Brian J. Miles

Chopstick surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery

IntroductionSingle-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with wristed instruments could overcome this limitation, but the arms often collide when working coaxially. This study tests a new technique of “chopstick” surgery to enable use of the robotic arms through a single incision without collision.MethodsExperiments were conducted utilizing the da Vinci S® robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a Fundamentals of Laparoscopic Surgery (FLS) box trainer with three laparoscopic ports (1xa0×xa012xa0mm, 2xa0×xa05xa0mm) introduced through a single “incision.” Pilot work determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, five experienced robotic surgeons performed three FLS tasks utilizing either a standard robotic arm setup or the chopstick technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This results in separation of the robotic arms outside the box. To correct for the change in handedness, the robotic console is instructed to drive the “left” instrument with the right-hand effector and the “right” instrument with the left. Performances were compared while measuring time, errors, number of clutching maneuvers, and degree of instrument collision (Likert scale 1–4).ResultsCompared with the standard setup, the chopstick configuration increased surgeon dexterity and global performance through significantly improved performance times, eliminating instrument collision, and decreasing number of camera manipulations, clutching maneuvers, and errors during all tasks.ConclusionChopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.

Detection of Human Papillomavirus in Squamous Neoplasm of the Penis

Infection of the external human urogenital system with human papillomavirus has been implicated with the development of genital cancer. A modified polymerase chain reaction technique has been used to evaluate type specific deoxyribonucleic acid (DNA) sequences of unique E6 to E7 transforming regions of human papillomavirus genomes (types 6b/11, 16 and 18) in a morphological spectrum of in situ (carcinoma in situ) and invasive neoplasm of the penis. We studied 15 examples of carcinoma in situ [7 bowenoid and 8 nonbowenoid (squamoid or simplex)], 11 of invasive squamous carcinoma, 1 of verrucous carcinoma, 2 of verrucous hyperplasia, 1 of urethral adenocarcinoma and 1 solitary papilloma. Viral DNA was not detected in any of the nonbowenoid specimens of carcinoma in situ, the verrucous carcinoma, the adenocarcinoma or the papilloma of the penis. Human papillomavirus types 6b/11 and 18 specific sequences also were not detectable in any of the specimens examined. However, all 7 of the bowenoid forms of carcinoma in situ were positive for human papillomavirus type 16 DNA. The presence of human papillomavirus type 16 was also detected in 9 of 11 invasive squamous carcinomas and in both verrucous hyperplasias. Our results confirm that the bowenoid forms of intraepithelial neoplasms and most invasive squamous carcinomas contain the E6 to E7 portion of type 16 human papillomavirus genome.

Management of penile gunshot wounds

The management of 10 cases of penile gunshot wounds treated at Henry Ford Hospital from 1982 to 1986 is reviewed. All patients were assaulted by low velocity weapons (handguns). Eight patients had associated injuries, predominantly to the genital region (thigh, pubis, and scrotum). There were 5 urethral injuries; 4 were treated with primary repair, the remaining patient underwent delayed repair, complicated by severe urethral strictures requiring reoperation. Blood at the urethral meatus was suggestive of urethral injury but microscopic hematuria was not. Five penile injuries did not involve the urethra and were treated by debridement and primary wound closure with no immediate or delayed complications. In dealing with these injuries we recommend a high index of suspicion for urethral and regional organ injury and primary urethral closure if at all possible.

Current controversies in the management of localized prostate cancer

As longevity has improved and mortality from cardiovascular and other diseases has declined, the risk of death from prostate cancer has increased steadily. Though slow growing, prostate cancer is not a benign disease. Nearly 10% of men in Western countries will be diagnosed with prostate cancer sometime during their life and 3% will die of the disease. The prospects for long-term control of prostate cancer diminish rapidly once the cancer has spread beyond the immediate periprostatic tissue. The 5-year survival rate for men with metastases is less than 30% and almost all will eventually die of their disease. A simple blood test, prostate-specific antigen (PSA), is available. This test, when used in conjunction with ultrasound-guided systematic needle biopsy of the prostate, will detect potentially lethal prostate cancers earlier than digital rectal examination (DRE). Definitive treatment, especially with radical prostatectomy, can eradicate the tumor in 90% of patients if the cancer is still confined to the prostate pathologically, regardless of the tumor grade. Randomized, prospective clinical trials are now underway to demonstrate conclusively whether screening or early definitive therapy will substantially reduce the mortality rate from this disease. Until the results of these trials are available, we recommend that healthy men over age 50, who have a life expectancy of 10 years or longer, have an annual PSA and DRE to detect prostate cancer while it is still curable.

Urolithiasis and Race: Another Viewpoint

We describe 193 consecutive individuals with documented urolithiasis in a military population. In contrast to other reports, the prevalence of stone disease was nearly identical in white-and black patients. This unique black population refutes the concept that urinary calculi are rare in blacks.

Robotic Intracorporeal Continent Cutaneous Urinary Diversion: Primary Description.

The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patients right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III-V) 90-day complications were observed. At a follow-up of 1 year, the patient continues to catheterize without difficulty. We demonstrate the first description of robotic intracorporeal continent cutaneous urinary diversion after robot-assisted cystectomy. We present a systematic minimally invasive approach, replicating the principles of open surgery, which is technically feasible and safe with a good functional result.Abstract The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patients right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III–V) 90-day compl...

Diagnosis and management of incidental ureterocele during the treatment of clinically localized prostate cancer

Abstract Two instances of simultaneous diagnosis of prostate cancer and ureterocele were recently identified. In one patient an ectopic ureterocele in a duplex system with an obstructed upper pole was unroofed at the time of radical prostatectomy. Surgical excision of the ureterocele wall provided decompression of the obstructed system. In a second patient, bilateral intravesical ureteroceles associated with normal renal units were left untreated. Complications were not associated with the untreated ureteroceles. On rare occasions a ureterocele may be discovered incidentally during the evaluation of patients with prostate cancer. When radical prostatectomy is planned, treatment of the ureteroceles should be determined by the ureteroceles size, anatomic configuration, and location and by the degree of obstruction of the affected renal unit. Surgical excision of the ureterocele at the time of radical prostatectomy may be the best approach for patients requiring treatment.

Adjunctive Measures and New Therapies to Optimize Early Return of Urinary Continence

In the era of robotically assisted laparoscopic prostatectomy despite the powerful visualization, refined surgical techniques, minimal blood loss, and multiple nerve-sparing and reconstructive bladder neck techniques, urinary incontinence still creates a significant burden on patients and their treating physicians. Chapter 5 focuses on the preoperative, intraoperative, and postoperative technical and surgical skills and modifications that may improve urinary continence in the early and late postprostatectomy period. In this chapter, we review the literature on nonsurgical interventions that may improve urinary continence in the short near term. Return of urinary continence as reported in the literature varies considerably, depending on surgeon expertise, definition, surgical volume (of both the surgeon and the hospital/medical center), and whether or not the outcome is patient or surgeon reported. Furthermore, the incidence of urinary incontinence experienced by men prior to prostatectomy is generally not recorded and not well known. For instance, Johnson and Ouslander reported 15–30 % of men over age 65 had urinary incontinence to some degree before undergoing radical prostatectomy. Gibbs CF, Johnson 2nd TM, Ouslander JG. Office management of geriatric urinary incontinence. Am J Med. 2007;120:211.

Robotic intracorporeal continent cutaneous urinary diversion

The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patients right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III-V) 90-day complications were observed. At a follow-up of 1 year, the patient continues to catheterize without difficulty. We demonstrate the first description of robotic intracorporeal continent cutaneous urinary diversion after robot-assisted cystectomy. We present a systematic minimally invasive approach, replicating the principles of open surgery, which is technically feasible and safe with a good functional result.Abstract The purpose is to present the first report and describe our novel technique for intracorporeal continent cutaneous diversion after robotic cystectomy. After completion of robot-assisted cystectomy using a standard six-port transperitoneal technique, three additional ports are placed, and the robot is redocked laterally over the patients right side in the modified lateral position. Our technique replicates step-by-step the principles of the open approach. Ileocolonic anastomosis, ureteroenteral anastomoses, and construction of a hand-sewn right colonic pouch are all performed intracorporeally. Tapering of efferent ileal limb and reinforcement of the ileocecal valve are performed via the extraction site, while the stoma is matured through a prospective port site. Successful robotic intracorporeal creation of a modified Indiana pouch was achieved. Operative time for diversion was 3 hours, with negligible blood loss, and without any intraoperative complications. No major (Clavien III–V) 90-day compl...