Jens Rassweiler

Laparoscopy vs. Robotics: Ergonomics – Does It Matter?

Laparoscopy has brought many benefits to patients mainly by reducing the peri-operative morbidity. On the other hand, the distribution of the technique is handicapped by the difficulty of the procedure due to some significant limitations concerning the ergonomics of this surgical technique. Even more, it had been recognized, that laparoscopic surgery can also harm laparoscopic surgeons and this phenomenon is now under worldwide investigation.

Augmented Reality for Percutaneous Renal Interventions

Optimal access to the renal collecting system or renal parenchyma guarantees a successful operation. The use of augmented reality to navigate the surgeon during endoscopic and percutaneous procedures is increasing. Marker-based iPad-assisted puncture of the renal collecting system shows more benefit for trainees with reduction of radiation exposure. 3D laser-assisted puncture of the renal collecting system using Uro Dyna-CT realised in an ex vivo model enables minimal radiation time. Electromagnetic tracking for puncture of the renal collecting system using a sensor at the tip of the ureteral catheter worked in an in vivo model of a porcine ureter and kidney. Attitude tracking for ultrasound-guided puncture of renal tumours by accelerometer reduces puncture error. Intraoperative navigation is helpful during percutaneous puncture of the collecting system and biopsy of renal tumour using various tracking techniques. Combination of different tracking techniques may further improve this interesting addition to video-assisted surgery.

Laparoscopic Sacrocolpopexy: Indications, Technique and Results

The introduction of the pelvic lymph node dissection by Schuessler in 1991 represented a milestone for urological laparoscopy [1] . Within the last 15 years, this minimally invasive technique experienced an enormous technical development. Initially, urological laparoscopy was limited by technical problems such as subtle hemostasis or the difficulties with endoscopic suturing [2] . However, following the successful introduction of laparoscopic radical prostatectomy by Gaston, Guillonneau, and Vallancien in 1999, a significant increase of interest was observed [3– 5] . In 2001, Binder and Kramer performed the first robot-assisted laparoscopic radical prostatectomy using the da Vinci device [6] . However, in 2003, Menon and Ahlering showed the easy transfer of robotic-assisted from open radical prostatectomy, which thereafter revolutionized the management of localized prostate cancer in the United States [7, 8] . In 2007, almost 60% of all radical prostatectomies are performed with the da Vinci system. Interestingly, all these developments based on extensive experience with laparoscopic sacrocolpopexy by Gaston [5] . The technique of sacral fixation of the vagina for correction of genital prolapse (promontofixation) was first described in the year 1889, respectively, 1892, by Freund and Zweifel using a transperitoneal as well as a transvaginal approach [9] , but it was Ameilen Hugier who in 1957 presented a more detailed description of open sacral colpopexy [10] . Miller described in 1927 a transvaginal colpopexy to the sacrospinal ligaments [11] , which was further modified by various authors including Richter and Albrich [12] . Scali in 1974 proposed the suspension by placement of prosthetic slings between the vagina and the bladder, which was anchored to the sacral promontory [13] . In the early 1990s, the gynecologists Dorsey and Nezhat described a laparoscopic sacropexy [14, 15] . In contrast to the technique of laparoscopic bladder neck suspension or colposuspension, which has not been performed frequently after its introduction due to worse results, respectively, recent less invasive techniques such as tension-free vaginal tape (TVT) or (TOT) [16, 17] , laparoscopic sacrocolpopexy is used increasingly for pelvic floor repair [10, 18– 22] . In 2004, Di Marco reported the successful use of the da Vinci robot for a robotic-assisted laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse [23] followed by others [24]. In this chapter, we want to outline the indications and technical approach of laparoscopic sacrocolpopexy together with an analysis of results reported by other authors, particularly in comparison to new techniques, such as tension-free vaginal mesh (TVM) for repair of pelvic organ prolapse (POP).

Laparoscopic Radical Hysterectomy (LRH) with Anterior and Posterior Exenteration: Urological Perspectives

Objectives: Laparoscopic and robot-assisted radical cystectomy has become an established procedure in management of muscle-invasive bladder cancer and even accepted in the actual EAU-guidelines. 18 % of patients are women. The majority of female patients undergo anterior exenteration. In gynaecology, the main indications include invasive carcinoma of cervix stage IVA and IVB, respectively advanced endometrial cancer with isolated invasion in the bladder (FIGO IVA) and stage T3 (FIGO III) of vulvar cancer. Beside the ablative part, the form of urinary diversion becomes an important factor with significant impact on the quality of life for the patient, but also regarding complexity and morbidity of the procedure particularly when performed laparoscopically. There is an increasing experience with laparoscopic or robot-assisted ileal conduit and neobladders.

Validation of a novel cost effective easy to produce and durable in vitro model for kidney-puncture and PNL-Simulation

INTRODUCTION Nephrolithiasis is one of the most common diseases in urology. According to the EAU Guidelines, a percutaneous nephrolitholapaxy (PNL) is recommended when treating a kidney stone >2 cm. Nowadays, PNL is performed even for smaller stones (<1 cm) using miniaturized instruments. The most challenging part of any PNL is the puncture of the planned site. PNL-novice surgeons need to practice this step in a safe environment with an ideal training model. We developed and evaluated a new, easy to produce, in vitro model for the training of the freehand puncture of the kidney. MATERIALS AND METHODS Porcine kidneys with ureters were embedded in ballistic gel. Food coloring and preservative agent were added. We used the standard imaging modalities of X-ray and ultrasound to validate the training model. An additional new technique, the iPAD-guided puncture, was evaluated. Five novices and three experts conducted 12 punctures for each imaging technique. Puncture time, radiation dose, and number of attempts to a successful puncture were measured. Mann-Whitney-U, Kruskal-Wallis, and U-Tests were used for statistical analyses. RESULTS The sonography-guided puncture is slightly but not significantly faster than the fluoroscopy-guided puncture and the iPAD-assisted puncture. Similarly, the most experienced surgeons time for a successful puncture was slightly less than that of the residents, and the experienced surgeons needed the least attempts to perform a successful puncture. In terms of radiation exposure, the residents had a significant reduction of radiation exposure compared to the experienced surgeons. CONCLUSION The newly developed ballistic gel kidney-puncture model is a good training tool for a variety of kidney-puncture techniques, with good content, construct, and face validity.Abstract Introduction: Nephrolithiasis is one of the most common diseases in urology. According to the EAU Guidelines, a percutaneous nephrolitholapaxy (PNL) is recommended when treating a kidney s...

Extrakorporale Stoßwellentherapie der Urolithiasis

Die extrakorporale Stoswellenlithotripsie (ESWL) ist seit 1985 ein etabliertes Therapieverfahren der Urolithiasis. Ausgehend vom Dornier HM3 hat die Entwicklung neuer Lithotriptoren mehrere Phasen durchlaufen, wobei zunachst auf alternative Stoswellenquellen und die Integration in multifunktionelle urologische Rontgenarbeitsplatze Wert gelegt wurde. In jungster Zeit bestehen zunehmend Zweifel an der Effektivitat des Verfahrens im Vergleich zu endoskopischen Techniken. Dieser Trend wird auch dadurch unterstutzt, dass Harnleitersteine, die meist notfallmasig mit endourologischen Techniken (Stent, Ureteroskopie) behandelt werden konnen, deutlich zunehmen. Die Patienten wunschen bevorzugt die komplette Steinsanierung in einer Sitzung, statt nach mehreren ESWL-Sitzungen auf das Abgehen der Steinfragmente warten zu mussen. In Deutschland kommt hinzu, dass nur noch eine ESWL-Sitzung pro Jahr ambulant abgerechnet werden kann. Die deutliche Abnahme der ESWL im Vergleich zu anderen Verfahren betrifft vor allem Nierensteine groser 1 cm und Harnleitersteine. Jungere Studien zum Mechanismus der Steindesintegration und der Applikationstechniken der Stoswelle haben allerdings ein erneutes Umdenken bezuglich des Stellenwerts der ESWL angestosen.

Re: Willem M. Brinkman, Irene M. Tjiam, Barbara M.A. Schout, et al. Results of the European Basic Laparoscopic Urological Skills Examination. Eur Urol 2014;65:490–6

We read with great interest the study by Brinkman et al. investigating the level of laparoscopic skills of final-year residents in urology in Europe [1]. The authors pursued this aim by looking at the results of the European Basic Laparoscopic Urological Skills (E-BLUS) examination taken by the residents during the European Urology Residents Education Program in 2011 and 2012. The same group first conceived and introduced, at a national level in the Netherlands, the program for laparoscopic urologic skills (PLUS), demonstrating its face, content and construct validity [2]. The exam is quite straightforward in its design, consisting of five standardized tasks that are scored according to preestablished parameters. One interesting, probably not surprising, finding in their study is that when combining time and quality parameters, only 4.2% of the participants passed the examination according to the validated criteria. Moreover, 61% of the residents stated that they did not have the opportunity to receive structured training in laparoscopy during residency. These findings recall those of previous surveys conducted in Europe and reported in this journal [3] and in other urologic journals [4], highlighting the same enduring, unmet need (for both urologists in training and not) for access to adequate training in laparoscopic techniques [5]. Ultimately, laparoscopy still carries the burden of being a very appealing technique with a limited cost when compared with robotic surgery but negatively and persistently marked by a very steep learning curve. In this regard, we would like to point out that technological advancements can somehow foster the spread of laparoscopic skills. We recently assessed the potential impact that last-generation three-dimensional (3D) imaging can have on laparoscopic performance [6]. We conducted a prospective observational study during the 4th Minimally Invasive Urological Surgical Week course held in Braga, Portugal. The course participants (and faculty) were asked to

Robot-Assisted Laparoscopic Ureteral Reimplantation

Clinical indications for ureteral reconstruction include strictures, trauma (often iatrogenic), vesicoureteral reflux (VUR), fistulas and malignancy. Traditional open surgery remains the gold standard for ureteral reimplantation with good long-term results (success rates over 90%) (Campbell’s urology, Philadelphia, p. 2347, 2003; Stief et al., Br J Urol 91:138–142, 2003; Ahn and Laughlin, Urology 58:184–187, 2001). Short ureteral defects can be managed by uretero-ureterostomy or ureteroneocystostomy. Longer defects require complex procedures such as psoas hitch ureteral reimplantation often combined with a Boari flap.

Current State of Laparoscopic and Robotic Surgery

Minimally invasive surgical innovation has exploded in recent times. Currently, conventional laparoscopy is most widely adopted as the costs are relatively low. However, robotics and single port surgery are leading a revolution in surgery for wealthy health-care systems. We explore the historical and contemporary areas of this evolution.

Upper Urinary Tract (Kidney, Ureter and Adrenal Gland)

Whilst the patient is supine, following induction of anaesthesia, a urinary catheter is inserted. The patient is now rotated to the lateral position and the urinary bag is placed either at the top or bottom end of the bed for access by the anaesthetist. The legs are separated and protected with either pillows or a specially designed foam or rubber device between them as seen in the inset, in order to relieve any weight on pressure points, while the legs are slightly flexed at the knees. All other bony points, including shoulders and hips, are protected by the rubber or foam mat that is positioned on the operating table. The head and neck are supported with either pillows or a rubber head ring in order to maintain them in a neutral position. Depending on the softness of the table mattress, an axillary rubber roll may be required (not illustrated in these images) to prevent brachial plexus injury.