VID-02.03 Laparoscopic Extraperitoneal Adenomectomy: Comparative Study with Open Technique

VIDEO SESSIONS

Video Session 2 BPO/LUTS and Oncology Monday, October 17 15:15-16:45 VID-02.01 Initial Experience of Prostate Resection with Bipolar Surgimaster Scalpel in a Centre with Over 2000 Bipolar TURP Giulianelli R, Attisani F, Albanesi L, Brunori S, Gentile B, Mavilla L, Mirabile G, Schettini M, Shestani T, Vincenti G, Pisanti F Dept. of Urology, Villa Tiberia Clinic, Rome, Italy Introduction and Objective: Using Gyrus instrument, we performed over 2000 bipolar prostate resections. In June 2010 we started to use bipolar Surgimaster scalpel to perform endoscopic prostate resections. Materials and Methods: A man, 72 years old, suffering from hypertension in good hemodynamic compensation, came to our center for an episode of acute retention of urine. Bladder catheterization showed about 500cc of urine. Oral drug treatment, for about 5 years, consisted of Finasteride 5mg/ day and Tamsulosin 0.4mg/day. Normal PSA value. TRUS showed increasing volume (about 50g) and an obstructing third lobe confirmed by urodynamic tests. We performed a transurethral resection of the prostate (TURP) using Olympus bipolar Surgimaster scalpel, continuous-flow resectoscope, optical 12 degree. Surgical time was about 40 minutes. Histological examination showed prostate fibroadenomyomatosa hyperplasia with areas of chronic inflammation. The weight of the resected tissue was about 40g. Results: The endoscopic resection technique consisted in the removal of the lateral lobe followed by the demolition of the third one. Careful and complete removal of the apical tissue, careful control of hemostasis, placement of a catheter 20 CH. Postoperative course was uneventful, hemoglobin level was essentially unchanged after 24 hours, after 2 days the catheter was removed and the patient subsequently dismissed. After three months we made uroflussimetry which showed a standard maximum flow rat, no PVR and IPSS ⬍ 7. Conclusions: In our experience resection using bipolar SURGIMASTER scalpel is a safe technique with an easy control of hemostasis and excellent functional out-

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come results in the short to medium term. Bipolar SURGIMASTER TURP shows not only clinically advantages (no blodd loss, no TUR syndrome, short hospitalization time), but also a better preservation of the prostate tissue from an histologic point of view.

VID-02.02 Initial Experience of Prostate Transurethral Vaporization with Botton TURis in a Centre with Over 2000 Bipolar TURP Giulianelli R, Attisani F, Albanesi L, Brunori S, Gentile B, Mavilla L, Mirabileg, Schettini M, Shestani T, Vincentig, Pisanti F Dept. of Urology, Villa Tiberia Clinic, Rome, Italy Introduction and Objective: Since 2003 in our department, using Gyrus System, we performed over 2000 bipolar prostate resections. From June 2010 we started to use TURis (bipolar Surgimaster scalpel with vaporization button) to perform endoscopic prostate resections. Materials and Methods: A 78-year-old man, suffering from ischemic heart disease with previous position of two coronary stents (about three years ago) treated with antihypertensive therapy, anticoagulants, hypoglycaemic agents and 5 years long Finasteride 5mg OD and Tamsulosin 0.4mg OD, came to our departement because of an episode of UTI with severe hematuria. We performed an ultrasound examination of the whole urinary tract, which showed a severe cervico-urethral obstruction (bladder wall thickening, PVR ⬎ 100 ml) and an increased prostate volume with a third lobe (about 40g). The obstruction was confirmed by urodynamic evaluation. We performed a transurethral resection of the prostate (TURis) using Olympus bipolar Surgimaster scalpel with vaporization button, continuous-flow resectoscope, optical 12 degree. Surgical time was about 50 minutes. Histological examination showed fibroadenomyomatosa hyperplasia of the prostate with some areas of chronic inflammation. Results: The endoscopic resection technique consisted of removing the lateral lobes followed by the demolition of the third one, careful and complete removal of the apical tissue, careful control of hemostasis, placement of a 20 Ch catheter. The optimized spherical shape button in combination with the easy to learn “honering technique” results in an effective, fast ablating and virtually bloodness vaporization of the tissue. The plasma corona

creates well coagulated tissue and a smooth surface. The vaporization button in coagulation mode showed excellent results. Postoperative course was uneventful and hemoglobin level essentially unchanged. After 2 days the 20 Ch catheter was removed and the patient subsequently dismissed. After three months we made uroflowmetry showing a standard maximum flow rate, no PVR and IPSS was ⬍ 7. Conclusions: TURis is a bipolar electrical vaporization of the prostatic adenoma with a button-appearing electrode working in saline. TURis technique is a potential new alternative way to standard TURP and allows virtually bloodness resections, good tissue removal and a prostatic TURPlike cavity. In our opinion TURis is an easy to learn technique, much more costefficient than laser equipment.

VID-02.03 Laparoscopic Extraperitoneal Adenomectomy: Comparative Study with Open Technique García-Segui A, Bercowsky E, Gomez I, Gibernau R, Gascon M Dept. of Urology, Hospital General Mateu Orfila, Menorca, Spain Introduction and Objective: Despite the development of minimally-invasive techniques, open adenomectomy is frequently performed in many countries for large adenomas. Laparoscopic and robotic adenomectomy have been reported previously. We present our experience with Laparoscopic Extraperitoneal Adenomectomy (LEA) and prospectively compared with open technique. Materials and Methods: Thirty-nine men with symptomatic BPH (prostate volume ⱖ 80cc) were included. The first 11 consecutive cases underwent LEA. Subsequent cases were included in the comparative study. Fifteen patients underwent LEA and thirteen patients were treated by open Millin technique.The steps of extraperitoneal 4-port technique include inverted T incision just proximal to the prostato-vesical junction, development of the subcapsular plane, enucleation, urethral transection, trigonization to prostatic fossa or posterior urethral stump, and suture-repair of the prostatic capsule. Results: There was no significant difference in age, prostate size, uroflow rate (Qmax), mean International Prostate Symptom Score (IPSS), and quality of life score (QoLs) between the two groups. Postoperative IPSS, QoLs, specimen weight and catheter time were similar.

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VIDEO SESSIONS

Post-operative Qmax showed adequate improvement in urinary flow in both groups, but was significantly improved in the open group (19.7 range 14.6-28.5 vs. 23 range 20-28.6 ml/seg, P⫽0.12). Mean operative time was longer in the laparoscopic group, but was not significant (135 range 90-210 vs. 113,23 range 70-150 minutes, P⫽0.07). Mean Estimated Blood Loss (228.6 range 100-500 vs. 421.5 range 2501000 mL, P⫽0.003), mean irrigation time (22.86 range 0-36 vs. 31.38 range 24-48 hours, P⫽0.02), and average hospital stay (3.7 range 2-5 vs. 4.8 range 3-8 days, P⫽0.04) were significantly less in the laparoscopic group. There were more incidences of hemorragic and related abdominal wall complications in the open group. Conclusion: LEA is relative complex technique that requires skill in laparoscopy, but is a feasible and safe alternative to open prostatectomy. In LEA an excellent view achieved and allows a meticulous dissection between capsule and adenoma toget a haemostatic and careful technique with accurate urethral cut. LEA offers advantages in term of shorter irrigation, shorter hospital stay, lower blood loss, and complications rate; in addition to the known benefits of laparoscopy (limited pain, faster recovery, cosmetic, simultaneous treatment of concomitant surgical pathologies).

VID-02.04 Cost-Effective Treatment of the Stress Urinary Incontinence and Complete Reconstruction of the Pelvic Floor with the Non-Tailored Mesh Ignjatovic I, Medojevic N, Dinic L, Potic M Clinic of Urology, Clinical Center Nis, Serbia Introduction and Objective: There is an increased number of patients who request both treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The number of patients treated with the synthetic material is growing. In low currency countries only a minor part of the patients could be treated with the best industrially tailored materials due to limited financial resources. The aim of the study was to perform treatment of SUI and POP with the cheaper, non-tailored mesh. Material and Methods: A total of 38 patients with clinically proved SUI, and POP grade 2-4 were operated. Macroporous, polypropylene, 46gr/m2, 10x15cm, mesh was used, which was enough to

perform: midurethral sling, transobturatory cystocele support, sacrospinous fixation, and reinforcement of the rectovaginal fascia as well. Five 15x1.2cm strips were created, and two larger parts remained for the posterior vaginal wall support. Polidioxanon pulling suture 2-0 was passed through the each strip. Mid-urethral transobturatory sling was created and passed with helicoidal needles “outside in”. Four corner fixation of the bladder base with two stripes was performed transobturatory. Sacrospinous support was performed with two mesh stripes through the sacrospinous ligament and ischiortectal fossa. Posterior meshes were laid free, after creation of the space. Follow-up was one-year long. Results: SUI was cured in 34/38 patients (89.4%). POP was cured (grade 0-1) in 31/38 (81.5%) patients, and improved in 4/38(10.5%) patients. Mean hospital stay was 3.2 after the surgery. The most important complications were: one iatrogenic bladder perforation (which did not delay mesh placement) and exteriorization of the mesh in one case. Urgency was present before the surgery in 12/38 (31.5%) and was reduced after treatment to 4/38 (15.7%), without cases of urgency incontinence. Prolapse symptoms (vaginal bulging, pelvic pressure, voiding symptoms, bowel symptoms), moderate or more intensive, were significantly improved after the surgery. Vaginal bulging was the most significantly improved (p⬍0.00) and improvement of bowel symptoms was borderline (p⫽0.05). Conclusion: Non-tailored meshes are a useful option for the simultaneous treatment of SUI and POP. Treatment is equally successful like with industriallytailored meshes.

VID-02.05 Adjustable Transobturator Sling (Argus T®) for the Treatment of Post Radical Prostatectomy Urinary Incontinence (PRPUI) Trigo Rocha F, Gomes C, Bruschini H, Figueiredo J, Srougi M Division of Urology, São Paulo University, São Paulo, Brazil Introduction and Objective: This video describes the surgical implantation of the Argus T®. Argus T® is an adjustable male sling developed for the treatment of post prostatectomy urinary incontinence (PRPUI). The use of a transobturator approach avoids bladder perforation. The device also allows postoperative adjust-

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ments in order to recover continence in patients who looses continence with time. Material and Methods: In this video we show the Argus T placement in a patient suffering of PRPUI. We show the urethral dissection and the identification of the correct place to insert the sling just lateral to the urethra and medial to the pubic bone. We also show the landmarks for needle insertion in the high medial portion of the obturatorium foramen avoiding the neurovascular bundle. Finally, we demonstrate the sling adjustment using a retrograde urethral pressure profilometry, pulling the sling fixation arms until a pressure of 30 to 35 centimeters of water is reached. The patient is kept with a urethral catheter for one day and discharged overnight. Results: Our experience involves 20 patients suffering from PRPUI with a longterm follow-up. All of them had sphincter deficiency demonstrated by urodynamics. Preoperative pads use ranged from 2 to 6 (mean⫽ 5.2) pads a day. All the patients had a preoperative poor quality of life evaluated by an analogue scale. The surgical procedure was uneventful in all patients. With a mean follow-up of 32 months, the results showed 15 (75%) patients dry or wearing a pad/day, 3 improved (15%) and 2 (10%) unchanged. Five patients required postoperative adjustments. There was a dramatic improvement in quality of life. One patient who required simultaneous urethrotomy developed erosion and the device was removed. Conclusions: Argus T is a safe and straightforward procedure. We did not have any major surgical complication. The procedure is effective promoting cure of incontinence in almost 80% of the patients and additionally 15% showed improvement. Our population included severe incontinent patients as demonstrated by pad counts. The unique feature of post-operative adjustability of Argus is very important to reach these continence rates. The procedure can be considered a first line treatment for PRPUI patients.

VID-02.06 Complications in Minimally Invasive Radical Cystectomy Sotelo R1, Castle E2, Castillo O3, Giedelman C1, Spinelli M1, Saavedra J1, De Andrade R1, Carmona O1, Canes D4, Rodriguez C1 1 Instituto Medico La Floresta, Caracas, Venezuel; 2Mayo Clinic, Phoenix, USA; 3 Dept. of Urology, Clínica Santa María, Santiago, Chile; 4Lahey Institute of

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