Mantu Gupta

Nomenclature of Natural Orifice Translumenal Endoscopic Surgery (NOTES™) and Laparoendoscopic Single-Site Surgery (LESS) Procedures in Urology

INTRODUCTION The twenty first century has witnessed some amazing advancements in surgery. In urology minimally invasive surgery has become the standard treatment for many disease processes and procedures. One of the newest innovations into this field has been the development of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Laparoendoscopic Single-site Surgery (LESS). While the practice and application of these new techniques are in their infancy, there has been a great deal of confusion regarding the nomenclature and terminology associated with these procedures. The aim of this publication is to attempt to define the many issues associated with the standardization of terminology for these procedures in order to promote effective scientific progress and communication. MATERIALS AND METHODS A literature search using Medline and pubmed focusing on all terminology to describe NOTES and LESS from 1990 to 2008 was done. In addition, various acronyms were searched using four separate online acronym databases. The information was recorded by number of citations and by the number of citations specific to the urologic literature. Based on common usage, definitions and criteria were developed to describe these procedures for current scientific publication. These terms were then collectively reviewed and agreed upon by the Urologic NOTES Working Group as a platform for consensus to begin the arduous process of standardization. RESULTS There is wide variation in the terminology and use of acronyms for natural orifice translumenal endoscopic surgery and laparo-endoscopic single-site surgery. The keyword literature search uncovered 8710 citations from MEDLINE and pubmed, with 363 citations specific to urology. There was significant overlap in the search of different terms. The search of established abbreviation and acronym databases revealed many citations, but relatively few specific to urology. CONCLUSION Standardization of the nomenclature applied to natural orifice transluminal endoscopic surgery (NOTES) and laparo-endoscopic single-site surgery (LESS) is essential as the body of literature continues to grow in order to allow clear and precise scientific communication. As the techniques continue to evolve, we propose that NOTES and LESS be designated as the common terms to define these new procedures in urology.

Treatment of proximal ureteral calculi: holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy.

PURPOSE We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. MATERIALS AND METHODS A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. RESULTS Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. CONCLUSIONS Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.

Consensus statement on natural orifice transluminal endoscopic surgery and single-incision laparoscopic surgery: heralding a new era in urology?

Matthew T. Gettman *, Geoffrey Box , Timothy Averch , Jeffrey A. Cadeddu , Edward Cherullo , Ralph V. Clayman , Mihr Desai , Igor Frank , Indebir Gill , Mantu Gupta , Georges-Pascal Haber , Mitchell Humphreys , Jihad Kaouk , Jaime Landman , Estevao Lima , Lee Ponsky e Mayo Clinic, Department of Urology, Rochester, MN, United States University of California Irvine, CA, United States University of Pittsburgh Medical Center, PA, United States University of Texas Southwestern Medical Center, Dallas, TX, United States Case Western Reserve University, Cleveland, OH, United States Cleveland Clinic, Cleveland, OH, United States Columbia University Medical Center, New York, NY, United States University of Minho, School of Health Science, Braga, Portugal

Where do we really stand with LESS and NOTES

Matthew T. Gettman *, Wesley M. White, Monish Aron, Riccardo Autorino, Tim Averch, Geoffrey Box, Jeffrey A. Cadeddu, David Canes, Edward Cherullo, Mihir M. Desai, Igor Frank, Indebir S. Gill, Mantu Gupta, Georges-Pascal Haber, Mitchell R. Humphreys, Brian H. Irwin, Jihad H. Kaouk, Louis R. Kavoussi, Jaime Landman, Evangelos N. Liatsikos, Estevao Lima, Lee E. Ponsky, Abhay Rane, Maria Ribal, Robert Rabenhalt, Pradeep Rao, Lee Richstone, Mark D. Sawyer, Rene Sotelo, Jens-Uwe Stolzenburg, Chad R. Tracy, Robert J. Stein; Endourological Society NOTES and LESS Working Group; European Society of Urotechnology NOTES and LESS Working Group E U RO P E AN URO LOGY 5 9 ( 2 0 1 1 ) 2 3 1 – 2 3 4

Skin to Stone Distance Is an Independent Predictor of Stone-Free Status Following Shockwave Lithotripsy

INTRODUCTION In recent years several new parameters such as Hounsefield unit density and skin to stone distance (SSD) have been determined to correlate with successful extracorporeal shockwave lithotripsy (SWL). SSD has been shown to independently predict successful SWL for lower pole calculi. The objective of this study was to determine which stone characteristics on noncontrast computed tomography (NCCT), including SSD, independently predict for SWL success regardless of stone location within the kidney. MATERIALS AND METHODS A retrospective review of all 1282 SWL procedures between 2004 and 2007 at a single institution revealed 83 patients meeting inclusion criteria for current study. All patients were treated using a single electromagnetic lithotriptor (DoLi 50; Dornier Medical Systems, Marrieta, GA) with a single technician. Stone-free (SF) status was determined by NCCT or abdominal plain film radiographs at 6 weeks post-SWL. Logistic regression analysis was computed to assess SF rates using SSD, stone size, location, and Hounsefield unit density as predictors. RESULT Of the 83 patients, 51 were SF and 32 had residual stones at a mean follow-up of 2.3 months. The mean SSD in the SF group was 83.3 +/- 21.9 mm in comparison to those in the residual stone group who had a mean SSD of 107.7 +/- 28.9 mm (p < or = 0.05). Multivariate logistic regression analysis revealed that SSD was the only significant independent predictor of treatment outcome. CONCLUSION SSD is an easily measured parameter on NCCT that independently correlates with SWL efficacy in treating stones in all locations.

Ureteroscopic management of upper tract transitional cell carcinoma

The expanding experience with endoscopic techniques for treating upper tract urothelial malignancy demonstrates its safety and efficacy in carefully selected patients. Diagnostic accuracy can be enhanced, and pathologic confirmation of tumor grade and stage is possible. In carefully selected patients who have low-grade and low-stage disease, the results of endourologic management have been encouraging. Patients with an anatomic or functionally solitary kidney, bilateral disease, or significant renal insufficiency can often be considered candidates for endoscopic treatment as the first line of therapy. In the setting of low-grade, low-stage disease in a patient with a normal contralateral kidney, the role of endourologic management remains controversial. Adjuvant topical therapy with mitomycin C or BCG seems to be safe and well tolerated after endoscopic management of upper tract TCC.

Post-Percutaneous Nephrolithotomy Systemic Inflammatory Response: A Prospective Analysis of Preoperative Urine, Renal Pelvic Urine and Stone Cultures

PURPOSE Prior studies suggest that renal pelvic urine culture is a more accurate predictor of urosepsis. We prospectively determined the correlation between preoperative bladder urine cultures, intraoperative renal pelvis cultures and stone cultures in patients undergoing percutaneous nephrolithotomy. We also examined post-procedure risk factors for systemic inflammatory response syndrome. MATERIALS AND METHODS From February 2009 to February 2011 urine samples from the bladder and renal pelvis were collected from patients undergoing percutaneous nephrolithotomy. Extracted stones were also sent for culture analysis. Postoperatively patients were closely monitored for any signs of systemic inflammatory response syndrome. The concordance of urine and stone cultures across different sites was examined. Regression analysis was done to identify clinical variables associated with systemic inflammatory response syndrome. RESULTS A total of 204 percutaneous nephrolithotomies were done in 198 patients, of whom 20 (9.8%) had evidence of systemic inflammatory response syndrome postoperatively, including 6 (30%) requiring intensive care. The concordance among stone, renal pelvic and preoperative cultures was 64% to 75% with the highest concordance between renal pelvic urine and stone cultures. In a multivariate model multiple access tracts and a stone burden of 10 cm(2) or greater were significant predictors of systemic inflammatory response syndrome postoperatively. CONCLUSIONS Even appropriately treated preoperative urinary infections may not prevent infected urine at percutaneous nephrolithotomy. Renal pelvic urine and stone cultures may be the only way to identify the causative organism and direct antimicrobial therapy. We recommend collecting pelvic urine and stone cultures to identify the offending organism in patients at risk for sepsis, particularly those with a large stone burden requiring multiple access tracts.

Validating the Use of the Mimic dV-trainer for Robotic Surgery Skill Acquisition Among Urology Residents

OBJECTIVE To compare robotic surgery skill acquisition of residents trained with Mimic dVTrainer (MdVT) and da Vinci Surgical System (dVSS) console. No standardized curriculum currently exists for robotic surgical education. The MdVT is a compact hardware platform that closely reproduces the experience of the dVSS. METHODS Sixteen urology trainees were randomized into 3 groups. A baseline evaluation using dVSS was performed and consisted of 2 exercises requiring endowrist manipulation (EM), camera movement and clutching (CC), needle control (NC), and knot-tying (KT). Groups 1 and 2 completed a standardized training curriculum on MdVT and dVSS, respectively. Group 3 received no additional training. After completion of the training phase, all trainees completed a secondary evaluation on dVSS consisting of the same exercises performed during baseline evaluation. RESULTS There was no difference in baseline performance scores across the 3 groups. Although Group 3 showed no significant improvement in EM/CC domain (P = .15), Groups 1 and 2 had statistically significant improvement in EM/CC domain (P = .039 and P = .007, respectively). The difference in improvement between Groups 1 and group 2 was not statistically different (P = .21). Only Group 2 trainees showed significant improvement in the NC and KT domains during secondary evaluation (P = .02). CONCLUSION Curriculum-based training with MdVT or dVSS significantly improves robotic surgery aptitude. Similar improvements are seen for exercise domains shared between MdVT and dVSS groups. Follow-up studies are necessary to assess the efficacy of MdVT over a wider spectrum of domains.

Tips and Tricks for the Management of Retained Ureteral Stents

BACKGROUND AND PURPOSE Retained ureteral stents, especially those that are encrusted and associated with a stone burden, can be a difficult management problem. We review our experience and the different options employed for treating this complication. PATIENTS AND METHODS From July 1998 to February 2002, 26 retained ureteral stents were managed in our department. The average patient age was 45.9 years (range 8-77 years). The average time the stent had been in place was 10.7 months (range 3-28 months). Prior to planning definitive therapy, a plain radiograph with tomographic views was reviewed. RESULTS A guidewire or Glidewire was often placed adjacent to the stent in order to maintain ureteral access and in some cases was able to facilitate removal of the retained stent. The patients required an average of 2.7 endourologic procedures (range 1-4) performed at one or more sessions to remove the stent and all associated stone burden. If the stone burden could not be entirely removed then stent extraction and subsequent sessions were performed until stone-free status was achieved. Cystolitholapaxy was required to treat the distal component of stent encrustation in 20 cases. Percutaneous nephrolithotomy was performed in four patients, antegrade ureteroscopy with or without intracorporeal lithotripsy in four patients, retrograde ureteroscopy with or without laser lithotripsy in five patients, and extracorporeal shockwave lithotripsy in seven patients to treat the proximal component of stent encrustation. The stent could be removed in a single anesthetic session in 23 of 26 cases (88.5%). Analysis revealed that the major component of the encrustations was a combination of calcium oxalate and phosphate. CONCLUSION Successful management of retained ureteral stents requires careful planning and may entail a combination of endourologic approaches. It is imperative to avoid using significant force, which can result in severe ureteral injury or breakage of the stent. If encrustations are present along the stent, we believe in treating the distal component prior to managing any proximal or ureteral components.

Silodosin to Facilitate Passage of Ureteral Stones: A Multi-institutional, Randomized, Double-blinded, Placebo-controlled Trial

BACKGROUND Using a selective α-blocker for medical expulsive therapy (MET) is a cost-effective treatment approach widely used for ureteral stones. OBJECTIVE To evaluate the efficacy of silodosin, a selective α-1a receptor antagonist, in this setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, phase 2 study conducted in adult patients with a unilateral ureteral calculus of 4-10mm. Of 239 patients in the safety population, six discontinued due to adverse events. INTERVENTION Patients were randomized 1:1 to receive silodosin 8 mg or placebo for up to 4 wk. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was spontaneous stone passage, analyzed using logistic regression. Secondary outcomes included time to stone passage, emergency room (ER) visits, hospital admissions, analgesic use, and incidence and severity of pain. RESULTS AND LIMITATIONS No significant differences between the silodosin and placebo groups were observed for passage rate of all stones (52% vs 44%, respectively; p=0.2). However, silodosin achieved a significantly greater rate of distal ureter stone passage than placebo (p=0.01). Significant differences were not observed for ER visits, hospital admission, or use of analgesics. The number of patients in the intent-to-treat population was slightly below the calculated sample size (232 vs 240) and sample sizes were not calculated for subgroup analyses. CONCLUSIONS This is among the first prospective, randomized, multi-institutional trials to examine the efficacy of a selective α-1a antagonist as MET in patients with ureteral calculi and did not demonstrate a benefit to the entire ureter. However, silodosin was found to be well tolerated and beneficial in facilitating the passage of distal ureteral stones, warranting additional future studies on distal stone elimination. PATIENT SUMMARY In this report, we looked at the efficacy of silodosin for the treatment of ureteral stones. We found that silodosin increased passage of distal ureteral stones.