocavernosus muscle, forming the perineal body. At the level of the superficial transverse perineal muscle, this small muscle bundle headed laterally and intertwined with the longitudinal muscle in the region of the perineal body. At the level of the rectourethralis and deep transverse perineal muscle, the external urethral sphincter was found to occupy an almost completely circular space along the membranous part of the urethra. The dorsal part of the external urethral sphincter was found to be thin at the point of attachment of the rectourethralis muscle, the ventral part of the longitudinal muscle of the rectum. We identified a venous plexus from the NVB located close to the oral and ventral side of the deep transverse perineal muscle. Many vascular branches from the NVB were found to be penetrating the longitudinal muscle and the ventral part of rectourethralis muscle at the level of the apex of the prostate. The rectourethral muscle was wrapped ventrally around the membranous urethra and apex of the prostate. The boundary between the longitudinal muscle and prostate gradually became more distinct, being located at the anterior end of the transabdominal dissection plane. (3) Histological examination showed that the dorsal part of the external urethral sphincter (striated muscle) is thin adjacent to the striated muscle fibers from the deep transverse perineal muscle and the NVB dorsally and close by. The rectourethral muscle was found to fill the space created by the internal anal sphincter, deep transverse perineal muscle, and both levator ani muscles. Many tortuous vessels and tiny nerve fibers from the NVB were identified penetrating the muscle fibers of the deep transverse perineal and rectourethral muscles. The structure of the superficial transverse perineal muscle was typical of striated muscle. These findings were reconstructed three-dimensionally. Conclusions: In intersphincteric resection or abdominoperineal resection for very low rectal cancer, the anterior dissection plane behind Denonvilliers' fascia disappears at the level of the apex of the prostate. The prostate and both NVBs should be used as landmarks during transanal dissection of the non-surgical plane. The rectourethralis muscle should be divided near the rectum side unless tumor involvement is suspected. The superficial and deep transverse perineal muscles, as well as their supplied vessels and nerve fibers from the NVB. In addition, the cutting direction should be adjusted according to the anorectal angle to minimize urethral injury.

V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP)

You have accessJournal of UrologyCME1 Apr 2023V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP) Arman Walia, Vi Nguyen, Aditya Bagrodia, and Jennifer Anger Arman WaliaArman Walia More articles by this author , Vi NguyenVi Nguyen More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile inversion vaginoplasty is a common technique for feminizing gender-affirming surgery in which a vaginal canal can be created from full thickness scrotal skin graft. Based on surgeon preference or when scrotal skin is limited, the Davydov technique described for patients with vaginal agenesis can be used (Zhao et al). In this approach, the proximal canal is formed from peritoneum as a peritoneal cap. However, a peritoneal cap may not necessary in those with adequate graft length. Here we demonstrate a modified Davydov technique is which the apex of the vaginal canal is closed and peritoneal flaps are utilized for coverage and blood supply only, rather than inclusion as the neovaginal apex. METHODS: We utilized a standard pelvic robotic port placement using the Da Vinci Xi. Side docking allows for perineal dissection and penile disassembly. Posterior dissection is performed similar to robotic prostatectomy. The peritoneum is incised and Denonvillier’s followed. The perineal surgeon directs the robotic surgeon in avoiding the rectum. Under vision from above the perineal surgeon enters the dissected space. With guidance from below, the robotic surgeon separates the lateral levator muscle until the opening is calibrated to vaginal stent diameter. Vaginal packing can be placed to facilitate remaining perineal work. The lateral peritoneal flaps are created by incising peritoneum over the external iliac artery distally. Flap length is assessed to avoid constriction over the sigmoid, and further released as needed. After confirming adequate length, the canal is delivered from below. The apex can be closed prior to delivery or robotically. The anterior peritoneal flap is harvested by continuing the lateral dissections in an inverted "U". The lateral flaps are then secured to the canal with barbed suture. Depending on patient anatomy, the anterior flap can be rotated for coverage or simply advanced posteriorly. The anterior and posterior peritoneal flaps are then approximated over the canal apex to provide blood supply to the graft. RESULTS: The above technique has been applied to our last 5 penile inversion vaginoplasty patients. Each had an unremarkable postoperative recovery and is doing well at follow up. CONCLUSIONS: Gender-affirming surgery is a growing field with evolving techniques. A robotic-assisted approach provides additional visibility and maneuverability. A modified Davydov technique for peritoneal coverage can be added to our surgical repertoire for patients with adequate canal length so that the vaginal graft can be fully closed at the apex. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Vi Nguyen More articles by this author Aditya Bagrodia More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

A retrospective study long term complications and outcome of Ano rectal malformation following LAARP (Laparoscopic Assisted Ano Rectal Pull through) procedure

Background: The laparoscopic procedure has many added advantages of being less time consuming, early discharge from the hospital, less tissue damage, and better visualization of the pelvic structures. Objective: to study the complications and outcomes in ARM patients following LAARP. Methods: This study was conducted on 55 ARM patients in the Raichur Institute of Medical Sciences RIMS/ RGSSH (OPEC) Raichur Karnataka. The study period is from Dec 2016 to Dec 2020. Results: All the fifty five patients who are operated for anorectal malformation, they underwent first surgery (high sigmoid loop colostomy) within the second and third day of neonatal period, and second surgery the LAARP within the six weeks to three months of the first surgery, a Demographics, type of ARM, and age at pull-through. All LAARP surgery was done by single surgeon, there were no anaesthetic complications. Conclusion: This study emphasizes the emerging laparoscopic technique for management of anorectal malformations. Using this approach it is possible to achieve better continence rates as the extent of perineal dissection is minimal, hence inflicting minimal neural and sphincter injury.

Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment

BackgroundExtralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes.MethodsMedical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed.ResultsThe mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%.ConclusionsLaparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh.

Robotic Transanal Total Mesorectal Excision Compared to Laparoscopic Transanal Total Mesorectal Excision: Oncologic Results of the Past 5 Years

Colorectal cancer is one of the deadliest diseases on the planet. Rectal cancer (RC) is the 8 th most common type of cancer disease worldwide, accounting for over 300,000 fatalities in 2018. Total mesorectal excision (TME) is considered as the gold standard approach for surgical RC management. To alleviate technical problems associated with dissection of distal rectal, transanal procedure to mesorectum was developed. The robotic operating platforms’ development has brought about the most significant change. The robotic method, which was described first in the year 2001, is gaining popularity in colorectal surgery. A stable camera platform with three-dimensional imaging and tremor filtering, motion scaling, instruments with numerous degrees of freedom, 3 rd arm for fixed retraction, ambidextrous capability, superior ergonomics, and less fatigue, all these advantages have all influenced robotics implementation. However, there are certain disadvantages to robotic surgery, such as high expenses, lengthy time of operation, a bulky cart, and absence of haptic sense. Robotic transanal TME (R-TA TME) is unique method that integrates potential advantages of perineal dissection with precise control of distal margins, along with all robotic technology advantages with respect to dexterity and greater precision. This review goal is to evaluate the available literature critically regarding R-TA TME in comparison to laparoscopic TA TME (L-TA TME) using the most prevalent histopathological metrics, which are the circumferential resection margin, the distal rectal margin, recurrence rate, specimen quality, advantages, and disadvantages. Oncological results for the past 5 years were used. The resources were obtained from electronic sources such as Google Scholar and PubMed. The conclusion of this review revealed that R-TA TME is as safe as well as feasible as L-TA TME, is technically possible, and has comparable oncological results and short-term post-operative outcomes. However, further investigation is required to evaluate long-term oncological or functional results.

Laparoscopic management of a congenital H-type rectovaginal fistula in an infant

Congenital H-type rectovaginal fistula with a normal anal opening is a rare malformation. The authors encountered such a case in a 2-month-old girl. Both direct inspection and fluoroscopic examination did not identify the location of the fistula, but passage of contrast media through the vagina was observed. Using a 3-port transperitoneal laparoscopic technique, complete resection of the fistula was successfully performed. Without a protecting colostomy, laparoscopic approach appeared to be safe and feasible in an infant with an H-type rectovaginal fistula and a normal anal opening. Division of pelvic muscle floor and perineal dissection could be successfully avoided.

EDITORIAL COMMENT

Robotic assisted reconstruction for recalcitrant posterior urethral obstruction has now enabled the surgeon to preserve the pelvic floor and often avoid the need and morbidity associated with a perineal dissection. Aside from pelvic fracture related urethral injuries, posterior urethral obstruction typically presents in several scenarios: (1) bladder neck contracture after transurethral prostate resection, which is associated with excellent results utilizing a Y-V technique, (2) vesicourethral anastomotic stenosis after radical prostatectomy with a dense and often obliterative scar at the anastomosis amenable to transabdominal excision and redo of the anastomosis, and (3) post-prostatectomy post-radiation outlet obstruction.

Creation of Neovagina Using Complete Laparoscopic Dissection

Study Objective Exclusive laparoscopic dissection for creation of neovagina in MRKH Design Video with step-by-step description of technique Setting Department of Gynaecology at BLK Max Superspeciality Hospital, a tertiary care teaching hospital in Delhi, India Patients or Participants 27-year-old patient with MRKH syndrome, married for 6 months came for creation of neo-vagina Interventions Neovagina was created using complete laparoscopic dissection. Measurements and Main Results The surgery required lesser time than combined laparoscopic-perineal approach. The operation duration was 25 minutes. Blood loss was 20 ml. The vaginal lumen accommodated the vaginal mould well and patient could very comfortably change the vaginal mould herself from 4th day onwards. Conclusion For creation of neovagina, MacIndoe's method had been gold standard for many years. Combined laparoscopic and perineal technique with peritoneal pull through has become popular due to minimal morbidity. In this video, we show the technique of complete laparoscopic dissection right up to skin at vaginal dimple. As this dissection is completely under vision, it minimises the risk of damage to the bladder and rectum, which is not uncommon with perineal dissection. In addition, few medial fibers of levator ani can be divided under vision with this technique which avoids cicatrisation of vagina in future. Exclusive laparoscopic dissection for creation of neovagina in MRKH Video with step-by-step description of technique Department of Gynaecology at BLK Max Superspeciality Hospital, a tertiary care teaching hospital in Delhi, India 27-year-old patient with MRKH syndrome, married for 6 months came for creation of neo-vagina Neovagina was created using complete laparoscopic dissection. The surgery required lesser time than combined laparoscopic-perineal approach. The operation duration was 25 minutes. Blood loss was 20 ml. The vaginal lumen accommodated the vaginal mould well and patient could very comfortably change the vaginal mould herself from 4th day onwards. For creation of neovagina, MacIndoe's method had been gold standard for many years. Combined laparoscopic and perineal technique with peritoneal pull through has become popular due to minimal morbidity. In this video, we show the technique of complete laparoscopic dissection right up to skin at vaginal dimple. As this dissection is completely under vision, it minimises the risk of damage to the bladder and rectum, which is not uncommon with perineal dissection. In addition, few medial fibers of levator ani can be divided under vision with this technique which avoids cicatrisation of vagina in future.

Single-Port Robotic Posterior Urethroplasty Using Buccal Mucosa Grafts: Technique and Outcomes

ObjectiveTo describe the technique, feasibility and short-term outcomes of buccal mucosa grafts in robotic lower urinary tract reconstruction. MethodsWe reviewed 9 patients who underwent single-port robotic posterior urethroplasty with buccal mucosa graft from May-December 2019. Variables included patient demographics, diagnosis/etiology, and intraoperative parameters. Intraabdominal or extraperitoneal transvesical approaches are used for the stricture via supraumbilical access, and if necessary, perineal dissection is performed. Cystoscopy identifies the extent of stenosis. Anastomosis is completed with buccal mucosal graft and rectus abdominis, omental or gracilis flaps as needed. ResultsThe mean age was 65.4 years. Robotic urethroplasty with buccal mucosa graft was performed for vesicourethral anastomotic strictures (n = 7), urethral strictures (n = 4), pubic fistula after robotic posterior urethroplasty (n = 1), and anastomotic distraction (n = 1). Strictures occurred after prostate cancer treatments (n = 8) and trauma (n = 1). All patients had prior failed endoscopic interventions: balloon dilatation, resection/incision of bladder neck, internal urethrotomy under direct vision, urethral stents, and posterior urethroplasty. Mean defect length was 3.9 cm. Five of 9 patients had ancillary procedures including rectus abdominis (n = 3), omental or gracilis (both n = 1) flap harvests. No intraoperative complications occurred. Median operative time was 377 minutes, blood loss was 200 mL, and length of stay was 2 days. Postoperative 30-day complications included urinary tract infection, epididymitis, anemia, recurrent stricture, and small bowel obstruction requiring surgery (all n = 1). Median follow-up was 11.7 months. ConclusionBuccal mucosa grafts with ancillary maneuvers such as flap interposition or adjacent tissue transfer in robotic lower tract reconstruction is durable, safe, and comparable to open approaches.

Robotic transanal total mesorectal excision: Is the future now?

Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.

Laparoscopic Rectal and Vaginal Pull-Through in the Same Setting in Cloaca with Common Channel of More Than 3 cm Separation.

Aim of the Study: This study aims at evaluating the feasibility and outcome of a laparoscopically assisted rectal and vaginal pull-through procedure in the same setting for cases of long common channel in a cloaca >3 cm in length. Methods: I have 4 cases with a cloaca with long common channel >3 cm in length diagnosed by cloacogram and cystoscopy. As for the ages of our cases, two of them were 1 year old, and the other 2 cases were 2 years old. Laparoscopic rectal and vaginal pull-through in the same setting was performed in all cases. The operative time was 3 hours. A tension-free anastomosis of the rectum in anal complex was carried out; also anastomosis of vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through. This is to avoid perineal or perirectal dissection. Results: Frequent anal and vaginal dilation after 2 weeks from operation was carried out. Our cases have not demonstrated any stricture, or urethrovaginal fistula. This procedure resulted in a good cosmetic and unimpaired functional outcome. It has been conducted also to avoid excessive perineal dissection, and reduce risk of urinary incontinence by evading the occurrence of urethral sphincter damage. Conclusion: Laparoscopic-assisted rectal and vaginal pull-through is a new approach for long common channel cloaca that avoids perineal dissection, reducing dissection, and risk of urinary incontinence. This technique should be used and implemented on a wide scale.

Abdominoperineal Tunnel Crafted with Alken's Telescopic Dilators: A Novel Technique!

Background:Abdomino-perineal pull through procedure needs perineal dissection and for that swap of supine to prone may be necessary. To avoid that as well as to avoid neuro-muscular damage; we are describing a simple minimal invasive procedure with help of Alken's telescopic dilators.Patients & Methods:We created abdomino-perineal tunnel with Alken's telescopic dilators to bring down the lumen of intestine in perineum in eight patients.Results:Operative time happened to be less and procedure found to be less traumatic. All the eight patients had satisfactory outcomeConclusions:Actually, we have repurposed the Alken's dilator for creation of abdomino-perineal tunnel or track to get benefit of minimal dissection of perineum during pull-through procedure as well as to avoid neuro-muscular damage.

A novel method for near‐infrared fluorescence imaging of the urethra during perineal and transanal surgery: demonstration in a cadaveric model

Transanal total mesorectal excision is a promising novel sphincter-saving procedure for low rectal cancer. However, the transanal bottom-up dissection is associated with increased rates of iatrogenic urethral injuries. Near-infrared fluorescence (NIRF) imaging, given its deeper tissue penetration, has been explored in a limited number of studies for enhanced intra-operative urethral visualization. In this study, we explored the feasibility of a novel, ultrabright, biocompatible fluorescent polymer to coat urinary catheters for the purpose of intra-operative urethral visualization. In an ex vivo experiment, using a near-infrared laparoscope, the fluorescent signal of a coated catheter (near-infrared coating of equipment, NICE) was qualitatively and quantitatively compared to the signal of indocyanine green (ICG)/Instillagel® mixtures and ICG-filled catheters at several concentrations. Also, in three male human torsos, using fluorescent urinary catheters, NIRF-guided perineal dissections and a transanal total mesorectal excision were performed. Intra-operative NIRF-based urethral visualization was performed systematically. During the qualitative and quantitative fluorescence signal assessment, NICE-coated catheters were clearly superior to the ICG-based solutions. In the cadaveric experiments, enhanced urethral visualization was possible even at early stages of dissection, when the organ was covered by several tissue layers. NICE-coated catheters represent a promising potential to allow for NIRF-based intra-operative urethral visualization.

V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY

You have accessJournal of UrologyLower-Tract Reconstruction I: Sling/ Sphincter/ Penile & Urethral Reconstruction (V06)1 Apr 2020V06-07 ROBOTIC ASSISTED BUCCAL MUCOSA GRAFT POSTERIOR URETHROPLASTY Min Suk Jun*, Michael Siev, and Lee Zhao Min Suk Jun*Min Suk Jun* More articles by this author , Michael SievMichael Siev More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000885.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted posterior urethral reconstruction has shown great promise in early series with excellent patency rates. While Y-V or T plasty remains useful for short supra-sphincteric stenoses, longer stenoses, especially those that are trans-sphincteric, pose a great surgical challenge. The standard approach usually involves urethral transection, often including the bulbar arteries. This increases the risk for incontinence, bulbar urethral necrosis, and future AUS erosion. A buccal mucosa graft posterior urethroplasty may obviate the need for urethral transection, potentially avoiding the aforementioned complications. We present our technique of robotic assisted buccal mucosa graft posterior urethroplasty (RBMGPU). METHODS: This is a retrospective chart review of men who underwent RBMGPU by a single surgeon with the Da Vinci SP robot during 2019. Indications included vesicourethral anastomotic stenosis, radiation induced stenosis, and fistula. Nonobliterative stenoses were approached retropubically or transvesically, while obliterative stenoses were approached posteriorly. A simple prostatectomy was performed if the prostate was in situ. If the stenosis spanned both sides of the sphincter, a perineal dissection was performed. When a well-vascularized flap was required for graft backing or interposition, a rectus or omental flap was used. The primary endpoint was surgical success defined by the absence of obstructive voiding symptoms or urethral patency >16 French. The secondary endpoint was de novo incontinence. RESULTS: 7 men with mean age of 65 years (range 49-72) underwent RBMGPU. Mean operative time was 512 minutes with mean estimated blood loss of 185 mL. Average length of stay was 1.4 days. At a mean of 2.2 months follow up (range 0.8-4.5), 6 of 7 patients reached the primary endpoint while 1 patient experienced de novo incontinence. There was 1 major complication (Clavien > 2), which was a Richter hernia related to the rectus flap. CONCLUSIONS: RBMGPU is a feasible approach to posterior urethroplasty, while minimizing known risk factors for future incontinence surgery. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e557-e558 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Min Suk Jun* More articles by this author Michael Siev More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Male-to-Female Gender-Affirming Surgery Using Nile Tilapia Fish Skin as a Biocompatible Graft

Insufficient penile skin is common during vaginoplasty for male-to-female transition. This issue may be compensated by a scrotal skin flap, with the drawback of hair growth [1]. In recent studies, Nile tilapia skin was successfully used for the surgical management of Mayer-Rokitansky-Küster-Hauser syndrome [2,3] and vaginal stenosis [4,5]. This study aims to describe a novel technique for primary vaginoplasty in male-to-female gender-affirming surgery using Nile tilapia skin as a biocompatible graft to ensure adequate vaginal depth. Stepwise demonstration of the procedure with narrated video footage. Transgender health clinic. A 29-year-old patient with gender dysphoria was referred to our office because of a desire for gender-affirming surgery. A physical examination revealed normal male genitalia with a 14-cm-long penis. Before surgery, approval from the institutional review board and written permission from the patient were obtained. After orchiectomy, penile disassembly, perineal dissection, and urethroplasty were performed, and a hollow Nile tilapia skin mold was prepared and sutured to the distal edge of the remaining penile skin. This structure was inverted, covering the newly created canal. The neocavity was then filled with a handmade inflatable vaginal mold, held in place by sutures in the labia majora. Finally, labiaplasty and clitoroplasty were conducted. After 7 days, the inflatable mold was removed, and the use of progressively larger dilators was initiated. After 3 weeks, a neovagina that was 16 cm long and able to accommodate the width of 2 fingers was detected. At that time, the Nile tilapia skin was completely reabsorbed into the neovaginal mucosa. There were no complications in the early postsurgical period. Nile tilapia skin, a safe, low-cost, and easy-to-use biocompatible material, may be an alternative option to scrotal skin grafts for neovaginal augmentation in primary vaginoplasty for male-to-female gender transition. However, further studies are needed to confirm this assertive.

Ectopic Ureter in Single System Kidney in Association with Anorectal Malformation in Male Patient

Anorectal Malformations (ARM) are known to be associated with urogenital abnormalities. However, the incidence of ectopic ureter in these patients is rare. This report is about a two-year-old male child with ARM. The patient presented after a failed Posterior Sagittal Anorectoplasty (PSARP). The presenting complaint was urinary leak from rectum. Subsequently, the patient was taken up for redo-PSARP. During surgery, bilateral ectopic ureters were identified, incidentally. Surgeons operating on the patients of ARM should be vigilant about this rare association of ectopic ureter with ARM, so as to avoid its injury during perineal dissection.

Robotic-assisted Proximal Perineal Urethroplasty: Improving Visualization and Ergonomics

ObjectiveTo describe the use of the robotic platform for proximal suture placement during perineal urethroplasty in the posterior and proximal anterior urethra. Repair of posterior urethral and proximal bulbar strictures requires deep perineal dissection, making visualization and accurate placement of sutures challenging. The robotic platform has demonstrated benefits in these characteristics in deep pelvic surgery. MethodsWe report a retrospective review of 10 patients who underwent robotic-assisted urethroplasty at a single institution by a single surgeon in a 1 year period. All patients underwent a standard perineal dissection with robotic-assisted placement of proximal sutures. Postoperative outcomes include urethroplasty leak rate as determined by voiding cystourethrograms, urethroplasty success rate, and perioperative complications. ResultsThe mean age of this cohort was 43 years old (14-68). Average stricture length was 2.2 cm (1.5-3.0 cm) and most frequently in the bulbar urethra (5/10). Seven patients underwent nontransecting urethroplasties while 3 underwent transecting anastomotic repair. At postoperative voiding cystourethrograms, no patient had urinary extravasation. Average set-up time for the robotic portion of the surgery was 15 minutes with 30-45 minutes needed for suture placement. ConclusionRobotic-assisted urethroplasty provides excellent visualization and ergonomics for posterior and proximal bulbar urethral reconstruction. This is particularly helpful in patients with narrow pelvic anatomy and long distances from the perineal skin to the proximal urethral edge. Operative and postoperative outcomes are comparable to the standard approach with improved surgeon comfort and visualization. Additional follow-up is required to assess long-term outcomes in comparison to a standard approach.

Simulation of Supralevator Abscesses and Complex Fistulas in Cadavers: Pelvic Dissemination and Drainage Routes.

Most perianal abscesses have a cryptoglandular origin, following the pathogenesis described by Parks in 1961. Supralevator abscesses have the most uncommon location. Nevertheless, such pathology results in a high morbidity because of their difficult diagnosis and treatment. This study aimed to deepen the knowledge of the pathogenesis and management of supralevator abscesses, as well as the complications derived from incorrect treatment, by using simulation in cadavers. This study is an anatomosurgical description of pelvic and perianal zone and simulation of the different types of supralevator abscesses, their correct drainage routes, and secondary complex fistulas due to incorrect drainage. This dynamic article is based on cadaveric simulation. Three cadaveric pelvises (2 male and 1 female) were prepared in formalin and sagittally sectioned, and one perineal dissection was performed of a fresh male pelvis. This is an iconographic description of 3 patients treated for supralevator abscesses in our colorectal surgical unit. The virtual anatomical spaces map out a correct treatment. We reproduced the origin of the different types of supralevator abscesses, as well as their locations and possible drainage pathways, and we determined the definitive treatment of secondary fistulas and their morbidity due to their incorrect drainage. The limitations of this study are inherent to anatomical studies without real case intervention. A proper anatomical knowledge of the supralevator abscesses and surgical training by using cadaveric simulations could improve the diagnostic criteria, facilitate the correct decision on surgical drainage pathways, and, thus, decrease postoperative morbidity in patients with this disease.