Marie-Claire Rassweiler

The past, present and future of minimally invasive therapy in urology: A review and speculative outlook

Abstract Introduction: Twenty-five years of SMIT represents an important date. In this article we want to elaborate the development of minimally invasive surgery in urology during the last three decades and try to look 25 years ahead. Material and methods: As classical scenarios to demonstrate the changes which have revolutionized surgical treatment in urology, we have selected the management of urolithiasis, renal tumour, and localized prostate cancer. This was based on personal experience and a review of the recent literature on MIS in Urology on a MEDLINE/PUBMED research. For the outlook to the future, we have taken the expertise of two senior urologists, middle-aged experts, and upcoming junior fellows, respectively. Results: Management of urolithiasis has been revolutionized with the introduction of non-invasive extracorporeal shock wave lithotripsy (ESWL) and minimally invasive endourology in the mid-eighties of the last century obviating open surgery. This trend has been continued with perfection and miniaturization of endourologic armamentarium rather than significantly improving ESWL. The main goal is now to get rid of the stone in one session rather in multiple non-invasive treatment sessions. Stone treatment 25 years from today will be individualized by genetic screening of stone formers, using improved ESWL-devices for small stones and transuretereal or percutaneous stone retrieval for larger and multiple stones. Management of renal tumours has also changed significantly over the last 25 years. In 1988, open radical nephrectomy was the only therapeutic option for renal masses. Nowadays, tumour size determines the choice of treatment. Tumours >4 cm are usually treated by laparoscopic nephrectomy, smaller tumours, however, can be treated either by open, laparoscopic or robot-assisted partial nephrectomy. For patients with high co-morbidity focal tumour ablation or even active surveillance represents a viable option. In 25 years, imaging of tumours will further support early diagnosis, but will also be able to determine the pathohistological pattern of the tumour to decide whether the patient requires removal, ablation or active surveillance. Management of localized prostate cancer underwent significant changes as well. 25 years ago open retropubic nerve-sparing radical prostatectomy was introduced as the optimal option for effective treatment of the cancer providing minimal side-effects. Basically, the same operation is performed today, but with robot-assisted laparoscopic techniques providing 7-DOF instruments, 3D-vision and tenfold magnification and enabling the surgeon to work in a sitting position at the console. In 25 years, prostate cancer may be managed in most cases by focal therapy and/or genetically targeting therapy. Only a few patients may still require robot-assisted removal of the entire gland. Discussion: There has been a dramatic change in the management of the most frequent urologic diseases almost completely replacing open surgery by minimally invasive techniques. This was promoted by technical realisation of physical principles (shock waves, optical resolution, master-slave system) used outside of medicine. The future of medicine may lie in translational approaches individualizing the management based on genetic information and focalizing the treatment by further improvement of imaging technology.

New technology in ureteroscopy and percutaneous nephrolithotomy.

Purpose of review New developments of retrograde intrarenal and percutaneous endoscopic surgery for nephrolithiasis have significantly enhanced the indications of endourology compared to extracorporeal shock wave lithotripsy. We want to review the most significant new technologies Recent findings New technology to access the renal collecting system includes marker-based tracking with iPAD, laser-guided puncture on (Uro)Dyna-CT, electromagnetic tracking (only experimental), and optical tracking for ultrasound-guided puncture. Miniaturization percutaneous nephrolithotomy has been further extended and classified to Midi-PCNL (20-22F/L), Mini-PCNL (16-18F/M), Ultra/Super-mini-PCNL (12-14F/S), and Micro-PCNL (8-10F/XS). Knowledge of Ho:YAG-laser lithotripsy including power settings for fragmentation (depending on stone composition), dusting (0.5J/20Hz), and popcorn-effect/laser-burst (1J/30Hz) becomes mandatory. Also hydrodynamic mechanisms for retrieval of fragments (active/passive washout, purging, vacuum-cleaner-effect) have gained importance. Improvements of FURS focus on digital-HD-video-technology with post-processing software (NBI/SPIES) providing better resolution and increased optical field, further miniaturization of endoscopes to fit in smaller access sheath (12/14F), additional tip-less Nitinol baskets and graspers, and introduction of a robotic device (Avicenna Roboflex) to improve ergonomics of the procedure. Summary Based on recent technical developments, percutaneous nephrolithotomy and particularly flexible ureteroscopy will further gain preference in management of urolithiasis compared to ESWL. Endourology may offer a higher rate of primary success with minimal side-effects which could weigh out the slightly higher degree of invasiveness.

Classification of Complications: Is the Clavien-Dindo Classification the Gold Standard?

We congratulate de la Rosette et al. for focusing on the practicability of standardised documentation of complications following percutaneous nephrolithotomy (PCNL) [1]. The Clinical Research Office of the Endourological Society PCNL Study Group database [2] will permit us to (1) collect and analyse all complications, (2) summarise and classify complications using the Clavien-Dindo system, (3) create a set of complications-management combinations, and (4) evaluate the intersurgeon validity of the Clavien system using an Internet-based survey. The paper by de la Rosette et al. will stimulate discussion about several topics.

The Uro Dyna-CT Enables Three-dimensional Planned Laser-guided Complex Punctures.

BACKGROUND Ultrasound and fluoroscopy are the standard imaging techniques used to perform punctures in urology. Cross-sectional and three-dimensional (3D) imaging may enable safer procedures, especially in complex cases. OBJECTIVES To assess the feasibility of 3D planned laser-guided punctures in urology performed with the Uro Dyna-CT (Siemens Healthcare Solutions, Erlangen, Germany). DESIGN, SETTING, AND PARTICIPANTS A total of 27 punctures using the laser-guided system syngo iGuide (Artis Zee Ceiling; Siemens Healthcare Solutions, Erlangen, Germany) for the Uro Dyna-CT have been performed to date. Patients with complex puncture indications due to unclear ultrasound findings or a suspicion of surrounding bowel were included. SURGICAL PROCEDURE Image acquisition was performed using a customized 8s syngo iGuide protocol of the Uro Dyna-CT. The puncture tract was planned after 3D and cross-sectional image reconstruction. The puncture was performed supported by the laser-guiding system. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point of our assessment was accuracy and applicability of the system in a clinical setting. Secondary end points were planning time, puncture time, and radiation exposure of the patient. RESULTS AND LIMITATIONS Overall, 24 of 27 punctures were successful. No severe complications occurred. Median radiation dose of the Uro Dyna-CT scan was 6113.1 micrograys meter squared (μGym(2); range: 1081.6-7957.2μGym(2)). The small patient cohort is the major limitation of our study. CONCLUSIONS We believe the Uro Dyna-CT-based puncture technique is an excellent additional instrument that allows the urologist to handle complex punctures. Image acquisition leads to higher radiation doses than standard fluoroscopy but does not exceed the radiation exposure of alternative procedures such as computed tomography (CT)-guided punctures with multidetector CT, which is used mainly for complex cases. PATIENT SUMMARY We report our experience with a three-dimensional planning and laser-guiding tool to perform complex punctures for urologic indications. The technique is feasible in the endourologic intervention suite.

Extracorporeal shock wave lithotripsy: An opinion on its future.

The development of miniaturized nephroscopes which allow one-stage stone clearance with minimal morbidity has brought the role of shock wave lithotripsy (SWL) in stone management into question. Design innovations in SWL machines over the last decade have attempted to address this problem. We reviewed the recent literature on SWL using a MEDLINE/PUBMED research. For commenting on the future of SWL, we took the subjective opinion of two senior urologists, one mid-level expert, and an upcoming junior fellow. There have been a number of recent changes in lithotripter design and techniques. This includes the use of multiple focus machines and improved coupling designs. Additional changes involve better localization real-time monitoring. The main goal of stone treatment today seems to be to get rid of the stone in one session rather than being treated multiple times non-invasively. Stone treatment in the future will be individualized by genetic screening of stone formers, using improved SWL devices for small stones only. However, there is still no consensus about the design of the ideal lithotripter. Innovative concepts such as emergency SWL for ureteric stones may be implemented in clinical routine.

Influence of endourological devices on 3D reconstruction image quality using the Uro Dyna-CT.

PurposeThe urological Dyna-CT (Uro Dyna-CT) was established in clinical use for classical imaging as well as for interventional surgery. To evaluate whether irradiation artefacts may occur during interventional surgery, we analysed the impact of different instruments on 3D reconstruction in the Uro Dyna-CT.Materials and methodsTen different endourological instruments [ureterorenoscope (URS)-fibrescope, percutaneous nephrolithotomy (PCNL) working sheath] and accessory equipments such as ureteral catheter, guide wires and stents (DJ, MJ) were introduced in a porcine renal pelvis either retrograde via the ureter or transparenchymally. Subsequently, digital fluoroscopy, standard X-ray and an Uro Dyna-CT were performed. Three colleagues evaluated the image quality independent from each other.ResultsThere were basically no limitations regarding image quality in digital fluoroscopy and standard X-ray. In the Uro Dyna-CT, only with the URS fiberscope and the PCNL working sheath, small artefacts and irradiations were detected, whereas ureteric catheter with and without wire, as well as the hydrophilic guide wire, showed no artefacts at all. The remaining material demonstrated minimal artefacts, which did not affect the image quality.ConclusionsThe Uro Dyna-CT can be used for all interventional endourological procedures using the common armamentarium and instruments without significant limitation of image quality. There are only minor limitations according a PCNL working sheath and the rigid URS. These instruments should be removed out of the examination field before performing the computed tomography and be replaced afterwards by using a safety wire.

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.

Neue Punktionstechniken in der Urologie mittels 3D-gestützter Bildgebung

The selective use of various puncture techniques for diagnostic or therapeutic purposes is a component of the daily routine of urologists. The aim of these interventions is always a safe and rapid puncture at the appropriate target point. Nowadays, imaging systems are increasingly being used in urology with the aim to achieve a more precise and safer planning and execution of punctures through an increased accuracy by the use of 3D representation. An approach to the solution to achieve this aim is the fusion of 3D reconstruction by magnetic resonance imaging (MRI) or computed tomography< (CT) with real-time imaging procedures, such as sonography or fluoroscopy.ZusammenfassungDer gezielte Einsatz verschiedener Punktionstechniken in diagnostischer oder therapeutischer Absicht ist Bestandteil der alltäglichen Arbeit eines Urologen. Das Ziel dieser Interventionen ist immer eine sichere und zügige Punktion des jeweiligen Zielpunktes. Heutzutage finden zunehmend bildgebende Systeme Einsatz in der Urologie, die durch die Anwendung von dreidimensionaler (3D-)Darstellungen die Planung und Durchführung von Punktionen durch eine höhere Zielgenauigkeit sicherer und exakter machen sollen. Ein Lösungsansatz zur Erfüllung dieses Wunsches ist die Fusion von 3D-Rekonstruktionen aus MRT- oder CT-Untersuchungen mit bildgebenden Verfahren mit Echtzeitdarstellung wie der Sonographie oder der Durchleuchtung.AbstractThe selective use of various puncture techniques for diagnostic or therapeutic purposes is a component of the daily routine of urologists. The aim of these interventions is always a safe and rapid puncture at the appropriate target point. Nowadays, imaging systems are increasingly being used in urology with the aim to achieve a more precise and safer planning and execution of punctures through an increased accuracy by the use of 3D representation. An approach to the solution to achieve this aim is the fusion of 3D reconstruction by magnetic resonance imaging (MRI) or computed tomography< (CT) with real-time imaging procedures, such as sonography or fluoroscopy.

Komplikationen bei der perkutanen Steinbehandlung@@@Complications in percutaneous lithotomy

BACKGROUND Percutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them. OBJECTIVES Relevant steps of percutaneous stone treatment with possible complications and their management are presented. MATERIALS AND METHODS Current topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented. RESULTS Careful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss. CONCLUSIONS Percutaneous stone treatment is a safe and effective therapy in an experienced physicians hands. Careful planning and accurate performance help to avoid severe complications.ZusammenfassungHintergrundDie perkutane Nephrolithotomie stellt in der Behandlung größerer Nierensteine den Goldstandard der Therapie dar. Einzelne Schritte des Eingriffs können mit schwerwiegenden Komplikationen behaftet sein, deren Erkennung und Behandlung von größter Wichtigkeit bei der optimalen Patientenversorgung sind.Ziel der ArbeitEs werden die wichtigsten Schritte des Eingriffs und mögliche Komplikationen sowie Strategien zur Erkennung und Behandlung derselben dargestellt.Material und MethodenDie Arbeit berücksichtigt Übersichtsarbeiten mit der Analyse großer Patientenkollektive und Darstellung einzelner, seltener Komplikationen mit Lösungswegen.ErgebnisseSorgfältige präoperative Diagnostik und Indikationsstellung sind essentiell für die sichere Durchführung einer perkutanen Steintherapie. Die komplikationsträchtigsten Operationsschritte sind die Punktion des Nierenbeckenkelchsystems und die Dilatation des Zugangsweges. Die häufigste Komplikation stellen Blutungen dar, gefolgt von infektiologischen Problemen. Die Möglichkeit einer notfallmäßigen radiologischen interventionellen Versorgung ist ein wichtiges Sicherheitsnetz zur Durchführung des Eingriffs und verhindert die operative Versorgung von Blutungskomplikationen mit möglichem Organverlust in den meisten Fällen.SchlussfolgerungenDie perkutane Nephrolithotomie stellt in der Hand eines Experten eine sichere und effektive Steintherapie dar. Eine optimale Planung und exakte Punktion stellen die wichtigsten Eckpfeiler zur Vermeidung schwerwiegender Komplikationen dar.AbstractBackgroundPercutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them.ObjectivesRelevant steps of percutaneous stone treatment with possible complications and their management are presented.Materials and methodsCurrent topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented.ResultsCareful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss.ConclusionsPercutaneous stone treatment is a safe and effective therapy in an experienced physician’s hands. Careful planning and accurate performance help to avoid severe complications.

Complications in percutaneous lithotomy

BACKGROUND Percutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them. OBJECTIVES Relevant steps of percutaneous stone treatment with possible complications and their management are presented. MATERIALS AND METHODS Current topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented. RESULTS Careful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss. CONCLUSIONS Percutaneous stone treatment is a safe and effective therapy in an experienced physicians hands. Careful planning and accurate performance help to avoid severe complications.ZusammenfassungHintergrundDie perkutane Nephrolithotomie stellt in der Behandlung größerer Nierensteine den Goldstandard der Therapie dar. Einzelne Schritte des Eingriffs können mit schwerwiegenden Komplikationen behaftet sein, deren Erkennung und Behandlung von größter Wichtigkeit bei der optimalen Patientenversorgung sind.Ziel der ArbeitEs werden die wichtigsten Schritte des Eingriffs und mögliche Komplikationen sowie Strategien zur Erkennung und Behandlung derselben dargestellt.Material und MethodenDie Arbeit berücksichtigt Übersichtsarbeiten mit der Analyse großer Patientenkollektive und Darstellung einzelner, seltener Komplikationen mit Lösungswegen.ErgebnisseSorgfältige präoperative Diagnostik und Indikationsstellung sind essentiell für die sichere Durchführung einer perkutanen Steintherapie. Die komplikationsträchtigsten Operationsschritte sind die Punktion des Nierenbeckenkelchsystems und die Dilatation des Zugangsweges. Die häufigste Komplikation stellen Blutungen dar, gefolgt von infektiologischen Problemen. Die Möglichkeit einer notfallmäßigen radiologischen interventionellen Versorgung ist ein wichtiges Sicherheitsnetz zur Durchführung des Eingriffs und verhindert die operative Versorgung von Blutungskomplikationen mit möglichem Organverlust in den meisten Fällen.SchlussfolgerungenDie perkutane Nephrolithotomie stellt in der Hand eines Experten eine sichere und effektive Steintherapie dar. Eine optimale Planung und exakte Punktion stellen die wichtigsten Eckpfeiler zur Vermeidung schwerwiegender Komplikationen dar.AbstractBackgroundPercutaneous lithotomy is the gold standard in the treatment of large kidney stones. Several steps of the operation might cause severe complications. Safe procedures depend on careful planning, accurate performance, recognition of problems and knowledge of how to handle them.ObjectivesRelevant steps of percutaneous stone treatment with possible complications and their management are presented.Materials and methodsCurrent topics in percutaneous stone treatment taking into consideration the relevant literature are discussed. Furthermore, rare complications and strategies for safe management are presented.ResultsCareful planning and adequate preoperative diagnostic workup are essential for safe procedures. Puncture of the renal calyceal system and tract dilation might lead to severe complications. Bleeding and infectious complications are the most common problems. Availability of interventional radiology provides ideal emergency treatment in case of severe bleeding and helps to avoid surgical revision with high risk of organ loss.ConclusionsPercutaneous stone treatment is a safe and effective therapy in an experienced physician’s hands. Careful planning and accurate performance help to avoid severe complications.