Guido Kamphuis

Volumetric In-Vivo Visualization of Upper Urinary Tract Tumors Using Optical Coherence Tomography: A Pilot Study

PURPOSE Knowledge of tumor stage and grade is paramount for treatment decision making in cases of upper urinary tract urothelial carcinoma but this condition cannot be accurately assessed by current techniques. Optical coherence tomography can hypothetically provide the urologist with real-time intraoperative information on tumor grade and stage. In this pilot study we report what are to our knowledge the first results of optical coherence tomography for grading and staging upper urinary tract urothelial carcinoma. MATERIALS AND METHODS Eight consecutive patients underwent ureterorenoscopy for suspicion or followup of upper urinary tract urothelial carcinoma. Optical coherence tomography data sets were intraoperatively obtained from the ureter and renal pelvis. All patients eventually underwent nephroureterectomy. Optical coherence tomography staging was done by visual inspection of lesions found on optical coherence tomography images. Optical coherence tomography grading was done by quantifying optical coherence tomography signal attenuation in mm(-1) on lesions and comparing results with the histopathological diagnosis. The Wilcoxon rank sum test was used for statistical analysis. RESULTS For 7 in vivo optical coherence tomography diagnoses staging was in accordance with histology. In patient 8 tumor thickness transcended optical coherence tomography imaging depth range and, therefore, invasiveness findings were inconclusive. For grading the median attenuation coefficient for grade 2 and 3 lesions was 1.97 (IQR 1.57-2.30) and 3.53 mm(-1) (IQR 2.74-3.94), respectively (p<0.001). Healthy urothelium was too thin to reliably determine the attenuation coefficient. CONCLUSIONS Optical coherence tomography is a promising, minimally invasive tool for real-time intraoperative optical diagnosis of tumors in the upper urinary tract. Our results warrant future research in a larger sample size to determine the accuracy of grading and staging by optical coherence tomography, and its possible implementation in the diagnostic algorithm for upper urinary tract urothelial carcinoma.

Diagnostic dilemmas in patients with upper tract urothelial carcinoma

Upper tract urothelial carcinoma (UTUC) is a rare condition and recommendations based on a high level of evidence for diagnosis, treatment and follow-up monitoring are lacking. Current decision-making is often based on evidence from trials investigating urothelial carcinoma of the lower tract. Radical nephroureterectomy has been the standard of care for UTUC but kidney-sparing treatment using endoscopic approaches has been established for a select patient group with low-grade and low-stage disease. Optimal treatment choice requires correct tumour characterization. According to available recommendations, diagnostic work-up of UTUC includes evaluation by CT urography or MRI urography, cystoscopy and urine cytology. Ureterorenoscopy and lesion biopsy are grade C recommendations in patients with suspected UTUC. When kidney-sparing treatment is planned, ureterorenoscopy and biopsy should be considered and are the procedures of choice in most cases. These diagnostics have limitations and their accuracy varies in defining tumour characteristics and predicting grade and stage. Urinary tests have higher sensitivity than cytology for detection of lower tract urothelial carcinoma but evidence of their benefit in UTUCs is lacking. New optical and image enhancement techniques are being developed to facilitate real-time diagnostics with increased accuracy. A new diagnostic algorithm for patients with suspected UTUC that integrates the diagnosis, treatment and clinical risk stratification is required.

Update of the ICUD-SIU consultation on stone technology behind ureteroscopy

IntroductionUreteroscopy is now the most frequent treatment used around the world for stone disease. Technological advancement, efficiency, safety, and minimally invasiveness of this procedure are some of the reasons for this change of trend.Materials and methodsIn this review of the literature, a search of the PubMed database was conducted to identify articles related to ureteroscopy and accessories. The committee assigned by the International Consultation on Urological Disease reviewed all the data and produced a consensus statement relating to the ureteroscopy and all the particularities around this procedure.ConclusionThis manuscript provides literatures and recommendations for endourologists to keep them informed in regard to the preoperative, intraoperative, and postoperative consideration in regard of a ureteroscopy.

How well tolerated is supine percutaneous nephrolithotomy

Purpose of review Supine percutaneous nephrolithotomy (PCNL) has been described in 1988 and several modifications followed since. Despite claimed benefits, supine PCNL is still neglected by the majority of urologists. Lack of experience and the fear of complications are possible explanations for the resistance to supine positioning. This review evaluates recent literature on the use of supine PCNL, focussing on benefits and safety. Recent finding The Clinical Research Office of the Endourological Society Global Study and several (retrospective) reports comment on efficacy and safety of PCNL, differences in techniques, or identify conditions and patient factors for best practice. Anesthesiologic benefits (especially in the high risk, cardiopulmonary compromised, patient) and anatomical advantages are described in supine position theoretically favoring safety of supine PCNL. However, there are no prospective randomized studies conducted to support this assumption. Overall, benefits in efficacy or safety, of one position over the other, are not yet proven. Summary Supine PCNL has advantages in selected patients. Ultimately, the decision on position should be made on patients characteristics and surgeons preference and experience.

Bladder Cancer Segmentation on Multispectral Images

Nonmuscle Invasive Bladder Cancer (NMIBC) has high incidence, and close follow-up with cystoscopy is necessary due to its high recurrence rate after initial treatment, estimated to be as high as 75%. Because of the high recurrence rate, it is vital that the detection of bladder cancer is improved. Computer automated detection algorithms have shown to be exceptionally effective in achieving this goal. This paper presents the first automated segmentation algorithm for bladder cancer in endoscopic images. The second purpose of this study is to determine which modality is best suited for computer-aided segmentation of bladder cancer. Gabor and color features are extracted from 20 patients in four different modalities with a block-based strategy. Three different classifiers are used to classify the blocks and post-processing is applied to obtain a segmented region. The best classification results were obtained by using a support vector machine and the Spectrum B modality. Additionally, color features were found to be effective for obtaining segmentations comparable to experts.

Durability of Flexible Ureteroscopes: A Prospective Evaluation of Longevity, the Factors that Affect it, and Damage Mechanisms

BACKGROUND Flexible ureteroscopy is an established treatment modality for evaluating and treating abnormalities in the upper urinary tract. Reusable ureteroscope (USC) durability is a significant concern. OBJECTIVE To evaluate the durability of the latest generation of digital and fiber optic reusable flexible USCs and the factors affecting it. DESIGN, SETTING, PARTICIPANTS Six new flexible USCs from Olympus and Karl Storz were included. The primary endpoint for each USC was its first repair. Data on patient and treatment characteristics, accessory device use, ureteroscopy time, image quality, USC handling, disinfection cycles, type of damage, and deflection loss were collected prospectively. INTERVENTION Ureteroscopy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS USC durability was measured as the total number of uses and ureteroscopy time before repair. USC handling and image quality were scored. After every procedure, maximal ventral and dorsal USC deflection were documented on digital images. RESULTS AND LIMITATIONS A total of 198 procedures were performed. The median number of procedures was 27 (IQR 16-48; 14h) for the six USCs overall, 27 (IQR 20-56; 14h) for the digital USCs, and 24 (range 10-37; 14h) for the fiber optic USCs. Image quality remained high throughout the study for all six USCs. USC handling and the range of deflection remained good under incremental use. Damage to the distal part of the shaft and shaft coating was the most frequent reason for repair, and was related to intraoperative manual forcing. A limitation of this study is its single-center design. CONCLUSIONS The durability of the latest reusable flexible USCs in the current study was limited to 27 uses (14h). Damage to the flexible shaft was the most important limitation to the durability of the USCs evaluated. Prevention of intraoperative manual forcing of flexible USCs maximizes their overall durability. PATIENT SUMMARY Current flexible ureteroscopes proved to be durable. Shaft vulnerability was the most important limiting factor affecting durability.

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

V12-02 CONFOCAL LASER ENDOMICROSCOPY FOR BLADDER CANCER DIAGNOSIS: HOW TO DO IT & OUR PRELIMINARY RESULTS

tumor identification and characterization. Given their respective strengths and complementary characteristics, we postulate that combining wide-field (PDD and NBI) with microscopic (CLE) imaging technologies will further enhance TURBT. Towards that goal, we report our preliminary experience with multimodal enhanced cystoscopy. METHODS: The study received IRB approval. PDD was performed using hexaminolevulinate (Photocure) in combination with blue light cystoscope (Storz). NBI (Olympus) was performed with an NBIenabled camera head attached to the standard resectoscope. Probebased CLE was performed with fluorescein as the contrast agent along with 2.6 or 0.85 mm endomicroscopes (Cellvizio, Mauna Kea Technologies). Following TURBT with PDD or NBI, the resection bed was imaged with CLE. Imaging features of the resection bed were characterized by 3 urologists and achieved consensus. RESULTS: To date, 10 subjects have undergone multimodal imaging. No adverse events were noted due to the combination of instruments or imaging agents used. Confocal imaging features of the resection bed including elastin fibers (network of thin, interwoven strands), muscle fibers (sheets of straight, connected columns) and perivesical fat (collection of dark, round globules) were observed. Muscularis propria was present in the resected tissue on pathology assessment, confirming adequate resection. Patients are currently undergoing follow-up for cancer recurrence. CONCLUSIONS: We report real-time microscopic inspection of the resection bed to assess for adequate depth of resection with CLE in combination with the macroscopic imaging technologies PDD and NBI. Further studies are needed to determine if multimodal enhanced cystoscopy results in improved TURBT with adequate depth and margins of resection and decreased recurrence rate, which may eventually translate to a decreased need for repeat TURBT.

PD30-03 SAME SESSION BILATERAL URETEROSCOPY FOR MULTIPLE STONES: RESULTS FROM THE CLINICAL RESEARCH OFFICE OF ENDOUROLOGICAL SOCIETY (CROES) URETEROSCOPY (URS) GLOBAL STUDY

increased risk of sepsis and PUC was found in patients with fever at the initial presentation. Interestingly, PUC was more frequent in patients with lower serum magnesium levels. There was a significant correlation with time delay until the intervention and the risk of urosepsis and PUC, individually. CONCLUSIONS: Ureteroscopy is a safe option in evaluation of pregnant patients with unresolved renal colic. According to the current findings, timing of the operation is the most important factor affecting the septic risks and abortion threat. Surgical intervention with URS must be planned as soon as possible.

Same Session Bilateral Ureteroscopy for Multiple Stones: Results from the CROES URS Global Study

Purpose: This study presents a comparison of the international experience with ipsilateral and bilateral ureteroscopy for multiple, bilateral ureteral and renal stones vs single stone treatment. Patient and treatment characteristics and outcomes were compared. Materials and Methods: The CROES (Clinical Research Office of the Endourological Society) Ureteroscopy Global Study includes 114 centers in 32 countries. Patients undergoing bilateral ureteroscopy, ipsilateral ureteroscopy for multiple stones and ureteroscopy for a single stone were examined from January 2010 to October 2012. Intraoperative characteristics and postoperative outcomes were identified for each patient. Inverse probability weighted regression adjustment analyses were done to compare outcomes independent of differences among centers and patient characteristics. Results: The CROES Ureteroscopy Global Study consists of 11,885 patients. A total of 2,153 patients (18.7%) were treated for multiple stones, of whom 1,880 (87.3%) and 273 (12.7%) underwent ipsilateral and bilateral ureteroscopy, respectively. Inverse probability weighted regression adjustment models for bilateral vs ipsilateral ureteroscopy and multiple vs single stone treatments showed that patients with bilateral ureteroscopy and multiple stone treatments had lower stone‐free rates, higher re‐treatment rates and longer operative times compared to patients who underwent ipsilateral ureteroscopy and single stone treatment. There was no difference in complication rates among bilateral, ipsilateral and single stone ureteroscopy. Conclusions: This study presents a large series of patients who underwent bilateral and ipsilateral ureteroscopy. Our findings suggest a decrease in stone‐free rates, increased re‐treatment rates, increased operative times and longer hospital stay in patients treated for multiple stones. The treatment of multiple stones and bilateral ureteroscopy are safe compared to single stone treatment and ipsilateral ureteroscopy, respectively.