Ali Serdar Goezen

iPad-assisted percutaneous access to the kidney using marker-based navigation: initial clinical experience.

of T1 tumours. In support of this, AQP3 has been shown to play an emerging role in other malignancies such as gastric adenocarcinoma. Moreover, abnormalities of chromosome 9p, where the AQP3 gene is located, are also commonplace in TCC, adding extra evidence for a role for AQP3. Taken together, this is the first description of a potential role for AQP3 in bladder cancer. Despite the very limited number of samples, our findings are a solid platform for further studies comprising adequate numbers of tumours of all grades and stages as well as considering cancer progression and survival to appropriately elucidate the role of AQP3 in TCC.

Complications in 2200 Consecutive Laparoscopic Radical Prostatectomies: Standardised Evaluation and Analysis of Learning Curves

BACKGROUND Laparoscopic radical prostatectomy (LRP) represents an established treatment modality for localised prostate cancer. OBJECTIVE To report standardised complication rates for LRP, evaluate the development of complication rates over time, and show changes within the learning curves of laparoscopic surgeons. DESIGN, SETTING, AND PARTICIPANTS We conducted a standardised analysis of 2200 consecutive patients who underwent LRP between 1999 and 2008 at a single institution. INTERVENTION LRP was performed using a transperitoneal (n=871) or extraperitoneal (n=1329) retrograde Heilbronn technique. Five surgeons operated on 96% of the patients. MEASUREMENTS Complications were classified according to the modified Clavien system. Total complication rates and changes over time were analysed. Three generations of surgeons were defined for evaluation of learning curves. RESULTS AND LIMITATIONS Minor complications occurred in 21.7% of patients (Clavien 1: 6.8%; Clavien 2: 14.9%); anaemia requiring transfusion (10.4%) dominated. Early reinterventions were necessary in 6.7% of patients (Clavien 3a: 3.6%; Clavien 3b: 1.5%; Clavien 4a: 1.5%; Clavien 4b: 0.1%). Late Clavien 3b complications occurred in 4.7% of patients-most of them anastomotic strictures. Mortality was 0.1% (Clavien 5). There was a significant decrease in overall complication rates over time, resulting predominantly from decreasing Clavien 1-2 events. Learning curves of third-generation surgeons plateaued earlier compared to the first generation (250 vs 700 cases). The limitation of this study is that data concerning comorbidity were not included. CONCLUSIONS LRP is a safe procedure characterised by an acceptable profile of complications. Specifically, few major complications are reported. According to the complication rates, the learning curve of third-generation surgeons is significantly shorter compared to first- and second-generation surgeons.

Future of robotic surgery in urology

To provide a comprehensive overview of the current status of the field of robotic systems for urological surgery and discuss future perspectives.

A New Platform Improving the Ergonomics of Laparoscopic Surgery: Initial Clinical Evaluation of the Prototype

[1] Zimskind PD, Fetter TR, Wilkerson JL. Clinical use of long-term indwelling silicone rubber ureteral splints inserted cystoscopically. J Urol 1967;97:840–4. [2] Saltzman B. Ureteral stents. Indications, variations, and complications. Urol Clin N Amer 1988;15:481–91. [3] Liatsikos E, Kallidonis P, Kyriazis I, et al. Ureteral obstruction: is the full metallic double-pigtail stent the way to go? Eur Urol 2010; 57:480–7. [4] Alvarez-Vijande R. A simple method for the removal of indwelling ureteral stents in women. J Urol 1993;150:149–50. [5] Murthi GV, Cuckow P. Cystoscopic removal of a JJ stent using a suture ‘lasso’. BJU Int 2005;96:439.

Laparoscopic Sacrocolpopexy: Indications, Technique and Results

The introduction of the pelvic lymph node dissection by Schuessler in 1991 represented a milestone for urological laparoscopy [1] . Within the last 15 years, this minimally invasive technique experienced an enormous technical development. Initially, urological laparoscopy was limited by technical problems such as subtle hemostasis or the difficulties with endoscopic suturing [2] . However, following the successful introduction of laparoscopic radical prostatectomy by Gaston, Guillonneau, and Vallancien in 1999, a significant increase of interest was observed [3– 5] . In 2001, Binder and Kramer performed the first robot-assisted laparoscopic radical prostatectomy using the da Vinci device [6] . However, in 2003, Menon and Ahlering showed the easy transfer of robotic-assisted from open radical prostatectomy, which thereafter revolutionized the management of localized prostate cancer in the United States [7, 8] . In 2007, almost 60% of all radical prostatectomies are performed with the da Vinci system. Interestingly, all these developments based on extensive experience with laparoscopic sacrocolpopexy by Gaston [5] . The technique of sacral fixation of the vagina for correction of genital prolapse (promontofixation) was first described in the year 1889, respectively, 1892, by Freund and Zweifel using a transperitoneal as well as a transvaginal approach [9] , but it was Ameilen Hugier who in 1957 presented a more detailed description of open sacral colpopexy [10] . Miller described in 1927 a transvaginal colpopexy to the sacrospinal ligaments [11] , which was further modified by various authors including Richter and Albrich [12] . Scali in 1974 proposed the suspension by placement of prosthetic slings between the vagina and the bladder, which was anchored to the sacral promontory [13] . In the early 1990s, the gynecologists Dorsey and Nezhat described a laparoscopic sacropexy [14, 15] . In contrast to the technique of laparoscopic bladder neck suspension or colposuspension, which has not been performed frequently after its introduction due to worse results, respectively, recent less invasive techniques such as tension-free vaginal tape (TVT) or (TOT) [16, 17] , laparoscopic sacrocolpopexy is used increasingly for pelvic floor repair [10, 18– 22] . In 2004, Di Marco reported the successful use of the da Vinci robot for a robotic-assisted laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse [23] followed by others [24]. In this chapter, we want to outline the indications and technical approach of laparoscopic sacrocolpopexy together with an analysis of results reported by other authors, particularly in comparison to new techniques, such as tension-free vaginal mesh (TVM) for repair of pelvic organ prolapse (POP).

Robotic-Assisted Surgery: Low-Cost Options

Open surgery is based on the access to the treated organ via one large 5- to 30-cm incision dividing the skin and abdominal muscles or fascias. This large skin incision provides the surgeon and assistant(s) with a direct view of the anatomy, enabling the introduction of their hands and instruments. They can look down at their work with their heads and necks in a neutral position, using both hands, with natural hand-eye coordination (Fig. 6.1a). For delicate surgical actions, it is even possible to support the wrists by leaning on the patient’s body or on a specially developed armrest [7, 21, 33]. However, there are also some drawbacks, particularly in case of pelvic surgery:

New Robotic Platforms

Robotic surgery has been introduced successfully to facilitate laparoscopic surgery including even radical cystectomy and urinary diversion (Rassweiler et al., Curr Opin Urol 11:309–20, 2001; Wilson et al., Eur Urol 67:363–75, 2015). However, this was accompanied by monopoly of Intuitive Surgical (Teber et al., Curr Opin Urol 19:108–13, 2009; Ghezzi and Corleta, World J Surg 40:2550–7, 2016). The company owns more than 1500 patents regarding robotic surgery of which some of earlier patents will expire in following years (Table 1.1). This promotes new manufacturers to introduce alternate devices (Table 1.2). Recently, we updated significant developments of robotic devices used for urologic surgery and endourology (Minimally invasive surgery in urology, 353–410; Rassweiler et al., BJU Int, 2017). Based on this, we want to focus on technical modifications of upcoming devices with special emphasis on future clinical applicability.

Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature

Objective To compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV). Methods Our database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification. Results Comparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1–2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP. Conclusion LRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.

851 A NEW PLATFORM IMPROVING ERGONOMY OF LAPAROSCOPIC SURGERY: EXPERIMENTAL STUDIES AND INITIAL CLINICAL EVALUATION

INTRODUCTION AND OBJECTIVES: Distribution of laparoscopic surgery is handicapped due to significant ergonomic limitations. We want to present experimental and clinical evaluation of a new operating chair used as a platform for laparoscopic surgery. METHODS: The surgical chair (ETHOS-platform) consists of a saddle-like seat, an adjustable chest-support, two individually adjustable armrests, and footrests. We compared suturing standing laterally to pelvi-trainer (“Torero-position”) versus standing behind pelvi-trainer and sitting on ETHOS. Every participant and surgeon (N 18) filled out a questionnaire focusing on ergonomic issues. Since August 2010, we performed 164 laparoscopic and retroperitoneoscopic procedures using ETHOS involving four different surgeons. Two frequent procedures (radical prostatectomy, pyeloplasty) underwent detailed comparison to matched-paired patients from our laparoscopic database. RESULTS: Ex-vivo, there was no significant different anastomotic time standing behind pelvi-trainer and sitting on ETHOS; the difference became significant compared to Torero-position mimicking clinical scenario (44.4 vs. 37.6 minutes). Independent from laparoscopic experience and workload complaints (total score) were significantly less with ETHOS-assistance (31.6 vs. 13.9). In-vivo comparison did not show different OR-times, but revealed statistically significant differences with respect to anastomotic times of ETHOS and DaVinci (23 vs. 19 vs. 19 minutes). CONCLUSIONS: Ergonomics of laparoscopy may be significantly improved by new platforms supporting the sitting position of the surgeon with armrests and integrated foot pedals.