Search

Introduction: Novel training modalities are being investigated to overcome the challenges associated with learning retrograde intrarenal surgery (RIRS). Consequently, a series of 3D printed models of the upper urinary tract and stones designed for ex vivo surgical simulation was introduced in 2021. This study aims to provide external validation of the training model and assess its role in the development of surgical skills. Materials and Methods: A mixed cohort of 20 urologists at different levels of expertise participated in a whole-day live simulation event to examine the model and perform a timed simulation of intrarenal navigation, stone relocation, and laser fragmentation. Operative times were recorded and two independent expert endourologists scored the simulations according to a modified "Objective Structured Assessment of Technical Skills" (OSATS) scale. Five novice urologists from the cohort performed three further simulations in a subsequent event to assess improvement in surgical skills. Results: Face validity was demonstrated with a median score of ≥4/5 in each of the 11 items investigated. Content validity was also effectively reached, with 100% positive impressions with regard to the usefulness for the acquisition of surgical skills. Significant differences were observed among operative times stratified per surgeon experience (all p  < 0.0050), thus providing construct validity. Median total OSATS score for novices was 14 (range 8, 25) and was found to be significantly different from expected expert performance ( p  = 0.0010). Repeated simulations by novices led to a progressive reduction of operative times ( p  = 0.0313) and increase in median total OSATS ( p  = 0.0625). Conclusion: The 3D printed models of upper urinary tract and synthetic training stones for the high-fidelity simulation of each phase of RIRS were validated by this study. The results encourage the usage of the models in simulation courses and the evaluation of their potential role in standardized training curricula.

Purpose: We aimed to make a general comparison between the safety and feasibility of a novel robotic platform, da Vinci ® single-port (SP) system with conventional robotic multiport (MP) and laparoendoscopic single-site systems (da Vinci Xi or Si) in three upper urinary tract procedures including robot-assisted partial nephrectomy (RAPN), robot-assisted pyeloplasty (RAP), and robot-assisted adrenalectomy (RA). Materials and Methods: After systematical searching of the literature up to October 2022 in PubMed ® , Web of Science™, and the Cochrane Library and Scopus ® databases, we extracted and processed the data in eligible literature for operative time, warm ischemia time (WIT), morphine milligram equivalent (MME), postoperative complications, and positive surgical margins (PSMs). Results: A total of 752 patients who underwent robotic surgery for SP or MP from 11 articles were included in this meta-analysis. There was no statistically significant difference in operative time for either RAPN (standardized mean difference [SMD] -0.14, 95% confidence interval [CI] -0.30 to 0.03) or RA (SMD -0.51, 95% CI -1.08 to 0.06). However, for RAP, SP can save operation time (SMD -0.73, 95% CI -1.24 to -0.22). The introduction of SP did not increase complications to any degree, including total complication (risk ratio [RR] 0.89, 95% CI 0.52-1.53), minor complication (RR 0.43, 95% CI 0.13-1.36), and major complication (RR 0.85, 95% CI 0.34-2.09), nor the incidence of PSMs (RR 1.04, 95% CI 0.54-1.99). It is worth noting that although the SP system increased WIT (SMD 0.44, 95% CI 0.26-0.62), it had the benefit of reducing intraoperative pain for RAPN with regard of MME (SMD -0.40, 95% CI -0.71 to -0.09). Conclusions: In terms of postoperative pain, SP robotic surgery is beneficial for RAPN but will make WIT prolonged. RAP is probably the most suitable upper urinary tract procedure for which SP is an option, which helps to shorten the surgery time and achieve a minimally invasive wound at the same time. Our study has been registered in PROSPERO (Registration No.: CRD42022350317).

Background and Purpose: Routine imaging following ureteroscopy for treatment of renal/ureteral calculi continues to be a topic of debate. However, with the increasing focus on healthcare costs and quality, judicious use of diagnostic imaging to optimize outcomes while minimizing resource utilization is a priority. We sought to identify post-ureteroscopy imaging practices among experienced urologists., Materials and Methods: A REDcap questionnaire was sent to urologists in North America. The questionnaire surveyed demographic data, clinical volume, and imaging preferences post-ureteroscopy. Additionally, we surveyed the extent to which stone, anatomic, and procedure-related factors influenced these preferences. The likelihood of altering clinical practice and the desire for specific imaging guidelines were also assessed. The interquartile range (IQR) was utilized as a measure of median consensus., Results: Three hundred twenty-two urologists completed the questionnaire. The mean number of years in practice was 18 ± 10; 82% of respondents performed more than five ureteroscopic stone procedures monthly. Routine postoperative imaging was obtained by 48% of participants as follows: ultrasound (US) (47%), kidneys, ureters, and bladder (KUB) (17%), CT (4%), intravenous pyelogram (IVP) (2%), and KUB+US (30%). Urologists who did not routinely image patients were more concerned about cost (55% vs 25%, p ≤ 0.0001), radiation exposure (69% vs 44%, p ≤ 0.0001), and diagnostic inaccuracy of US (57% vs 44%, p ≤ 0.02). These urologists were also less likely to have completed an endourology fellowship (7% vs 23%, p ≤ 0.0001). The most compelling predictors of obtaining postoperative imaging were postoperative pain and fever (median 5, IQR 1), residual stones (median 5, IQR 1), ureteral perforation (median 5, IQR 2), and presence of a solitary kidney (median 4.5, IQR 2)., Conclusions: Currently, about 50% of urologists who regularly perform ureteroscopic stone procedures obtain postoperative imaging. Imaging preferences were guided by the presence of residual fragments, ureteral perforation, solitary kidney, and postoperative pain or fever.

Purpose: To assess the degree of postoperative storage symptoms after GreenLight™ laser photoselective vaporization of the prostate (PVP) and Holmium laser enucleation of the prostate (HoLEP) for management of benign prostatic hyperplasia (BPH) and its predictors., Methods: A retrospective review was performed for patients who underwent HoLEP or PVP for non catheter-dependent patients with BPH. Patients were followed up at 1, 3, 6, and 12 months and then annually by International Prostate Symptoms Score (IPSS), quality of life index, peak flow rate, residual urine volume, and prostate-specific antigen (PSA) level. Moderate or severe storage symptoms were defined as IPSS storage subscore ≥ 9., Results: Of 1673 laser procedures, a total of 1100 procedures met the inclusion criteria including 809 HoLEPs and 291 PVPs. The HoLEP group had significantly larger preoperative prostates and longer operative time. In the HoLEP group, postoperative IPSS was significantly better than in the PVP group at all follow-up points (P<0.05). Storage subscore was significantly higher after PVP and did not improve until 6 months postoperatively when it became comparable with that of the HoLEP group. The number of patients with IPSS-storage score ≥ 9 were significantly higher in the PVP group at 1 and 3 months follow-up (37.3% vs 15.1%, P<0.001) and (26.4% vs 17.5%, P=0.004), respectively. XPS-180W was associated with the lowest storage symptoms among the three GreenLight generations at all follow-up visits. In multivariate analysis, baseline IPSS-storage subscore ≥ 9, prolonged operative time >100 minutes, and lower percent of postoperative PSA level reduction significantly predicted less improvement of postoperative storage symptoms regardless of the laser procedure., Conclusion: Storage urinary symptoms significantly improved more after HoLEP compared with PVP, irrespective of the generation of GreenLight laser used. Recovery from bothersome storage urinary symptoms after prostate vaporization is time dependent, and baseline degree of storage symptoms, prolonged operative time, and lower percent of postoperative PSA level reduction negatively predicts postoperative improvement of storage symptoms regardless of the laser procedure.

Objective: Conservative treatment (CT) with flexible ureteroscopy and laser ablation is an alternative to radical nephroureterectomy (RNU) for the treatment of the upper urinary tract urothelial carcinoma (UTUC). The purpose of this study was to compare the pathology results obtained after immediate RNU or after attempt of CT for elective indication., Patients and Methods: A retrospective study was conducted in a single tertiary center. All patients who had an RNU for urothelial carcinoma between 2007 and 2012 have been included. The patients were classified into two groups: group 1 is immediate RNU, and group 2 is RNU after CT (only elective indications). Preoperative data collected were as follows: age, sex, chronic kidney failure, radiological classification for cancer staging (TNM), tumor size, localization, and multifocal indication of CT. The pathological RNU data collected were tumor stage and grade. The T stage was divided into two groups (primary endpoint): pTa-T1-T2 and pT3-T4. The χ(2) test and Mann-Whitney was performed to compare the independent qualitative and quantitative variables, respectively., Results: A total of 51 patients were included (40 patients in the immediate RNU group and 11 patients in the delayed RNU group after CT). Patients in both groups had comparable characteristics regarding age, sex, location, T stage, and preoperative tumor grade. On final pathology, 23 tumors were classified as pTa-T1-T2 in the immediate RNU group compared with 6 in the delayed RNU group. Seventeen and five tumors were classified as T3 in group 1 and group 2, respectively. These results were not significantly different between both groups (p=0.866). The pathological RNU grade was not significantly different between the groups., Conclusion: Within the limits of this retrospective study, the pathological RNU data showed no significant difference when RNU was done immediately or after CT for UTUC.

Background and Purpose: An integral component of many urologic reconstructive surgical procedures is the positioning of a Double-J stent to span the anastomosis. Some surgeons prefer to place a retrograde stent during cystoscopy, either during or after the reconstruction. In this communication, we describe our straightforward and effective approach of performing this critical step intracorporeally using robotic assistance in a variety of upper tract urologic reconstructive procedures., Patients and Methods: We examined our Institutional Review Board-approved database of robotic surgeries to identify reconstructive operations that included the intracorporeal placement of a Double-J stent since 2008. Our step-by-step method for stent placement during various robotic urologic reconstructions is detailed, including procedures involving the proximal, mid, and distal ureter. With the aid of a bedside assistant-surgeon, we delineate how the console surgeon is able to perform this step of the procedure completely intracorporeally, without the need for repositioning or cystoscopy., Results: Since the inception of our robotic surgical program in 2008, we have used these robotic stent placement techniques in 150 patients. The average time of robotic intracorporeal stent placement across the anastomosis was 3.5 minutes. Three patients did experience proximal stent migration, as documented on postoperative radiographs, but all were treated with conservative measures, because their anastomosis was not affected and severe symptoms did not develop. No patient needed stent replacement, and each stent was subsequently removed ureteroscopically without sequelae., Conclusions: Our robotic intracorporeal Double-J stent placement approach is simple and effective, avoids the need for cystoscopy and fluoroscopy, and can be used in any type of upper urinary tract urologic reconstruction.

Purpose: The study investigated factors that affect operating times and bleeding complications associated with percutaneous nephrolithotomy (PCNL) in the PCNL Global Study., Patients and Methods: All patients who underwent PCNL for primary or secondary treatment of kidney stone indications during the study period (November 2007-December 2009) were eligible for inclusion. PCNL procedures were performed according to local clinical guidelines and practices. Nephrostomy tract dilation was performed using balloon dilation, metal telescopic dilation, or Amplatz serial dilation. Hematologic complications assessed included bleeding rates, transfusion rates, and preoperative and postoperative hematocrit values., Results: The median operating time with balloon dilation (n=2277) was significantly longer than with telescopic/serial dilation (n=3260) at 94.0 vs 60.0 minutes, respectively (P<0.0001). In the balloon dilation group, there was significantly more bleeding (9.4% vs 6.7%, respectively; P<0.0001) and more transfusions (7.0% vs 4.9%, respectively; P=0.001) compared with the telescopic/serial dilator group. Univariate analysis showed that the probability of bleeding complications was higher with balloon vs telescopic/serial dilation (odds ratio [OR] 1.75; P=0.0001) and larger sheath size (OR 1.42; P=0.0001). By multivariate analysis, sheath size but not dilation method was predictive of bleeding complications. Other significant predictive factors included operating time, stone load, and caseload., Conclusion: This study shows that in PCNL, factors that are associated with bleeding/transfusion include sheath size, operating time, stone load, and caseload.

Purpose: The study focused on the use of balloon or telescopic/serial dilation methods in percutaneous nephrolithotomy (PCNL) in the Global PCNL Study., Patients and Methods: Centers worldwide provided data from consecutive patients who were treated with PCNL during a 1-year period. Tract dilation was performed using a balloon or telescopic/serial dilator. Patient characteristics, perioperative complications, and treatment outcomes were assessed by the treating physician. Postoperative complications were graded according to the modified Clavien grading system., Results: A total of 5537 eligible patients were entered in the database from November 2007 to December 2009, including 2277 (41.1%) who received balloon dilation and 3260 (58.9%) who received telescopic/serial dilation. The predominant method used was telescopic/serial dilation in Asia (94.7%) and South America (98.0%), and balloon dilation in North America (82.6%). In Europe, the rates of balloon (50.7%) and telescopic/serial (49.3%) dilation procedures were similar. The rates of bleeding (9.4% vs. 6.7%), blood transfusions (7.0% vs. 4.9%), and drop in mean hematocrit level (4.5% vs. 2.5%) were higher in the balloon vs. telescopic/serial dilator group. Clavien scores II and IIIA were slightly in favor of the telescopic/serial dilator group. Median operative time was longer in the balloon dilation group (94.0 min vs. 60.0 min)., Conclusions: The Global PCNL Study has identified differences in the method of dilation used between centers in Asia, Europe, and the United States. In the balloon dilation group, a total longer operative time and higher bleeding and transfusion rates were observed. The differences in outcome may be influenced by patient heterogeneity, including previous anticoagulation therapy or surgical procedures, in addition to the number of stones treated and rate of staghorn calculi, which were all higher in the balloon group.

Minimal bleeding during endoscopic surgery of the urinary tract may prevent optimum vision. We used neurosurgical patties for dissection during our laparoscopic procedures in the pediatric population and aimed to describe this technique as an alternative to standard ways of dissection during laparoscopic procedures. We have performed 21 procedures, including pyeloplasties, nephrectomies, and management of duplication anomalies, by using 0.5 inch Codman neurosurgical patties.™ Use of neurosurgical patties during laparoscopic urologic procedures yields a clear vision that enables the surgeon to perform the procedure more comfortably and effectively.

Purpose: To assess the clinical usefulness of Memokath® stent placement in the external sphincter region in men with neurogenic bladder dysfunction from spinal cord injury after failed sphincterotomy., Patients and Methods: Twenty-two men with elevated (> 100 mL) residual urine and/or voiding difficulties/autonomic dysreflexia were treated with a Memokath stent. Follow-up examinations comprised residual urine, video-urodynamics, renal sonography, and assessment of subjective outcome., Results: No intraoperative complications were observed. Transient autonomic dysreflexia developed in one patient. Stent repositioning from dislocation was necessary in four (18.2%) patients. After a median follow-up of 10.3 months, 18 (81.8%) patients still had a stent in place. In two men, the stents were removed because of newly diagnosed urothelial bladder cancer; in another two patients, they were removed because of lack of success. At follow-up, residual urine was significantly reduced from 229 to 105 mL. Residual urine was < 100 mL in 14 of 18 (77.8%) patients. Changes in bladder capacity, detrusor leak point pressure, bladder compliance, and maximum detrusor pressure were not statistically significant. Renal sonography did not reveal any pathologic findings., Conclusions: According to our data, the Memokath stent is not only an alternative treatment option to sphincterotomy, but it is a safe and successful second-line treatment after sphincterotomy failure.

Objectives: We developed minimal incision-assisted retroperitoneoscopic surgery (MARP) in an attempt to pursue optimized patient-related benefits. We evaluated the clinical value of MARP for upper urinary tract diseases compared with pure retroperitoneoscopic surgery (PRPS)., Patients and Methods: Between January 2003 and September 2008, PRPS and MARP were carried out in 338 and 85 patients, respectively. The upper urinary tract surgical procedures were defined as simple and complex procedures. We defined our experience from January 2003 to December 2005 as our early stage of PRPS learning curve. Our experience from January 2006 to September 2008 was defined as our late stage of PRPS learning curve. Patients' perioperative details were compared., Results: MARP was associated with shorter operative time for each complex procedure and with less frequent conversion to open surgery (2.4% vs. 11.3%, p = 0.023). A significantly greater proportion of MARP patients underwent complex procedures (81.2% vs. 49.1%, p < 0.001), and a significantly greater proportion of MARP were carried out at the early stage of PRPS learning curve (62.4% vs. 44.1%, p = 0.003). Estimated blood loss, hospital stay, the amount of analgesic use (diclofenac sodium suppository), and intraoperative and postoperative complications were comparable., Conclusions: MARP maintains the patient-related benefits of PRPS while allowing surgeons to perform more complex cases of upper urinary tract diseases and shortening the relevant operative time. It can be useful for cases in which the specimen is going to be extracted intact, when starting out learning retroperitoneoscopy, or when unable to progress the case using laparoscopic techniques.

Objective: To evaluate the clinical presentation, diagnosis, treatment, and prognosis of primary localized amyloidosis of the upper urinary tract., Methods: Patients with primary localized amyloidosis of the upper urinary tract were identified by database inquiry, and their medical records were reviewed., Results: Primary localized amyloidosis was identified in the ureter in two patients and in the renal pelvis in one patient. Systemic disease and amyloidosis secondary to a medical condition were excluded. All three patients presented with gross painless hematuria, and two also reported flank pain. None endorsed irritative urinary symptoms. Initial evaluation consisted of renal ultrasonography or intravenous urogram, and subsequently additional imaging and ureteroscopies with biopsies were performed. Congo red staining of the biopsies displayed apple green birefringence under polarized light. One patient was treated with distal ureterectomy and Boari flap ureteroneocystostomy, whereas the other two were followed with surveillance imaging. None of the patients have developed progressive disease or recurrence of their symptoms during follow-up of 15 months, 6 years, and 8 years., Conclusions: Primary localized amyloidosis of the upper urinary tract is a rare condition that is of interest because the clinical presentation and radiographic and endoscopic appearance mimic malignancy. Many commonalities exist between upper urinary tract and bladder amyloidosis, but obstructive features, like flank pain and hydronephrosis, are unique to upper urinary tract lesions. In the absence of significant obstruction, early eradication of an upper urinary tract lesion may not be necessary. Rather, follow-up with serial imaging is sufficient to monitor for disease progression.

Keratinizing desquamative squamous metaplasia (KDSM), also known as leukoplakia or cholesteatoma, of the genitourinary tract is a rare condition that is difficult to differentiate from a malignant process without surgical intervention. We present a case of KDSM of the upper urinary tract that was managed via percutaneous endoscopic approach. Although KDSM is a benign lesion, there are rare reports of it occurring concurrently with squamous-cell carcinoma; however, no direct causal relationship has been identified. This case demonstrates the ease with which KDSM can be removed by peeling it away from the underlying parenchyma; however, surgical intervention may not be necessary in the asymptomatic patient after evaluation has ruled out malignancy. Regardless of how KDSM is managed, follow-up is important because these lesions are known to recur.

Purpose: The aim of this study was to assess the feasibility and morbidity of single-step acute dilation, named "one-shot" technique, including a single dilation of the nephrostomy tract with a 28F or 30F Amplatz dilator compared with metal telescopic dilation technique., Patients and Methods: Two hundred fourteen patients who underwent percutaneous nephrolithotomy (PNL) for stone disease from September 2005 to October 2007 were included in the study, and they were randomly divided into two groups according to the type of tract dilation technique: in group 1 (112 patients), Alken telescopic dilators were used; in group 2 (102 patients), one-shot technique was used. Access tract dilation time, X-ray exposure time, success rate, and blood loss and other complications were evaluated., Results: One-shot technique was compared using Alken telescopic dilators without an increase in morbidity and with significant reduction in X-ray exposure (p = 0.003). There was no significant difference in the procedural success rate between groups 1 and 2 (100% v 96.07%, respectively) (p = 0.765). There was no any significant difference in complications. Access time was similar in both groups (p = 0.14)., Conclusion: One-shot dilation was proved to be safe and effective like metal telescopic dilation even in patients with a history of ipsilateral open renal surgery. In this procedure, X-ray exposure is lower.

Purpose: To prospectively evaluate and study the role, relative safety, and efficacy of using absorbable gelatin tissue hemosealant (Spongostan) in patients selected for a gelatin-assisted "tubeless" percutaneous nephrolithotomy (PCNL); to study whether it facilitates and further reduces the morbidity vis-à-vis tubeless PCNL without gelatin; and to compare postoperative pain, analgesia requirement, hospital stay, return to work time, and other parameters in patients undergoing tubeless PCNL with gelatin and tubeless PCNL without the gelatin sealant. In addition, we briefly review various hemosealants used in tubeless PCNL by other workers., Patients and Methods: Fifty selected previously qualified patients underwent tubeless PCNL. All procedures were performed by a single urologist (IS), and a resident administered random chit numbers and recorded pain scores and results of all the chosen parameters. Patients who fulfilled our criteria for tubeless PCNL were randomized to either the placement of a gelatin sealant or its omission. The data were analyzed with respect to several parameters., Results: The mean age, stone burden, preoperative hemoglobin, blood urea, and serum creatinine values, hematocrit drop, and the time to return to work were not significantly different between the two groups. The hospital stay (P = 0.057), urinary extravasation (P < 0.001), and analgesia requirement (P < 0.001) were significantly lower in the patients who had undergone gelatin-sealant-assisted tubeless PCNL., Conclusions: Significantly less pain, lower analgesia requirement, and shorter hospital stay with lower wound soakage/discomfort were observed in the gelatin-assisted tubeless PCNL group v tubeless PCNL without gelatin packing. The use of absorbable gelatin sealant is safe, feasible, and a useful adjunct toward a safer tubeless PCNL in patients who previously qualified for tubeless PCNL.

The ideal treatment for ureteropelvic junction (UPJ) obstruction should have the highest success rate, enable treatment of all types of obstruction, allow removal coexisting renal stones, and be minimally invasive. Open pyeloplasty offers all these features except the last (minimal invasiveness), whereas endourology techniques guarantee only the last one. Different techniques of pyeloplasty can be applied laparoscopically, although the best results are seen with dismembered pyeloplasty (Anderson-Hynes technique). Various methods of tissue approximation have been devised to avoid the difficult-to-master, time-consuming conventional suturing technique. Laparoscopic (antegrade) stenting is preferred by some surgeons, but we consider retrograde stenting is superior, as this rules out the presence of associated distal-ureteral obstruction. The transperitoneal approach has the advantages of a larger working space and readily identifiable anatomic landmarks. However, access to the renal pelvis requires considerable mobilization and retraction of the overlying loops of bowel. The retroperitoneal approach has the perceived disadvantage of a somewhat limited working space and absence of readily identifiable intra-abdominal anatomic structures such as the liver and spleen. However, the retroperitoneal approach has the advantage of greater familiarity, better detection of crossing vessels, direct and rapid access to the UPJ, and less risk of ileus. The robot-assisted technique has made suturing easier and may allow expansion of advanced laparoscopic procedures to surgeons without expertise in advanced laparoscopic surgery. The optimal length of follow-up after pyeloplasty is still unclear. Although most failures occur within the first 2 years, failures continue to appear after 5 and 10 years.

Purpose: We present our first-year experience with pediatric transperitoneal laparoscopic dismembered pyeloplasty (TLDP) in a large referral center., Patients and Methods: A chart review was conducted in 27 consecutive children (M:F 23:4) aged 4 to 17 years (mean 9.7 years) with ureteropelvic junction obstruction who underwent TLDP (21 on the left, 6 on the right) in 2005. The key steps implemented to facilitate and streamline this procedure were: (1) clamping the Foley catheter before surgery to distend the renal pelvis and facilitate the transmesenteric approach; (2) stabilizing the renal pelvis with a traction suture; (3) performing the dismembered pyeloplasty using a modified double-armed suture; and (4) placing the ureteral stent percutaneously antegrade before completing the anastomosis. Operative time, hospital stay, complications, and follow-up radiologic studies were reviewed., Results: The TLDP was performed with no open conversions. Crossing vessels and horseshoe kidney were present in 8 patients and 2 patients, respectively. The mean operative time was 221 minutes. Stent insertion was successful in all but one patient. Postoperative pain management was successful in all 27 patients. There were 4 postoperative complications (14.8%) consisting of prolonged leakage in two, obstruction in one, and obstruction with pyelonephritis in one. These last two complications occurred early in our experience and were treated successfully by percutaneous nephrostomy with subsequent retrograde endopyelotomy. The average hospital stay was 2.1 days (range 1-4 days). Radiologic studies 8 to 20 months after removal of the Double-J stents showed reduction of the degree of hydronephrosis in all patients., Conclusion: Our 1-year experience with TLDP gave us the opportunity to implement key steps to establish a standardized technique for this procedure. Although the follow-up period was short, most complications occurred early in this series, demonstrating that a learning curve is inevitable.

Purpose: We suggest that when surgical correction is considered to treat a duplicated collecting system with well-functioning moieties, a laparoscopic approach at the renal level is feasible even in cases requiring complex reconstruction., Patients and Methods: Six children between the ages of 4 months and 10 years (mean age 5.2 years) presented with urinary-tract infection, incontinence, or pain and underwent transperitoneal laparoscopic reconstruction for duplex collecting system pathology in renal moieties with preserved function. Five patients underwent laparoscopic upper pole-to-lower pole ureteroureterostomies, whereas one patient underwent a complex reconstruction of a long narrowing defect utilizing a Scardino-Prince vertical flap. Four patients underwent conventional laparoscopy, while the da Vinci Surgical System was used during the surgical procedures of the other two patients., Results: The mean operative time was 3.1 hours (range 2.6-4.9 hours) for the entire procedure, including cystoscopic evaluation. Stents were removed 6 weeks postoperatively. The patients were evaluated with retroperitoneal ultrasonography and either intravenous urography or diuretic radionuclide imaging to assess the anatomic integrity of the reconstruction. The presenting symptomatology resolved in all patients., Conclusions: We believe that complex laparoscopic upper-tract reconstruction in children who benefit from a parenchyma-preserving approach is possible and should be evaluated against open techniques.

Purpose: This paper describes the preliminary testing of a new laser, the thulium fiber laser, as a potential replacement for the holmium:YAG laser for multiple applications in urology., Materials and Methods: A 40 W thulium fiber laser operating at a wavelength of 1.94 microm delivered radiation in a continuous-wave or pulsed mode (10 msec) through either 300-microm- or 600-microm-core low-OH silica fibers for vaporization of canine prostate and incision of animal ureter and bladder-neck tissues., Results: The thulium fiber laser vaporized prostate tissue at a rate of 0.21+/-0.02 g/min. The thermal-coagulation zone measured 500 to 2000 microm, demonstrating the potential for hemostasis. Laser incisions were also made in bladder tissue and ureter, with coagulation zones of 400 to 600 microm., Conclusions: The thulium fiber laser has several potential advantages over the holmium laser, including smaller size, more efficient operation, more precise incision of tissues, and operation in either the pulsed or the continuous-wave mode. However, before clinical use will be possible, development of higher-power thulium fiber lasers and shorter pulse lengths will be necessary for rapid vaporization of the prostate and more precise incision of urethral/bladder-neck strictures, respectively.

Background and Purpose: To provide a realistic experience of lower urinary tract endoscopic procedures, we have developed and continue to expand a computer-based surgical simulator that incorporates a surgical tool interface with anatomic detail and haptic feedback., Methods: Surface-based geometric data for the lower urinary tract were generated from the National Library of Medicine Visible Human dataset. The three-dimensional texture map of the surface geometry was developed from recorded endoscopic video procedures. Geometry and associated texture maps were rendered in real time using the Silicon Graphics Extreme Impacts program. The surgical interface device incorporated all normal ranges of motion and resistance that occur within an actual operative environment. The hands-on endoscopic device attached to the interface device was provided by Circon-ACMI, Inc. Urologic residents evaluated the program for correlation with actual endoscopic procedures., Results: Texture-mapped digitized images provided a close anatomic similarity to actual videoendoscopic images. Virtual endoscopy of the lower urinary tract was reproducible and closely simulated actual visual and tactile endoscopic experience., Conclusions: Virtual reality surgical simulation is feasible for a variety of lower urinary tract procedures. This system coordinates visual perception with appropriate haptic feedback in both longitudinal and rotational axes. These types of procedures may be incorporated into future educational experiences for urologists to introduce new techniques and to provide documentation of surgical experience.

Background: Ureteral endoprostheses are used for dilatation of strictures in order to maintain upper urinary tract (UUT) function for a longer period., Materials and Methods: Three kinds of short (3-4-cm) endoprostheses were inserted into the ureter of mongrel dogs with intact UUT or experimental ureter strictures. The UUT function was evaluated by means of radiographic examinations and in terms of following measures of contractility: intraluminal pressure, electroureterography (EUG), and multichannel impedance ureterography (MIUG). Studies were performed 1, 3 to 6 months, and 1 to 3 years after prostheses implantation., Results: Similar urodynamic changes were registered in prosthetically treated ureters of dogs with initially intact UUTs and those with ureteral strictures. These disorders consisted of increased UUT intraluminal pressure and different functioning of the upper and lower regions of the ureter. The bioelectric and contractile activity of the upper UUT regions was reinforced, accelerated, and dysrhythmic, while peristaltic ureter wall function below the endoprosthesis was rare and weak., Conclusions: The changes observed are typical for ureteral prosthetics. The UUT urodynamic alterations could be attributable entirely to the excluding of the ureteral segment from active contraction and were the result of the local absence of the ureteral wall closing mechanism. One must keep in mind that UUT endoprostheses produce a high load on the ureter wall. The transition from UUT hyperfunction to contractile function decompensation may depend on the intrinsic compensatory reserves of the ureter.

Attempted endoscopic fetal interventions have been increasingly reported, given the knowledge that minimizing the trauma to the uterus by a small access portal can allow prolonged amnioscopic-guided surgery. Numerous fetal anomalies have been targeted for these interventions, including congential obstructive uropathies. This preliminary investigation explored innovative access strategies utilizing time-dated pregnant ewes, 95 to 100 days' gestation (term 145 days). Two strategies were specifically investigated: percutaneous, ultrasonographically guided microamnisocopy and ultrasonographically aided, laparoscopically guided amnioscopy. Both strategies provided excellent fetal visibility and were facilitated by the use of small trocars and microlaparoscopic instrumentation, which promoted prolonged amnioscopy with minimal access trauma.

Extensive pelvic carcinomatosis often results in bilateral ureteral obstruction and renal parenchymal loss. Percutaneous nephrostomies can be used for palliative means but may be poorly tolerated. Laparoscopic techniques can be applied to obtain a more permanent urinary diversion. An elderly gentleman with extensive pelvic transitional cell carcinoma of the bladder and only one functioning renal unit underwent percutaneous nephrostomy tube placement in combination with palliative cytoreductive radiation therapy. Poor patient tolerance led to repetitive nephrostomy tube replacement. A cutaneous ureterostomy was chosen as a more permanent urinary diversion, and laparoscopic techniques allowed this to be accomplished expeditiously. At 18 months postoperatively, the patient's unstented cutaneous ureterostomy is functioning well, and the serum creatinine concentration remains normal.