Comparative Study of the Influence of Three-Dimensional Versus Two-Dimensional Urological Laparoscopy on Surgeons' Surgical Performance and Ergonomics: A Systematic Review and Meta-Analysis.

Objective: The objective of this study is to compare the use of three-dimensional (3D) vision systems with traditional two-dimensional systems in laparoscopic urological surgery, analyzing the benefits, limitations, and impact of introducing this medical technology with regard to surgical performance and the surgeon's ergonomics. Methods: A systematic review with a structured bibliographic search was conducted in the electronic libraries (PubMed and EMBASE) until August 2019 and with no language restrictions. Studies on 3D visualization technology in laparoscopic urologic surgery, randomized controlled trials, and observational comparative studies were included. Relevant data were extracted and analyzed. Results: A total of 25 articles were obtained, of which 4 were clinical studies with patients, 2 studies were carried out in experimental animal models, and the remaining 19 were conducted in simulated environments. Regarding the European training program in basic laparoscopic urological skills, the results showed no significant differences in execution time using either imaging system. Three-dimensional vision led to a significant reduction in surgery time in pyeloplasty and radical nephrectomy. In addition, there was a reported decrease in blood loss in adrenalectomy, nephron-sparing nephrectomy, radical nephrectomy, simple nephrectomy, and pyeloplasty using 3D vision. Regarding ergonomics, the studies generally described no differences in side effects (headache, nausea, eye strain) when comparing the two types of visualization systems. Surgeons reported reduced workloads and stress with 3D vision than with traditional laparoscopy. Conclusions: Three-dimensional laparoscopic systems essentially advance surgical performance in less-experienced laparoscopic surgeons. Three-dimensional laparoscopy leads to improvements in surgery time, which is important for specific surgical procedures involving intracorporeal ligatures and sutures. The results achieved on the surgeons' ergonomics showed better depth perception and decreased stress and workloads during 3D vision with no differences in potential side effects.

[Evaluation of competencies in urology. Esscolap® basic, as aproximation to urologists skills improvement.] / Evaluación de competencias en Urología. Esscolap® basic, como aproximación a la mejora de las capacidades de los urólogos.

Urology needs models of competencies assessment, although there is a wide range of tools not yet integrated into the official training programs. CONTEXT: At present, there is no universal framework for measuring surgeons' level of competence. Urology training programs should provide and consider knowledge, pyschomotor/cognitive skills, and simulator, cadaver or animal models-based training. Validity is a complex concept that refers to the capacity of the evaluation tool, so it is necessary to demonstrate several types of validation to assure the capacity of a method, reinforced with different reliability tests and calculation of internal consistency between evaluators. OBJECTIVE: Based on a structured dossier of surgical skills, classified by groups, the ESSCOLAP® Basic system was proposed with 5 simulator tasks to evaluate basic laparoscopic skills. Once validated in the JUMISC (Spain), the tool was proposed to extend its scope and implementation in other locations. RESULTS: Our system has not yet demonstrated a full validity in the real clinical setting because a predictive validity needs to be demonstrated on the basis of clinical data. It also suffers from a certain range of subjectivity, thus implying clear and defined criteria for any situation. Factors like the number of evaluators and tasks to assess will influence the reliability tests that measure the degree of agreement between evaluators, so that a higher number of evaluated cases would imply a greater reliability of our system. Finally, we assume that the incorporation of this type of tools implies an added cost, charged to the public and private responsible institutions, which will only be considered cost-effective when it is demonstrated its real and positive traceability in health outcomes. CONCLUSIONS: ESSCOLAP® Basic, of quick and simple implementation capacity, has been validated and calibrated for the evaluation of basic technical skills in laparoscopy.

[Training in basic and advanced laparoscopy: Evaluation of a 30-year experience in a training program in Spain.] / Formación en cirugía laparoscópica urológica básica y avanzada: evaluación de 30 años de experiencia de un programa de formación en España.

The lack of globally established standards for learning urological laparoscopy has not prevented laparoscopic techniques from evolution and continuous development. Laparoscopy coexists with robotic surgery today, and in the last decade there have been many techniques that have undergone a boom with the use of a laparoscopic approach (total and partial nephrectomy, pyeloplasty, colposacropexy, etc.).We intend to evaluate the progressive incorporation of different surgical techniques in the laparoscopic learning program and, on the other hand, to analyze the evolution of training programs in urological laparoscopy to bring this type of techniques within the hospital surgical activity. We describe our 30-years experience in different training programs in urological laparoscopy that have been sponsored by the Spanish Association of Urology (AEU), and have undergone several validity studies to assess their capacity in order to evaluate effectively basic and advanced laparoscopic skills. We will also highlight the current and future trend towards training models based on surgical competences where individualized training, accreditation and specialization of tutors is crucial, and where the increase in the use of training and evaluation methods based on the simulation are increasingly common.

[Training and research in urologic laparoscopic surgery. Design of training programs and experimental models of renal tumor]. / Formación e investigación en cirugía laparoscópica urológica. Diseño de programas formativos y modelos experimentales de tumor renal.

We present our experience with surgical training programs development for basic and advanced laparoscopic urological surgery. Both training programs consist of 21 and 28 hours respectively. Basic surgical programs start with general knowledge of ergonomics and instrumentation, there after, attendants acquire basic skills on physical simulator. Posteriorly, techniques on animal model are undertaken, always assisted by an expert. Advanced activities start with surgical tasks on physical simulator. Posteriorly, reconstructive urological surgical techniques are undertaken on animal model, focused on partial nephrectomy, and always assisted by an expert tutor. We present our results on exophytic renal tumour model creation based chromatic Alginate.

[Usefulness of the holmium:yag laser in the endoscopic section of ureteral stenosis]. / Utilidad del láser de holmium:yag en la sección endoscópica de la estenosis ureteral.

OBJECTIVES: The incidence of ureteral stenosis is frequent in our environment. Lately, due to the massive use of endourological techniques its incidence has increased. Etiology represents a decisive factor for the final result of treatment, but there are also common characteristics to all stenosis that influence very importantly the final success: time of evolution, length of the stenosis, side and function of the affected renal unit. Over the last years, the use of endourological techniques for the treatment of upper urinary tract stenosis, that substitute the traditional open technique, have increased. Holmium:YAG laser endoureterotomy presents advantages in comparison with other endourological techniques, because it enables a precise incision with direct vision of the ureteral stenosis. Moreover, with laser fibers ureteroscopes achieve a degree of flexibility/deflection that enables us to reach in most cases the stenotic area. At the time of incision of the ureteral wall, it should be complete, acting on all ureteral layers down to the periureteral fat, always having in mind the anatomic relationships of the ureter with neighbour structures, mainly vascular, to avoid injuries. Its effectiveness and easy management permits a high success rate, with resolution of the stenosis and a very low complication rate. After all the anterior, holmium laser retrograde endoureterotomy should be included as a first line treatment for benign ureteral stenosis.

[Retrograde laser endopyelotomy]. / Endopielotomía retrógrada con láser.

Ureteropyelic junction obstruction (UPJO) is the most frequent congenital anomaly of the upper urinary tract. Until some years ago, the treatment of first choice was open pyeloplasty, but the development of endoscopic surgery and the clinical improvement on instruments, enables the treatment in a minimally invasive fashion, offering the advantages of shorter operative time, less morbidity, reduction of post operative analgesic requirements, shorter hospital stay, and shorter convalescence period. Retrograde endopyelotomy represents the natural evolution of the minimally invasive surgical treatment of the UPJO by eliminating the need of a percutaneous renal tract and its possible complications. It may be performed in three ways: semirigid ureteroscope and electrocautery, cold knife or laser incision; flexible ureteroscope and electrocautery or laser incision; and under x-ray control with the Acucise cutting balloon catheter. Currently, the development of smaller ureterorenoscopes (semirigid and flexible) and the use of safer and more effective energy sources, such as holmium:YAG laser, have improved the results of this technique. We present the technique step-by-step and a bibliographic review.

[Lower calyx lithiasis: usefulness of the laser]. / Litiasis en cáliz inferior: utilidad del láser.

There is controversy yet about which is the best treatment modality for lithiasis of the lower calyx. The range of lithiasis clearance of the stones localized in the lower calyx will depend on various factors such as size, composition of the stone, type of lithotripter employed, type of urinary transport, and anatomy of the lower calyx. The role of flexible ureteroscopy in the treatment of intrarenal pathology has experimented a dramatic evolution, impulsed by the improvements in design of flexible ureterscopes, their degree of deflection, and better quality of image, in the great diversification of small calibre accessory instruments, and the use of the holmium laser for lithotripsy. Its development makes possible to offer it as a therapeutic option for the failures of extracorporeal lithotripsy in stones smaller than 1 cm and as first-line treatment for stones smaller than 1 cm in size if they are cystine stones or they have an attenuation level over 1000 HU; also in obese patients or those with coagulation problems.

[Antimigration devices during endoscopic lithotripsy with holmium: yag laser]. / Dispositivos antimigración durante la litotricia endoscópica con láser de holmium:yag.

OBJECTIVES: Lithiasic pathology continues being very prevalent in our environment. There are multiple approaches and treatments to solve it in current urology. Lately, endourological techniques have suffered a spectacular advance which has permitted to increase their success rates, diminishing also their comorbidity very much. Nevertheless, despite all improvements we still face a series of complications that may reduce the success of the procedure. Among all of them, we emphasize stone retropulsion during endoscopic lithotripsy, because it appears in an important number of procedures and, it does not only diminish the range of stone free patients, but also is associated with a longer surgical time, and occasionally will make necessary the employment of additional procedures that increase cost and treatment morbidity. To reduce the incidence of this retropulsion classical manoeuvres have been employed: antitrendelenburg, decrease of the intensity of the irrigaton flow, modification of laser parameters, or pneumatic balloons. Currently, we have other more effective mechanisms to combat it, among them: the devices that occlude the ureteral lumen, and nitinol baskets/forceps. Adequate selection of the stone extraction device may be definitive for completion of the ureterorenoscopic procedure with success, and in the programmed time. The election of an inadequate device may make the procedure impossible or cause iatrogenic damage to the urinary tract. For all it, specific instruments to entrap and extract stones (baskets and ureteral lumen occlusion devices) is an armamentarium that every endourologist should be familiar with.

[Urological diseases in the works of Abulcasis]. / La patología urológica en la obra de Abulcasis.

OBJECTIVES: To perform a study on the surgical work of Abulcasis in the field of urology, to know the surgical tools and different techniques used, as well as the innovations applied to solve some features of urological diseases. METHODS: The part on urology from the book XXX by Tasrif, the edition from Strasbourg in 1532 was reviewed and translated from Latin. RESULTS: The author does not refer much to the clinical features of the various pathologies of the genitourinary apparatus; he focuses instead on the surgical treatment of them. The author usually used the "cautery" mainly to control hemorrhage in various operations. Some of these surgical practices are being used nowadays. CONCLUSIONS: Abulcasis was the first doctor born in Spain that studied the surgical treatment of urological diseases and performed a graphic study on the tools used. He introduced technical innovations on different operations and described for the first time the vesical lithotomy on women, and vesical and urethral lithotripsy.

[Antegrade and retrograde endourological techniques. Equipment and methodology]. / Técnica endourológica anterógrada y retrógrada. Instrumental y metodología.

Low grade and stage upper urinary tract tumors may be treated endoscopically by antegrade or retrograde approach. The approach mainly depends on tumor size and site. Generally, retrograde ureteroscopy is used for small size tumors of the ureter and kidney, whereas the antegrade approach is indicated for bigger tumors in the upper ureter or kidney, or those tumors which cannot be adequately managed in a retrograde manner because of their site (lower calyx) or previous urinary diversion. This article presents the techniques of retrograde ureteroscopy and percutaneous antegrade resection, as well as the equipment needed for adequate endoscopic treatment of the upper urinary tract urothelial tumors.

[Protocol for percutaneous treatment of upper urinary tract urothelial tumors]. / Protocolo en el tratamiento percutáneo del tumor de urotelio superior.

We develop the diagnostic methodology to select patients with upper urinary tract urothelial tumors who are candidates for percutaneous endoscopic treatment. This treatment is indicated for low grade and stage lesions in the pyelocalyceal system (> 3 cm), lumbar ureter (> 1-2 cm) and for failures of the retrograde approach. In this protocol, we emphasize the performance of intraoperative biopsy and pyelocalyceal mapping, as well as the need of a second look to rule out residual tumor.

[Is there a risk of carcinoma dissemination in the percutaneous access for endoscopical treatment of upper urinary tract urothelial tumors?]. / Existe riesgo de diseminación del carcinoma en el acceso anterógrado del tratamiento endoscópico del tumor de urotelio superior?

OBJECTIVES: The incidence of transitional cell carcinoma of the renal pelvis and ureter is low, and the standard treatment is nephroureterectomy with a bladder cuff. However, there are special circumstances, from both patient and tumor characteristics, which are subsidiary of a minimally invasive endoscopic treatment, such as percutaneous resection. Very satisfactory results have been obtained with this technique, which has been performed since 1985. Nevertheless, theoretically there exists a potential risk of disseminating tumor cells when performing this technique. The objective of this article is to review our experience, and that of other groups, performing percutaneous resection of upper urinary tract tumors, and to determine the incidence tumor dissemination. METHODS: We performed a bibliographic search in Medline (PubMed) and reviewed the articles about upper urinary tract tumors treated by percutaneous resection. We also evaluated the incidence of tumor dissemination related to surgery RESULTS: Published data show a very low incidence of tumor dissemination after endoscopic resection by a percutaneous approach. Theoretically tumor dissemination can be the result of dissemination to the blood or lymphatic circulation, or the implant of tumor cells in the contiguous or distant urothelial mucosa, or propagation of these tumor cells to the retroperitoneal space or the nephrostomy track. CONCLUSIONS: Percutaneous endoscopic resection of upper urinary tract urothelial tumors is a safe and effective technique that enables a minimally invasive and nephron sparing treatment. If some precautions are taken, this surgical technique does not involve a significant risk for tumor cell dissemination.

[Therapeutic advantages of rigid transurethral ureteroscopy in ureteral lithiasic pathology: retrospective study of 735 cases]. / Ventajas terapéuticas de la ureteroscopia transuretral rígida en la patología litiásica ureteral: estudio retrospectivo de 735 casos.

OBJECTIVE: To present the results achieved by rigid transurethral ureteroscopy for the management of ureteral calculi over a period of 10 years. METHODS: From January 1991 to November 2000, 735 rigid transurethral ureteroscopy procedures for ureteral calculi were performed in our Lithotripsy Unit. The rigid ureteroscopes utilized ranged from 9.5-11.5 F. There was a higher prevalence of male patients (63%). The mean age was 49.9 years. Calculi were more frequently localized in the pelvic ureter (74.2%). The mean maximum diameter of the calculi was 9.6 mm and caused moderate to severe uropathy in 78.6% of the cases and functional impairment in 3.7% of the cases. After performing ureteroscopy, a double-J catheter was left indwelling in 65.8% of the patients. The patients were discharged from hospital usually 12-18 h after the endoscopic procedure. RESULTS: Of the 735 ureteroscopies performed, satisfactory results were achieved in 676 cases (92%); stone resolution was not achieved in 59 cases. For complete resolution of the calculi, mechanical or electrokinetic fragmentation was used in a high proportion of patients (56.3%). Removal of the stone or stone fragments was mainly by forceps (79.7%); the Dormia basket was used in 18.2% of the cases. The complications occurred during or immediately after the procedure and were minor (10.7%), although there were 3 patients with major complications (2 ureteral eversion and one case of ureteral avulsion). CONCLUSIONS: In our view, rigid transurethral ureteroscopy is a useful, safe and efficient technique in the treatment of calculi in the pelvic ureter, and in selected cases of calculi in the sacral or lumbar level, after failed ESWL. Rigid transurethral ureteroscopy achieves excellent resolution and the complications are scanty.