Gabriella Mirabile

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 Efficacy of Novel Optically Activated Digital Endoscope Protection System Against Laser Energy Damage

OBJECTIVES To evaluate the reliability and efficacy of a novel endoscope protection system (EPS) against direct laser energy damage. METHODS We performed in vitro evaluations of a novel EPS prototype that uses optical feedback from the digital sensor of the DUR-D ureteroscope to terminate the laser energy on retraction of the laser fiber into the ureteroscope. We evaluated various speeds of retraction (0.5, 2.0, and 5.0 cm/s) in normal saline and various concentrations of indigo carmine and human blood. We also evaluated the protrusion distance at which shutdown occurred with the laser fiber cladding cleaved at 0, 3, and 5 mm from the end of the fiber. Twenty trials of each condition were performed. RESULTS In normal saline and blood dilutions of up to 10 g/L, the EPS worked with 100% efficiency for all trials. For blood dilutions of 10 g/L or greater and indigo carmine concentrations of 0.16 g/L or greater, the reliability of the EPS deteriorated. Lasers stripped of 0, 3, and 5 mm of cladding initiated shutdown at 2.9 +/- 0.13, 5.1 +/- 0.09, and 8.2 +/- 0.15 mm from the ureteroscope distal end, respectively (P <0.01). A single DUR-D ureteroscope was used for all trials and remained completely intact through 120 retractions of the active laser fiber into the channel. CONCLUSIONS In this evaluation, the novel EPS was highly effective and reliable. When using indigo carmine or high-density blood concentrations, the efficacy of the EPS was compromised. The EPS should be used to complement standard safe laser technique rather than to replace it.

Evaluation of a Novel Temperature-Sensitive Polymer for Temporary Ureteral Occlusion

PURPOSE Proximal stone migration during ureteroscopic procedures increases operative time and risk. This study was designed to evaluate the ability of a new temperature-sensitive polymer to prevent proximal stone migration during ureteroscopic procedures. MATERIALS AND METHODS Porcine urinary systems were harvested en bloc. The volume of gel needed to occlude the ureter, time to achieve a solid state, length of ureter filled, and pressure needed to dislodge the gel from the ureter were recorded. Radio opacity of the polymer was evaluated. Endoscopic laser lithotripsy was the performed after deploying the urologic polymer, and, after gel application and stone manipulation, all ureters were examined for histologic changes. RESULTS At 36.7 degrees C, 0.5 mL and 1 mL of polymer sufficiently occluded the ureter. Both amounts solidified in 25 to 40 seconds. The mean length of ureter occluded was 56.3 mm, and the mean pressure needed to dislodge the polymer was 159.2 mm Hg. The polymer was radiopaque and did not cause histologic alterations in the ureter. Proximal migration of stone fragments was not observed during any of the procedures performed. CONCLUSIONS Our in vitro study indicates that this radiopaque, thermosensitive polymer is able to transiently occlude the ureter without damaging the urothelium while withstanding the pressure of ureteroscopic irrigation, stone motion, and laser energy.

The effect of intraluminal content on the bursting strength of vessels ligated with the harmonic ACE and LigaSure V.

PURPOSE Energy-based surgical devices (ESDs) are critical for maintaining hemostasis during laparoscopy; however, there are no studies that have evaluated the function of ESDs under different physiologic conditions. We evaluated the effect of intraluminal vessel content on bursting pressure (BP) after ligation with two ESDs: the Harmonic ACE and the LigaSure V. MATERIALS AND METHODS Bursting trials were performed on the vasculature of 24 pigs. Blood vessels were distended with blood of different hematocrit concentrations or an albumin solution of varying protein content. The vessel size and BP of each vessel was recorded after ligation with each ESD. RESULTS In arteries 0 to 3 mm and veins 0 to 3 mm in size ligated with the Harmonic ACE or the LigaSure V, there were significantly elevated vessel BPs with supraphysiologic intraluminal hematocrits. In arteries and veins ligated with the Harmonic ACE, increasing albumin concentrations also led to increasing BPs, though these maximal BPs were lower than those obtained with supraphysiologic hematocrit levels. Increasing albumin concentrations did not increase the BP of the LigaSure V. Within the ranges tested, there was no decrease in vessel BP associated with anemia. CONCLUSION In small vessels, a supraphysiologic hematocrit increased the BP of both arteries and veins when using the Harmonic ACE or the LigaSure V. With the devices tested, anemia did not seem to affect BP. While factors such as intraluminal protein concentration may play a role with ultrasonic energy devices, the mechanism of the increased BP remains unclear. Better understanding of ESDs will help in the design of future devices.

Evaluation of Perirenal Fat as a Predictor of cT1a Renal Cortical Neoplasm Histopathology and Surgical Outcomes

BACKGROUND AND PURPOSE With the increasing detection of small renal cortical neoplasms (RCNs), the preoperative prediction of histopathology has become increasingly important. Because perirenal fat (PF) is known to be metabolically active, we evaluated PF as a predictor of renal tumor histopathology. PATIENTS AND METHODS We retrospectively evaluated patients who underwent laparoscopic nephron-sparing procedures for cT(1a) RCN at two institutions. PF was measured using the digital measuring tool function on standard imaging software, at the level of the renal hilum as the perpendicular distance between the posterior surface of the kidney and the external margin of the psoas muscle. The Mann-Whitney test and logistic regression were used to examine PF, selected demographic, clinical, and operative parameters, and their association with tumor histopathology. RESULTS Data from 250 patients were included in this study. There were 157 (63%) men and 93 (37%) women with a median body mass index (BMI) of 28 kg/m(2). Median tumor size was 2.4 cm, and the median PF distance was 12 mm. Significant correlations were noted between PF and sex and BMI. No significant correlations were found between PF and the operative parameters. Results of a multivariate logistic regression analysis revealed that PF (P<0.01), age (P<0.04), and tumor location (P<0.04) were significant predictors of clear-cell renal-cell carcinoma (RCC) histopathology. CONCLUSIONS In this study, PF, location of tumor, and age were significant predictors of clear-cell RCC histopathology. The correlation of PF and histopathology may be useful in preoperative decision-making and surgical planning in the management of small RCN.

Erythropoietin-induced optimization of renal function after warm ischemia.

BACKGROUND AND PURPOSE Recent preclinical data have indicated that erythropoietin (Epo) can protect organs from ischemic damage. We evaluated the ability of Epo to protect the kidney from the effects of ischemia. METHODS Thirty dogs underwent a laparoscopic nephrectomy and were allowed to recover for 2 weeks. The dogs were then divided into five groups. Animals in groups 1 and 2 underwent 1.5 hours of abdominal insufflation with placebo (saline) injection (group 1) or Epo injection (group 2) before; groups 3 to 5 underwent 1 hour of laparoscopic renal artery clamping after placebo injection (group 3), Epo injection (group 4), or mannitol injection (group 5). Serum evaluations and 24-hour urine collections were performed weekly. After 28 days, the animals were sacrificed. Statistical analysis was performed with the Kruskal-Wallis test. RESULTS After recovery from the initial nephrectomy, all dogs had similar serum hematocrit and creatinine levels. Hematocrit was not significantly affected by Epo administration at any time point. Immediately after the second surgery, dogs that underwent renal artery clamping (groups 3-5) had significantly lower 24-hour urine creatinine levels than those that were not clamped (groups 1-2). After 4 weeks of recovery, the dogs that had received Epo before ischemia (group 4) had recovered significantly more renal function than the dogs that received placebo or mannitol before ischemia (urine creatinine level = Epo 149.1 mg/dL v placebo 70.7 mg/dL v mannitol 80.7 mg/dL). At sacrifice, microalbuminuria was also significantly less in dogs receiving Epo before ischemia than their mannitol or placebo counterparts. CONCLUSION The current study demonstrates that administering Epo before warm ischemia can improve the recovery of renal function after ischemia better than placebo or mannitol.

The effect of argon gas pressure on ice ball size and rate of formation.

INTRODUCTION Contemporary cryoablation technology utilizes the Joule-Thomson effect, defined as a change in temperature that results from expansion of a nonideal gas through an orifice or other restriction. We evaluated the effect of initial gas tank pressures on freezing dynamics in a single-probe model and in a multiprobe model using contemporary cryoablation technology. MATERIALS AND METHODS Cryoablation trials were performed in a standardized system of transparent gelatin molds at 25°C. Two sets of trials were performed. The first trial evaluated temperature and ice ball size for a given tank pressure when a single needle was deployed. The second trial recorded ice ball temperatures for each probe when multiple probes were fired simultaneously. RESULTS Trial 1: The rate of temperature change is directly related to the initial pressure of the gas being released, and the group with the highest starting pressures reached the lowest mean temperature and had the largest mean ice ball size (p < 0.01). Trail 2: Multiple-probe ablation did not affect the rate of temperature change or final temperature compared with firing a single probe (p > 0.7). CONCLUSIONS In accordance with the Joule-Thomson effect, higher initial gas pressures used for cryoablation in a transparent gel model demonstrate statistically significant lower temperatures, faster decreases in temperature, and formation of larger ice balls than lower gas pressures do. With contemporary technology, multiple simultaneous cryoprobe deployment does not compromise individual probe efficacy. The use of higher initial tank pressures will theoretically help future cryoprobes be more effective, creating a greater volume of cell necrosis and a smaller indeterminate zone.

Comparison of Manual and Computer Assisted Ultrasonic Guidance for Transparenchymal Percutaneous Renal Needle Placement

PURPOSE We evaluated a novel computer based guidance system for deploying needles into the renal parenchyma. We compared it to current standards, including a fixed needle guide and a freehand technique. MATERIALS AND METHODS We performed an in vitro comparison followed by a porcine trial. The in vitro model consisted of a bath of ultrasound medium with suspended metallic targets. We compared the number of attempts and the time needed by the novel guide design with and without its software and a support arm vs the freehand approach. In the porcine model we tested the software guide with and without a support arm for targeting a 5 mm lesion embedded in the renal parenchyma. Impressions of difficulty, time, the number of attempts, needle tip visualization and needle tip divergence were documented. RESULTS Compared to freehand targeting the software guide and support arm decreased the number of targeting attempts in the in vitro model from 4.8 to 1.6 (p <0.001) and decreased the time required from 31.8 to 11.4 seconds (p <0.001). In the porcine study needle tip visualization with the software and support arm received an average score of 1.3 vs 1.8 with the software guide alone (p = 0.04). Tip divergence received a score of 1.4 with the arm and 1.8 without it (p = 0.07). Overall contribution received a score of 1.4 with and without the support arm (p = 0.35). CONCLUSIONS Computer assisted needle deployment decreased the time and number of attempts required to successfully target simulated parenchymal lesions and also decreased the subjective difficulty inherent in the standard freehand approach.

Bipolar Plasma Enucleation of the Prostate (B-TUEP) in Benign Prostate Hypertrophy Treatment: 3-Year Results

OBJECTIVE To investigate numerous endoscopic techniques that have been described for the treatment of benign prostate enlargement. Plasma-button enucleation of the prostate (B-TUEP) is a successful treatment option because the large surface creates a fast enucleation process, vaporization, and concomitant hemostasis. The aim of this study was to evaluate the efficacy of bipolar button electrode transurethral adenoma enucleation (B-TUEP) in saline solution. The second end point was to determine the change of International Prostate Symptom Score (IPSS), post-void residual urine, International Index of Erectile Function, transrectal ultrasound gland volume evaluation, and prostate-specific antigen. MATERIALS AND METHODS Between July 2011 and March 2012, 50 consecutive patients underwent B-TUEP in our facility, all performed by a single surgeon (R.G.). All patients were preoperatively assessed with maximum urinary flow rate, single-question quality of life assessment, IPSS and the International Index of Erectile Function questionnaires, transrectal ultrasound gland volume evaluation, prostate-specific antigen, and post-void residual urine. RESULTS We observed a significant improvement at 12, 24, and 36 months in terms of maximum urinary flow rate (22.3 ± 4.74 mL/s, 23.2 ± 0.30 mL/s, and 23.6 ± 1.26 mL/s, respectively, P <.01) and quality of life (5.28 ± 0.97, 5.69 ± 0.90, and 5.73 ± 0.87). IPSS and IEEF scores improved significantly (P <.05). Gland volume evaluation and post-void residue decreased (P <.001). The prostate-specific postoperative antigen levels were 0.76 ± 0.61 ng/mL, 0.7 ± 0.51 ng/mL, and 0.62 ± 0.18 ng/mL, at 12, 24, and 36 months, respectively. Two patients (4%) had persistent bladder outlet obstruction requiring reoperation. CONCLUSION After 3-year follow-up, B-TUEP represents an effective, durable, and safe form of surgical intervention. B-TUEP is an alternative treatment for symptomatic benign prostate enlargement.

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.