Domenico Veneziano

Laparoendoscopic single-site radical nephrectomy for renal cancer: technique and surgical outcomes.

BACKGROUND Laparoendoscopic single-site (LESS) surgery has been developed in attempt to further reduce the morbidity and scarring associated with surgical intervention. OBJECTIVE To describe the technique and report the surgical outcomes of LESS radical nephrectomy (RN) in the treatment of renal cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS LESS-RN was performed in 33 patients with renal tumours. The indications to perform a LESS-RN were represented by renal tumours not greater than T2 and without evidence of lymphadenopathy or renal vein involvement. SURGICAL PROCEDURE The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The sequence of steps of LESS-RN was comparable to standard laparoscopic RN. MEASUREMENTS Demographic data and perioperative and postoperative variables were recorded and analysed. RESULTS AND LIMITATIONS The mean operative time was 143.7±24.3 min, with a mean estimated blood loss of 122.3±34.1 ml and a mean hospital stay of 3.8±0.8 d. The mean length of skin incision was 4.1±0.6 cm and all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9±0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumours. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2±3.9 mo, all patients were alive without evidence of tumour recurrence or port-site metastasis. CONCLUSIONS LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

Clampless laparoendoscopic single-site partial nephrectomy for renal cancer with low PADUA score: technique and surgical outcomes

Laparoendoscopic single‐site (LESS) surgery has proved to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons in well‐selected patients. All extirpative and reconstructive urological procedures have been described in the literature, but LESS partial nephrectomy (PN) is one of the most complex procedures and few studies have been published on this subject. The study describes a clampless technique for LESS PN, by reducing the blood pressure and increasing the intra‐abdominal pressure of the pneumoperitoneum to 20 mmHg, timed to precisely coincide with excision of the tumour. This technique was found to be safe and feasible in the treatment of low‐risk T1a RCC.

The SimPORTAL fluoro-less C-arm trainer: an innovative device for percutaneous kidney access.

INTRODUCTION AND OBJECTIVES Achieving proper renal access is arguably the most challenging component of percutaneous nephrolithotomy. A core skill required during this procedure is the use of C-arm fluoroscopic imaging and parallax techniques for proper needle insertion into a predetermined calyceal papilla. The trainers available for these skills include virtual reality (VR) simulators and physical models requiring actual fluoroscopy and radiation exposure precautions. In this study we present the successful proof-of-concept of a low-cost physical fluoro-less C-arm trainer (CAT) for training percutaneous renal access. MATERIALS AND METHODS The SimPORTAL CAT includes a mini C-arm for simulating fluoroscopic imaging and a silicon flank simulation model for needle insertion. The C-arm has two mounted video cameras and is jointed to tilt and rainbow. The flank model contains an anatomically accurate cast of the upper urinary tract, including the ureter, calyces, and the renal pelvis, with an overlay of ribs to visually and tactically simulate the 10th-12th ribs. The simulated fluoroscopic imaging is viewed on a computer screen allowing for real-time visualization. Preliminary surveys were completed by participants (n=14) at a training course that took place in Hemel Hampsted to obtain information on the acceptability of version 2.1 of the model. RESULTS We have successfully created a fluoro-less CAT that achieves the goals of training percutaneous access of the kidney. All participants (100%) considered the concept of avoiding radiation exposure during training as a highly valuable feature. About 92.8% of the enrolled participants considered the CAT of at least equal value to existing VR training models. CONCLUSIONS The fluoroscopy-less CAT is an economically feasible and accurate model for training parallax. It effectively replicates the functions of a C-arm X-ray system for percutaneous access to the kidney without any radiation exposure to the learner. Further studies will examine construct validity for training and assessing percutaneous access skills.

Low vs. high fidelity: the importance of ‘realism’ in the simulation of a stone treatment procedure

Purpose of review Simulation training for stone surgery is now increasingly used as part of training curricula worldwide. A combination of low and high fidelity simulators has been used with varying degrees of ‘realism’ provided by them. In this review, we discuss low and high fidelity simulators used for ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) stone procedures with their advantages, disadvantages and future direction for endourological simulation surgery. The final goal will be to understand whether or not ‘realism’ has to be considered as a critical element in simulation for this field. Recent findings There is a wide range of simulators available for URS and PCNL training ranging from basic bench-type model to advanced virtual reality and cadaveric models, all providing various levels of realism. Although basic models might be more useful to novices, advanced models allow for complex and more realistic simulation training. Summary With a wide variety of simulators now available and given the latest novelties in modular training curriculums, combination of low and high fidelity simulators that provide a realistic and cost-effective option seems to be the way forward. It is unavoidable that simulators will play an increasing role in endourological training.

Thermal image processing for accurate realtime decision making in surgery

Human body has its basal temperature that can be exploited for different uses. Obviously, thermal properties of human tissues allow to retrieve specific characteristics if special attention is paid. Therefore, thermal imaging is a suitable tool for many applications. It could be used in medical issues for checking temperature variations displayed by a volume under investigation during surgery operations related to humans. It plays a double role: imaging and temperature measurements. This paper presents a wide and joint experimental research for determining the decreasing temperature encompassed in a volume during an urological intervention in order to established, in a realtime, which tissues and adherences must be taken in consideration for continuing and optimizing the surgery process. A further processing is performed using Hough transform that exhibits encouraging results for this specific approach. This is very important for some other applications like contour extraction, contour matching and surface spline fitting.

Laparoendoscopic single-site radical nephrectomy for kidney tumor. Surgical technique, cosmetic and postoperative pain control outcomes

INTRODUCTION Over the last few years, many urological laparoscopic operations have been successfully performed by LESS. However, the actual role of LESS in the field of minimally invasive urologic surgery remains to be determined with controversial data about postoperative pain control and almost no results on cosmetic data. The aim of the present study is to describe the technique and report the surgical outcomes of LESS radically nephrectomy (RN) in the treatment of renal cell carcinoma with special emphasis for postoperative pain control and almost no results on cosmetic data. MATERIALS AND METHODS LESS-RN was performed in 33 patients with renal tumors. The indications to perform a LESS-RN were represented by renal tumors not greater than T2, and without evidence of lymphadenopathy or renal vein involvement. SURGICAL PROCEDURE The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The step sequence of LESS-RN was comparable to standard laparoscopic RN. Demographic data and perioperative and postoperative variables were recorded and analyzed. RESULTS The mean operative time was 143.7 ± 24.3 min, with a mean estimated blood loss of 122.3 ± 34.1 mL and a mean hospital stay of 3.8 ± 0.8 d. The mean length of skin incision was 4.1 ± 0.6 cm; all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9 ± 0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumors. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2 ± 3.9 mo, all patients were alive without evidence of tumor recurrence or port-site metastasis. CONCLUSIONS LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

European Association of Urology Section of Urolithiasis (EULIS) Consensus Statement on Simulation, Training, and Assessment in Urolithiasis

BACKGROUND Simulation-based training offers an acceptable adjunct to the traditional mentor-apprentice model in helping trainees to traverse the early stages of the learning curve for ureteroscopy and percutaneous renal surgery. In addition, nontechnical skills are increasingly important in preventing adverse events in the operating room, and simulation-based training can be used for training in such skills. Incorporation of simulation into formalised, standardised, and validated curricula offers an applicable method for training residents. OBJECTIVE To develop a curriculum for urolithiasis procedures incorporating technical and nontechnical skills training for implementation across Europe. DESIGN, SETTING, AND PARTICIPANTS An international panel of experts from EULIS, EUREP, ESU and ESUT was consulted in five stages. The study incorporated a mix of qualitative and quantitative data for collection and analysis. Responses were drawn out in (1) an opinion survey and (2) a curriculum development survey, which were discussed in (3) a focus group meeting. Group responses from this meeting were analysed for themes, which were discussed at (4) a focus group meeting, where consensus was reached among the group. Data analysis and integration at this stage were used to draft the curriculum. RESULTS AND LIMITATIONS All group meetings were transcribed from the focus group discussion. Eight themes were generated, into which all data were categorised. These were: need for a training curriculum; curriculum objectives; curriculum structure; curriculum content; teaching platforms and tools; assessment and certification; validation and implementation; and global integration of the curriculum. A curriculum, including recommended simulators for use, was subsequently proposed. CONCLUSIONS We propose a comprehensive curriculum for training in urolithiasis. Additional planning is required for full validation and implementation before it can be used to train residents. PATIENT SUMMARY Stone disease accounts for a major proportion of surgical interventions worldwide. We describe a consensus guideline for effective training of stone surgeons.

Live Surgery: Is Operating at Home the Way Forward?

Live surgery events are a popular educational tool, but concerns have been raised, especially regarding patient safety. The Italian Society of Urology has implemented a novel concept in which surgeons operate on their own patients at their own institutions, with the procedures broadcast live at the annual society meetings. This approach retains the live nature of the surgery but removes the risks associated with operating in a foreign environment with distractions.

Evolution and Uptake of the Endoscopic Stone Treatment Step 1 (EST-s1) Protocol: Establishment, Validation, and Assessment in a Collaboration by the European School of Urology and the Uro-Technology and Urolithiasis Sections

Endourology training has evolved over the last two decades, with more emphasis now being placed on simulation-based training. While the EBLUS training curriculum and examination have been well established [1], there was a lack of standardised training for endourology. The European School of Urology (ESU), together with the European Association of Urology (EAU) sections on uro-technology and urolithiasis, started development of the Endoscopic Stone Treatment step-1 (EST-s1) simulation protocol in 2014. This was produced in accordance with the EAU guidelines by following the full life-cycle curriculum development template. The outcomes and metrics were defined via a cognitive task analysis by the EAU Young Academic Urology group and the simulator requirements were then tested. The final task list consisted of four exercises that replicated the basic skills required for endoscopic stone treatment: (1) flexible cystoscopy; (2) rigid cystoscopy and placement of a safety guidewire; (3) semi-rigid ureteroscopy and placement of an access sheath; and (4) flexible ureterorenoscopy. The curriculum development process took 2 yr of consensus meetings and expert consultation; this led to addition of content validity evidence to the protocol [2]. Face and construct validity data were collected during the annual EUREP course in 2016 and will be reported in an upcoming publication. This validation study involved 124 participants using low-fidelity simulators. The rules for the exercises and the expected goals were strictly derived from the development process and were summarised in a tutor instruction sheet. Video explanation of the tasks was available on the

The simportal fluoro-less c-Arm trainer

INTRODUCTION AND OBJECTIVES Achieving proper renal access is arguably the most challenging component of percutaneous nephrolithotomy. A core skill required during this procedure is the use of C-arm fluoroscopic imaging and parallax techniques for proper needle insertion into a predetermined calyceal papilla. The trainers available for these skills include virtual reality (VR) simulators and physical models requiring actual fluoroscopy and radiation exposure precautions. In this study we present the successful proof-of-concept of a low-cost physical fluoro-less C-arm trainer (CAT) for training percutaneous renal access. MATERIALS AND METHODS The SimPORTAL CAT includes a mini C-arm for simulating fluoroscopic imaging and a silicon flank simulation model for needle insertion. The C-arm has two mounted video cameras and is jointed to tilt and rainbow. The flank model contains an anatomically accurate cast of the upper urinary tract, including the ureter, calyces, and the renal pelvis, with an overlay of ribs to visually and tactically simulate the 10th-12th ribs. The simulated fluoroscopic imaging is viewed on a computer screen allowing for real-time visualization. Preliminary surveys were completed by participants (n=14) at a training course that took place in Hemel Hampsted to obtain information on the acceptability of version 2.1 of the model. RESULTS We have successfully created a fluoro-less CAT that achieves the goals of training percutaneous access of the kidney. All participants (100%) considered the concept of avoiding radiation exposure during training as a highly valuable feature. About 92.8% of the enrolled participants considered the CAT of at least equal value to existing VR training models. CONCLUSIONS The fluoroscopy-less CAT is an economically feasible and accurate model for training parallax. It effectively replicates the functions of a C-arm X-ray system for percutaneous access to the kidney without any radiation exposure to the learner. Further studies will examine construct validity for training and assessing percutaneous access skills.