Thomas R. W. Herrmann

EAU Guidelines on Robotic and Single-site Surgery in Urology

CONTEXT This is a short version of the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology, as created in 2013 by the EAU Guidelines Office Panel on Urological Technologies. OBJECTIVE To evaluate current evidence regarding robotic and single-site surgery in urology and to provide clinical recommendations. EVIDENCE ACQUISITION A comprehensive online systematic search of the literature according to Cochrane recommendations was performed in July 2012, identifying data from 1990 to 2012 regarding robotic and single-site surgery in urology. EVIDENCE SYNTHESIS There is a lack of high-quality data on both robotic and single-site surgery for most upper and lower urinary tract operations. Mature evidence including midterm follow-up data exists only for robot-assisted radical prostatectomy. In the absence of high-quality data, the guidelines panels recommendations were based mostly on the review of low-level evidence and expert opinions. CONCLUSIONS Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations. Further documentation including long-term oncologic and functional outcomes is deemed necessary before definite conclusions can be drawn regarding the superiority or not of robotic assistance compared with the conventional laparoscopic and open approaches. Laparoendoscopic single-site surgery is a novel laparoscopic technique providing a potentially superior cosmetic outcome over conventional laparoscopy. Nevertheless, further advantages offered by this technology are still under discussion and not yet proven. Due to the technically demanding character of the single-site approach, only experienced laparoscopic surgeons should attempt this technique in clinical settings. PATIENT SUMMARY This work represents the shortened version of the 2013 European Association of Urology guidelines on robotic and single-site surgery. The authors systematically evaluated published evidence in these fields and concluded that robotic assisted surgery is possible and safe for most urologic operations. Whilst laparoendoscopic single-site surgery is performed using the fewest incisions, the balance between risk and benefit is currently unclear. The evidence to support the conclusions in this guideline was generally poor, but best for robotic assisted radical prostatectomy. As such, these recommendations were based upon expert opinion, and further high-quality research is needed in this field.

EAU Guidelines on Laser Technologies

CONTEXT The European Association of Urology (EAU) Guidelines Office has set up a guideline working panel to analyse the scientific evidence published in the world literature on lasers in urologic practice. OBJECTIVE Review the physical background and physiologic and technical aspects of the use of lasers in urology, as well as current clinical results from these new and evolving technologies, together with recommendations for the application of lasers in urology. The primary objective of this structured presentation of the current evidence base in this area is to assist clinicians in making informed choices regarding the use of lasers in their practice. EVIDENCE ACQUISITION Structured literature searches using an expert consultant were designed for each section of this document. Searches were carried out in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Medline and Embase on the Dialog/DataStar platform. The controlled terminology of the respective databases was used, and both Medical Subject Headings and EMTREE were analysed for relevant entry terms. One Cochrane review was identified. EVIDENCE SYNTHESIS Depending on the date of publication, the evidence for different laser treatments is heterogeneous. The available evidence allows treatments to be classified as safe alternatives for the treatment of bladder outlet obstruction in different clinical scenarios, such as refractory urinary retention, anticoagulation, and antiplatelet medication. Laser treatment for bladder cancer should only be used in a clinical trial setting or for patients who are not suitable for conventional treatment due to comorbidities or other complications. For the treatment of urinary stones and retrograde endoureterotomy, lasers provide a standard tool to augment the endourologic procedure. CONCLUSIONS In benign prostatic obstruction (BPO), laser vaporisation, resection, or enucleation are alternative treatment options. The standard treatment for BPO remains transurethral resection of the prostate for small to moderate size prostates and open prostatectomy for large prostates. Laser energy is an optimal treatment method for disintegrating urinary stones. The use of lasers to treat bladder tumours and in laparoscopy remains investigational.

Technical aspects of lasers in urology

During the course of history a variety of laser principles have been introduced in surgery. Some erroneous developments probably could have been kept out of the market place if not for the magic which accompanies the acronym LASER and with more understanding for the underlying principles governing the process when light meets tissue. The interaction of light with tissue is exemplified on the basis of natural body chromophores when compared with available lasers at different wavelengths and operational modes. Furthermore the meaning of fibre flexibility and durability is elucidated.

Laser Treatment of Benign Prostatic Obstruction: Basics and Physical Differences

CONTEXT Laser treatment of benign prostatic obstruction (BPO) has become more prevalent in recent years. Although multiple surgical approaches exist, there is confusion about laser-tissue interaction, especially in terms of physical aspects and with respect to the optimal treatment modality. OBJECTIVE To compare available laser systems with respect to physical fundamentals and to discuss the similarities and differences among introduced laser devices. EVIDENCE ACQUISITION The paper is based on the second expert meeting on the laser treatment of BPO organised by the European Association of Urology Section of Uro-Technology. A systematic literature search was also carried out to cover the topic of laser treatment of BPO extensively. EVIDENCE SYNTHESIS The principles of generation of laser radiation, laser fibre construction, the types of energy emission, and laser-tissue interaction are discussed in detail for the laser systems used in the treatment of BPO. The most relevant laser systems are compared and their physical properties discussed in depth. CONCLUSIONS Laser treatment of BPO is gaining widespread acceptance. Detailed knowledge of the physical principles allows the surgeon to discriminate between available laser systems and their possible pitfalls to guarantee high safety levels for the patient.

Oncological and functional results of open, robot-assisted and laparoscopic radical prostatectomy: does surgical approach and surgical experience matter?

The treatment of prostate cancer has undergone a fundamental change in the last decade. New surgical and nonsurgical minimal invasive methods have evolved. As the methodology of the different treatments is commonly known to urologists, this article focuses on oncological and functional outcome of open retropubic (ORP), trans- or extraperitoneal endoscopical (LRP), and robot-assisted radical prostatectomy (RALP), based on personal experience and review of the literature. A MEDLINE search was performed to review the literature on LRP and RALP between 1982 and 2007 with special emphasis on oncological and functional results, technical considerations, comparison of LRP and RALP to ORP, laparoscopic training, historical aspects, and cost-efficiency of the techniques. Based on diligent training and proctoring programs, a continuous dissemination of laparoscopic techniques takes place. There is a trend towards the extraperitoneal access in most of the minimal invasive programs at least in the European community. Mid-term outcomes of LRP and short-term outcomes of RALP achieved equivalence to open surgery with regards to complications, oncologic and functional results. Distinct advantages of LRP include less postoperative pain, lower transfusion rates, shorter convalescence, and better cosmetics. In contrast to RALP, LRP reaches cost-equivalence with open surgery in selected centers. LRP and RALP reproduce the short-term results of open surgery while providing the advantages of a minimal access. Video-assisted teaching improves the transfer of anatomical knowledge and technical knowhow, but the discussion about the longer learning curve for laparoscopy handling remains. The future will show if European centers adopt the use of robots comparable to the United States.

Thulium laser versus holmium laser transurethral enucleation of the prostate: 18-month follow-up data of a single center.

OBJECTIVE To compare the clinical outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) (70 W) and holmium laser transurethral enucleation of the prostate (HoLEP) (90 W) in a prospective randomized trial with 18 months of follow-up. Both ThuLEP and HoLEP effectively relieve the obstructive symptoms due to benign prostatic hyperplasia (BPH). METHODS A total of 133 consecutive patients with BPH were randomized to either ThuLEP (n = 71) or HoLEP (n = 62). An energy setting of 70 W and 90 W was used for the thulium and holmium laser in the enucleation procedure, respectively. The mushroom technique was used to fragment the enucleated lobes with the resection loop. The preoperative and postoperative parameters were compared. RESULTS ThuLEP required a longer operation time (72.4 vs 61.5 minutes, P = .034) but resulted in less blood loss than HoLEP (130.0 vs 166.6 mL, P = .045). The catheterization time was comparable. At 18 months, the lower urinary tract symptom indexes were improved significantly in both groups compared with the baseline values. The International Prostate Symptom Score decreased to 5.2 in the ThuLEP group and 6.2 in the HoLEP group. The quality of life score and peak urinary flow rate were similar between the 2 groups (1.3 vs 1.2 and 23.4 vs 24.2 mL/s) and the postvoid residual urine volume decreased by 82.50% and 81.73% in the ThuLEP and HoLEP groups, respectively. The mean prostate-specific antigen decrease after HoLEP and ThuLEP was 30.43% and 43.36%, respectively. No urethral or bladder neck stricture were found in either group. CONCLUSION Both ThuLEP (70 W) and HoLEP (90 W) relieve lower urinary tract symptoms equally with high efficacy and safety. ThuLEP was statistically superior to HoLEP in blood loss and inferior to HoLEP in operation time, although the differences were clinically negligible. The mushroom technique could be adequate, without an additional mechanical tissue morcellator.

Working tools in flexible ureterorenoscopy--influence on flow and deflection: what does matter?

INTRODUCTION Flexible renoscopes offer access to almost all points within the collecting system. For stone workup, excellent visualization is mandatory. Therefore, irrigation flow is of critical importance. The aim of this study was to evaluate the effect of tools and probes on deflection angle and irrigation flow volume in the latest generation of flexible renoscopes. METHODS Five flexible renoscopes [Wolf (Viper), Storz (FlexX(2)), ACMI (DUR-8 Elite, DUR-D), Olympus (URF-P5)] were tested. Deflection angle, lowest diameter of the bent tip, and flow rates were measured. Recorded parameters were deflection angle and flow rate of the empty and loaded scopes. A laser probe (273 mum), biopsy forceps (2.4-3.0 French), and tipless nitinol baskets (1.5-2.4 French) were tested. RESULTS Deflection has no influence on flow rate. The size of the basket has no influence on the maximum angle of deflection. Introducing the laser fiber or the biopsy forceps leads to relevant loss of deflection (laser fiber: 4.44%-10.21%; biopsy forceps: 30.7%-57.8%). The inner diameter of the bent tip increases with introduction of a laser fiber (+1 to 3 mm) or the biopsy forceps (+13 to 34 mm). Flow rates are dependent on the size of the tool used. Loss of irrigation volume varies from 62.24% (1.5 French) to 99.1% (3.0 French). The use of a laser fiber leads to a decrease in irrigation volume of 53.7%. CONCLUSION Irrigation flow, loss of deflection, and intraoperative visualization are dependent on the working tool used. The provided data, in awareness of the patients anatomy, help to select scopes, probes, and tools correctly for successful ureterorenoscopy.

Thulium:YAG Vapoenucleation in Large Volume Prostates

PURPOSE Tm:YAG vapoenucleation was introduced as a minimally invasive treatment in patients with benign prostatic obstruction. The efficiency and safety of Tm:YAG vapoenucleation must still be confirmed in large volume prostates to prove the size independence of this promising treatment option. We evaluated the safety and efficiency of Tm:YAG vapoenucleation in patients with a prostate volume of 80 cc or greater and benign prostatic obstruction during a 12-month followup. MATERIALS AND METHODS Included in this trial were 90 consecutive patients undergoing 90 W Tm:YAG vapoenucleation. Vapoenucleation was done using the 2 μm continuous wave Tm:YAG laser combined with a mechanical tissue morcellator. We analyzed patient demographic, perioperative and 12-month followup data. Complications were assessed. RESULTS Mean preoperative prostate volume was 108.6 cc (range 80 to 200), mean International Prostate Symptom Score was 23.5 (range 8 to 35) and mean quality of life score was 4.3 (range 1 to 6). There was an 86% reduction (range 67% to 99%) in prostate volume on transrectal ultrasound by 12 months and an 88% decrease (range 58% to 100%) in prostate specific antigen. International Index of Erectile Function score remained stable. Peak urinary flow rate, International Prostate Symptom Score and quality of life improved significantly (p <0.001), as did post-void residual urine. The overall complication rate was manageable. Two patients required blood transfusion and 10 experienced early postoperative stress incontinence. During followup 7% of patients had symptomatic urinary tract infection and 2 had persistent grade I stress urinary incontinence. The reoperation rate due to urethral stricture was 1.8% during the 12-month followup. CONCLUSIONS Tm:YAG vapoenucleation is a safe, effective and size independent treatment option for benign prostatic obstruction. As shown by reductions in transrectal ultrasound prostate volume and prostate specific antigen, complete removal of the adenoma can be achieved by this procedure.

Thulium:yttrium-aluminium-garnet laser prostatectomy in men with refractory urinary retention

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

Current evidence for transurethral laser therapy of non-muscle invasive bladder cancer

IntroductionBladder cancer is the second most common malignancy of urologic tumors. Back in 1976, lasers were added to the endourological armetarium for bladder tumor treatment. Despite nowadays’ standard procedure for staging and treating non-muscle invasive bladder tumor by transurethral resection of bladder tumors (TURB) via a wire loop, laser resection techniques for bladder tumor came back in focus with the introduction of Ho:YAG and not to mention recently Tm:YAG lasers. This review aims to display the current evidence for these techniques.Materials and methodsThroughout April 2010, MEDLINE and the Cochrane central register of controlled trials were searched previously for the following terms: “Laser, resection, ablation, coagulation, Nd:YAG Neodym, HoYAG: Holmium, Tm:YAG Thulium and transitional carcinoma, bladder, intravesical.”ResultsEleven articles on Ho:YAG and 7 on Tm:YAG were identified. Searches by Cochrane online library resulted in no available manuscripts.ConclusionToday, Nd:YAG does not play any role in treatment of lower urinary tract transitional cell carcinoma. Ho:YAG and Tm:YAG seem to offer alternatives in the treatment of bladder cancer, but still to prove their potential in larger prospective randomized controlled studies with long-term follow-up. Future expectations will show whether en bloc resection of tumors are preferable to the traditional “incise and scatter” resection technique, in which is contrary to all oncological surgical principles. For the primary targets, here are within first-time clearance of disease, in addition to low in-fields and out-of-fields recurrence rates.