Ergonomic evaluation and guidelines for use of the daVinci Robot system.

INTRODUCTION: The daVinci Robot system has been widely lauded for its improved ergonomic characteristics when compared with the pure laparoscopic technique. Our goal in this study was to assess for the existence of guidelines to maximize the ergonomic benefits of the daVinci system. We also compared the surgeon's console with the recommendations of similar workstations. METHODS: A literature review of seated ergonomics was performed to identify recommendations for work areas similar to the robotic system, where prolong seating is necessary. An upper body biomechanics and ergonomic expert was consulted to evaluate the daVinci system and aid in the formation of ergonomic positioning guidelines. Link-length proportions were used to evaluate size constraints of potential robot operators. RESULTS: No published guidelines exist for proper positioning using the daVinci surgeon console. There are, however, several Occupational Safety and Health Administration workstation guidelines as well as microscope ergonomic guidelines. The use of link-length proportions showed that the surgeon console allows a comfortable posture for individuals with height between 64 and 73 inches. Review of the microscope ergonomics literature indicates that a neutral vertical seating position has been associated with decreased strain and musculoskeletal disorders. CONCLUSIONS: The body mechanics of the daVinci robot system best mimics that of microscopy. Future surgeon console modifications could emulate those reported in the microscope ergonomic literature, where a neutral vertical position has been recommended. This may help avoid potential musculoskeletal disorders similar to those previously seen with microscopy usage. Guidelines are suggested to optimize the surgeon's console position.

Buccal mucosa graft urethroplasty for anterior urethral stricture repair: evaluation of the impact of stricture location and lichen sclerosus on surgical outcome.

PURPOSE: We report our experience with buccal mucosa grafts for anterior urethral strictures. We compared outcomes in the pendulous and bulbar urethra as well as the impact of lichen sclerosus on success. MATERIALS AND METHODS: A total of 53 men underwent buccal mucosa graft urethroplasty from 1997 to 2004 for strictures of all etiologies, including lichen sclerosis in 13. Of the patients 46 underwent 1-stage repair and 7 with full-thickness circumferential disease underwent multistage repair. For 1-stage repair strictures were limited to the bulb in 33 cases and they involved the pendulous urethra in 13. A dorsal onlay was used in 24 cases and a ventral onlay was used in 22. For multistage urethroplasty 2 strictures were in the bulbar urethra and 5 were in the pendulous urethra. Success was defined as no postoperative procedures or complications. RESULTS: The success rate of all urethroplasties was 81% (43 of 53 cases) at a mean followup of 52 months. For bulbar vs pendulous urethroplasty the success rate was 86% (30 of 35 cases) vs 72% (13 of 18, p = 0.23). For 1-stage urethroplasty by graft location success was achieved in 20 of 24 cases (83%) for dorsal onlay vs 17 of 22 (77%) for ventral onlay (p = 0.61), in 18 of 21 (86%) for bulbar-dorsal onlay, in 10 of 12 (83%) for bulbar-ventral onlay, in 2 of 3 (66%) for pendulous-dorsal onlay and in 7 of 10 (70%) for pendulous-ventral onlay. For multistage urethroplasty success was achieved in 2 of 2 cases (100%) for bulbar repair vs 4 of 5 (80%) for pendulous repair. In the 13 patients with lichen sclerosus success was achieved in 4 of 8 (50%) with 1-stage repair vs 4 of 5 (80%) with multistage repair (p = 0.28). Complications developed in 10 of 53 cases (19%), including fistula in 1, urinary tract infection in 1 and stricture in 8 that required treatment, including dilation in 3, internal urethrotomy in 4 and perineal urethrostomy in 1. Five of these 8 recurrent strictures (63%) developed in patients with lichen sclerosus, including 4 in urethras in which 1-stage repair was done for lichen sclerosus. There were no donor site complications, postoperative erectile dysfunction or chordee. CONCLUSIONS: A buccal mucosa graft placed dorsally or ventrally remains an excellent graft material in the bulbar and pendulous urethra. When lichen sclerosus is present, careful consideration should be given to complete excision of the diseased urethra with multistage repair vs accepting a higher rate of stricture recurrence with 1-stage repair.

Persistent motile sperm after ligation band vasectomy.

PURPOSE: We evaluated the efficacy and mechanism of failure in a small case series of VasClip vasectomies. MATERIALS AND METHODS: Between September 2003 and March 2004, 8 patients underwent elective vasectomy using the VasClip ligation band. Microscopic semen analysis was done a minimum of 4 weeks postoperatively and after at least 15 ejaculations. The number of sperm and motility were quantified in 15 or more high power fields. Successful vasectomy was defined as 2 consecutive postoperative unspun semen analyses containing no sperm. Patients with failed vasectomy underwent bilateral surgical removal of the vas deferens segments containing the ligation band for gross and histological analysis. RESULTS: Six of 8 patients (75%) were deemed azoospermic after 2 semen analyses at a mean followup of 7 and 11 weeks postoperatively, respectively. Two of 8 patients (25%) had semen analyses containing multiple motile sperm after vasectomy. In the 2 failed cases 1 side was patent, as demonstrated by vasal cannulation and irrigation with dilute methylene blue despite a well positioned, intact and secure ligation band. Histological analysis showed extravasation and sperm granuloma on the patent side. CONCLUSIONS: The VasClip was found to fail at an unexpectedly high rate. Pathological analysis suggests sperm extravasation and fistula tract formation as the mechanism. One failure resulted in an unwanted pregnancy, which demonstrates the need for patient counseling regarding postoperative followup.

Voiding frequency in a sample of asymptomatic American men.

PURPOSE: There are sparse published data concerning the urinary habits of asymptomatic American men. We studied those urinary habits, as revealed by a 24-hour voiding diary. MATERIALS AND METHODS: Men without lower urinary tract symptoms completed the International Prostate Symptom Score (I-PSS) and a 24-hour voiding diary. Demographic and diary data were analyzed using multivariate linear and logistic regression. RESULTS: A total of 284 asymptomatic males 18 to 66 years old returned interpretable diaries. Subjects voided a median of 7 times in 24 hours (range 2 to 21) with 95% voiding fewer than 12 times daily. Median 24-hour urine volume was 1,650 ml (range 290 to 6,840). Median fluid intake was 2,747 ml (range 500 to 10,520). Of the men 82 (29%) reported at least 1 nocturic episode. The 24-hour frequency was related to total urine volume (beta = 1.2, p <0.001) and total fluid intake (beta = 0.1, p <0.001), inversely related to mean voided volume (beta = -1.1, p <0.001) and lower in white men (beta = 0.1, p <0.02) but independent of age and body mass index. The probability of nocturia was highly related to the nighttime diuresis rate (beta = 15, p <0.001), inversely related to mean voided volume (beta = 1, p = 0.001) and less likely in white men. Median I-PSS was 2 (range 0 to 22). I-PSS increased with age, body mass index and total urinary frequency, and it was lower in white men. CONCLUSIONS: This study suggests that the threshold of 8 to define abnormal urinary frequency may not be correct since more than a third of our sample of asymptomatic men voided more than 8 times daily. It is probably inadvisable to apply a single set of normative values to all American men because of significant variability in regional climates and populations.

Efficacy and morbidity of autologous fascia lata sling cystourethropexy.

PURPOSE: Sling cystourethropexy for intrinsic sphincter deficiency has more recently been accepted as effective surgical treatment for all types of stress urinary incontinence. We report our experience using autologous fascia lata for sling cystourethropexy, regarding treatment efficacy, harvest site morbidity and patient satisfaction. MATERIALS AND METHODS: A retrospective data base review identified all women who underwent sling cystourethropexy using autologous fascia lata for stress urinary incontinence. A followup survey study using questionnaires (Black and Urogenic Distress Inventory-6) combined with questions regarding pad use, satisfaction and leg morbidity was done. RESULTS: A total of 100 women who could be contacted and who had undergone autologous fascia lata sling cystourethropexy performed by a single surgeon between 1993 and 2002 were surveyed. Mean patient followup was 4.4 years (range 0.8 to 9.3). Of the women 85% stated that they were dry or improved and 93% were pain-free at the harvest site by 7 days. There was no harvest site infection and no lower extremity thrombotic complication. Of the patients 83% indicated that the procedure had a positive effect on their life with only 4% stating that it had a negative effect, while 77% were satisfied with the procedure, 82% would recommend the procedure to a friend with incontinence and 83% would undergo the procedure if making the decision again. CONCLUSIONS: Autologous fascia lata sling cystourethropexy is associated with high patient satisfaction and treatment efficacy comparable to that of other sling cystourethropexy materials, as determined by questionnaire. Harvest site morbidity is low. Sling cystourethropexy using autologous fascia lata should be considered as a primary surgical approach in women with stress urinary incontinence.