V678 LAPARO-ENDOSCOPIC SINGLE-SITE (LESS) EXTRAVESICAL REPAIR OF VESICOVAGINAL FISTULA

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THE JOURNAL OF UROLOGY姞

of pelvic organ prolapse using a mesh kit. To our knowledge, this the first reported purely transvaginal approach to the management of mesh complications involving the lower urinary tract. METHODS: Transvaginal excision of mesh erosion involving the bladder after mesh placement using a prolapse kit was performed. A reverse C-shaped incision was made in the anterior vaginal wall, mesh arms were identified laterally, divided and then dissected from the bladder. The bladder was closed in 3 layers transvaginally, followed by closure of the vaginal wall as a fourth layer. RESULTS: Removal of eroded mesh within the bladder was completed with all operative steps performed transvaginally. The patient was discharged home within 23 hours. There were no postoperative complications. CONCLUSIONS: Transvaginal removal of mesh erosion involving the bladder is safe, technically feasible, and allows for rapid return to normal function. Source of Funding: None

V678 LAPARO-ENDOSCOPIC SINGLE-SITE (LESS) EXTRAVESICAL REPAIR OF VESICOVAGINAL FISTULA Aly Abdel-Karim*, Ahmed Moussa, Salah Elsalmy, Alexandria, Egypt INTRODUCTION AND OBJECTIVES: In this video we describe for the first time the technique of laparo-endoscopic single-site (LESS) extravesical repair of vesicovaginal fistula (VVF). METHODS: The case that we present in this video is a 52 years old female that presented with persistent urinary leakage per vagina following abdominal hysterectomy. Computed tomography (CT) of the abdomen and pelvis and cystoscopy revealed a supratrigonal vesicovaginal fistula. The fistula was repaired through extravesical LESS surgery using the R-port and curved instruments. The fistulas tract was identified and completely excised extravesically using sharp dissection. The edge of the bladder was trimmed at the site of fistulas tract. The vagina was closed in one layer with continuous 3/0 vicryl sutures, while urinary bladder was closed in 2 layers using 3/0 vicryl suture. An additional 5-mm extraport was added at time of suturing to allow triangulation and hand-free intracoprporeal suturing. An omental flap was interposed between the bladder and vagina. The urinary bladder was drained by an indwelling urethral catheter for 3 weeks. RESULTS: The operative time was 240 minutes. Blood loss was 90c.c. There were no intraoperative or postoperative complications. Postoperative hospital stay was 2 days. There was no postoperative urinary leakage. Follow up of the patient for 10 months showed complete continence and no recurrence of VVF. CONCLUSIONS: LESS extravesical repair of VVF is technically feasible and effective procedure that adheres to the principles of transabdominal open surgical repair. However, the technique requires advanced laparoscopic skills. Source of Funding: None

V679

Vol. 185, No. 4S, Supplement, Sunday, May 15, 2011

tion, repair of fistula, flap placement, and post-operative care for the extra-vesicle approach to vesico-vaginal fistula repair are demonstrated in this video. RESULTS: Successful completion of robotic extravesicle repair of vesico-vaginal fistula is demonstrated in this video. CONCLUSIONS: Vesico vaginal fistula can be repaired robotically and utilizing the extra-vesicle approach utilizing the techniques demonstrated in this video. Source of Funding: None

V680 THE ELEVATE SYSTEM FOR ANTERIOR & APICAL VAGINAL PROLAPSE Larry T. Sirls, Dmitriy Nikolavsky*, Royal Oak, MI INTRODUCTION AND OBJECTIVES: The Elevate® polypropylene mesh system corrects pelvic organ prolapse (POP). Direct insertion of tined tipped mesh anchors into the sacrospinous ligament and pubococcygeus muscle avoid groin/perineal incisions and blind trocar passage. We report the Elevate® systems operative time, blood loss, post-operative pain, length of stay and peri-operative complications. METHODS: Retrospective review of inpatient/computerized records provided baseline, operative, and post-operative data. Operative data included compartment repaired, concurrent vaginal hysterectomy, operative time (OT), estimated blood loss (EBL), and adjacent organ injury. Post-operative data included changes in hemoglobin and hematocrit, blood transfusion, self reported pain scale, length of stay (LOS) and complications. Data were analyzed for each procedure type (anterior, posterior or total Elevate®) and separately for those having concurrent hysterectomy. RESULTS: Elevate® was used in 43 women between August 2009 and August 2010. Mean age was 68.4 ⫾ 10.2 years and body mass index (BMI) was 26.6 ⫾ 4.2. All patients had grade 3 or 4 prolapse. Anterior Elevate® was placed in 31, posterior Elevate® in 4, and 8 had a total Elevate®. Concurrent hysterectomy was done in 11 and these patients had anterior Elevate® only. Median OT for anterior, posterior, or total Elevate® without hysterectomy was 61, 57 and 101 minutes, median hemoglobin drop was 2.3, 2.6 and 2.3 gm respectively and LOS was 1, 1, 2 days respectively. Post-operative complications included 4 women requiring catheter reinsertion, 3 urinary tract infections (UTI), 1 hematoma and 1 pelvic abscess requiring drainage but not mesh removal. First 24 hour visual analog scale mean pain scores were 2.7, 2.8 and 0.6 on a 0-10 scale. Concurrent hysterectomy median OT was 148 minute and LOS was similar to the total mesh group at 2 days. Urethral catheter was reinserted in 4, 3 developed post op UTI. There were no adjacent organ injuries and no Elevate® patient required transfusion. CONCLUSIONS: POP repair with Elevate® avoids trocar passage, has short OT, minimal blood loss, and few complications. Patients have little pain and many are discharged home on the first post-operative day. Long-term observations are needed to assess Elevate mesh complications, failure rates and compare the outcomes with other mesh repair kits. Source of Funding: None

ROBOTIC-ASSISTED LAPAROSCOPIC VESICO-VAGINAL FISTULA REPAIR: THE EXTRA-VESICLE TECHNIQUE Alex Rogers, David Thiel*, Jacksonville, FL; Theodore Brisson, Charelston, SC; Steven Petrou, Jacksonville, FL INTRODUCTION AND OBJECTIVES: Vesico-vaginal fistulae are a known complication of hysterectomy. Open and vaginal repairs of vesico-vaginal fistulae have been described. All prior reports of laparoscopic and robotic vesico-vaginal fistula repair involve an intravesicle approach. We describe our extra-vesicle technique of robotic vesicovaginal fistula repair. METHODS: Pre-operative imaging, patient selection, patient positioning, fistula localization, port placement, intra-operative dissec-

V681 UTERINE PRESERVATION: BILATERAL SACROSPINOUS SUSPENSION USING MESH (UPHOLD ®) Gamal Ghoniem*, Melanie Crites, Bader Almosaieed, Weston, FL INTRODUCTION AND OBJECTIVES: Nowadays, many women desire to keep their uterus during pelvic prolapse repair. Sacrospinous suspension is generally highly effective and well tolerated surgical treatment for uterovaginal prolapse. Long term sup-