A comparison between vapor tunnel and virtual basket for the treatment of proximal ureteral stones using holmium:YAG laser (Cyber Ho): which is the best tool to reduce retropulsion?

PURPOSE: To compare vapor tunnel (VT) and virtual basket (VB) tools to reduce retropulsion in the treatment of proximal ureteral stones. METHODS: Patients with a single proximal ureteral stone were randomly assigned to holmium laser lithotripsy with the use of VT (Group A) or VB (Group B) tool. The 150W holmium:YAG cyber Ho generator was used. We compared operative time, dusting time, need for flexible ureteroscopy due to stone push-up and occurrence of ureteral lesions. The stone-free rate (SFR) and the occurrence of postoperative ureteral strictures were assessed. RESULTS: 186 patients were treated, of which 92 with the VT (49.5%, Group A) and 94 with the VB (50.5%, Group B). Mean stone size was 0.92 vs. 0.91 cm in Groups A vs. B (p = 0.32). Mean total operative time and dusting time were comparable between groups. 7 (7.6%) vs. 6 (6.4%) patients in Groups A vs. B required a flexible ureteroscope because of stone push-up (p = 0.12). Ureteral mucosa lesions were observed in 15 (16.3%) vs. 18 (19.1%) cases in the VT vs. VB group (p = 0.09). 1-Month SFR was comparable (97.8% vs. 95.7%, p = 0.41). We observed one case (1.1%) of postoperative ureteral stricture in the VT group vs. two cases (2.1%) in the VB group (p = 0.19). CONCLUSIONS: VT and VB are equally safe and effective tools in reducing retropulsion of ureteral stones. Operative time, dusting time and SFR were comparable. They also equally avoided stone push-up and prevented ureteral lesions, which may later occur in ureteral strictures.

Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort.

PURPOSE: To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon. METHODS: Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. RESULTS: Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload. CONCLUSIONS: In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.

Transfer of acquired practical skills from dry lab into live surgery using the avatera robotic system: An experimental study.

OBJECTIVE: To evaluate the transfer of the practical skills of robot-assisted surgery acquired in the dry-lab into a real live experimental setting for performing upper and lower urinary tract surgeries. MATERIAL AND METHODS: An in vivo experimental study design was utilized. Six urology trainees and fellows; two 2nd year trainees with no previous exposure to laparoscopic surgery (Group 1), two 4th year residents with medium exposure to laparoscopic surgery (Group 2) and two fellows trained to perform laparoscopic surgeries (Group 3) performed ureteral reimplantation into the bladder, pyeloplasty, and radical nephrectomy on three female pigs under general anesthesia. Prior to performing the requested procedures, each participant completed 10-14 h dry-lab robotic training acquiring skills in basic surgical tasks, such as suturing, cutting and needle passage. The recorded variables were the successful completion of the procedures, the console time, and the time to perform different steps and major complications. RESULTS: All procedures were completed successfully by all groups except the pyeloplasty by group 1 which was complicated by bleeding from the renal vein, and the procedure was abandoned. Group 3 achieved shorter console time for all successfully completed procedures and for separate surgical steps compared to all groups, followed by Group 2. The slowest group for all procedures and steps analyzed was Group 3. CONCLUSIONS: Although further clinical evidence is needed, the robotic-assisted urological procedures and the most challenging steps could be performed safely and effectively after proper training in the dry lab under mentor supervision according to our study.

Evolution and simplified terminology of natural orifice transluminal endoscopic surgery (NOTES), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML).

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) are the next steps in the evolution of laparoscopic surgery, promising reduced morbidity and improved cosmetic result. The inconsistent terminology initially used led to confusion. Understanding the technical evolution, the current status and a unified and simplified terminology are key issues for further acceptance of both approaches. OBJECTIVE: To present LESS and NOTES in its historical context and to clarify the associated terminology. METHOD: Extensive literature search took place using the PubMed. Several hundred publications in general surgery and urology regarding LESS are present including the expert opinion of members the European Society of Uro-technology (ESUT). RESULTS: The increasing interest on NOTES and LESS is reflected by a raising number of publications during the last 4 years. The initial confusion with the terminology of single-incision surgery represented a significant issue for further evolution of the technique. Thus, consortiums of experts searched a universally acceptable name for single-incision surgery. They determined that 'laparoendoscopic single-site surgery' (LESS) was both scientifically accurate and colloquially appropriate, the term being also ratified by the NOTES working group (Endourological Society) and the ESUT. For additional use of instruments, the terms hybrid NOTES and hybrid LESS should be used. Any single use of miniaturized instruments for laparoscopy should be called mini-laparoscopy. DISCUSSION: The evolution of LESS and most likely NOTES to a new standard of minimally invasive surgery could represent an evolutionary step even greater than the one performed by the establishment of laparoscopy over open surgery.

Management of lymph nodes in early prostate cancer.

This article is a review of the literature concerning the management of lymph nodes (LNs) in early prostate cancer. The literature review was performed using the PUBMED database. The treatment of LNS in early prostate cancer usually requires a pelvic LN dissection (PLND), which is performed in all patients with localized prostate cancer. Sometimes nomograms are used to select patients requiring lymphadenectomy. No consensus is available concerning the indications for the performance of PLND and the extent of the lymphadenectomy that should be performed. Recent non-surgical methods detecting LN invasion seem promising, but further investigations and a consensus attainment for terminology and investigation methodologies are advisable.