Track and Teach: Identifying Key Movement Patterns in Endoscopic Transurethral Enucleation of the Prostate.

PURPOSE: We evaluated a system for noninvasive quantitative motion tracking to recognize differences in the movement pattern of experienced surgeons and beginners. Since performing endoscopic procedures requires extensive training, and tissue damage due to disruptive movements with sudden acceleration is possible, the learning curve for beginners is of clinical relevance. Steepening this curve may improve patient outcome. MATERIALS AND METHODS: We used a commercial gyroscope sensor with a wireless data link, which was attached to the resectoscope handle (RH). After recording, orientation was retrieved by application of the calculated rotation matrices to the RH vector relative to the sensor under the boundary condition of rotational movement around and quasi-constant distance to the pivot point at pelvic floor level. Data alignment, normalization, interpolation, and analysis were performed in custom software scripts. RESULTS: Experienced surgeons and beginners were recorded in n = 36 and n = 14 holmium laser enucleation of the prostate (HoLEP), respectively. Prostate size, patient age, and recorded procedure duration were comparable. Mean lever angle of the individual normalized motion patterns was considerably lower (19.28 ± 0.54° [SEM]) in the advanced than in the beginners' group (24.52 ± 1.00°; p = 0.0001). Further parameters such as velocity and motion variation demonstrated additional differences between both groups. CONCLUSIONS: We demonstrate the feasibility of motion tracking in HoLEP. Pronounced differences exist between different stages of surgeon experience with this procedure. The method can easily be adopted to aide young surgeons in resectoscope handling and identification of improvable motion patterns. Damage to the pelvic floor and surrounding tissue may thus be reduced.

[Clinical application value of the endoscopic surveillance system in transurethral bipolar plasmakinetic resection of the prostate].

OBJECTIVE: To evaluate the clinical application of the endoscopic surveillance system (ESS) in transurethral bipolar plasmakinetic resection of the prostate (TUPKRP). METHODS: We retrospectively analyzed 136 cases of TUPKRP performed with the assistance of ESS from September 2018 to March 2019. According to the prostate volume (PV), we divided the patients into a PV ≥ 60 ml and a PV < 60 ml group, and compared the surgery-related parameters between the two groups of patients. RESULTS: Operations were successfully completed in all the 136 cases. Statistically significant differences were observed between the PV ≥ 60 ml and a PV < 60 ml groups in the operation time (ï¼»78.93 ± 28.63ï¼½ vs ï¼»51.77 ± 14.85ï¼½ min, P < 0.05), intraoperative blood loss (ï¼»261.61 ± 204.25ï¼½ vs ï¼»69.26 ± 61.13ï¼½ ml, P < 0.05) and absorption of the rinse fluid (ï¼»948.20 ± 656.00ï¼½ vs ï¼»347.39 ± 256.53ï¼½ ml, P < 0.05), but not in the postoperative red cell count, levels of hemoglobin, hematocrit and ions, hospital stay, incidence of prostatic perforation or blood transfusion (P > 0.05). The patients also showed statistically significant differences between the baseline and postoperative parameters in red cell count (ï¼»4.62 ± 0.63ï¼½ vs ï¼»4.31 ± 0.74ï¼½ ×1012/L, P < 0.05) and levels of hemoglobin (ï¼»141.83 ± 18.30ï¼½ vs ï¼»135.20 ± 19.91ï¼½ g/L, P < 0.05), K+ (ï¼»4.01 ± 0.43ï¼½ vs ï¼»3.92 ± 0.54ï¼½ mmol/L, P < 0.05) and Na+ (ï¼»141.90 ± 3.11ï¼½ vs ï¼»139.42 ± 3.81ï¼½ mmol/L, P < 0.05), but not in the levels of Cl－ (ï¼»103.74 ± 9.32ï¼½ vs ï¼»103.70 ± 4.50ï¼½ mmol/L, P > 0.05) and Ca2+ (ï¼»2.21 ± 0.13ï¼½ vs ï¼»2.19 ± 0.21ï¼½ mmol/L, P > 0.05). CONCLUSIONS: Large-volume absorption of rinse fluid may overburden the circulatory system and induce left ventricular failure, pulmonary edema or massive bleeding during PKRP for patients with PV ≥ 60 ml due to long operation time and rich blood supply in the hyperplasia gland. The endoscopic surveillance system can provide real-time data on the absorption of rinse fluid and bleeding, reduce complications, and improve surgical safety.

Novel thulium fiber laser for endoscopic enucleation of the prostate: A prospective comparison with conventional transurethral resection of the prostate.

OBJECTIVE: To compare the efficacy and safety of a novel thulium fiber laser for endoscopic enucleation of the prostate with monopolar transurethral resection of the prostate in patients with smaller glands (<80 cc). METHODS: A total of 51 patients underwent thulium fiber laser enucleation of the prostate, and 52 patients underwent monopolar transurethral resection of the prostate. All patients were assessed preoperatively, and at 3, 6, and 12 months postoperatively (International Prostate Symptom Score, maximum urine flow rate, International Prostate Symptom Score-quality of life). Preoperative prostate volumes and prostate-specific antigen levels were comparable (P = 0.543 and P = 0.078, respectively). The complications were graded according to the Clavien classification. RESULTS: Mean surgery time was longer in the thulium fiber laser enucleation of the prostate group (46.6 ± 10.2 vs 39.9 ± 8.6 min, P < 0.001), while catheterization and hospital stay were greater in the transurethral resection of the prostate group (P < 0.001). At 12 months, there were no differences in functional outcomes (International Prostate Symptom Score, maximum urine flow rate). Despite comparable prostate volumes at 12 months (P = 0.864), the prostate-specific antigen level in the thulium fiber laser enucleation of the prostate group (0.5 ± 0.5 ng/mL) was lower than in the transurethral resection of the prostate group (1.1 ± 1.0 ng/mL; P < 0.001). Hemoglobin and serum sodium decrease was lower in the thulium fiber laser enucleation of the prostate group (1.01 ± 0.4 g/dL and 1.1 ± 1.1 mmol/L) than in the transurethral resection of the prostate group (1.8 ± 0.8 g/dL and 4.1 ± 1.1 mmol/L; P < 0.001). Urinary incontinence rates at 12 months were comparable (P = 0.316). CONCLUSIONS: Thulium fiber laser enucleation of the prostate with novel thulium fiber laser in patients with smaller prostate glands (<80 cc) is comparable to transurethral resection of the prostate in voiding parameters improvement and complication rates. At the same time, the technique allows for a more substantial prostate-specific antigen decrease, indicating more complete removal of adenoma.

Impact of endoscopic enucleation of the prostate with thulium fiber laser on the erectile function.

BACKGROUND: The impact of number of endoscopic enucleation of the prostate techniques (holmium laser enucleation - HoLEP for example) on erectile function have already been investigated. However, the thulium-fiber laser, in this setting remains unstudied. In this study, we compared sexual function outcomes in patients with benign prostatic hyperplasia (BPH) treated with transurethral resection of the prostate (TURP) or thulium-fiber laser enucleation (ThuFLEP). METHODS: We performed a retrospective analysis of patients who underwent transurethral resection and endoscopic enucleation of the prostate for BPH; inclusion criteria was the presence of infravesical obstruction (IPSS > 20, Qmax < 10 mL/s). Erectile function (EF) was assessed using the International Index of Erectile Function (IIEF-5) both prior to endoscopic examination, and six months after. RESULTS: A total of 469 patients with BPH were included in the study; of these, 211 underwent to ThuFLEP, and 258 TURP. Preoperative IIEF-5 in TURP and ThuFLEP groups were 11.7 (±4.5) and 11.1 (±5.0), respectively (p = 0.17). At six month the IIEF-5 score was unchanged (p = 0.26 and p = 0.08) and comparable in both groups (p = 0.49). However, mean IIEF-5 score shown significant increase of 0.72 in ThuFLEP group, comparing to decrease of 0.24 in TURP patients (p < 0.001). CONCLUSIONS: Both TURP and ThuFLEP are effective modalities in the management of infravesical obstruction due to BPH. At six months follow-up after surgery, both techniques lead to comparable IIEF-5 score. However, our results demonstrated that the ThuFLEP is more likely to preserve the erectile function leading to increase of IIEF-5 at six months in contrast to TURP which lead to slight drop in IIEF-5 score.

Endoscopic near infrared photoimmunotherapy using a fiber optic diffuser for peritoneal dissemination of gastric cancer.

Near infrared photoimmunotherapy (NIR-PIT) is a highly selective tumor treatment that employs an antibody-photo-absorber conjugate (APC) which is activated by near infrared light. Here, we describe the efficacy of endoscopic NIR-PIT using the APC trastuzumab-IR700DX (tra-IR700) in the setting of human epidermal growth factor 2 positive (HER2 + ) gastric carcinoma with peritoneal disseminations. In this in vivo study, fluorescence endoscopy showed high tumor accumulation of tra-IR700 within disseminated peritoneal implants. Mice with disseminated peritoneal gastric cancer were separated into 4 groups: (i) control (no treatment); (ii) tra-IR700 i.v. only; (iii) NIR light only; and (iv) endoscopic NIR-PIT. NIR light irradiation was carried out through a fiber optic diffuser under endoscopic guidance. In vivo bioluminescence images showed significantly greater therapeutic effect in the endoscopic NIR-PIT group than that in the control groups (P < .01 vs other control groups). Histological analysis showed diffuse cancer cell death in NIR-PIT-treated tumors. In conclusion, NIR-PIT with NIR light delivered via an endoscopic fiber optic diffuser is a promising method for the treatment of peritoneal dissemination of gastric cancer. Moreover, this technique could be readily used in other types of cancers with peritoneal dissemination provided that suitable antibodies could be found.

Semi-random multicore fibre design for adaptive multiphoton endoscopy.

This paper reports the development, modelling and application of a semi-random multicore fibre (MCF) design for adaptive multiphoton endoscopy. The MCF was constructed from 55 sub-units, each comprising 7 single mode cores, in a hexagonally close-packed lattice where each sub-unit had a random angular orientation. The resulting fibre had 385 single mode cores and was double-clad for proximal detection of multiphoton excited fluorescence. The random orientation of each sub-unit in the fibre reduces the symmetry of the positions of the cores in the MCF, reducing the intensity of higher diffracted orders away from the central focal spot formed at the distal tip of the fibre and increasing the maximum size of object that can be imaged. The performance of the MCF was demonstrated by imaging fluorescently labelled beads with both distal and proximal fluorescence detection and pollen grains with distal fluorescence detection. We estimate that the number of independent resolution elements in the final image - measured as the half-maximum area of the two-photon point spread function divided by the area imaged - to be ~3200.

Hidden incision endoscopic surgery (HIdES) trocar placement for pediatric robotic pyeloplasty: comparison to traditional port placement.

Robotic assisted laparoscopy pyeloplasty (RALP) has been associated with shorter recovery, less pain and improved cosmesis. To minimize visible scars, the hidden incision endoscopic surgery (HIdES) trocar placement has been previously developed. Our aim was to compare outcomes between the HIdES and traditional port placement (TPP) for pediatric RALP. A retrospective study was performed on patients under 15 years of age who underwent RALP at a single institution between August 2011 and November 2013. Patient demographics, intraoperative details, narcotic administration, and complications were reviewed. A total of 49 patients were identified (29 in HIdES, 20 in TPP). There was no difference in median age (p = 0.77) or median height (p = 0.88) between the two groups. Median operative time was 180 min for HIdES and 194 min for TPP (p = 0.27). Eleven patients (11/29, 37.9%) in the HIdES group and fourteen patients (14/20, 70%) in the TPP group received postoperative narcotics (p < 0.05). Median follow-up was 42 months for HIdES and 41 months for TPP (p = 0.96). There were two complications (2/29, 6.9%) with HIdES, and one complication (1/20, 5.0%) with TPP (p = 1.00). The success rates were 96.6% (28/29) for HIdES and 100% (20/20) for TPP (p = 1.00). HIdES trocar placement for pediatric robotic pyeloplasty is a safe and viable alternative to TPP. HIdES is comparable to TPP regarding operative time, narcotic administration, hospital stay, and complication rate, without compromising success.

A novel robotic platform for laser-assisted transurethral surgery of the prostate.

Benign prostatic hyperplasia (BPH) is the most common pathology afflicting ageing men. The gold standard for the surgical treatment of BPH is transurethral resection of the prostate. The laser-assisted transurethral surgical treatment of BPH is recently emerging as a valid clinical alternative. Despite this, there are still some issues that hinder the outcome of laser surgery, e.g., distal dexterity is strongly reduced by the current endoscopic instrumentation and contact between laser and prostatic tissue cannot be monitored and optimized. This paper presents a novel robotic platform for laser-assisted transurethral surgery of BPH. The system, designed to be compatible with the traditional endoscopic instrumentation, is composed of a catheter-like robot provided with a fiber optic-based sensing system and a cable-driven actuation mechanism. The sensing system allows contact monitoring between the laser and the hypertrophic tissue. The actuation mechanism allows steering of the laser fiber inside the prostatic urethra of the patient, when contact must be reached. The design of the proposed robotic platform along with its preliminary testing and evaluation is presented in this paper. The actuation mechanism is tested in in vitro experiments to prove laser steering performances according to the clinical requirements. The sensing system is calibrated in experiments aimed to evaluate the capability of discriminating the contact forces, between the laser tip and the prostatic tissue, from the pulling forces exerted on the cables, during laser steering. These results have been validated demonstrating the robot's capability of detecting sub-Newton contact forces even in combination with actuation.

Implantable photonic devices for improved medical treatments.

An evolving area of biomedical research is related to the creation of implantable units that provide various possibilities for imaging, measurement, and the monitoring of a wide range of diseases and intrabody phototherapy. The units can be autonomic or built-in in some kind of clinically applicable implants. Because of specific working conditions in the live body, such implants must have a number of features requiring further development. This topic can cause wide interest among developers of optical, mechanical, and electronic solutions in biomedicine. We introduce preliminary clinical trials obtained with an implantable pill and devices that we have developed. The pill and devices are capable of applying in-body phototherapy, low-level laser therapy, blue light (450 nm) for sterilization, and controlled injection of chemicals. The pill is also capable of communicating with an external control box, including the transmission of images from inside the patient's body. In this work, our pill was utilized for illumination of the sinus-carotid zone in dog and red light influence on arterial pressure and heart rate was demonstrated. Intrabody liver tissue laser ablation and nanoparticle-assisted laser ablation was investigated. Sterilization effect of intrabody blue light illumination was applied during a maxillofacial phlegmon treatment.

Fiber-optic polarization diversity detection for rotary probe optical coherence tomography.

We report a polarization diversity detection scheme for optical coherence tomography with a new, custom, miniaturized fiber coupler with single mode (SM) fiber inputs and polarization maintaining (PM) fiber outputs. The SM fiber inputs obviate matching the optical lengths of the X and Y OCT polarization channels prior to interference and the PM fiber outputs ensure defined X and Y axes after interference. Advantages for this scheme include easier alignment, lower cost, and easier miniaturization compared to designs with free-space bulk optical components. We demonstrate the utility of the detection system to mitigate the effects of rapidly changing polarization states when imaging with rotating fiber optic probes in Intralipid suspension and during in vivo imaging of human airways.

Color reflectance fiber bundle endomicroscopy without back-reflections.

Coherent fiber imaging bundles can be used as passive probes for reflectance-mode endomicroscopy providing that the back-reflections from the fiber ends are efficiently rejected. We describe an approach specific to widefield endomicroscopy in which light is injected into a leached fiber bundle near the distal end, thereby avoiding reflections from the proximal face. We use this method to demonstrate the color widefield reflectance endomicroscopy of ex vivo animal tissue.

Enhanced imaging colonoscopy facilitates dense motion-based 3D reconstruction.

We propose a novel approach for estimating a dense 3D model of neoplasia in colonoscopy using enhanced imaging endoscopy modalities. Estimating a dense 3D model of neoplasia is important to make 3D measurements and to classify the superficial lesions in standard frameworks such as the Paris classification. However, it is challenging to obtain decent dense 3D models using computer vision techniques such as Structure-from-Motion due to the lack of texture in conventional (white light) colonoscopy. Therefore, we propose to use enhanced imaging endoscopy modalities such as Narrow Band Imaging and chromoendoscopy to facilitate the 3D reconstruction process. Thanks to the use of these enhanced endoscopy techniques, visualization is improved, resulting in more reliable feature tracks and 3D reconstruction results. We first build a sparse 3D model of neoplasia using Structure-from-Motion from enhanced endoscopy imagery. Then, the sparse reconstruction is densified using a Multi-View Stereo approach, and finally the dense 3D point cloud is transformed into a mesh by means of Poisson surface reconstruction. The obtained dense 3D models facilitate classification of neoplasia in the Paris classification, in which the 3D size and the shape of the neoplasia play a major role in the diagnosis.

Use of a micromanipulator system (NeuRobot) in endoscopic neurosurgery.

NeuRobot, a micromanipulator system with a rigid neuroendoscope and three micromanipulators, was developed for less invasive and telecontrolled neurosurgery. This system can be used to perform sophisticated surgical procedures through a small, 10-mm-diameter, window. The present study was performed to evaluate the feasibility of using NeuRobot in neuroendoscopy. Four different intraventricular neurosurgical procedures were simulated in three fixed cadaver heads using NeuRobot: (1) fenestration of the floor of the third ventricle; (2) fenestration of the septum pellucidum; (3) biopsy of the thalamus; and (4) biopsy of the choroid plexus of the lateral ventricle. Each procedure required less than 2 min, and all procedures were performed accurately. After these surgical simulations, a third ventriculostomy was carried out safely and adequately in a patient with obstructive hydrocephalus due to a midbrain venous angioma. Our results confirmed that NeuRobot is applicable to lesions in which conventional endoscopic neurosurgery is indicated. Furthermore, NeuRobot can perform more complex surgical procedures than a conventional neuroendoscope because of its maneuverability and stability. NeuRobot will become a useful neurosurgical tool for dealing with lesions that are difficult to treat by conventional neuroendoscopic surgery.

Interhemispheric endoscopic resection of large intraventricular and thalamic tumors.

A transfrontal route is the traditional endoscopic approach to intraventricular tumors. Small lesions can be biopsied using the parallel port channel of the endoscope. For larger tumors a ventriculoport can be used for resection. This technique nevertheless requires traversing the brain tissue, is difficult in the setting of small ventricles, and allows only limited mobility. The authors describe the endoscopic resection of large intraventricular tumors via an interhemispheric route using rigid suction with a mounted endoscope, and thus circumventing some of the problems with the traditional approach.

Single portal endoscopic carpal tunnel release: modification of Menon's technique and data from 65 cases.

The purpose of our study is to make a follow-up evaluation of endoscopic carpal tunnel release under focal anesthesia using the Wolf single portal system. A total of 65 patients with a mean age of 50 years undergoing 79 procedures were retrospectively studied. Preoperative complaints, intraoperative findings, and postoperative results of all the patients were recorded. Follow-up was conducted at 1, 5, 12, and 24 weeks and at 1 year postoperatively. Wound pain, analysis of satisfaction, Levine functional status scales, and surgical complications were included. No patients sustained iatrogenic neurovascular injury or hematoma formation. The average Levine functional severity score decreased from 2.82 points preoperatively to 1.2 points at the most recent survey. One case recurred at 1 year after the surgery and subsequently underwent open release. Surgery using the Wolf single portal system under focal anesthesia is a safe and efficacious option for endoscopic carpal tunnel release.