Franzo Marruffo

Prospective Comparison of Flexible Fiberoptic and Digital Cystoscopes

OBJECTIVES To compare the optics, performance, and durability of digital (DC) and fiberoptic (FC) cystoscopes. METHODS In an office setting, we randomly assigned staff urologists to 1 of the 4 cystoscopes, the Gyrus-ACMI ICN-0564 (AD), Gyrus-ACMI ACN-2 (AF), Olympus CYF-V2 EndoEYE Cysto-Nephro Videoscope (OD), Olympus CYF-5 Cysto-Fiberscope (OF), to perform diagnostic or surveillance cystoscopy and stent removal. The documented metrics included a subjective surgeon assessment of cystoscope optics and function characteristics on a 10-point scale (1, poor to 10, excellent). The measurement of the upward and downward cystoscope deflection and damage and repairs were all documented. RESULTS A total of 1022 cases were performed. The DC and FC were used 690 and 332 times, respectively. Two repairs (0.2%) were documented (1 AF and 1 AD); both resulted directly from incorrect cystoscope handling/cleaning. The mean operative time per case for the DC and FC was 4.5 and 4.6 minutes, respectively (P = .66). The mean surgeon optical ranking for the DC and FC was 8.4 and 7.8, respectively (P = .0076). The mean surgeon deflection ranking for the DC and FC was 8.6 and 8.0, respectively (P = .0001). The mean surgeon retroflex deflection ranking for the DC and FC was 8.4 and 7.8, respectively (P = .001). The mean overall cystoscope score surgeon ranking for the DC and FC was 8.6 and 7.9, respectively (P = .0001). CONCLUSIONS In the office setting, with proper care, FCs and DCs are durable for office applications. Overall, surgeons significantly preferred the DCs as demonstrated by discrepancies in both use and differences in the subjective metrics.

Evaluation of a protective laser sheath for application in flexible ureteroscopy.

OBJECTIVES Despite the obvious utility of the holmium laser, laser fibers frequently damage flexible ureteroscope components, such as the working channel, flexible component cable system, and fiber optical systems during routine ureteroscopic procedures. As such, we investigated the effects of the use of a flexible protective sheath on ureteroscope operation and its ability to protect ureteroscopes from laser fiber damage. METHODS The effects of insertion of the FlexGuard sheath into the working channel on endoscope deflection and irrigant flow rate were documented. Additionally, the force required to advance the laser fiber through a fully deflected endoscope, as well as the amount of laser energy required to penetrate the FlexGuard sheath, were assessed using two different ureteroscopes. RESULTS The FlexGuard sheath was easily inserted through the maximally deflected ureteroscopes. The presence of the laser sheath and a laser fiber in the working channel decreased the maximum deflection angle of the ureteroscopes by a mean of 7 degrees (from 73 degrees to 66 degrees). FlexGuard sheath insertion into the working channel also significantly diminished irrigant flow rates, from 0.55 mL/sec to 0.02 mL/sec, at an irrigation pressure of 100 cm H(2)O. The FlexGuard sheath reduced the amount of maximum force required to insert the laser fiber through each ureteroscope from 0.8 N to 0.2 N. The FlexGuard sheath was unable to protect the ureteroscope from laser energy damage. CONCLUSION The FlexGuard laser sheath significantly reduced the amount of force required to insert the laser fiber through the working channel. This reduction in force may have be protective against mechanical damage caused by laser fiber insertion. However, deployment of the sheath significantly diminished the rate of irrigant flow and the maximal deflection of the two ureteroscopes tested. Also, the sheath does not protect the ureteroscope from damage caused by laser energy. In each case the urologist will need to determine if the mechanical protective value of the sheath outweighs the negative impact on flow and deflection.

Complete Ileal Neobladder Intracorporeal Construction With Standard Sutured Technique and Novel Technology

PURPOSE We compared the surgical efficacy and efficiency of a completely suture based procedure with a novel entero-urethral anastomosis device and an EndoGIA stapler to create an ileal neobladder. MATERIALS AND METHODS Two groups of 7 pigs each were survived for 8 weeks. In group 1 the neobladder was constructed using a U-shaped segment of ileum sealed with the stapler. The entero-urethral anastomosis was created with a novel sutureless anastomosis device. All other procedures were completed with standard intracorporeal suturing techniques. In group 2 animals completely intracorporeal sutured technique was used. Total procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomosis times were recorded. Cystograms done immediately postoperatively, at 2 weeks and at sacrifice to evaluate the newly constructed system were rated from 0-no leakage to 3-severe leakage. RESULTS In group 1 vs 2 the overall procedure, and enteroenteric, ileal neobladder, uretero-enteric and entero-urethral anastomoses were completed in 285.3, 32.3, 58.8, 54.2 and 5.5 vs 350.1, 29.9, 139.1, 58.0 and 46.3 minutes, respectively. In groups 1 and 2 the average postoperative cystogram rating was 0.83 and 1.6, respectively (p = 0.63). At 2 weeks and at sacrifice cystograms showed no extravasation in either group. The overall surgical procedure, pouch creation and entero-urethral anastomosis were statistically briefer in group 1 (p = 0.036, 0.01 and 0.039, respectively). Average survival in groups 1 and 2 was 30 (range 4 to 56) and 41 days (range 1 to 56), respectively (p = 0.36). All animals had voiding complications within 1 week after ureteral and urethral catheters were removed. One neobladder ruptured in group 1. CONCLUSIONS Combining stapled ileal neobladder construction and the entero-urethral anastomosis device significantly decreases operative time, pouch creation and urethral anastomoses.