Renai Yoon

Applications of three-dimensional printing technology in urological practice.

A rapid expansion in the medical applications of three‐dimensional (3D)‐printing technology has been seen in recent years. This technology is capable of manufacturing low‐cost and customisable surgical devices, 3D models for use in preoperative planning and surgical education, and fabricated biomaterials. While several studies have suggested 3D printers may be a useful and cost‐effective tool in urological practice, few studies are available that clearly demonstrate the clinical benefit of 3D‐printed materials. Nevertheless, 3D‐printing technology continues to advance rapidly and promises to play an increasingly larger role in the field of urology. Herein, we review the current urological applications of 3D printing and discuss the potential impact of 3D‐printing technology on the future of urological practice.

Endockscope: using mobile technology to create global point of service endoscopy.

BACKGROUND AND PURPOSE Recent advances and the widespread availability of smartphones have ushered in a new wave of innovations in healthcare. We present our initial experience with Endockscope, a new docking system that optimizes the coupling of the iPhone 4S with modern endoscopes. MATERIALS AND METHODS Using the United States Air Force resolution target, we compared the image resolution (line pairs/mm) of a flexible cystoscope coupled to the Endockscope+iPhone to the Storz high definition (HD) camera (H3-Z Versatile). We then used the Munsell ColorChecker chart to compare the color resolution with a 0° laparoscope. Furthermore, 12 expert endoscopists blindly compared and evaluated images from a porcine model using a cystoscope and ureteroscope for both systems. Finally, we also compared the cost (average of two company listed prices) and weight (lb) of the two systems. RESULTS Overall, the image resolution allowed by the Endockscope was identical to the traditional HD camera (4.49 vs 4.49 lp/mm). Red (ΔE=9.26 vs 9.69) demonstrated better color resolution for iPhone, but green (ΔE=7.76 vs 10.95), and blue (ΔE=12.35 vs 14.66) revealed better color resolution with the Storz HD camera. Expert reviews of cystoscopic images acquired with the HD camera were superior in image, color, and overall quality (P=0.002, 0.042, and 0.003). In contrast, the ureteroscopic reviews yielded no statistical difference in image, color, and overall (P=1, 0.203, and 0.120) quality. The overall cost of the Endockscope+iPhone was

Redefining the Autonomic Nerve Distribution of the Bladder Using 3-Dimensional Image Reconstruction

154 compared with

Comparison of Optics and Performance of Single Channel and a Novel Dual-channel Fiberoptic Ureteroscope

46,623 for a standard HD system. The weight of the mobile-coupled system was 0.47 lb and 1.01 lb for the Storz HD camera. CONCLUSION Endockscope demonstrated feasibility of coupling endoscopes to a smartphone. The lighter and inexpensive Endockscope acquired images of the same resolution and acceptable color resolution. When evaluated by expert endoscopists, the quality of the images overall were equivalent for flexible ureteroscopy and somewhat inferior, but still acceptable for flexible cystoscopy.

Development of a Novel iPad-Based Laparoscopic Trainer and Comparison With a Standard Laparoscopic Trainer for Basic Laparoscopic Skills Testing

PURPOSE We sought to create a 3-dimensional reconstruction of the autonomic nervous tissue innervating the bladder using male and female cadaver histopathology. MATERIALS AND METHODS We obtained bladder tissue from a male and a female cadaver. Axial cross sections of the bladder were generated at 3 to 5 mm intervals and stained with S100 protein. We recorded the distance between autonomic nerves and bladder mucosa. We manually demarcated nerve tracings using ImageScope software (Aperio, Vista, California), which we imported into Blender™ graphics software to generate 3-dimensional reconstructions of autonomic nerve anatomy. RESULTS Mean nerve density ranged from 0.099 to 0.602 and 0.012 to 0.383 nerves per mm2 in female and male slides, respectively. The highest concentrations of autonomic innervation were located in the posterior aspect of the bladder neck in the female specimen and in the posterior region of the prostatic urethra in the male specimen. Nerve density at all levels of the proximal urethra and bladder neck was significantly higher in posterior vs anterior regions in female specimens (0.957 vs 0.169 nerves per mm2, p<0.001) and male specimens (0.509 vs 0.206 nerves per mm2, p=0.04). CONCLUSIONS Novel 3-dimensional reconstruction of the bladder is feasible and may help redefine our understanding of human bladder innervation. Autonomic innervation of the bladder is highly focused in the posterior aspect of the proximal urethra and bladder neck in male and female bladders.

Comparative analysis of techniques to prevent laparoscopic fogging

OBJECTIVE To evaluate performance characteristics and optics of a novel dual-working channel fiberoptic ureteroscope (Wolf Cobra) with 2 single-channel fiberoptic ureteroscopes and to a single-channel distal sensor standard definition digital ureteroscope URF-V (SD-DS). METHODS Four new ureteroscopes (Cobra, Viper, X(2), and SD-DS) were compared for active deflection, irrigation flow, and optical characteristics. We performed a porcine ureteroscopy and measured the time for cleaning the middle calyx after injection of 10 cc of a standardized bloody solution. RESULTS The SD-DS showed a higher resolution (7.42 lines/mm; P = .0001) compared with the fiberoptic ureteroscopes; among the fiberoptic ureteroscopes, the Cobra had the highest resolution than the Viper and X(2) (P = .0001). Grayscale distribution and color representation were identical for the fiberoptic ureteroscopes, whereas the SD-DS provided a superior color representation and a significant higher depth of field. The Cobra provided superior flow with empty working channel (86 cc/min vs 68 cc/min [Viper] vs 62.5 cc/min [X(2)] vs 62 cc/min [SD-DS]; P = .0001) and with various accessories (P <.0001). With regard to deflection, the Storz X(2) and the Cobra provided superior deflection up and down (P <.0001). When evacuating a standardized bloody field, the Cobra provided significant shorter evacuation times compared with those of the Viper, X(2), and SD-DS (36.6 vs 72 vs 65.6 vs 72.6 seconds, respectively; P = .0001). CONCLUSION The additional working channel of the Wolf Cobra may improve vision and performance during challenging ureteroscopic cases by providing an increased flow. The enhanced irrigation capabilities of the Cobra have to be balanced with a larger diameter of this ureteroscope.

The Endockscope Using Next Generation Smartphones: “A Global Opportunity”

INTRODUCTION We developed the iTrainer (iT) as a portable laparoscopic trainer, which incorporates the iPad tablet. We then compared the iT with a standard pelvic trainer (SPT) to assess surgical skills as well as its image quality, resolution, brightness, comfort, and overall performance. MATERIALS AND METHODS We designed and constructed the iT to be compatible with the Apple iPad 3 and standard laparoscopic instruments. Participants were assigned to perform the thread-the-loops task on both trainers and were prospectively randomized to start on either the iT or the SPT. Each participant was allowed a 2-minute warm-up before the 2-minute testing period. We scored participants using the product of skill quality (0-4 scale) and quantity of loops threaded (0-10 scale). Participants then rated each trainer on image quality, resolution, brightness, comfort, and overall performance on a 5-point Likert scale. RESULTS A total of 45 subjects including 10 undergraduates, 10 medical students, 10 general surgery and urology residents, and 15 experts (fellows and attending surgeons) participated in this study. There was no significant difference between thread-the-loops task scores completed on the iT when compared with the SPT for all groups tested (p > 0.05) with the exception of the medical student group, who performed better on the SPT (p < 0.05). On evaluation of each trainer, participants rated the iT as having superior image quality and resolution when compared with the SPT (p < 0.05) but rated the SPT higher in overall performance (p < 0.05). Brightness and comfort were rated similarly for both trainers. CONCLUSIONS We have demonstrated face validity and criterion validity for the thread-the-loops task on the iT. The iT rated superior in image quality and resolution but inferior in overall performance compared with the SPT. The iT provides trainees a unique advantage over SPT as an additional resource to laparoscopic training as it is inexpensive, portable, and can be readily available for training.

PD41-10 EVALUATION OF THE FEASIBILITY OF REMOTELY MANUFACTURED LOW-COST THREE-DIMENSIONALLY PRINTED LAPAROSCOPIC TRAINERS AND COMPARISON TO STANDARD LAPAROSCOPIC TRAINERS

Abstract Purpose: To evaluate the efficiency and efficacy of two common and commercially available methods to resolve lens fogging: a Fluid Warming System (O.R. Solutions, Chantilly, VA) and the Clearify Visualization System (Covidien, Mansfield, MA). Material and methods: We prospectively evaluated 40 patients undergoing laparoscopic renal procedures with the Fluid Warming System (first 20 cases) and then the Clearify Visualization System (second 20 cases). We utilized the standard Fluid Warming System per a 30-second modified protocol established in our laboratory. We used the Clearify according to manufacturer instructions. For each procedure we documented the etiology of each episode of visual obstruction, procedure type and surgery duration. We performed a cost analysis. For all cases we used the same insufflator, insufflation trocar location and trocar configuration. Results: All 40 patients completed the study protocol without incident. The mean fogging events per hour for the Fluid Warming System and Clearify Visualization System were 0.7 (0–2.52) and 1.4 (0–5.02), respectively (P = 0.045). Surgery duration and cost per procedure were similar for both systems. Conclusion: The Fluid Warming System with modified technique was found to have less fogging events than the Clearify Visualization System, with no difference in operative time or cost.

PD42-09 CLINICAL COMPARISON OF CONVENTIONAL AND MOBILE ENDOCKSCOPE VIDEOCYSTOSCOPY USING AN AIR OR FLUID IRRIGANT

INTRODUCTION The Endockscope combines a smartphone, a battery powered flashlight and a fiberoptic cystoscope allowing for mobile videocystoscopy. We compared conventional videocystoscopy with the Endockscope paired with next generation smartphones in an ex-vivo porcine bladder to evaluate its image quality. MATERIALS AND METHODS The Endockscope consists of a three-dimensional (3D) printed attachment that connects a smartphone to a flexible fiberoptic cystoscope plus a 1000 lumen light-emitting diode (LED) cordless light source. Video recordings of porcine cystoscopy with a fiberoptic flexible cystoscope (Storz) were captured for each mobile device (iPhone 6, iPhone 6S, iPhone 7, Samsung S8, and Google Pixel) and for the high-definition (HD) H3-Z versatile camera setup with both the LED light source and the xenon light (XL) source. Eleven faculty urologists, blinded to the modality used, evaluated each video for image quality/resolution, brightness, color quality, sharpness, overall quality, and acceptability for diagnostic use. RESULTS When comparing the Endockscope coupled to a Galaxy S8, iPhone 7, and iPhone 6S with the LED portable light source to the HD camera with XL, there were no statistically significant differences (p < 0.01) in any metric. Eighty-two percent and 55% of evaluators considered the iPhone 7 + LED light source and iPhone 6S + LED light, respectively, appropriate for diagnostic purposes as compared with 100% who considered both the HD camera with XL and Galaxy S8 + LED appropriate. The iPhone 6 and Google Pixel coupled with the LED source were both inferior to the HD camera with XL in all metrics. CONCLUSIONS The Endockscope system with a LED light source (

MP52-17 EVALUATION AND COMPARISON OF CONTEMPORARY ENERGY-BASED SURGICAL VESSEL SEALING DEVICES

45) when coupled with either an Apple iPhone 7 or Samsung Galaxy S8 is comparable to conventional videocystoscopy with a standard camera and XL light source (total cost: