Ashleigh Menhadji

Evaluation of the impact of three-dimensional vision on laparoscopic performance.

INTRODUCTION Recent technological advancements have led to the introduction of new three-dimensional (3D) cameras in laparoscopic surgery. The 3D view has been touted as useful during robotic surgery, however, there has been limited investigation into the utility of 3D in laparoscopy. MATERIALS AND METHODS We performed a prospective, randomized crossover trial comparing a 0° 3D camera with a conventional 0° two-dimensional (2D) camera using a high definition monitor (Karl Storz, Tuttlingen, Germany). All participants completed six standardized basic skills tasks. Quality testing scores were measured by the number of drops, grasping attempts, and precision of needle entry and exiting. Additionally, resolution, color distribution, depth of field and distortion were measured using optical test targets. RESULTS In this pilot study, we evaluated 10 medical students, 7 residents, and 7 expert surgeons. There was a significant difference in the performance in all the six skill tasks, for the three levels of surgical expertise and training levels in 2D vs 3D except for the cut the line quality score and the peg transfer quality score. Adjusting for the training level, 3D camera image results were superior for the number of rings left (p=0.041), ring transfer quality score (p=0.046), thread the rings (no. of rings) (p=0.0004), and thread the rings quality score (p=0.0002). The 3D camera image was also superior for knot tying (quality score) (p=0.004), peg transfer (time in seconds) (p=0.047), peg transfer pegs left (p=0.012), and for peg transfer quality score (p=0.001). The 3D camera system showed significantly less distortion (p=0.0008), a higher depth of field (p=0.0004) compared with the 2D camera system. CONCLUSION 3D laparoscopic camera equipment results in a significant improvement in depth perception, spatial location, and precision of surgical performance compared with the conventional 2D camera equipment. With this improved quality of vision, even expert laparoscopic surgeons may benefit from 3D imaging.

Interobserver Reliability and Reproducibility of S.T.O.N.E. Nephrolithometry for Renal Calculi

PURPOSE To assess the reliability of the S.T.O.N.E. (stone size [S], tract length [T], obstruction [O], number of involved calices [N], and essence or stone density [E]) nephrolithometry scoring system by testing its reproducibility between different observers. PATIENTS AND METHODS Preoperative images of 58 patients who underwent percutaneous nephrolithotomy (PCNL) were reviewed. Medical students, urology residents, one fellow, and a urology attending independently reviewed all images and scored the renal stones. Interobserver reliabilities of the total score for all categories and each component were evaluated by the intraclass correlation (ICC) and a κ coefficient. RESULTS The interobserver reliability for the total score demonstrated high correlations for all components and total score (ICC=S, T, O, N, E and total 0.80, 0.97, 0.89, 0.84, 0.91, and 0.87, respectively). κ rates for individual components between two medical students were 0.36, 1, 0.31, 0.45, 0.33, and 0.30 for the S, T, O, N, E components and total score, respectively. κ values between the two urology residents were 0.71, 1, 0.92, 0.79, 0.93, and 0.67 for S, T, O, N, E components and total score, respectively. κ values between the urology fellow and an attending physician were 0.95, 1, 0.88, 0.94, 0.89, and 0.87 for S, T, O, N, E components and total score, respectively. P value for all the scoring components was <0.05, indicating that the estimated κ was not a result of chance. CONCLUSIONS The S.T.O.N.E. nephrolithometry has excellent interobserver reliability. Quantifying the S and N metrics was the most challenging and least reliable. Standardized protocols to measure these components should be considered to improve accuracy and reproducibility of the scoring system.

Comparison of Optics and Performance of Single Channel and a Novel Dual-channel Fiberoptic Ureteroscope

OBJECTIVE To evaluate performance characteristics and optics of a novel dual-working channel fiberoptic ureteroscope (Wolf Cobra) with 2 single-channel fiberoptic ureteroscopes and to a single-channel distal sensor standard definition digital ureteroscope URF-V (SD-DS). METHODS Four new ureteroscopes (Cobra, Viper, X(2), and SD-DS) were compared for active deflection, irrigation flow, and optical characteristics. We performed a porcine ureteroscopy and measured the time for cleaning the middle calyx after injection of 10 cc of a standardized bloody solution. RESULTS The SD-DS showed a higher resolution (7.42 lines/mm; P = .0001) compared with the fiberoptic ureteroscopes; among the fiberoptic ureteroscopes, the Cobra had the highest resolution than the Viper and X(2) (P = .0001). Grayscale distribution and color representation were identical for the fiberoptic ureteroscopes, whereas the SD-DS provided a superior color representation and a significant higher depth of field. The Cobra provided superior flow with empty working channel (86 cc/min vs 68 cc/min [Viper] vs 62.5 cc/min [X(2)] vs 62 cc/min [SD-DS]; P = .0001) and with various accessories (P <.0001). With regard to deflection, the Storz X(2) and the Cobra provided superior deflection up and down (P <.0001). When evacuating a standardized bloody field, the Cobra provided significant shorter evacuation times compared with those of the Viper, X(2), and SD-DS (36.6 vs 72 vs 65.6 vs 72.6 seconds, respectively; P = .0001). CONCLUSION The additional working channel of the Wolf Cobra may improve vision and performance during challenging ureteroscopic cases by providing an increased flow. The enhanced irrigation capabilities of the Cobra have to be balanced with a larger diameter of this ureteroscope.

In vitro comparison of a novel facilitated ultrasound targeting technology vs standard technique for percutaneous renal biopsy.

OBJECTIVE To improve the understanding of the epidemiology of renal cortical neoplasms through pretreatment biopsy, we evaluated a facilitated ultrasound targeting (FUT) technology. The technology allows a needle to be passed through the transducer probe and guided along a virtual dotted line on the monitor. We compared the FUT with standard percutaneous biopsy (PB) technique. MATERIALS AND METHODS Forty-eight participants with various levels of training were recruited. Participants performed ultrasound-guided biopsies on phantom models using FUT and the standard biopsy technique in a randomized sequence. The phantom models consisted of pimento olives embedded in an opaque mold of Metamucil and Knox gelatin. Patients were given up to 10 attempts to achieve 3 complete specimens from the olives. Patients rated each biopsy technique. Results were stratified by level of experience. RESULTS The mean time to obtain 3 complete biopsy specimens was significantly faster for FUT compared with the standard technique (140 seconds vs 246 seconds, P = .0001). The mean number of attempts needed to obtain 3 specimens was significantly less with FUT compared with the standard technique (4.3 vs 5.6 attempts, P = .0007). Patients reported that FUT was significantly easier to use compared with the standard technique (P = .0005). No significant order effect was observed. CONCLUSION In this in vitro comparison, FUT increased the efficiency and efficacy of PB for users of all experience levels. FUT may allow urologists with limited PB experience to perform the procedure reliably and easily. Clinical evaluation of this technology is actively in progress.

Tracking and assessment of technical skills acquisition among urology residents for open, laparoscopic, and robotic skills over 4 years: is there a trend?

BACKGROUND AND PURPOSE Tracking the progression of technical skill acquisition during urology residency training is an essential yet challenging task that has been mostly based on anecdotal and subjective performance assessment. We evaluated five surgical tasks used at our institution to assess skill acquisition among residents over 4 consecutive years in an effort to determine appropriate skill testing for resident proficiency relative to level of training for future performance testing. METHODS Urology residents were tested yearly throughout the course of their residency with five surgical tasks in an open, laparoscopic, and robotic format. The five tasks were: (1) rings on a peg, (2) thread the rings, (3) cut the line, (4) hexagonal suturing, and (5) suture and knot tying. Evaluation was performed by a trained instructor to assess quantity and quality of the skill task performance. RESULTS The highest scores were obtained on all open tasks regardless of training level. Residents performed second best on robotic and lowest on the laparoscopic skill tasks. The score difference among surgery platforms was statistically significant P<0.0005 across all tasks. It was Tasks 2 and 5, however, that showed a statistically significant difference in overall quantity×quality score between different postgraduate year (PGY) residents (P=0.03 and P=0.02). In addition, the quantity score for Task 5 also showed a statistically significant difference among PGY residents (P=0.04). There was no statistically significant difference in time to perform tasks among PG years. CONCLUSIONS The high-level Tasks 2 and 5 were the most useful in differentiating different levels of skill task competency among urology residents and appear to be most useful in assessing the degree of improvement among residents during training. These tasks have subsequently been worked into our institutions testing curriculum.

Technique for office-based, ultrasonography-guided percutaneous biopsy of renal cortical neoplasms using a novel transducer for facilitated ultrasound targeting.

To help clarify which small renal cortical neoplasms (RCNs) require surgery by using office‐based, ultrasonography‐guided percutaneous renal biopsy.

Comparison of Optics and Performance of a Distal Sensor High Definition Cystoscope, a Distal Sensor Standard Definition Cystoscope, and a Fiberoptic Cystoscope

OBJECTIVE To evaluate performance characteristics and optics of a new generation high-definition distal sensor (HD-DS) flexible cystoscope, a standard-definition distal sensor (SD-DS) cystoscope, and a standard fiberoptic (FO) cystoscope. METHODS Three new cystoscopes (HD-DS, SD-DS, and FO) were compared for active deflection, irrigation flow, and optical characteristics. Each cystoscope was evaluated with an empty working channel and with various accessories. Optical characteristics (resolution, grayscale imaging, color representation, depth of field, and image brightness) were measured using United States Air Force (USAF)/Edmund Optics test targets and illumination meter. We digitally recorded a porcine cystoscopy in both clear and blood fields, with subsequent video analysis by 8 surgeons via questionnaire. RESULTS The HD-DS had a higher resolution than the SD-DS and the FO at both 20 mm (6.35 vs 4.00 vs 2.24 line pairs/mm) and 10 mm (14.3 vs 7.13 vs 4.00 line pairs/mm) evaluations, respectively (P <.001 and P <.001). Color representation and depth of field (P = .001 and P <.001) were better in the HD-DS. When compared to the FO, the HD-DS and SD-DS demonstrated superior deflection up and irrigant flow with and without accessory present in the working channel, whereas image brightness was superior in the FO (P <.001, P = .001, and P <.001, respectively). Observers deemed the HD-DS cystoscope superior in visualization in clear and bloody fields, as well as for illumination. CONCLUSION The new HD-DS provided significantly improved visualization in a clear and a bloody field, resolution, color representation, and depth of field compared to SD-DS and FO. Clinical correlation of these findings is pending.

1072 In vivo and ex vivo comparison of optics and performance of a novel dual channel fiberoptic ureteroscope

INTRODUCTION AND OBJECTIVES: Flexible ureteroscopy has become a standard for the treatment of small renal calculi. Ureteroscopic equipment has a well-documented limited lifespan prior to need for maintenance. The most common location and etiology of scope damage is due to passing or misfiring a laser fiber in the working channel of a flexible ureteroscope. Conventional laser fibers utilize a blunt tip that can be difficult to pass through a deflected scope, and can potentially result in damage. A new laser fiber has become commercially available with a ball-shaped output tip. This is proposed to pass more easily through a fully deflected ureteroscope in an atraumatic manner. Our objective was to evaluate the use of this ball-tipped fiber and its effect on the incidence and cost of ureteroscope repairs. METHODS: Our institution began using the single-use ball-tipped fibers in January 2013. We retrospectively reviewed the charts of the first 80 patients undergoing ureteroscopy with laser lithotripsy utilizing the ball-tipped laser fiber, and compared them to the 80 patients immediately prior to the switch, where a reusable blunt tip fiber was utilized. We collected basic patient demographics, as well as stone location, stone size, type of ureteroscope used, use of a ureteral access sheath, total operative time, and energy used for lithotripsy. Repair data of the flexible ureteroscopes, including cost and type of damage was obtained. Pertinent repair costs included those related to damaged working channels. A cost analysis was performed to see if decrease ureteroscope repair cost justified the increase cost of the single use ball-tip fiber. RESULTS: During the review period, 58 patients underwent flexible ureteroscopy with the traditional blunt tip laser fiber and 60 patients with the ball tip fiber. There was no significant difference in patient age, stone burden, or operative time between the two groups. During use of the blunt tip fiber there were 5 repairs to working channels, incurring a cost of

In Vitro Randomized Comparison of a Standard and Novel Echogenic Needle for Ultrasonography-Guided Renal Targeting

28,018, while 2 working channel repairs, costing

Comparison of Pneumoperitoneum Stability Between a Valveless Trocar System and Conventional Insufflation: A Prospective Randomized Trial

12,408 were attributed to use of the ball-tipped fiber. Accounting for the increased cost of the ball tipped fiber of