Arkadiusz Miernik

Postureteroscopic Lesion Scale: A New Management Modified Organ Injury Scale—Evaluation in 435 Ureteroscopic Patients

BACKGROUND AND PURPOSE Objective parameters for the classification of ureteral injuries and resulting indications for ureteral stent placement after ureteroscopy are lacking. We hereby present a new classification system including proof of interrater reliability and validation of recommendations for postoperative ureteral stent placement. PATIENTS AND METHODS The Postureteroscopic Lesion Scale (PULS) was applied in 435 patients undergoing ureteroscopy. Interrater reliability between three surgeons (junior resident, senior resident, and specialist) was evaluated in 112 patients. Postoperative ureteral stent placement was performed according to PULS. For follow-up with ultrasonography, we assumed hydronephrosis to be an indirect sign for significant postoperative ureteral obstruction. RESULTS No ureteral lesion was seen in 46.2% of patients (grade 0). A grade 1, 2, or 3 lesion was seen in 30.8%, 19.1%, and 3.9% of patients, respectively. No grade 4 or 5 lesions were observed in our series. Interrater reliability was high (Kendall W=0.91; mean Spearman Rho=0.86). This was particularly true between senior resident and specialist (Rho=0.95), compared with junior resident and senior resident or specialist (Rho=0.83, Rho=0.79, respectively). All patients with documented lesions had a Double-J stent placed. Indwelling time varied according to PULS. Results of a postoperative ultrasonographic follow-up could be obtained in 95.6% of cases. No patient showed clinical or sonographic signs of upper urinary tract obstruction. CONCLUSIONS According to these preliminary data for the clinical application of PULS, interrater reliability is high. Standardized empiric recommendations for the use and duration of postoperative stent placement after ureteroscopy might be useful in guiding urologists in this conversely discussed issue, ultimately preventing ureteral strictures as a late complication of ureteroscopy. These will have to be confirmed, however, by controlled trials in the future.

Pre-bent instruments used in single-port laparoscopic surgery versus conventional laparoscopic surgery: comparative study of performance in a dry lab.

BackgroundDifferent types of single-incision laparoscopic surgery (SILS) have become increasingly popular. Although SILS is technically even more challenging than conventional laparoscopy, published data of first clinical series seem to demonstrate the feasibility of these approaches. Various attempts have been made to overcome restrictions due to loss of triangulation in SILS by specially designed SILS-specific instruments. This study involving novices in a dry lab compared task performances between conventional laparoscopic surgery (CLS) and single-port laparoscopic surgery (SPLS) using newly designed pre-bent instruments.MethodsIn this study, 90 medical students without previous experience in laparoscopic techniques were randomly assigned to undergo one of three procedures: CLS, SPLS using two pre-bent instruments (SPLS-pp), or SPLS using one pre-bent and one straight laparoscopic instrument (SPLS-ps). In the dry lab, the participants performed four typical laparoscopic tasks of increasing difficulty. Evaluation included performance times or number of completed tasks within a given time frame. All performances were videotaped and evaluated for unsuccessful attempts and unwanted interactions of instruments. Using subjective questionnaires, the participants rated difficulties with two-dimensional vision and coordination of instruments.ResultsTask performances were significantly better in the CLS group than in either SPLS group. The SPLS-ps group showed a tendency toward better performances than the SPLS-pp group, but the difference was not significant. Video sequences and participants` questionnaires showed instrument interaction as the major problem in the single-incision surgery groups.ConclusionsAlthough SILS is feasible, as shown in clinical series published by laparoscopically experienced experts, SILS techniques are demanding due to restrictions that come with the loss of triangulation. These can be compensated only partially by currently available SILS-designed instruments. The future of SILS depends on further improvements in the available equipment or the development of new approaches such as needlescopically assisted or robotically assisted procedures.

[Modern urinary stone therapy: is the era of extracorporeal shock wave lithotripsy at an end?].

BACKGROUND Treatment of urolithiasis saw major changes with the introduction of extracorporeal shock wave lithotripsy (ESWL) and percutaneous and ureteroscopic techniques in the 1980s. Since then these minimally invasive treatment modalities have continuously been developed further. RESULTS For years ESWL has been the treatment of choice. However, recent years have seen a significant shift towards endoscopic therapies. This can be attributed to the evolving surgical experience in the use of these techniques, but even more to major improvement in the technical equipment. This trend is not backed sufficiently by high-level data (RCTs). Some of the newer data on endoscopic techniques are presented in cohort studies, but most studies are case series. Accordingly, recommendations of the German and international guidelines still focus on ESWL as first-line therapy for most locations and sizes of urinary stones. CONCLUSION The analysis of treatment data of our institution confirms these trends and demonstrates high treatment efficiency in modern stone management and a consecutive significant lowering of socio-clinical expenses.

Clinical significance of residual fragments in 2015: impact, detection, and how to avoid them

PurposeResidual fragments are common after stone treatment. Little is known about clinical outcomes relevant to the patient. This comprehensive review of the literature highlights the impact of residual fragments, modes of detection, and treatment strategies to avoid residual fragments in shock wave therapy, ureteroscopy, and percutaneous nephrolithotomy.MethodsA comprehensive review of current literature was performed using PubMed®, MEDLINE®, Embase™, Ovid®, Google Scholar™, and the Cochrane Library. Publications relevant to the subject were retrieved and critically appraised.ResultsResidual fragments after treatment for urinary stones have a significant impact on a patient’s well-being and future course. (Ultra-) low-dose non-contrast computed tomography detects small residuals most reliably. In shock wave lithotripsy, adherence to basic principles helps to improve results. Various techniques and devices facilitate complete stone clearance in conventional and miniaturized percutaneous nephrolithotomy and (flexible) ureteroscopy. Promising new technologies in shock waves, lasers, and robotics (and potentially microrobotics) are on the horizon.ConclusionsResidual fragments are relevant to patients. Contemporary treatment of urolithiasis should aim at complete stone clearance.

Predictive Power of Objectivation of Phimosis Grade on Outcomes of Topical 0.1% Betamethasone Treatment of Phimosis

OBJECTIVE To evaluate the predictive power of the objectivation of the phimosis grade according to the classification defined by Kikiros and Woodward, with regard to the expected efficacy of 0.1% betamethasone cream as a treatment option. METHODS From October 2010 to May 2011, a total of 55 boys (aged <10 years) were treated for phimosis at our department. An assessment of the category of phimosis and the retractability of the foreskin, according to the classification of Kikiros and Woodward, was performed. The proposed treatment options included complete circumcision or topical treatment with steroid cream (0.1% betamethasone-17-valerate). RESULTS Of the 55 patients, 19 (34.5%) underwent conventional circumcision, and 36 (65.5%) were treated with an 8-week course of topical steroid cream. The mean age was 3.9 years (range 0.6-10). Grade 1, 2, 3, 4, and 5 phimosis was seen in 1 (2.8%), 4 (11.1%), 8 (22.2%), 16 (44.4%), and 7 (19.4%) of the cases in the topical steroid cream group, respectively. The success rate for the topical steroid cream was 69.4% and 63.9% at 3 and 8.3 months, respectively. The objectivation of the phimosis grade did not predict the outcome (P > .05). No side effects were associated with the topical steroid treatment. CONCLUSION The pretreatment classification of phimosis did not allow the prediction of success with the topical steroid treatment. We believe that topical steroid therapy with foreskin retraction and daily cleansing is a valid therapy modality that should be offered before any surgical intervention, regardless of the degree of phimosis.

Stereoscopic (3D) versus monoscopic (2D) laparoscopy: comparative study of performance using advanced HD optical systems in a surgical simulator model

PurposeTo compare task performances of novices and experts using advanced high-definition 3D versus 2D optical systems in a surgical simulator model.MethodsFifty medical students (novices in laparoscopy) were randomly assigned to perform five standardized tasks adopted from the Fundamentals of Laparoscopic Surgery (FLS) curriculum in either a 2D or 3D laparoscopy simulator system. In addition, eight experts performed the same tasks. Task performances were evaluated using a validated scoring system of the SAGES/FLS program. Participants were asked to rate 16 items in a questionnaire.ResultsOverall task performance of novices was significantly better using stereoscopic visualization. Superiority of performances in 3D reached a level of significance for tasks peg transfer and precision cutting. No significant differences were noted in performances of experts when using either 2D or 3D. Overall performances of experts compared to novices were better in both 2D and 3D. Scorings in the questionnaires showed a tendency toward lower scores in the group of novices using 3D.ConclusionsStereoscopic imaging significantly improves performance of laparoscopic phantom tasks of novices. The current study confirms earlier data based on a large number of participants and a standardized task and scoring system. Participants felt more confident and comfortable when using a 3D laparoscopic system. However, the question remains open whether these findings translate into faster and safer operations in a clinical setting.

Bringing excellence into urology: How to improve the future training of residents?

Abstract The problem: The demographic development of society leads to an increased demand for physicians. Particularly in the surgical disciplines, there is a noticeably declining interest among graduates from medical schools worldwide. For reasons discussed in detail, this applies especially to urology. Solutions: We indicate possibilities on how to counteract this trend, by improving the training for urology residents. Whereas some major changes for the better have already been introduced into the curricula in some countries, others will have to be further specified in the future. This article gives an overview of the requirements of a specific training programme, from a planning phase to its certification. Aspects such as the selection of candidates, the goals of a good training programme, and an implementation strategy are presented. Essential elements of a urology resident programme for effective coaching, improving medical skills (e.g. in surgical laboratories), knowledge revision, progress evaluation, and retrospection are discussed critically, giving an understanding of the crucial requirements of a good and attractive education in urology. Conclusion: A structured and well organised training programme might attract additional medical students towards urology and contribute significantly to the further development of the speciality. This can be seen as an initiative to counteract the decline of urology as an attractive field of interest to upcoming generations of physicians, and therefore to ensure urological care of the highest quality that patients deserve.

Complete Removal of the Foreskin – Why?

Partial circumcision techniques frequently lead, on account of the remaining foreskin, to functional complications and unsatisfactory cosmetic results requiring re-operation. A series of pictures taken from our own sample of patients illustrates the problem. Review of the literature also attests to higher complication rates after partial circumcision. From a medical point of view, complete circumcision is preferable.

Training in robotics: The learning curve and contemporary concepts in training.

Abstract Objective: To define the learning curve of robot-assisted laparoscopic surgery for prostatectomy (RALP) and upper tract procedures, and show the differences between the classical approach to training and the new concept of parallel learning. Methods: This mini-review is based on the results of a Medline search using the keywords ‘da Vinci’, ‘robot-assisted laparoscopic surgery’, ‘training’, ‘teaching’ and ‘learning curve’. Results: For RALP and robot-assisted upper tract surgery, a learning curve of 8–150 procedures is quoted, with most articles proposing that 30–40 cases are needed to carry out the procedure safely. There is no consensus about which endpoints should be measured. In the traditional proctored training model, the surgeon learns the procedure linearly, following the sequential order of the surgical steps. A more recent approach is to specify the relative difficulty of each step and to train the surgeon simultaneously in several steps of equal difficulty. The entire procedure is only performed after all the steps are mastered in a timely manner. Recently, a ‘warm-up’ before robotic surgery has been shown to be beneficial for successful surgery in the operating room. Conclusion: There is no clear definition of the duration of the effective learning curve for RALP and robotic upper tract surgery. The concept of stepwise, parallel learning has the potential to accelerate the learning process and to make sure that initial cases are not too long. It can also be assumed that a preoperative ‘warm up’ could help significantly to improve the progress of the trainee.

Incidence of Balanitis Xerotica Obliterans in Boys Younger than 10 Years Presenting with Phimosis

Objective: Evaluation of the true incidence of balanitis xerotica obliterans (BXO) among boys younger than 10 years. Methods: In a period of 13 months, 75 boys younger than 10 years were treated for phimosis. Suspicion of BXO was raised in phimosis grade 2 or 3 (classification by Kikiros). Patients were offered primarily either circumcision or conservative therapy and circumcision secondarily (if treatment failed in the conservative group). Each circumcision specimen was examined histopathologically. Results: Circumcision was primarily performed in 29 and secondarily in 17 patients. The mean age was 3.7 years (range 1-10). BXO, chronic inflammation, and normal histological results were found in 8/26/12 (17.4/56.5/26.1%) cases, respectively. The mean follow-up was 8.1 months. No recurrences were reported. Conclusions: The incidence of BXO appears to be higher than previously reported. The clinical appearance in children may be confusing. The preoperative BXO suspicion did not correlate with the final histopathological results.