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ABSTRACT: The study was approved by the animal care and use committee. The purpose of the study was to prospectively establish proof of principle in vivo in canines for a magnetic resonance (MR) imaging-compatible robotic system designed for image-guided prostatic needle intervention. The entire robot is built with nonmagnetic and dielectric materials and in its current configuration is designed to perform fully automated brachytherapy seed placement within a closed MR imager. With a 3.0-T imager, in four dogs the median error for MR imaging-guided needle positioning and seed positioning was 2.02 mm (range, 0.86-3.18 mm) and 2.50 mm (range, 1.45-10.54 mm), respectively. The robotic system is capable of accurate MR imaging-guided prostatic needle intervention within a standard MR imager in vivo in a canine model.
Radiology 06/2008; 247(2):543-9. · 5.73 Impact Factor
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ABSTRACT: The aim of this study was to compare the perioperative outcomes of open (OPN) and laparoscopic (LPN) partial nephrectomy in obese and non-obese patients.
We analyzed records for a cohort of 56 patients (28 obese and 28 non-obese) who underwent OPN, as well as 112 (56 obese and 56 non-obese) who underwent LPN.
Obese patients undergoing OPN had increased operative time (285.9 +/- 69.7 versus 195.2 +/- 59.8 minutes), blood loss (484.5 +/- 272.1 versus 391.7 +/- 308.6 mL), clamp time (44.4 +/- 12.8 versus 28.2 +/- 10.5 minutes), intraoperative complications (14.3% versus 1.8%), postoperative complications (35.7% versus 17.9%), and hospital stay (6.4 +/- 2.8 versus 3.2 +/- 2.2 days) than those undergoing LPN. Comparison of obese versus non-obese patients who underwent LPN revealed similar perioperative outcomes, with the exception of a greater blood loss in the obese patient cohort (391.7 +/- 308.6 versus 280.9 +/- 202.1 mL). Finally, in comparing perioperative data among non-obese patients who underwent OPN versus LPN, those who underwent LPN were found to have improved operative times (248.9 +/- 45.0 versus 181.1 +/- 62.4 minutes), less blood loss (412.4 +/- 274.6 versus 280.9 +/- 202.1 mL), fewer intraoperative complications (21.4% versus 1.8%), and shorter length of hospital stay (6.3 +/- 2.8 versus 3.2 +/- 1.6 days).
Laparoscopic partial nephrectomy has significantly better perioperative outcomes than open partial nephrectomy in both the obese and non-obese populations.
Urology 06/2008; 71(5):806-9. · 2.43 Impact Factor
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ABSTRACT: To address the incidence of local recurrence and port site metastasis in patients who underwent laparoscopic radical nephroureterectomy (RNU) for upper tract transitional cell carcinoma (TCC).
Between August 1993 and February 2006 116 laparoscopic RNU were performed in 115 patients at our institution. A traditional open excision, a laparoscopic stapler resection or a different approach was used for the management of the distal ureter in 76, 27, and 11 cases, respectively. Clinical follow-up as well as perioperative and pathologic data were retrospectively collected.
Perioperative and pathologic data were available in all 116 cases. Clinical outcomes were available in 107 patients with a mean follow-up of 30.5 months (range 1 to 148). Six patients (5.6%) had a local recurrence develop, including 1 patient with port site metastasis (0.9%) at an average of 5.7 months. In 2 of these patients, violation of the ipsilateral urinary tract was noted perioperatively.
We report, in this large single-center series of laparoscopic RNU, a low incidence of local recurrence. Our results confirm that a laparoscopic approach to upper tract TCC does not result in a clinically significant increased risk of tumor spillage provided that principles of oncologic surgery are followed.
Urology 12/2007; 70(5):864-8. · 2.43 Impact Factor
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ABSTRACT: To evaluate the safety and oncologic efficacy of extravesical laparoscopic stapling of the distal ureter and bladder cuff during nephroureterectomy for pelvicaliceal transitional-cell carcinoma (TCC).
Patients with primary pelvicaliceal TCC and no history of TCC of the bladder or ureter who underwent extravesical laparoscopic control of the bladder cuff were compared with a similar group of patients submitted to the open transvesical approach. Operative results and oncologic outcomes were compared.
Operative time, estimate blood loss, length of hospital stay, rate of positive margins, and postoperative complications were not statistically different in the two groups of patients. With an average of almost 4 years of follow-up, the laparoscopic approach to the bladder cuff was associated with an increase in the overall rate of recurrence and a shorter recurrence-free survival, although these differences were not statistically significant. Rates of local and bladder recurrence and distant metastases were similar.
Laparoscopic stapling of the bladder cuff has oncologic efficacy and outcomes similar to those of the open transvesical approach. However, the laparoscopic procedure may carry a higher risk of recurrence and a shorter recurrence-free interval than the open transvesical approach.
Journal of Endourology 10/2007; 21(9):1025-7. · 1.85 Impact Factor
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ABSTRACT: The paper presents a robotic method of performing low dose rate prostate brachytherapy under magnetic resonance imaging (MRI) guidance. The design and operation of a fully automated MR compatible seed injector is presented. This is used with the MrBot robot for transperineal percutaneous prostate access. A new image-registration marker and algorithms are also presented. The system is integrated and tested with a 3T MRI scanner. Tests compare three different registration methods, assess the precision of performing automated seed deployment, and use the seeds to assess the accuracy of needle targeting under image guidance. Under the ideal conditions of the in vitro experiments, results show outstanding image-guided needle and seed placement accuracy.
IEEE Transactions on Biomedical Engineering 09/2007; 54(8):1499-506. · 2.28 Impact Factor
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ABSTRACT: The influence of surgical treatment of bladder outlet obstruction on sexual function is uncertain and available evidence is conflicting. Transurethral resection of the prostate (TURP) causes retrograde ejaculation, but its effect on erectile function is controversial. We have prospectively investigated the influence of TURP on erectile and ejaculatory function.
Between January 2000 and January 2005, 11 hospitals in Switzerland informed the Verein Outcome (VO), an independent institution specialising in outcome measurements in the Swiss health care system, about patients scheduled for TURP. VO obtained the Danish Prostate Symptom Score (DAN-PSS) including the sexual function domain (DAN-PSSsex) before and 4 mo after surgery and compared the respective scores.
Data from 1014 patients were evaluated. Mean patient age was 69 yr. DAN-PSSsex questionnaires were returned by 988 patients before and 642 patients after TURP; 722 (73.1%) and 474 (73.8%) of the patients, respectively, stated that they were still sexually active. The mean erectile function score improved insignificantly from 1.66 to 1.47 (p=0.11), the mean ejaculatory function score worsened from 1.27 to 2.34 (p<0.00) and the mean discomfort on ejaculation score improved from 0.37 to 0.29 (p=0.10) before and after TURP, respectively.
The results confirm that TURP has no negative influence on the quality of erections measured by self-assessment questionnaires. The loss of ejaculatory function is significant and is associated with considerable bother. However, three of four patients undergoing TURP are still sexually active and the surgery has no influence on this ratio.
European Urology 08/2007; 52(2):510-5. · 8.49 Impact Factor
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European Urology 07/2007; 51(6):1482-4. · 8.49 Impact Factor
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ABSTRACT: To assess the long-term oncologic efficacy of laparoscopic radical nephroureterectomy (RNU).
Between August 1993 and May 2001, 39 patients underwent laparoscopic RNU for upper tract transitional cell carcinoma (TCC) at our institution. The medical records of these patients were retrospectively reviewed.
Clinical outcomes were available in all 39 patients with an actual follow-up ranging from 60 to 148 mo (median: 74). During this time 27 patients (69%) developed at least one TCC recurrence. Eighteen patients had urothelial recurrences, and 9 patients had nonurothelial recurrences. Of these latter patients, 2 patients (5%) had local recurrences. No patient developed a port site metastasis. Eleven patients ultimately had disease progression and died from TCC 7-59 mo (median: 31) after the operation. On statistical analysis, tumor stage was the only factor significantly associated with death from the disease, and tumor location (ureter) was the only factor significantly associated with disease recurrence.
The long-term overall and disease-specific survival rates after laparoscopic RNU for upper tract TCC are well within the range of results reported after open surgery. Thus, the results of the present study support the continued development of laparoscopic techniques in the management of this aggressive disease.
European Urology 07/2007; 51(6):1639-44. · 8.49 Impact Factor
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European Urology 05/2007; 51(4):1134-5. · 8.49 Impact Factor
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ABSTRACT: Crossed renal ectopia is a rare congenital malformation. We report a case of renal cell carcinoma in a 51-year-old man with right-to-left crossed fused renal ectopia. The patient was treated with ultrasound-guided laparoscopic heminephrectomy. Postoperative three-dimensional computed tomography showed normal perfusion of the remaining part of the kidney, with good excretion of contrast from both units of the cross-fused kidney.
Urology 05/2007; 69(4):779.e11-3. · 2.43 Impact Factor
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ABSTRACT: Pleural effusions have not been reported after percutaneous cryoablation of the kidney. In our initial experience, we identified and treated two patients who had the complication of hemothorax after percutaneous cryoablation for renal malignancy. The occurrence of pleural effusions is frequently related to technical aspects of the procedure. The pathogenesis of this serious complication is discussed and preventive measures are highlighted.
European Urology 04/2007; 51(3):841-3. · 8.49 Impact Factor
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ABSTRACT: To report our experience with laparoscopic treatment of liver tumors during right-sided transperitoneal laparoscopic nephrectomy.
Two patients undergoing transperitoneal laparoscopic radical nephrectomy on the right side each had a concomitant tumor in the right lobe of the liver. The first patient was incidentally found to have a lesion suspicious for metastatic disease. The second had a known asymptomatic giant hemangioma of the liver.
Total operative time was 130 and 101 min. Estimated blood loss was 400 and 300 ml. There were no complications. The first patient had bilateral papillary renal cell carcinoma and concomitant fibroadipose tissue within the liver. The second patient presented with clear cell carcinoma of the right kidney and a cavernous hemangioma of the liver.
When indicated, simultaneous right-sided kidney and liver tumors may be treated by a combined laparoscopic transperitoneal approach. Laparoscopic expertise is advised.
Urologia Internationalis 02/2007; 79(2):142-4. · 0.99 Impact Factor
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ABSTRACT: Primitive neuroectodermal tumors of the kidney are rare neoplasms that may mimic renal cell carcinoma, especially in the presence of locally advanced or metastatic disease. Although several cases have been identified as primary renal tumors, this is the first report of metastatic spread of a primitive neuroectodermal tumor to the kidney.
Urologia Internationalis 02/2007; 78(3):286-8. · 0.99 Impact Factor
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ABSTRACT: The paper reports an important achievement in MRI instrumentation, a pneumatic, fully actuated robot located within the scanner alongside the patient and operating under remote control based on the images. Previous MRI robots commonly used piezoelectric actuation limiting their compatibility. Pneumatics is an ideal choice for MRI compatibility because it is decoupled from electromagnetism, but pneumatic actuators were hardly controllable. This achievement was possible due to a recent technology breakthrough, the invention of a new type of pneumatic motor, PneuStep 1, designed for the robot reported here with uncompromised MRI compatibility, high-precision, and medical safety. MrBot is one of the "MRI stealth" robots today (the second is described in this issue by Zangos et al.). Both of these systems are also multi-imager compatible, being able to operate with the imager of choice or cross-imaging modalities. For MRI compatibility the robot is exclusively constructed of nonmagnetic and dielectric materials such as plastics, ceramics, crystals, rubbers and is electricity free. Light-based encoding is used for feedback, so that all electric components are distally located outside the imager's room. MRI robots are modern, digital medical instruments in line with advanced imaging equipment and methods. These allow for accessing patients within closed bore scanners and performing interventions under direct (in scanner) imaging feedback. MRI robots could allow e.g. to biopsy small lesions imaged with cutting edge cancer imaging methods, or precisely deploy localized therapy at cancer foci. Our robot is the first to show the feasibility of fully automated in-scanner interventions. It is customized for the prostate and operates transperineally for needle interventions. It can accommodate various needle drivers for different percutaneous procedures such as biopsy, thermal ablations, or brachytherapy. The first needle driver is customized for fully automated low-dose radiation seed brachytherapy. This paper gives an introduction to the challenges of MRI robot compatibility and presents the solutions adopted in making the MrBot. Its multi-imager compatibility and other preclinical tests are included. The robot shows the technical feasibility of MRI-guided prostate interventions, yet its clinical utility is still to be determined.
Minimally Invasive Therapy & Allied Technologies 02/2007; 16(4):241-8. · 0.94 Impact Factor
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ABSTRACT: Traditionally transperitoneal laparoscopic access to ureteropelvic junction obstruction has been performed in retrocolic fashion. We assessed transmesenteric laparoscopic pyeloplasty to correct ureteropelvic junction obstruction and compared results to those in patients undergoing traditional retrocolic laparoscopic pyeloplasty.
Between August 1999 and July 2005, 188 consecutive transperitoneal laparoscopic pyeloplasties were performed at our institution. A total of 18 patients underwent a transmesenteric approach and 170 underwent the classic retrocolic approach. Patient selection for the transmesenteric approach was at surgeon discretion with the inclusion criterion of recognition of the renal pelvis and/or ureter through the descending colonic mesentery.
Compared to patients undergoing traditional retrocolic procedure the transmesenteric approach was more commonly applied in younger individuals and males, and for pathological conditions on the left side and malrotated kidneys. The transmesenteric approach lowered operative time by a mean of 22.5% and decreased hospital stay by 19.2%. The patency success rate was 100% at a mean followup of 18.6 months for the transmesenteric approach and 94.1% at a mean followup of 22 months for the retrocolic approach.
In a select group of patients transmesenteric pyeloplasty may represent a more rapid alternative to the transperitoneal retrocolic approach and speed convalescence with similar success rates.
The Journal of Urology 01/2007; 176(6 Pt 1):2526-9. · 3.75 Impact Factor
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ABSTRACT: To introduce the development of the first magnetic resonance imaging (MRI)-compatible robotic system capable of automated brachytherapy seed placement.
An MRI-compatible robotic system was conceptualized and manufactured. The entire robot was built of nonmagnetic and dielectric materials. The key technology of the system is a unique pneumatic motor that was specifically developed for this application. Various preclinical experiments were performed to test the robot for precision and imager compatibility.
The robot was fully operational within all closed-bore MRI scanners. Compatibility tests in scanners of up to 7 Tesla field intensity showed no interference of the robot with the imager. Precision tests in tissue mockups yielded a mean seed placement error of 0.72 +/- 0.36 mm.
The robotic system is fully MRI compatible. The new technology allows for automated and highly accurate operation within MRI scanners and does not deteriorate the MRI quality. We believe that this robot may become a useful instrument for image-guided prostate interventions.
Urology 01/2007; 68(6):1313-7. · 2.43 Impact Factor
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ABSTRACT: Continued experience with the laparoscopic technique has allowed for controlled resection of renal neoplasms invading the renal vein and inferior vena cava. We present the case of a patient with a primary renal tumor extending into the vena cava that was completely managed with a laparoscopic approach.
Urology 12/2006; 68(5):1112-4. · 2.43 Impact Factor
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ABSTRACT: The increasing popularity of robot-assisted radical prostatectomy has put the field of robotics in the spotlight. However, the relationship between medical robotics and the field of urology is older than most urologists know and it will most likely have a bright future beyond any contemporary application. The objective of this review is to provide an insight into the fundamentals of medical robotics and to highlight the history, the present and the future of urological robotic systems with an emphasis on robotic prostate interventions.
Expert Review of Medical Devices 10/2006; 3(5):575-84. · 2.63 Impact Factor
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ABSTRACT: Describe a unique simplified experimental technique for total laparoscopic gastrocystoplasty in a porcine model.
We performed laparoscopic gastrocystoplasty on 10 animals. The gastroepiploic arch was identified and carefully mobilized from its origin at the pylorus to the beginning of the previously demarcated gastric wedge. The gastric segment was resected with sharp dissection. Both gastric suturing and gastrovesical anastomosis were performed with absorbable running sutures. The complete procedure and stages of gastric dissection, gastric closure, and gastrovesical anastomosis were separately timed for each laparoscopic gastrocystoplasty. The end-result of the gastric suturing and the bladder augmentation were evaluated by fluoroscopy or endoscopy.
Mean total operative time was 5.2 (range 3.5 - 8) hours: 84.5 (range 62 - 110) minutes for the gastric dissection, 56 (range 28 - 80) minutes for the gastric suturing, and 170.6 (range 70 to 200) minutes for the gastrovesical anastomosis. A cystogram showed a small leakage from the vesical anastomosis in the first two cases. No extravasation from gastric closure was observed in the postoperative gastrogram.
Total laparoscopic gastrocystoplasty is a feasible but complex procedure that currently has limited clinical application. With the increasing use of laparoscopy in reconstructive surgery of the lower urinary tract, gastrocystoplasty may become an attractive option because of its potential advantages over techniques using small and large bowel segments.
International braz j urol 33(1):94-9; discussion 99. · 1.07 Impact Factor
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ABSTRACT: To report our experience with laparoscopic-assisted nephroureterectomy for upper tract transitional cell carcinomas after radical cystectomy and urinary diversion.
Seven patients (53-72 years-old) underwent laparoscopic-assisted nephroureterectomy 10 to 53 months after radical cystectomy for transitional cell carcinoma at our institution. Surgical technique, operative results, tumor features, and outcomes of all patients were retrospectively reviewed.
Mean operative time was 305 minutes with a significant amount of time spent on the excision of the ureter from the urinary diversion. Estimate blood loss and length of hospital stay averaged 180 mL and 10.8 days, respectively. Intraoperative and postoperative complications occurred in two patients each. There was one conversion to open surgery. Pathology confirmed upper-tract transitional cell carcinoma in all cases. Metastatic disease occurred in two patients after a mean follow-up of 14.6 months.
Nephrouretectomy following cystectomy is a complex procedure due to the altered anatomy and the presence of many adhesions. A laparoscopic-assisted approach can be performed safely in properly selected cases but does not yield the usual benefits seen with other laparoscopic renal procedures.
International braz j urol 32(6):631-8; discussion 638-9. · 1.07 Impact Factor
