Timothy D. Averch

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.

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

Safety and Efficacy of Flexible Ureterorenoscopy and Holmium:YAG Lithotripsy for Intrarenal Stones in Anticoagulated Cases

PURPOSE We compared perioperative outcomes in patients undergoing ureterorenoscopy and Ho:YAG lithotripsy for renal calculi with or without anticoagulation. MATERIALS AND METHODS We reviewed the records of all patients undergoing flexible ureterorenoscopy and Ho:YAG lithotripsy for renal calculi at 2 institutions from 2001 to 2007. We identified 37 patients on anticoagulation with Coumadin, clopidogrel or aspirin in whom anticoagulation therapy was not discontinued before surgery. Data on the anticoagulation group were retrospectively compared to those on a contemporary matched cohort of 37 controls without anticoagulation who underwent a similar operative procedure. The 2 groups were compared with regard to the stone-free rate, and intraoperative and postoperative complications with specific reference to bleeding and thromboembolism. RESULTS The 2 groups were matched for stone size, stone location, number of stones, bilateral procedures and concomitant ureteral stones. Anticoagulation group patients were older (58.2 vs 50.4 years, p = 0.0209) and had a greater American Society of Anesthesiologists score (2.8 vs 1.9, p <0.0001) compared to the control group. No procedure had to be terminated in the anticoagulation group due to poor visibility from bleeding. The median postoperative hemoglobin decrease was greater in the anticoagulation group than in the control group (0.6 vs 0.2 gm/dl, p <0.0001). The stone-free rate (81.1% vs 78.4%, p = 0.7725), intraoperative complications (0% vs 3%, p = 0.3140), postoperative complications (11% vs 5%, p = 0.3943) and hemorrhagic or thromboembolic adverse events were comparable in the 2 groups. CONCLUSIONS When necessary, ureterorenoscopy and Ho:YAG lithotripsy can be performed safely and efficaciously for renal calculi in patients on anticoagulation therapy without the need for perioperative manipulation.

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

PURPOSE To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.

Use of social media in urology: data from the American Urological Association (AUA)

To characterise the use of social media among members of the American Urological Association (AUA), as the use of social media in medicine has greatly expanded in recent years.

A nephrolithometric nomogram to predict treatment success of percutaneous nephrolithotomy.

PURPOSE Imaging is routinely done preoperatively and postoperatively to assess patients treated with percutaneous nephrolithotomy. We developed a nomogram for percutaneous nephrolithotomy success. MATERIALS AND METHODS From November 2007 to December 2009 the CROES (Clinical Research Office of the Endourological Society) collected data on consecutive patients at 96 centers globally. Patients were evaluated for stone-free status using plain x-ray of the kidneys, ureters and bladder. Treatment success was defined as no visible stones or residual fragments less than 4 mm. Multivariate regression was used to model the relationship between preoperative descriptors and the stone-free rate. Variables included case load, prior treatment, body mass index, staghorn stones, renal anomalies, and stone burden, location and count. Bootstrapping techniques were used to validate the model. Adjusted chi-square statistic values were used to rank the prognostic value of variables. A nomogram was developed using significant predictors from the model. We assessed the predictive accuracy of the nomogram using the ROC curve AUC. The nomogram was calibrated. RESULTS Stone burden was the best predictor of the stone-free rate (chi-square = 30.27, p <0.001). Other factors associated with the stone-free rate were case volume (chi-square = 35.75, p <0.001), prior stone treatment (chi-square = 14.55, p <0.012), staghorn stone (adjusted chi-square = 4.73, p <0.029), stone location (chi-square = 14.74, p <0.001) and stone count (chi-square = 4.78, p <0.004). A nephrolithometric nomogram was developed with predictive accuracy (AUC 0.76). CONCLUSIONS The percutaneous nephrolithotomy stone-free rate can be predicted using preclinical data and radiological information. We present a nephrolithometric nomogram for percutaneous nephrolithotomy.

Laparoscopic Live Donor Nephrectomy: The Initial 3 Cases

PURPOSE Successful laparoscopic live donor nephrectomy in 3 patients is described. MATERIALS AND METHODS The procedures were performed completely laparoscopically and the kidneys were extracted via 8 cm. infraumbilical incisions. RESULTS In all 3 cases warm ischemic time was less than 5 minutes, and the renal vessels and ureter of the harvested kidneys were of adequate length for routine transplantation. Donors required minimal postoperative parenteral analgesia and were discharged home 1 to 3 days after the procedure. All harvested kidneys were successfully transplanted, and functioned well initially and at hospital discharge. CONCLUSIONS Laparoscopic live donor nephrectomy may be an alternative surgical modality to conventional open nephrectomy. Advantages include less postoperative pain, shorter hospital stay and convalescence, and a more desirable cosmetic result. Additionally, these advantages may encourage more individuals to consider live donation, resulting in an increase in organ supply.

Staged Retrograde Endoscopic Lithotripsy as Alternative to PCNL in Select Patients with Large Renal Calculi

BACKGROUND AND PURPOSE Percutaneous nephrolithotomy (PCNL) is currently the gold standard for management of large renal calculi. PCNL is associated, however, with a higher complication rate, degree of risk, and longer recovery period compared with ureteroscopy. In a selected group of patients who were not ideal candidates for PCNL because of extenuating health factors, a staged retrograde endoscopic approach was used to manage upper urinary tract calculi. METHODS We conducted a retrospective review of 23 patients (selected because of comorbidities, obesity, anatomy, and previous treatment failure as poor candidates for PCNL) who underwent staged retrograde endoscopic lithotripsy to manage upper urinary tract calculi. Lithotripsy was based on the application of small-diameter fiberoptic ureteroscopes and the holmium laser. Successful therapy was defined as total fragmentation of stone burden on repeated imaging. Data were analyzed using descriptive statistics. RESULTS Of the 468 patients who underwent ureteroscopy at our institution from 2003 to 2006, 23 patients (52% men, 57.70 +/- 11.44 years of age) were treated with retrograde endoscopic procedures for upper urinary tract calculi (52.2% lower pole). Stone burden at the initial procedure was 2.13 +/- 2.34 stones with a total linear length of 30.91 +/- 14.28 mm and an estimated total stone volume of 12,040.78 +/- 11101.54 cc (median value, 7,234.00 cc). There were no intraoperative complications; three patients were admitted postoperatively for observation. Ten 43.5%) patients (progressed to second-stage procedures (34.6 +/- 10.8 days apart). After repeated imaging, 73.9% of patients were stone free (88% lower pole), and 8.7% progressed to further intervention. Total linear stone length <4 cm and estimated calculus volume > or =15,000 cc predicted treatment failure (40%, 42.9%). CONCLUSIONS Percutaneous methods of managing renal stones have an increased rate of complications compared with ureteroscopy. In patients with complex medical histories, upper urinary tract calculi <4 cm can be safely and effectively managed using a staged retrograde endoscopic approach.

Percutaneous Nephrolithotomy Among Patients with Renal Anomalies: Patient Characteristics and Outcomes; a Subgroup Analysis of the Clinical Research Office of the Endourological Society Global Percutaneous Nephrolithotomy Study

PURPOSE This study compared the characteristics and outcomes of percutaneous nephrolithotomy (PCNL) in patients with and without renal malformations using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. PATIENTS AND METHODS The CROES PCNL Global Study collected prospective data for consecutive patients who were treated with PCNL at centers around the world during 1 year. Patient characteristics, operative data, and outcomes of PCNL in patients with renal anomalies and those with normal kidneys were compared. RESULTS Of 5542 patients whose renal anatomy was recorded, 202 (3.6%) patients had a renal malformation. The most frequent anomalies were horseshoe kidneys (1.8%) and malrotated kidneys (1.3%). The prone position was the most frequently used position for patients with renal anomalies as was upper pole puncture. PCNL achieved stone-free rates of 76.6% in patients with anomalous kidneys and 76.2% in those with normal kidneys. The frequency of complications was similar in the two groups. Median operative time was significantly longer (87 min vs 75 min, P=0.037), and access for PCNL was unsuccessful in significantly more patients (5% vs 1.7%, P=0.001) in whom renal anomalies were present. CONCLUSION In patients undergoing PCNL, the presence of renal malformation is likely to extend operative time. Stone-free rates as well as incidence of complications after PCNL are similar irrespective of the presence of renal anomalies.

Preoperative stenting decreases operative time and reoperative rates of ureteroscopy.

PURPOSE Large stone burden can be treated ureteroscopically, but the treatment often requires more than one procedure. Placement of a preoperative stent may theoretically enhance stone clearance by dilating the ureter to facilitate both access and stone removal. This study determines the impact of stent placement before ureteroscopy on operative time, radiologic stone clearance, and reoperative rates. MATERIALS AND METHODS We retrospectively reviewed the records of patients who underwent ureteroscopic stone intervention at our institution from 2002 to 2008 by a single surgeon. Nonstented matched controls were used for comparison. Demographics, stone characteristics (size, number, density, and location), presence of preprocedural ureteral stent, operative time, and results of postoperative imaging were compared between the two cohorts. Statistical analysis was performed. RESULTS There were 104 patients included in the study (45 prestented and 59 nonstented). Median stone size was 1 cm (range 0.3-4 cm). Overall stone clearance was 95.8%. The median number of procedures was one. Prestenting significantly reduced operative time during first ureteroscopy in patients with large stone requiring multiple ureteroscopies (p = 0.008) and total operative time to stone clearance in patients with stone >1 cm (p = 0.01), but not in patients with stone burdens <1 cm (p = 0.48). Prestenting also significantly reduced reoperative rates in patients with stone burden >1 cm (p = 0.001), especially for stones located in proximal ureter and kidney. Prestenting improves postoperative radiologic clearance, but this was not statistically significant (p = 0.56). CONCLUSIONS Results show that ureteroscopic lithotripsy of large stone burden can be performed with a high success rate. Preureteroscopic stent placement was associated with a decreased operative time and reoperative rates in patients with larger stone burdens of >1 cm.