FIREFLYâ TECHNOLOGY TO VISUALIZE THE âLANDMARK. ARTERYâ FOR NERVE ... Kenneth Palmer, Vipul Patel, Celebration, FL. INTRODUCTION AND ...
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V4-07 USE OF INTRA-OPERATIVE INDOCYANINE GREEN AND FIREFLYâ TECHNOLOGY TO VISUALIZE THE “LANDMARK ARTERY” FOR NERVE SPARING ROBOT ASSISTED RADICAL PROSTATECTOMY Anup Kumar*, Srinivas Samavedi, Anthony Bates, Rafael Coelho, Bernardo Rocco, Jeff Marquinez, Cathy Jenson, Kenneth Palmer, Vipul Patel, Celebration, FL INTRODUCTION AND OBJECTIVES: The “Landmark Artery” has been shown to be a valuable landmark during nerve sparing radical prostatectomy in improving the quality of the neurovascular bundle (NVB) preservation. Sometimes this landmark can be challenging to find due to inexperience of the surgeon or anatomical challenges. Our goal was to evaluate an innovative intra-operative tool, Near-infrared (NIR) Fireflyâ technology in conjunction with intravenous indocyanine green (ICG) to help identification of this “Landmark Artery ”during nerve sparing(NS) robot assisted radical prostatectomy(RARP). METHODS: Ten patients underwent nerve sparing RARP. Prior to clamping the pedicle or dissection of the NVB,0.75 cc of ICG was given. The Fireflyâ technology was engaged on the robotic console and a period of 20-40 seconds was allowed for the ICG to enter the vascular system. The landmark artery was then observed bilaterally. After this time period we switched back to the non-firefly mode and proceeded with out normal NS operation. Data was collected regarding the % chance of being able to visualize this landmark in the 10 patients. RESULTS: In ten patients 20 NVB were examined with the ICG and Fireflyâ technology. The landmark prostatic artery and its pathway could be identified in 17/20 NVB (85%). In the other 3 patients we were unable to visualize the artery as it was underneath some large veins. The artery was seen visually in these patients during the normal NS surgery. The use of ICG did not significantly increase operative time or result in any immediate or long term complications. CONCLUSIONS: The use of ICG and Fireflyâ technology during NS radical prostatectomy has the potential to more accurately and more frequently identify the landmark prostatic artery that runs along the NVB. For experienced and novice surgeons the pathway of this artery is valuable for NS and can help improve nerve sparing quality. Source of Funding: None
V4-08 DEHYDRATED HUMAN AMNIOTIC MEMBRANE ALLOGRAFT NERVE WRAP AROUND THE PROSTATIC NEUROVASCULAR BUNDLE ACCELERATES EARLY RETURN TO CONTINENCE AND POTENCY FOLLOWING RADICAL ROBOT ASSISTED RADICAL PROSTATECTOMY : A PROPENSITY SCORE MATCHED ANALYSIS Anup Kumar*, Srinivas Samavedi, Anthony Bates, Rafael Coelho, Bernardo Rocco, Jeff Marquinez, Ignacio Camacho, Cathy Jenson, Kenneth Palmer, Vipul Patel, Celebration, FL INTRODUCTION AND OBJECTIVES: Allografts of dehydrated human amniotic membrane (dHAM) have cytokines and growth factors that have been shown to reduce the inflammatory response during tissue healing and promote nerve regeneration. We performed this study to evaluate the early quality of life outcomes after placement of dehydrated human amniotic membrane on the neurovascular bundle (NVB) during nerve sparing robot assisted laparoscopic prostatectomy (RALP) in a propensity score matched analysis. METHODS: From March 2013 to July 2014, 58 pre-operatively potent [Sexual Health Inventory for Men (SHIM) score >19] and continent patients underwent full nerve sparing RALP, followed by intraoperative dHAM placement at our institution. In each patient, dHAM was wrapped around the NVB following the RALP procedure. We performed propensity matching using our prospective database in matched, nongrafted patients from the same time period. Pre-, peri- and
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postoperative outcomes were analyzed between patient groups including time to return to continence and potency. RESULTS: The use of dHAM was not associated with increased operative time, blood loss or negative oncologic outcomes (p >0.50). The mean follow up was 4 months. Continence at 8 weeks returned in 79.3 % of patients the dHAM group and 72.4% of the group not receiving dHAM (p¼0.37). The mean time to continence and potency was significantly lower in dHAM group as compared to the matched non-dHAM group (1.21 months vs. 1.83 months, p¼0.03) and (1.34 months vs. 3.39 months, p¼0.007). Potency at 8 weeks returned in 63.8 % (n¼39) patients receiving dHAM patients and 51.7 % patients in the no-dHAM group (p¼0.13). There were no adverse effects related to the graft. CONCLUSIONS: The use of dehydrated human amniotic membrane allograft appears to hasten the early return of continence and potency in patients following RARP. Longer term follow up is required to assess the benefits over a broader period of time and to evaluate and potential negative events. A long term randomized trial is warranted. Short term results are very encouraging for patient care. Source of Funding:
V4-09 TRANSPERINEAL PROSTATE BIOPSY WITH NEW MAPPING SOFTWARE Nelson Stone*, New York, NY; Vassilios Skouteris, Athens, Greece; Paul Arangua, E. David Crawford, Aurora, CO INTRODUCTION AND OBJECTIVES: To demonstrate new mapping software designed to improve accuracy of transperineal prostate biopsy (TPMB) and focused therapy (FT). METHODS: TPMB has been shown to greatly increase the detection of additional lesions over transrectal biopsy in patients with low volume disease or prior negative biopsy. However tracking the location of the positive biopsy sites is limited because no software exists that records their locations. We developed a software program that can detect a lesion of 5 mm or greater with 95% accuracy. The software also allows the physician to incorporate the pathology results at the positive biopsy sites creating a 2 and 3-dimensional model which can then be incorporated into a focused therapy treatment planning system. The patient is placed under anesthesia in the lithotomy position. Prostate images are acquired using the mapping software via a video card linked to the US output to create the 3D model. A biopsy plan is generated at 5 mm intervals in transverse which can be adjusted based on core length, distance from capsule and urethra and in-line needle number (for cores requiring multiple punctures for prostate length>2cm). The physician starts the biopsy procedure at needle #1 (upper right lateral of prostate). The virtual needle can be moved so it overlies the actual puncture needle in the gland. Imaging is switched to sagittal, the needle is brought back to apex and fired. The virtual needle is moved to be aligned with the biopsy needle after it takes the core. Biopsies are taken from left to right working from the top row down to the most posterior of the gland. The entire procedure takes 45-60 min. Each specimen is inked at the base end so the pathologist can report the presence of cancer, its distance from the ink and the length of the tumor. A 3D model of the gland and the lesion size and locations are generated. RESULTS: 9 men with a mean age of 59.3 years (range 4766), mean PSA of 4.3 ng/ml (range 2-7) and mean prostate volume of 48.5 cc (range 29-73) underwent 3D mapping using the new software. 6/9 had a prior biopsy of which 4 were positive for 1 or 2 cores of focal disease. After mapping 7/9 (77.8%) were positive. A mean of 71.8 cores (range 43-127) were taken and a mean of 4.4 (range 1-12) had prostate cancer. Of the 7 positive case, 4 were bilateral. One case with a single focus of Gleason 7 was negative with 3D mapping. 2 patients decided on focal treatment, 2 brachytherapy, 1 radical prostatectomy, 1 surveillance and 2 are undecided.
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CONCLUSIONS: 3D mapping provides a new method to assess prostate gland pathology. FT can be accurately performed using the 3D roadmap to ablate individual lesions. Source of Funding: 3DBiopsy LLC
V4-10 ROBOTIC-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION: OUR TECNIQUE AND OUTCOMES Daniel Zainfeld*, Andrew Windsperger, Moben Mirza, David Duchene, Kansas City, KS INTRODUCTION AND OBJECTIVES: Robotic assistance has facilitated performance of many complex reconstructive procedures previously relegated to an open approach with numerous reported advantages. Distal ureteral reconstruction and reimplantation is one such procedure which is now often performed laparoscopically with robotic assistance using the da Vinci robotic surgical system. We evaluated perioperative and long-term outcomes among patients who underwent treatment with robotic-assisted laparoscopic ureteral reimplantation (RALUR) at a single center. METHODS: Patients who underwent RALUR between 7/2006 and 10/2012 were identified. In all procedures, the distal ureter was spatulated for 1.5 centimeters. An approximately 1 centimeter cystotomy was created. The ureterovesical anastomosis was completed in a triangular fashion including two arms of 4-0 PDS suture up the sides of the spatulation and a third arm anteriorly following stent placement to form a widely patent, refluxing anastomosis. All procedures were performed at a single institution. A retrospective review of perioperative and clinical data was performed assessing operative time, estimated blood loss, length of admission, and success of procedure as indicated by the absence of obstruction on follow-up imaging. RESULTS: A total of 21 patients underwent RALUR in the study period. Mean age of patients was 43.2 years. 20 of the 21 RALUR were completed robotically with conversion to open in one patient. Etiology of injury included 11 due to gynecologic procedural injury and three secondary to iatrogenic ureteral injuries. The remainder were comprised of congenital, non-gynecologic surgery, radiation, and idiopathic. 13 required psoas hitch procedure as well. Mean operative time was 237 minutes. Mean estimated blood loss was 85cc. Mean length of hospital admission was 3.1 days. Currently, all patients remain non-obstructed by Lasix renogram at mean follow-up of 12.4 months. CONCLUSIONS: RALUR with psoas hitch (when indicated) is a safe and effective option for distal ureteral reconstruction. Further investigation will help to more clearly refine patient selection and delineate patient benefits in comparison to an open procedure. Source of Funding: none
V4-11 STEP-BY-STEP ROBOTIC URETEROURETEROSTOMY: TIPS AND TRICKS TO OPTIMIZE OUTCOMES Hiury Andrade*, Jihad Kaouk, Homayoun Zargar, Peter Caputo, Cleveland, OH; Jayram Krishnan, Las Vegas, NV; Oktay Akca, Daniel Ramirez, Luis Felipe Brandao, Georges-Pascal Haber, Robert Stein, Cleveland, OH INTRODUCTION AND OBJECTIVES: Mid/proximal ureteral stricture is a complex disease with few treatment options. Ureteroureterostomy is a challenging technique utilized to manage cases not amenable to endoscopic treatment or ureteroneocystostomy. The robotic approach is technically feasible and utilizes the same principles of open ureteral reconstruction. We demonstrate the step-by-step operative technique with emphasis on key steps that are useful to achieve a tension-free anastomosis. METHODS: The surgery depicts a 27 year old female with a history of left mid ureteral stone who underwent rigid ureteroscopy and
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laser lithotripsy for an impacted stone. After stent removal, patient had subsequent pain requiring several secondary procedures. A retrograde pyelogram revealed a 5 mm length stricture in the mid left ureter. The robotic ureteroureterostomy was performed using the following steps: Key step 1: The patient is placed in 60 modified flank position. The table is not flexed as this may place tension on the eventual anastomosis. The ipsilateral arm is positioned on the side of patient, so the robot will not have any clashing with it while performing distal ureter. Key step 2: All ports are placed in a straight-line configuration as this allows for unobstructed distal ureteral dissection. Key step 3: The robot is then docked at a 90 angle, perpendicular to the patient. This configuration allows versatility with proximal and distal dissection of the ureter. Key Step 4: The transection must be done directly on the strictured segment. This will ensure that healthy ureteral tissue is not compromised during transection of the affected area. Key step 5: After spatulating the ureteral ends, the proximal and distal ureter are brought into close apposition with at least 2 peri-ureteral sutures. This allows for a tension-free mucosal anastomosis. RESULTS: In total, 6 patients have undergone robotic ureteroureterostomy. All cases were successful and no patient has required additional procedures. Ipsilateral urine drainage and renal function have improved or remained stable as assessed by diuretic renal scintigraphy for all patients. No radiographic or symptomatic recurrence has been noted in the follow up period over two years. CONCLUSIONS: Ureteroureterostomy using a robotic technique is a feasible and effective surgery, which follows standardized principles in ureteral reconstruction. The demonstrated technique with key steps can simplify this challenging procedure and make it more reproducible. Source of Funding: None
V4-12 ROBOTIC REPAIR FOR RECTOURETHRAL FISTULA: A NEW TECHNIQUE Rene Sotelo*, Oswaldo Carmona, Robert De Andrade, Caracas, Venezuela; David Canes, Burlington, MA; Victor Machuca, ~ ez, Eric Saenz, Luis Medina, Carlos Marrugo, Luciano Nun Marino Cabrera, Caracas, Venezuela INTRODUCTION AND OBJECTIVES: Rectourethral fistulas (RUFs) are rare but challenging entities. They most frequently appear as an iatrogenic complication of extirpative or ablative prostate procedures. After a failed initial attempt at spontaneous closure of fistulas with conservative measures, many surgical techniques and approaches have been proposed for the treatment of RUF, including minimally invasive approaches. Herein we describe a novel robotic technique of RUF repair. METHODS: An 80 year-old man with a post-radiation rectourethral fistula in the prostatic urethra next to the verumotanum. This developed after chemoradiation protocol and surgical removal of a rectal adenocarcinoma with end-to-end bowel restoration in continuity. The technique included intrafascial robotic simple prostatectomy with seminal vesicle preservation, two layer rectal closure, bladder mobilization, and urethrovesical anastomosis in a standard running fashion over a urethral catheter. A suprapubic catheter and surgical drain were left in place RESULTS: The mean operative time was 180 min, mean estimated blood loss 250ml, the hospital stay was 3 days, and no intraoperative complications occurred. The drain was removed on the 5th day. After one month of follow up, a cystogram was performed and evidence of filiform tract with contrast towards the rectum was seen and the catheter was left in place. After 2 months, a small blind ending tract remained, the suprapubic catheter was removed and urethral catheter was left in for 1 additional month. At that point the small tract was assumed to be epithelialized and not a fistula. The catheter was removed. Restoring bowel continuity is planned.
