Journal of endourology / Endourological Society

Published by Mary Ann Liebert
Online ISSN: 1557-900X
Publications
Article
The article "Simulated Life-Threatening Emergency during Robotic Surgery" featured in this month's issue is a prospective observational study investigating the impact of high fidelity team simulation on time to removal of the robot, first chest compression, first defibrillation and time to restoration of stable circulation. This article is pertinent because it demonstrates how interdisciplinary simulation can be utilized to effect change in practitioners' behavior and to identify system-based opportunities for improvement. Evidence in educational research is often separated into Kirkpatrick levels, with Kirkpatrick Level 1 being participant satisfaction, Level 2 representing knowledge acquisition, Level 3 being participant behavior change and Level 4 being improved patient outcome . "Simulated Life-Threatening Emergency during Robotic Surgery" is an addition to the current Level 3 simulation literature showing that simulation of cardiac arrest can improve practitioners' performance. Kirkpatrick evidence Level 1 and 2 research is commonly found in the simulation literature; higher evidence levels should be aspired for in simulation, if only because it is such an expensive educational modality. Simulation also has the benefit of uncovering system-based opportunities to improve practitioners' performance. Following a simulated critical event, the participants have the opportunity to discuss the events of the simulation in the debriefing. In this article, the teams developed a flow poster to improve their team coordination. This sort of system-based opportunity is infrequently uncovered outside simulation and directly influences the practitioners' practice. Much of the simulation literature focuses on participant satisfaction and knowledge acquisition. As seen in "Simulated Life-Threatening Emergency during Robotic Surgery," simulation offers the opportunity to practice critical event response, make system-based changes and impact participant behavior. I applaud these authors' success in achieving Kirkpatrick level 3 evidence. However, with the high cost of simulation, it is time to move to research outcomes more directly linked to patient outcomes.
 
Equianalgesic Dosages 
Pain score averaged over entire hospital stay. The box plot demonstrates the median with interquartile range (IQR). The whiskers represent 1.5 times the IQR or the range, whichever is the least distance from the IQR. Outliers are data beyond these values and denoted by small circles. 
Pain score in 8-hour intervals. The box plot demonstrates the median with interquartile range (IQR). The whiskers represent 1.5 times the IQR or the limits of the scale (0-10). Outliers are data beyond these values and denoted by small circles. 
Article
Liposomal bupivacaine is a delayed-release preparation providing up to 72 hours of local analgesia. However, it costs much more than standard bupivacaine. A prospective, randomized, patient-blinded, controlled trial was performed to assess the efficacy of liposomal bupivacaine versus 0.25% bupivacaine when injected into surgical incisions during laparoscopic and robotic urologic surgery. A total of 206 adults were randomized to receive liposomal bupivacaine or 0.25% bupivacaine. All surgical incisions were injected with liposomal bupivacaine or 0.25% bupivacaine with systematic dosing. The primary outcome was total opioid consumption during the postoperative hospital stay. All opioid doses were converted to morphine equivalents. Secondary endpoints included pain scores using visual analog pain scales, duration of hospital stay, and the time to first opioid use. A subgroup analysis was performed for renal surgery patients. There was no significant difference in median total opioid use during the hospital stay between those who received liposomal bupivacaine (15 [IQR 6.7 - 27] mg) and 0.25% bupivacaine (17.3 [IQR 8.3 - 30.5] mg) (p = 0.39). Furthermore, pain scores, length of hospital stay, and time to first opioid use did not differ between groups. Subgroup analysis of laparoscopic renal surgery revealed no difference between liposomal bupivacaine and 0.25% bupivacaine. For laparoscopic and robotic urologic surgery, there is no significant difference between liposomal bupivacaine and 0.25% bupivacaine for local analgesia at the incision sites.
 
Article
Background and purpose: CT has become a well-established modality in the evaluation of urinary calculi. The advent of multidetector CT (MDCT) scanners and submillimeter thick slice acquisitions has yielded CT images with even greater resolution. MDCT scanners allow for source data slice acquisition with submillimeter slice thickness. These source images can then be reconstructed to thicker slices for more convenient interpretation of the CT scan. Previous authors have looked at the effect of slice thickness on detection of urinary calculi. We investigated whether the thin slice source images yielded detection of additional stones and the potential significance of detecting these additional stones. Patients and methods: Ninety-five consecutive patients who were referred to our outpatient imaging center for CT, with a clinical history placing them at risk for urinary calculi, were included in the study. Results: In 49 (52%) of the 95 patients, more calculi were visualized using the 0.625-mm thick images than with the 5-mm thick images. In 34 (69%) of these 49 patients, the additional findings were thought to be "clinically significant," while in the remaining 15 (31%) patients, the additional findings were not thought to be clinically significant. In 46 (48%) of the 95 patients, there were no additional urinary calculi identified on the 0.625-mm thick images compared with that observed on 5-mm thick images. Conclusion: The results from this study encourage reviewing the thin slice source images of MDCTs in patients at risk for urinary calculi, because important clinical decisions may hinge on the additional findings made on these images.
 
Article
We greatly value the editorial comments. Given the complexity of the management of staghorn renal stones, several modifications have been proposed and practiced after the original description of open anatrophic nephrolithotomy (AN) by Smith and Boyce...
 
Article
Post operative "pain" after TURP is generally related to bladder spasms. They are usually treated with antimuscarinic agents given either orally, transdermally or by suppository. However, these agents, in the short term, may result in constipation and more difficulty in voiding when the catheter is removed. In this study, the author's premise is that using prilocaine in the irrigant fluid can mitigate the use of postoperative narcotic and or anti-inflammatory analgesics. In part, by "numbing" sensory receptors, patients may have less pain. The hypothesis deserves merit however the methodology of the study is of concern. Of note, the authors stop postoperative irrigation after 24 hours as hematuria resolves. Yet, there is relatively prolonged catheterization, i.e. 2.8 days in the prilocaine group and 3.3 days on the control group? These results are not consistent with current post TURP catheter management. Moreover, one would suspect that prilocaine would not have any discernable effect after it was stopped 24 hours postoperatively. Even if the hypothesis of numbing of sensory receptors were true, it would only be of short duration. Therefore, why was there such a difference in analgesic use between the two groups after the first day? In summary, this is an interesting premise. If these are results are reproducible, one can envision less catheter time, more efficient trial of voids after catheter removal and ultimately better results after TURP.
 
Article
I congratulate the authors for addressing the importance of ergonomics affecting the well-being of surgeons during laparoscopic surgery. Few studies addressed the consequences of a laparoscopic surgeon's ergonomics during surgery. Uhrich et al. reported the fatigue of laparoscopic surgeons due to the static contraction of muscle groups from the neck down to the lower extremities (1). Moreover, Park et al. reported that 87% of minimally invasive surgeons suffer from physical pain or discomfort (2). Therefore, the concept of an ergonomic chair for laparoscopic surgeons is sought after but not widely investigated by the medical device industry. The ETHOS chair with adjustable resting arms for the elbow facilitates a resting position of the shoulders, and arms, facilitating the surgeon's position during laparoscopic surgery (3). This manuscript compare three types of positions during a pelvic suturing exercise mimicking the clinical scenario of laparoscopic urethro-vesical anastomosis (UVA). The "bad" effects of uncomfortable posturing during the laparoscopic exercises were evaluated and illustrated. Although it seems intuitive that good posture and relaxed muscles are pivotal during surgery, these data demonstrate the superiority of the ETHOSTM ergonomic device when compared with other positions during the laparoscopic UVA regarding surgeon's pain level and discomfort. Ultimately, the effectiveness in the operating room depends on surgeons and patient's safety including long-term well-being of the work force. 1. Uhrich ML, Underwood RA, Standeven JW, Soper NJ, Engsberg JR: Assessment of fatigue, monitor placement, and surgical experience during simulated laparoscopic surgery. Surg Endosc. 2002; 16: 635-9. 2. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter D. Patients benefit while surgeons suffer: an impending epidemic. J Am Coll Surg 2010; 210(3):306-13. 3. Kim FJ, Sehrt DE, Molina WR, Huh J_S, Rassweiler J, Craig T: Initial experience of a novel ergonomic surgical chair for laparoscopic surgery. Int Braz J Urol 2011; 37(4):455-60.
 
Article
Editorial Comment on END-2014-0061-TE.R1.
 
Article
This is an editorial comment. No abstract available.
 
Article
Editorial Comment on END-2013-0093.R3.
 
Article
Renal hemorrhage is the most common adverse effect of SWL, and it has been speculated to be related to the type of lithotripter used. We investigated the incidence of renal hemorrhage in patients with urinary stones who underwent lithotripsy using either the EDAP LT-01 or the Siemens Lithostar. In addition, we performed in vitro experiments using pressure-sensitive paper in conjunction with gelatin, agar, or porcine tissue models of renal lithotripsy. Thirty-one (16.6%) of 187 kidneys treated with the EDAP LT-01 and 44 (19.6%) of 225 kidneys treated with the Siemens Lithostar showed intrarenal or subcapsular hemorrhage or perinephric hematoma. In particular, the incidence of subcapsular hematoma was significantly higher in the Lithostar-treated patients (P < 0.0001). We discuss our results in light of the patterns of pressure distribution obtained from the two lithotripter units using in vitro models with colorometric, pressure-sensitive paper. It appears that the Siemens Lithostar exerts a greater pressure on the renal capsule, which may account for the higher incidence of subcapsular hematoma.
 
Article
The stone-free rate of 248 cases of clinically insignificant residual fragments (CIRF) was 32.7% by 1 month, 73.0% by 3 months, and 92.7% by 6 months of follow-up. The stone-free rate decreased but not remarkably in accordance with the increment of the caliceal dilatation (92.9%, 94.9%, 85.7%, and 83.3% for no, mild, moderate, and severe dilatation, respectively) by 6 months of follow-up. The clearance of the CIRF was not influenced by their location, the pelviocaliceal angle, the infundibular length, or the number of the lower calices. Of 16 patients who had residual stone fragments at 6 months and underwent an additional session of extracorporeal shock wave lithotripsy (SWL), 12 became stone free by another 6 months of follow-up. Therefore, it is desirable to wait for clearance of CIRF for at least 6 months before offering further treatment, regardless of their location and anatomic variation of the calices containing CIRF. Repeated SWL, even for stone fragments of 3 to 4 mm in diameter found initially 1 month after the last session of SWL, might promote clearance of the CIRF, and additional SWL for persistent CIRF could be an appropriate adjunctive measure.
 
Article
A total of 419 calculi in the upper urinary tract of 402 patients were treated by SWL with the EDAP LT-01 lithotripter from July 1988 to September 1989. Subcapsular hematomas resulted in 17 kidneys of 16 patients, an incidence of 4.1%. On CT scan, fractures with subcapsular hematomas were observed in nine kidneys, and a retroperitoneal hematoma was observed in one patient. There was no significant difference in stone location and size, grade of hydronephrosis, number of shock waves, applied energy, or post-treatment fever between the groups with and without hematomas. However, the hematoma group revealed significantly (P < 0.01) higher incidences of pretreatment hypertension (> 160/95 mm Hg) and use of antiplatelet agents. It is difficult to detect some disorders of blood coagulation in ordinary laboratory studies in patients receiving low dosages of antiplatelet agents; and many drugs including analgesic and anti-inflammatory agents, calcium antagonists, coronary vasodilators, antiplatelet agents, beta-blockers, and lipid-regulating agents have antiplatelet actions. Therefore, particular care should be taken in SWL when a patient is using those drugs.
 
Article
The authors performed a single institution retrospective review of 887 renal units subjected to ureteroscopic lithotripsy procedures for renal calculi to identify the rate and risk factors for the occurrence of symptomatic renal or perirenal hematomas. Seven patients were identified including four that had developed renal hematomas and three with perinephric bleeds. All patients presented with pain, and all but one was diagnosed within 48 hours of the procedure. Two patients required blood transfusion. Potential risk factors for hematoma development were compared using bivariate analysis. Factors identified in the authors' analysis that correlated statistically with hematomas included female gender, pre-operative hypertension, pre-operative ureteral stenting, the use of a ureteral access sheath and post-procedure ureteral stenting. Three of the seven cases involved intraoperative scenarios that may have precipitated renal bleeding including a stone being pushed into the renal parenchyma, an infundibulotomy and papillotomies. The study methodology precludes the ability to prove causality for any of the possible risk factors assessed in this report. As the authors correctly state, the characteristics assessed may only be surrogates for as yet unrecognized additional factors. What role do anatomical issues such as thin renal parenchyma or renal collecting system anomalies play? Could there be technical issues related to elevated intrarenal pressures generated by the irrigation fluid with subsequent barotrauma, or holmium laser shock wave induced effects tissue effects? Does sudden decompression of an obstructed system lead to vascular changes that predispose to hemorrhage? The authors are to be credited for raising awareness of a rarely described but possibly under-reported phenomenon. Clearly, further attention should be directed to understanding the mechanisms and risk factors. This seems to be especially relevant as the application of flexible ureteroscopy continues to expand as a primary management option for intrarenal calculi.
 
Article
The authors have conducted a study to evaluate the mechanism and effectiveness of transurethral balloon dilation of the prostate for the management of bladder outlet obstruction. The patients selected have moderate to significant obstructive voiding symptoms, had moderately enlarged prostates (avg. 48 cc) and underwent a single session of transurethral balloon dilation of the prostate. The patients appeared to have good outcomes based on pre and postoperative evaluation of their QOL and IPSS scores and the results were relatively durable. CT scans in some patients confirmed anterior disruption of the prostate with resultant sustained defect anteriorly in some. The authors conclude that the use of a columnar balloon is superior to the use of a spherical balloon in achieving this clinical outcome; however, there are no direct comparisons in this patient population between the use of a spherical balloon and the use of a columnar balloon. Review of the literature from the 1980s and 1990s, when transurethral balloon dilation of the prostate was introduced and in relatively widespread use, showed conflicting but generally disappointing results in terms of the durability of clinical outcomes.1,2,4 A review of the literature reveals that balloons similar to the one described in this study were in use at that time.3,4 It is possible that the differentiating aspect of the procedure described in this study was that the balloon was left fully inflated for five to six hours after the procedure. It is possible that this expansion and compression of the prostate could lead to some vascular compromise of the tissue and perhaps result in more scar tissue formation and decreased collagen deposition as well as some atrophy of the glandular tissue itself. If the proposed mechanism of action is correct, very similar results could theoretically be obtained by simple transurethral incision of the prostate and capsule anteriorly.
 
Article
Editorial Comment on END-2013-0225.TE.R1.
 
Article
The authors are to be congratulated for their initial and very thorough investigation of 3D printing endourologic tools. They focused on two very practical and universal tools we use daily - stents and trocars. Working through several iterations, they ultimately demonstrated the feasibility of printing functional stents and trocars. This technology could revolutionize hospital practice where instruments are literally "made to order." The consequence would be reduced inventory costs for hospitals including elimination of expired material. As others pursue this research, what can be 3D printed on demand and used in the operating room is only limited by one's imagination. Several obvious hurdles remain including sterility, cost and time of printing tools, materials, and volume of equipment needed. It may not be that the most common tools are printed (stents and trocars) since their frequent use likely justifies stocking them on the shelf. Rather I envision the occasional instruments that "expire" while never being used the obvious target for this technology. Finally and perhaps most daunting, I doubt the designs and specifications for any particular tool will be readily available as open source code. As such my enthusiasm for this technology is tempered by reality where very real economic, intellectual property, and legal hurdles will be erected and need to be overcome.
 
Article
Editorial comment, END 2012-0293-OR.R1 The authors are to be congratulated on reporting an important pilot rotation experience for urology residents in interventional radiology. No doubt, few urologists would argue that branching into fields such as interventional radiology offers clear benefits to the clinical spectrum of urologic diseases manageable by urologists. As such, the majority of the cases in which residents were trained involved vascular interventions, most of which have some relevance to potential urologic interventions. I am in full agreement that this elective may serve a greater good for both urology and radiology, and further enhances the crossover and clinical efficiency between the 2 services. While the authors have demonstrated the feasibility of this sort of collaboration, going forward, it will be important to develop benchmarks to assess performance. Given the existing certification process required for radiologists, a more rigorous documentation than the self-reported performance assessment used by the authors in this study will likely be necessary for urologists and trainees. Regardless, in time we will see where this type of collaboration will lead us. As urologists begin to perform more renal ultrasound and other hands-on imaging techniques, it would be no surprise if urologists became more involved with radiologic and interventional procedures. Stephen Y. Nakada, MD, FACS Sara L. Best, MD Madison, Wisconsin.
 
Article
Simple but clever, that describes any good surgical procedure. Dr. de Castro Abreu and colleagues from USC have come up with an excellent and simple modification to the difficult problem of a large protruding intravesical lobes of the prostate. As they point out, deviation of the Foley balloon is the first tip off to the surgeon that a large median lobe is coming. Second, a clear picture of the trigonal anatomy and ureteral orrifices allows the surgeon to quickly get into the correct plane and onto the seminal vesicals, as opposed to developing a subcapsular plane which can lead to the disasterous result of leaving prostatic tissue behind. I would encourage all robotic surgeons to study and adopt this clever technique.
 
Article
None required -- this is an editorial comment.
 
Article
In the article presented by Cho et al, a trocarless technique for liver retraction during right laparoscopic nephrectomy is presented. This technique has potential advantages over the conventional trocar-based retraction including cosmesis, pain, and reduced trocar interference. The third advantage seems most clear, while the other potential advantages need further validation.
 
Article
References 1) Sharma V, and Meeks JJ. Open conversion during minimally invasive radical prostatectomy: impact on perioperative complications and predictors from national data. J Urol 2014 192 1-6. 2) Park S, Readal N, Jeong BC, et al. Risk factors for intraprostatic incision into malignant glands at radical prostatectomy. Eur Urol 2014, in press. 3) Obesity, weight gain, and risk of biochemical failure among prostate cancer patients following prostatectomy. Clin Cancer Res 2005; 11: 6889-6894. 4) Chalfin HJ, Lee SB, Chang B et al. Obesity and long-term survival after radical prostatectomy. J Urol 2014; 192: 1100-1104. 5) Liang Y, Ketchum NS, Goodman PJ, et al. Is there a role for body mass index in assessment of prostate cancer risk on biopsy? J Urol 2014; 192: 1094-1099. 6) Ribeiro R. Obesity and genitourinary cancer risks. J Urol 2014; 192: 1015-1016.
 
Article
A percutaneous nephrostomy (PCN) done on the same side as a previous open nephrolithotomy is always technically challenging. A novel one-step PCN tube that allows the puncture and placement of a drainage tube to be done in a single step has been developed. The hydrophilic coating on the tube's surface significantly reduces friction and allows easier insertion. We evaluated the tube's efficiency and safety compared with the traditional fascial dilator system. Sixty-five patients with a history of open nephrolithotomy were randomly allocated (with the aid of a computer-derived assignment number) into two groups to have PCN performed in one step or multiple steps. In the one-step group, a new type of PCN tube was used. In the multistep group, fascial dilators were used serially prior to tube insertion. The two groups were similar in terms of mean age, width of target calix, and baseline serum creatinine and hemoglobin concentrations. The operating times, intubation rates, and complications in the two groups were compared. The mean number of attempts required to access the collecting system was 1.1 +/- 0.6 in the one-step group v 2.3 +/- 1.2 in the multistep group (P = 0.002), the successful intubation rate was 96.9% v 78.8% (P = 0.012), the mean operating time was 10.2 +/- 2.4 minutes v 25.6 +/- 2.8 minutes (P = 0.029), and the rate of intraoperative and postoperative complications was 3.1% v 15.2%, respectively (P = 0.019). No major complications occurred in the one-step group. The one-step PCN tube is a convenient and efficacious method for accessing an anatomic region where open nephrolithotomy was done previously and is a simple method for nephrostomy tube placement.
 
Article
The implications of the article by Anderson et al go far beyond monitoring of cystoscopies. We are in an era of a growing doctor shortage and retrenched healthcare budgets. There will be an increased need for innovative approaches to deliver healthcare more efficiently and economically. There are at least three reasons that the technology described by Anderson et al should be embraced. 1) Transformation of Teaching Methods: Medical school teaching has always been a dynamic process and most of what we learn during medical school is obsolete within a decade. The old operating theaters have been replaced by wide screen monitors, teaching videos and three dimensional computer programs illustrating anatomy. Just as medical knowledge is ever mutable, so should be the dynamics of teaching. 2) Growing Doctor Shortage: It has been estimated that by 2020, the United States will have a doctor shortage of 200,000.1 It is inevitable that physician extenders such as nurse practioners and physicians assistants will have an expanded role in healthcare delivery. However, it would be struthian to think that it will not also be necessary for the individual physician to increase his/her own clinical productivity. Remote supervision of procedures will become commonplace, especially in rural areas, where the doctor shortage will be even more pronounced. There are increasing reports of remote monitoring by anesthesiologists and remote consultations via the internet by pathologists. Remote clinical consultations are already being done routinely in many areas. 3) Retrenched Healthcare Budget: It is imperative that the cost of providing healthcare be drastically reduced. Remote monitoring of procedures and consultations offer a tangible option to provide care more economically in many circumstances. The surest way to curtail healthcare costs is to embrace innovation. Anderson et al in their report have given us a glimpse into the future. Such innovations in medical practice must be embraced by both patients and physicians.
 
Article
The best way to compare the effectiveness of 2 procedures is with an appropriately powered, well-designed, prospective randomized controlled trial. While this study is limited by its retrospective design, certain inferences can be made. Totally tubeless percutaneous nephrolithotomy can be successfully performed in well-selected patients. However, this study does not prove that this approach is superior to the standard approach. Certain maneuvers can be undertaken to reduce pain in those undergoing the standard approach. Utilization of a small-bore nephrostomy tube may reduce analgesic requirements and pain particularly in the earlier postoperative period. Tract infiltration at the end of the case with bupivacaine also attenuates postoperative pain. The cost differential reported in this study could have been eliminated by discharging the patient the day after surgery with their nephrostomy tube in place with subsequent removal a few days later in an outpatient setting. The majority of patients are amenable to this approach.
 
Article
Vesicovaginal fistula sometimes reveals itself somewhat challenging in terms of diagnosis and precise identification of the orifice, calling for several tests to be performed, such as intravaginal tampon, cystoscopy, retrograde pyelography, vaginal examination, voiding cystourethography and intravenous pyelography, which may worsen the problems of both patient and physician. There is no consensus about the best test to be performed as well as a debate regarding the best surgical technique. In 2003 it was reported a technique using a device that permits simultaneous viewing on the same display (picture in picture) of 2 images called combined vaginoscopy-cystoscopy (CVC) during evaluation for vesicovaginal fistula. (1) The presented paper uses simultaneous view provided by a scope as a means of treatment and claims for better visualization that could provide a more efficient result. It is a technical innovation, maybe simpler than CVC, with equipments available in most hospitals. However, there are few results to report in this initial experience and it is needed to have a further comparison with conventional approach either by vaginal approach or as some surgeons would have chosen an abdominal approach for supratrigonal fistula, then we will know better the role of the proposed technique. 1. Andreoni C, Bruschini H, Truzzi J, Simonetti R, Srougi M. Combined vaginoscopy-cystoscopy: a novel simultaneous approach improving vesicovaginal fistula evaluation. J Urol, 2003;170:2330-2.
 
Article
The financial aspects of medicine are increasingly more pertinent in our contracting health finance environment and will continue to have a direct impact on our practice. Although hospital profitability is not an immediate concern for many clinicians, it has an indirect effect on our practice ultimately. Therefore studies such this one by Tosoian J et al are timely and important. These investigators have described in simplified form the complex finances of ureteroscopy. And although their mathematical model may differ from institution to institution--, depending on payer mix, surgeon practice patterns, laser ownership versus rental, presence of repair contracts versus fee for individual repairs-it is encouraging that the procedure is viable financially within certain caveats. They specifically highlight that inpatient care for ureteroscopy threatens the financial return but outpatient surgery remains profitable. Since inpatient ureteroscopy is occasionally indicated, it is imperative to understand how to mitigate the costs associated with it. Equally, maintaining high collection rates will also sustain the return on investment with an inpatient admission. Lastly, and most important to this study is the threat that repairs have on financial returns. These authors have nicely shown that repairs erode at return but potentially not enough to diminish the profitability of their business.
 
Article
This is an editorial comment.
 
Article
The authors show that complex hilar lesions can be resected using minimally invasive surgical techniques without clamping the renal vessels. Everyone agrees short warm ischemic times are better than long ischemic times for preserving postoperative renal function. It remains to be proved that a case with no renal ischemia leads to improved postoperative renal function over a case performed with a short ischemic time. Case selection is crucial for success. Exophytic masses should be chosen initially. Dissection of the hilar vessels is prudent to allow for emergent vascular control in cases where bleeding occurs during off-clamp resection. At Washington University, we start the resection at the medial aspect of the mass. We dissect the mass away from the large vessels. Usually it is not hard to develop this plane. In most cases, vessels feeding the mass are small and can be cauterized and divided. Once the mass has been mobilized away from the hilar vessels, the renal parenchyma on the cephalad, caudal and lateral aspects can usually be divided with very little bleeding since most of the blood supply to the mass has been controlled in the medial dissection. This technique evolved as we sought to minimize warm ischemic times by doing as much of the dissection as possible prior to clamping the vessels. Surprisingly, we found most masses could be resected without clamping the renal artery. Further study is required to determine whether off-clamp minimally invasive partial nephrectomy improves patient outcomes. The authors have shown in this small series that excellent renal functional and oncologic outcomes can be achieved when managing complex renal masses without ischemia to the kidney using minimally invasive surgical techniques. Sherb Figenshau, MD Taylor Family and Ralph V. Clayman, MD Chair in Minimally Invasive Urology Division of Urologic Surgery Washington University School of Medicine.
 
Article
Persistent urinary leaks or urinary fistula formation are a troublesome complication of minimally invasive or open partial nephrectomy. Chu and colleagues outline a clever technique of using a highly flexible 1.9F nitinol basket to fulgurate the fistulous tract and the ureteroscopic injection of fibrin glue to further obliterate the tract. Endourologists should keep this technique in mind the next time they encounter a difficult or persistent urinary fistula after partial nephrectomy.
 
Article
In the realm of continually growing Pediatric Robotic Urological surgery this is the next milestone, in regards to its applications for redo reconstructive surgery. The, at par outcomes, in complex lower urinary tract reconstruction (ref 3 in manuscript) has allowed the surgeons with experience to achieve this next step. The utmost importance is to know that these procedures require a certain level of expertise, and need to be exercised at well-established centers. The important point to note about the added advantage, here as demonstrated by the authors, is the reduced intraperitoneal adhesions that we have previously seen in the porcine model (1), which may be an additional benefit for the spina bifida population to further reduce abdominal complications with multiple surgeries (e.g. intestinal obstruction) with this approach. The question remains is, how can we convince the readers about reduced morbidity and sustainable results? Hence, the next goal in this field should be to conduct a comparative study with prospective long-term follow up. It is also crucial to develop a robust training program for these complex reconstructions (2) , and create an algorithm to prevent complications, especially stomal incontinence (ref 16 in manuscript). 1 Does robotic-assisted laparoscopic ileocystoplasty (RALI) reduce peritoneal adhesion compared to open surgery? Razmaria, A.A., Marchetti, P.E., Prasad, S.M., Shalhav, A.L., Gundeti, M.S BJU Int. 2014 Mar;113(3):468-75. Epub 2013 Dec 2. 2 Pediatric robotic urologic surgery-2014. Kearns JT, Gundeti MS. J Indian Assoc Pediatr Surg. 2014 Jul; 19(3): 123-8. doi: 10.4103/0971-9261.136456.
 
Article
This is a retrospective study, analyzing Medicare claims information, to compare resource utilization when either extracorporeal shockwave lithotripsy (SWL) or ureteroscopy (URS) is used as primary treatment for ureteral or kidney stones in this population. The results of the study are not surprising: SWL was used 74% of the time for renal stones and URS utilized 80% of the time for ureteral stones. Conclusions that can be drawn from the data analysis for this study are limited because information on stone size and specific stone location is not available. It is well established that the outcome (stone free and ancillary procedures) of a chosen treatment is dependent on stone size, specific location within the kidney (e.g., renal pelvis vs lower pole) or ureter (proximal vs distal), stone type, and stone size. As such, the number of ancillary procedures necessary may be related not only to the treatment modality chosen but also to the stone size and location. For example, it is likely that the urologist will choose URS for distal ureteral stones and SWL for proximal ureteral stones and the outcomes, including secondary procedures, are different based on ureteral stone location. There are other potential reasons for urologists to choose between SWL and URS regardless of the stone characteristics; comfort with flexible ureteroscopy for proximal ureteral and kidney stones, financial interest as owners of lithotripsy machines, and other re-imbursement issues. As mentioned by the authors, the increasing cost of treating kidney stones is a significant economic issue and future Medicare reimbursement may be determined by a value driven system. In that context, the choice of stone treatment for a particular stone characteristic is likely to be determined by the treatment that is most efficacious the first time and requiring the least number of secondary procedures.
 
Article
The authors describe performing a modified-PCNL procedure using a smaller 24F sheath, as compared to a standard 30F sheath, by simply removing the outer sheath of a standard 26F nephroscope. With the outer sheath removed, the nephroscope and associated standard instruments are able to be used through the 24F sheath with apparent efficacy and no reported increase in morbidity. While no standardized definition of "mini-PCNL" exists, and the relative benefits of mini-PCNL remains equivocal, the authors of this manuscript appropriately choose to call the use of a 24F sheath as a "modified-PCNL" rather than a "mini-PCNL".1, 2 While concern is raised over the safety of using the nephroscope without the outer sheath, the authors describe using additional care while inserting the instruments under direct vision and guiding the instruments with their fingers to keep them in close approximation to the nephroscope. Once in place, they report that no other modifications are needed and their results demonstrate no additional problems with excellent overall results. Ultimately a prospective, randomized trial comparing this modified-PCNL technique with a standardized 30F sheath is needed to accurately assess both risks and benefits to the patient. In the meanwhile, this helpful technique adds to the repository of options available to the endourologist making the decision to use a smaller 24F tract in select circumstances, such as a very tight collecting system, in children, or when multiple tracts are needed.
 
Article
Editorial Comment on END-2012-0694-OR.R1 Monitoring laparoscopic radiofrequency renal lesions in real time using contrast-enhanced ultrasonography:an open-label, randomized, comparative trial The authors are first and foremost to be congratulated for completing a randomized surgical trial. These are rare in the urologic surgical literature. This study proposed that CEUS during RFA may improve the short term local tumor control rate. As it stands, the results were not statistically significant leaving the authors to, at most, suggest that CEUS may improve laparoscopic RFA effectiveness. A power analysis to justify the size of the study arms is not provided in the manuscript raising the issue of whether additional patient enrollment may identify a statistically significant advantage for CEUS utilization to improve local tumor control rate. Perhaps the authors can provide this analysis in their response. Nevertheless, the shortcoming of laparoscopic RFA is an inability to image the ablation zone in real time or at least immediately after treatment as occurs with CT-guided percutaneous procedures where IV contrast is administered to delineate the ablation zone. Thus the use of CEUS during the laparoscopic approach would logically provide the surgeon with a comparable "perfusion-deficit" surrogate for treatment success. Currently, temperature monitoring and needle position confirmation by ultrasound are the only laparoscopic methods. It must be emphasized that immediate ablation success, defined as lack of enhancement immediately (or upon the initial post-treatment CT), does not translate perfectly to long term treatment success. Recurrences as late as 5 yrs after RFA and cryoablation have been reported despite initial success. Whether the lack of perfusion on CEUS at the time of ablation improves the long term oncologic outcome of the procedure is not known. Unfortunately this study's follow-up was insufficient (median 16 months) to assess whether the oncologic efficacy was improved with CEUS. This would be the ultimate test and cost justification for using CEUS routinely during laparoscopic RFA.
 
Article
Microperc is a significant advance in miniaturization of PNL procedure. The whole procedure is done in one step manner using 16 G needle. In any PNL, outer sheath (Amplatz sheath) keeps on draining the fluid from the PC system this maintaining low intra renal pressures. Microperc can have disadvantage that intrarenal pressures during procedures can increase leading to complications thereof. Although this issue is addressed by previously published articles1 , there are no prospective trials to study this aspect. Authors technique addresses this concern & is a step ahead to reduce intrarenal pressures during surgery. Authors have nicely highlighted the advantages of using 14 G angiocath sheath, however some concerns have to be addressed: 1) Angiocath needles are short in length & hence its use is presently limited only to pediatric population. 2) Angiocath sheaths are soft - hence are collapsible & kinkable. It is possible that tough tract tissue may not allow sheath to remain patent through out the procedure & drain the fluid efficiently. It is also possible that sheath may get bent leading problems. 3) It would be worthwhile trying to use metal sheath if available & comparing it with angiocath sheath. 4) Also word of caution is - by using this technique, initial punctures is of 14G needle. If surgeon takes multiple attempts to get access to PC System, then it may pose some problems (like clots in PCS) as these attempts are with 14 G needle, which is much thicker than 20 or 18 G needle, which is routinely used. Authors have to consider these points in their future studies and come out with relevant data. Ref 1) Desai MR et al, Single step percutaneous nephrolithotomy (microperc): The initial clinical report. J.Urol 2011: 186;140.
 
Article
Robotic ureteral reimplantation is a procedure taken for granted as being a simple approach to correcting vesicoureteral reflux (VUR). This misconception flows from the fact that VUR is so widespread that its experience with minimally invasive surgery must be large just due to shear numbers. Both extravesical and intravesical techniques have been described. The outcomes reported across the U.S. might be considered unacceptable, and vary even amongst outstanding surgeons with great minimally invasive experience.
 
Article
Probe-based confocal laser endomicroscopy (pCLE) is an emerging technology for dynamic, in vivo imaging of the urinary tract with micron-scale resolution. We conducted a comparative analysis of pCLE with a 2.6-mm probe and a 1.4-mm probe that is compatible with flexible endoscopes. Sixty-seven patients scheduled for bladder tumor resection were recruited. pCLE imaging was performed using 2.6- and 1.4-mm probes. Image quality with the different probes was examined and further compared with standard histopathology. Images with the 2.6-mm probe have better resolution of cell morphology. The 1.4-mm probe has a wider field of view and better view of microarchitecture. While image quality with the 2.6-mm probe is superior, the 1.4-mm probe is compatible with flexible cystoscopy and maneuverability is maintained, enabling imaging of areas of the bladder that were previously challenging to access with the larger probe. The optical specifications of the 2.6-mm probe are more suitable for distinguishing urinary tract histopathology. Further design optimization to improve resolution and additional validation of the diagnostic accuracy of the smaller probe are needed to help extend application of pCLE for optical biopsy of the upper and lower urinary tract.
 
Article
We present a series of cystinuric patients with renal cystine calculi between 1.5 and 3.0 cm treated with retrograde renoscopy and intracorporeal lithotripsy and report our results, complications, and inpatient utilization with this approach. The hospital and office charts of five consecutive patients with six treated renal units who underwent retrograde renoscopy and electrohydraulic lithotripsy for renal cystine stones between 1.5 and 3.0 cm were reviewed. Data on stone size and location, procedures performed, results, complications, and inpatient hospital days were compiled. Five of the six renal units were either rendered stone free or had fragments totalling 3 mm or less. Three renal units required only a single procedure, one required repeat ureteroscopy for Steinstrasse, and one required SWL and repeat ureteroscopy for Steinstrasse. One renal unit was left with a 6-mm fragment for which the patient refused further treatment. There were no major complications. The mean hospital stay was 1 day, and the mean number of procedures per patient was 1.3. Retrograde renoscopy and intracorporeal lithotripsy for renal cystine stones 1.5 to 3.0 cm is safe and effective and should be considered as an alternative to percutaneous nephrolithotomy in these patients.
 
Article
This paper describes the preliminary testing of a new laser, the thulium fiber laser, as a potential replacement for the holmium:YAG laser for multiple applications in urology. A 40 W thulium fiber laser operating at a wavelength of 1.94 microm delivered radiation in a continuous-wave or pulsed mode (10 msec) through either 300-microm- or 600-microm-core low-OH silica fibers for vaporization of canine prostate and incision of animal ureter and bladder-neck tissues. The thulium fiber laser vaporized prostate tissue at a rate of 0.21+/-0.02 g/min. The thermal-coagulation zone measured 500 to 2000 microm, demonstrating the potential for hemostasis. Laser incisions were also made in bladder tissue and ureter, with coagulation zones of 400 to 600 microm. The thulium fiber laser has several potential advantages over the holmium laser, including smaller size, more efficient operation, more precise incision of tissues, and operation in either the pulsed or the continuous-wave mode. However, before clinical use will be possible, development of higher-power thulium fiber lasers and shorter pulse lengths will be necessary for rapid vaporization of the prostate and more precise incision of urethral/bladder-neck strictures, respectively.
 
Article
Purpose: To determine whether minimally invasive PCNL (MPCNL) is as safe and effective in the management of complex renal caliceal stones as it is for simple renal stones. Patients and methods: We retrospectively reviewed 5761(41.2%) simple caliceal stones (isolated renal pelvis including isolated calix) and 8223 (58.8%) complex caliceal stones (renal pelvis accompanying two calices at least) that were managed by MPCNL between 1992 nd 2011. The safety, efficacy, and outcome were compared and analyzed. Results: Stone burden was larger in complex caliceal stones (1763.0 vs 1018.6 mm(2), P<0.05). Patients with simple stones had significantly shorter operative time, less frequency of multiple percutaneous accesses, and less hemoglobin drop. They also had a higher initial stone-free rate (SFR) (77.6% vs 66.4%) after a single session of MPCNL (P<0.05). The differences diminished in the final SFR (86.7% vs 86.1%) after relook and/or auxiliary procedures (P>0.05). The complication rate (17.9% vs 19.0%) and blood transfusion rate (grade II) (2.2% vs 3.2%) were similar in both groups (P>0.05). Both groups had a low rate of high Clavien grade complications. Renal vascular embolizations (grade III), however, were significantly higher in patients with complex caliceal stones (P<0.05). Conclusions: MPCNL is a safe and effective treatment option for patients with complex caliceal stones except there is a slightly higher frequency rate of embolization. There was a higher initial SFR in simple stones, but this difference diminished with secondary procedures.
 
Characteristics of Patients Submitted to Transurethral Resection of Prostate 
Transurethral Resection of Prostate Outcome 
Article
TURis((R)) is an emerging technique that shows the same efficacy of monopolar resection. However, there is currently little available data on the safety of bipolar devices. We assessed outcome and safety of TURis on a large cohort of patients with at least 6 months' follow-up. Between January 2006 and October 2007, 1000 consecutive transurethral resection (TUR), 376 transurethral resection of prostate, 480 transurethral resection of bladder neoplasm, and 144 transurethral incision of prostate were performed. All procedures were carried out with a bipolar device in physiologic saline (TURis). The resectoscope used was an Olympus 26F in continuous flow-type Iglesias with continuous aspiration. The loops were all disposable/single use. The incidence of unwanted stimulation of the obturator reflex, TUR syndrome, thermal skin lesion, blood transfusion, urethral strictures, and bladder neck contractures were recorded. None of the patients operated experienced a TUR syndrome or a thermal skin lesion. The median follow-up of the entire cohort was 12 months (range, 6-24 months); 663 patients had at least 1-year follow-up (66.3%). Urethral stricture occurred in 27 patients (2.7%). Four patients developed a bladder neck contracture after transurethral resection of prostate (1%). Early postoperative clot retention occurred in 21 patients (2.1%), and 11 patients needed one or more transfusion (1.1%). Only six patients (2%) submitted to TUR of a neoplastic lesions at the lateral bladder wall experienced an unwanted trigger of the obturator reflex. TURis offers the patient the same results as monopolar technology guaranteeing maximum safety without increasing the incidence of urethral strictures.
 
Article
The Vattikuti Institute prostatectomy (VIP), a robotic radical prostatectomy approach, was conceived, designed, and refined with the goal of finding the most surgeon-friendly technique while minimizing patient morbidity and continuing to follow the standards of open radical prostatectomy. In this approach, the entire procedure is performed extraperitoneally after the ports have been placed transperitoneally and the bladder is dissected off the anterior abdominal wall. The evolution of the VIP is an amalgam of knowledge gained from the different procedures and recreated mixing in the technical nuances of robotic assistance. The procedure has been modified further from what we began with to obtain better outcomes. In our experience, robotic assistance, with its virtues of wristed movements, three-dimensional magnified vision, and filtered movements, allowed us to adjudicate a better operation with good oncologic and functional outcomes. It is also associated with decreased morbidity and earlier convalescence with excellent cosmesis. It is an ideal choice of the treatment at our center for localized cancer of prostate. Herein, the technique is described, detailing the different steps.
 
Top-cited authors
Olivier Traxer
  • Sorbonne Université
Mahesh R Desai
  • Muljibhai Patel Urological Hospital
Glenn Preminger
  • Duke University
Evangelos Liatsikos
  • University of Patras
Roberto Mario Scarpa
  • Azienda Ospedaliero Universitaria San Luigi Gonzaga