Search

To describe our initial experience with a novel modification of the Mitrofanoff conduit technique utilizing the Yang-Monti ileovesicostomy and the serosa lined extramural tunnel of the T-pouch to create a continent catheterizable stoma in patients with a prior enterocystoplasty.A 14 cm segment of bowel was harvested, and the distal 4 cm was divided and reconfigured utilizing the Yang-Monti technique. The remaining segment was folded into a U and secured with a serosal basting stitch. Half of the Yang-Monti tube is laid in the trough of the U-shaped segment and secured. Next, the U-shaped segment was incised along the anti-mesenteric border for the length of the tube. The newly created flaps adjacent to the tube was then laid over the tube and sutured together completing the serosa lined tunnel. The entire patch was anastomosed to a cystostomy through the previous enterocystoplasty. Finally, the proximal end of the tube was brought through the umbilicus and matured as a stoma.Two patients with prior enterocystoplasties underwent the procedure described above. At follow-up of 18 and 24 months, both patients reported excellent continence. To date, there have been no revisions or significant complications.The construction of continent catheterizable stoma in adults with prior history of enterocystoplasty presents many technical challenges. The combination of the Yang-Monti ileovesicostomy and the extramural tunnel of the T-pouch provides an effective option for creating a continent catheterizable stoma in adults with prior history of enterocystoplasty.

Robotic-assisted sacrocolpopexy (RASC) provides a minimally invasive alternative to the traditional open approach. By taking advantage of both the increased magnification of the laparoscope and precision of the surgical robot, RASC can be safely and efficiently performed. Furthermore, RASC provides the advantages of reduced morbidity with decreased incisional pain and faster return to normal activity.

Groin pain is a challenging clinical problem with a myriad of underlying causes spanning multiple medical specialties. Urological etiologies are often the focus of the diagnostic process; thus, a working knowledge of urological causes is helpful for all specialists who treat groin pain. Although there are multiple identifiable causes of chronic groin pain, often in practice no clear underlying cause is found, and the diagnosis of “chronic pelvic pain syndrome” is given. We still have much to learn about the pathophysiology of chronic groin pain. More robust animal model and clinical studies are needed to develop targeted therapies. In this chapter, we present a review of our current knowledge of how groin pain is classified, evaluated, and managed by urologists. Although complete resolution of chronic pain can be an elusive goal in some patients, effective medical and surgical strategies toward a cure are available for most.

INTRODUCTION AND OBJECTIVES: Robotic surgery has a variable learning curve with multiple factors potentially affecting operative times. We sought to measure the effect of patient, provider, and system-related variables on operative time. METHODS: Retrospective data was collected over a 3.5 year period on 1,099 patients undergoing 11 robotic surgeries by 23 urologists and gynecologists at Cedars-Sinai Medical Center in Los Angeles. Data included patient age, BMI, comorbidities, operative time, surgeon volume, and type of robot (da Vinci Standard vs da Vinci S System). Analyses were performed by linear regression modeling. RESULTS: Average procedure time was 4.87 þ/1.33 hours. Surgeons performed an average of 49 þ/83 surgeries (range 1 to 362, median 1⁄4 8). The upper 25th percentile of surgeons by volume performed 60 or more procedures, and the lower 25th percentile performed four or less. Patients with 25 30) was 0.35 þ/0.08 hours longer vs BMI < 25 (p < 0.001). Diabetes was also associated with increased procedure time, but age and heart disease were not. After performing a subset analysis of surgeons who performed 20 or more surgeries (n 1⁄4 10), the average procedure time for the first 10 surgeries was 4.82 þ/2.83 hours and for the last 10 was 5.03 þ/2.90 hours. The upper (n1⁄45) and lower (n1⁄46) 25th percentile of surgeons had an average procedure time of 5.31 þ/0.74 hours and 4.36 þ/0.77 hours, respectively (p 1⁄4 0.067). After accounting for covariates such as robot type and BMI, high volume surgeons took 0.90 þ/0.44 hours longer than low volume surgeons (p1⁄40.042). The average time for the da Vinci Standard was 4.70 þ/1.12 hours (n1⁄4639 procedures) and for the da Vinci S was 5.10 þ/1.55 hours (n1⁄4493 procedures) (p < 0.001). After accounting for surgeon volume, BMI, department and procedure type, the first generation da Vinci Standard had procedure times 0.35 þ/0.08 hours shorter than the second generation da Vinci S (p < 0.001). CONCLUSIONS: Unexpectedly, surgeon operative times did not tend to improve over time, and operative times were not significantly different between high and low volume surgeons. Also surprisingly operative times were not faster with the newer generation da Vinci model. After overcoming learning curves, surgeons may have an inherent “pace” that dictates their operative time.

514 (82%) patients completed questionnaires. Mean duration of followup questionnaire was 55 months (range 4-173). 193 (37%) patients had at least 5-years follow-up with questionnaire. RESULTS: Prolapse failure occurred in 105/509 (20%) patients at an average of 34 months (range 3-128). 39 (7.6%) patients had cystocele recurrence, 60 (12%) vault prolapse, and 6 (1%) uterine prolapse. 63 (60%) patients chose no intervention. 42 (40%) patients had additional surgery: abdominal sacralcolpopexy (22), transvaginal fascia repair (18), and transvaginal mesh repair (12). 88/514 (17%) patients were sexually active. 25/88 (28%) reported discomfort with intercourse. At the time of each patient’s last questionnaire, 422/514 (82%) patients would recommend surgery and 422/514 (82%) patients would repeat surgery. 311/514 (60%) patients reported satisfaction 8 on a visual analogue scale of 1-10, 10 being extremely satisfied. The complication rate was 4% (19/509) including: small bowel injury during suprapubic tube placement requiring bowel resection (1), infected vaginal hematoma requiring debridement (1), vaginal mesh erosion (2), ureteral obstruction requiring stent (1), vaginal granulation tissue removed in the OR (10), difficulty with intercourse due to vaginal suture which was removed (1), and wound separation treated with estrogen cream (3). CONCLUSIONS: 80% of patients who underwent the CaPS procedure had no significant cystocele recurrence, with average and maximum follow-up exams of 39 months and >13 years, respectively. There was high patient satisfaction and low morbidity.