E U R O P E A N U R O L O G Y 6 1 ( 2 0 1 2 ) 2 2 5 – 2 3 1 229

[8] Wauben OSGL, van Veelen MA, Gossor D, Goossens RHM. Application

of ergonomic guidelines during minimally invasive surgery: a ques-

tionnaire survey of 284 surgeons. Surg Endosc 2006;20:1268–74.

[9] Bagrodia A, Raman JD. Ergonomics considerations of radical prosta-

tectomy: physician perspective of open, laparoscopic, and robot-

assisted techniques. J Endourol 2009;23:627–33.

Jens J. Rassweilera,*

Ali S. Goezena

Akbar Ali Jalala

Michael Schulzea

Vito Pansadorob

Giovannalberto Pinia

Fernando Kimc

Craig Turnerd

aDepartment of Urology, SLK Kliniken Heilbronn,

University of Heidelberg, Germany

bLaparoscopy and Robotic Section, Vincenzo Pansadoro Foundation,

Rome, ItalycDepartment of Urology, Denver Health Medical Center,

Denver, CO, USAdSt. Vincent Hospital, Portland, OR, USA

*Corresponding author. Department of Urology, Am Gesundbrunnen 20,

D-74078 Heilbronn, Germany.

Tel. +49 7131 492400; Fax: +49 7131 492429

E-mail address: jens.rassweiler@slk-heilbronn.de

URL: http://www.urologie-heilbronn.de

(J.J. Rassweiler)

September 16, 2011

Published online ahead of print on September 28, 2011

doi:10.1016/j.eururo.2011.09.018

[(Fig._1)TD$FIG]

Fig. 1 – The peritoneal flap is harvested from the right iliac fossa and fixedabove the vaginal suture. The bladder closure follows next.

Robot-Assisted Laparoscopic Repair of High Vesicovagi-

nal Fistulae With Peritoneal Flap Inlay

We would like to present the technique and our experience

in the management of vesicovaginal fistulae with peritoneal

flap inlay using the da Vinci system. So far, only a few

reports can be found about robot-assisted fistula repair

[1–5]. The first one was described in 2005 by Melamud et al

at the University of California [1].

We operated on three females aged 40–64 yr who were

diagnosed with a supratrigonal fistula as a complication

after abdominal hysterectomy with no malignancy. Indica-

tions for the operation were high vaginal fistulae difficult to

achieve by vaginal approach. We chose the laparoscopic

access to get the best exposure to the fistula and to avoid

laparotomy, thereby causing less morbidity to the patients

and giving a superior view for fistula dissection. The fistulae

were diagnosed and localized by cystoscopy and conven-

tional cystography.

The operation was performed under general anesthesia.

We started with the vaginoscopy in lithotomy position. First

we inserted a 5F Fogarty catheter from the vagina through

the fistula into the bladder and verified the position

cystoscopically. Ureteral stents were inserted bilaterally.

A sponge stick was inserted into the vagina to ease

subsequent intraoperative identification. After establishing

the pneumoperitoneum via the camera port, two additional

8-mm robotic trocars and two assistant trocars (5 mm and

10 mm) were placed.

After initial adhesiolysis, we performed sharp and blunt

dissection using the PK bipolar forceps and monopolar

curved scissors to expose the abdominal surface of the

bladder and the vaginal stump, entering into the vesicovagi-

nal space. After getting good exposition, we opened the

fistula between the bladder and the vagina. The fistula was

finally resected completely including perifistular scar

tissue. Sharp dissection is used to protect the ureteric

orifices and to prevent wide excisions.

The next step was to mobilize the bladder dorsally to get

a tension-free suture. The closure of the vagina was

performed using 2-0 Vicryl. Before the closure of the

bladder, we mobilized the adjacent peritoneum to use it as a

vital layer between the vaginal and bladder sutures. This

peritoneal inlay flap prevents time-consuming mobilization

of the greater omentum as an alternative (Fig. 1). The

bladder was finally closed using 4-0 Biosyn. After a leakage

test of the bladder, we removed all the ports.

The most demanding steps are the preparation of

the fistula and the closing of the vagina and the bladder

as well as harvesting the peritoneal flap. The peritoneal flap

was mobilized from the iliac fossa or from the pararectal

space.

Postoperatively, the wound drain could be removed after

24–48 h. The patients were discharged after 5 d with the

indwelling Foley catheter. After 14 d, cystography was

performed prior to the catheter removal.

Sexual intercourse was prohibited for 4 wk. After a

follow-up period of 4–42 wk, all patients were still

continent and there were no signs of fistula recurrence.

E U R O P E A N U R O L O G Y 6 1 ( 2 0 1 2 ) 2 2 5 – 2 3 1230

Robot-assisted laparoscopic repair with peritoneal flap

inlay seems to be a very promising approach for high

vesicovaginal fistulae.

Conflicts of interest: The authors have nothing to disclose.

References

[1] Melamud O, Eichel L, Turbow B, Shanberg A. Laparoscopic vesicova-

ginal fistula repair with robotic reconstruction. Urology 2005;65:

163–6.

[2] Sundaram BM, Kalidasan G, Hemal AK. Robotic repair of vesico-

vaginal fistula: case series of five patients. Urology 2006;67:970–3.

[3] Hemal AK, Kolla SB, Wadhwa P. Robotic reconstruction for recurrent

supratrigonal vesicovaginal fistulas. J Urol 2008;180:981–5.

[4] Schimpf MO, Morgenstern JH, Tulikangas PK, Wagner JR. Vesico-

vaginal fistula repair without intentional cystotomy using the lapa-

roscopic robotic approach: a case report. JSLS 2007;11:378–80.

Table 1 – Outcomes on positive first and second biopsies

Parameter Positive initial biopsy

n = 3669

Age, median (IQR) 65.0 (9.0)

PSA, median (IQR) 6.54 (3.00)

Volume, median (IQR) 43.0 (26.0)

TRUS volume, n (%)

<30 607 (17.1)

30–49 1635 (46.2)

50–70 776 (21.9)

�70 523 (14.8)

Gleason grade, n (%)

6 1693 (46.1)

7 1479 (40.3)

�8 497 (13.5)

Low risk, n (%) 865 (23.6)

IQR = interquartile range; PSA = prostate-specific antigen; TRUS = transrectal ultra Wilcoxon rank-sum test.b Chi-square test.

[5] Engel N, John H. Laparoscopic robot assisted vesico-vaginal fistula

repair with peritoneal flap inlay [abstract]. J Urol 2008; 179(Suppl 4):

666.

Michael Kurz

Marcus Horstmann

Hubert John*

Kantonsspital Winterthur, Division of Urologic Surgery, Brauerstrasse 15,

Winterthur 8401, Switzerland

*Corresponding author

E-mail address: hubert.john@ksw.ch (H. John)

September 25, 2011

Published online ahead of print October 3, 2011

doi:10.1016/j.eururo.2011.09.022

Does Low-Risk Prostate Cancer Detection Change With

Repeat Biopsies?

Many patients with a negative prostate biopsy (PBx) but

persistent clinical suspicion of prostate cancer (PCa)

undergo repeat PBx. On repeat PBx, there are higher rates

of low-grade and organ-confined PCa, which are associated

with lower risk of disease progression and cancer-specific

mortality [1,2]. Increasing emphasis is being placed on

treating only clinically significant disease [1]. We hypothe-

size that a considerable risk of clinically significant

PCa remains on repeat PBx. Therefore, we reviewed a

contemporary cohort of patients who underwent one or

more PBx.

We retrospectively reviewed the data from a cohort of

25 584 patients who underwent PBx at two institutions.

One dedicated uropathologist evaluated 90% of PBx speci-

mens; the remaining specimens were evaluated by two

other uropathologists. To ensure current pathologic grading

standards, the study was limited to patients biopsied from

2004 to 2010. Only patients with at least 10 cores taken

were included. Statistical analysis was performed using

SPSS v.17.0 (SPSS Inc., IBM Corp., Armonk, NY, USA).

Descriptive statistics are reported as medians with inter-

quartile ranges (IQRs). All tests were two-sided, and a

p value of 0.05 was considered statistically significant.

Of 25 584 patients, 6729 met the inclusion criteria, and

764 (11.3%) of those underwent a second PBx after negative

initial biopsy. The median age was 65 yr (IQR: 9.0), prostate-

specific antigen (PSA) was 6.20 ng/ml (IQR: 4.79), and

prostate volume was 47 ml (IQR: 30). Overall, 3671 (54.6%)

men were diagnosed with PCa on first PBx, whereas 199

Positive second biopsy p

n = 199

66.0 (9.25) >0.05a

7.26 (5.02) >0.05a

47.5 (30.0) <0.01a

<0.01b

21 (11.5)

71 (38.8)

50 (27.3)

41 (22.4)

<0.01b

121 (60.8)

60 (30.2)

18 (9.0)

72 (36.2) <0.01b

asound.