V9-07 MICROSURGICALLY-ASSISTED INGUINAL HERNIA REPAIR

V9-07 MICROSURGICALLY-ASSISTED INGUINAL HERNIA REPAIR

e1058 THE JOURNAL OF UROLOGYâ CONCLUSIONS: LESS varicocelectomy using ICG angiography and indigo carmine lymphatic dye facilitates visualization and...

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e1058

THE JOURNAL OF UROLOGYâ

CONCLUSIONS: LESS varicocelectomy using ICG angiography and indigo carmine lymphatic dye facilitates visualization and identification of spermatic vessels. Continued investigation should determine whether it could reduce the disadvantages of laparoscopic varicocelectomy. Source of Funding: None

V9-06 ROBOT ASSISTED PENILE INVERSION VAGINOPLASTY: A NOVEL TECHNIQUE Temitope Rude*, New York, NY; Kiranpreet Khurana, Cleveland, OH; Aaron Weinberg, Jamie Levine, New York, NY; Michael Stifelman, Hackensack, NJ; Lee C. Zhao, New York, NY INTRODUCTION AND OBJECTIVES: Gender confirmation surgery is an essential component in the management of gender identity disorder. However, short vaginal length, vaginal stenosis, or complications in the perineal dissection are significant limitations of current techniques in male to female surgery. Here we describe our technique for the robot assisted penile inversion vaginoplasty that addresses these needs. METHODS: The patient is prepped and draped in low lithotomy position. The penis is degloved through a circumcision incision. The neurovascular bundle, urethra and corpora cavernosa are dissected out. A six cm bulbar perineal incision is then made, and the dissection is carried to the bulbar urethra. The dissected urethra, neurovascular bundle, glans and corpora are delivered through this incision. The bilateral corpora are transected at their most proximal limit and overswen. The penile skin is inverted and gently retracted to allow a two cm incision above the neovagina for the neoclitoris. Immediately below this, an incision for the neomeatus is made. The urethra is brought through this incision and sutured to the skin. The remaining urethral tissue is used as an inlay onto the incised dorsal epithelial surface of the penile skin. The robotic portion of the surgery uses 4 port incisions: periumbiical Gelport with two pre-placed robotic trocars, right and left lateral ports, and an assistant port in the upper right abdomen. The dissection is from the posterior prostate, staying above Denonviller’s fascia to reach the endopelvic fascia. Under direct vision, the endopelvics are opened sharply from below and opened to a width of two fingerbreadths. The neovagina is passed into robotic field and pexed to the anterior reflection of the posterior peritoneum. The peritoneal reflection is then closed. The neoclitoris is fashioned from the glans penis and approximated. Labia majora and minora are fashioned with local skin flaps. A foley catheter is left indwelling as well as a vaginal stent. RESULTS: The index case required 7 hours of surgical time with an estimated blood loss of 100 mL. The vaginal length was greater than 15 cm. The patient was discharged home on post-operative day three, with no complications. The patient endorses sensation at the neoclitoris and anterior neovagina, and finds the vaginal depth satisfactory CONCLUSIONS: Our novel method for robot assisted penile inversion vaginoplasty is an important step in optimizing outcomes for our patients. This technique achieves maximal vaginal length in a safe and reproducible manner. Source of Funding: none

V9-07 MICROSURGICALLY-ASSISTED INGUINAL HERNIA REPAIR Ryan Flannigan*, Brian Dinerman, New York, NY; Phil Bach, New Yrok, NY; Michael Shulster, Philip Li, Marc Goldstein, New York, NY INTRODUCTION AND OBJECTIVES: Inguinal hernia repair is the most commonly performed general surgical procedure, with mesh repair being the favored method. Complications such as chronic pelvic

Vol. 197, No. 4S, Supplement, Monday, May 15, 2017

pain and iatrogenic vasal obstruction can occur in up to 19% and 3% of patients, respectively. Better intraoperative visualization of the ilioinguinal nerve has been associated with decreased postoperative pelvic pain. The operating microscope offers the best visualization of inguinal structures and is commonly used in highly precise male infertility procedures. We describe the rationale, technique, and surgical outcomes of microsurgically assisted inguinal hernia repair. METHODS: We conducted a retrospective review of 252 microsurgically assisted hernia repairs with mesh performed by a single surgeon (M.G.). In all procedures, the vas deferens, deferential vessels and nerves, ilioinguinal nerve, genital branch of the genitofemoral nerve, and spermatic vasculature were identified and preserved under 6-25X magnification. Surgical outcomes and complications were abstracted retrospectively from patient charts. RESULTS: Mean follow-up was 26.7 months. Mean patient age was 50.5 years. 196/252 (78%) of patients were symptomatic from their hernias. 215/252 (86%) of patients were undergoing concomitant microsurgical fertility related procedures such as varicocelectomy (56%) and hydrocelectomy (28%). No chronic post-operative pain or vasal injuries were reported. Additionally, no sensory loss or infections were reported. The only complications were one post-operative one hematoma (0.4%) that was managed conservatively and one recurrence (0.4%). CONCLUSIONS: Operating microscopes have an established record of facilitating extremely difficult male infertility procedures. The application of the operating microscope for inguinal hernia repair resulted in very low complication rates under 1%. Remarkably, there were no instances of chronic post-operative pain or sensory loss, representing significantly improved surgical outcomes compared to those reported in the literature. Source of Funding: Frederick J and Theresa Dow Wallace Fund of the New York Community Trust & the Agency for Healthcare Research and Quality (T32HS00066)This work was supported in part by the Urology Care Foundation Research Scholar Award Program and AUA New York Section Research Scholar Fund

V9-08 MALE INFERTILITY MICROSURGERY TRAINING e TRICKS OF THE TRADE Phil V. Bach*, New York, NY; Filipe Neto, Recife, Brazil; Ryan Flannigan, Benjamin Stone, Omar Al Hussein Alawamlh, Miriam Feliciano, Richard Lee, Peter Schlegel, Marc Goldstein, Philip Li, New York, NY INTRODUCTION AND OBJECTIVES: Male infertility microsurgery (MIM) is physically, technically and mentally challenging, with surgical outcomes that are heavily dependent on the surgeon0 s skills. MIM training programs that incorporate systematic evaluation protocols offer an excellent platform to teach microsurgical skills while avoiding the acquisition of bad habits. In this report, we describe the most common mistakes made by trainees who attended our MIM training program. METHODS: We conducted a retrospective review of prospectively collected data from five trainees who attended the MIM training program between July 2015 and December 2015. Briefly, the IRBapproved MIM training program at Weill Cornell Medicine is a two-week training course offered to urologists of all levels that is held in a dedicated MIM training lab. During the first week, trainees are introduced to the operating microscope, microsurgical instruments and sutures, and focus on developing basic microsurgical suturing skills. During the second week, the trainees start to perform live MIM procedures (vasovasostomy and vasoepididymostomy) on a rodent model. Instructors provide intense supervision and continuous evaluation throughout all phases of the training. Trainees are also able to observe surgical cases performed at our institution. Evaluations are conducted four times throughout the training course using a structured score form measuring