Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009 THE JOURNAL OF UROLOGY ® 553 V1546 DIAPHRAGMATIC RECONSCONSTRUCTION OF THE DIAPHRAGM WITH GORE-TEX™ GRAFT Ricardo Brandina*, Monish Aron, Andre Berger, Roberto Colombo, Burak Turna, Robert J Stein, David Canes, Kazumi Kamoi, Georges- Pascal Haber, Sebastien Crouzet, Brian H Irwin, Marcelo Miranda, Denilson C Santos, Gauarang Shah, Mihir M Desai, Inderbir S Gill, Cleveland, OH INTRODUCTION AND OBJECTIVES: In a 10-year (1997 to 2006) review of 1,850 upper abdominal renal and/or adrenal laparoscopic procedures at our institution 13 patients (0.7%) sustained diaphragmatic entry. We present our experience with and the technique of laparoscopic mesh reconstruction or suture repair of intentional resection or intraoperative injury of the diaphragm. METHODS: In this video, we present a 66 year-old male with history of left open radical nephrectomy for RCC in 2001. During follow- up he presented with a metastatic1.6-cm left diaphragm nodule and a 3-cm right adrenal nodule. He underwent a right adrenalectomy and excision of the diaphragmatic nodule in the same procedure. RESULTS: The excision of the diaphragmatic nodule was completed in 3.5 hours.Total operative time was 5 hours. Estimated blood loss was 150 ml. Post-operative course was uneventfull. No chest tube was required. Hospital stay was 3 days. Final pathology revealed metastaic RCC for both adrenal and diaphragm nodules. After 1 year follow-up, there was no evidence of recurrence. In our experience, laparoscopic repair techniques involved primary suture repair in 11 cases and primary reconstruction with a synthetic graft in 2. A rubber catheter and water seal system were used to primarily evacuate the pneumothorax. Inadvertent diaphragmatic injury in 7 cases occurred during transperitoneal (6) and retroperitoneal (1) laparoscopy, including partial nephrectomy in 4, radical nephrectomy in 2 and adrenalectomy in 1. A diaphragmatic breach occurred due to hook electrocautery in 5 cases, trocar insertion in 1 and liver retraction in 1. Deliberate diaphragmatic excision and mesh reconstruction in 2 cases were performed after en bloc excision of the diaphragm during radical nephrectomy in 1 and during excision of a metastatic diaphragmatic nodule in 1. Four transthoracic transdiaphragmatic adrenalectomies were completed successfully without any intraoperative complications. All cases were completed laparoscopically without open conversion. A chest tube was placed prophylactically in the initial 2 patients undergoing transthoracic transdiaphragmatic adrenalectomy. CONCLUSIONS: Laparoscopic and transthoracic repair/ reconstruction of the diaphragm is safe and effective. It requires advanced laparoscopic skills. Source of Funding: None V1547 ROBOT ASSISTED LAPAROSCOPIC BOARI FLAP & URETERAL REIMPLANTATION Joseph R Wagner*, Megan O Schimpf, Hartford, CT INTRODUCTION AND OBJECTIVES: Ureteral reimplantation is frequently performed after distal ureterectomy, ureteral injury, and ureteral stricture. An adequate blood supply, wide lumen, and lack of tension are necessary for a successful anastomosis. At times, creation of a Boari flap is necessary to achieve these goals. METHODS: We have performed 9 robot-assisted laparoscopic ureteral reimplantations using the da Vinci system. Two cases (one for ureteral cancer and one for recurrent stricture) required a Boari flap. RESULTS: Both cases were completed intracorporeally. The first patient undewent a Boari flap and ureteral reimplantation. The second patient underwent distal ureterectomy, pelvic lymph node dissection, Boari flap, and ureteral reimplantion. Total operative times were 172 and 224 minutes. Robot times were 150 and 188 minutes. Blood loss was 125 and 200 cc. An intraoperative iliac vein injury was repaired robotically without short or long term sequelae. There were no other peri-operative complications. Foley catheters were removed on postoperative day 7 and stents were removed postoperative week 5-6. There were no long term complications or strictures with follow-up of 4 and 14 months. CONCLUSIONS: Robot-assisted laparoscopic ureteral reimplantation requiring a Boari flap is feasible and maintains all the principles of an open approach. Source of Funding: None V1548 A NEW TECHNIQUE FOR NEOPHALLOPLASTY BASED ON TWO LOWER ABDOMINAL SKIN FLAPS AND SIMULTANEOUS BUCCAL MUCOSA GRAFT IN THE VENTRAL SURFACE OF NEOPHALUS (TWO-STAGE URETHROPLASTY): DETAILED “STEP-BY-STEP” DESCRIPTION IN TWO PATIENTS Antonio Macedo, Jr*, Riberto Liguori, Gilmar Garrone, Sergio Leite Ottoni, Luiz Luna Barbosa, Jesus A Pires, Petrus Oliva, Eulalio Damazio, Roberto De Castro, Mauro Barbosa, Valdemar Ortiz, São Paulo, Brazil INTRODUCTION AND OBJECTIVES: Penile agenesis and acquired loss of penis (trauma or necrosis after priapism) is a devastating condition and patients are faced with the same gender assignment dilemma as patients with ambiguous genitalia. There is a recent trend on penile reconstruction before puberty restoring self-image of those patients and making future prostesis implantation possible. We describe in this video a new technique of neophaloplasty based on two lower abdominal skin flaps and simultaneous buccal mucosa graft in the ventral surface of neophalus (two-stage urethroplasty) in two similar cases. METHODS: : Two horizontal 15 cm x 3 cm island flaps from the lower abdominal wall were designed keeping vascular support from subcutaneous tissue and inferior epigastric vessels, rotated 90 degrees and medially approximated . The lateral edges of each flap were sutured, defining the dorsal surface of the neophallus. A groove was left in the ventral surface of the neophallus, and a 13 x 2 cm free buccal mucosa graft secured with interrupted 5.0 vycril sutures, having the subcutaneous tissue of the flaps as a bed for vascular integration of the graft. Abdominal wall was closed with minimal mobilization of superior abdominal wound. A compressive dressing remained intact for 7 days as well as indwelling Foley tube (urethral meatus hypospadic). RESULTS: Patients presented excellent cosmetical appearance with still short follow-up (6 months). Second stage urethroplasty and penile prostesis is scheduled for one patient whereas second one decided to keep perineal urethrostomy. CONCLUSIONS: We found in this limited clinical experience a promissing alternative for penile reconstruction of congenital and acquired etiology. Long term follow-up is required for more definitive conclusion. Source of Funding: None V1549 LAPAROSCOPIC ROBOTIC ASSISTED URETEROPYELOSTOMY Shawn M Beck*, Adam G Kaplan, Orange, CA; Geoffrey N Box, Columbus, OH; Eric R Sargent, Elspeth M McDougall, Orange, CA INTRODUCTION AND OBJECTIVES: Complete ureteral obstruction in a Y bifid duplication can be managed with open surgery or minimally invasive techniques. We performed a laparoscopic robotic assisted ureteropyelostomy to correct a complete upper pole ureteral obstruction 6 weeks following surgical injury at the Y- insertion site. METHODS: A 49 y/o female previously underwent a total abdominal hysterectomy with salpingo-oophorectomy for uterine fibroids. During the procedure there was difficulty in the dissection in the right pelvis and question of a ureteral injury. A cystoscopy noted a single ureteral orifice bilaterally and a right ureteral stent was placed. No retrograde pyelogram was performed. 10 days post-operatively, the patient developed urinary drainage from her vagina. CT IVP confirmed a duplication of the right collecting system with a Y bifid ureter with the stent in the lower pole moiety and complete obstruction of the upper pole