Market potentials of robotic systems in medical science: analysis of the Avatera robotic system.

PURPOSE: To evaluate the potential opportunities and possible competitiveness of Avatera robotic system (ARS) (Avateramedical, Germany), and perform predictive cost-analysis for its implementation and dissemination. MATERIAL AND METHODS: Our study employed a projective quantitative research design. SWOT (strengths, weaknesses, opportunities, threats) analysis was used to map ARS internal competencies towards external contexts, and potential opportunities and risks in the robotic market. The ARS purchase and procedural costs were evaluated in two different scenarios. RESULTS: In the first scenario, setting the purchase cost of the Avatera at around $1.3-1.5 million, a total $400 procedural cost reduction compared to the RAS performed with the da Vinci Xi can be calculated. In the second scenario, with a purchase cos of the ARS of $700.000-800.000 and considering a 5-year period with an annual ARS volume of 500 procedures, only an additional $300 will be attributed to the robot itself. Our projections revealed that for an effective competition the purchase cost of ARS should range between $700.000 and $800.000 during the initial phase of market entry. The marketing strategy of the ARS should be oriented towards countries without any robotic system in operational use, followed by countries where the competition intensity in the marketplace is low. CONCLUSION: The introduction of new robotic systems will greatly affect and reshape the market of robotic surgery. The ARS has all the technical capacity ensuring the performance of high-quality surgical procedures. A fast spread and implementation of the ARS could be expected should the purchase and maintenance costs be kept low.

European Section of Urotechnology educational video on fluoroscopic-guided puncture in percutaneous nephrolithotomy: all techniques step by step.

OBJECTIVE: To describe the most common fluoroscopic-guided access techniques during percutaneous nephrolithotomy (PCNL) in a step-by-step manner and to assist in the standardisation of their technique and terminology. METHODS: A high-quality animation video was created for each of the respective fluoroscopic techniques, focusing into the parallel projection of external surgical manoeuvres and their effect in the three-dimensional space of the kidney. RESULTS: Four predominant fluoroscopic-guided percutaneous access techniques are available, each with different advantages and limitations. Monoplanar access is used when a stable single-axis fluoroscopic generator is available and is mostly based on surgeons' experience. Biplanar access uses a second fluoroscopy axis to assess puncture depth. The 'bull's eye' technique follows a coaxial to fluoroscopy puncture path and is associated with a shorter learning curve at the cost of increased hand radiation exposure. Hybrid and conventional triangulate techniques use target projection by two fluoroscopic planes to define the exact localisation of the target in space and access it through a third puncture site. CONCLUSIONS: Fluoroscopic guidance during PCNL puncture is a very efficient method for access establishment. The percutaneous surgeon should be familiar with all available variations of fluoroscopic approach in order to be prepared to adapt puncture technique for any given scenario.

Challenging the wisdom of puncture at the calyceal fornix in percutaneous nephrolithotripsy: feasibility and safety study with 137 patients operated via a non-calyceal percutaneous track.

OBJECTIVES: To present our experience with a central, non-calyceal puncture protocol for percutaneous nephrolithotripsy (PCNL) in an attempt to challenge the opinion of worldwide adopted calyceal puncture as the less traumatic site of percutaneous entrance into the collecting system. PATIENTS AND METHODS: During 2012, a total of 137 consecutive, unselected patients were subjected to PCNL in our department. Non-calyceal punctures were performed to all cases and followed by subsequent track dilations up to 30 Fr. Perioperative and postoperative data were prospectively collected and analyzed. RESULTS: Mean operative time (from skin puncture to nephrostomy tube placement) was 48 min. Patients with single, multiple and staghorn stones had primary stone-free rates of 89.2, 80.4 and 66.7 % after PCNL, respectively. The overall complication rate was 10.2 %, while bleeding complications were minimal. Only 4 patients (2.9 %) required blood transfusion. Five patients (3.6 %) had Clavien Grade IIIa complications requiring an intervention for their management and none Grade IV or V. CONCLUSIONS: Despite the absence of evidence that non-calyceal percutaneous tracts could be a risk factor for complications, the concept of calyceal puncture has been worldwide adopted by PCNL surgeons as the sole safe percutaneous entrance into the collective system. Based on our experience, other pathways than the worldwide recognized rule, calyceal puncture, are possible and probably not as dangerous as has been previously stated.

Acute focal bacterial nephritis is associated with invasive diagnostic procedures - a cohort of 138 cases extracted through a systematic review.

BACKGROUND: Acute focal bacterial nephritis (AFBN) is a rare disease currently described only in case reports and small case series. In this study we summarize the clinical features of AFBN as has been documented in the literature and draw recommendations on the proper diagnosis and therapy. METHODS: A systematic literature review was undertaken in PUBMED, Web of Science and The Cochrane Library online databases for relevant literature on AFBN in adults. RESULTS: Literature review revealed a total of 38 articles according to our inclusion criteria, of which we could extract data from 138 cases of AFBN. Fever (98%) and flank pain (80%) were most commonly reported symptoms. E. coli was the most frequent pathogen. Diagnosis was set by CT and/or MRI (52%) with or without sonography or by sonography alone (20%) as well as by sonography combined with IVU. In total, sonography was applied in 83% of cases. All but one patient received antibiotic treatment. Kidney lesions were occasionally mistaken for neoplasms or renal abscesses and as a result, cases were subjected to percutaneous puncture (12.3%), surgical exploration (5.1%) and partial or radical nephrectomy (4.4%). Four cases (2.9%) developed a renal abscess. CONCLUSIONS: The diagnosis of AFBN is set by characteristic clinico-radiological findings. Differential diagnoses of this interstitial bacterial infection include renal abscess and tumor. Correct diagnosis is occasionally impeded by atypical symptoms. Invasive diagnostic and therapeutic procedures should be limited as the majority of cases respond well to conservative treatment.

Acute Focal Bacterial Nephritis Can Lead to Unnecessary Invasive Procedures: A Report of Three Cases.

Acute focal bacterial nephritis (AFBN) is a rarely diagnosed interstitial bacterial infection of the kidney. Due to the non-specific clinical presentation of this entity, correct diagnosis can be challenging. In this work, we present three cases of AFBN aiming to stress the diversity of clinical presentation associated with the disease and the fact that patients with AFBN are at risk of undergoing unnecessary invasive procedures. The employment of invasive diagnostic and therapeutic procedures on the management of AFBN should be limited, as the majority of patients respond well to conservative therapy.

Transvaginal specimen removal in minimally invasive surgery.

The demand for urological surgical treatment associated with better cosmesis, lower morbidity rates and shorter hospitalization constantly grows. The transvaginal route has been proposed in an attempt to avoid long abdominal incisions for the removal of the large laparoscopic specimens. Moreover, the transvaginal NOTES approach represents a promising evolution of laparoscopic surgery to a more "minimally invasive" alternative. The current review summarizes the available experience in the literature in transvaginal conventional laparoscopy and NOTES in urology, gynecology and general surgery. The clinical outcome is presented. The most important issues associated with the transvaginal approach are the complications and the postoperative sexual function. These issues are presented.

National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany.

OBJECTIVE: In this study, we document trends in radical prostatectomy (RP) employment in Germany during the period 2005-2012 and compare the morbidity of open (ORP), laparoscopic and robotic-assisted RP based on nationwide administrative data of Allgemeine Ortskrankenkassen (AOK) German local healthcare funds. MATERIALS AND METHODS: Administrative claims data of all AOK patients subjected to RP during 2005-2012 (57,156 cases) were used to evaluate the employment of minimally invasive RP (MIRP) procedures, pelvic lymph node dissection (PLND) and nerve-sparing approaches during this period. In addition, data from the most recent three-year period of our dataset (2010-2012) were used to compare the morbidity among the different surgical approaches. Study end points comprised 30-day mortality, 30-day transfusion, 1-year reintervention and 30-day adverse events, as well as 1-year overall complications. RESULTS: A 20 % reduction in RP utilization from 2007 to 2012 was documented. ORP remained the predominant RP approach in Germany. MIRP approaches carried a lower risk of 30-day transfusions, 1-year reinterventions and 1-year overall complications than ORP when adjusting for confounding factors. PLND was associated with an increased risk of complications, while age in the highest quintile and the presence of comorbidities were independent risk factors for morbidity and mortality. Lack of pathological data was the main limitation of the study. CONCLUSIONS: RP utilization in Germany is dropping, but the use of MIRP has risen steadily during the years 2005-2012, which is expected to have a positive impact on the morbidity of the operation.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology.

OBJECTIVE: To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide. METHODS: A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities. RESULTS: Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis. CONCLUSIONS: Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Complications of percutaneous nephrolithotomy: classification, management, and prevention.

PURPOSE OF REVIEW: Percutaneous nephrolithotomy (PCNL) provides the highest stone-free rate after one session and low morbidity rates in cases of large or multiple renal calculi. The classification, management, and prevention of complications of PCNL are reviewed. RECENT FINDINGS: PCNL is a well tolerated and very effective procedure for the management of renal stones. Specific complications limit the surgical outcome of PCNL whereas the majority of the complications are resolving with conservative or minimally invasive management. Experience with the technique is important for minimizing complications. There is an ongoing effort to classify the complications and to achieve a consensus in reporting the complications and surgical outcome of the procedure. SUMMARY: The knowledge of risk factors, complications, and their management is important for every endourologist. Establishing of a PCNL-specific classification system for reporting outcomes and complications could set the basis for further improvement of the PCNL technique and outcomes.

Current evidence on lasers in laparoscopy: partial nephrectomy.

INTRODUCTION: Laser-assisted partial nephrectomy (PN) can benefit from the excellent coagulative properties of lasers to provide a bloodless tumor excision without the necessity for renal artery clamping. In this review, we aim to determine the current clinical implementation of laser assistance during laparoscopic nephron-sparing surgery. MATERIALS AND METHODS: An extensive literature evaluation on laser-assisted PN was performed. Experimental work on animals and review articles were excluded. RESULTS: Current literature regarding laser-assisted PN is scarce. Available data consist mostly of small cohorts providing low level of evidence. Even though initial studies with currently available laser modalities demonstrated promising results, several drawbacks in each technique need to be addressed before being widely accepted as a standard care. CONCLUSIONS: Experience with laser-assisted laparoscopic PN is steadily increasing and uniformly documenting favorable results. As urologist became more familiar with laser technology by its implementation in other clinical entities and with the increasing interest in nephron-sparing management of renal tumors, the use of laser assistance during PN should be expected to play a major role in future.

Complications in percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is generally considered a safe technique offering the highest stone-free rates after the first treatment as compared to the other minimal invasive lithotripsy techniques. Still, serious complications although rare should be expected following this percutaneous procedure. In this work, the most common and important complications associated with PCNL are being reviewed focusing on the perioperative risk factors, current management, and preventing measures that need to be taken to reduce their incidence. In addition, complication reporting is being criticized given the absence of a universal consensus on PCNL complications description. Complications such as perioperative bleeding, urine leak from nephrocutaneous fistula, pelvicalyceal system injury, and pain are individually graded as complications by various authors and are responsible for a significant variation in the reported overall PCNL complication rate, rendering comparison of morbidity between studies almost impossible. Due to the latter, a universally accepted grading system specialized for the assessment of PCNL-related complications and standardized for each variation of PCNL technique is deemed necessary.

Transurethral anatomical enucleation of the prostate with Tm:YAG support (ThuLEP): review of the literature on a novel surgical approach in the management of benign prostatic enlargement.

PURPOSE: Retrograde transurethral anatomical enucleation of the prostate is gaining momentum as a new concept in transurethral surgery of benign prostatic hyperplasia. Its adaptation is boosted by the familiarity of urologists with the finger-assisted anatomical enucleation of the adenoma during open prostatectomy and the combination of this well-established concept with the minimal invasive characteristics of transurethral surgery. The thulium laser appears as an ideal energy source for such operation. In this work, current evidence on thulium laser-assisted anatomical enucleation of the prostate (ThuLEP) is being reviewed. MATERIALS AND METHODS: A comprehensive literature review was performed on Medline, PubMed, and Cochrane databases retrieving all literature on thulium laser-assisted prostatectomy between 2006 and 2015. Experimental studies, review articles and editorial comments as well as studies on thulium laser-assisted approaches other than ThuLEP (i.e., ThuVEP, ThuVAP or ThuVARP) were excluded from the analysis. RESULTS: In total, six original articles on either surgical technique or clinical outcomes were retrieved. With regard to functional results, ThuLEP presented no significant differences toward the standard treatment (TURP/HoLEP) arm in two randomized controlled trials and favorable outcomes in available prospective cohorts. Observed morbidity was minimum and comparable with the rest of transurethral literature. CONCLUSIONS: ThuLEP literature is still very limited. Based on the available data, the approach is safe and effective, demonstrating favorable outcomes, comparable with the current standard treatment options. Further documentation of ThuLEP outcomes is necessary to define the optimum indications of this novel technique.

In vitro evaluation of ureteral contractility: a comparative assessment of human, porcine and sheep ureteral response to vardenafil.

OBJECTIVES: Basic science studies of ureteral physiology and pathophysiology are commonly performed on animal ureters due to several limitations associated with human ureteral sampling. In this work we question whether animal ureters are good replicas of human ureteral behavior for pharmacological studies. MATERIALS AND METHODS: Ureteral rings from human, porcine and ovine ureters underwent the same organ bath protocol. After stimulation with KCl, ureters were subjected to different doses of vardenafil. Basic contractility and ureteral response to vardenafil were analyzed. RESULTS: A different pattern of basic contractility was evidenced between species. Vardenafil administration induced a dose-dependent reduction in KCl-induced amplitude increase in human ureters and a dose-dependent reduction in autonomic contractile rhythm of porcine and ovine ureters. Although animal ureters could predict the relaxant response of human samples to vardenafil, its effect would have been overestimated using only animal models. CONCLUSIONS: Human ureteral investigations cannot entirely be replaced by existing animal models since results of the latter will vary significantly according to the tested pharmaceutical agent.

Novice surgeons: do they benefit from 3D laparoscopy?

In this study, the impact of two-dimensional (2D) and three-dimensional (3D) vision on laparoscopic performance of novice surgeons is examined. Twenty-five novice surgeons were directed to complete four basic tasks from European Training in Basic Laparoscopic Urological Skills (E-BLUS) with both 2D and 3D systems in a random order: task 1: needle guidance, task 2: cutting a circle, task 3: laparoscopic suturing, and task 4: pegs transfer. Quality and quantity scores for each task were measured. Participants completed all of the tasks in one modality of vision and than switched to the other. NASA Task Load Index was used for subjective workload assessment. Statistically significant differences in favor of 3D vision were detected in tasks 1 and 4 both in terms of quality and quantity. In task 2 and task 3, a significantly better performance was observed with the 3D vision only in quantity assessment. The participants who started the tasks in the 3D vision were better in performing the skills in 2D when compared to the participants who started with 2D vision. Overall, the participants reported a better perception of depth and spatial orientation with the 3D mode. Subjective work load was also lower for the tasks performed in 3D. Novice surgeons tended to perform better and felt much more comfortable with 3D in comparison to 2D laparoscopy. Even though previous task experience seemed to have an important impact on laparoscopic performance regardless of imaging modality, 3D laparoscopy seemed to facilitate the learning for novice surgeons.

The full metallic double-pigtail ureteral stent: Review of the clinical outcome and current status.

The full metallic double-J ureteral stent (MS) was introduced as a method for providing long-term drainage in malignant ureteral obstruction. Experimental evaluation of the MS revealed that its mechanical features allow efficient drainage in difficult cases, which could not be managed by the insertion of a standard polymeric double-J stent. Clinical experience with the MS showed controversial results. Careful patient selection results in efficient long-term management of malignant ureteral obstruction. The use of the MS should also be considered in selected benign cases. Major complications are uncommon and the minor complications should not hinder its use. Experience in pediatric patients is limited and warrants additional study. The cost-effectiveness of the MS seems to be appropriate for long-term treatment. Further investigation with comparative clinical trials would document the outcome more extensively and establish the indications as well as the selection criteria for the MS.

'Scarless' laparoscopic urologic surgery by the combination of mini-laparoscopic and laparoendoscopic single-site surgery equipment.

OBJECTIVE: We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment. PATIENTS AND METHODS: 30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected. RESULTS: The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy. CONCLUSION: The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for 'scarless' urologic surgery.

Drug-eluting metallic stents in urology.

Drugeluting metal stents (DESs) have been extensively used in coronary and vascular disease. This type of stents has been proven to provide significantly lower restenosis rates due to the reduction of neo-intimal hyperplasia in comparison to the traditionally used bare metal stents (BMSs). The latter stents have been evaluated for more than a decade in urological practice in an attempt to provide permanent relief of urethral or ureteral obstruction. Although the initial results were promising, long-term experience revealed significant complications, which are mainly attributed to stent-related hyperplastic reaction compromising stent patency. The favorable experience of vascular DESs led to the application of DESs in both the urethra and ureter of animal models. These experimental results demonstrated a reduction of hyperplastic reaction of DESs in comparison to BMSs. Nevertheless, clinical data are currently not available. Considering the fact that DESs are under continuous development, the use of DESs in urology holds promise for the future and seems to be an intriguing field.

Assessing the use of haemostatic sealants in tubeless percutaneous renal access and their effect on renal drainage and histology: an experimental porcine study.

OBJECTIVE: To evaluate the mid-term effects of haemostatic sealant application during tubeless percutaneous nephrolithotomy (PCNL) on renal drainage and histology in an in vivo porcine study. MATERIALS AND METHODS: Bilateral percutaneous access was established in 28 porcine renal units. At the end of the procedure, a type 1 absorbable fish origin collagen powder, a human fibrinogen- and thrombin-coated sponge or a cross-linked gelatin granule/topical thrombin matrix were randomly placed on the nephrostomy tracts. Four nephrostomy accesses were left intact and served as controls. No percutaneous tube, ureteric stent or bladder catheter was left in place postoperatively. Computed tomography urography on postoperative days 1, 15, 30 and 40 was used to access renal drainage. On postoperative day 40, all animals were killed and both kidneys from each animal were harvested for histological evaluation. RESULTS: Evidence of risk for drainage occlusion after sealant application was found. The use of haemostatic sealants was associated with significant histological lesions in the renal parenchyma, regardless of which sealant was used. No sealant was identified as superior to the others. Nephrostomy tracts that were left without sealant application (control group) were associated with no morbidity and fewer histopathological changes. CONCLUSIONS: Based on these experimental results, the safety of the application of haemostatic sealants in tubeless PCNL should be reassessed, focusing not only on the potential of such materials to occlude urinary drainage but also on their effect on renal histology. Further investigation is considered necessary.

Unfavorable outcomes of laparoscopic pyeloplasty using barbed sutures: a multi-center experience.

PURPOSE: Barbed self-retaining sutures (SRS) have been introduced as an advance in suture technology, facilitating reconstructive laparoscopic surgery. We present the experience of three centers performing laparoscopic pyeloplasty with the use of SRS. METHODS: Preoperative, intraoperative and follow-up data were collected for 6 patients undergoing pyeloplasty using the Quill SRS (Angiotech, Vancouver, CAN) in three centers. Standard laparoscopic pyeloplasty technique was used and a knot-less continuous anastomosis between the spatulated ureter and the renal pelvis was created. RESULTS: Knot-less uretero-pelvic anastomosis creation was feasible in all six cases. Peri-operative data were similar to standard pyeloplasty using conventional suture materials. A very high stricture recurrence rate (5/6 patients) was noted during follow-up. Further endourologic and open interventions were needed to address the recurrence of the strictures. CONCLUSIONS: Knotless intracorporeal laparoscopic suturing using SRS for the reconstruction of UPJ during laparoscopic pyeloplasty is associated with high rates of stricture recurrence at least in the initial cases of each surgeon. Until further investigations elucidate the cause of treatment failure, SRS should not be recommended for upper urinary tract reconstruction.

PDE5 inhibition against acute renal ischemia reperfusion injury in rats: does vardenafil offer protection?

PURPOSE: To evaluate the effect of vardenafil on renal function after renal ischemia-reperfusion (IR) injury (IRI) in a rat model. MATERIALS AND METHODS: Seventy-one Wistar rats were divided into 7 groups including (1) a vehicle-treated group, (2) a vehicle pretreated-IR group, (3-6) vardenafil pretreated-IR groups in doses of 0.02, 0.2, 2 and 20 µg/kg, respectively, (7) a group of IR followed by treatment with 2 µg/kg of vardenafil. Vardenafil or vehicle solution was administered one hour before unilateral nephrectomy and the induction of 45 min of ischemia on the contralateral kidney by clamping of renal pedicle. Four hours of reperfusion were allowed after renal ischemia. Studied parameters were serum creatinine, fractional excretion of sodium (FENa), and histological evaluation of renal specimens. In addition, renal tissue cGMP levels, ERK1/2 phosphorylation as well as renal function by renal scintigraphy were also evaluated. RESULTS: Administration of vardenafil before the induction of ischemia resulted in a significant reduction in creatinine and FENa levels as well as in less histological lesions observed in treated kidneys in comparison with the vehicle-treated group. The underlying mechanism of cytoprotection was cGMP depended and involved the phosphorylation of ERK proteins. Renal scintigraphy confirmed that PDE5 inhibition attenuates renal IRI. CONCLUSIONS: Vardenafil attenuates renal IRI. Based on similar results from relevant studies on other PDE-5 inhibitors in renal and cardiac IRI, it can be assumed that all PDE-5 inhibitors share a common mechanism of cytoprotection.