Robotic For Precise Percutaneous Needle Insertion
Dan Stoianovici Ph.D.
Jeffrey A. Cadeddu, M.D. , Louis L. Whitcomb, Ph.D.
Russell H. Taylor, Ph.D. . Louis R. Kavoussi M.D.
Johns Hopkins University, The James Buchanan Brady Urological Institute,
Whiting School of Engineering
TWe present a novel robotic system for precise needle insertion
under radiological guidance. The system was developed to facilitate
percutaneous renal access for surgical interventions and delivery
of therapy. The robot has an extremely low profile making it compatible
with portable X-ray units (for OR environments) and CT scanners.
Using this system the urologist defines the skin insertion site,
prescribes the anatomical target using radiological data, controls
and confirms the needle orientation, and finally commands needle
insertion. The system is comprised of a passive mechanical arm mounted
on the OR table, a novel RCM (Remote Center of Motion) robot and
a radiolucent needle injector (PAKY). The overall system exhibits
three motorized degrees of freedom: one translation accounting for
needle insertion and two rotations allowing needle orientation in
imager space. These three degrees of freedom are sufficient for
accessing any anatomical target while priory setting the skin insertion
site. The system offers an unquestionable improvement of needle
placement occuracy and procedure time as compared to the classic
manual procedure. In addition, the system reduces the radiation
exposure to patient and urologist. The reduced number of degrees
of freedom of the robot insures patient safety.
An Automated Comprehensive Videourodynamic
Report and Test System of Improved Accuracy Incorporating Mathematical
Analysis of Multimodal Information
Edward F. Wahl, Ph.D,
P.E., Bernard M. Churchill, M.D., F.R.C.S. (C) and Steven Lerman,
M. D., Department of Urology, UCLA School of Medicine
A test system generating an integrated comprehensive report
combining patient characteristics, cystometrogram and imaging data,
known urological information and medical criteria with improved
accuracy has been developed and used on 120 patients to date. Patient
characteristics of age, height, weight and sex are combined mathematically
with urologic knowledge/data bank to produce patient specific background
templates which display minimal and mean bladder volumes, infusion
rate based on maximum physiologic diuresis and pressure whether
safe, questionable, or dangerous. Color is used to add a third dimension
to a planer plot. The CMG data collected using specially designed,
highly accurate equipment uses averaging and unique filters to remove
electronic noise and patient and test artifacts such as coughing.
This results in specialized curves each indicating different patient
conditions such as compliance, urologic instabilities, and leak
point pressures in a more quantifiable manner than heretofore available.
Several case examples are reported to demonstrate this. Spot images
timed by fluoroscopy and real time system display are delivered
as digitized images to the computer memory. The above are analyzed
to produce the comprehensive real time monitor and hardcopy reports
without operator intervention. The theory, methodology, and mathematics
Transcutaneous Neurostimulation and Bladder
Ian K. Walsh, Robin Johnson,
Patrick F. Keane and Gordon WG Loughridge,
Department of Urology, Level 3, Belfast City Hospital, Belfast,
Modulation of third sacral nerve (S3) activity is effective for
irritative voiding dysfunction, but requires the invasive neurostimulator
implantation. We studied the effect of transcutaneous S3 neurostimulation
on bladder activity during filling. 32 patients with irritative
voiding dysfunction (sensory urgency or detrusor instability) underwent
filling cystometry at 50ml/min. In the study group (n=16), transcutaneous
neurostimulation was then applied to both S3 dermatomes. Current
(10mA) was set at 10Hz frequency, 200ms pulse width in continuous
mode at maximum tolerable level. Neurostimulation continued throughout
a second filling cystometry. The control group (n= 16) underwent
second fill without neurostimulation. Bladder volume (ml) and cletrusor
pressure (cmH2O) values for second fill cystometry (mean+/-standard
error; statistical analysis by Mann-Whitney U nonparametric testing):
|First Desire To Void
||176.9 +/- 2.6
|Pressure At First Desire To Void
|| 307.5 +/- 5.9
|End Fill Pressure
Transcutaneous S3 stimulation significantly improves bladder filling activity in patients with irritative
voiding dysfunction. This non-invasive, ambulatory treatment may be effective for such patients.
Yim Needle: Confirming Percutaneous Access
Through Urinary Impedance
Dan Stoianovici Ph.D.
1,2 . Mohamad E. Allaf B.S., Stephen V. Jackman M.D.', Louis R.
Kavoussi M.D., Johns Hopkins University, The James Buchanan Brady
Urological Institute, Whiting School of Engineering
Introduction: Image guided percutaneous renal access is required for various minimally invasive urologic
operations. Common radiological techniques offer limited means to assess whether successful access was
achieved and the depth of needle insertion often relies upon the surgeon's experience. Specifically, in
the process of needle insertion the surgeon may overshoot the target without observing that the needle
passed through the urinary tract. To overcome this problem we developed a sensor (YIM) to detect urine
at the needle tip, hence confirming needle insertion into the urinary tract.
Methods: YIM uses a modified trocar needle allowing the measurement of electrical impedance at its tip.
A battery powered purpose built electronic circuit measures this impedance using a low voltage, high
frequency oscillator. The circuit triggers if and only if the tip of the needle is immersed into urine
(window-comparator on impedance). Ex-vivo experiments were performed using porcine kidneys filled with
urine under pressure (50 cm H20) at 370C. Renal access was determined classically (urine flow through the
needle) as well as electronically and the results were compared.
Results: For 24 trials the success rate was 91.7% with one false positive and one false negative.
The errors were related to technically correctable factors encountered early in the study.
Conclusion: The YIM sensor
is accurate and easily provides a reliable and quick confirmation of needle access into the urinary
Bladder Mucosa Ablation by Diode Laser
Fumio Nakajima, Shigeki
Tokonabe, Tomohiko Asano, Masamichi Hayakawa, Hiroshi Nakamura,
Takuya Hayashi, Tsunenori Arai, and Makoto Kikuchi Department
of Urology, National Defense Medical College
This study was performed to evaluate the ability of diode laser
to ablate bladder pathology and its enhancement by submucosal indocyanine
green (ICG) injection. The laser source was Diomed 25 (Diomed Company,
UK). The applied power was 5 W (non-contact mode). Excised swine
bladder and anesthetized canine bladder were utilized to examine
the effect in non-blood circulating and blood circulating condition,
respectively, To assess the enhancement effect of ICG, normal saline
or ICG solution were injected submucosally immediately before irradiation.
The subadventitial temperature was also measured. In non-blood circulating
condition, while the laser only minimally coagulated mucosal surface
in 180 seconds without ICG pretreatment, ablation was obvious within
10 seconds and the whole mucosal layer was vaporized in 60 seconds
with ICG pretreatment. In blood circulating condition, although
ICG pretreatment always accelerated ablation, the control bladder
was also vaporized probably because of laser absorption by blood
stream. Moreover, the subadventitial temperature increase following
laser irradiation was suppressed by ICG treatment, suggesting that
the laser was absorbed by ICG. These results suggest that diode
laser is capable of ablating mucosal pathology of the bladder, and
ICG injection facilitates ablation and limit the thermal damage
up to the ICG layer.
Bladder Neck Suspension Using Bone Anchors
Treatment of Female Stress Incontinence
Mordechay Beyar, Boaz
Moskovitz, Elias Issaq, Alexander Condrea, Alexander Kastin, Sarel
Halachimi, Joseph Burbura, Shahar Madjar and Ofer Nativ.
Bnai Zion Medical Center, Haifa, Israel
A new technique and related devices for the treatment of female
urinary stress incontinence were developed and tested. It involves
soft tissue to bone fixation by means of miniature bone anchors
and a bone anchor driver. The novel bone anchors are made of a shape-memory
nickel titanium alloy (Nitinol) attached to two sutures. It has
a sharp conical tip enabling it to easily penetrate the vaginal
mucosa and pubic bone without requiring vaginal incisions or bone
drilling. Two holes in the anchor's tail are used for threading
sutures. Inserted in a straight configuration, the shape memory
anchors transform to their original C shape when inserted into the
bone medulla and heated to body temperature. This assures excellent
anchor fixation to the bone. With the patients in the lithotomy
position, the bone anchor driver is introduced into the vagina and
pulled towards the posterior surface of the pubic bone. Pressing
a button releases the energy stored in the loaded spring inside
the driver and drives the bone anchor through the cortex of the
pubic bone. Two anchors are positioned lateral to each side of the
urethra. Each ipsilateral pairs of sutures are tied together resulting
in fixation of the periurethral tissue to the posterior surface
of the pubis. The procedure has minimal morbidity and a short learning
curve. This procedure was successfully performed in 300 patients
Teleradiology In Urology: A Comparison of
Mohamad Allaf, Benjamin
R. Lee, M.D., Ron Khazan, M.D.,
Stephen Jackman, M.D., Alan W Partin, M.D., Ph.D., and Louis R.
There is increasing interest in developing teleradiology systems
because of their potential to provide rapid, accurate, and cost
effective diagnostic radiographs to off-site physicians. Radiographic
image size may average over 10 megabytes of information per film.
A limiting factor in clinical application of teleradiology may be
the time needed to transmit large files over conventional data lines.
To address this issue, a comparison of bandwidth was performed using
IVP images over a 28.8 Kb/sec modem, Ethernet network system (~100
kb/sec), ISDN (128 kb/sec) line, and a cable modem (45 Mb/sec).
Variables measured included weekday vs. weekend, transfer time length,
loss of resolution with compression 20:1, and the effect of the
amount of RAM (random access memory) on file transfer. The increased
amount of bandwidth available at lower cost may allow transfer of
images in a clinically useful timeframe.
Laparoscopic Visual Field: Voice Versus Foot
Pedal Interfaces for Control of the AESOP Robot
From the Brady Urological
Institute, Johns Hopkins Medical Institutions, Baltimore, MD. Mohamad
E. Allaf, Peter G. Schulam, Stephen V. Jackman, Jeffrey A. Cadeddu,
Roland N. Chen, Robert G. Moore and Louis R. Kavoussi
Introduction: in an efort to gain direct control over the laparoscopic visual field, robots are being
used to hold the laparoscope. The foot pedal is the current standard controller but has limitations which
led to the development of voice control as a more transparent interface. We compared the speed, accuracy,
learning curves, durability of learning at two weeks and operator-interface failures of these two
Methods: A purpose-built robotic laparoscopic camera holder (AESOP, Computer Motion, Goleta CA) was used in
a series of set maneuvers with each interface. These were repeated 2 weeks later. Time to complete maneuvers, "pass points," and operator-interface failures were recorded.
Results: Foot control was significantly faster and had less operator-interface failures. Voice control was
significantly more accurate as measured by "pass points". The foot control learning curve reached a plateau
at the third trial while the voice control did not fully plateau. Durability of learning favored the foot
control but was not significant.
|Time for trial completion on day 1
||97±13* sec. |
|Operator-interface failures per trial
|"Pass points" per trial
|Durability (% improvement retained at 2 weeks)
Conclusion: Currently, the voice control is more accurate and has the advantage of not requiring the
surgeon to look away from the operative field. However, it is slower and requires more attention as an
interface. As voice recognition software continues to advance, speed and transparency should improve.
Applications of Automated Urinary Sediment
for Evaluation of Hematurla
*Shinji Hirakawa , lkuo
M ikagawa , Masakazu Fukuda and Tokuhiro Okada
Department of Urology, Tottori University School of Medicine, Yonago,
Japan Toa Medical Electronics Co. Ltd., Kobe, Japan
A newly developed automated urinary sediment analyser (LIF-
100) has been recently employed in our facilities to evaluate patients
with hematuria. This analyser uses flowcytometric technology to
differentiate components in the urine without centrifugation and
demonstrates the results on a display within 72 seconds. The UF-100
can also analyse automatically the morphological profiles of urinary
erythrocytes (dysmorphic, isomorphic and mixed). Selective RBC patterns
can indicate the origin of urinary red cells (glomerular or non-glomerular
origin). In this study, urine specimens from 75 cases with hematuria
were analysed by UF-100 and by the real time confocal laser microscope
(RCLM) in order to evaluate the morphological patterns of erythrocytes
in the urine. The sensitivity, specificity and accuracy for glomerular
disease by the UF- 100 were 84.8%, 71.4% and 77.3%, whereas, those
for non-glomerular disease were 71.4%,84.8% and 77.3%. On the other
hand, the sensitivity, specificity and accuracy for glomerular disease
by the RCLM were 72.7%, 95.2% and 85.3%, whereas, those for non-glomerular
disease were 73.87o, 90.9% and 81.37o. The current results suggest
that the UF- 100 represents an easy and rapid mode for the diagnosis
of the origin of urinary erythrocytes.
Development and Clinical Evaluation of Flexible
Ureteroscopes and Accessories
Robert U. Bregman, M.D.
and Arthur L. Wollman, M.D., Ph.D., San Diego, CA.
We have been working on this project for 18 years with optical
scientists and engineers. Ten prototype and production instruments
evolved over the past 15 years in 7.0, 9.0, 10.0, and 11.0 French
sizes with.020" to.052"operating channels. 1.4 to 4.0 French diameter
surgical accessories have been developed and used with these instruments,
as well as rigid ureteroscopes.
Home Bladder Pressure Monitoring: An Update
Margot S. Damaser, Ph.D,
Rehabilitation Research & Development Center, Hines VA Hospital
We have developed a system for measurement of bladder pressures
at home by individuals, such as those with spinal cord injury (SCI)
or spina bifida (SB) who, use clean intermittent catheterization
to empty the bladder. This system provides an easy and inexpensive
method for these patients to frequently monitor bladder function.
It could supplement urodynamic recordings to enable early identification
of high bladder pressures that, if endured chronically, could lead
to kidney damage. Over the post two years, we have used an analog
pressures gouge to obtain home recordings in 5 SCI and 11 SB patients.
We have developed a reliable method for estimating abdominal pressures
without a rectal catheter. We have also developed a new digital
device and have obtained FDA market approval for home use. In this
talk, progress so far and plans for the future will be summarized.
The Usefulness of Suction Effusion Fluid
as a Sample for Blood Biochemistry
Fumio Nakajima, Tomohiko
Asano, Masamichi Hayakawa, Hiroshi Nakamura
Department of Urology, National Defense Medical College, Tokorozawa,
We have evaluated a new technique to obtain biological sample fluid by applying negative pressure to the
skin surface (percutaneous suction method) and determined the usefulness of the fluid as a sample for
Female mongrel dogs were utilized to evaluate the procedure under general anesthesia. The procedure was
started by removing the horny substance covering the skin by stripping.
The appropriate intraluminal pressure was 300mgHg and the effusion fluid was obtained at a rate of
0.6 - min/cm2 . The blood biochemistry test of the effusion fluid revealed that molecules of smaller weight
as creatinine (Cr) and urea (BUN) showed concentrations very close to those in plasma whereas those of
larger weight as proteins and lipids showed a large discrepancy. The six-hour continuous studies
demonstrated Cr and BUN levels of the fluid consistent with the plasma and a continuous effusion rate.
In uremia models, Cr. and BUN levels in the effusion fluid was close to those of plasma in a wide range
(Cr: 0.8 - 15.5 mg/dI, BUN: 10.0 - 295 mg/dI) and showed extremely high correlation (r=).985 and 0.982
respectively). Skin biopsy revealed that the invasiveness of the suction was small and regeneration of the
horny substance had started at in a week following the procedure.
Our results suggest that the effusion fluid is a reliable sample for plasma Cr and Bun levels, and because
of its lower levels of proteins and lipids, it might be a good sample for biochemical measurement using
Prediction of Superficial Bladder Cancer
Chemoresponse Using the Comet Assay
Ian K. Walsh, James
JA McAteer, Stephanie R. McKeown,
Valerie J. McKelvey-Martin and Robin S. Johnston,
Department of Urology, Belfast City Hospital, Northern Ireland
Objectives: To quantify and predict individual bladder tumor
chemoresponse to intravesical (IVCT) by single gel electrophoresis
Methodology: Cell suspensions of forty freshly resected superficial
bladder tumors were exposed to a panel of standard IVCT agents (doxorubicin,
epiubicin, mitomycin and thiotepa). The cells were embedded in agarose,
cell membranes were lysed and the nucleoids subjected to alkaline
electrophoresis. The DNA was stained with ethidium bromide and nuclear
damage was measured by image analysis.
Results: A dose-response curve was derived for each agent
using eight tumors. DNA repair kinetics were examined in twelve
tumors. When repair occurred, it was complete by 120 minutes. Each
of twenty tumors demonstrated a differential, unique response to
the panel of agents. 70% of tumors responded to at least one agent.
Mitomycin caused the greatest DNA damage in ten (50%) of tumors.,
thiotepa caused the greatest damage in 307o, doxorubicin in 10%
and epirubicin in 10%. These results were statistically significant
(MannWhitney U test p<0.01). Correlation with clinical response
Conclusion: The Comet assay is an accurate ex vivo method
for quantifying the chemoresponse of individual bladder tumors to
different agents. The highest in vitro and in vivo chemoresponse
was with mitomycin. The comet assay may indicate the most effective
agent for managing each individual patient's bladder tumor.
Intraureteral Ultrasound System
Department of Urology, Tohoku Kohsai Hospital, Sendai, Japan
The authors have developed a new ultrasound diagnostic system,
which visualizes cross sections of the ureter. Several types of
scanning method are used for intraluminal examination for cardiac
or vascular diseases. We employed a mechanical rotating type probe.
The probe is composed of two main parts, e.g. and inner and an outer
part. The inner part of the probe is composed of a flexible shaft
and an oscillating disk mounted at the very tip of the shaft. The
oscillating disk has a flat surface and is a square shape, I mm
in size. The oscillating frequency of the disk is 20 MHz. The oscillating
disk rotates for a radial scanning; the rotating speed of the disk
is 6 to 10 times per second. The outer part is a tube like sheath
made of flexible polymer, only 2mm in diameter. The inner part of
the probe is completely covered by the sheath. Only the inner part
rotates for scanning, so the scanning procedure is safe for patients
both mechanically and electrically. The intraureteral probe is inserted
into the ureter, using just the manner with retrograde catheterivation
into the ureter. The tomograms of the ureter are taken continuously,
pushing up the pre from the distal end of the ureter up to renal
pelvis and calyces. The tomograms of the ureter are taken again
continuously, pulling down the probe from calyx down to the distal
end of the ureter. This newly developed intraureteral ultrasonography
will give us new information concerning details of cross-section
of the urinary system. This method is easy to perform for the urologists,
and safe for the patients.
A Novel Method of Surgical Instruction: International
Benjamin R. Lee, Jay
T. Bishoff , Gunter Janetschek, Pichai Bunyaratavep, Wichcan Kamolpronwijitt
Jeffrey Cadeddul, Supoj RatchanW and Louis Kavoussi, James Buchanan
Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD,
Department of Urology, Chulalongkom Hospital, Bangkok, Thailand,
Department of Urology, University of Innsbruck, Austria, Bangkok
General Hospital, Lerdsin General Hospital, Bangkok, Thailand.
Introduction: Telemedicine is the
use of communication technologies to deliver health care. Telesurgical
telementoriing represents an advanced from of telemedicine, whereby
an experienced surgeon can guide and teach practicing surgeons new
operative techniques utilizing current video technology, medical
robots and high bandwidth telecommunications. Telesurgical laparoscopic
telementoriing has successfully been implemented between the Johns
Hopkins Bayview Medical Center and the Johns Hopkins Hospital in
27 prior operations. In this previously reported series, telerobotic
mentoring was achieved between two institutions 3.5 miles away.
We report our experience in performing three international surgical
Purpose: To determine the clinical utility of international
surgical telementoring during laparoscopic surgical procedures.
Method: A laparoscopic adrenalectomy was telementored between
Innsbruck, Austria (5,083 miles) and Baltimore. As well, a laparoscopic
varicocelectomy and laparoscopic nephrectomy was telemonitored between
Bangkok and Baltimore (10,880) miles) both over three ISDN lines
Results: All procedures were successfully accomplished with
an uneventful postoperative course. Remote functions of telestration
AESOP (Computer Motion, Inc., Goleta, CA) robot control to manipulate
the laparoscope, and electrocautery activation were achieved. Time
delay of image transmission was approximately one second.
Conclusion: International telementoring is a viable method
that can potentially enhance surgeon education, increase patient
access to experienced surgeons and decrease the likelihood of complications
due to inexperience with new techniques.
Role of Serum P.S.A. in the Diagnosis of
Muhammad Choudhury, M.D.,
Department of Urology, New York Medical College, Valhalla, NY
Routine utilization of serum P.S.A. for early detection and
monitoring of men with prostate cancer has resulted in dramatic
changes in the day-to-day clinical practice of urology with respect
to prostatic diseases. Over the past several years major changes
in the use of Prostate Specific Antigen (P.S.A.) have occurred.
These changes include the use of age-specific P.S.A. range, P.S.A.
density, P.S.A. velocity and most recently use of free P.S.A. in
the early detection of prostate cancer. This lecture will present
the New York Medical College experience in the use of P.S.A. involving
over 400 patients over an eight year period.
Role of Melatonin in Regulation of
Night Time Urinary Frequency
Shehla Shabnam, M.D.,
Zafar Khan, M.D., New York, NY
Nocturia in men is caused by many factors, frequently it is
associated with benign prostatic hypertrophy (13PH). However in
many patients even after prostatectomy the symptoms of nocturia
were not relived. It has been our observation that nocturia in these
patients is due to nocturnal diuresis. The observation in children
with enuresis have shown that the defective regulation of vasopressin
diurnal rhythm may be at fault. Recent research has shown that diurnal
rhythm may be under control of the pineal gland, melatonin being
the chief mediator. Our observations of melatonin will be presented.
The Bioengineering and Ergonomic Mechanisms
Elevation of P.S.A After Abdominal Exercise
Irving M. Bush, M.D.,
Center for the Study of GU Diseases, West Dundee, IL
Total P.S.A., levels vary more than is generally reported. It is well know that bacterial prostatic inflammation, B.P.H. and middle lobe hypertrophy will elevate P.S.A. In 1989 we showed that medications such as aspirin, guafenesin, testonolactone and antibiotics will also affect levels of total P.S.A. Since then we have used various antibiotics to ameliorate elevated P.S.A.'s to a relative resting state, in an attempt to reduce the number and morbidity of prostatic biopsies.
Forty-two men with elevated P.S.A.'s above 4 (4-16) (method) with and without BPH as determined by rectal, ultrasound or intravenous pyelogram were placed on antibiotics (Cephalosporins or Quinolones) for 4 weeks and then retested. If the total P.S.A. levels dropped, antibiotics were continued till 2 stable levels. If P.S.A. levels dropped, antibiotics were administered. At the end of the study period, 80% of the P.S.A.'s were reduced. If the P.S.A.'s were still elevated or there was a suspicion of P.C.A. on subsequent testing, prostatic biopsies were obtained.
In 1983 we pointed out that machine type abdominal exercises, certain weight training sit-ups and crunches increases the incidence of prostate-seminal vesiculitis and epididymitis due to prostatic duct and vasal reflux. This urological mechanical problem was defined by the use of ultrasound and CT scans.
Recently, 12 patients being followed on the antibiotic protocol developed a paradoxical P.S.A. rise. On questioning, I 1 /12 had performed vigorous abdominal exercise for one to several hours just before the blood drawn. A P.S.A. check after 3 days of exercise abstinence revealed the P.S.A.'s to be lower or at baseline levels. The biomedical engineering mechanisms behind the phenomena will be explored. Is it due to exercise with a full bladder pushing urine through the weak bladder neck sphincter into already dilated prostatic ducts? Would voiding before abdominal exercise, running, bicycling, etc., alleviate the phenomena? is exer
cise hazardous to man's health