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Louis Eichel

Publications and source records attributed to Louis Eichel.

At least 19 recordsLinked to original sources
PubMed2006

Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children.

OBJECTIVES: To compare the initial results of robotic-assisted laparoscopic versus open pyeloplasty in children with ureteropelvic junction obstruction. METHODS: From June 2002 to July 2004, 8 pediatric patients underwent robotic-assisted laparoscopic pyeloplasty and were matched by age group with patients undergoing conventional open pyeloplasty. The mean age was 11.5 years (range 6.4 to 16.5) in the robotic-assisted group and 9.8 years (range 6.0 to 15.6) in the open group. A four-port transperitoneal technique was used to perform the Anderson-Hynes pyeloplasty with the da Vinci Surgical System. RESULTS: The mean operative time and estimated blood loss was 363 minutes (range 255 to 522) and 13.1 mL (range 5 to 25) in the robotic-assisted group versus 248 minutes (range 144 to 375) and 53.8 mL (range 5 to 200) in the open group, respectively. The mean length of hospitalization and pain medication use was 2.4 days (range 1 to 5) and 7.4 mg morphine (range 0 to 23) in the robotic-assisted group compared with 3.3 days (range 1 to 8) and 22.0 mg morphine (range 0 to 100) in the open group, respectively. At a mean follow-up of 14.7 months (range 2 to 24), all robotic procedures were successful as determined by subjective data using pain scales and radiologic data. CONCLUSIONS: Robotic-assisted laparoscopic pyeloplasty appears to decrease the length of hospitalization and use of pain medication, but has a longer operative time. Additional clinical experience is required to determine the long-term efficacy of this method.

Adolescent↗
PubMed2006

Robotic surgical education: a systematic approach to training urology residents to perform robotic-assisted laparoscopic radical prostatectomy.

OBJECTIVES: Robotic-assisted surgery using the da Vinci Surgical System is gaining popularity among urologists. However, training residents to use this system presents new challenges for surgical educators. We describe a method for training residents to perform robotic-assisted radical prostatectomy. METHODS: Residents first received da Vinci certification training followed by table-side assistance with a second attending urologist present to provide real-time instruction. After demonstrating proficiency with assistance, residents performed segments of robotic prostatectomies as the console surgeon. The procedure was divided into five steps: (a) bladder take-down, (b) endopelvic fascia and dorsal venous complex, (c) bladder neck and posterior dissection, (d) neurovascular bundles, and (e) urethral anastomosis. Performance was rated using an analog scale (0, very poor to 5, outstanding). The resident was allowed to proceed to the next step once proficiency (score greater than 3 of 5) had been demonstrated on three separate occasions. In addition, each procedure was digitally recorded and reviewed with the attending physician after the operation. RESULTS: Two chief residents underwent this training regimen. All 83 cases with surgical console involvement during a 7-month period were reviewed. The combined residents' mean operative time in minutes and overall performance (score 0 of 5 to 5 of 5) for each step were recorded. Using logistic regression analysis, a statistically significant trend was seen, with faster operative times and greater analog scores over time for both residents (P <0.005). CONCLUSIONS: A systematic approach can be used to safely and effectively train urology residents to perform robotic radical prostatectomy using the da Vinci robotic system.

Humans↗
PubMed2006

The use of robotically assisted surgery for treating urachal anomalies.

OBJECTIVE: To report the management of urachal anomalies using a robotically assisted approach. PATIENTS AND METHODS: Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma. RESULTS: All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence. CONCLUSIONS: Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.

Adult↗
PubMed2005

Impact of obesity on clinical outcomes in robotic prostatectomy.

OBJECTIVES: To assess the preoperative parameters and clinical outcomes of patients undergoing robotic laparoscopic radical prostatectomy with specific attention to the body mass index (BMI). Little is known about the impact of obesity (BMI greater than 30) on the clinical outcomes of patients undergoing radical prostatectomy. METHODS: The data of 100 men undergoing robotic laparoscopic radical prostatectomy between June 2002 and October 2003 were prospectively entered into a database. The standard clinical characteristics (eg, prostate-specific antigen, Gleason score) and perioperative and postoperative parameters were evaluated. Additionally, all were assessed preoperatively and postoperatively for American Urological Association symptom and bother scores, uroflowmetry, postvoid residual urine volume, and sexual function. RESULTS: Nineteen men were obese (BMI greater than 30) and 81 were not (BMI less than 30). The two groups had a similar need for transfusion, length of stay, and pathologic outcome. However, the obese men had poorer baseline urinary function (peak flow rate 13.9 versus 18.3 mL/s; voided volume 306 versus 454 mL; P < or =0.05) and sexual function (Sexual Health Inventory of Men score 14.1 versus 18.2; P < or =0.05). Obese men had significantly more complications (26.3% versus 4.9%; P = 0.01) and required more time to return to baseline activities (7 versus 4.3 weeks; P = 0.09) and urinary function. Finally, at 6 months, only 47% of obese patients versus 91.4% of nonobese patients had achieved pad-free urinary continence (P < or =0.001). CONCLUSIONS: In this study, obese patients had significantly worse baseline urinary and sexual function, had complications, and did not recover urinary function as quickly or as well as nonobese patients. Obese patients also demonstrated a strong trend toward a delay in recovery time.

Adult↗
PubMed2005

Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation.

INTRODUCTION: Efforts continue to develop techniques that maintain the neurovascular bundles and minimize trauma for robotic laparoscopic radical prostatectomy. We evaluated the feasibility of preserving the nerve bundles without cautery or surgical clips. TECHNICAL CONSIDERATIONS: The seminal vesicles were dissected using scissors and bipolar cautery. After the rectum was mobilized, the vascular pedicles (VPs) were delineated. Laparoscopic bulldog clamps (30 mm) were placed at least 1 cm from the prostate. Using scissors, the VPs were divided right at the prostate. The neurovascular bundle was gently dissected off the prostatic capsule. After mobilizing the bundle, FloSeal was applied along its entire length. The FloSeal was then covered with a dry 1 x 4-cm sheet of Gelfoam. Once the prostate was removed, the bulldog clamps were sequentially withdrawn. The VPs were observed, and, if pulsatile bleeding was encountered, a 3-0 figure-of-eight suture was precisely placed for hemostasis. When hemostasis was complete, the anastomosis was performed. RESULTS: In 17 men, temporary vascular occlusion was applied to 27 VPs and FloSeal and Gelfoam was applied each time. In 4 cases (15%), hemostasis was inadequate because of continued arterial bleeding that was easily controlled with a superficial figure-of-eight ligature of 3.0 absorbable suture. The average estimated blood loss was 91 mL (range 75 to 150). CONCLUSIONS: Cautery-free, clip-free, nerve-sparing robotic laparoscopic radical prostatectomy is feasible using a combination of temporary occlusion of the thick posterior prostatic pedicles with bulldog clamps followed by application of FloSeal. The effect on potency needs further follow-up.

Adult↗
PubMed2005

Effect of holmium:YAG laser pulse width on lithotripsy retropulsion in vitro.

BACKGROUND AND PURPOSE: The effect of laser pulse width on calculus retropulsion during ureteroscopic lithotripsy is poorly defined because of the limited availability of variable pulse-width lasers. We used an adjustable pulse-width Ho:YAG laser to test the effect of pulse width on in vitro phantom-stone retropulsion and fragmentation efficiency. METHODS AND MATERIALS: An Odyssey 30 Ho:YAG laser (Convergent Laser Technologies, Oakland, CA) with adjustable pulse width (350 or 700 microsec) was used to treat spherical 10-mm plaster calculi in a model ureter (N = 40) and calix (N = 16) utilizing 200- and 400-microm fibers (10 Hz, 1.0 J). Calculi were placed in a waterfilled clear polymer tube, and laser energy was applied continuously in near contact until the stone had moved 8 cm. The time (seconds) and energy (joules) needed to cause the stone to traverse this distance was recorded. Stones were also placed in a stainless-steel mesh calix model in which retropulsion was limited. Laser energy was applied for 5 minutes at each pulse width. A laser-energy meter (Molectron Detector Inc, Portland OR) was used to quantify fiber transmission efficiency after 1 minute of continuous lithotripsy for each fiber at each pulse width. RESULTS: Retropulsion was greater for stones treated at 350 microsec, indicated by a shorter time to traverse the model ureter. For the 200-microrm fiber at 350 microrsec, the average time was 11.5 seconds v 20.3 seconds at 700 microsec (P < 0.001). The average total energy delivered was 114.9 J at 350 microsec v 199.8 J at 700 microsec (P < 0.001). For the 400-microm fiber at 350 microsec, the average time was 5.8 seconds v 11.9 seconds at 700 microsec (P < 0.001). The average total energy was 57.1 J at 350 microsec v 127.3 J at 700 microsec (P < 0.001). In the caliceal model, at 350 and 700 microsec with the 200- and 400-microm fibers, mass loss was 34.9% and 33.4% (P = 0.8) and 14.6% and 21.6% (P = 0.04), respectively. The reduction in energy transmission at 350 microsec and 700 microsec with the 200- microm fiber after 60 seconds of continuous lasing was 8.82% v 9%, respectively (P = 0.95). For the 400-microm fiber, the transmission loss was 18.4% at 350 microsec v 4.4% at 700 microsec (P = 0.0002). CONCLUSION: When treating ureteral calculi, retropulsion can be reduced by using a longer pulse width without compromising fragmentation efficiency. For caliceal calculi, the longer pulse width in combination with a 400-microm fiber provides more effective stone fragmentation.

Aluminum↗
PubMed2005

Third Prize: Comparison of radical nephrectomy, laparoscopic microwave thermotherapy, cryotherapy, and radiofrequency ablation for destruction of experimental VX-2 renal tumors in rabbits.

BACKGROUND AND PURPOSE: Currently available minimally invasive renal tumor-ablation procedures include cryotherapy, radiofrequency ablation, and microwave thermotherapy. In this study, we investigated the ability of these three approaches to destroy experimental renal tumors in rabbits. The mechanism of potential tumor metastasis was also explored. MATERIALS AND METHODS: The VX-2 tumor line is an aggressive rabbit epidermoid tumor with a high metastatic potential. An initial experiment comparing cooled-tip microwave thermotherapy with cryotherapy and radical nephrectomy for treatment of small VX-2 tumors revealed that all microwave-treated rabbits had local recurrence and that several also had diffuse intraperitoneal carcinomatosis. In view of these results, a second experiment was performed in which 45 New Zealand White rabbits were implanted laparoscopically with VX-2 xenografts underneath the kidney capsule and divided into five groups of 9 each. The test groups were microwave thermotherapy with a 3.5-mm cooled-tip probe, microwave thermotherapy with a 3.5-mm noncooled- tip probe, radiofrequency ablation with a 1.5-mm cooled-tip probe, radiofrequency ablation with a 1.5- mm non-cooled tip probe, and cryotherapy with a 2.3-mm cryoprobe. The control groups were five rabbits that were not treated, five rabbits with tumors that had the tumor pierced with a probe but were untreated, and five rabbits that underwent nephrectomy after piercing of the tumor. Treatment was initiated 5 days after tumor implantation. One month later, all animals were euthanized and autopsied. RESULTS: At 5 days after tumor implantation, laparoscopic inspection revealed no visible peritoneal metastases. At 1 month, in the cooled and non-cooled microwave-thermotherapy groups, carcinomatosis occurred in five and six of nine animals, respectively. In comparison, carcinomatosis was detected in two of nine animals in the cryotherapy group at autopsy. With respect to cooled and non-cooled radiofrequency ablation, carcinomatosis was observed in four of nine rabbits in each group. In the control groups, none of the animals with unpierced tumors exhibited carcinomatosis, while carcinomatosis was seen in two of the five rabbits with tumor violated by piercing and in three of the five rabbits that underwent immediate nephrectomy after piercing of the tumor. CONCLUSION: Carcinomatosis occurred most frequently in animals treated with microwave thermotherapy, followed by radiofrequency ablation, and lastly cryoablation. The simple act of piercing a highly aggressive tumor can result in local spread. More disconcerting, and less well understood, is why certain ablative modalities appear to increase the rate of intraperitoneal spread.

Animals↗
PubMed2005

Effect of urine specific gravity on effectiveness of shockwave lithotripsy.

PURPOSE: To determine the effect of urine specific gravity (SG) and radiographic contrast medium on the efficiency of extracorporeal shockwave lithotripsy (SWL) fragmentation using a previously published in vitro model. MATERIALS AND METHODS: Artificial kidney stones (BegoStone [BEGO USA, Smithfield, RI]) of a standard size (10 x 10 mm) and weight (mean 1.90 g; range 1.89-1.91 g) were randomly allotted to one of four test media with differing SG: group 1: synthetic urine, SG 1.003; group 2: synthetic urine, SG 1.040; group 3: 50% radiographic contrast (Cysto-Conray II, Mallinckrodt Inc., Hazelwood, MO), 50% synthetic urine, SG 1.069; and group 4: 100% contrast, SG 1.121. The stones were placed in cups made of 2.2-mm screen mesh and exposed to 500 shockwaves at 20 KV from a spark-gap lithotripter (Econolith 2000; Medispec, Germantown, MD). The stone fragmentation rate (i.e., percent fragmentation) was determined by dividing the dry residual stone weight by the prelithotripsy dry weight (X 100). RESULTS: The mean fragmentation rate for the four groups was 31.7%, 37.6%, 31.8%, and 27.2%, respectively. Statistical significance was not achieved (P = 0.1). CONCLUSION: Stone breakage tends to be more effective when urine SG is about 1.040 than at higher or lower values. Hence, the recommendation for an overnight fast prior to SWL is well founded. Introduction of contrast medium may inhibit stone breakage because it increases the specific gravity.

Humans↗
PubMed2005

What happens to hemostatic agents in contact with urine? An in vitro study.

BACKGROUND AND PURPOSE: As the indications for topical hemostatic agents increase in urology, the question arises: what happens to these agents when they enter the urinary collecting system? To answer this question, we performed a series of in-vitro experiments mixing three hemostatic agents with normal and sanguineous urine. MATERIALS AND METHODS: Four commercially available topical hemostatic products: oxidized regenerated cellulose (Surgicel; Ethicon, Somerville, NJ), fibrin sealant (Tisseel VH Kit; Baxter Health Care Corporation, Irvine, CA), gelatin matrix hemostatic sealant (FloSeal; Baxter Health Care), and polyethylene glycol (CoSeal; Cohesion Technologies, Palo Alto, CA) were studied. Human urine (10 mL) was added to samples of each substance; this was done in triplicate. The 12 sample tubes were then capped and placed on a tube shaker at slow speed and 37 degrees C. Observations regarding consistency of the material were made at 6, 12, 24, 48, 72, 96, and 120 hours (5 days). Gelatin matrix hemostatic sealant was further tested in urine with various amounts of blood or blood clot; observations were again recorded out to 5 days. RESULTS: Surgicel maintained its solid form when it initially came in contact with urine, but over a period of 5 days, it transformed into a mucoid substance with visible free-floating fibers. It did not dissolve completely in urine within 5 days. Gelatin matrix was immediately transformed by urine into a fine colloidal suspension that did not change over the 5 days of the study. Fibrin glue, after mixing of the two components (fibrinogen and thrombin) directly in the urine, and polyethylene glycol immediately formed a solid clot at the bottom of the test tube on contact with the urine. When the mixture of fibrin sealant was allowed to form for 15 minutes and then added to urine, it again maintained a solid form. After 72 hours, the fibrin glue became a semisolid gelatinous plug. On analysis at 5 days, the fibrin sealant clot had transformed into a cohesive mucoid gel, and the polyethylene glycol clot had not changed. The gelatin matrix hemostatic sealant, when in contact with blood or blood clot, appeared to either become part of a clot or to remain in a colloidal suspension. At 5 days, all clots had dissolved to fine particulate suspensions, and the gelatin matrix appeared as a fine suspension. CONCLUSION: Fibrin glue and oxidized regenerated cellulose maintain a solid form when initially placed in direct contact with urine and then assume a semisolid gelatinous state, which is still present at 5 days. Polyethylene glycol forms a solid clot initially and does not change after 5 days. Only hemostatic gelatin matrix remained as a fine particulate suspension in both normal and sanguineous urine. The implications of these findings with regard to sealing the renal parenchyma or small violations of the collecting system after percutaneous or laparoscopic surgery await in-vivo testing.

Blood Loss, Surgical↗
PubMed2005

Initial impact of a dedicated postgraduate laparoscopic mini-residency on clinical practice patterns.

BACKGROUND AND PURPOSE: Laparoscopic surgical techniques are difficult to master, especially for surgeons who did not receive this type of training during their residencies. We have established a 5-day mentor-preceptor- proctor-guided postgraduate "mini-residency" (M-R) experience in minimally invasive surgery. The initial results from the first 16 participants in the laparoscopic M-R modules are presented. PARTICIPANTS AND METHODS: On the first and the last day of the M-R, all participants underwent surgical skills testing using an open-surgery, standard laparoscopic, and robot-assisted laparoscopic format. A written examination was also administered on the last day. The influence of M-R on the participants' practice pattern was then assessed by a follow-up questionnaire survey 1 to 7 months after their attendance. RESULTS: Data from the first 16 participants were analyzed. Of note, the score was significantly improved for only one of the four tested laparoscopic skills (i.e., threading a suture through loops). Nonetheless, on the follow-up survey, of the 15 respondents, two laparoscopically naïve participants had performed laparoscopic nephrectomy, and of the eight participants who had prior renal-ablative laparoscopic experience, four had performed advanced reconstructive laparoscopic cases. CONCLUSIONS: A 5-day dedicated postgraduate M-R in laparoscopy appears to be helpful for urologists wishing to incorporate this surgical approach into their practices. The "take rate" among participants is initially at the 40% level, similar to what has been previously reported after a 1 to 2-day hands-on didactic laparoscopy course.

Adult↗
PubMed2005

Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions.

PURPOSE: We present our experience with standard laparoscopic wedge resection of small renal tumors using a fibrin glue-oxidized cellulose sandwich for hemostasis. MATERIALS AND METHODS: From May 2002 to December 2003, 15 patients underwent laparoscopic wedge resection for a total of 15 nonhilar renal masses. Renal hilar clamping was performed in 1 patient and no sutures were placed. We used ultrasonic shears and an argon beam coagulator to resect and then coagulate the tumor bed. Tisseel (Baxter Corp., Deerfield, Illinois) was applied to the resection bed, followed by a layer of oxidized, regenerated cellulose (Surgicel, Ethicon, Somerville, New Jersey) and a final layer of Tisseel. RESULTS: Mean preoperative tumor size was 2.2 x 2.2 x 2.1 cm. Lesions were subdivided based on the percent of the lesion that extended beyond the renal parenchymal border on computerized tomography as exophytic-greater than 60% in 6 cases, endophytic-less than 40% in 4 and mesophytic-40% to 60% in 5. Mean operative time was 3.8 hours (range 3 to 5). Mean blood loss was 108 ml (range 20 to 300). No patient required blood transfusion. There was no significant difference in blood loss or change in creatinine among the endophytic, exophytic and mesophytic groups (150, 121 and 93 ml, and 0.03, 0.07 and 0.04 mg/dl, respectively). Margin status was negative in all cases (mean thickness 3.2 mm). Average hospital stay and time to the resumption of oral intake were 2.7 and 1.4 days, respectively. CONCLUSIONS: Small exophytic or mesophytic renal lesions can be safely excised laparoscopically without vessel clamping. Excellent hemostasis was achieved in each case with the newer hemostatic agents.

Aged↗
PubMed2005

Comparison of flexible ureteroscopes: deflection, irrigant flow and optical characteristics.

PURPOSE: We measured and compared the deflection, irrigation flow rates, distortion, resolution and light transmission of new generation flexible ureteroscopes. MATERIALS AND METHODS: Multiple characteristics of 5 flexible ureteroscopes (ACMI DUR-8 Elite, Olympus URF-P3, Storz 11278AU1 [Flex-X], Wolf 7330.072 and Wolf 7325.172) commonly available in the market were measured and compared. Measured data included active deflection, irrigation flow rates and optical characteristics. Each ureteroscope was evaluated with an empty working channel and with various accessories. Optical characteristics, specifically resolution and distortion, were measured using test targets (Edmund Optics, Barrington, New Jersey). Light transmission was also measured from the ureteroscope tip at 50% and 100% intensity. All 5 flexible ureteroscopes were tested in a laboratory setting using a Storz OR 1 system to capture the images. RESULTS: For all 5 ureteroscopes the angle of deflection was most impaired by a 365 microm laser fiber probe and least impaired by a 2.2Fr nitinol basket. Among all 5 ureteroscopes irrigation flow rate was most impaired with a 3.0Fr basket and least impaired with 200 microm laser fiber. The Wolf 7325.172 had the highest observed resolution of 25.39 lines per mm and the Wolf 7330.072 had the lowest distortion at 11.9%. The Karl Storz Flex-X and the ACMI DUR-8 Elite had the highest light output at 374 and 364 mV, respectively. CONCLUSIONS: The various flexible ureteroscopes differ with regard to flow rates as well as degree of deflection with either an empty or an occupied working channel. The Wolf flexible ureteroscope with a slightly larger working channel and a fused quartz bundle provided for superior flow and better optical performance. However, the greatest amount of tip deflection and highest light output were found in the ACMI and Karl Storz flexible ureteroscopes.

Artifacts↗
PubMed2004

Role of robotics in laparoscopic urologic surgery.

Robotic surgery is in its infancy. Small series of cases are emerging from various centers that indicate a strong role for robotics in the future of urology, surgery, and general medicine. Robotic technology is progressing on every level and will continue to be a driving force in the progress of science and medicine.

Equipment Design↗
PubMed2004

Robot-assisted versus open radical prostatectomy: a comparison of one surgeon's outcomes.

OBJECTIVES: To compare internally one surgeon's standard open radical prostatectomy (RP) and robot-assisted laparoscopic RP (RLP) results. RLP, like standard laparoscopic RP, ultimately needs to produce similar or improved results compared with standard RP techniques. Little information comparing RLP with standard RP exists. METHODS: As an internal control, we selected the last 60 standard RPs performed by one surgeon (T.A.) before initiating RLPs. For the RLP group, we selected cases 46 to 105 (n = 60) after the learning curve had adequately matured. We compared the clinical characteristics, perioperative results, and early clinical outcomes. RESULTS: The study and control groups had similar clinical characteristics (age, body size, preoperative prostate-specific antigen level, clinical stage, and Gleason score). No statistically significant differences were found between groups for prostate size, pT stage, Gleason score, or margin status (16.7% versus 20%; P = nonsignificant). The RLP group had a statistically significant advantage for estimated blood loss (103 versus 418 mL), postoperative hemoglobin change (1.6 versus 3.3 mg/dL), and hospital stay (1.02 versus 2.2 days). Complete continence (0 pads) at 3 months of follow-up and the rate of postoperative complications were similar for the RLP and RP groups (76% versus 75% and 6.7% versus 10%, respectively). CONCLUSIONS: We present the results of RLP and RP performed by one surgeon. With only a 100-case experience, RLP had oncologic and urinary outcomes that were at least equal to those after RP. RLP offers the benefits of minimally invasive surgery and does not compromise clinical or pathologic outcomes.

Adult↗
PubMed2004

Robotic laparoscopic radical prostatectomy with a single assistant.

INTRODUCTION: As experience with robot-assisted laparoscopic radical prostatectomy (rLRP) grows, the importance of the role of the assistant cannot be overstated. Key elements of the operation, dependent on the assistant, have not been reported. The focus of this report was to describe the key elements, which include positioning of the patient and assistant port sites, appropriate equipment, and the assistant-dependent steps of the procedure. TECHNICAL CONSIDERATIONS: During the course of the initial 100 cases, we reviewed the patient and port site positioning and reviewed the videotapes to identify key elements of the assistant's role that facilitate rLRP. We identified three important elements pertaining to patient positioning. In contrast to standard port site recommendations, we found that dominant and nondominant handedness dictate the assistant port site locations. Finally, we identified specific steps of the procedure that require the assistant to have laparoscopic skills necessary for the console surgeon to dissect the bladder neck, seminal vesicles, rectum, and neurovascular bundles. CONCLUSIONS: The assistant in rLRP is critical to the success of rLRP, especially in the learning phases. Right or left-handed dominance determines on which side the assistant should be positioned. In contrast to the console surgeon, the assistant should have intermediate to advanced laparoscopic skills.

Dissection↗
PubMed2004

Robotic radical prostatectomy: a technique to reduce pT2 positive margins.

OBJECTIVES: To describe a technique using the da Vinci robotic system that enhances one's ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer. TECHNICAL CONSIDERATIONS: The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler. RESULTS: The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003). CONCLUSIONS: The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.

Adult↗
PubMed2004

Ureteroscopes: flexible, rigid, and semirigid.

Since its introduction, the ureteroscope has undergone significant improvements. Using the currently available rigid, semirigid, and flexible ureteroscopes and working instruments, urologists can diagnose and treat lesions throughout the upper urinary tract. Over the past 25 years, the ureteroscope in combination with shock wave lithotripsy has transformed the diagnosis and treatment of more than 90% of upper urinary tract pathology from an open to an endourologic procedure. With endoscope manufacturers continually incorporating new technology into their ureteroscopes, future models will undoubtedly provide better optics, increased durability, and improved capabilities, resulting in greater success when urologists perform endoscopic forays into the upper urinary tract.

Equipment Design↗