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Study Type - Therapy (case series) Level of Evidence 4 OBJECTIVE To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology. [ABSTRACT FROM AUTHOR]

Background: Surgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision. Methods: A total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups. Results: The experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools. Conclusion: The findings of the study provide support for the utility of assessing strategic gaze behaviour to better understand the way in which surgeons utilise visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this experimental study was to assess the possibility of decreasing the size of the ureteral stents used after an endopyelotomy. To this end, an experimental study was performed which compared a ureteral double-J wire stent versus a standard 7F ureteral stent after endopyelotomy. Methods: Twenty healthy female pigs were randomly divided into 2 groups: group I (double pigtail ureteral stent 7F) and group II (lumenless ureteral double-J wire stent, Zebrastent™, 0.035 inches in diameter). Percutaneous, endoluminal ultrasonographic and fluoroscopic studies were analyzed during the 3 different phases of the study. The first phase included premodel documentation of normal urinary tracts and laparoscopic ureteropelvic junction (UPJ) obstruction induction. During the second phase, 6 weeks later, diagnosis and endopyelotomy were carried out. Sixteen weeks after the obstruction treatment, follow-up imaging studies and postmortem evaluations of all animals were performed. Results: After the sonographic and fluoroscopic assessments, we determined the success rate for each group: 80% for group I and 90% for group II. No significant statistical differences were evident in the evolution of the diameter of the UPJ between groups. Better healing of the UPJ and a lower level of retroperitoneal repercussions were seen in group II. Conclusions:The ureteral double-J wire stent (Zebrastent) has been shown to be highly effective after endopyelotomy. This means that it is possible to reduce the size of ureteral stents after endopyelotomy with the advantages that this entails. Double-J ureteral stents probably act as a scaffold rather than a mold. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Ureteral metal stents (MSs) present a minimally invasive tool to preserve the drainage of renal pelvis whenever ureteral patency is at risk to be obstructed due to extrinsic or intrinsic etiologies. Clinical experience with these stents demonstrates that they impose a promising alternative treatment option in ureteral pathologies that are difficult to be treated via common polymeric stents. Current application of MSs in the treatment of both benign and malignant ureteral obstruction reveals quite promising results. Nevertheless, the ideal MS that would provide uncomplicated long-term effectiveness is still lucking and current MS usage is facing several adverse effects between which stent obstruction, encrustation, infection, migration, and patient discomfort. Ongoing attempts to create more inert stent with sophisticated novel designs are expected to improve current MS eficiency. MSs will play a major role in the future as a routine management of a variety of ureteral pathologies. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Urology is the property of Turkish Association of Urology and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVES To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot-assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation. PATIENTS AND METHODS In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation. RESULTS Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow-up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6). CONCLUSIONS In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss. [ABSTRACT FROM AUTHOR]

Natural orifice translumenal endoscopic surgery (NOTES) involves the use of flexible endoscopes to perform intra-abdominal or intra-thoracic surgeries. Surgery in the operating room usually involves sterile instrumentation, whereas in the endoscopy suite high-level disinfection seems to be sufficient. Our objective was to assess the necessity for endoscope sterilization for clinical NOTES and to develop an endoscope processing protocol based on a score for the available processing options. Score and processing protocol development for clinical NOTES endoscopes was based on a comprehensive review of the available relevant literature. Options for sterilization for flexible endoscopes in the Good Samaritan Hospital, Legacy Health in Portland, Oregon, were analyzed for patient safety, potential for recontamination, cost, and validation. Literature survey indicated that there is controversy surrounding the necessity for sterilization of surgical endoscopes. However, standard of practice seems to call for sterile instrumentation for surgery and it is possible to terminally sterilize flexible endoscopes. Within our institution, a score was created to rank the available sterilization options. We successfully introduced a protocol for sterilization of endoscopes for use in clinical NOTES procedures. The protocol involved mechanical cleaning and high-level disinfection per Multi-Society Guidelines, with subsequent terminal sterilization using a validated peracetic acid protocol. It remains controversial whether sterile instrumentation is truly needed for surgery. It is difficult but possible to terminally sterilize flexible endoscopes. We recommend sterile instrumentation for clinical NOTES until well-designed, randomized, clinical trials are available and guidelines are published. [ABSTRACT FROM AUTHOR]

AbstractIntroduction:The prone position has been considered the only position for percutaneous access to the kidney for the past 25 years, whereas the supine Valdivia position has recently started to gain acceptance, although it was originally described in the late 1980s. Even more recently, the Galdakao-modified supine Valdivia position was described. However, there is no consensus on which is the best position for percutaneous nephrolithotomy, and the choice is currently based on the surgeon's preference.Materials and Methods:The prone, supine, and modified supine positions are described, pointing out the advantages, disadvantages, and results of each technique.Results:A number of potential advantages have been described for the supine over the prone position: less cardiovascular change; no need for patient repositioning (with less associated risk of central and peripheral nervous system injury); less X-ray exposure to the surgeon; and less risk of colonic injury. The recently described Galdakao-modified supine Valdivia position allows for a simultaneous anterograde and retrograde approach to the renal cavities for the one-stage treatment of complex renal stones or concurrent renal and ureteral calculi. Moreover, the use of a flexible ureteroscope allows for Endovision puncture to achieve perfect access to the kidney.Conclusions:The prone position still represents the standard for percutaneous access to the kidney, and other positions should be compared with this position. However, the supine and the modified supine positions have potentially important advantages for both patients and surgeons that need to be investigated in a large randomised trial to define their superiority over the traditional prone position. [ABSTRACT FROM AUTHOR]

Laparoscopic training traditionally follows open surgical training. This study aimed to investigate the impact of experience in open surgery on the laparoscopic proficiency gain process. A survey form investigating the importance of open experience before the start of laparoscopic training was sent to surgical experts and trainees in the United Kingdom. A separate experimental study objectively assessed the effects of open experience on laparoscopic skill acquisition using a virtual reality simulator. In the study, 11 medical students with no prior surgical experience (group A) and 14 surgical trainees with open but no laparoscopic experience in (group B) performed 250 simulated laparoscopic cholecystectomies. Psychomotor skills were evaluated by motion analysis and video-based global rating scores. Before the first and after the fifth and tenth operation, knowledge of laparoscopic techniques was assessed by a written test and by self-reported confidence levels indicated on a questionnaire. The 80 experts and 282 trainees who responded to the survey believed prior open experience aids confidence levels, knowledge, and skills acquisition. In the simulation study, no intergroup difference was found for any parameter after the first procedure. Group B scored significantly higher in the laparoscopic knowledge test before training began (42.7% vs. 64.3%; p = 0.002), but no significant difference was found after five operations. The two groups did not differ significantly in terms of confidence. Group B had a significantly shorter total operation time only at the first operation (2,305.6 s vs. 1,884.6 s; p = 0.037). No significant intergroup difference in path length, number of movements, or video-based global rating scores was observed. Prior open experience does not aid the laparoscopic learning process, as demonstrated in a simulated setting. Given the wealth of evidence demonstrating translation of virtual skills to the operating theater, we propose that the safe and effective introduction of well-supervised laparoscopic training may be possible at the beginning of a surgical training curriculum. [ABSTRACT FROM AUTHOR]

Obstruction of the ureters caused by extrinsic compression from a primary tumour or retroperitoneal lymph node masses is not unusual in the course of advanced pelvic malignancies. Most of the cases are of gynaecological or gastrointestinal origin, and the situation can be aggravated by peri-ureteric fibrosis, a long-term adverse event of previous chemotherapy or radiotherapy. Undoubtedly upper urinary tract decompression and maintenance of ureteric patency, even as a palliative measure, is important in managing these patients. Options for upper tract decompression include percutaneous nephrostomy, retrograde stenting and open urinary diversion. Plastic stents have long been used for managing malignant ureteric obstruction, but their overall success remains limited. Plastic stents often fail to be placed correctly, require regular exchange, and are faced with a high incidence of encrustation and migration. For these reasons plastic stents have been unsuccessful for long-term maintenance of ureteric patency. To overcome these limitations metal stents were introduced and recently developed in an effort to ensure better long-term patency of the obstructed ureter, fewer hospital admissions for stent change and better overall quality of life. In the present review the clinical applications of different types of metal stents are discussed, with a specific focus on the latest advances and the future options for managing malignant ureteric obstruction. [ABSTRACT FROM AUTHOR]

Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed. Pubmed was searched for citations since 1966. The following terms were used: “lasers”, “calculi”, “endopyelotomy”, and “transitional cell carcinoma”. Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma. Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To analyse retrospectively the clinicopathological features of incidental prostate cancer in patients undergoing radical cystoprostatovesiculectomy (RCP) for invasive bladder cancer, as recent studies suggest that prostatic apex-sparing surgery in patients undergoing RCP improves urinary continence and erectile function after surgery, but in those with incidental prostate cancer, leaving the apical region endangers the oncological outcome. PATIENTS AND METHODS From 2004 to 2007, at our institution, 95 men had RCP for invasive bladder cancer. We reviewed their clinicopathological variables, especially apical involvement, and the course of prostate-specific antigen (PSA) levels before and after surgery. We compared clinically significant and insignificant prostate cancers. RESULTS Of the 95 patients, 26 had incidental prostate cancer (mean age 68 years, range 53–80) on definitive histological examination. The mean (sd, range) preoperative PSA level in all 26 men was 3.6 (0.8, 0.2–14) ng/mL, but six of the 26 patients had preoperative PSA levels of >4 ng/mL and one other had suspicious findings on a digital rectal examination. Involvement of the apex was histologically confirmed in seven of the 26 patients (27%), including four with significant prostate cancer ( P = 0.039). Preoperative PSA levels did not differ significantly between the seven patients with significant and 19 with insignificant prostate cancer, but seven patients with apical involvement had significantly higher PSA levels before RCP than the 19 who did not ( P < 0.04). PSA levels after RCP remained below the limit of detection in all patients over a mean (range) follow-up 14.3 (3–32) months. CONCLUSION In our series, preserving the apex of the prostate to decrease morbidity after RCP carried a 7.3% risk (seven of 95 patients) of leaving significant cancer in the residual prostatic tissue. No preoperative clinical value could exclude apical involvement. Therefore, our findings stress the oncological need for a careful and complete excision of the prostate during RCP. [ABSTRACT FROM AUTHOR]

Background: 30 patients, with T1 renal cell carcinomas (RCC) who underwent open enucleoresection of the tumour, were randomized to the use of a topical haemostatic agent (Floseal) or to an infrared-sapphire coagulator (ISC), to compare their efficacy in achieving haemostasis. Methods: Successful intra-operative haemostasis, intra- and postoperative bleeding, operative time, hospital discharge were evaluated. Results: Statistically higher rates of successful haemostasis and shorter time-to-haemostasis (8,1 vs 12,9 min) were observed in the FloSeal group (p < 0.001 both). Patients operative time was not different between Group 1 vs 2 (58.7 ± 12 vs 62.4 ± 15; p > 0.05). The average blood loss during surgery was less (60 +/- 25.5 mL) for the FloSeal group than for the ISC group (85 +/- 40.5 mL) (p < 0.05). Postoperative blood loss was 25 +/- 5 mL and 40 +/- 45 mL for Floseal and ISC respectively, (p < 0.05). Length of the postoperative hospital discharge was 2.5 +/- 1.2 days for FloSeal group and 3.5 +/ - 1.3 for the Group 2 (p < 0.05). No major immediate or delayed complications were observed in either Groups. Conclusions: The use of Floseal and ISC offer a safe and efficacy haemostasis in the enucleoresection of RCC. Moreover, our results show a less intra-operative and post-operative blood loss as well as a shorter time to haemostasis of Floseal in respect to ISC. [ABSTRACT FROM AUTHOR]

Introduction and Objective: Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called 'tubeless' PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on 'nephrostomy-free' or 'tubeless' PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL. Materials and Methods: We performed a MEDLINE database search to retrieve all published articles relating to 'tubeless' PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved. Results: The majority of the studies have shown 'tubeless' PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. Tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery. Conclusion: Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials. [ABSTRACT FROM AUTHOR]

With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ-confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic-assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported. We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated. [ABSTRACT FROM AUTHOR]

AbstractBackground and Purpose:Caliceal diverticula are rare congenital abnormalities that can become symptomatic if associated with a calculus or infection. We review percutaneous management of caliceal diverticula.Methods:Pathogenesis, clinical evaluation, management options, and recommended follow-up for symptomatic caliceal diverticula are reviewed. We present our single-stage and prepercutaneous nephrolithotomy opacification techniques for the management of caliceal diverticula. This involves complete extraction of all stone particles and ablation of the diverticular cavity without infundibular identification or dilation. Comparison of outcomes between our current ablative technique and our previous dilation technique is evaluated.Results:Percutaneous management of caliceal diverticula offers the highest symptomatic relief and stone-free rate of available management options. We identified 106 patients with caliceal diverticula who were treated with a percutaneous approach. Review of 85 of these patients demonstrated that most procedures can be performed with a small nephrostomy tube in place for 24 hours and an overnight hospital stay. Minimal complication and stone recurrence rates were observed. Patients treated with caliceal diverticular ablation experienced a shorter hospital stay, fewer complications, and a higher stone-free status than those patients who were treated with dilation of the diverticular infundibulum.Conclusions:Percutaneous management of caliceal diverticula using cavity ablation is a minimally invasive technique that offers long-term symptomatic relief with minimal complications. [ABSTRACT FROM AUTHOR]

AbstractTubeless percutaneous nephrolithotomy (PCNL) is a viable option for selected patients, particularly those with solitary calculi, multiple stones located in a single location, or those that can be accessed using one access tract. Benefits over the standard PCNL include reduced hospital stay, decreased pain, and decreased urine leak from the access site that would typically occur from around the nephrostomy tube. Hemostatic agents in the form of fibrin “glue” or gelatin matrix substances have been demonstrated to be safe and effective to augment the tubeless procedure. The most appropriate sealant agent available is yet to be determined. We present a review of the contemporary literature on the use of hemostatic agents for tubeless PCNL. [ABSTRACT FROM AUTHOR]

AbstractObjective:To evaluate the clinical therapeutic effects of retroperitoneal laparoscopic radical nephrectomy for T1 renal cell carcinoma (RCC).Methods:A total of 352 patients with T1 RCC underwent radical nephrectomy in our study, and they were randomly divided into two groups, including 185 cases of retroperitoneal laparoscopic radical nephrectomy and 167 cases of open radical nephrectomy through an extraperitoneal 11th rib flank incision. All operations were performed by the same platoon doctors. There were no statistically significant differences in age, sex ratio, tumor stage, and serum creatinine between the two groups. The operation time, blood loss during operation, hospital stay, and postoperative complications were analyzed and compared. All cases were followed up for 25 ± 4 months (6–42 months) and the survival rates, wound healing, and carcinoma metastasis were recorded.Results:The operation time in retroperitoneal laparoscopic radical nephrectomy group versus open radical nephrectomy was 75.6 ± 11.2 min (55–130 min) versus 68 ± 10.6 min (50–140 min), without statistically significant difference (p> 0.05). The blood loss was 110.6 ± 32.3 mL (50–1200 mL) versus 160.8 ± 38.1 mL (50–1500 mL), with statistically significant difference (p< 0.05); narcotic was required in 8 cases versus 132 cases between the two groups (p< 0.05); the fasting period was 1.3 ± 0.5 days (1–2 days) versus 2.9 ± 1.2 days (2–5 days), and hospital stay was 4.6 ± 1.2 days (3–7 days) versus 8.9 ± 1.6 days (7–14 days), with statistically significant differences (p< 0.05).Conclusions:Compared with open radical nephrectomy, retroperitoneal laparoscopic radical nephrectomy is associated with less blood loss, narcotic requirement, and complications; shorter hospital stay; and earlier resumption of routine activities. Therefore, retroperitoneal laparoscopic radical nephrectomy is a better therapy for T1 RCC. [ABSTRACT FROM AUTHOR]

The article presents a study relative to the use of a scientific methodology for development of a virtual reality (VR) training curriculum for laparoscopic cholecystectomy. The study involves 30 inexperienced, 11 intermediate and 16 experienced surgeons in the field of laparoscopic cholecystectomies. Results show that the use of scientific methodology makes it possible to define and develop a whole-procedure VR training curriculum for laparoscopic cholecystectomy.

AbstractPurpose:To report the outcomes of patients with ureteroenteric strictures after ileal conduit urinary diversion that were managed with Resonance®metallic ureteral stents.Patients and Methods:Ten ureteroenteric strictures in patients with ileal conduits that were managed with metallic ureteral stenting were retrospectively identified. Charts were examined for patient age, anastomosis type, stricture cause, stricture laterality, complications, and follow-up.Results:Nine of 10 (90%) cases resulted in distal stent migration. Mean time to stent migration was 21 days (range 3–60 d).Conclusions:Placement of Resonance®metallic stents in patients with ileal conduits is ineffective for management of ureteroenteric strictures because of the high rate of distal migration. [ABSTRACT FROM AUTHOR]

The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers' musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future. INSET: Key issues. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the safety of tubeless percutaneous nephrolithotomy (PCNL) in geriatric patients. Materials and Method: This is a retrospective review of 401 patients who received tubeless PCNL in a single institute. Among these, 50 were performed in patients aged older than 70 years (group 1), while 351 were performed in the remaining younger patients (group 2). Results: There was no significant difference in stone size between the 2 groups (3.6 ± 1.9 vs. 3.5 ± 2.0 cm). The average operative time was similar in both groups (92.8 ± 34.5 vs. 86.6 ± 32.0 min). The stone-free rate in groups 1 and 2 was 68.0% (34/50) and 83.8% (294/351), respectively, which was statistically significantly different. The average postoperative hospital stay was longer in group 1 (4.6 ± 3.4 days) than in group 2 (3.9 ± 2.5 days), but the difference was not statistically significant. There was no significant difference in postoperative urinary tract infection rate and blood transfusion rate in both groups (urinary tract infection: 18.0 vs. 8.8%; blood transfusion: 4 vs. 2.6%). Two patients in group 1 and 3 patients in group 2 experienced pulmonary complications. There was no other severe complication. Conclusion: Tubeless PCNL is a safe procedure for the treatment of geriatric patients with urolithiasis. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Over the past decade, there has been an exponential growth of robot-assisted procedures and of publications concerning robotic-assisted laparoscopic surgery. From a review of the available literature, it becomes apparent that this technology is safe and allows more complex procedures in many fields of surgery, be it at relatively high costs. Although randomised controlled trials in gynaecology are lacking, available evidence suggests that particularly in gynaecology robotic surgery might not only reduce morbidity but also be cost effective if performed in high-volume centres. Training in robotic surgery and programs for safe and effective implementation are necessary. [ABSTRACT FROM AUTHOR]

Percutaneous nephrolithotomy (PNL) is the procedure of choice for large renal stones. Since its introduction in 1976, many aspects of the operative technique and the endoscopic equipments have had constant evolution, increasing the success rates of the procedure. We performed a literature search using Entrez Pubmed from January 2000 to July 2007 concerning PNL and many aspects related to all steps of the procedure.We could verify that PNL in supine position has been proved as an acceptable option, but more worldwide experience is necessary. Urologists must be trained to gain their own renal tract access. Minipercutaneous PNL still needs equipments improvements for better results. Tubeless PNL is increasing in popularity and different tract sealants have been studied. Medical prevention is proved to be effective against stone recurrence and should be always used after PNL.Although the evolution of the technique in the last 20 years, urologists must continue to improve their skills and develop new technologies to offer to the patients more and more a safe and effective option to treat large renal stones. [ABSTRACT FROM AUTHOR]

Computer-based, virtual-reality laparoscopic surgical simulators have several advantages over traditional video trainers. One of these advantages is that performance can be evaluated using unique computer-derived metrics, which can be digitally archived for analysis at a time convenient to instructors. This study sought to determine whether the computer-derived metrics for a unique hybrid simulator correlated with laparoscopic surgical skill. For this study, 24 medical students (3rd year), 19 surgical residents (postgraduate years 1–5), and 3 attending surgeons were invited to perform four different tasks three times in a hybrid laparoscopic trainer (ProMIS). Instruction with minimal supervision occurred at a time convenient to each subject. The four tasks in order of complexity were laparoscopic orientation, object positioning, sharp dissection, and intracorporeal knot tying. The metrics automatically recorded were time, path length, and smoothness. The laparoscopic operative experience for each user was quantified using case logs. A statistically significant correlation was observed between experience and performance for all three metrics for tasks 2 to 4 ( p < 0.01). Smoothness was the only metric that correlated with the laparoscopic orientation task. Within tasks, time and smoothness correlated much more strongly with experience and to a similar degree. The strongest correlation was observed for the knot-tying task ( r 2 = 0.60 for time and 0.59 smoothness). The computer-derived metrics measured by the hybrid trainer correlate with laparoscopic experience. These metrics are automatically calculated and stored. This may make skills assessment and training a more time-efficient endeavor for instructors and trainees alike. Further study is necessary to determine whether specific metrics are better indicators of actual skill. [ABSTRACT FROM AUTHOR]

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Objectives: The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1.2 cm in maximum dimension. Materials and Methods: A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed. Results: PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL. Conclusions: PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands. [ABSTRACT FROM AUTHOR]

Long-term ureteral stenting is used to ensure urinary drainage if a reconstructive approach or a release of an extrinsic obstruction is not possible. In this contribution, a long-term experience with a new full-length, metal indwelling stent is presented. Fourteen patients with ureteral obstruction received full metal indwelling stents in 18 collecting systems (benign disease in 5 and malignant disease in 13). Stent placement was performed cystoscopically under fluoroscopic guidance. Follow-up was done every 3 months with ultrasonographic examination, creatinine levels, and a visual analog pain score. Eight stents were removed, whereas eight are still in situ. One patient without stent-related problems died because of progressive rectal cancer 9 months after bilateral stent insertion. Mean stent duration (8 stents still in situ) is 8.6 months, whereas mean stent duration for benign and malignant disease is 11.8 (median 13) and 7.3 (median 6) months, respectively ( p < 0.05). All removed stents were extracted endoscopically without any problems and had no incrustation except two. Neither migration nor mechanical damage was observed. This novel stent is easy to insert and remove. It is an option for patients in which a surgical reconstruction of the obstructed ureter is not possible. Stents have been developed further and are now available in various lengths. This might result in a reduction of problems associated with inadequate stent length and should increase patient comfort and stent durability. [ABSTRACT FROM AUTHOR]

Background and PurposeThere have been several reports of rhabdomyolysis occurring after prolonged laparoscopic procedures in the flank position. Accordingly, we evaluated interface pressures between the skin and three commonly used operating room table surfaces. The aim of our study was to determine if pressure changes could be related to body mass index (BMI), sex, position, andor the table surface material.Patients and MethodsTen men and 10 women were grouped according to BMI <25 or ≥25, with five participants in each group. Subjects were placed in the left lateral decubitus position with the operating table flat, half flexed, fully flexed, half flexed with the kidney rest elevated, and fully flexed with the kidney rest elevated. Interface pressures were recorded, using an X-Sensor pressure sensing mat, for 5-minute periods in each of the described positions on each surface.ResultsSex and BMI were statistically significant predictors of increased pressures (P 0.0042 and 0.0402, respectively). The parameter estimate for the difference between men and women was 4.63 mm Hg (P 0.0002), and the difference for BMI ≥ 25 compared with <25 was also significant (P< 0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P 0.0001) and the half-flexed (25-degree) position (P< 0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P< 0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P 0.0117).ConclusionWomen have significantly lower interface pressures when compared with men. BMI ≥ 25 also increases interface pressures. The use of the kidney rest is associated with markedly increased pressure; use of a half-flexed position is preferable to a full-flexed position. These data have implications for patient positioning and identification of persons at risk for rhabdomyolysis during laparoscopic renal surgery. [ABSTRACT FROM AUTHOR]

PurposeWe evaluated factors that impact the ability to learn hand-assisted laparoscopic donor nephrectomy (HALDN) to identify impediments to diffusion of this procedure.MethodsFrom February 2002 to June 2004, we collected data from our institutional database on 70 patients who underwent HALDN. Time for individual steps of the procedure (colon mobilization, kidneyureter mobilization, renal vein tributary dissection, renal hilum dissection, removal of the kidney, and overall time) were recorded. The impact of patient factors on surgical times was assessed using a general linear model. The impact of individual operative steps on overall operative time was assessed using Pearson correlation. The influence of case experience and training level were evaluated graphically and in a multivariable model.ResultsA total of 13 residents, 2 fellows, and 1 attending surgeon participated in procedures for 70 patients. Body mass index (P 0.03) and male sex (P 0.04) prolonged operative times. Colon mobilization and hilar dissection were most correlated with overall operative time. While experience improved operative times for several steps, level of training appeared more likely to influence the time for individual operative steps.ConclusionsImpediments to learning HALDN include patient factors, level of training, and particular surgical steps. Repeated exposure at increasing levels of training may improve diffusion of laparoscopic nephrectomy among urologists. [ABSTRACT FROM AUTHOR]

Image-guided percutaneous renal access for placement of an access sheath for percutaneous nephrolithotomy can be a challenging procedure, especially in patients with nondilated collecting systems, obstructed infundibula (stones or stricture), or extreme body habitus. We describe our experience using ureteroscopy along with a zero-tip stone basket to facilitate a through-and-through (percutaneous–urethra) access to the collecting system. [ABSTRACT FROM AUTHOR]

PurposeWe present a randomized study of tubeless or nephrostomy-free percutaneous nephrolithotomy (PCNL), a modification of the standard technique, compared with standard PCNL to evaluate the role of tubeless PCNL in minimizing postoperative discomfort and reducing duration of hospital stay.Patients and methodsTwo hundred and two patients undergoing PCNL were randomized to two groups Group A (standard PCNL) with nephrostomy tube placement postoperatively, and group B (tubeless PCNL) with antegrade placement of a Double-J stent without nephrostomy. Inclusion criteria were normal renal functions, single tract procedure with complete clearance, and minimal bleeding at completion. The two groups were comparable in age and sex and in metabolic and anatomic features. Factors evaluated included postoperative pain, analgesia requirement, blood loss, postoperative morbidity, hospital stay, and time to recovery.ResultsAll patients had an uneventful postoperative recovery. The average visual analogue scale pain score on postoperative day 1 for group A patients was 59 5.1 compared with 31 4.8 in group B (P< 0.01). The mean analgesia requirement for group A (meperidine 126.5 33.3 mg) was significantly more compared with group B (meperidine 81.7 24.5 mg) (P< 0.01). The difference in average blood loss and urinary infection for the two groups was not statistically significant. The incidence of urinary leakage from the nephrostomy site was significantly less for the tubeless group (0101), compared with the standard PNL group (7101). The average hospital stay in the tubeless group (21.8 3.9 hours) was significantly shorter than that of the standard PCNL group (54.2 5 hours) (P< 0.01). Tubeless group patients took 5 to 7 days for complete convalescence whereas standard PCNL patients recovered in 8 to 10 days. No long-term sequelae were noticed in the median follow-up period of 18 months in any patient.ConclusionNephrostomy-free or tubeless PCNL reduces postoperative urinary leakage and local pain related to the drainage tube. It also minimizes hospital stay; the majority of patients were discharged from the hospital in fewer than 24 hours. [ABSTRACT FROM AUTHOR]

Background: A standard of care for the treatment of small renal masses is partial nephrectomy. The open and laparoscopic approaches have been well described in the literature. Robotic assistance may augment partial nephrectomy by aiding in dissection and renal reconstruction. In this communication we describe the surgical outcomes of 35 patients undergoing robotic partial nephrectomy. Methods: Patient records and databases were reviewed for 35 consecutive patients undergoing RPN. Clinical, pathological, and radiographic data were obtained. The data was deidentified. Results: Thirty five patients successfully underwent RPN. An additional 2 patients were converted to other nephron sparing procedures. Mean tumor size was 2.8 cm, and mean OR time was 142 minutes. Mean warm ischemia time was 20 minutes. All margins were negative. There were 4 complications, and no patients required reoperation. Conclusion: Robotic partial nephrectomy can produce excellent initial results. Further studies should be performed to compare the outcomes to laparoscopic and open operations. [ABSTRACT FROM AUTHOR]

Background: This study was carried out to investigate whether eye-hand coordination skill on a virtual reality laparoscopic surgical simulator (the LAP Mentor) was able to differentiate among subjects with different laparoscopic experience and thus confirm its construct validity.Methods: A total of 31 surgeons, who were all right-handed, were divided into the following two groups according to their experience as an operator in laparoscopic surgery: experienced surgeons (more than 50 laparoscopic procedures) and novice surgeons (fewer than 10 laparoscopic procedures). The subjects were tested using the eye-hand coordination task of the LAP Mentor, and performance was compared between the two groups. Assessment of the laparoscopic skills was based on parameters measured by the simulator.Results: The experienced surgeons completed the task significantly faster than the novice surgeons. The experienced surgeons also achieved a lower number of movements (NOM), better economy of movement (EOM) and faster average speed of the left instrument than the novice surgeons, whereas there were no significant differences between the two groups for the NOM, EOM and average speed of the right instrument.Conclusions: Eye-hand coordination skill of the nondominant hand, but not the dominant hand, measured using the LAP Mentor was able to differentiate between subjects with different laparoscopic experience. This study also provides evidence of construct validity for eye-hand coordination skill on the LAP Mentor. [ABSTRACT FROM AUTHOR]

Purpose To characterize the flow of a novel ureteral stent composed of a nickel-cobalt-chromium-molybde-num alloy and compare it with flow in a standard ureteral stent.Materials and Methods Six 6F Resonance stents and six 6F standard Black Beauty ureteral stents were placed in six Yucatan minipigs, with each pig serving as its own control. Flow assessment was performed on all stents via a nephrostomy tube delivering a standard rate of 0.9 saline at 35 cm H2O. Flow studies on the standard stents encompassed extraluminal (i.e., lumen of stent occluded with a guidewire), intraluminal (i.e., ureter secured to stent with a constricting suture), and combined (i.e., open lumen without constricting suture) flow. In the Resonance stent, only combined and intraluminal flow could be addressed, as there is no access to the lumen of this stent.Results With the Resonance stent, intraluminal flow was much greater than combined flow, with mean values of 5.15 mLmin and 2.50 mLmin, respectively (P 0.057; SD 7.73). Intraluminal flow was similar to combined flow in the 6F standard stent, with mean values of 7.34 mLmin and 7.30 mLmin, respectively (P 0.88; SD 1.76). The standard stent had significantly greater combined flow than the Resonance stent (P 0.023) but not intraluminal flow (P 0.247). Of note, whereas it was possible to occlude the 6F standard stent completely with a ureteral ligature (i.e., no guidewire placed in the lumen), it was not possible to occlude the Resonance stent regardless of how tightly the suture was tied.Conclusion The Resonance metal alloy stent provides less overall flow than a standard stent. However, under circumstances of extrinsic ureteral compression sufficient to occlude a standard stent (e.g., extrinsic compression plus an internal guidewire), the metal stent continues to provide satisfactory drainage. [ABSTRACT FROM AUTHOR]