Real-time tomographic reflection in facilitating percutaneous access to the renal collecting system.

BACKGROUND AND PURPOSE: Real-time tomographic reflection is a novel technique that uses a geometrically fixed arrangement of a conventional ultrasound transducer, a transducer-incorporated monitor, and a half-silvered mirror. This device, dubbed the Sonic Flashlight, generates a virtual anatomically scaled image, obviating the need for a separate monitor. It may therefore facilitate invasive procedures, such as percutaneous access to the kidney. This proof-of-concept study assesses the feasibility of this technique for renal imaging and concomitant needle puncture guidance. MATERIALS AND METHODS: In a swine model with induced hydronephrosis, the Sonic Flashlight was used to visualize and guide needle access to the renal pelvis. Passage of a 7-inch, 18-gauge spinal needle was performed. Entry into the collecting system was confirmed by the aspiration of urine. RESULTS: The anechoic renal pelvis and hyperechoic needle tip could be seen with the Sonic Flashlight device. Successful access to the collecting system was obtained twice without dificulty. The sonographic image, appearing to emanate from the tip of the transducer, makes visualization and manipulation more intuitive. Furthermore, by placing the operator's eyes and hands in the same field as the sonogram, image-guided procedures are potentially easier to learn. CONCLUSION: The relatively shallow depth of penetration of the current device limits its clinical usefulness. A new Sonic Flashlight with a greater depth of penetration is in development.

Hand-assisted laparoscopic ureteroureterostomy with renal mobilization for delayed recognition of a proximal ureteral injury after lumbar disk surgery.

We present hand-assisted laparoscopic ureteroureterostomy (HALUU) with renal mobilization as a novel approach to the management of proximal ureteral injury after lumbar disk surgery. A 63-year-old female underwent L4-L5 diskectomy and facetectomy with cage placement for back and leg pain. Postoperatively, she developed fever, nausea, abdominal pain, ileus and leukocytosis. A computed tomography scan of the abdomen and pelvis with intravenous contrast and delayed imaging demonstrated a left proximal ureteral injury with contrast extravasation. Retrograde and antegrade ureteral stent placement was unsuccessful; a nephrostomy tube was placed. Antegrade and retrograde ureterograms revealed a 3-cm proximal ureteral defect. All treatment options were discussed, and the patient chose to undergo hand-assisted laparoscopic renal mobilization with ureteroureterostomy, which was completed successfully without complications. Operative time was 381 minutes; estimated blood loss was 50 mL. The patient was discharged after 2 days, her ureteral stent was removed in 8 weeks, and follow-up with furosemide-mercaptoacetyltriglycine (MAG-3) renal scan demonstrated 30% function without evidence of obstruction. Hand-assisted laparoscopic ureteroureterostomy with renal mobilization can be performed as definitive management of a medium-length proximal ureteral injury. This is the first case describing this management technique after lumbar disk surgery.

The history of NOTES.

Throughout history, medicine has witnessed paradigm shifts that significantly change patient treatment. Recently, the introduction and development of laparoscopic surgery has had a major impact on patient treatment. On the horizon is natural orifice translumenal endoscopic surgery (NOTES), which has tremendous potential. This review focuses on the history of natural orifice endoscopy in urology with the progression through therapeutic natural orifice endoscopy and resection to the development of upper tract natural orifice surgery. Further delineated is how technology has improved these procedures to set the stage for NOTES.

Robot-assisted laparoscopic prostatectomy: the first 100 patients-improving patient safety and outcomes.

BACKGROUND AND PURPOSE: Patient safety and outcomes are paramount when using new technology. We report our initial experience of 100 patients with robot-assisted laparoscopic prostatectomy (RALP) with a focus on patient safety and outcomes. MATERIALS AND METHODS: Data were prospectively collected from the first 100 consecutive patients who underwent RALP for localized prostate cancer from October 2004 to August 2007. To determine our learning curve, the cases were divided into quarters of 25 patients and stratified to identify trends. RESULTS: Mean age was 59.4 years (range 44.5-72.6 yrs), body mass index was 28.4 (range 20.4-40.1), preoperative prostate-specific antigen (PSA) level was 5.7 ng/mL (range 0.4-15.0 ng/mL), and follow-up was 12.7 months (range 7 days-38 mos). Mean operative time was 5.9 hours (range 3.7-10.9 hr), and estimated blood loss (EBL) was 218 mL (range 25-600 mL). Thirty bilateral pelvic lymphadenectomies were performed. Twelve patients had pT(2a) disease, 3 had T(2b), 61 had T(2c), 22 had T(3a)N(0), and 1 had T(3b)N(1). Positive surgical margin rate was 23%. Overall complication rate was 26%. At last follow-up, 88% (76/86) of patients had undetectable PSA levels, and 80% (70/87) of patients were using no pads. Improvement in EBL and operative time was noted throughout the series, and changes in surgical technique and perioperative management were made to improve patient safety and outcomes. CONCLUSIONS: RALP perioperative parameters improved throughout the first 100 cases, while postoperative outcomes remained acceptable. Methods to improve patient safety and outcome occurred throughout the series. Even during the initial learning curve for this procedure, RALP appears to be another alternative for achieving prostate cancer control.

Status of women in urology: based on a report to the Society of University Urologists.

PURPOSE: Written responses from American trained women in urological surgery were obtained to evaluate practice patterns, career choices and workplace satisfaction. MATERIALS AND METHODS: A 3-page unblinded questionnaire was mailed in March 2003 to American trained women in urological surgery available through the databases of the Society of Women in Urology with subsequent statistical analysis. RESULTS: The response rate was 60% but inclusive of all women in current academic practice in the United States. A total of 61% reported working 51 or more hours a week whereas 2% have left practice due to retirement or medical infirmity. There were 41% who had completed fellowships including 87% reporting active practice within their subspecialty, whereas 62% of fellowship trained surgeons remained in an academic practice. Among United States women in academic urological practice, academic progression has occurred in a third of this cohort. CONCLUSIONS: Threats to successful practice, consistent with other workplace surveys of physicians and professional women including gender based role limitation and inadequate mentoring, were commonly reported. These correctable workplace deficiencies represent an opportunity for American urology to enhance the professional workplace for all urologists regardless of gender.