Global Assessments of the Endockscope System: Long-Term Impact of Cyber Endoscopy.

Introduction: The disproportionate costs of state-of-the-art endoscopic equipment prohibit urologists from performing endoscopy in underserved countries. Given the global prevalence of smartphones, we engineered a $45 alternative endoscope utilizing three-dimensional printed attachments, an 8 × lens, and a 1000-lumen light-emitting diode cordless flashlight (Endockscope System [ES]). Materials and Methods: At the 34th World Congress of Endourology in Cape Town, South Africa (WCE 2016; 4-year group), and at the 39th Congress of the Société Internationale d'Urologie (SIU) in Athens, Greece (SIU 2019; 8-month group), a total of 40 ES kits were distributed free of charge to an international group of urologists. Participants were given instructions and a hands-on demonstration of the device. Urologists given an ES were subsequently asked to complete a survey between June and September 2020 that included questions regarding user satisfaction, comfort, and comparability of the ES to standard endoscopic systems. Results: Urologists from 23 countries received ES kits. Overall, 10 of 22 urologists (10/22; 45%) from the 4-year group and 18 of 18 urologists (18/18; 100%) from the 8-month group completed the survey. The ES device was used by 80% (8/10) and 83% (15/18) of urologists from the 4-year and the 8-month groups, respectively. Of note, the greatest impact of ES usage was among urologists from the most impoverished countries. Of those who used the ES, 44% (4/9) of urologists from the 4-year cohort and 47% (8/17) from the 8-month cohort reported they were able to perform more endoscopic procedures directly because of the ES. Moreover, 57% (4/7) of the 4-year participants and 67% (10/15) of the 8-month participants found the ES equal or superior in quality to their standard endoscopic equipment. Conclusion: The ES provided an effective and inexpensive system that enabled urologists in resource-challenged countries to effectively perform and expand their use of urologic endoscopy.

In Vitro Evaluation of Stone Fragment Evacuation by Suction.

Introduction: Contemporary, flexible stone baskets are unable to extract submillimeter stone fragments at the time of ureteroscopic laser lithotripsy. In this in vitro study, the feasibility of suctioning submillimeter fragments with a standard Luer Lock syringe through the working channel of a flexible ureteroscope was assessed. Materials and Methods: Phantom stones made from industrial plaster were mechanically fragmented into ≤1 and ≤0.5-mm groups. Both stone groups were divided into five preweighed trial samples. Each stone group was then mixed in a beaker filled with normal saline. A standard 10-mL Luer Lock syringe was connected to a fiber-optic ureteroscope with a 1.2-mm working channel. The syringe was then used to suction stone fragments from the beaker. The suctioned stone fragments and the stone fragments remaining in the beaker after removing the overlying solution were separated, centrifuged with supernatant removed, and dried in an incubator set at 33°C for 1 week. Dried weights were recorded. Results: Mean total weights for ≤0.5 and ≤1.0-mm stone groups at baseline were 0.807 and 0.806 g, respectively. The mean percentages of stone fragments suctioned through the ureteroscope for ≤0.5 and ≤1.0-mm groups were 86% and 86%, respectively (p = 0.973). During suctioning, 64% of stones in the ≤0.5-mm group were trapped in either the working channel of the ureteroscope or within the Luer Lock syringe compared with 78% of stones in the ≤1-mm group (p = 0.001) requiring cessation of the procedure to clear the channel. Conclusions: It is feasible to suction submillimeter stone fragments by connecting a Luer Lock syringe to the working channel of a flexible ureteroscope. The limiting factor for removing stone fragments appears to be the small working channel of flexible ureteroscopes as trapping of fragments during suctioning is common and requires time-consuming removal of the endoscope and clearing of the channel.

Surface-Treated Pellethanes: Comparative Quantification of Encrustation in Artificial Urine Solution.

Introduction: Encrustation of implanted urinary tract devices is associated with significant morbidity. Pellethane® is a polyether-based compound noted for its strength, porosity, and resistance to solvents. We assessed Pellethane thermoplastic polyurethane (TPU) with and without surface coatings 2-hydroxyethyl methacrylate (HEMA) and tetraethylene glycol dimethyl ether (TETRA) for the potential to resist encrustation in an artificial urine environment. Materials and Methods: Samples of Pellethane TPU, HEMA Pellethane TPU, TETRA Pellethane TPU, and hydrogel-coated ureteral stent (Cook®) were suspended in a batch-flow model with an artificial urine solution (AUS). Every 48 hours for 90 days, 40% of the solution was replaced with fresh AUS. All samples were stored in a 37°C incubator. Subsequently, the samples were thoroughly dried for 48 hours before weighing. Scanning electron microscopy was used to assess the degree of encrustation. Nu-Attom Inductively Coupled Plasma Mass Spectrometry (ICP-MS) was used to determine the precise compositions of the encrustation specifically with regard to calcium, magnesium, and phosphate. Results: At the conclusion of the 90-day trial, the samples were analyzed, and the average mass changes were as follows: stent 63.78%, uncoated Pellethane TPU 11.50%, HEMA-coated Pellethane TPU 2.90%, and TETRA-coated Pellethane TPU 0.60%. Pellethane TPU products, and specifically those coated with HEMA and TETRA, exhibited less average mass increase and a lesser propensity to form encrustation than the traditional urinary tract stent. The mass increases noted on coated Pellethane devices were primarily ionic, whereas that of the stent was not. Conclusion: Pellethane, particularly with an HEMA-based preventative coating, may serve as a favorable alternative to traditional urinary stent material, providing its improved resistance to encrustation.

Smartphone technology and its applications in urology: a review of the literature.

PURPOSE: Smartphone technology has propelled the evolution of health-related mobile technology, referred to as mobile health (mHealth). With the rise of smartphone ownership and the growing popularity of health-related smartphone usage, mHealth offers potential benefits for both patients and health care providers. The objective of this review is to assess the current state of smartphone technology in urology. METHODS: A literature search of PubMed database was conducted to identify articles reporting on smartphone technology in urology. Publications were included if they focused on smartphone mHealth technology pertinent to the field of urology or included an evaluation of urological applications in digital stores. RESULTS: We identified 50 publications focused on the use of smartphones in urology. Studies were then grouped into the following categories: smartphones employing the built-in camera and light source, applications specific to prostate cancer, urolithiasis, pediatric urology, and as educational tools for urologists. In 23/50 (46%) studies, smartphone technology/intervention was compared to a control group or to standard of care. In this regard, smartphone technology did not demonstrate benefit over standard of care in 13 studies. In contrast, in 10 studies, smartphone interventions were proven beneficial over current practice. CONCLUSIONS: Smartphone technology is constantly evolving and has the potential to improve urological care and education. Of concern to consumer and urologist alike is that these downloadable programs are limited due to the accuracy of their content, risk of confidentiality breach, and the lack of central regulation and professional involvement in their development.

Initial Evaluation of a Novel Modulated Radiofrequency-based Bladder Denervation Device.

OBJECTIVE: To determine if targeted and modulated radiofrequency ablation (RFA) of the urinary bladder using our novel ablation device (Denerblate) reduces bladder nerve density, potentially leading to a novel strategy for the management of overactive bladder. METHODS: Fifteen pigs were divided into 4 groups: control (n = 3), 1-week (n = 4), 4-week (n = 4) and 12-week (n = 4) survival times. Denerblate was deployed on the trigone area of the bladder. Three 240-second cycles of modulated RFA were applied with 30 seconds between cycles. At the end of each survival term, urinary bladders were harvested for histopathologic evaluation. Nerve count and density were manually calculated. RESULTS: All procedures were successfully completed, and all animals survived to the desired time points. Mean nerve density (nerves/mm2) was highest in the control and 1-week survival group compared to the 4-week and 12-week groups, both of which demonstrated significant diminishment. Nerve density in the bladder neck at control, 1 week, 4 weeks, and 12 weeks were 1.8, 1.35, 0.87, and 0.12, respectively (P <.001). Nerve density in the bladder trigone area at control, 1 week, 4 weeks, and 12 weeks were 1.5, 0.98, 0.65, and 0.112, respectively (P <.001). Epithelial heat injury was observed in 14.3% at 1 week, 10.7% at 4 weeks, but completely resolved by 12 weeks. CONCLUSION: In the porcine model, modulated RFA delivered by our novel device reduced nerve density in the bladder neck and trigone by 88.6% and 88.9% at 12 weeks without evidence of lasting epithelial injury.

Endockscope: A Disruptive Endoscopic Technology.

Objective: To assess optical performance and diagnostic capability of the Endockscope system (ES) vs the standard endoscopic system (SES) using four rigid/semi-rigid endoscopes. The ES combines a smartphone, lens system, and a rechargeable light-emitting diode (LED) light source to provide a low-cost alternative ($45) to the standard camera and high-powered light source ($45,000) used in endoscopic procedures. Materials and Methods: Video clips (<20 seconds) of standard rigid nephroscopy, semi-rigid ureteroscopy, rigid cystoscopy, and laparoscopy in two adult male cadavers were recorded using the ES combined with either the Apple iPhone X or Samsung Galaxy S9+ and also with the high-definition SES (Karl Storz). Sixteen urologists blinded to the camera modality assessed the image resolution, brightness, color, sharpness, and overall quality using a Likert-type scale; acceptability for diagnostic purposes was judged on a binary scale (yes/no). Results: For rigid cystoscopy, there was no statistical difference between both ES systems and the SES. For semi-rigid ureteroscopy the two ES systems performed equal to or better than the SES. For rigid nephroscopy, the ES plus Galaxy was comparable to the SES, except in brightness (p < 0.05), whereas the ES plus iPhone was inferior in various parameters. For laparoscopy, the ES plus Galaxy was inferior to the SES in brightness and overall quality (p < 0.05); the ES plus iPhone was inferior for all laparoscopic image parameters compared with the SES. For diagnostic purposes, the ES plus Galaxy was equivalent to the SES for all endoscopes; the ES plus iPhone was equivalent to the SES for cystoscopy, ureteroscopy, and nephroscopy. Conclusion: The ES plus the Apple iPhone X or Samsung Galaxy S9+ offers comparable imaging and provides diagnostic information equivalent to the standard system for rigid endoscopy of the kidney, ureter, and bladder; the Galaxy S9+ provides comparable imaging and diagnostic capabilities for evaluation of the abdomen.

Multi-institutional Evaluation of Producing and Testing a Novel 3D-Printed Laparoscopic Trainer.

OBJECTIVE: To create, distribute, and evaluate the efficacy of a portable, cost-effective 3D-printed laparoscopic trainer for surgical skills development. METHODS: The UCI Trainer (UCiT) laparoscopic simulator was developed via computer-aided designs (CAD), which were used to 3D-print the UCiT. Once assembled, a tablet computer with a rear-facing camera was attached for video and optics. Four institutions were sent the UCiT CAD files with a 3D-printer and instructions for UCiT assembly. For a comparison of the UCiT to a standard trainer, peg transfer and intracorporeal knot tying skills were accessed. These tasks were scored, and participants were asked to rate their experience with the trainers. Lastly, a questionnaire was given to individuals who 3D-printed and assembled the UCiT. RESULTS: We recruited 25 urologists; none had any 3D-printing experience. The cost of printing each trainer was $26.50 USD. Each institution used the Apple iPad for optics. Six of eight participants assembled the UCiT in < 45 minutes, and rated assembly as somewhat easy. On objective scoring, participants performed tasks equally well on the UCiT vs the conventional trainer. On subjective scoring, the conventional trainer provided a significantly better experience vs the UCiT; however, all reported that the UCiT was useful for surgical education. CONCLUSION: The UCiT is a low cost, portable training tool that is easy to assemble and use. UCiT provided a platform whereby participants performed laparoscopic tasks equal to performing the same tasks on the more expensive, nonportable standard trainer.

The Endockscope Using Next Generation Smartphones: "A Global Opportunity".

INTRODUCTION: The Endockscope combines a smartphone, a battery powered flashlight and a fiberoptic cystoscope allowing for mobile videocystoscopy. We compared conventional videocystoscopy with the Endockscope paired with next generation smartphones in an ex-vivo porcine bladder to evaluate its image quality. MATERIALS AND METHODS: The Endockscope consists of a three-dimensional (3D) printed attachment that connects a smartphone to a flexible fiberoptic cystoscope plus a 1000 lumen light-emitting diode (LED) cordless light source. Video recordings of porcine cystoscopy with a fiberoptic flexible cystoscope (Storz) were captured for each mobile device (iPhone 6, iPhone 6S, iPhone 7, Samsung S8, and Google Pixel) and for the high-definition (HD) H3-Z versatile camera setup with both the LED light source and the xenon light (XL) source. Eleven faculty urologists, blinded to the modality used, evaluated each video for image quality/resolution, brightness, color quality, sharpness, overall quality, and acceptability for diagnostic use. RESULTS: When comparing the Endockscope coupled to a Galaxy S8, iPhone 7, and iPhone 6S with the LED portable light source to the HD camera with XL, there were no statistically significant differences (p < 0.01) in any metric. Eighty-two percent and 55% of evaluators considered the iPhone 7 + LED light source and iPhone 6S + LED light, respectively, appropriate for diagnostic purposes as compared with 100% who considered both the HD camera with XL and Galaxy S8 + LED appropriate. The iPhone 6 and Google Pixel coupled with the LED source were both inferior to the HD camera with XL in all metrics. CONCLUSIONS: The Endockscope system with a LED light source ($45) when coupled with either an Apple iPhone 7 or Samsung Galaxy S8 is comparable to conventional videocystoscopy with a standard camera and XL light source (total cost: $45,000).

Global Survey of a Novel Smartphone Mobile Endoscopy System.

INTRODUCTION: The most commonly performed procedure among urologists is cystoscopy. However, urologists in developing countries have limited access and funds to purchase the equipment necessary to perform this procedure. The novel Endockscope (ES) mobile endoscopic system aids in reducing this gap in both cost and accessibility. MATERIALS AND METHODS: ES kits were distributed at the 2016 World Congress of Endourology in Cape Town, South Africa. All participants were given instructions on how to use the device and each participant attended a live demonstration during the conference. Eight months later, all participants were contacted via email, regular mail, or phone to complete a questionnaire designed to assess the impact of the ES device. RESULTS: A total of 24 ES kits were distributed. After numerous emails, questionnaires sent by regular return mail, and phone calls, 12 (50%) participants completed the survey as instructed. Seventy percent of participants reported that they performed more endoscopic procedures due to the ES system. Overall, 90% of participants stated that they would purchase the ES system for personal use ($40.53). All participants reported that they would recommend the ES to others. CONCLUSION: The ES system provided an effective inexpensive system to enable urologists in resource-challenged countries to offer cystoscopy to more of their patients.

Evaluation and Comparison of Contemporary Energy-Based Surgical Vessel Sealing Devices.

INTRODUCTION: We evaluated and compared five currently available energy-based vessel sealing devices to assess typical surgical metrics. METHODS: We tested Caiman 5 (C5), Harmonic Scalpel Ace Plus (HA), Harmonic Ace +7 (HA7), LigaSure (LS), and Enseal G2 (ES) on small (2-5 mm), medium (5.1-7 mm), and large (7.1-9 mm) vessels obtained from 15 Yorkshire pigs. Vessels were randomly sealed and transected. We recorded sealing and transection time, charring and carbonization, thermal spread, and bursting pressure (BP). Specimens were sent for histopathologic evaluation of seal quality and thermal spread. RESULTS: A total of 246 vessels were evaluated: 125 were arteries and 121 were veins. There was no difference in BPs for small size arteries. For medium arteries, C5 provided the highest BP (proximal and distal jaw), followed by HA7, ES, LS, and HA [1740, 1600, 1165, 1165, 981, and 571 mm Hg, respectively, HA250 mm Hg.

Crowdsourcing Evaluation of Ureteroscopic Videos Using the Post-Ureteroscopic Lesion Scale to Assess Ureteral Injury.

INTRODUCTION AND OBJECTIVES: We hypothesized that crowdsourcing assessments could be applied to the Postureteroscopic Lesion Scale (PULS) for ureteral injury. METHODS: At a single institution, we prospectively digitally recorded 14 ureters at the terminal portion of standard ureteroscopic procedures. Each recording was reviewed by 10 global experts to determine a mean PULS score. Following training, the Crowd-Sourced Assessment of Technical Skills, C-SATS® (C-SATS, Inc., Seattle, WA) platform was used to obtain crowd-based reviews. The mean crowd PULS scores was determined using the linear mixed-effects (LME) model. The intraclass correlation coefficient (ICC) was calculated to measure the agreement among experts. Spearman's rank correlation (rho) was used to quantify the strength of the relationship between the crowd LME mean and the experts. RESULTS: Ten expert's reviews and 2100 layman reviews were obtained in 21 days and 49 hours, respectively. The ICC for the 10 experts was 0.68 (95% confidence interval 0.49, 0.86). When the expert mean PULS was <1, the crowd scored those recordings at 1 or greater. The highest scored recording by the experts was a 3.2, which the crowd scored at 2.25. The correlation between the crowd LME means and expert means across all videos was 0.70 (p = 0.0056) indicative of moderately strong agreement. CONCLUSION: In this initial application of crowd-sourced evaluation of ureteral injury, there was a moderately strong correlation between crowd and expert ratings. Refinement of the training, through exposure to the nuances of ureteral injuries, in particular for PULS <1 or ≥3, may lead to better crowd/expert correlation. Compared to expert review, crowd data can be collected with much greater efficiency.

Clinical Comparison of Conventional and Mobile Endockscope Videocystoscopy Using an Air or Fluid Medium.

OBJECTIVE: To compare conventional videocystoscopy (CVC) with a novel and affordable (approximately $45) mobile cystoscopy system, the Endockscope (ES). We evaluated the ES system using both fluid (Endockscope-Fluid [ES-F]) and air (Endockscope-Air [ES-A]) to fill the bladder in an effort to expand the global range of flexible cystoscopy. METHODS: The ES system comprised a portable 1000 lumen LED self-contained cordless light source and a three-dimensional printed adaptor that connects a mobile phone to a flexible fiber-optic cystoscope. Patients undergoing in-office cystoscopic evaluation for either stent removal or bladder cancer surveillance received three examinations: conventional, ES-F, and ES-A cystoscopy. Videos of each examination were recorded and analyzed by expert endoscopists for image quality/resolution, brightness, color quality, sharpness, overall quality, and whether or not they were acceptable for diagnostic purposes. RESULTS: Six of the 10 patients for whom the conventional videos were 100% acceptable for diagnostic purposes were included in our analysis. The conventional videos scored higher on every metric relative to both the ES-F and ES-A videos (p < 0.05). There was no difference between ES-F and ES-A videos on any metric. Fifty-two percent and 44% of the ES-F and ES-A videos, respectively, were considered acceptable for diagnostic purposes (p = 0.384). CONCLUSIONS: The ES mobile cystoscopy system may be a reasonable option in settings where electricity, sterile fluid irrigant, or access to CVC equipment is unavailable.

Comparative analysis of techniques to prevent laparoscopic fogging.

PURPOSE: To evaluate the efficiency and efficacy of two common and commercially available methods to resolve lens fogging: a Fluid Warming System (O.R. Solutions, Chantilly, VA) and the Clearify Visualization System (Covidien, Mansfield, MA). MATERIAL AND METHODS: We prospectively evaluated 40 patients undergoing laparoscopic renal procedures with the Fluid Warming System (first 20 cases) and then the Clearify Visualization System (second 20 cases). We utilized the standard Fluid Warming System per a 30-second modified protocol established in our laboratory. We used the Clearify according to manufacturer instructions. For each procedure we documented the etiology of each episode of visual obstruction, procedure type and surgery duration. We performed a cost analysis. For all cases we used the same insufflator, insufflation trocar location and trocar configuration. RESULTS: All 40 patients completed the study protocol without incident. The mean fogging events per hour for the Fluid Warming System and Clearify Visualization System were 0.7 (0-2.52) and 1.4 (0-5.02), respectively (P = 0.045). Surgery duration and cost per procedure were similar for both systems. CONCLUSION: The Fluid Warming System with modified technique was found to have less fogging events than the Clearify Visualization System, with no difference in operative time or cost.

Development and evaluation of a retroperitoneal dialysis porcine model.

OBJECTIVES: We attempted to create a surgical model to evaluate the retroperitoneal space for the ability to transfer solutes through the retroperitoneal membrane. Our dual objectives were to develop a technique to assess the feasibility of retroperitoneal dialysis (RPD) in a porcine model. METHODS: We incorporated two 35-kg Yorkshire pigs for this pilot study. In the first animal, we clamped renal vessels laparoscopically. In the second animal, we embolized renal arteries. In both animals, we dilated the retroperitoneal space bilaterally and deployed dialysis catheters. We measured serum creatinine (Cr), urea, and electrolytes at baseline 6 hours before the dialysis and every 4 hours after. RESULTS: We successfully created retroperitoneal spaces bilaterally and deployed dialysis catheters in both animals. In the first animal, dialysate and plasma Cr ratio (D/P) on the left and right side were 0.43 and 0.3, respectively. Cr clearance by 40 minutes of dialysis treatment was 6.3 mL/min. The ratio of dialysate glucose at 4 hours dwell time to dialysate glucose at 0 dwell time (D/D0) for left/rights sides were 0.02 and 0.02, respectively. kt/Vurea was 0.43. In the second animal, D/P Cr for left/right sides were 0.34 and 0.33, respectively. kt/Vurea was 0.17. We euthanized the pigs due to fluid collection in the peritoneal space and rapid increase of serum Cr, urea, and electrolytes. CONCLUSIONS: We demonstrated the feasibility of creation of a functionally anephric porcine model with successful development of retroperitoneal spaces using balloon inflation. Notwithstanding minimal clearance and limited diffusion capacity in this experiment, additional studies are needed to examine potential use of retroperitoneal space for peritoneal dialysis.

Comparison of Flow Characteristics of Novel Three-Dimensional Printed Ureteral Stents Versus Standard Ureteral Stents in a Porcine Model.

PURPOSE: We compared the flow characteristics of novel three-dimensional (3D) printed ureteral stents with four conventional double-pigtail stents in an ex vivo porcine model. MATERIALS AND METHODS: In six ex vivo porcine urinary systems with kidneys and ureters intact, we deployed a 5F occlusion catheter in an interpolar calix. We tested each system with antegrade irrigation with a 0.9% saline bag placed 35 cm above the renal pelvis. We evaluated four standard stents (6F Universa® Soft, 7F Percuflex,™ 7/10F Applied Endopyelotomy, 8.5F Filiform Double Pigtail) and compared them with a 9F 3D printed prototype stent. For each stent, we measured the total, extraluminal, and intraluminal flow rates. RESULTS: The mean total flow rates for 3D printed stents were significantly higher than the 6F, 7F, and 7/10F stents (P<0.05). No significant difference was seen in the total flow rate for the 3D printed stent and the 8.5F stent. The mean extraluminal flow rates for the 3D stents were similar to those of 7F stents, but significantly lower than 6F stents (P<0.001) and 8.5F stents (P<0.05) and higher than 7/10F stents (P<0.001). The mean intraluminal flow rates for the 3D printed stents were significantly higher than the 6F, 7F, 7/10F, and 8.5F stents (P<0.05). CONCLUSIONS: In this pilot study, 3D printed stents manifested a mean total flow rate comparable to the flow rates of contemporary stents. Continued advances in technology and material may permit functionally feasible 3D printed ureteral stents.

Applications of three-dimensional printing technology in urological practice.

A rapid expansion in the medical applications of three-dimensional (3D)-printing technology has been seen in recent years. This technology is capable of manufacturing low-cost and customisable surgical devices, 3D models for use in preoperative planning and surgical education, and fabricated biomaterials. While several studies have suggested 3D printers may be a useful and cost-effective tool in urological practice, few studies are available that clearly demonstrate the clinical benefit of 3D-printed materials. Nevertheless, 3D-printing technology continues to advance rapidly and promises to play an increasingly larger role in the field of urology. Herein, we review the current urological applications of 3D printing and discuss the potential impact of 3D-printing technology on the future of urological practice.

Redefining the Autonomic Nerve Distribution of the Bladder Using 3-Dimensional Image Reconstruction.

PURPOSE: We sought to create a 3-dimensional reconstruction of the autonomic nervous tissue innervating the bladder using male and female cadaver histopathology. MATERIALS AND METHODS: We obtained bladder tissue from a male and a female cadaver. Axial cross sections of the bladder were generated at 3 to 5 mm intervals and stained with S100 protein. We recorded the distance between autonomic nerves and bladder mucosa. We manually demarcated nerve tracings using ImageScope software (Aperio, Vista, California), which we imported into Blender™ graphics software to generate 3-dimensional reconstructions of autonomic nerve anatomy. RESULTS: Mean nerve density ranged from 0.099 to 0.602 and 0.012 to 0.383 nerves per mm2 in female and male slides, respectively. The highest concentrations of autonomic innervation were located in the posterior aspect of the bladder neck in the female specimen and in the posterior region of the prostatic urethra in the male specimen. Nerve density at all levels of the proximal urethra and bladder neck was significantly higher in posterior vs anterior regions in female specimens (0.957 vs 0.169 nerves per mm2, p<0.001) and male specimens (0.509 vs 0.206 nerves per mm2, p=0.04). CONCLUSIONS: Novel 3-dimensional reconstruction of the bladder is feasible and may help redefine our understanding of human bladder innervation. Autonomic innervation of the bladder is highly focused in the posterior aspect of the proximal urethra and bladder neck in male and female bladders.

Development of a novel iPad-based laparoscopic trainer and comparison with a standard laparoscopic trainer for basic laparoscopic skills testing.

INTRODUCTION: We developed the iTrainer (iT) as a portable laparoscopic trainer, which incorporates the iPad tablet. We then compared the iT with a standard pelvic trainer (SPT) to assess surgical skills as well as its image quality, resolution, brightness, comfort, and overall performance. MATERIALS AND METHODS: We designed and constructed the iT to be compatible with the Apple iPad 3 and standard laparoscopic instruments. Participants were assigned to perform the thread-the-loops task on both trainers and were prospectively randomized to start on either the iT or the SPT. Each participant was allowed a 2-minute warm-up before the 2-minute testing period. We scored participants using the product of skill quality (0-4 scale) and quantity of loops threaded (0-10 scale). Participants then rated each trainer on image quality, resolution, brightness, comfort, and overall performance on a 5-point Likert scale. RESULTS: A total of 45 subjects including 10 undergraduates, 10 medical students, 10 general surgery and urology residents, and 15 experts (fellows and attending surgeons) participated in this study. There was no significant difference between thread-the-loops task scores completed on the iT when compared with the SPT for all groups tested (p > 0.05) with the exception of the medical student group, who performed better on the SPT (p < 0.05). On evaluation of each trainer, participants rated the iT as having superior image quality and resolution when compared with the SPT (p < 0.05) but rated the SPT higher in overall performance (p < 0.05). Brightness and comfort were rated similarly for both trainers. CONCLUSIONS: We have demonstrated face validity and criterion validity for the thread-the-loops task on the iT. The iT rated superior in image quality and resolution but inferior in overall performance compared with the SPT. The iT provides trainees a unique advantage over SPT as an additional resource to laparoscopic training as it is inexpensive, portable, and can be readily available for training.

Comparison of optics and performance of single channel and a novel dual-channel fiberoptic ureteroscope.

OBJECTIVE: To evaluate performance characteristics and optics of a novel dual-working channel fiberoptic ureteroscope (Wolf Cobra) with 2 single-channel fiberoptic ureteroscopes and to a single-channel distal sensor standard definition digital ureteroscope URF-V (SD-DS). METHODS: Four new ureteroscopes (Cobra, Viper, X(2), and SD-DS) were compared for active deflection, irrigation flow, and optical characteristics. We performed a porcine ureteroscopy and measured the time for cleaning the middle calyx after injection of 10 cc of a standardized bloody solution. RESULTS: The SD-DS showed a higher resolution (7.42 lines/mm; P = .0001) compared with the fiberoptic ureteroscopes; among the fiberoptic ureteroscopes, the Cobra had the highest resolution than the Viper and X(2) (P = .0001). Grayscale distribution and color representation were identical for the fiberoptic ureteroscopes, whereas the SD-DS provided a superior color representation and a significant higher depth of field. The Cobra provided superior flow with empty working channel (86 cc/min vs 68 cc/min [Viper] vs 62.5 cc/min [X(2)] vs 62 cc/min [SD-DS]; P = .0001) and with various accessories (P <.0001). With regard to deflection, the Storz X(2) and the Cobra provided superior deflection up and down (P <.0001). When evacuating a standardized bloody field, the Cobra provided significant shorter evacuation times compared with those of the Viper, X(2), and SD-DS (36.6 vs 72 vs 65.6 vs 72.6 seconds, respectively; P = .0001). CONCLUSION: The additional working channel of the Wolf Cobra may improve vision and performance during challenging ureteroscopic cases by providing an increased flow. The enhanced irrigation capabilities of the Cobra have to be balanced with a larger diameter of this ureteroscope.

Development and initial porcine and cadaver experience with three-dimensional printing of endoscopic and laparoscopic equipment.

INTRODUCTION: Recent advances in three-dimensional (3D) printing technology have made it possible to print surgical devices. We report our initial experience with the printing and deployment of endoscopic and laparoscopic equipment. MATERIALS AND METHODS: We created computer-aided designs for ureteral stents and laparoscopic trocars using SolidWorks. We developed three generations of stents, which were printed with an Objet500 Connex printer, and a fourth generation was printed with an EOSINT P395 printer. The trocars were printed with an Objet30 Pro printer. We deployed the printed stents and trocars in a female cadaver and in vivo porcine model. We compared the printed trocars to two standard trocars for defect area and length using a digital caliper. Paired T-tests and ANOVA were used to test for statistical difference. RESULTS: The first two generations of stents (7F and 9F) were functional failures as their diminutive inner lumen failed to allow the passage of a 0.035 guidewire. The third generation 12F stent allowed passage of a 0.035 guidewire. The 12F diameter limited its deployment, but it was introduced in a cadaver through a ureteral access sheath. The fourth-generation 9F stents were printed and deployed in a porcine model using the standard Seldinger technique. The printed trocars were functional for the maintenance of the pneumoperitoneum and instrument passage. The printed trocars had larger superficial defect areas (p<0.001) and lengths (p=0.001) compared to Karl Storz and Ethicon trocars (29.41, 18.06, and 17.22 mm(2), respectively, and 14.29, 11.39, and 12.15 mm, respectively). CONCLUSIONS: In this pilot study, 3D printing of ureteral stents and trocars is feasible, and these devices can be deployed in the porcine and cadaver models. Three-dimensional printing is rapidly advancing and may be clinically viable in the future.