1391INTEGRATED ROBOTIC NEAR-INFRARED FLUORESCENCEDURING ROBOTIC PARTIAL NEPHRECTOMY: CORRELATIONWITH TUMOR HISTOLOGY

Ronney Abaza*, Columbus, OH

INTRODUCTION AND OBJECTIVES: Robotic platforms canfacilitate integration of complementary technologies to augment lapa-roscopic surgery. A recently-introduced integration of established near-infrared fluorescence (NIRF) technology with the robotic camera sys-tem allows surgeon-controlled visualization of tissue fluorescence afterintravenous indocyanine green (ICG). Normal kidney is known to fluo-resce with ICG when exposed to 806nm wavelength laser light due tobilitranslocase transport of ICG into proximal tubule cells, a proteinabsent in clear cell renal cell carcinoma (cRCC). This may allowdifferential fluorescence of normal kidney and cRCC, possibly allowingbetter visualization of tumor borders during robotic partial nephrectomy(RPN). Additionally, bilitranslocase is present in oncocytoma, whichmay allow differentiation from cRCC intraoperatively if the tumor fluo-resces. We evaluated fluorescence of renal tumors during RPN andcompared this with tumor histology to determine the reliability of inte-grated robotic NIRF imaging.

METHODS: RPN was performed with integrated NIRF imagingin 20 patients. Intraoperative assessment of tumor fluorescence wasprospectively recorded at the time of surgery by the surgeon beforepathologic assessment of tumors. Final histology was compared withNIRF findings.

RESULTS: Mean age (range) was 58yrs (26-89) with meanbody mass index of 31kg/m2 (18-44). Mean preoperative estimatedGFR was 93mL/min (43-151). Mean tumor size on imaging studies was4.3cm (1.8-9.7) with mean R.E.N.A.L. nephrometry score of 9.0 (6-12),including 10 hilar tumors and 15 tumors �50% endophytic. Meanoperative time, blood loss, and warm ischemia time were 184min,132cc, and 14.5min, respectively, with no positive margins. One tumorcould not be assessed for fluorescence due to adherent fat covering thetumor. Among 5 tumors that fluoresced, 3 were oncocytomas, 1 wascRCC, and 1 was chromophobe RCC, which is known to expressbilitranslocase. Of 14 tumors that did not fluoresce, 10 were cRCC, 1was an oncocytic neoplasm, 1 was an oncocytoma, and 1 was a knownangiomyolipoma. Among 11 cRCCs, 10 did not fluoresce. Overall, 15tumors (79%) behaved as would be predicted based on histology.

CONCLUSIONS: Integrated robotic NIRF imaging was highlyreliable (91%) in visualizing differential fluorescence of cRCC andsurrounding normal parenchyma but less so in predicting histology.Further study is needed to determine whether this improves outcomesof RPN either by reducing positive margins or increasing preservationof normal renal tissue during resections.

Source of Funding: None

1392AUTOLOGOUS RETROPUBIC URETHRAL SLING: A NOVEL,QUICK, INTRA-OPERATIVE TECHNIQUE FOR IMPROVINGCONTINENCE AFTER ROBOTIC ASSISTED LAPAROSCOPICPROSTATECTOMY

Jacqueline D. Villalta*, Sanoj Punnen, Jared M. Whitson, Janet E.Cowan, Peter R. Carroll, San Francisco, CA

INTRODUCTION AND OBJECTIVES: Post-prostatectomy uri-nary incontinence has a significant impact on quality of life. We de-scribe a novel technique using the medial umbilical ligament or vasdeferens as a urethral sling placed at the time of robotic assistedlaparoscopic prostatectomy (RALP) and evaluate its impact on post-operative continence.

METHODS: In 2011, men who underwent sling placement werecompared to men who did not have a sling placed. Sling placementinvolved harvesting a segment of the medial umbilical ligament or vasdeferens, placing it under the vesico-urethral anastomosis, affixing it tothe pubic symphysis, and adjusting the tension to create a slight

elevation of the vesicourethral angle. The association of sling place-ment on time to no pads per day (PPD) was assessed using Coxproportional hazards regression analysis. In addition, multivariate for-ward stepwise-selection was used to identify factors that were associ-ated with early continence.

RESULTS: The study cohort consisted of 46 men who under-went sling placement and 19 men who did not during the same timeperiod. Median follow-up was 2 months in the sling patients and 5months in the non-sling patients (p�0.15). Clinical and pathologicalcharacteristics were similar between the groups, except Gleason score,with sling patients displaying more high-grade disease (p�0.02). Theplacement of a sling was associated with a two-fold increased likeli-hood of requiring no PPD on univariate analysis (HR 2.0; 95% CI1.02-3.97; p�0.04). After adjustment for age, pre-operative IPSS,prostate weight and surgical Gleason, the association barely lost sta-tistical significance. However, there was a definite trend towards im-proved continence with sling placement (HR 2.1; 95% CI 0.98-4.34;p�0.06). Furthermore, multivariate analysis with forward stepwise se-lection found placement of a sling to be the only factor significantlyassociated with time to no pad use (HR 2.2; 95% CI 1.05-4.39;p�0.04).

CONCLUSIONS: The placement of an autologous urethralsling was associated with improved likelihood of complete continencefollowing RALP. The procedure takes little time. A randomized con-trolled trial is planned to better assess the value of sling placement onurinary continence following such surgery.

Source of Funding: None

1393SHOULD ANTERIOR PROSTATIC FAT DURING RADICALPROSTATECTOMY UNDERGO PATHOLOGICAL EXAMINATION?

Brooke Harnisch*, Boston, MA; Charlotte Caligiuri, Kevin Tomera,Alexander Perepletchikov, Ingolf Tuerk, Brighton, MA

INTRODUCTION AND OBJECTIVES: Dissection of the ante-rior fat overlying the prostate allows for visualization during roboticassisted laparoscopic radical prostatectomy (RARP). Although notusually sent enbloc for pathological analysis, anterior prostatic fat(APF) can harbor lymph nodes involved with prostate cancer. Thepurpose of this study was to evaluate APF and the incidence forpositive nodes.

METHODS: An IRB approved retrospective study was con-ducted between July 2010 and October 2011 on patients who under-went RARP with � pelvic lymph node dissection and had APF sent forpathologic analysis. Clinical and pathological data was analyzed.

RESULTS: A total of 302 patients were identified. Perioperativepatient characteristics are summarized in Table 1. Overall, 30/302patients (10%) had APF lymph nodes (range 1-3) and 272 patients(90%) had no APF lymph nodes. Four of 302 patients (1.3%) hadpositive APF nodes. Two patients had concomitant positive pelviclymph nodes (PLN). The pre-operative biopsy Gleason score andprostate specific antigen was 4�3 and 5.6 ng/ml for patient 1, 4�3 and2.6 ng/ml for patient 2, 4�3 and 5.1 ng/ml for patient 3, 3�4 and 6.4ng/ml for patient four. Pathological data is summarized in Table 2.

CONCLUSIONS: APF lymph nodes were present in 10% ofpatients with no clinical or pathological characteristics that could iden-tify these men. Four of 302 patients (1.3%) had positive APF nodes.Pathological upstaging occurred in 2/304 patients (0.7%). Since lymphnode involvement is a significant prognosticator for adjuvant treatmentincluding radiation and hormone therapies, routine excision and pathologicanalysis of the APF should be considered during RARP. Future studieswith large cohorts of patients are needed to validate our findings.

Vol. 187, No. 4S, Supplement, Monday, May 21, 2012 THE JOURNAL OF UROLOGY� e565

Table 1. Perioperative patient characteristics

APF nodes notpresent(n�272)

APF nodespresent(n�30) P value

Patient age 60.7 � 6.7 59.4 � 10.9 0.35

BMI (kg/m2) 27.9 � 11.6 29.3 � 3.7 0.08

Pre-op PSA 6.8 � 10.8 6.9 � 6.8 0.99

Average Gleason biopsy score 7 � 0.8 6.7 � 0.8 0.89

OR time (minutes) 121�27 125 � 22 0.42

EBL (mls) 169 � 169 154 � 97 0.47

Table 2. Pathological dataSeminalvesicle

invasionExtraprostatic

extensionPerineuralinvasion

Lymphovascularinvasion

PositivePLN

Pathologicalstaging

Patient one (�) (�) (�) (�) No pT2aN1Mx

Patient two (�) (�) (�) (�) No pT2cN1Mx

Patient three (�) (�) (�) (�) Yes pT3bN1Mx

Patient four (�) (�) (�) (�) Yes pT3bN1Mx

Source of Funding: None

1394TECHNICAL RAY OF HOPE IN THE CONTEXT OF MINIMALLYINVASIVE URINARY DIVERSION: SEWING WITH THEPROTOTYPE DEVICE ENDOSEW® - RESULTS OF ANINTRAOPERATIVE HUMAN PILOT SERIES

Beat Roth*, Frederic D. Birkhaeuser, George N. Thalmann, PascalZehnder, Bern, Switzerland

INTRODUCTION AND OBJECTIVES: Minimally invasive cys-tectomy is rapidly developing. However, complete intracorporeal con-fection of the urinary diversion remains challenging. Therefore, staplerdevices are widely used to facilitate the reconstructive part of theprocedure despite the known risk of infections and stone formation. Ourgoal was to evaluate feasibility and safety of an absorbable runningsuture for ileal conduits using the prototype sewing device EndoSew®.

METHODS: Consecutive series of 10 patients scheduled forurinary diversion with an ileal conduit. In order to close the proximal endof the resected bowel segment an extracorporeal running suture (Vicryl3-0) was performed with the use of the prototype device EndoSew®.Feasibility and time requirements of the procedure were analyzed aswere the number of stitches and length of suture line. Water tightnessof the suture line was assessed with methylene blue intraoperativelyand with loopographies on postoperative day 7 and 14. Technicalrequirements and complications were recorded as were overall andintervention specific complications occurring within 30d following sur-gery.

RESULTS: A complete running suture with EndoSew® wasfeasible in all but 1 patient (90%). Median suturing time was 5.5min(range:3-10), median suture length was 4.5cm (range:2-5.5). In threepatients, an additional single freehand stitch was needed at the begin-ning and/or the end of the suture line in order to anchor the runningmachine thread. In one patient, suturing with the device had to beabandoned due to a mechanical problem after 50% of the suturingdistance. Finally, all conduits were watertight at any time. No suturerelated complications were observed.

CONCLUSIONS: We present the first consecutive series ofpatients undergoing urinary diversion with an ileal conduit using thesewing device prototype EndoSew®. The procedure per se is feasibleand safe. All sutures were watertight. Therefore, EndoSew® has thepotential to facilitate the intracorporeal confection of the urinary diver-sion. However, technical refinements are necessary.

Source of Funding: None

1395ADVANTAGE OF BARBED SUTURES FOR VESICO-URETHRALANASTOMOSIS DURING DA-VINCI RADICAL PROSTATECTOMY

Julien Renard*, Alessandro Caviezel, Julien Schwartz, Christophe E.Iselin, Geneva, Switzerland

INTRODUCTION AND OBJECTIVES: During Da Vinci radicalprostatectomy (PRDV), urethro-vesical anastomosis is performed withrunning sutures whose tension needs to be constant to achieve awaterproof reconstruction. New “barbed” sutures which prevent loss ofrunning suture tension have recently been available. We assess theirefficacy in comparison to classical sutures.

METHODS: All patients treated by PRDV with the use of barbed(V-locTM180) sutures were included. Each anastomosis entailed 2 halfrunning sutures with posterior reconstruction, performed by 3 differentoperators. Waterproofness was verified performing cystography onpostop day 10 before catheter removal, and in case of leakage at timeof catheter removal. We compared these cases to a group of patientspreviously operated with classical sutures We analyzed operative andanastomosis time as well as time to catheter removal and the presenceof urinary leakage.

RESULTS: 44 patients underwent PRDV using V-locTM180from June 2010 to March 2011.One patient (2.3%) presented leak-age requiring bladder catheterization for 20 days. Of the 44 patientsof the control group, 3 (6.8%) showed leakage requiring catheter-ization for a mean 21.3 days (20-22). All other had catheter removalat 10 post-operative days without complications. Mean anastomosistime was significantly shorter in the V-locTM180 group (24.4 versus30 minutes; p�0.01). No significant difference was found in terms ofurinary leakage (p�0.39) nor operative time (p�0.45).

CONCLUSIONS: The use of barbed sutures during PRDVreduces significantly anastomosis time and allows a reduction in uri-nary leakage from 7 to 2%, This has led us to renounce to postopcystographic control.

Source of Funding: None

1396STEEP TRENDELENBURG POSITION DURING ROBOTIC PELVICSURGERY DOES NOT AFFECT CARDIAL FUNCTION ANDHEMODYNAMIC OUTPUT AS MEASURED BY CONTINUOUSTRANSOESOPHAGEAL ECHOCARDIOGRAPHY

Andreas Becker*, Sebastian Haas, Thomas Kubitz, Alwin Goetz,Alexander Haese, Hamburg, Germany

INTRODUCTION AND OBJECTIVES: Robotic assisted laparo-scopic radical prostatectomy (RALP) is a continuously upcoming pro-cedure in prostate cancer surgery. To provide optimal conditions forsurgical access in RALP steep Trendelenburg positioning (STP) of thepatient is necessary. STP is suspected to be associated with cardiacimpairment and right ventricular dysfunction especially when capno-peritoneum is applicated like in RALP.

The aim of our clinical trial was to explore hemodynamic con-sequences by advanced hemodynamic monitoring and to analyzemyocardial and valvular function by transoesophageal echocardiogra-phy in STP during urological procedures in transperitoneal pelvic ap-proach.

METHODS: 10 patients were enrolled, 9 with RALP and 1with robotic assisted laparoscopic cystoprostatectomy. Hemody-namic measurements and echocardiography were performed before(T1), 10 min (T2) and 60 min (T3) after STP and capnoperitoneum.

RESULTS: Patients physical status classification by the Amer-ican society of anaesthesiology revealed a score of 2.5 � 1,7. Bloodloss in all patients was below 300 ml and no blood transfusion wasrequired. Heart rate remained nearly unchanged (T1: 74.8 � 3.1; T2:75.2 � 2.81; T3: 77.3 � 2.91 min-1). Mean arterial pressure (T1:69.7 � 1.55; T2: 82.9 � 3.05 mmHg), central venous pressure (T1:

e566 THE JOURNAL OF UROLOGY� Vol. 187, No. 4S, Supplement, Monday, May 21, 2012