Svetozar Subotic

Robotics and telesurgery – an update on their position in laparoscopic radical prostatectomy

Laparoscopy is handicapped by the reduction of the range of motion from six to only four degrees of freedom. In complicated cases (i.e. radical prostatectomy), there is often a crossing of the hands of surgeon and assistant. Finally, standard laparoscopes allow only 2D‐vision. This has a major impact on technically difficult reconstructive procedures such as laparoscopic radical prostatectomy. Solutions include the understanding of the geometry of laparoscopy, but also newly developed surgical robots. During the last five years, there has been an increasing development and experience with robotics in urology. This article reviews the actual results focussing on the benefits and problems of robotics in laparoscopic radical prostatectomy. Own experiences with robot‐assisted surgery include more than 1200 laparoscopic radical prostatectomies using a voice‐controlled camera‐arm (AESOP) as well as six telesurgical interventions with the da Vinci‐system. Substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and models for simulation of urethrovesical anastomosis. The recent literature on robotics in urology has been reviewed based on a MEDLINE/PUBMED research. The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25° to 45°; the angles between the instrument and the working plane that should not exceed 55°; and the bi‐planar angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90° to 110°. 3‐D‐systems have not yet proved to be effective due to handling problems such as shutter glasses, video helmets or reduced brightness. At the moment, there are only two robotic surgical systems (AESOP, da Vinci) in clinical use, of which only the da Vinci provides stereovision and all six degrees of freedom (DOF).To date, more than 3000 laparoscopic radical prostatectomies have been performed worldwide at 92 centres with this system. The main advantage of the system represents the translation of open surgical skills to laparoscopy. Despite recent development of basic tools (e.g. bipolar forceps) for the da Vinci robot, investment and maintenance costs still represent the major problem of the device. Additionally, the device does not provide any haptic sense (i.e. tactile feedback). Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Interestingly, more than in the field of cardiac surgery, there seems to be a need for telemanipulators in urology, mainly to reduce the learning curve of standard laparoscopy. However, new training concepts used in combination with mono‐tasking computerized robots (AESOP) have proved their efficacy associated with a significant cost reduction.

The position of laparoscopic surgery in pediatric urology

ZusammenfassungMit zunehmender Erfahrung in der Laparoskopie vollzieht sich auch in der Kinderurologie die Evolution von ablativen hin zu rekonstruktiven Eingriffen. Neben den etablierten Verfahren der laparoskopischen Nephrektomie und der Orchidopexie haben auch die Heminephrektomie und die Pyeloplastik längst den Charakter von Kasuistiken mit Demonstration der prinzipiellen Machbarkeit verloren und sind zu standardisierten Therapiealternativen herangereift. Wie in unserem eigenen Patientengut nimmt dabei, bedingt auch durch instrumentelle Weiterentwicklung, der Anteil an Kleinkindern zu. Viele dieser Eingriffe setzen allerdings eine hohe Erfahrung in laparoskopischen Präparations- und Nahttechniken voraus und bleiben somit Zentren mit großer Erfahrung in der Erwachsenenlaparoskopie vorbehalten, wobei die tägliche Erfahrung mit laparoskopischen Eingriffen bei Erwachsenen urologische gegenüber kinderchirurgischen Kliniken prädestiniert.AbstractWith growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.

Stellenwert der Laparoskopie in der Kinderurologie

ZusammenfassungMit zunehmender Erfahrung in der Laparoskopie vollzieht sich auch in der Kinderurologie die Evolution von ablativen hin zu rekonstruktiven Eingriffen. Neben den etablierten Verfahren der laparoskopischen Nephrektomie und der Orchidopexie haben auch die Heminephrektomie und die Pyeloplastik längst den Charakter von Kasuistiken mit Demonstration der prinzipiellen Machbarkeit verloren und sind zu standardisierten Therapiealternativen herangereift. Wie in unserem eigenen Patientengut nimmt dabei, bedingt auch durch instrumentelle Weiterentwicklung, der Anteil an Kleinkindern zu. Viele dieser Eingriffe setzen allerdings eine hohe Erfahrung in laparoskopischen Präparations- und Nahttechniken voraus und bleiben somit Zentren mit großer Erfahrung in der Erwachsenenlaparoskopie vorbehalten, wobei die tägliche Erfahrung mit laparoskopischen Eingriffen bei Erwachsenen urologische gegenüber kinderchirurgischen Kliniken prädestiniert.AbstractWith growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.

Intubation with transillumination: nasal or oral?

Transillumination-guided intubation is a useful back-up method when laryngoscopic intubation proves to be difficult or impossible. The Trachlight (Laerdal, N-4001 Stavanger, Norway) is suited for both nasal and oral use. Intubation times (IT) and success rates (SR) for nasal and oral intubation with the Trachlight were compared. Twenty-four medical students, inexperienced in intubation were instructed in the use of the Trachlight. A demonstration also was performed. Subsequently, they were asked to intubate a Laerdal Airway Management Trainer (Laerdal, Stavanger, Norway) using the Trachlight. Each student intubated 10 times orally and 10 times nasally (five times through the right and five times through the left nostril). The succession of the students was randomized. The intubation times were measured and the position of the tube noted. Nasal and oral intubation times for the tenth trial (steady state conditions) were compared using the rank-order test for paired observations. Oral and nasal success rates were compared using the sign test for paired observations. The differences between nasal and oral intubation concerning intubation time and the success rates were not significant. Nasal intubation with the Trachlight seems to be more difficult than the oral intubation.

Laparoskopischen Pyeloplastik bei der Behandlung der Nierenbeckenabgangsstenose im Kindesalter

INTRODUCTION Open pyeloplasty has been the gold standard for treating ureteropelvic junction obstruction, with a success rate greater than 90%. However, during the last decade the management has been revolutionized with the introduction of laparoscopy and endourology, yielding comparable results and fewer morbid outcomes. MATERIALS AND METHODS Between 1997 and 2007, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 31 children with a medium age of 123 months (range 36-192 months). Fourteen children underwent dismembered pyeloplasty (Anderson-Hynes) and 16 children underwent non-dismembered pyeloplasty (YV plasty) and in one child we performed an ureterolysis. RESULTS The mean operating time was 120 min (range 67-257 min). In 21 cases, intraoperative findings revealed a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 93%. The two failures (laparoscopic YV plasty and laparoscopic ureterolysis) occurred in the early phase of laparoscopy and have been treated by open Anderson-Hynes plasty. CONCLUSION With increasing improvement of the suture techniques, laparoscopic pyeloplasty represents, in experienced hands, an alternative method with success rates comparable to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants.

Experience with laparoscopic pyeloplasty for treating ureteropelvic junction obstruction in children. Technique and results

INTRODUCTION Open pyeloplasty has been the gold standard for treating ureteropelvic junction obstruction, with a success rate greater than 90%. However, during the last decade the management has been revolutionized with the introduction of laparoscopy and endourology, yielding comparable results and fewer morbid outcomes. MATERIALS AND METHODS Between 1997 and 2007, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 31 children with a medium age of 123 months (range 36-192 months). Fourteen children underwent dismembered pyeloplasty (Anderson-Hynes) and 16 children underwent non-dismembered pyeloplasty (YV plasty) and in one child we performed an ureterolysis. RESULTS The mean operating time was 120 min (range 67-257 min). In 21 cases, intraoperative findings revealed a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 93%. The two failures (laparoscopic YV plasty and laparoscopic ureterolysis) occurred in the early phase of laparoscopy and have been treated by open Anderson-Hynes plasty. CONCLUSION With increasing improvement of the suture techniques, laparoscopic pyeloplasty represents, in experienced hands, an alternative method with success rates comparable to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants.

Renal Cell Carcinoma in a Young Adult - Do We Need Further Investigations?

Renal cell carcinomas (RCC), mostly occurring in adults aged 60–70 years, can result from well-known factors like cigarette smoking, obesity and hypertension. However, they have been associated with genetic alterations in children and young adults. A 28 year-old male patient with a confirmed RCC underwent biomolecular and immunohistochemical analyses due to his young age. A point mutation of the von Hippel-Lindau tumor suppressor gene was identified. Young patients under 40 years with diagnosed RCC should undergo additional diagnostic investigation, hence the discovery of an underlying cause. This could be important for further treatment and counseling of these young patients.

1093 THE PREDICTION OF INSIGNIFICANT PROSTATE CANCER USING THE PRIAS CRITERIA – ANALYSIS OF 566 CONSECUTIVE SWISS PATIENTS

INTRODUCTION AND OBJECTIVES: Surgical treatment of prostate cancer (PCa) remains the gold standard for organ confined disease. Since introduction of the Epstein criteria, which are assumed to predict insignificant PCa, active surveillance (AS) became an accepted treatment option. The purpose of our retrospective study was to verify the accuracy of inclusion criteria of the prospective international Prostate Cancer Research International: Active Surveillance (PRIAS) study to predict clinically insignificant PCa in Swiss men. METHODS: The study population consisted of 566 Swiss men who underwent laparoscopic radical prostatectomy (LRP) at the Department of Urology, University Hospital Basel, Switzerland between 2001 and 2010. Thirty-five patients (6.2%) fulfilled the inclusion criteria of the PRIAS study (Clinical stage T2b, Gleason Sum 6, positive biopsy cores 2, PSA level 10 ng/ml and PSA density 0.2 ng/ml/ ml). The percentage of unfavourable PCa (pathological Gleason sum 7 and/or positive etxraprostatic extension (Pathological Stage T3a)) among these men was assessed. RESULTS: Among 35 patients with clinically insignificant PCa according to the PRIAS criteria, 12 (34.3%) showed pathological Gleason sum 7 after LRP and in one patient (8.3%) extraprostatic extension was observed. One (4.3%) of 23 patients, who did not present Gleason score upgrading in histopathological examination, harboured non-organ-confined disease. In summary, the inclusion criteria of PRIAS study for clinically insignificant PCa were inaccurate in 37.1% (n 13) of our study population. CONCLUSIONS: Application of the PRIAS criteria showed an inappropriate prediction of insignificant prostate cancer in 37.1% of our study population indicating that the application of the PRIAS criteria in selecting Swiss patients for active surveillance should be critical verified.

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.

Laparoskopischen Pyeloplastik bei der Behandlung der Nierenbeckenabgangsstenose im Kindesalter@@@Experience with laparoscopic pyeloplasty for treating ureteropelvic junction obstruction in children: Erfahrungen und Ergebnisse@@@Technique and results

INTRODUCTION Open pyeloplasty has been the gold standard for treating ureteropelvic junction obstruction, with a success rate greater than 90%. However, during the last decade the management has been revolutionized with the introduction of laparoscopy and endourology, yielding comparable results and fewer morbid outcomes. MATERIALS AND METHODS Between 1997 and 2007, dismembered and non-dismembered retroperitoneoscopic pyeloplasty was performed in 31 children with a medium age of 123 months (range 36-192 months). Fourteen children underwent dismembered pyeloplasty (Anderson-Hynes) and 16 children underwent non-dismembered pyeloplasty (YV plasty) and in one child we performed an ureterolysis. RESULTS The mean operating time was 120 min (range 67-257 min). In 21 cases, intraoperative findings revealed a significant crossing vessel. Based on a furosemide nephrogram and subjective complaints, the success rate was 93%. The two failures (laparoscopic YV plasty and laparoscopic ureterolysis) occurred in the early phase of laparoscopy and have been treated by open Anderson-Hynes plasty. CONCLUSION With increasing improvement of the suture techniques, laparoscopic pyeloplasty represents, in experienced hands, an alternative method with success rates comparable to the open technique. In our opinion, retroperitoneoscopic pyeloplasty is technically possible and feasible even in infants.