VIRTUAL REALITY MODEL
OF THE NORMAL FEMALE PELVIC FLOOR:
PROOF OF CONCEPT
M.L. Rasmussen,2 R. Evenhouse,2 L. Brubaker,3
C. Salomon,3 K. Sakamoto,3 M. North,2,4
Z. Ai,2 M.S. Damaser1,3
1Hines VA Hospital, Hines, IL
2University of Illinois, Chicago, IL
3Loyola University of Chicago Medical Center, Maywood,
4Argonne National Laboratory, Argonne, IL
Aims: The goal of this project
was to establish the methods necessary to test the hypothesis
that with high resolution magnetic resonance imaging (MRI) scans,
an accurate virtual reality (VR) model of the normal female pelvic
floor can be created. The long-term goal of this research is to
implement functionality into the VR model of the pelvic floor.
The model could then be used as a tool for both teaching and testing
Methods: IRB approval was obtained
and one subject was recruited for the study: an asymptomatic nulliparous
twenty-three year old female with no urinary incontinence symptoms.
She underwent a high resolution pelvic floor MRI scan with a field
of view restricted to the area of interest (24 X 24cm with an
imaging matrix of 256 X 128mm). The scan had 107 T2–weighted
slices in 2 series of axial T2-weighted images with a slice thickness
of 3.0mm and slice gap of 0.0mm (General Electric 1.5 Tesla magnet).
The slices from both series were interleaved to obtain a slice
gap of 1.5mm. The ratio of repetition to echo time was 4200/102ms.
Sagittal T2-weighted fast spin echo images were also acquired
with slice thickness of 4.0mm, slice gap of 1.0mm, field of view
of 24 X 19cm, imaging matrix of 512 X 256mm, and ratio of repetition
to echo time of 25513/66.5ms. The digitized scans were imported
into MIMCS image analysis software (Materialise) and pelvic floor
structures (bladder, urethra, vagina, uterus, cervix, levator
ani, obturator externus, obturator internus, and pubic bone) were
manually segmented. CTM software (Materialise) was used to create
3-dimensional polygonal models which were then imported to Geomagics
(Raindrops), for polygon reduction and surface smoothing. The
completed models were displayed on an ImmersaDesk Virtual Reality
system, which has a 67 X 50-inch rear projected screen at a 45-degree
angle and provides a large angle of view, stereovision, and viewer-centered
perspective. Wireless liquid crystal shutter glasses were used
to support stereovision while a receiver tracked head position,
enabling the computer to alter the perspective view for each eye.
The VR model was visually verified by a Urologist and a Urogynecologist.
Results: With a high resolution
MRI scan, accurate manual segmentation of pelvic floor structures
was feasible. The 3-D models of the structures depicted the anatomy
of the female pelvic floor accurately (figure 1). The 9 segmented
structures were combined to create a virtual pelvic floor (figure
2), the anatomy of which was verified as accurate by 2 clinicians.
A. Axial MRI image of female pelvis. B. Segmentation
Posterior view of the model in VR display.of pelvice floor
Conclusion: A three-dimensional
model of the female pelvic floor is feasible from a high resolution
MRI scan. It has the potential to be used as both a teaching and
research tool to enhance our understanding of both normal and
pathological anatomy and physiology.
Acknowledgements: This research
was supported in part by support from the RR&D Service of
The URO Mentor: A New Computer
Training System for Virtual Life-like Simulation of Diagnostic
and Therapeutic Endourological Procedures
Thomas Knoll, Kai Uwe
Köhrmann, Peter Alken, Maurice Stephan Michel
Department of Urology, University Hospital Mannheim, Germany
Introduction: Rapid developments
in the urological field, as an expanding knowledge base and emerging
new techniques require continuing urological education to achieve
life long learning and to keep the urologists up to date. Consequently,
specific training is necessary to guarantee qualification of the
urologists. The goal of the development of the URO Mentor (Simbionix,
Israel) is to overcome the current drawbacks of traditional training
methods for ureterorenoscopy and PNL procedures.
Methods: A computer-assisted simulator for training
and quality control in ureterorenoscopy was developed using virtual
reality, multimedia technology and intelligent tutoring systems.
The software system is the heart of the simulator system. It features
a proprietary visualization engine (SVE). SVE makes real-time
simulation possible by offering a high level object oriented Application
Program Interface written in C++, available for use with either
Microsoft® DirectX 7® or OpenGL as platforms. SVE includes
general procedures that allow for: 2D and 3D rendering, collision
detection, collision correction, 3D morphing, 2D image manipulation,
mapping, video texture, X-ray rendering, special effects (blood,
smoke, stone fragments and more) reflections.
Results: The system allows for a full training
session on a wide range of procedures by offering different types
of cases and different types of virtual patients. The URO Mentor
simulator features full representation of the endourological procedures
under direct vision and by using interactive fluoroscopy with
a contrast agent. The supported tools include: baskets, graspers,
intracorporal lithotripters, guide wires, catheters, stents, biopsy
devices, dilation devices. The following endourological procedures
can be performed: lithotripsy, tumor resections, treatment of
strictures and obstructions, stent placement, biopsies.
Conclusions: The URO Mentor introduces a new
generation mannequin equipped with a special haptic device, providing
trainees with an unparalleled true-to-life sensation while training
for diagnostic and therapeutic endourological procedures. By bringing
key advances in the area of urological simulation--with the real-time
x-ray renderer for instance--and by integrating in a single system
both high quality simulation and learning tools, the URO Mentor
opens new perspectives for computer based urological training
systems and methods.
Comparison of Robotic versus Laparoscopic suturing:
Analysis of the learning curve.
Benjamin R Lee, M.D.,
Paul Rotariu, M.D., Peter Pinto, M.D.,
Arthur D. Smith, M.D., and Paulos Yohannes*, M.D. Long Island
Jewish Medical Center,
New Hyde Park, NY and *Creighton University, Omaha, NE.
Introduction: Urologic laparoscopy
has continued to evolve from a diagnostic to a therapeutic modality,
and from mainly an extirpative procedure to presently allow reconstructive
procedures. Laparoscopic reconstructive procedures have been limited
by needle driver instrumentation, fixed angles at the trocar level,
and small working spaces to place the suture. Robotic-assisted
laparoscopic suture placement may improve the angle of suture
placement and facilitate laparoscopic reconstructive procedures.
The purpose of this study was to evaluate the learning curve between
robotic-assisted versus manual laparoscopic suturing, as well
as assess other skills.
Method: There were eight participants in this
study. A series of five trials were performed to assess dexterity
(task 1) and free-hand suturing (task 2). Each task was performed
using robotic-assisted and manual laparoscopy. The participants
were categorized as novice and experienced laparoscopists. Task
1 involved passing sutures through the eye of seven needles positioned
one cm apart in a P configuration. Task 2 involved tying one surgeon’s
knot, followed by two subsequent knots, for a total of 3 knots.
Results: Average time for trials one and five
(Task 1, Robotic-assisted laparoscopy) were 242.6± 106
(SD) and 101.8 ± 50 (SD) seconds, respectively (p<0.001).
Both groups demonstrated a statistically significant difference
(p<0.001) between the first and last trial. The average time
for trials one and five (Task 1, Manual Laparoscopy) were 205.3
and 169 seconds, respectively. Learning curves for robotic-assisted
and manual laparoscopy were statistically significant in favor
of robotic-assistance. Manual laparoscopic suturing did not demonstrate
as much of a difference for the experienced surgeon. Overall difference
in improvement between robotic-assisted and manual laparoscopy
was not statistically significant.
Conclusion: Robotic-assisted laparoscopy allows
suturing and dexterity skills to be performed quicker than manual
laparoscopy. The degree of improvement for robotic-assisted suture
placement is less for the experienced laparoscopist.
DEVELOPMENT OF A CRYOTHERAPY
FOR PROSTATE CANCER
Michael J. Manyak,
MD,1 James K. Hahn, PhD,3 Ge Jin,
3 Dongho Kim,3 John Rewcasle, PhD,4Sunil
Kim, PhD3 and Raymond J. Walsh,PhD2
the Departments of Urology1 and Anatomy2,
School of Medicine,
and the School of Applied Science and Engineering3,
The George Washington University;
and Endocare, Inc.4
Introduction: Cryotherapy uses
a technique to selectively freeze tissue to cause controlled tissue
destruction. Cryotherapy for localized prostate cancer requires
perineal insertion of multiple small diameter probes into the
prostate at selected spatial intervals. Transrectal ultrasound
(TRUS) is used to both properly position the cylindrical probes
before activation of the cooling element and to monitor tissue
effect. Greater destruction occurs with 2 freeze-thaw cycles during
treatment. Despite the prevalence of surgical simulation systems,
very few are used routinely for training due to techical difficulties
in engineering a system that specifically addresses a discrete
task. This simulator was developed as part of a comprehensive
computer-based, hands-on training program designed to familiarize
the physician with the technical aspects of prostate cryotherapy.
Methods: The computer-based
cryotherapy simulation system mimics the major surgical steps
involved in the procedure. The performance objective of the trainer
is to simulate 3 principle surgical maneuvers: perineal entry
site selection for the cryoprobes, cryoprobe tip positioning within
the prostate gland, and tissue freezing based on cryoprobe position.
The mock procedure is viewed on a simulated ultrasound display
whose image is manipulated in real time by the user, mimicking
the TRUS display of the actual surgical procedure. The simulated
TRUS display is generated from 3-D ultrasound where both the interaction
of the ultrasound with the instruments and the ice balls are simulated
using ray-casting methods. The thermal and mechanical simulation
of the tissue is done using a modified finite-element method.
The prostate is segmented out and rendered in 3-D to give a longitudinal
overview of the prostate with probes inserted. Multiple anatomic
variations provide the user with a rich variety of simulated case
scenarios. A surgery planning software is incorporated into the
simulator to give the ideal probe placement for each anatomic
Results: The simulation system
has been developed with several refinements. Preliminary evaluation
indicates that the system is effective for training the user in
both technique and treatment.
Conclusion: This system development
demonstrates the practical application of a simulator in a comprehensive
prostate cryotherapy training program.
A NOVEL PHANTOM BLADDER MODEL
FOR 3D-CT VIRTUAL CYSTOSCOPY
Shane T. Russell, Akira
Kawashima, Michael R. Bruesewitz,
Andrew J. LeRoy, Bernard F. King,
Terri J. Vrtiska, Cynthia H. McCollough, George K. Chow, Robert
Departments of Urology and Radiology, Mayo Clinic, Rochester,
(3D) computed tomography (CT) virtual cystoscopy is a rapidly
evolving non-invasive diagnostic imaging technique for detecting
intraluminal bladder pathology. The value of virtual cystoscopy
is currently limited by the visual resolution of the bladder wall
and hence the ability to accurately identify and characterize
small and sessile lesions. We report a novel phantom pelvis/bladder
model to define the optimal scanning parameters to improve the
diagnostic accuracy of virtual cystoscopy.
Methods/Results: A Plexiglas
rectangular phantom pelvis measuring 25cmx18cmx20cm was constructed
and filled with a diluted contrast material solution with an attenuation
value of 30 Hounsfield Units (HU) to simulate pelvic soft tissue.
A 12.5cm diameter circular “bladder” with a watertight
removable lid was constructed from 2mm thick Plexiglas, and mounted
to a removable Plexiglas plate. A “trigonal ridge”
made from liquid rubber was secured to the bladder floor in the
correct anatomical position. A 20cm tall Plexiglas stand consisting
of 2 vertical 12mm diameter pillars and 4 5mm diameter horizontal
“arms” was designed to support a 2.5cm diameter hollow-tube
“rectum” posterior to the bladder, two anterolaterally
placed porcine hip bones, and a sealed sack of minus 100HU processed
animal fat surrounding the bladder to simulate perivesical fat.
Simulated “tumors” made from Solidwater plastic polymer
(Gammex RMI, Middleton, WI) varied in shape and size (2mm to 10mm
in height and diameter), and had a CT density of 30HU. The phantom
bladder was scanned filled with either air, mimicking in vivo
studies performed with retrograde insufflated bladder air or carbon
dioxide, or with a water/contrast medium mixture measuring 1000HU
to simulate passive antegrade bladder filling on delayed images
of an intravenous urogram. Scanning was performed with a Light
Speed multi-detector helical CT scanner (GE Medical Systems, Milwaukee,
WI) with varying slice thickness of 1.25 to 5.0mm and with 0%,
50%, and 75% overlap. Virtual 3D-CT cystoscopic images were generated
on an Advantage workstation using GE 4.0 Navigator software. Improved
visualization of the bladder wall and polyps was noted with decreasing
collimation thickness, increasing percent overlap, decreased table
speed, and lower pitch, giving optimal screening parameters of
1.25mm slice thickness, 75% or 50% overlap, and 3.75mm/rot HQ
Conclusion: The challenge of
this project was to develop a phantom bladder model which most
accurately recreated the anatomic and physiologic milieu of the
human pelvis, which could then be subjected to an infinite number
of repeat CT studies. Using an anatomically accurate bladder phantom
could thereby spare human subjects the risks inherent in the numerous
scans needed to develop the optimal scanning techniques which
find the ideal balance between radiation exposure and image resolution.
A Robotic System for CT-Guided Percutaneous Access
Stoianovici*, Dumitru Mazilu, Alexandru Patriciu,
Alexandru Stanimir, Nicolae Craciunoiu, Louis Kavoussi
URobotics Laboratory, Urology Department
Johns Hopkins Medical Institutions, Baltimore, MD
We report the development of a new robotic system
for CT-guided operations. Its name, “Tracker”, or
“T” for short, was derived from its capability of
performing active tracking of respiratory and other soft tissue
motion. Tracker performs precise manipulation of a needle or other
surgical instrument in the confined space of the imager without
interfering with the imager functionality (Figure 1).
Front and Side Views of the Tracker Robot Mounted on the
Tracker is connected to the mobile table of the
CT allowing the patient and the robot to be jointly sent into
the CT gantry for imaging and interventional procedures. The robot
presents six degrees of freedom configured for decoupled positioning,
orientation, and insertion of the instrument. The Tracker robot
comprises the PAKY radiolucent needle driver and the RCM robotic
module previously developed in our URobotics Laboratory. In addition,
two other modules have been purposely designed: a new passive
positioning arm and an active three degrees of freedom translational
stage mounted on a bridge-like support. A new ball-worm drive
version of the RCM robot is also included. The entire system comprises
only two components, the robot and the control box, connected
with a single cable. A touch-screen display and a joystick are
conveniently mounted on the robot.
Acknowledgement: This work was partially supported
by grant No. 1R21CA088232-01A1 from the National Cancer Institute
(NCI). Its contents are solely the responsibility of the authors
and do not necessarily represent the official views of NCI.
A NOVEL METHOD OF STUDYING PERISTALTIC
ACTIVITY IN-VIVO USING A MAGNETIC SENSOR
Venkatesh, Jaime Landman, Scott Minor*, David Lee, Maged Ragab,
Jamil Rehman, Chandru P. Sundaram, Ralph V. Clayman**
Affiliation: Division of Urology, Washington University School
of Medicine, St. Louis, MO
* Division of Physical Therapy, Washington University School of
Medicine, St. Louis, M0
** Professor and Chairman, Department of Urology, University of
California, Irvine, CA
Introduction: Peristalsis is an important physiological
mechanism of various tubular structures such as bowel, ureter,
fallopian tube and vas deferens. The process of peristalsis is
affected by different patho-physiological conditions. We describe
a novel method of studying the peristaltic activity of a small
tubular structure, in this case the ureter, using a magnetic sensor
that can be deployed laparoscopically in an extraluminal fashion.
This technology can be used simultaneously with electromyographic
(EMG) needle electrodes that measure electrical potentials.
Materials: The GMR (Giant Magneto Resistive)
technology uses a magnet to create a magnetic field and a sensor,
which is very sensitive to changes in the magnetic field, to accurately
detect small movements of an object within a magnetic field. The
technology is based on the giant magneto-resistive phenomenon
first described in 1988 in the metallurgy literature. The GMR
sensor allows measurement of displacements of an object in the
linear, radial and rotational systems making it applicable for
studying peristaltic activity. Modified insulated bipolar EMG
‘needle’ electrodes were used for recording ureteric
Methods: Porcine ureteral peristaltic function
was evaluated for studying the electro-mechanical activity of
the ureter. The GMR device and EMG electrodes were deployed to
simultaneously record the mechanical contractions and the electrical
potentials of the ureter. These devices were deployed laparoscopically:
with minimal disturbance to the ureter. The first set of EMG electrodes
was placed on the proximal ureter just below the uretero-pelvic
junction; the GMR sensor and the magnet were positioned on the
surface of the ureter 3 cms. distal to the EMG electrodes. Next,
2 additional sets of EMG electrodes were placed 3 and 6 cms. distal
to the GMR sensor. Signals depicting ureteral electro-mechanical
activity were amplified and displayed synchronously on the oscilloscope.
Recordings were correlated with direct laparoscopic visual observation
of the ureter for peristalsis.
Results: We evaluated the GMR device on three
ureters in three porcine models. After establishment of pneumoperitoneum
and exposure of ureter, the mean times to deploy the GMR device
and 3 pairs of EMG electrodes were 75 and 65 minutes respectively.
The pigs were hydrated under basal standard intravenous infusion
rate of 5mls. /lb./hour and the intraabdominal pressure was maintained
between 10-12 mm. Hg. A peristaltic wave of contraction was seen
in the pig ureter at an average of once every 26 seconds. A consistent
correlation was found between laparoscopically observed ureteral
peristalsis and the peristaltic signals picked up by the magnetic
sensor. The electrical potentials generated just before the mechanical
ureteric contractions were shown as rapid onset and restoration
of bipolar deflections by the EMG electrodes. The mechanical contractions
detected by the GMR sensor were depicted as unipolar upward deflections
from the baseline with varying amplitude corresponding to the
force of ureteric contraction. On forced diuresis the ureter was
distended with urine with no visible peristaltic activity and
there was no recordable electro-mechanical signal.
Conclusions: The GMR sensor provides a novel
method for studying peristaltic activity of ureter in-vivo. It
is sensitive, small, minimally invasive and can be deployed with
little dissection of the structure under study. Magnetic sensor
technology has the potential to facilitate the study of peristaltic
activity in other tubular structures such as bowel, fallopian
tube and perhaps even the vas deferens. It can potentially provide
additional information regarding the impact of medications and
intraluminal stents on ureteral physiology.
A novel device to prevent recurrent bacterial urinary tract
infection (RBUTI) in females with persistent vaginal voiding
M. Bush, M.D., Linda Zielinski, R.N., Roland Williby, P.A.and
West Dundee, Illinois
With the recent increased resistance of E-coli to trimethoprim/sulfa
methoxazole (<22%), and the effect of urine on bacterial adhesion
and mucosal surface laminar flow we reviewed our 20-year experience
with 543 non-cystocele RBUTI patients (ages 20-45) with persistent
A 4-month protocol utilizing a temporarily placed vaginal absorptive
device before each voiding was completed by 174 RBUTI patients.
After ruling out urethra stricture, neurogenic disturbances, bladder
neck obstruction and partner’s prostatitis, 148 had 3 negative
cultures post-protocol. 26 had persistent RBUTI. 65/148 stopped
having vaginal voiding for at lease 4 additional months. This
simple method supplemented with short term urinary antiseptic
therapy, when indicated, is a better solution to RBUTI then continuous
long-term antibiotics which temporizes the problem rather than
LOCAL RECURRENCE OF PROSTATE CANCER
( rPCa ) TREATED BY HIGH INTENSIVE FOCUSED ULTRASOUND (HIFU)
G. Chaussy, S. Thüroff
Dep. of Urology, München Harlaching, Germany
Objectives Biopsy proven rPCa
after surgery (Ø> after 52m), radiation (Ø after
65m) or early hormonal ablation (:Øafter 32m) becomes an
increasing problem because of poor (highly invasive and high sideeffect
rate) therapeutic alternatives.
Methods In a prospective study of 69 patients
with rPCa and increased PSA were treated with HIFU [ABLATHERM;
EDAP -TMS] at 2.25/3.0 MHz and 5/4,5 sec/lesion. 24 had a previous
history of radical surgery (S), 23 of radiation (R), 22 of hormonal
ablation (HA) as primary failed therapy. Initial Gleason score
>= 7 showed in 79,2% (S), 87,7% (R), and 63,6% (HA). The typically
small volume tumors/prostates (S =Ø 4 cc, R= Æ 11
cc, HA=Ø 14 cc), visible in transrectal ultrasound (TRUS)
were treated locally with HIFU through a rectal approach in a
single session treatment. After treatment (Ø 35-92 min)
discharge followed within 23 hours. All patients had a suprapubic
urinary drainage (Ø 29 days). Follow up by PSA, biopsies,
complaint score, was in month 1,3,6, 9, 12, 18, etc.
Results Biopsies (min 2 consecutive sextant sets)
were cancer free in 66 %(S)/ 72,3% (R) and 70,6 % (HA). In the
group which had been pretreated with HA one patient developed
a fistula but we found no incontinence. In patients after radiation
5 fistulae (21,7%) and in 43,5% incontinence I°-II° occurred.
After previous surgery we observed one fistula and in 33,3% incontinence
I°-II°. The pretreatment PSA at 1,9 ng/ml(S), 8(R) and
14(HA) and decreased to PSANadir to 1,5 ng/ml(S), 1 (R) and 0
(HA). Follow up was 216 (S) / 32 (R) / 339 (HA) days.
Conclusions Transrectal HIFU was proven to be a successful
method for the treatment of rPCa because of its minimal invasiveness
and its single session tissue ablative character. Side effects
differ according to number, period of time and type of local pre-treatment
and have to be balanced against the classical therapeutic alternatives.
Biopsy short term efficacy between 66-72% and last PSA values
of 1(S), 2( R) and 1ng/ml (HA) after HIFU showed to be more than
USE OF THE CAVITRON ULTRASONIC SURGICAL ASPIRATOR
(CUSA) FOR LAPAROSCOPIC PARTIAL NEPHRECTOMY
IN A PORCINE MODEL
Stefan Corvin, Christoph
Adam, Alfons Hofstetter
Department of Urology, Ludwig-Maximilians-Universitaet, Munich,
Objectives. Partial nephrectomy is still one
of the most challenging operations in urological laparoscopy.
Control of hemorrhage is very difficult to achieve with laparoscopic
techniques. In open surgery, the Cavitron Ultrasonic Surgical
Aspirator (CUSA, Tyco Healthcare) has been shown to cut renal
parenchyma selectively, avoiding damage of vascular structures
or the collecting system. It was the aim of this study to evaluate
whether the CUSA can provide a safe and effective laparoscopic
Methods. Laparoscopic pole resections of the
left or right kidney were performed in 6 pigs under general anesthesia.
Following exposure of the kidney the renal capsule was incised
by means of electrocautery. The CUSA was then used for dissection
of the renal parenchyma. After complete circular dissection of
the renal parenchyma the collecting system and central vessels
were divided using an Endo-GIA. Hemostasis was achieved by electrocoagulation.
8 weeks later the animals were sacrificed and the kidneys were
removed for clinical investigation.
Results. The operations were performed successfully
in all animals without temporary ischemia. The CUSA allowed precise
and effective tissue dissection without significant hemorrhage.
Parenchymal vessels were coagulated selectively. The collecting
system and central vessels remained intact and could be divided
following application of the Endo-GIA. Mean operation time was
80±15 min. Urinary fistula or other complications were
not seen postoperatively.
Conclusions. These experimental results demonstrate
the suitability of the CUSA for a safe laparoscopic partial nephrectomy
without temporary ischemia and with reduction of the operative
trauma for the kidney. Based on own experiences with other techniques
including electrocautery and laser technology for partial nephrectomy
it can be concluded that the CUSA represents an interesting alternative
to other techniques.
Financial support was provided by Tyco Healthcare, Toenisvorst,
Germany and by the Friedrich-Baur-Foundation, Ludwig-Maximilians-Universitaet,
Noninvasive Male Sterilization by Focused Ultrasound Ablation
of the Epididymis: Thermal Measurements in a Canine Model
M. Fried, PhD1, William W. Roberts, MD1, E. James Wright,
MD1, Stephen B. Solomon, MD
1,2Depts. of Urology1 and Radiology2,
Johns Hopkins School of Medicine, Baltimore, MD
Introduction: Therapeutic focused ultrasound
has previously been shown to thermally occlude the vas deferens
and may offer a noninvasive, incisionless alternative to conventional
surgical vasectomy. However, problems with skin burns and inconsistent
vas occlusion have been encountered during preliminary animal
studies. In this study we explore focused ultrasound ablation
of the epididymis as an alternative anatomical target for noninvasive
male sterilization. Experimental thermocouple temperature measurements
were conducted to determine the optimal range of ablation parameters
for thermal occlusion of the epididymis without skin burns.
Methods: A two-radian ultrasound transducer mounted
on a plastic clip delivered 4 MHz ultrasound energy to the canine
epididymis. Thermocouples placed in the epididymis, intradermally,
and on the skin surface recorded temperatures during ablation.
A wide range of ablation parameters were studied (Control, 3W/120s,
5W/90s, 7W/60s) on both the left and right testicles (n=2) in
a total of four dogs.
Results: A large therapeutic window (Power =
3-5 W, SI = 0.8 – 1.4 W/cm2, Time = 60-120 s) exists over
which thermal occlusion of the epididymis may be achieved without
adverse effects (e.g. skin burns, testicular injury). Epididymis
thermal occlusion rates measured 83 % (10/12) compared with 40
% (4/10) for vas ablation, while skin burn complications measured
0 % compared with 40 % for the vas, during preliminary animal
Conclusions: The epididymis represents a larger
target than the vas deferens for thermal occlusion, eliminating
problems with co-location of the ultrasound focus within the target
and skin burns. Future research will focus on conducting long-term,
pre-clinical azoospermia studies to definitively confirm sterilization
after focused ultrasound ablation of the vas and epididymis.
Telerobotic Surgery between Baltimore and München
Frimberger(1), L. Kavoussi(2), C., A. Patriciu (2), D. Mazilu
A. Hofstetter(1), R. Oberneder(1), D.Stoianovici(2)
1 Department of Urology,
Klinikum Großhadern, Ludwig-Maximilians- Universität
2 Brady Urological Institute, Johns Hopkins Medical Institutions,
Purpose: The rapid development of laparoscopy
in urology necessitates the training of specialists to warrant
the high standard of patient care. Additionally continuos training
is crucial, which not all resident programs can due to the high
cost and the lack of patient numbers. Telementoring allows a specialist
to assist an operation team in a variable distance by real time
data communication over ISDN lines. For the first time a telerobotic
surgery, using two robots was performed between the USA and Germany.
Methods and results: Two surgical robots, AESOP
and the at the Johns Hopkins Hospital (JHH) developed PAKY+ RCM
were used to perform a laparoscopic renal cyst removal at the
University hospital of Großhadern in Munich. The hardware
of the computer system utilizes Pentium III PCs and Zydacron boards
(Zydacron, Inc., Manchester, N.H., USA) along with Video and Audio
software for the communication. The telementor in Baltimore, USA
was able to maneuver the robots from a distance of 8000 km via
8 ISDN lines (512kB). Additionally the Telementor was able to
draw lines and arrows on the screen to suggest port sites or incision
lines to the local team. Communication was managed by webcams
and microphones. The telerobotic operation was performed without
complications or system- and communication failures, respectively.
Conclusions: Telementoring enables physicians
to work together online with specialists from distant centers.
Next to the training experience, telemedicine can be used to consult
specialists in emergency settings, or in situations where no experienced
surgeon is available.
Cryotherapeutic Assisted Partial Nephrectomy
For Localized Renal Masses.
A. Ghafar(2), Vlad Bargman(1) and Ihor S. Sawczuk(1,2),
(1)Hackensack University Medical Center, Hackensack, NJ and (2)
Columbia University, New York, NY
Introduction: Cryotherapeutic assisted partial
nephrectomy may be a useful technique for the excision of intrarenal
masses. The purpose of this study was to evaluate the technique
and results of treating patients with localized renal masses by
cryotherapeutic assisted partial nephrectomy.
Methods: Nineteen patients had cryotherapeutic
assisted partial nephrectomy of 20 renal tumors ranging in size
from 1.5 to 10 cm under intraoperative ultrasonographic guidance.
Seventeen patients had tumors ranging from 1.5 to 9.3 cm and a
normal contralateral kidney, 1 patient had a tumor (10 cm) and
renal insufficiency, and 1 patient had hereditary bilateral tumors
(Von Hippel?Lindau). Tumors were located at the upper (7), middle
(5), lower (8) pole of the kidney and were biopsied before cryosurgery.
All tumors were surgically removed during a single freezing technique
using the ice ball as a guide for excision. Mean cryoablation
time was 11 minutes for the single freezing
Results: There were no intraoperative complications.
Cryosurgery was technically successful in all patients, and the
ice ball was created up to 1 cm beyond the tumor edge. By resecting
the frozen lesion, margins were easily discernable and allowed
for intraparenchymal masses to be accessible to partial resection
irrespective of location within the kidney. Mean surgical time
was 162 minutes and blood loss averaged 312 ml. There was no difference
between preoperative and postoperative creatinine (mean 0.93 mg/dl
pre and mean 0.99 mg/dl post). No positive margins were encountered.
Mean follow up was 11 months (range 2 to 20 months) and no recurrences
have been detected. Pathology revealed 13 clear cell renal cancers,
2 chromophobe renal cancers, 3 oncocytomas and 2 angiomyolipomas.
Conclusions: Open cryotherapeutic, assisted
partial nephrectomy is an alternative technique for facilitating
excision of intracortical renal masses.
HOLMIUM LASER ENUCLEATION OF THE PROSTATE
COMBINED WITH TRANSURETHRAL MECHANICAL
MORCELLATOIN IS SUPERIOR TO TURP FOR THE RELIEF
OF BLADDER OUTFLOW OBSTRUCTION (BOO).
Peter J Gilling, Katie
M Kennett R.N., Andre Westenberg, Mark R Fraundorfer.
Tauranga Hospital, Tauranga, New Zealand.
Introduction: TURP has been
considered the endoscopic standard for the relief of BOO due to
Benign Prostatic Hyperplasia in the past. A true endoscopic enucleation
which mimics Open Prostatectomy has been developed utilizing the
Holmium Laser. A transurethral tissue morcellator has been developed
to remove this tissue. Endoscopic resection (TURP) and Endoscopic
enucleation and morcellation (HoLEP) are compared in a randomized
Patients and Methods. 60 urodynamically obstructed
patients with prostate volumes 40 -200 ml.were randomized. AUA
scores, Qmax values, Pdet/Qmax, Schaffer grade, TRUS and Post-void
residual (PVR) urine volumes were measured preoperatively and
at 6 months postop. Intraoperative and perioperative values were
also compared. Adverse events were assessed.
Results: The patients were well-matched for all
preoperative parameters. More tissue was retrieved/removed by
HoLEP and morcellation (40.4+/-5.7 vs. 24.7+/-3.4g, p<0.05)
intra-operatively and the TRUS prostate volume at 6 months was
significantly smaller at 6 months in the HoLEP group (28.4+/-1.8
vs. 45.4+/-4.4 ml) p<0.001. Catheter times and Hospital stay
were significantly shorter in the HoLEP group. There was one transfusion
in the TURP arm. At the 6 month mark the Pdet/Qmax values (20.8+/-2.8
vs. 38.5+/-2.7 cmH2O) and the Schaffer grade (0.2+/-0.09 vs. 1.2+/-0.2)
were both significantly less (p<0.001) in the HoLEP group
Conclusions: HoLEP combined with mechanical morcellation
removes more tissue than TURP and is superior to TURP for the
relief of bladder outflow obstruction.
The Electrical Prostate Morcellator: An Alternative to Manual
Morcellation for Laparoscopic Nephrectomy Specimens?
Avrum I Jacobson, Robert
Marcovich, Joel Patrick A. Aldana, Daniel Lowe,
Arthur D. Smith, and Benjamin R. Lee
Department of Urology, Long Island Jewish Medical Center, New
Hyde Park, NY
Introduction and Objectives:
Renal morcellation after laparoscopic nephrectomy has traditionally
been performed with either the Cook high speed electrical laparoscopic
morcellator (HSEL) or by manual morcellation. Manual morcellation
is tedious and time consuming, and unforeseen morbidity has led
to the removal of the HSEL from the market. A new safer method
of morcellation would therefore be of great benefit to the laparoscopic
urologist. This is the second study to investigate the use of
the Coherent electrical prostate morcellator (EPM) for renal morcellation.
In a previous study (Landman et al. Urology 56:677-681, 2000),
morcellation was performed under external laparoscopic visualization.
We hypothesized that direct vision from inside the sack may decrease
the risk of perforation.
Methods: 30 porcine kidneys,
divided into 3 groups of 10, were evaluated. All morcellation
was performed inside a LapSacTM (Cook Urological), in a pelvic
trainer. Group 1 underwent morcellation using the EPM in a fluid
environment under direct vision. Group 2 underwent morcellation
using the EPM in a fluid environment, monitored by laparoscopic
vision outside the LapSac. Finally, Group 3 underwent manual morcellation
with ring forceps. The groups were assessed for time of morcellation,
size of fragments, and sac integrity.
Results: The mean morcellation
time for the three groups respectively was 86.9, 47.1, and 15.1
minutes (p<0.0001). The mean fragment size was 0.011g, 0.015g,
and 1.36g respectively. This was significantly different between
the manual morcellation group and the EPM groups (p<0.001),
but not between the two EPM groups (p=0.12). In Group 1, 1 pinhole
perforation occurred; in Group 2, 9 perforations occurred (5 large
and 4 pinhole); in Group 3, there were no perforations (p<0.001).
Conclusions: Despite use of
the LapSac, which has been shown to be the most resistant retrieval
systems (Rassweiler et al. J Endourol 12(4):325-333, 1998), a
90% perforation rate occurred in the external vision group. Although
direct vision inside the LapSac does allow for safer use of the
EPM for renal morcellation, the prohibitively long morcellation
time would preclude its clinical use. As well, manual morcellation
was superior to either EPM group in all categories.
Multiple Urethral Tubation (MUT) : A Continuing Dilatation
and Drainage for Benign Urethral Diseases
E. Macalalag, M. Macalalag,
M. Cruz, E. Perez, A. Macalalag, L. Velarde
The Multiple Urethral Tubation (MUT) or catheterization is an
innovation by bundling together two or more catheters. It is effective
in stenting the urethra, draining the urinary bladder and the
peri-urethral gland secretion. The movement of individual catheters
on each other and its bundle provides repeated and progressive
dilatation. The spaces between catheters also provides adequate
drainage of periurethral gland secretions.
One large and one small French foley catheters are chosen for
multiple urethral Tubation. These respective catheters are tied
together in a parallel fashion using non-absorbable sutures. The
summation of the two French sizes of catheter would equal a French
size that would allow passage both catheters inserted together
into the urethral lumen as the MUT (Multiple Urethral Tubation).
Insertion of the bundled catheters of MUT (Multiple Urethral Tubation)
is assisted by a mandarine urethral catheter guide which affords
rigidity and control of insertion. Insertion is may be done under
local,r spinal anesthesia and /or sedation. Multiple urethral
Tubation are left indwellin for a range of three to fifteen days.
After MUT removal, patients are followed up bimonthly then quarterly
for monitoring of any obstructive symptoms. At 1 year post-operatively,
Urethrogram is done.
Out of 601 cases only 491 were complete for collation from treatment
to a minimum follow up of 3 years. The diseases of the urethra
were 278 strictures sub classified into: simple, complex and complicated;
28 Urethral injuries 102 Congenital anomalies 39 Fistula/sinus;
28 urethral stricture surgeries and 12 complicated strictures
of irradiation, tuberculosis and post-infectious.
The over all success rate of MUT is 78% with the least of effective
(50%) in irradiated and Tuberculous strictures. The 86% success
for recurrent strictures and 80% for complex urethral strictures
put this into the highly effective therapy. The 78% success on
congenital anomalies even with pereneal hypospadia lessens the
headache of management.
1.8% complication rate showing cases of epidydimo-orchitis, false
passage, urethral injury, extravasation of urine.
50% to 92% effectivity of MUT is attributed to the utility model
to provide more adequate urinary drainage, periurethral glands
drainage and washing; alingment of disease and injured urethra,
reduction of edema and local instillation of medicine for a fast
unimpaired healing and devoid of stricture recurrences. Urethral
catheter with or without balloon, silk 2-0 or 3-0 are readily
available, easy to assemble and inexpensive.
CULTURE OF PORCINE URINARY TRACT CELLS ON SMALL INTESTINAL SUBMUCOSA
FOR TISSUE ENGINEERING APPLICATIONS.
A Jacobson, J Aldana, BR Lee, L Kushner, and AD Smith.
Department of Urology, Long Island Jewish Medical Center, New
Hyde Park, NY, USA
INTRODUCTION AND OBJECTIVES:
Despite efforts to develop new materials for urinary tract replacement
or augmentation, autologous bowel remains the only clinically
available material currently suited to these tasks. Small intestinal
submucosa (SIS) has been used experimentally in animals for bladder
augmentation and ureteral segmental replacement, but has met with
sub-optimal long-term success. Pre-seeding of SIS grafts with
autologous urinary tract smooth muscle and epithelial cells grown
in culture prior to implantation could potentially lead to a more
favorable long-term outcome. In vitro characterization of human
urinary tract cell growth has been previously described (Zhang
et al., J Urol 164:928). However, in vivo application in humans
would first require testing of this technique in a large animal
model. The purpose of this study was to generate a muscle- and
urothelium-lined SIS graft in a porcine model, for eventual use
in experimental segmental urinary tract replacement in pigs.
MATERIALS AND METHODS: Ureteral and bladder
tissue were surgically removed from 20-25 kg domestic female pigs.
The urothelium was microdissected from the muscle, dissociated
with collagenase 200 units/ml, and plated onto tissue culture
flasks in keratinocyte serum-free medium (KSFM). The muscle was
minced into 1 mm2 pieces and plated onto 100 mm2 tissue culture
dishes in medium 199 (M199) with 20% fetal bovine serum (FBS).
When cells were near confluence, they were dissociated from the
growth vessels using a commercially available non-enzymatic dissociation
solution. Muscle cells were seeded onto 3 cm x 10 cm strips of
SIS placed in modified single-well tissue culture plates and,
24-48 hours later, the urothelial cells were seeded on top of
the muscle cells. The graft cultures were then maintained in equal
parts KSFM and M199/FBS for 4 weeks, then fixed in formalin. Grafts
were processed for routine histology as well as for immunohistochemical
staining for cytokeratin AE1/AE3 and smooth-muscle actin.
RESULTS: Although porcine urothelium proved
quite susceptible to harvest-related injury and did not grow in
KSFM as efficiently as human urothelium does, we were able to
establish growth of porcine urothelial cells in culture. Porcine
smooth muscle cells grew well in M199/FBS, but were often contaminated
by residual epithelial cells, which also grew well in this media.
A technique was therefore developed to select for growth of the
muscle cells. Histological and immunohistochemical analysis of
the cell-seeded grafts revealed the presence of a multilaminar
myoepithelial structure distributed on the surface of the SIS
graft, with muscle cell penetration into the SIS.
CONCLUSION: Although their in vitro characteristics
differ to a degree from their human counterparts, porcine urothelial
and smooth muscle cells can be grown in culture and on sheets
of small intestinal submucosa. These grafts represent a first
step towards tissue engineering applications in the porcine urinary
RESIDUAL DNA IN BIOLOGICAL SLING MATERIALS:
A COMPARISON BETWEEN PO-TREATED BOVINE PERICARDIUM,
HUMAN DERMIS, SOLVENT-EXTRACTED AND
FREEZE-DRIED CADAVERIC FASCIA LATA
L. Mooradian, Amy Lambert, Robert Wonsetler and B. Nicholas Oray
Biovascular, Inc., St. Paul, MN
Purpose: The pubvaginal sling procedure has
emerged as an effective surgical treatment for stress urinary
incontinence. A variety of biological materials are currently
used in this procedure, but the extent to which processing prior
to sterilization and use succeeds in removing residual cellular
material such as DNA remains unclear. In this report, we compare
the levels of extractable DNA found in a novel non-crosslinked,
propylene oxide (PO)-treated, acellular collagen matrix derived
from bovine pericardium to biological sling materials currently
Materials & Methods: Three (3) samples (10-25
mg) of four (4) biological sling materials: solvent-extracted
cadaveric fascia lata (Suspendâ, Mentor, Inc.), freeze-dried
cadaveric fascia lata (MTF, Musculoskeletal Transplant Foundation),
Processed human dermis (Repliformä, Microvasive, Inc.) and
PO-treated bovine pericardium (Veritasä Collagen Matrix,
Bio-Vascular, Inc.) were rehydrated in PBS, pH 7.4, minced and
then subjected to Proteinase K digestion at 55oC. Extracted DNA
was then isolated on a nucleic acid binding column (Sigma #C-9471).
Total DNA was quantitated spectrophotometrically at A260 and expressed
as mg DNA/mg tissue. The ratio of absorbance at A260 and A280
was calculated to insure the quality of the DNA preparation (i.e.
Results: As seen in Table 1, the amount of DNA
extracted from PO-treated pericardium was significantly lower
– on a per milligram tissue basis - than that the amount
extracted from each of the other materials tested. Indeed, freeze-dried
fascia lata contained 5.73 times as much extractable DNA as did
PO-treated pericardium. Solvent-extracted cadaveric fascia lata
contained less extractable DNA than freeze-dried fascia lata,
but 2.94 times as much as PO-treated pericardium. Finally, processed
human dermis contained 4.16 times as much extractable DNA as did
Table 1: Extractable DNA in Biological Sling Materials
0.182 ± 0.039
|Solvent-extracted Fascia Lata
0.535 ± 0.149*
|Processed Human Dermis
0.757 ± 0.029**
|Freeze-dried Fascia Lata
1.043 ± 0.151***
Significantly different from PO-treated
Pericardium, *p = 0.165, **p = 0.0001, ***p = 0.0007
Conclusions: These results
confirm that Veritasä collagen matrix, a non-crosslinked,
PO-treated bovine pericardium-derived sling material contains
an exceptionally low level of extractable DNA when compared
to a variety of biological sling materials currently in use.
BIPOLAR RADIOFREQUENCY (RF) ABLATION OF THE KIDNEY:
COMPARISON TO MONOPOLAR RF ABLATION
Stephen Y. Nakada,
Travis J. Jerde, Thomas F. Warner, Andrew S. Wright,
Christopher D. Johnson, Dieter Haemmerich, Alan H. Rappe, David
M. Mahvi, Fred T. Lee, Jr., Madison, WI.
Introduction: We report initial ex vivo and
in vivo studies using bipolar RF ablation of porcine kidneys.
Methods: Ex vivo preparations of 10 porcine
kidneys were perfused with continuous Ringer’s solution
and treated with either 1) standard external grounded RF (n=3)
or 2) bipolar RF ablation with 1 (n=2), 2 (n=3) or 3 (n=2) cm
separation between the ground probe and the RF probe using a
Model 30 RITA generator (RITA, Mountain View, CA). Gross and
histologic assessments were made acutely. Target temperatures
were 90°C for 8 minutes. The in vivo study utilized 4 domestic
pigs treated with monopolar RF ablation of the lower pole of
one kidney and bipolar RF with 12 mm separation between the
probes of the contralateral lower pole kidney. Animals were
harvested 48 hours later for gross and histologic assessments.
Results: Ex vivo studies revealed grossly monopolar
lesions 1.5 cm in maximum diameter and 1.75 cm3 in volume. In
comparison, bipolar lesions were 2.7 cm in maximum diameter
and 10.3 cm3 in volume using 3 cm electrode separation. In vivo
studies showed there were 2 distinct gross lesions using RF:
a blanched lesion and a hemorrhagic lesion. Using bipolar RF,
larger blanched lesions were achievable than with monopolar
RF (2.80 cm3 vs. 1.63 cm3). Overall, the combination of blanched
and hemorrhagic lesions were similar between monopolar and bipolar
RF (5.01 vs. 5.31 cm3). Histologic assessment verified cell
death in the blanched lesions.
Conclusions: Based on ex vivo data, bipolar
RF can create larger lesions than with monopolar RF. Based on
in vivo data, blanched lesions were associated with complete
cell death and predominated when performing bipolar RF.
PHYSICAL AND BIOCHEMICAL CHARACTERIZATION OF A
NOVEL NON-CROSSLINKED, PROPYLENE OXIDE-TREATED
ACELLULAR COLLAGEN MATRIX: COMPARISON WITH
SOLVENT-EXTRACTED AND FREEZE-DRIED CADAVERIC FASCIA LATA
B. Nicholas Oray,
Amy Lambert, Robert Wonsetler and D. L. Mooradian
Bio-Vascular, Inc., St. Paul, MN
Purpose: The pubvaginal sling
procedure has emerged as an effective surgical treatment for
stress urinary incontinence (SUI). The selection of materials
for use in this procedure is complicated by uncertainty regarding
the mechanical and biochemical demands placed on sling materials
in vivo. In this report, we compare key physical and biochemical
properties of a novel non-crosslinked, propylene oxide (PO)-treated,
acellular collagen matrix derived from bovine pericardium to
biological sling materials currently in use.
Materials & Methods: Six (6) samples of
three (3) biological sling materials: solvent-extracted cadaveric
fascia lata (Suspends®, Mentor, Inc.), freeze-dried cadaveric
fascia lata (MTF, Musculoskeletal Transplant Foundation) and
PO-treated bovine pericardium (VeritasTM Collagen
Matrix, Bio-Vascular, Inc.) were tested. Mechanical testing
was performed on 3mm wide “dogbone” samples on a
Chemdyne MC-1000 uniaxial tensile tester. Samples were loaded
to failure (cross-head speed 5 mm/min), stress/strain curves
were generated, and ultimate tensile strength (UTS) was calculated.
Suture retention strength (cross-head speed 100 mm/min) was
Results: As seen in Table 1, VeritasTM
was thinner than each of the other materials tested. Mechanical
testing revealed that the tensile strength of VeritasTM
was equivalent to that of both SuspendTM and MTF
fascia lata, but the suture retention strength of VeritasTM
was higher than either SuspendTM or MTF fascia Lata.
*Suture retention is significantly lower than
PO-treated pericardium (p = 0.0009).
||Tensile Strength (MPa)
||Suture Retention (g)
0.590 ± 0.11
5.02 ± 3.2
900.7 ± 291.6
1.230 ± 0.45
4.27 ± 1.9
340.5 ± 51.7y *
0.720 ± 0.14
4.12 ± 3.1
584.2 ± 207.4g **
**Suture retention is significantly lower than PO-treated pericardium
(p = 0.0275).
Conclusions: These results
indicate that VeritasTM, a non-crosslinked, PO-treated
bovine pericardium-derived sling material is comparable to and
in some instances stronger than products currently used in pubvaginal
SAFYRE: A NEW CONCEPT FOR ADJUSTABLE MINIMALLY INVASIVE
SLING FOR FEMALE URINARY STRESS INCONTINENCE.
Paulo Palma, Cassio
Riccetto, Míriam Dambros, Marcelo Thiel, Viviane Herrmann,
Nelson Netto Jr.
(University of Campinas – UNICAMP, Campinas, Brazil),
Aparecida Pacetta (Unmiversity of São Paulo – USP,
São Paulo, Brazil),
Omar Grossi (Buenos Aires, Argentina) Mario Paladini (Córdoba,
INTRODUCTION AND OBJECTIVES: Safyre Sling is
a new technique to create a support to mid-urethra, in order
to restore the continence in women with stress urinary incontinence
(SIU). Safyre consists of a polypropylene mesh that acts as
a urethral support, held between two self-anchoring columns
which are made of an implant grade polydimethylsiloxane polymer.
These columns are the basis of the autofixing system, for minimum
surgical damage of pelvic floor natural support structures.
A specially designed insertion needle permits both suprapubic
or transvaginal approach, according to the surgeon best skills,
by changing the needle holder between it’s extremities.
METHODS: Two 0.5 cm transverse incisions are
made close to the superior aspect of the pubic bone 5 cm apart.
A longitudinal vaginal incision, 1.5 cm in length is made, starting
0.5 cm from the urethral meatus. Notice that this incision is
not allowed to encroach on the bladder neck. Dissection is done
to create a 1 cm tunnel lateral to the urethra for the introduction
of the Safyre insertion needle. First, the needle is advanced
through the vaginal tunnel until the perforation of pelvic floor
at the level of the mid-urethra. Then, it is redirected against
the back of pubic bone and advanced continuously to the benchmarks
in the suprapubic area. Cystoscopy is performed to rule out
bladder perforation. After the removal of the holder, Safyre
Sling is attached to the needle and pulled out to the suprapubic
area. The same maneuvers are repeated on the other side. The
proper tension of the sling is adjusted maintaining a Metzenbaum
pair of scissors between the urethra and the sling, to prevent
undue tension. The extremities of the sling are cut and the
Metzembaum scissors are removed. No further fixation is needed
and the incisions are closed in the usual manner. An indwelling
catheter is left in place overnight.
RESULTS: The initial results obtained in 33
patients have showed a cure rate of 97 %. One patient underwent
a vaginal mobilization of the sling due to urinary retention.
One patient had vaginal exposition of the sling that was removed.
Suprapubic pain was notice in 3 patients.
CONCLUSIONS: This sling allows for postoperative
adjustment under local anesthesia should it became necessary.
It can become an alternative for restoring the urethral support,
if the good short-term results prove to be long lasting.
SABRE SLING (SELF ANCHORING BIO REABSORBABLE):
A NEW MINIMALLY INVASIVE PROCEDURE, USING
BIODEGRADABLE URETHRAL SLING FOR TREATMENT
OF URINARY STRESS INCONTINENCE.
Paulo Palma, Cássio
Riccetto, Míriam Dambros, Marcelo Thiel,
Viviane Herrmann, Nelson Rodrigues Netto Jr.
Division of Urology, University of Campinas – UNICAMP,
São Paulo, Brazil.
INTRODUCTION AND OBJECTIVES: A new sling material
is now available for surgical treatment of stress urinary incontinence
(SUI). SABRE sling consists of copolymer of polylactictic acid
(PLA) and polycaprolactone (PCL) that acts as a suburethral
support. In this study, it is reported on the early outcomes
with the SABRE sling for the treatment of SUI.
MATERIAL AND METHODS: Since March 2001 twenty
women with proven stress incontinence underwent to a suburethral
sling using SABRE sling. The mean patient age was 54 years.
Valsalva leak point pressure (VLPP) showed urethral hypermobility
in 46% (mean VLPP 68 cm H2O) and sphincteric intrinsic deficiency
was diagnosed in 54% (mean VLPP 102 cm H2O). All the procedures
were done under spinal anesthesia. The sling was applied through
a 1cm longitudinal vaginal incision at midurethra using a specially
designed insertion needle.
RESULTS: The mean follow up was 5 months. Of
the 20 patients, 14 (70 %) were cured of stress incontinence
and 3 (15%) reported significant improvement and 3 (15%) maintained
the symptoms. Neither wound infection nor rejection was detected.
CONCLUSION: SABRE sling can become an alternative
for restoring the suburethral support, but these early results
warrant further evaluation.
Residual Gas Persists in the Collecting System
Following Percutaneous Nephrolithotomy
Joel Patrick A. Aldana
MD, Benjamin R Lee MD, Won J Lee MD,
Robert Marcovich MD, Avrum I Jacobson, Arthur D Smith MD
Department of Urology and Radiology, Albert Einstein College
Long Island Jewish Medical Center, New Hyde Park, New York
Introduction and Objectives:
Presence of gas in the kidney following surgical procedures
may represent renal abscess, xanthogranulomatous pyelonephritis,
other infection or residual gas. The rate of gas absorption
following percutaneous nephrolithotomy (PCNL) is unknown. We
determined the presence or absence of gas in the renal collecting
system 48 hours following percutaneous nephrolithotomy (PCNL)
in this study.
The study population consists of records of 100 consecutive
patients who underwent a percutaneous nephrolithotomy due to
stone disease from 1999-2000. Post-PCNL nephrostogram films
were reviewed by two urologists, an attending and a fellow,
and one attending uroradiologist who determined the presence
or absence of air in the urinary tract and location.
The nephrostograms were routinely performed 48 hours after the
percutaneous nephrolithotomy and all films of 100 patients were
reviewed. Gas was detected in 98 out of 100 cases which appeared
as gas pyelograms outlining the renal calyces. Out of the 98,
33 (34%) demonstrated gas in the upper calyx, 10 (10%) in the
middle calyx, 12(13%) in the lower calyx, and 43 (44%) in more
than 1 calyx. Gas was not detected in the renal parenchyma nor
Gas persists within the renal collecting system 48 hours after
a percutaneous procedure. Prospective studies should be done
in order to document the amount of time needed for complete
resolution of gas within the collecting system.
Figure 1: Gas in the upper pole of the collecting
system 48 hours after PCNL.
MODIFICATION OF THE BALISTIC
Dr. Daniel Porto and Dr. Javier Zeballos
Hospital Maciel, Departamento de Urologia, Montevideo, Uruguay
For the percutaneous lithotripsy procedure,
we use a Storz Balistic Lithotripter. One of the problems we
encounterd was when we introduced the probe of the lithotripter
of about 3mm diameter, into the operating channel we sometimes
could not hit the stone because the probe slipped past the stone.
We realized it was because the operating channel was much wider,
therefore the probe was modified to enlarge the diameter of
its tip to improve its performance during lithotripsy procedures.
HIGH INTENSITY FOCUSED ULTRASOUND ABLATION
OF THE VAS DEFERENS IN A CANINE MODEL
William W. Roberts,
David Y. Chan, Nathaniel M. Fried, E. James Wright,
Theresa Nicol, Thomas W. Jarrett, Louis R. Kavoussi, Stephen
Brady Urological Institute and the Johns Hopkins Medical Institutions,
PURPOSE: High intensity focused
ultrasound (HIFU) is an ablative technology capable of producing
thermal coagulative necrosis of sub-surface structures without
injuring intervening tissues. We assessed the feasibility of
using HIFU to produce occlusion of the canine vas deferens.
MATERIALS AND METHODS: A
tunable HIFU transducer was incorporated into a hand-held clip,
specially designed to transcutaneously grasp the vas deferens.
Slots within the jaws of the clip ensured that the vas deferens
and HIFU target zone were properly co-located. Ten vasa were
ablated using a range of power and time parameters. Two weeks
after ablation, each vas, epididymis, and testis was surgically
harvested en-bloc. Retrograde vasography was performed to assess
vasal occlusion, followed by pathologic analysis.
RESULTS: HIFU occlusion of the vas deferens
was confirmed in four specimens, ablated with parameters at
the upper end of the parameter range, 2 of 2 vasa ablated with
7 Watts, 60 sec and 2 of 4 vasa ablated with 7 Watts, 30 sec.
Histologic injury was seen in 8 of the 10 ablated specimens.
Skin burns developed over four of the targeted vasa and were
conservatively managed. Bilateral sham procedures in a control
dog resulted in patent vasa and no associated skin burns.
CONCLUSIONS: We have demonstrated
the feasibility of noninvasive, transcutaneous HIFU occlusion
of the vas deferens with ablation powers at the upper end of
the tested range (7 Watts). Modifications of the hand-held clip
and optimization of ablation parameters will likely improve
the success rate of this procedure. Refinement of this technology
may provide a rapid, non-invasive alternative to conventional
PORCINE SMALL INTESTINAL SUBMUCOSA IMPLANTED
A PUBOVAGINAL SLING IN 115 FEMALE PATIENTS WITH STRESS
URINARY INCONTINENCE: A 3 YEAR SERIES EVALUATED
FOR DURABILITY OF THE RESULTS
Authors: Alvin B.
Rutner, MD, Sari R. Levine, MD, John F. Schmaelzle, MD
Affiliation: El Camino Urology Group, Mt. View, CA
Processed porcine small intestinal submucosa
(SIS) has been shown in pre-clinical studies to have innate
and unique properties that could make it an ideal material for
pubovaginal slings (PVS) for patients with stress urinary incontinence
(SUI). Following surgical placement of the SIS graft, local
host cells are induced to infiltrate into the graft biomaterial
and replace it in approximately 90 days. During that time the
acellular collagen graft remains non-allergic and biocompatible.
It resists infection and initiates minimal tissue reaction.
In the 3 year period between 1-1-99 and 12-31-01,
115 consecutive women with type II and/or type III SUI underwent
implantation of an SIS sling through a small anterior vaginal
incision. The ends of the graft were secured to the inner surface
of the pubic bone with small bone screws. Concurrent cystocele
repairs were frequently reinforced with the same material. Patients
were maintained on a Foley catheter until they were voiding
satisfactorily (usually 1-7 days ) and were followed thereafter
as an outpatient.
108/115 (94%) of the patients in this series
have had an excellent result and remain relieved of their SUI.
Only 7 patients are classified as failed as follows:
One bone screw dislodged spontaneously
2 weeks postoperatively and patient developed mild SUI even
though dry initially.
One bone screw would not stay in the soft
bone during surgery. Our attempt to work around this dilemma
failed to correct the SUI. A followup suprapubic procedure
did clear the stress incontinence.
One patient failed immediately after surgery.
A repeat sling 11 months later also failed. Urodynamic studies
and consultation was advised.
One patient failed soon after surgery
and is being considered for a repeat procedure.
One patient was dry for 11 months and
then developed recurrence of SUI. She is considering a redo.
One patient failed after 9 months and
was greatly improved after injection of the proximal urethra
with a bulking agent.
One patient was relieved of SUI but voided
poorly because of a too tight sling. Urethrolysis solved that
problem and she remains dry.
Advances in lithotripsy with a frequency-doubled
YAG laser (FREDDY)
Affiliation: World of Medicine USA, Inc., 4531 36th Street,
Orlando, FL 32811, phone (407) 246-7084, email email@example.com
The use of laser technology in urology has
increased tremendously over the past ten years. Today laser
equipment has become a routinely used tool in many endourology
suites. Indications include intracorporal lithotripsy, which
accounts for the majority of laser uses in the urology practice,
as well as tumor resection, stricture treatment and BPH.
Since the mid 1980s a variety of different lasers were investigated
for the treatment of urinary calculi, a condition affecting
approximately one out of ten people throughout their lifetime.
An innovative technology that is utilized in a new shockwave
lithotripsy laser is presented. It is based on a Nd:YAG solid
state laser that emits at 1064 nm which is partially frequency
doubled to 532 nm by a KTP and simultaneously applied to the
stone. The introduction of a 50 meter intracavity fiber into
the resonator allows for a pulse duration of 1.2 microseconds
resulting in high peak power and low mean power outputs. Unlike
thermal lasers the FREDDY laser (Frequency-doubled dual-pulse
Nd:YAG) fragments calculi with shockwaves that are created at
the distal tip of the laser fiber in contact mode (also referred
to as the photoacoustic effect by plasma formation). This results
in very rapid fragmentation, especially noticeable for large
calculi such as bladder stones.
Due to low absorption of green light by soft tissue the FREDDY
laser demonstrates a high level of ‘intrinsic safety’,
virtually eliminating the risk of perforation.
Clinical data and cases performed from Winterpark Urology at
Florida Hospital Kidney Stone Center will be presented.
INITIAL HUMAN STUDIES WITH A NEW DEVICE FOR
MANAGEMENT OF URINE INCONTINENCE
(Followup of a concept presented during the
Daniel Yachia, MD
Department of Urology. Hillel Yaffe Medical Centre. Hadera - Israel
Bruce Rappaport Medical School. Technion - Israel Institute of
Technology. Haifa - Israel
INTRODUCTION : Urinary incontinence
(Ul) is one of the major social and medical problems affecting
about 40 million adults of both sexes in the Western world.
From diapers to vaginal pessaries, from surgery to bulking injectables,
to intraurethral plug-like devices are currently being used
for the management of (UI). Although some of the surgical techniques
are successful in the treatment of stress incontinence, about
50% of the patients need re-treatment after 5 to 7 years. Intraurethral
plug-like devices which were introduced during the last years
can mechanically block the involuntary leaking in female patients.
However, these devices by being positioned in the urethra caused
a communication between the bladder and the vulva, resulting
in very high rates of ascending urinary infections.
METHODS : In order to block
the bladder outlet (BO) in both sexes and open it voluntarily
for voiding a family of intra-vesical devices were designed.
The in-vitro and animal study results were presented a year
ago. From the 3 device designs presented a year ago 1 was found
to be most comfortable to the patient and successful in preventing
urine leakage. The device was inserted very easily and was retrieved
as easily. It was activated voluntarily using a small magnet
placed in the underwear.
RESULTS : The device was left in the bladder
up to 29 days in 20 patients. In 70% of the patients the device
could occlude the BO completely (0 to 3 gr. in pad weight test).
10% reported significant improvement (1 pad per day instead
of 4-7 a day). 20% of the patients could not tolerate the feeling
of a foreign body in their bladder. The BO could be opened by
removing the magnet situated in the underwear. Voiding measured
by uroflow was unobstructed. Device related UTI developed in
15% of the patients.
CONCLUSIONS : The use of an entirely intravesical
device for the management of incontinence is a novel approach.
The initial clinical studies showed that this device is safe
and effective in the management of UI. The device is in its
final stages of development and large scale clinical studies
will commence in the near future.
SOLO SURGERY : VIDEO-ASSISTED MINILAPAROTOMY RADICAL NEPHRECTOMY
- THE INITIAL CASE REPORT
Authors: Seung Choul
Yang, Koon Ho Rha, Jin Won Jung, Duck Hyung Kwon, Jae Wook Kim
Affiliation: Department of Urology, Yonsei University, Seoul,
Introduction and Objectives:
Recently more interest in minimally invasive procedures with
intent of reducing manpower has occurred. Based on the experience
with minilaparotomy nephrectomies(J Urol 165(4): 1099-1102,
2001), we have successfully performed a first solo radical nephrectomy
using a newly developed retractor system.
A 3.5 cm sized heterogenous enhancing mass on lateral aspect
of left kidney midportion was noted on CT in a 40 year old man.
He weighed 63 kg and was 157 cm tall. On lateral decubitus position,
a 8 cm sized incision was made on the pararectal area at the
tip of 10th rib and using specially developed retractor system
(Thompson Surgical Instruments Inc, USA), the abdominal wall
was elevated and peritoneal contents were pushed medially to
secure operative space. Telescopic monitoring was done by laparoscopic
holding device, avoiding the use of an assistant. Procedure
was performed via minilaparotomy under both direct vision and
video monitoring. The kidney and enveloping Gerota's fascia
was dissected intact and specimen was delivered using entrapment
bag via minilarotomy incision.
The oepative time was 2 hours and 20 minutes, and blood loss
was 300 cc. Oral intake resumed 18 hours after surgery. One
dose of morphine sulfate (4 mg) was given intravenously 5 hours
after the procedure. The patient was discharged on the porstoperative
Solo surgery (radical nephrectomy) utilizing minilaparotomy
using video-assistance and retractor system has been successfully
performed. We believe this minimally invasive technique with
the elimination of surgical assistant has broad implications
that go well beyond the urological realm.
PROPERTIES OF UROMAX™ BALLOON DILATORS
*Yohannes P., Lee B.R.,
New Hyde Park, New York; *Omaha, Nebraska, USA.
Objectives: To evaluate the
properties of Uromax™ balloon dilators.
Materials and Methods: The surface friction
and repeatability of radial force generated were tested in an
in vitro model using Uromax (7 mm and 9 mm) balloon dilators.
The force of insertion was defined as the force required to
push the balloon through a percuflex conduit that represented
an in vitro model of the ureter. Surface friction was measured
through the percuflex tubing with and without an external restrictive
force using a Digital Force Gauge™ (Ametek®, Largo,
FL). The balloon was dilated at 20 atm P (7 mm balloon dilator)
to 17 atm P (9 mm balloon dilator) for 60 seconds between each
pass. The radial force generated by the two sizes was measured
using the Instron™ (Instron Ltd., Canton, MA). The radial
force was measured after three to eight cycles. In addition,
changes in the outer diameter of the balloon dilator after multiple
inflation/deflation cycles was assessed using the Laser Mike
183™ (Dayton, OH).
Results: The force of insertion (lbs.) of the
non-conformed balloon dilator after deflation was significantly
greater (0 lbs. vs. 0.55 lbs.) than the conformed balloon (0
lbs vs. 0.02 lbs.). Similarly, the force of insertion through
a percuflex tubing with external compression (¯ 20% OD)
showed significant difference between first time insertion after
removal of the wing tool and non-conformed balloon (0.24 lbs.
vs. 0.40 lbs.). After three cycles of balloon dilatation, the
radial force did not significantly change (0.51 vs. 0.48 lbs./force
for 21 F, and 2.08 vs. 2.48 lbs./force for 27 F). In addition,
the outer diameter of the balloon increased after repeat cycles
Conclusion: Reconforming the uromax balloon
using the wing tool can help maintain a constant level of low
surface friction. The balloon diameter and radial force generated
by the balloon do not change with repeat dilatations at constant
HYDRO-EXPANDING DEVICES FOR ENDOUROLOGY
Dr. Javier Zeballos
and Dr. Daniel Porto
Maciel Hospital, Department of Urology, Montevideo, Uruguay
The use of the new plyuretanic materials (PU)
could make possible the production and design of new multiple
hydro-expanding devices to be used with the present endourological
techniques. This could open new trends of research and the creation
of devices for a progressive slower dilatation of the urinary
tract and stent that would facilitate the endourological access
with lower morbility.
Kidney acces percutaneous devices, catheters, guides, made of
PU which slowly expand absorbing water (within 24 - 48 hs.)
up to twenty times its size, could be suitable for urethral
acces, uretheric access, for the treatment of stenosis or stones,
and for kidney percutaneous techniques.
This is important since small diameter devices can be introduced
in the urinary tract , causing a slower dilatation in 24-48
hs which increases the size in the tract so as to introduce
endoscopic instruments in a less traumatic way with better results.
The material we are proposing was tested at LATU (Technological
Laboratory of Uruguay) with FTIR, ITR.PLA.217 and is now being
evaluated in different aspects:
Biocompatibility in transitory devices
Laboratory testing to determine its exact
variation in water and urine.
Laboratory testing to determine the materials
which can successfully be combined with PU in the different
This hydro-expanding system is in the preliminatory
stages of development and is to be improved with further laboratory
testing and clinical experience.