Smith's textbook of endourology [Volume 1, 2, 4 ed.] 9781119245155, 111924515X, 9781119245162, 1119245168, 9781119245193, 1119245192

Citation preview

Smith’s Textbook of Endourology

Smith’s Textbook of Endourology Fourth Edition VOLUME 1 Edited by Arthur D. Smith, MD

Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Glenn M. Preminger, MD

James F. Glenn Professor of Urology and Chief Division of Urology, Department of Surgery Duke University Medical Center Durham, NC, USA

Louis R. Kavoussi, MD

Waldbaum Gardner Professor and Chairman The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Gopal H. Badlani, MD, FACS, FRCS (Hon) Vice Chair Urology Professor of Urology and Gynecology Wake Forest University Winston‐Salem, NC, USA

Assistant Editor

Ardeshir R. Rastinehad, DO, FACOS

Associate Professor of Urology and Radiology Director of Focal Therapy and Interventional Urologic Oncology Department of Radiology and Urology Icahn School of Medicine at Mount Sinai New York, NY, USA

This edition first published 2019 © 2019 by John Wiley & Sons Ltd Edition History Wiley‐Blackwell (3e, 2012) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi and Gopal H. Badlani to be identified as the authors of the editorial material in this work has been asserted in accordance with law. Registered Offices John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. A catalogue record for this book is available from the Library of Congress and the British Library. ISBN 9781119241355 Cover images: © Tewan/iStock/Getty Images Plus; © ilbusca/Getty Images; © Gopal H. Badlani Cover design by Wiley Set in 10/12 pt Warnock Pro by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1

v

Contents List of Contributors  xvi Foreword  xl Preface  xli About the Companion Website  xliii

VOLUME 1 SECTION 1 

BASIC PRINCIPLES

  1

Care and Sterilization of Instruments  3 Carol Olsen

  2

Radiation Safety During Diagnosis and Treatment  14 Yasser A. Noureldin & Sero Andonian

  3

Enhanced Endoscopic Imaging  38 Ghalib A. Jibara & Michael E. Lipkin

  4

Preoperative Antibiotics and Prevention of Sepsis in Urologic Endoscopic Surgery  57 Manish N. Patel & Jorge Gutierrez-Aceves

  5

Management of the Anticoagulated Patient  73 Zeph Okeke SECTION 2  PERCUTANEOUS RENAL SURGERY Part 1  Perioperative Considerations

  6

Surgical Anatomy of the Kidney for Endourological Procedures  87 Francisco J.B. Sampaio

  7

Nephrolithometric Scoring Systems for Percutaneous Nephrolithotomy  108 Roshan Patel, Daniel J. Lama, & Zhamshid Okhunov

  8

Pathophysiology of Urinary Tract Obstruction  124 Frederick A. Gulmi & Diane Felsen

  9

Organizing the Endourological Operating Room  143 Ravindra B. Sabnis, Abhishek Singh, & Shashikant Mishra

10

Endoscopic Training/Simulation  159 Zichen Zhao & Robert M. Sweet

vi

Contents

Part 2 

Patient Positioning for Percutaneous Access

11

Patient Positioning, the Supine Position, and the Rationale of ECIRS  173 Cesare M. Scoffone & Cecilia M. Cracco

12

Prone, Lateral, and Flexed: Patient Positioning for Percutaneous Nephrolithotomy  185 Robert J. Sowerby, A. Andrew Ray, & R. John D’A. Honey Part 3 

Imaging for Access

13

Percutaneous Nephrolithotomy Access Under Fluoroscopic Control  210 Norberto O. Bernardo & Maximiliano Lopez Silva

14

Dyna-CT-Guided versus Standard CT-Guided Renal Access  221 Manuel Ritter & Maurice-Stephan Michel

15

Endoscopically Guided Percutaneous Renal Access  229 Zhamshid Okhunov, Kamaljot S. Kaler, Simone Vernez, Rahul Dutta, Jaime Landman, & Ralph V. Clayman

16

Percutaneous Nephrolithotomy Access Under Ultrasound  237 Mahesh R. Desai & Arvind P. Ganpule

17

New Concepts of Renal Access: iPad, GPS, and Others  244 Estevao Lima, Pedro L. Rodrigues, Marie-Claire Rassweiler-Seyfried, & João L. Vilaça Part 4 

Selection of Access and Dilation

18

Percutaneous Nephrolithotomy: Upper Pole Access  255 Davis P. Viprakasit & Nicole L. Miller

19

Percutaneous Nephrolithotomy Access Without Image Guidance  264 Arthur D. Smith

20

Percutaneous Nephrolithotomy Access: Robotic  269 Michelle Jo Semins, Dan Stoianovici, & Brian R. Matlaga

21

Dilation of the Nephrostomy Tract  275 Peter Alken Part 5 

Stone Removal

22

Rigid and Flexible Nephroscopy  285 Timothy Y. Tran & Mantu Gupta

23

Percutaneous Antegrade Ureteroscopy  294 Burak Turna, Umit Eskidemir, & Oktay Nazli

24

Small-caliber Percutaneous Nephrolithotomy: Mini, UMP, and Micro-Perc  301 Janak D. Desai & Arkadiusz Miernik

25

Percutaneous Nephrolithotomy: Special Problems with Staghorns  310 Monica A. Farcas & Kenneth T. Pace

Contents

26

Percutaneous Nephrolithotomy: Stone Extraction and Lithotripsy  322 Samir Derisavifard & Arthur D. Smith

27

Percutaneous Nephrolithotomy in Children  332 Adam S. Howe, Jordan S. Gitlin, & R. John D’A. Honey Part 6 

Other Uses of Nephrostomy Access

28

Percutaneous Nephrolithotomy of Calyceal Diverticula, Infundibular Stenosis, and Simple Cysts  341 Nadya E. York & James E. Lingeman

29

Percutaneous Instillation of Chemolytic, Chemotherapeutic, and Antifungal Agents  353 Mohamed A. Elkoushy, Philippe D. Violette, & Sero Andonian

30

Percutaneous Treatment of Ureteropelvic Junction Obstruction  377 Michael W. Sourial, Bodo E. Knudsen, & Paul J. Van Cangh

31

Percutaneous Management of Upper Tract Urothelial Carcinoma  384 Shu Pan & Piruz Motamedinia Part 7 

Exit Strategy and Complications

32

The Access-related Complications of Percutaneous Nephrolithotomy  390 Vinaya Vasudevan, Zeph Okeke, & Arthur D. Smith

33

Hemorrhagic Complications Associated with Percutaneous Nephrolithotomy  397 Sriram V. Eleswarapu & David A. Leavitt

34

Diagnosis and Management of Thoracic Complications of Percutaneous Renal Surgery  409 John R. Bell & Stephen Y. Nakada

35

Bowel and Other Organ Injuries with Percutaneous Nephrolithotomy  422 John J. Knoedler, Matthew T. Gettman, & Chad J. Fleming

36

Exit Strategies After Percutaneous Nephrolithotomy  427 Damien M. Bolton & Derek B. Hennessey

37

Problems with Residual Stones  441 Noah E. Canvasser & Margaret S. Pearle SECTION 3  URETEROSCOPY Part 1  General Principles

38

Ureteral Anatomy   455 Gary Faerber, Amir H. Lebastchi, & Rita P. Jen

39

Rigid Ureteroscopes  465 Omar M. Aboumarzouk & Francis X. Keeley, Jr.

40

Flexible Ureteroscopes  475 Vincent G. Bird & John M. Shields

vii

viii

Contents

41

Rigid Ureteroscope with Flexible Tip and Special Instrumentation  486 Yinghao Sun & Xiaofeng Gao

42

Digital Ureteroscopes  497 Murat Binbay & Burak Ucpinar

43

Ureteroscopy Working Instruments  506 Renato N. Pedro & Manoj Monga

44

Access to the Ureter: Rigid Ureteroscopy  514 Jose De La Cerda, III & Timothy Y. Tseng

45

Access to the Ureter: Flexible Ureteroscopy  521 Ojas Shah & Mark V. Silva

46

Ureteroscopy Energy Sources  532 Daniel A. Wollin & Glenn M. Preminger

47

Ureteroscopic Management of Ureteral Calculi  542 Charles U. Nottingham, Melanie A. Adamsky, Richard J. Fantus, & Glenn S. Gerber

48

Ureteroscopic Management of Renal Calculi  549 Steeve Doizi & Olivier Traxer

49

Diagnostic Ureteroscopy  562 Hendrik Heers & Benjamin W. Turney

50

Ureteroscopic Diagnosis and Treatment of Upper Urinary Tract Neoplasms  568 Scott G. Hubosky & Demetrius H. Bagley

Part 2 

Ureteroscopic Management of Ureteral Obstruction

51

Retrograde Endopyelotomy  584 Weil R. Lai & Raju Thomas

52

Endoscopic Management of Mid-ureteral Obstruction  592 Samuel Abourbih & D. Duane Baldwin

53

Endoscopic Management of Distal Ureteral Strictures  604 Michael Zhang, Ali Fathollahi, Joel Hillesohn, & Majid Eshghi

54

Endoscopic Management of Ureteroenteric Strictures  629 Thomas Masterson & Robert Marcovich

55

Ureterorenoscopy: Ureteral Stents and Postoperative Care  642 Ben H. Chew, Anthony Emmott, Dirk Lange, & Ryan F. Paterson

56

Ureteroscopy Complications  653 Joel E. Abbott & Roger L. Sur

57

Retrograde Intrarenal Surgery in the Future: Robotics  668 Anup Patel

Contents

SECTION 4 

SHOCK-WAVE LITHOTRIPSY

58

Physics of Shock-wave Lithotripsy  691 Andreas Neisius & Pei Zhong

59

Lithotripsy Systems  713 Geert G. Tailly

60

Shock-wave Lithotripsy of Renal Calculi  731 Brian H. Eisner & Naren Nimmagadda

61

Shock-wave Lithotripsy of Ureteral Calculi  745 Thomas Tailly & Hassan Razvi

62

Complications of Shock-wave Lithotripsy  756 Christian Türk & Aleš Petřík SECTION 5  STONE MANAGEMENT IN UROLOGY Part 1  General Principles

63

Natural History of Stones  765 Johann P. Ingimarsson & Amy E. Krambeck

64

Initial Choice of Therapy in the Stone Patient  777 Peter L. Steinberg & David M. Hoenig

65

Management of Urolithiasis in Pregnancy  786 Husain Alenezi & John D. Denstedt

66

Management of Renal Colic and Triage in the Emergency Department  798 Marius C. Conradie Part 2 

Management of Stones in Abnormal Situations

67

Management of Stones in Horseshoe Kidneys  811 Chandra Shekhar Biyani & Adrian D. Joyce

68

Pelvic Kidneys  818 Win Shun Lai, Vidhush K. Yarlagadda, & Dean G. Assimos

69

Management of Stone Disease in Renal Transplant Kidneys  827 Brian Duty & Michael Lam

70

Stones in Urinary Diversions  836 Bodo E. Knudsen & Michael W. Sourial

71

Management of Stones in Obesity  843 Omer L. Tuncay & Cenk Acar Part 3 

72

Cost-effectiveness and Long-term Stenting

Cost-effective Strategies for Stone Management  853 Justin I. Friedlander & Eric M. Ghiraldi

ix

x

Contents

73

Long-term Stenting of the Ureter  864 Panagiotis Kallidonis, Wissam Kamal, Dimitrios Kotsiris, Dimitrios Karnabatidis, & Evangelos Liatsikos Index  i1

VOLUME 2 SECTION 6  LAPAROSCOPY AND ROBOTIC SURGERY Part 1  General Principles 74

New Surgical Robotics  881 Alabdulaali Ibrahim & Koon Ho Rha 

75

Training and Credentialing Laparoscopic and Robotic Surgery  887 Domenico Veneziano & David M. Hananel

76

Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery  901 Weil R. Lai & Benjamin R. Lee

77

Patient Preparation and Operating Room Setup for Robotic Surgery  909 Dima Raskolnikov, Mahir Maruf, & Arvin K. George

78

Physiologic Considerations in Laparoscopic and Robotic Surgery  917 Adam G. Kaplan & Michael N. Ferrandino

79

Anesthetic Management During Laparoscopic/Robotic Surgery  928 Judith Aronsohn, Oonagh Dowling, & Greg Palleschi Part 2 

Instrumentation, Access, and Exit

80

Laparoscopic Surgery: Basic Instrumentation  944 Ornob Roy

81

Robotic Surgery: Basic Instrumentation and Troubleshooting  954 Wooju Jeong, Mouafak Tourojman, & Craig G. Rogers

82

Minimally Invasive Reconstructive Techniques: Suture, Staple, and Clip Technology  960 Ali Abdel Raheem & Koon Ho Rha

83

Transperitoneal Access and Trocar Placement  973 Angelo Territo & Alberto Breda

84

Retroperitoneal Access and Trocar Placement  987 Lambros Stamatakis & Soroush Rais-Bahrami

85

Basic Hand-assisted Laparoscopic Techniques  994 Sapan N. Ambani & J. Stuart Wolf, Jr.

86

Laparoscopic Exit: Specimen Removal, Closure, and Drainage  1010 Fernando J. Kim, Riccardo Autorino, & Rodrigo Donalisio da Silva Part 3 

87

Complications

Complications in Urologic Laparoscopy  1021 David Canes, Camilo Giedelman, & Rene J. Sotelo

Contents

88

Complications of Laparoscopy Including Robotics  1032 Friedrich-Carl von Rundstedt, Marcelo Chen, & Richard E. Link Part 4 

Laparoscopy/Robotics for Malignant Disease

89

Pelvic Lymphadenectomy  1048 Marc D. Manganiello & Andrew A. Wagner

90

Endoscopic Subcutaneous Modified Inguinal Lymph Node Dissection for Squamous Cell Carcinoma of the Penis  1060 Jay T. Bishoff & Kefu Du

91

Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection  1066 James R. Porter

92

Laparoscopic Radical Nephrectomy  1077 Simpa S. Salami

93

Robotic Partial Nephrectomy: Advancements and Innovations  1088 Sameer Chopra, Mehar Bains, & Inderbir S. Gill

94

Intraoperative Assessment of Tumor Resection Margins  1097 Ilan Z. Kafka & Timothy D. Averch

95

Laparoscopic Radical Nephroureterectomy  1101 Wayland J. Wu & Jessica E. Kreshover

96

Laparoscopic and Robotic Radical Cystectomy in Males and Females  1107 Douglas S. Scherr, David M. Golombos, & Abimbola Ayangbesan

97

Robot-assisted Laparoscopic Partial Cystectomy  1115 Manish A. Vira & Paras H. Shah

98

Laparoscopic Cystoprostatectomy with Intracorporeal Ileal Conduit  1125 Alvin C. Goh, Brian J. Miles, & Arun Rai

99

Laparoscopic/Robotic Continent Diversion  1128 Christopher R. Reynolds & Ashok K. Hemal

100

Laparoscopic Radical Prostatectomy  1140 Jens Rassweiler, Giovannalberto Pini, Marcel Fiedler, Ali Serdar Goezen, & Dogu Teber

101

Robot-assisted Laparoscopic Radical Prostatectomy  1169 Zeyad Schwen & Misop Han

102

Optimizing Outcomes During Laparoscopic and Robot-assisted Radical Prostatectomy  1179 Matthew Goland-Van Ryn, Daniel Rosen, Thomas Bessede, & Ashutosh Tewari Part 5 

103

Laparoscopy/Robotics for Benign Disease

Laparoscopic and Robotic Reconstructive Ureteral Surgery: Basic Principles  1194 Aaron C. Weinberg, Yuka Yamaguchi, Lee C. Zhao, & Michael D. Stifelman

xi

xii

Contents

104

Laparoscopic Applications to Renal Calculus Disease  1208 Christopher S. Han & Sammy E. Elsamra

105

Laparoscopic Treatment of Renal Cysts and Diverticula  1221 Salvatore Micali, Eugenio Martorana, Giacomo Maria Pirola, & Giampaolo Bianchi

106

Laparoscopic and Robotic Techniques for Management of Pelvic Organ Prolapse  1234 Sandeep Gurram & Farzeen Firoozi

107

Laparoscopic and Robotic Techniques for Repair of Female Genitourinary Fistulas  1242 Chad Baxter & Vishnukamal Golla

108

Laparoscopic, Laparoendoscopic Single-site, and Robot-assisted Living Donor Nephrectomy  1250 Ganesh Sivarajan & Ravi Munver

109

Robotic Kidney Transplantation  1259 Rajesh Ahlawat, Sohrab Arora, & Mani Menon

110

Minimally Invasive Surgery for Benign Prostate Disease: Laparoscopic and Robotic Techniques  1269 Mark Ferretti, Amul Bhalodi, & John Phillips

111

Laparoscopic Adrenalectomy  1278 Tadashi Matsuda, Hidefumi Kinoshita, Yoshihide Kawasaki, & Akira Miyajima

112

Laparoscopic and Robotic Surgery of the Seminal Vesicles  1292 Eric H. Kim, R. Sherburne Figenshau, & Gerald L. Andriole

113

Modern Techniques in Abdominal Wall Hernia Repair: a Guide for the Practicing Endourologist  1299 Douglas K. Held

114

Robot-assisted Vasectomy Reversal  1313 Parviz K. Kavoussi Part 6 

Laparoscopy/Robotics in Children

115

Laparoscopic Considerations in Children  1323 Rajeev Chaudhry, Michelle Yu, & Michael C. Ost

116

Laparoscopic and Robotic Pyeloplasty in Children  1328 Kai-wen Chuang

117

Lower Ureteral Reconstruction: Robotic Surgery  1335 S. Duke Herrell

118

Laparoscopic Management of the Undescended Testicle  1344 Brian A. VanderBrink

119

Laparoscopic Varicocelectomy  1353 Bradley A. Morganstern & Lane S. Palmer Part 7 

120

Laparoscopy and Robotics: LESS and NOTES

Laparoendoscopic Single-site Surgery: Ports, Access, and Instrumentation  1361 Noah E. Canvasser & Jeffrey A. Cadeddu

Contents

121

Laparoendoscopic Single-site Upper Tract Surgery  1373 Christian Tabib, Geoffrey Gaunay, & Lee Richstone

122

Robotic Laparoendoscopic Single-site Lower Tract Surgery  1385 Daniel Ramirez, Matthew J. Maurice, & Jihad H. Kaouk SECTION 7  IMAGE-GUIDED DIAGNOSTICS AND THERAPEUTICS Part 1  Upper Tract

123

Diagnosis of Renal Masses: Radiological  1393 Gail S. Smith, Carolyn K. Donaldson, & Richard M. Gore

124

Renal Mass Biopsy  1425 M. Pilar Laguna & Jean de la Rosette

125

Radiofrequency Ablation of Renal Tumors  1442 Ryan L. Steinberg & Chad R. Tracy

126

Percutaneous Cryoablation of Renal Masses  1454 David N. Siegel & Alok A. Anand Part 2 

Angio-embolization in Urology

127

Gonadal Vein Embolization  1464 Pratik A. Shukla, Gajan Sivananthan, & Ardeshir R. Rastinehad

128

Renal Angiography and Embolization  1479 Igor Lobko & Anthony D. Mohabir

129

Selective Arterial Prostate Embolization  1488 Robert C. Blue, Aaron M. Fischman, & Ardeshir R. Rastinehad Part 3 

Focal Therapy Lower Tract

130

The Role and Methodology of Multiparametric MRI and Fusion-guided Biopsy in the Management of Prostate Cancer Patients  1495 Raju R. Chelluri, Arvin K. George, Joseph A. Baiocco, Baris Turkbey, & Peter A. Pinto

131

Focal Therapy of Prostate Cancer  1509 Kae Jack Tay & Thomas J. Polascik

132

Focal Laser Ablation for Carcinoma of Prostate  1523 Tonye A. Jones, Shyam Natarajan, & Leonard S. Marks

133

Image-guided Prostate Brachytherapy  1534 Michael R. Folkert, Neil B. Desai, & Yoshiya Yamada

134

Image-guided External Beam Radiotherapy  1550 Brett Cox, Lucille Lee, & Louis Potters

135

High-intensity Focused Ultrasound of the Prostate  1567 Edward J. Bass, Mark Emberton, & Hashim U. Ahmed

xiii

xiv

Contents

136

Cryotherapy of the Prostate  1580 Daniel B. Rukstalis

137

Cryosurgical Ablation of the Prostate  1589 Rajan Ramanathan, Yaw A. Nyame, & J. Stephen Jones

138

Contrast-enhanced Ultrasound in Urology  1605 Rogier R. Wildeboer, Jean de la Rosette, Massimo Mischi, & Hessel Wijkstra

139

Principles of Prostate Magnetic Resonance Imaging  1616 Sonia Gaur, Baris Turkbey, & Peter L. Choyke

140

Male Lower Urinary Tract Symptoms and Assessment  1627 Henry Tran, Matthew P. Rutman, Doreen E. Chung, & Jerry G. Blaivas

141

Office-based Cystoscopy: Continued Advances  1643 Judson D. Davies & Sam S. Chang

142

Equipment Setup and Patient Handouts  1649 John R. Schwabe, Amanda P. Hughes, Crystal R. Combs, & Gopal H. Badlani

143

Local Anesthesia for Minimally Invasive Treatment of the Prostate in the Office Setting  1661 Arun Rai & Ricardo R. Gonzalez

144

Laser in Benign Prostatic Hyperplasia Treatment: Basic Principles  1672 Christopher Netsch, Bilal Chughtai, Alexis E. Te, Ahmed M. Elshal, Mostafa M. Elhilali, & Andreas J. Gross

145

Holmium Laser Therapy of the Prostate  1681 Ahmed M. Elshal & Mostafa M. Elhilali

146

532 nm High-power Transurethral Laser Prostatectomy  1693 Bilal Chughtai, Dominique Thomas, & Alexis E. Te

147

Thulium Lasers  1707 Andreas J. Gross & Christopher Netsch

148

The Prostatic Urethral Lift Procedure Using UroLift Implants: Novel, Minimally Invasive Therapy for Benign Prostatic Hyperplasia  1719 Daniel B. Rukstalis

149

Goals and Expectations of Ablation Techniques and Emerging Therapies for Benign Prostatic Hyperplasia: An Editorial  1727 Catriona I. MacRae & Peter J. Gilling

150

Monopolar Transurethral Resection of Prostate  1733 Madhu S. Agrawal & Dilip K. Mishra

151

Ablation of Prostate: Bipolar Resection  1743 Jaspreet S. Sandhu

152

Bipolar Vaporization of the Prostate  1752 Ahmet Karakeci, Kyle Richards, & Gopal H. Badlani

153

Single Port for Prostate Surgery  1762 Rene J. Sotelo, Oscar D. Martín Garzón, Camilo Giedelman, Fatima Z. Husain, & Mihir Desai

Contents

154

Bladder Injections for Refractory Overactive Bladder: Intra- and Transvesical Procedures  1775 Adam Althaus & Anurag K. Das

155

STING Procedure for Reflux  1784 Steve J. Hodges

156

Minimally Invasive Therapy for Bladder Pain Syndrome (Interstitial Cystitis)  1792 Ricardo Palmerola, Sandeep Gurram, & Robert Moldwin

157

New Techniques for Resecting Bladder Tumors  1806 Alexey G. Martov, Dmitry V. Ergakov, Nikolay A. Baykov, & Zhamshid Okhunov

158

Incision: Endoscopic Management of Urethral Stenoses  1815 Gerald H. Jordan & Kurt A. McCammon

159

Endoscopic Management of Bladder Neck Contracture Following Radical Prostatectomy  1826 Susan MacDonald, R. Caleb Kovell, Joseph Tortora, & Ryan P. Terlecki

160

Single-incision Slings  1832 Michael J. Kennelly & Dina A. Bastawros

161

Bioinjectables for Stress Urinary Incontinence  1847 Ryan Dobbs, Simone Crivellaro, & John J. Smith III

162

Midurethral Slings for the Treatment of Female Stress Urinary Incontinence  1854 Alice Drain & Victor W. Nitti

163

Maxi/Pubovaginal Sling  1871 Gopal H. Badlani & Joao P. Zambon

164

Mesh Complications Associated with Vaginal Prolapse Surgery  1880 Jeffrey S. Schachar & G. Willy Davila

165

Male Slings for Treatment of Post-prostatectomy Incontinence  1890 Ajay K. Singla & Nirmish Singla

166 Neuromodulation  1902 Dayron Rodríguez & Anurag K. Das Index  i1

xv

xvi

List of Contributors Joel E. Abbott, DO

Hashim U. Ahmed, FRCS(Urol), PhD, BM, BCh, MA

Associate Director Advanced Kidney Stone Center of the Americas Chesapeake Urology University of Maryland School of Medicine Hanover, MD, USA

Chair of Urology & Consultant Urological Surgeon Division of Surgery Department of Surgery and Cancer Faculty of Medicine Imperial College London; Imperial Urology Imperial College Healthcare NHS Trust London, UK

Omar M. Aboumarzouk, MBChB, MSc, PhD, MRCS(Glasg), FRCS(Urol)

Consultant Urological Surgeon Department of Urology Glasgow Urological Research Unit Queen Elizabeth University Hospital Glasgow, UK Samuel Abourbih, MDCM

Assistant Professor of Urology Loma Linda University Medical Center Loma Linda, CA, USA Cenk Acar, MD

Associate Professor Eryaman Hospital Department of Urology Ankara, Turkey Melanie A. Adamsky, MD

Husain Alenezi, MD

Consultant Urologist Urology Unit Department of Surgery Sabah Al‐Ahmad Urology Center and Al‐Adan Hospital Kuwait Peter Alken, MD, PhD

Professor of Urology Consultant Urologist Department of Urology University Clinic Mannheim Mannheim, Germany

Urology Resident Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA

Adam Althaus, MD

Madhu S. Agrawal, MBBS, MS, MCh, MNAMS

Assistant Professor Department of Urology University of Michigan Health Systems Ann Arbor, MI, USA

Head Department of Urology & Center for Minimally Invasive Endourology Global Rainbow Healthcare Agra, India Rajesh Ahlawat, MS, MCh

Chairman Medanta Kidney and Urology Institute Gurgaon, India

Resident in Urology Harvard Longwood Program in Urology Boston, MA, USA Sapan N. Ambani, MD

Alok A. Anand, MD, DABR, CIIP

Interventional Radiologist Chairman and Chief Quality Officer Department of Radiology – Eastern Connecticut Health Network Manchester, CT, USA

List of Contributors

Sero Andonian, MD, MSc, FRCSC, FACS

Demetrius H. Bagley, MD

Associate Professor Division of Urology McGill University Health Centre McGill University Montreal, QC, Canada

The Nathan Lewis Hatfield Professor of Urology Professor of Radiology Department of Urology Sidney Kimmel Medical College at Thomas Jefferson University Hospital Philadelphia, PA, USA

Gerald L. Andriole, MD

Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Judith Aronsohn, MD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA Sohrab Arora, MS, MCh

Senior Fellow – Robotic Surgery Vattikuti Urology Institute Detroit, MI, USA Dean G. Assimos, MD

Anton Bueschen Chairman Professor of Urology Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Riccardo Autorino, MD

Attending Urologist and Associate Professor of Urology Division of Urology McGuire VAMC and Virginia Commonwealth University Richmond, VA, USA Abimbola Ayangbesan, BA

Urology Resident Vanderbilt University Medical Center Nashville, TN, USA Timothy D. Averch, MD, FACS

Professor Vice Chair for Quality Director of Endourology Division Chief of Urology – UPMC Presbyterian Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Gopal H. Badlani, MD, FACS, FRCS (Hon)

Vice Chair Urology Professor of Urology and Gynecology Wake Forest University Winston‐Salem, NC, USA

Mehar Bains

Research Intern USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA Joseph A. Baiocco, BS

Medical Research Scholar Urologic Oncology Branch National Cancer Institute National Institutes of Health Bethesda; Medical Student Sidney Kimme Medical College Thomas Jefferson University Philadelphia, PA, USA D. Duane Baldwin, MD

Professor of Urology Director of Urologic Research Loma Linda University Medical Center Loma Linda, CA, USA Edward J. Bass, MBChB (Hons)

Urology Specialist Registrar The Division of Surgery and Interventional Science University College London London; Department of Urology University College London Hospitals London, UK Dina A. Bastawros, MD

Fellow Department of Obstetrics and Gynecology Female Pelvic Medicine and Reconstructive Surgery Atrium Health Charlotte, NC, USA Chad Baxter, MD

Assistant Professor of Urology David Geffen School of Medicine at UCLA Los Angeles, CA, USA

xvii

xviii

List of Contributors

Nikolay A. Baykov, MD

Chandra Shekhar Biyani, MS, D Urol, FRCS (Urol), FEBU, MSc

Doctor of Urology Department of Urology Municipal Hospital No. 57 Moscow, Russia

Consultant in Urology Department of Urology St James’ University Hospital Leeds, UK

John R. Bell, MD

Jerry G. Blaivas, MD

Assistant Professor Department of Urology University of Kentucky Lexington, KY, USA

Professor of Urology Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA

Norberto O. Bernardo, MD

Robert C. Blue, MD

Professor of Urology Chief, Endourology Hospital de Clínicas José de San Martín Universidad de Buenos Aires Buenos Aires, Argentina

Assistant Professor of Radiology Department of Radiology Icahn School of Medicine at Mount Sinai New York, NY, USA

Thomas Bessede, MD

Professor Department of Urology Austin Hospital Heidelberg; Olivia Newton‐John Cancer Wellness and Research Institute Heidelberg, VIC, Australia

Assistant Professor Department of Urology University of Paris‐Sud Orsay, France Amul Bhalodi, MD

Chief Resident New York Medical College Department of Urology Valhalla, NY, USA Giampaolo Bianchi, MD

Full Professor of Urology Department of Urology University of Modena and Reggio Emilia Modena, Italy Murat Binbay, MD

Associate Professor of Urology Chairman of Urology Department Department of Urology Haseki Training and Research Hospital Istanbul, Turkey Vincent G. Bird, MD

Professor of Urology Department of Urology University of Florida Gainesville, FL, USA Jay T. Bishoff, MD

Director Intermountain Urological Institute Intermountain Health Care Salt Lake City, UT, USA

Damien M. Bolton, MD, MBBS, BA, FRACS, FRCS

Alberto Breda, MD

Chief Uro‐Oncology Division and Kidney Transplant Units Fundació Puigvert Autonoma University of Barcelona Barcelona, Spain Jeffrey A. Cadeddu, MD

Professor Ralph C. Smith, MD, Distinguished Chair in Minimally Invasive Urologic Surgery Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA David Canes, MD

Associate Professor of Urology Tufts University Medical Center; Institute of Urology Lahey Hospital & Medical Center Burlington, MA, USA Noah E. Canvasser, MD

Assistant Instructor Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA

List of Contributors

Sam S. Chang, MD, MBA

Kai‐wen Chuang, MD

Patricia and Rodes Hart Endowed Chair of Urologic Surgery Professor of Urologic Surgery and Oncology Department of Urological Surgery Vanderbilt University Medical Center Nashville, TN, USA

CHOC Children’s Urology Pediatric Urologist HS Assistant Clinical Professor Department of Urology University of California Irvine, CA, USA

Rajeev Chaudhry, MD

Bilal Chughtai, MD

Pediatric Urology Fellow Children’s Hospital of Pittsburgh of UPMC Pittsburgh, PA, USA Raju R. Chelluri, MD, MS

Urology Resident Division of Urology Department of Surgery University of Pennsylvania Perelman School of Medicine; Research Fellow Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD, USA Marcelo Chen, MD, PhD

Senior Attending Urologist Department of Urology MacKay Memorial Hospital; Associate Professor Department of Medicine MacKay Medical College Taipei, Taiwan Ben H. Chew, MD, MSc, FRCSC

Associate Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Sameer Chopra, MD, MS

Resident Physician USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA Peter L. Choyke, MD

Program Director Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA

Assistant Professor of Urology Department of Urology Weill Cornell Medical College New York Presbyterian Hospital New York, NY, USA Doreen E. Chung, MD, FRCSC

Assistant Professor Department of Urology Female Pelvic Medicine & Reconstructive Surgery Columbia University New York, NY, USA Ralph V. Clayman, MD

Professor of Urology Department of Urology University of California Irvine, CA; Dean Emeritus University of California Irvine School of Medicine Orange, CA, USA Crystal R. Combs, RN, CNOR

Clinical Education Resource Nurse ‐ Robotics Wake Forest Baptist Health Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Marius C. Conradie, MD

Urologist in Private Practice President Southern African Endourology Society Netcare Waterfall City Hospital Johannesburg, South Africa Brett Cox, MD

Interim Chair Department of Radiation Medicine Lenox Hill Hospital; Chief of Brachytherapy Northwell Health; Co‐Director GU Center of Excellence Northwell Cancer Institute; Associate Professor of Radiation Medicine

xix

xx

List of Contributors

Zucker School of Medicine at Hofstra/Northwell Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Cecilia M. Cracco, MD, PhD

Urologist Department of Urology Cottolengo Hospital Torino, Italy Simone Crivellaro, MD

Assistant Professor of Urology Department of Urology University of Illinois at Chicago Chicago, IL, USA Anurag K. Das, MD, FACS

Director Center for Neuro‐urology and Continence Division of Urology Department of Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA Judson D. Davies, MD

Clinical Assistant Professor of Surgery Department of Urological Surgery Vanderbilt University Medical Center Nashville, TN, USA G. Willy Davila, MD

Chairman Department of Gynecology Section of Urogynecology and Reconstructive Pelvic Surgery Cleveland Clinic Florida Weston, FL, USA Jose De La Cerda III, MD, MPH

Urology Resident Department of Urology University of Texas Health Science Center at San Antonio San Antonio, TX, USA Jean de la Rosette, MD, PhD

Chairman Professor of Urology Department of Urology Istanbul Medipol University Istanbul, Turkey

John D. Denstedt, MD, FRCSC, FACS, FCAHS

Professor of Urology Division of Urology Department of Surgery Schulich School of Medicine & Dentistry The University of Western Ontario London, ON, Canada Samir Derisavifard, MD

Resident in Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Janak D. Desai, MS, MCh

Chief of Urology Services Samved Hospital and Sterling Hospitals Ahmedabad, India Mahesh R. Desai, MS, FRCS, FRCS, FACS

Medical Director Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Mihir Desai, MD

USC Institute of Urology Keck School of Medicine University of Southern California Los Angeles, CA, USA Neil B. Desai, MD, MHS

Assistant Professor Department of Radiation Oncology University of Texas Southwestern Medical Center Dallas, TX, USA Ryan Dobbs, MD

Urology Resident Department of Urology University of Illinois at Chicago Chicago, IL, USA Steeve Doizi, MD, MSc

Assistant Professor Sorbonne Université Department of Urology GRC n°20 Groupe de Recherche Clinique sur la Lithiase Urinaire Hôpital Tenon Paris, France Carolyn K. Donaldson, MD

Associate Professor Department of Radiology NorthShore University Health System

List of Contributors

University of Chicago Pritzker School of Medicine Evanston, IL, USA Rodrigo Donalisio da Silva, MD

Assistant Professor of Surgery/Urology University of Colorado Denver Denver Health Medical Center Denver, CO, USA Oonagh Dowling, PhD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA Alice Drain, MD

Department of Urology New York University Langone Medical Center New York, NY, USA

Mostafa M. Elhilali, MD (Deceased)

Division of Urology McGill University Montreal, QC, Canada Mohamed A. Elkoushy, MD, MSc(Urol), PhD(Urol)

Professor of Urology Department of Urology Suez Canal University Ismailia, Egypt Sammy E. Elsamra, MD

Assistant Professor Division of Urology Rutgers Robert Wood Johnson Medical School New Brunswick, NJ, USA Ahmed M. Elshal, MD

Urology and Nephrology Center Mansoura University Egypt Mark Emberton

Kefu Du, MD

Endourology Fellow Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Rahul Dutta, MD

Resident Physician Department of Urology University of California Irvine, CA, USA Brian Duty, MD

Associate Professor Department of Urology Oregon Health and Science University Portland, OR, USA Brian H. Eisner, MD

Assistant Professor Department of Urology Massachusetts General Hospital Boston, MA, USA

The Division of Surgery and Interventional Science University College London; Department of Urology University College London Hospitals London, UK Anthony Emmott, BSc, MD

Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Dmitry V. Ergakov, MD, PhD

Associate Professor Department of Urology Municipal Hospital No. 57 FMBA State Institute of Continuous Medical Education Moscow, Russia Majid Eshghi, MD, FACS, MBA

Professor of Urology Department of Urology Westchester Medical Center Health System New York Medical College Valhalla, NY, USA Umit Eskidemir, MD, FEBU

Sriram V. Eleswarapu, MD, PhD

Chief Urology Resident Vattikuti Urology Institute Henry Ford Health System Detroit, MI, USA

Urologist Department of Urology School of Medicine Ege University İzmir, Turkey

xxi

xxii

List of Contributors

Gary Faerber, MD

Professor Division of Urology University of Utah School of Medicine Salt Lake City, UT, USA Richard J. Fantus, MD

Resident Physician Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA Monica A. Farcas, MEng, MD, FRCSC

Assistant Professor Department of Surgery Division of Urology St. Michael’s Hospital Toronto, ON, Canada Ali Fathollahi, MD

Fellow Department of Urology New York Medical College New York, NY, USA Diane Felsen, PhD

Associate Professor of Pharmacology Research in Urology (Retired) Weill Cornell Medicine New York, NY, USA Michael N. Ferrandino, MD

Associate Professor of Urology Director, Minimally Invasive Urologic Surgery Division of Urologic Surgery Duke University Medical Center Durham, NC, USA Mark Ferretti, MD

Resident New York Medical College Department of Urology Valhalla, NY, USA Marcel Fiedler, MD

Consultant and Senior Registrar Department of Urology SLK Kliniken Heilbronn University of Heidelberg Heidelberg, Germany R. Sherburne Figenshau, MD

Chair, Minimally Invasive Urology Division of Urologic Surgery

Washington University School of Medicine St. Louis, MO, USA Farzeen Firoozi, MD, FACS

Director FPMRS Associate Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Aaron M. Fischman, MD, FSIR, FCIRSE

Associate Professor of Radiology and Surgery Department of Radiology Icahn School of Medicine at Mount Sinai Department of Radiology New York, NY, USA Chad J. Fleming, MD

Assistant Professor of Radiology Mayo Clinic Department of Radiology Rochester, MN, USA Michael R. Folkert, MD, PhD

Assistant Professor Residency Program Director Department of Radiation Oncology University of Texas Southwestern Medical Center Dallas, TX, USA Justin I. Friedlander, MD

Assistant Professor of Urology Director of Endourology Department of Urology Einstein Healthcare Network; Fox Chase Cancer Center Philadelphia, PA, USA Arvind P. Ganpule, MS(General Surgery), DNB(Urology), MNAMS(New Delhi)

Vice Chairman Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Xiaofeng Gao, MD

Secretary, Urolithiasis Group Deputy Director of the Department of Urology Chinese Urological Association Shanghai, China Oscar D. Martín Garzón

Clínica Cooperativa de Colombia Universidad Cooperativa de Colombia – Facultad de Medicina Villavicencio, Colombia

List of Contributors

Geoffrey S. Gaunay, MD

Peter J. Gilling, MD, FRACS

The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Urologist Professor of Surgery University of Auckland Bay of Plenty Clinical School Tauranga, New Zealand

Sonia Gaur, BS

Research Fellow Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA Arvin K. George, MD

Assistant Professor Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD; Department of Urology Division of Urologic Oncology University of Michigan Ann Arbor, MI, USA Glenn S. Gerber, MD

Professor Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA Matthew T. Gettman, MD

Erivan Haub Family Endowed Professor of Urology Mayo Clinic Department of Urology Rochester, MN, USA Eric M. Ghiraldi, DO

Urology Resident Department of Urology Einstein Healthcare Network Philadelphia, PA, USA Camilo Giedelman, MD

Urologic Minimally Invasive Surgeon Clínica Marly and Fundación Universitaria Ciencia de la Salud Hospital de San Jose Bogotá, Colombia Inderbir S. Gill, MD

USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA

Jordan S. Gitlin, MD

Assistant Clinical Professor Department of Pediatric Urology Cohen Children’s Medical Center Zucker School of Medicine at Hofstra/Northwell Long Island, NY, USA Ali Serdar Goezen, MD

Vice‐chairman Department of Urology SLK Kliniken Heilbronn, University of Heidelberg Heidelberg, Germany Alvin C. Goh, MD

Director of Advanced Laparoscopic and Robotic Urology Surgery Programs Methodist Institute for Technology, Innovation, and Education; Assistant Professor of Urology Weill Cornell Medical College Department of Urology Houston Methodist Hospital Houston, TX, USA Matthew Goland‐Van Ryn, MD

Chief Resident, Urology Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Vishnukamal Golla, MD, MPH

Urology Resident Department of Urology University of California Los Angeles, CA, USA David M. Golombos, MD

Assistant Clinical Professor Department of Urology Stony Brook School of Medicine Stony Brook, NY, USA Ricardo R. Gonzalez, MD

Director, Center for Voiding Dysfunction Houston Methodist Hospital Houston, TX, USA

xxiii

xxiv

List of Contributors

Richard M. Gore, MD

Misop Han, MD, MS

Professor of Radiology Department of Radiology NorthShore University Health System University of Chicago Pritzker School of Medicine Evanston, IL, USA

David Hall McConnell Professor in Urology and Oncology James Buchanan Brady Urological Institute Johns Hopkins School of Medicine Baltimore, MD, USA

Andreas J. Gross, MD

Director Center for Research in Education & Simulation Technologies University of Washington School of Medicine Seattle, WA, USA

Head of Department Department of Urology Asklepios Klinik Barmbek Hamburg, Germany Frederick A. Gulmi, MD

Vice Chairman Department of Urology Clinical Associate Professor of Urology NYU School of Medicine New York; Chief of Urology NYU Langone Hospital-Brooklyn Brooklyn, NY, USA Mantu Gupta, MD

Chair of Urology Mount Sinai West New York; Professor Icahn School of Medicine at Mount Sinai New York; Director of Endourology Mount Sinai Health Care System New York; Director Mount Sinai Kidney Stone Center New York, NY, USA Sandeep Gurram, MD

Resident Physician The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Jorge Gutierrez‐Aceves, MD

Professor of Urology Director of Endourology Wake Forest University School of Medicine Department of Urology Winston-Salem, NC, USA Christopher S. Han, MD

Urology Resident Division of Urology Rutgers Robert Wood Johnson Medical School New Brunswick, NJ, USA

David M. Hananel, BSc, BA

Hendrik Heers, Dr. med

Senior Endourology Fellow (EBU) Department of Urology Nuffield Department of Surgical Sciences University of Oxford Oxford, UK Douglas K. Held, MD, FACS

Northwell Health Long Island Jewish Medical Centre New Hyde Park, NY, USA Ashok K. Hemal, MD, MCh, FACS, FRCS

Professor Wake Forest Institute for Regenerative Medicine; Chair, Robotics Committee Baptist Medical Center; Fellowship Director Robotics and Minimally Invasive Surgery; Fellowship Co-Director Endourology Wake Forest Baptist Medical Center and Wake Forest School of Medicine Winston‐Salem, NC, USA Derek B. Hennessey, MD, MBBChBAO, BMedSci, DHSM, PDipHS, FRCSI, FEBU

Fellow Department of Urology Austin Hospital Heidelberg Olivia Newton‐John Cancer Wellness and Research Institute Heidelberg, VIC, Australia S. Duke Herrell, MD, FACS

Professor of Urologic Surgery, Biomedical and Mechanical Engineering Vanderbilt University Medical Center Nashville, TN, USA

List of Contributors

Joel Hillesohn, MD

Chief Resident Department of Urology New York Medical College New York, NY, USA Steve J. Hodges, MD

Assistant Professor of Pediatric Urology Pediatric Urology Institute for Regenerative Medicine Wake Forest University School of Medicine Winston‐Salem, NC, USA David M. Hoenig, MD

Chief of Urology Professor The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA R. John D’A. Honey, MA, MB, BChir, FRCS(Eng), FRCSC

University of Southern California Los Angeles, CA, USA Alabdulaali Ibrahim, MD

Consultant of Urology Department of Surgery Prince Mohammed Bin Abdulaziz Hospital Riyadh, Saudi Arabia Johann P. Ingimarsson, MD

Clinical Assistant Professor Maine Medical Center and Tufts School of Medicine Division of Urology Portland, ME, USA Rita P. Jen, MD, MPH

Resident Physician Department of Urology University of Michigan Health System Ann Arbor, MI, USA

Professor of Surgery Division of Urology St. Michael’s Hospital Toronto; Department of Surgery University of Toronto Toronto, ON, Canada

Wooju Jeong, MD

Adam S. Howe, MD

Resident Physician in Urology Department of Surgery Division of Urology Duke University Hospital Durham, NC, USA

Pediatric Urology Fellow Department of Pediatric Urology Cohen Children’s Medical Center Zucker School of Medicine at Hofstra/Northwell Long Island, NY, USA Scott G. Hubosky, MD

The Demetrius H. Bagley, Jr. M.D. Associate Professor of Urology Director of Endourology Vice Chair of Quality and Safety Department of Urology Sidney Kimmel Medical College at Thomas Jefferson University Hospital Philadelphia, PA, USA Amanda P. Hughes, BSN, RN, CNOR

Clinical Coordinator for Urology Inpatient Surgical Services Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Fatima Z. Husain, MD

USC Institute of Urology Keck School of Medicine

Senior Urologist Vattikuti Urology Institute Department of Urology Henry Ford Health System Detroit, MI, USA Ghalib A. Jibara MD, MPH

J. Stephen Jones, MD, MBA

President Cleveland Clinic Regional Hospitals and Family Health Centers Professor and Horvitz/Miller Distinguished Chair in Urological Oncology Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Tonye A. Jones, MD

Urology Resident UCLA Department of Urology Los Angeles, CA, USA Gerald H. Jordan, MD

Professor Emeritus Department of Urology Eastern Virginia Medical School Norfolk, VA, USA

xxv

xxvi

List of Contributors

Adrian D. Joyce, MS, FRCS(Urol)

Parviz K. Kavoussi, MD, FACS

Honorary Consultant in Urology Department of Urology St James’ University Hospital Leeds, UK

Reproductive Urologist Department of Reproductive Urology Austin Fertility & Reproductive Medicine/Westlake IVF; Adjunct Assistant Professor Department of Urology University of Texas Health Sciences Center at San Antonio Austin, TX, USA

Ilan Z. Kafka, MD

Endourology/Minimally Invasive Surgery Fellow Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Kamaljot S. Kaler, MD

Fellow Department of Urology University of California Irvine, CA, USA Panagiotis Kallidonis, MD, PhD, FEBU

Assistant Professor Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece Wissam Kamal, MD

Consultant Urological Surgeon Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece Jihad H. Kaouk

Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH, USA Adam G. Kaplan, MD

Fellow in Endourology, Laparoscopy and Robotic Surgery Division of Urologic Surgery Duke University Medical Center Durham, NC, USA Ahmet Karakeci, MD

Assistant Professor (International Observer) Department of Urology Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Dimitrios Karnabatidis, MD, PhD

Professor Department of Radiology University Hospital of Patras Rion, Patras, Greece

Yoshihide Kawasaki, MD

Assistant Professor Department of Urology Tohuku University Graduate School of Medicine Sendai, Miyagi, Japan Francis X. Keeley, Jr., MD, FRCS(Urol)

Consultant Urologist Bristol Urological Institute Bristol, UK Michael J. Kennelly, MD, FPMRS, FACS

Professor Department of Urology and Gynecology Women’s Center for Pelvic Health Atrium Health Charlotte, NC, USA Eric H. Kim, MD

Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Fernando J. Kim, MD, MBA, FACS

Professor of Surgery Division of Urology Urology‐Denver; Chief of Urology Denver Health Medical Center Denver, CO, USA Hidefumi Kinoshita, MD, PhD

Professor Department of Urology and Andrology Kansai Medical University Hospital Hirakata, Osaka, Japan John J. Knoedler, MD

Assistant Professor of Surgery Division of Urology Penn State Milton S. Hershey Medical Center Hershey, PA, USA

List of Contributors

Bodo E. Knudsen, MD, FRCSC

Daniel J. Lama, MD

Associate Professor Department of Urology The Ohio State University Wexner Medical Center Columbus, OH, USA

Resident Division of Urology University of Cincinnati School of Medicine Cincinnati, OH, USA

Dimitrios Kotsiris, MD

Urology Specialist Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece R. Caleb Kovell, MD

Assistant Professor of Clinical Urology in Surgery Department of Urology University of Pennsylvania Philadelphia, PA, USA Amy E. Krambeck, MD

Michael O. Koch Professor of Urology Department of Urology Indiana University Indianapolis, IN, USA Jessica E. Kreshover, MD, MS

Assistant Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA M. Pilar Laguna, MD, PhD

Professor of Uro‐oncology Department of Urology AMC University of Amsterdam Amsterdam, The Netherlands Weil R. Lai, MD

Clinical Instructor Fellow Department of Urology Tulane University School of Medicine New Orleans, LA, USA Win Shun Lai, MD

Resident Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Michael Lam, MD

Resident in Urology Department of Urology Oregon Health and Science University Portland, OR, USA

Jaime Landman, MD

Professor Chair Department of Urology University of California Irvine, CA, USA Dirk Lange, PhD

Associate Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada David A. Leavitt, MD

Associate Director of Endourology Director of Laser Surgery Vattikuti Urology Institute Henry Ford Health System Detroit, MI, USA Amir H. Lebastchi, MD

Chief Resident Department of Urology University of Michigan Health System Ann Arbor, MI, USA Benjamin R. Lee, MD, FACS

Professor Chief Division of Urology University of Arizona College of Medicine Tucson, AZ, USA Lucille Lee, MD

Assistant Professor of Radiation Medicine Zucker School of Medicine at Hofstra/Northwell Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Evangelos Liatsikos, MD, PhD

Professor Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece

xxvii

xxviii

List of Contributors

Estevao Lima, MD, FEBU, PhD

Marc D. Manganiello, MD

Director of CUF Urology Department Portugal and Department of Urology of Braga Hospital; Professor of Physiology and Urology Life and Health Sciences Research Institute Braga; ICVS/3B’s – Associate Lab. Guimarães Braga; School of Medicine University of Minho Braga, Portugal

Assistant Professor of Urology Tufts School of Medicine Lahey Hospital and Medical Center Boston, MA, USA

James E. Lingeman, MD, FACS

Leonard S. Marks, MD

Professor of Urology Department of Urology Indiana University School of Medicine Indianapolis, IN, USA Richard E. Link, MD, PhD

Carlton‐Smith Endowed Chair in Urologic Education Associate Professor of Urology Director Division of Endourology and Minimally Invasive Surgery Scott Department of Urology Baylor College of Medicine Medical Center Houston, TX, USA Michael E. Lipkin, MD

Associate Professor in Urology Department of Surgery Division of Urology Duke University Medical Center Durham, NC, USA Igor Lobko, MD

Chief Division of Vascular and Interventional Radiology Director Vascular and Interventional Radiology Fellowship Department of Radiology Long Island Jewish Medical Center New Hyde Park, NY, USA Susan MacDonald, MD

Assistant Professor of Surgery Division of Urology Penn State Milton S. Hershey Medical Center Hershey, PA, USA Catriona I. MacRae, MBBS, BSc

Registrar Department of Urology Tauranga Hospital Tauranga, New Zealand

Robert Marcovich, MD

Associate Professor and Director of Endourology Department of Urology University of Miami Miller School of Medicine Miami, FL, USA Professor of Urology UCLA Department of Urology Los Angeles, CA, USA Eugenio Martorana, MD

Urology Resident Department of Urology University of Modena and Reggio Emilia Modena, Italy Alexey G. Martov, MD, PhD, Honored Doctor of Russia

Professor Chairman Department of Urology Federal Medico‐biology Agency; Professor of Urology Russian Medical Academy of Postgraduate Education; Head of Urology Department Moscow City Hospital No. 57 Moscow, Russia Mahir Maruf, MD

Research Volunteer Urologic Oncology Branch National Cancer Institute National Institutes of Health Bethesda, MD, USA Thomas Masterson, MD

Resident Department of Urology University of Miami Miller School of Medicine/Jackson Memorial Hospital Miami, FL, USA Brian R. Matlaga, MD, MPH

The Stephens Professor James Buchanan Brady Urological Institute Johns Hopkins University School of Medicine Baltimore, MD, USA

List of Contributors

Tadashi Matsuda, MD, PhD

Professor Chairman Department of Urology and Andrology Kansai Medical University Hirakata, Osaka, Japan Matthew J. Maurice, MD

Clinical Fellow Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH, USA Kurt A. McCammon, MD

Vanderbilt University Medical Center Nashville, TN, USA Massimo Mischi, PhD, MSc

Professor of Biomedical Signal Analysis Director of Biomedical Diagnostics Labs Department of Electrical Engineering Eindhoven University of Technology Eindhoven Noord‐Brabant The Netherlands Dilip K. Mishra, MBBS, MS, MRCS, MCh

Professor Chairman Department of Urology Eastern Virginia Medical School Norfolk, VA, USA

Consultant Urologist Department of Urology & Center for Minimally Invasive Endourology Global Rainbow Healthcare Agra, India

Mani Menon, MD

Shashikant Mishra, MS, DNB(Urol)

Chairman Vattikuti Urological Institute Detroit, MI, USA Salvatore Micali, MD

Associate Professor of Urology Department of Urology University of Modena and Reggio Emilia Modena, Italy Maurice‐Stephan Michel, MD

Full Professor of Urology Head of Department of Urology University Medical Centre Mannheim Heidelberg University Heidelberg, Germany Arkadiusz Miernik MD, PhD, FEBU

Associate Professor of Urology Head of Division of Urotechnology University of Freiburg – Medical Centre Department of Urology Freiburg, Germany Brian J. Miles, MD

Professor of Urology Weill Cornell Medical College Medical Director of Robotic Surgery Houston Methodist Hospital Houston, TX, USA Nicole L. Miller, MD

Associate Professor Department of Urology

Consultant Urologist Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Akira Miyajima, MD

Professor and Chairman Department of Urology Tokai University School of Medicine Isehara, Kanagawa, Japan Anthony D. Mohabir, MD

Consultant Urology Division of Vascular and Interventional Radiology Department of Radiology Long Island Jewish Medical Center New Hyde Park, NY, USA Robert Moldwin, MD

Director of Pelvic Pain Treatment Center The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Manoj Monga, MD

Professor of Surgery/Urology Director of the Stevan Streem Center of Endourology & Stone Disease Center of Endourology and Stone Disease The Cleveland Clinic Cleveland, OH, USA

xxix

xxx

List of Contributors

Bradley A. Morganstern, MD

Christopher Netsch, MD, FEBU

Assistant Professor of Pediatric Urology Chief, Pediatric Urology at Children’s Hospital of Georgia Medical College of Georgia Augusta University Augusta, GA, USA

Assistant Professor of Urology Fellow in Endourology Consultant Department of Urology Asklepios Klinik Barmbek Hamburg, Germany

Piruz Motamedinia, MD

Naren Nimmagadda, MD

Assistant Professor Department of Urology Yale University New Haven, CT, USA

Resident Physician Department of Urology Massachusetts General Hospital Boston, MA, USA

Ravi Munver, MD, FACS

Victor W. Nitti, MD

Professor Vice Chairman Department of Urology Hackensack University Medical Center Hackensack, NJ, USA Stephen Y. Nakada, MD, FACS

Professor Chairman The David T. Uehling Chair of Urology Departments of Urology, Radiology and Medicine University of Wisconsin School of Medicine and Public Health; Chief of Service Department of Urology UW Health Madison, WI, USA

Professor of Urology and Obstetrics and Gynecology Vice Chairman Department of Urology; Director Female Pelvic Medicine and Reconstructive Surgery Department of Urology New York University Langone Medical Center New York, NY, USA Charles U. Nottingham, MD

Resident Physician Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA

Shyam Natarajan, PhD

Yasser A. Noureldin, MD, MSc, PhD

Adjunct Assistant Professor Department of Urology and Bioengineering University of California Los Angeles, CA, USA

Lecturer Department of Urology Benha Faculty of Medicine Benha University Benha, Egypt

Oktay Nazli, MD

Professor Department of Urology School of Medicine Ege University İzmir, Turkey Andreas Neisius, MD

Associate Professor of Urology Department of Urology Brüderkrankenhaus Trier Johannes Gutenberg University Mainz, Germany

Yaw A. Nyame, MD, MBA

Resident Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Zeph Okeke, MD

Associate Professor The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

List of Contributors

Zhamshid Okhunov, MD

Shu Pan, MD

Endourology Fellow Department of Urology University of California Irvine, CA, USA

Resident Department of Urology Yale University New Haven, CT, USA

Carol Olsen, MSN, RN, CURN

Anup Patel, BSc, MBBS, FRCS, MS, FRCS(Urol)

Director System, Urology Clinical Services The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Michael C. Ost, MD

Chief Division of Pediatric Urology Children’s Hospital of Pittsburgh of UPMC; Associate Professor University of Pittsburgh School of Medicine; Vice Chairman Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Kenneth T. Pace, MD, MSc, FRCSC

Vice Chief of Surgery Head, Division of Urology Researcher, Keenan Research Centre Li Ka Shing Knowledge Institute St. Michael’s Hospital; Associate Professor Department of Surgery University of Toronto Toronto, ON, Canada Greg Palleschi, MD

Consultant Urological Surgeon London, UK Manish N. Patel, MD

Fellow in Endourology Wake Forest University School of Medicine Department of Urology Winston-Salem, NC, USA Roshan Patel, MD

Endourology Fellow Department of Urology University of California Irvine, CA, USA Ryan F. Paterson, MD, FRCSC

Assistant Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Margaret S. Pearle, MD, PhD

Professor Vice‐Chair Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA Renato N. Pedro, MD, PhD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA

Lithotripsy Center Coordinator – AME/SBO UNICAMP; Professor of Urology Faculdade de Medicina São Leopoldo Mandic Campinas, Brazil

Lane S. Palmer, MD

Aleš Petřík, MD, PhD

Professor of Urology and Pediatrics Chief, Division of Pediatric Urology Cohen Children’s Medical Center of New York Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Ricardo Palmerola, MD

Fellow, Female Pelvic Medicine and Reconstructive Surgery New York University Langone Medical Center New York, NY, USA

Assistant Professor Department of Urology Hospital Ceske Budejovice Ceske Budejovice; Charles University, 1st Faculty of Medicine Prague, Czech Republic John Phillips, MD, FACS

Residency Program Director New York Medical College

xxxi

xxxii

List of Contributors

Department of Urology Valhalla, NY, USA

Tanta University Hospital Tanta, Arab Republic of Egypt

Giovannalberto Pini, MD

Arun Rai, MD

Urologist Laparoscopy & Robotic Section Department of Urology San Raffaele Turro Hospital Milan, Italy

Resident Scott Department of Urology Baylor College of Medicine Houston, TX, USA

Peter A. Pinto, MD

Assistant Professor of Urology and Radiology Director, UAB Program for Personalized Prostate Cancer Care Departments of Urology and Radiology University of Alabama at Birmingham Birmingham, AL, USA

Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD, USA Giacomo Maria Pirola, MD

Urology Resident Department of Urology University of Modena and Reggio Emilia Modena, Italy Thomas J. Polascik, MD, FACS

Professor of Surgery Director, Urologic Oncology Fellowship Director, GU program on Focal Therapy Duke Comprehensive Cancer Center Duke Cancer Institute Duke University Durham, NC, USA James R. Porter, MD

Director, Robotic Surgery Providence Health and Services Swedish Urology Group Seattle, WA, USA Louis Potters, MD, FACR, FASTRO

Professor Chairperson Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Glenn M. Preminger, MD

James F. Glenn Professor of Urology and Chief Division of Urology Department of Surgery Duke University Medical Center Durham, NC, USA Ali Abdel Raheem, MD, PhD

Consultant of Uro-oncology Minimally Invasive Urological Surgery Unit

Soroush Rais‐Bahrami, MD

Rajan Ramanathan, MD

Professor of Surgery Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Daniel Ramirez, MD

Urology Associates of Nashville Nashville, TN, USA Dima Raskolnikov, MD

Resident Department of Urology University of Washington Seattle, WA, USA Jens Rassweiler, MD, FRCS(Glasg)

Professor of Urology Head of Department of Urology SLK Kliniken Heilbronn University of Heidelberg Heidelberg, Germany Marie‐Claire Rassweiler-Seyfried, MD, FEBU

Consultant of Urology Department of Urology University Medical Centre Mannheim Mannheim, Germany Ardeshir R. Rastinehad, DO, FACOS

Associate Professor of Urology and Radiology Director of Focal Therapy and Interventional Urologic Oncology Department of Radiology and Urology

List of Contributors

Icahn School of Medicine at Mount Sinai New York, NY, USA

2Ai – Polytechnic Institute of Cávado and Ave Barcelos, Portugal

A. Andrew Ray, MD, MSc, FRCSC

Dayron Rodríguez, MD, MPH

Adjunct Lecturer University of Toronto Royal Victoria Regional Hospital Barrie, ON, Canada Hassan Razvi, MD, FRCSC

Professor Chair Division of Urology Schulich School of Medicine and Dentistry Western University London, ON, Canada Christopher R. Reynolds

Fellow Robotics and Minimally Invasive Surgery Wake Forest Baptist Medical Center and Wake Forest School of Medicine Winston‐Salem, NC, USA Koon Ho Rha, MD, FACS, PhD

Professor of Urology Department of Urology Severance Hospital Yonsei University College of Medicine Seoul, South Korea Kyle A. Richards, MD, FACS

Assistant Professor Department of Urology University of Wisconsin-Madison Madison, WI, USA Lee Richstone, MD

Chief of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Manuel Ritter, MD

Associate Professor Department of Urology University Medical Centre Mannheim Heidelberg University Heidelberg, Germany

Resident in Urology Harvard Massachusetts General Hospital Program in Urology Boston, MA, USA Craig G. Rogers, MD

Director of Renal Surgery Vattikuti Urology Institute Henry Ford Hospital Detroit, MI, USA Daniel Rosen, MD

Resident Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Ornob Roy, MD

Assistant Professor of Urology Carolinas Medical Center Charlotte, NC, USA Daniel B. Rukstalis, MD

Professor Department of Urology Wake Forest University School of Medicine Winston-Salem, NC, USA Matthew P. Rutman, MD

Associate Professor of Urology at CUMC Director of Voiding Dysfunction and Female Urology Columbia University New York, NY, USA Ravindra B. Sabnis, MS, MCH

Chairman Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Simpa S. Salami, MD, MPH

Assistant Professor Department of Urology University of Michigan Ann Arbor, MI, USA

Pedro L. Rodrigues

Life and Health Sciences Research Institute ICVS/3B’s - Associate Lab. Guimarães Braga;

Francisco J.B. Sampaio, MD, PhD

Full Professor and Chairman Urogenital Research Unit

xxxiii

xxxiv

List of Contributors

State University of Rio de Janeiro; National Council for Scientific and Technological Development – CNPq Rio de Janeiro, Brazil

Columbia University Irving Medical Center Columbia University College of Physicians and Surgeons New York, NY, USA

Jaspreet S. Sandhu, MD

Paras H. Shah, MD

Associate Attending Urologist Department of Surgery Urology Service Memorial Sloan Kettering Cancer Center New York, NY, USA Jeffrey S. Schachar, MD

Fellow Female Pelvic Medicine and Reconstructive Surgery Cleveland Clinic Florida Weston, FL, USA Douglas S. Scherr, MD

Ronald Stanton Clinical Scholar in Urology Professor of Urology Clinical Director, Urologic Oncology Weill Cornell Medicine New York Presbyterian Hospital New York, NY, USA John R. Schwabe, MD

Resident Physician Wayne State University Department of Urology Detroit, MI, USA Zeyad Schwen, MD

Resident James Buchanan Brady Urological Institute Johns Hopkins School of Medicine Baltimore, MD, USA Cesare M. Scoffone, MD

Head of the Department of Urology Cottolengo Hospital Torino, Italy Michelle Jo Semins, MD

Assistant Professor Department of Urology University of Pittsburgh School of Medicine Pittsburgh, PA, USA Ojas Shah, MD

George F. Cahill Professor of Urology Director Division of Endourology and Stone Disease Department of Urology

Urologist Department of Urology Mayo Clinic Rochester, MN, USA John M. Shields, MD

Adjunct Clinical Post Doctorate Minimally Invasive Surgery and Endourology Fellow Department of Urology University of Florida Gainesville, FL, USA Pratik A. Shukla, MD

Radiology Resident Division of Vascular and Interventional Radiology Department of Radiology Mount Sinai Beth Israel New York, NY, USA David N. Siegel, MD, FSIR

Interventional Radiologist Vice Chairman, Clinical Affairs‐LIJMC Department of Radiology‐ Northwell Health Associate Professor of Radiology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Mark V. Silva, MD

Resident Department of Urology Columbia University Irving Medical Center/ NewYork‐Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, NY, USA Maximiliano Lopez Silva, MD

Staff, Urology Clínica San Camilo; Hospital Piñero Buenos Aires, Argentina Abhishek Singh, MS, MCH

MCH Urology Consultant Department of Urology

List of Contributors

Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Ajay K. Singla, MD

Program Director, Urology Residency Program Department of Urology Massachusetts General Hospital Faculty Harvard Medical School Boston, MA, USA Nirmish Singla, MD

Assistant Instructor Fellow, Urologic Oncology Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA Gajan Sivananthan, MD

Keck School of Medicine University of Southern California Los Angeles, CA, USA Michael W. Sourial, MD, FRCSC

Endourology and Minimally Invasive Surgery Fellow Department of Urology The Ohio State University Wexner Medical Center Columbus, OH, USA Robert J. Sowerby, MD, MHM, FRCSC

Urologist Endourology and Minimally Invasive Urologic Surgery Division of Urology Mackenzie Health Hospital Vaughan, ON, Canada

Assistant Professor of Radiology and Surgery Vascular and Interventional Radiology Mount Sinai Medical Center Department of Radiology Icahn School of Medicine at Mount Sinai New York, NY, USA

Lambros Stamatakis, MD

Ganesh Sivarajan, MD

Peter L. Steinberg, MD

Endourology, Laparoscopic and Robotic Surgery Fellow Department of Urology Hackensack University Medical Center Hackensack, NJ, USA Arthur D. Smith, MD

Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Gail S. Smith, MD

Assistant Professor of Radiology Department of Radiology NorthShore University Health System University of Chicago Pritzker School of Medicine Evanston, IL, USA John J. Smith III, MD

Senior Partner Novant Health Carolinas Pelvic Health Center Winston-Salem, NC, USA Rene J. Sotelo, MD

Professor of Clinical Urology USC Institute of Urology

Assistant Professor of Urology Department of Urology MedStar Washington Hospital Center Georgetown University Washington, DC, USA Director of Endourology Beth Israel Deaconess Medical Center Boston, MA, USA Ryan L. Steinberg, MD

Resident in Urology University of Iowa Department of Urology Iowa City, IA, USA Michael D. Stifelman, MD

Chairman Department of Urology; Chief of Urologic Oncology Hackensack University Medical Center Hackensack, NJ, USA Dan Stoianovici, PhD

Professor Director, Urology Robotics Program James Buchanan Brady Urological Institute Johns Hopkins University School of Medicine Baltimore, MD, USA Yinghao Sun, MD

Academician Chinese Academy of Engineering;

xxxv

xxxvi

List of Contributors

President Chinese Urological Association; President of Second Military Medical University Shanghai, China Roger L. Sur, MD

Director UCSD Comprehensive Kidney Stone Center Department of Urology University of California San Diego Health San Diego, CA, USA Robert M. Sweet, MD, FACS

Professor of Urology Executive Director WWAMI Institute for Simulation in Healthcare Medical Director Kidney Stone Program WWAMI Institute for Simulation in Healthcare (WISH) University of Washington Seattle, WA, USA Christian Tabib, MD, MBA

Senior Resident The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Geert G. Tailly, MD

Head of Department Department of Urology and Pediatric Urology AZ Klina Kapellen Belgium Thomas Tailly, MD, MSc, FEBU

Consultant Urologist Division of Urology University Hospital Ghent Ghent, Belgium Kae Jack Tay, MBBS, MRCS(Ed), MMed(Surg), MCI, FAMS(Urol)

Consultant Department of Urology Singapore General Hospital Singapore; Adjunct Assistant Professor Duke‐NUS Medical School SingHealth Duke‐NUS Academic Medical Center; Duke Comprehensive Cancer Center Duke Cancer Institute Duke University Durham, NC, USA

Alexis E. Te, MD

Professor of Urology Director, Brady Prostate Center; Director, Urology Program Iris Cantor Men’s Heath Center; Weill Medical College of Cornell University New York, NY, USA Dogu Teber, MD

Chairman of Department of Urology Klinikum Karlsruhe University of Heidelberg Heidelberg, Germany Ryan P. Terlecki, MD

Director, Men’s Health Clinic Director, Fellowship in Urologic Reconstruction, Prosthetic Urology, and Infertility Director, Medical Student Education Associate Professor of Urology and Obstetrics/Gynecology Department of Urology Wake Forest Baptist Health Winston-Salem, NC, USA Angelo Territo, MD

Medical Doctor Specialist in Urology Consultant in Uro-Oncology and Kidney Transplant Units Fundació Puigvert Autonoma University of Barcelona Barcelona, Spain Ashutosh Tewari, MBBs, MCh, FRCS

Chair Milton and Carroll Petrie Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Dominique Thomas, BS

Research Coordinator Department of Urology Weill Cornell Medical College New York Presbyterian Hospital New York, NY, USA Raju Thomas, MD, FACS, MHA

Professor Chairman Department of Urology Tulane University School of Medicine New Orleans, LA, USA

List of Contributors

Joseph Tortora, BSc, MS

Christian Türk, MD

Student Researcher Department of Urology Wake Forest Baptist Health Winston-Salem, NC, USA

Urologist Department of Urology Hospital of the Sisters of Charity; Urologische Praxis mit Steinzentrum Vienna, Austria

Mouafak Tourojman, MD

Senior Uro‐Oncology Robotic Fellow Vattikuti Urology Institute Department of Urology Henry Ford Health System Detroit, MI, USA Chad R. Tracy, MD

Associate Professor of Urology Director of Robotic and Minimally Invasive Surgery University of Iowa Department of Urology Iowa City, IA, USA Henry Tran, FRCSC, MD, BASc

Urologic Surgeon Department of Urology Columbia University Medical Center New York, NY, USA Timothy Y. Tran, MD

Assistant Professor of Urology Residency Site Director Providence VA Medical Center Brown University Providence, RI, USA Olivier Traxer, MD, PhD

Sorbonne Université Department of Urology GRC n°20 Groupe de Recherche Clinique sur la Lithiase Urinaire Hôpital Tenon Paris, France Timothy Y. Tseng, MD

Assistant Professor Department of Urology University of Texas Health Science Center at San Antonio San Antonio, TX, USA Omer L. Tuncay, MD

Chair Pamukkale University School of Medicine Department of Urology Denizli, Turkey

Baris Turkbey, MD

Staff Clinician Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA Burak Turna, MD, FEBU

Professor Department of Urology School of Medicine Ege University İzmir, Turkey Benjamin W. Turney, MA(Cantab), MSc(Oxon), DPhil(Oxon), FRCS(Urol)

Senior Clinical Researcher and Consultant Urological Surgeon University of Oxford and Oxford University Hospitals NHS Foundation Trust Oxford, UK Burak Ucpinar, MD

Resident in Urology Department of Urology Haseki Training and Research Hospital Istanbul, Turkey Paul J. Van Cangh, MD

Professor Chair University of Louvain Medical School Department of Urology Saint Luc University Hospital Brussels, Belgium Brian A. VanderBrink, MD

Associate Professor University of Cincinnati School of Medicine Cincinnati Children’s Hospital Medical Center Division of Urology Cincinnati, OH, USA Vinaya Vasudevan, MD

Resident Physician, PGY‐4 The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

xxxvii

xxxviii

List of Contributors

Domenico Veneziano, MD, FEBU

Hessel Wijkstra, MSc, PhD

Urologist Department of Urology and Kidney Transplant Grande Ospedale Metropolitano “Bianchi, Melacrino, Morelli” Reggio Calabria, Italy

Research Director Department of Urology AMC University Hospital Amsterdam, The Netherlands

Simone Vernez, BA

Researcher PhD Student Biomedical Diagnostics Labs Department of Electrical Engineering Eindhoven University of Technology Eindhoven, The Netherlands

Medical Student Department of Urology University of California Irvine, CA, USA João L. Vilaça, PhD

Life and Health Sciences Research Institute ICVS/3B’s – Associate Lab. Guimarães Braga; 2Ai – Polytechnic Institute of Cávado and Ave Barcelos, Portugal Philippe D. Violette

Assistant Professor Departments of Surgery and Health Research Methods Evidence and Impact (HEI) McMaster University Hamilton, ON, Canada Davis P. Viprakasit, MD, FACS

Clinical Associate Professor Department of Urology University of North Carolina Chapel Hill, NC, USA Manish A. Vira, MD

Associate Professor of Urology Vice Chair for Urologic Research The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Friedrich‐Carl von Rundstedt, MD

Senior Staff Physician Department of Urology University Hospital Jena Germany Andrew A. Wagner, MD

Director of Minimally Invasive Urologic Surgery Beth Israel Deaconess Medical Center; Associate Professor of Surgery Harvard Medical School Boston, MA, USA Aaron C. Weinberg, MD

Clinical Instructor Department of Urology New York University School of Medicine New York, NY, USA

Rogier R. Wildeboer, MSc

J. Stuart Wolf Jr., MD, FACS

Professor Department of Surgery and Perioperative Care Dell Medical School at the University of Texas Austin, TX, USA Daniel A. Wollin, MD

Endourology Fellow Division of Urology Department of Surgery Duke University Medical Center Durham, NC, USA Wayland J. Wu, MD

Resident Physician The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Yoshiya Yamada, MD, FRCPC

Senior Attending Radiation Oncologist Member Memorial Hospital Department of Radiation Oncology Memorial Sloan Kettering Cancer Center New York, NY, USA Yuka Yamaguchi, MD

Attending Physician Division of Urology Department of Surgery Alameda Health System Oakland, CA, USA Vidhush K. Yarlagadda, MD

Resident Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Nadya E. York, MD, FRACS

Endourology Fellow Department of Urology

List of Contributors

Indiana University School of Medicine Indianapolis, IN, USA Michelle Yu, MD

Resident Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Joao P. Zambon, MD, PhD

Associate Professor Department of Urology Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Michael Zhang, MD

Senior Resident Department of Urology New York Medical College New York, NY, USA

Lee C. Zhao, MD

Assistant Professor Department of Urology New York University School of Medicine New York, NY, USA Zichen Zhao, MD

ACS Simulation Fellow WWAMI Institute for Simulation in Healthcare (WISH) University of Washington Seattle, WA, USA Pei Zhong, PhD

Professor Department of Mechanical Engineering and Materials Science Duke University Durham, NC, USA

xxxix

xl

­Foreword “Endourology” was the 1978 branding brainchild of Elwin Fraley, Arthur Smith, and Paul Lange.1 Most felt that the Minnesota cold had finally gone beyond their woolen headgear to create a “brain freeze” of monumental proportions. Fast forward nearly 40 years and, today, endourology has become urology. Diagnostically, from the urethral meatus to the uppermost renal calyx, the entire urogenital tract can be revealed in great detail using both endoscopic and sophisticated imaging technologies. Therapeutically, urologists of talent, innovation, and persistence have supplanted standard incisional access with an endoscopic, image‐guided, or combined approach. If you are reading this Foreword then you are reading a book that contains every aspect of urology and how it is benefited by a minimally invasive (i.e. percutaneous, ureteroscopic, laparoscopic, robotic) or noninvasive ­ image‐guided (i.e. shock‐wave lithotripsy, focal therapy) approach. The authors are an international Who’s Who of experts in endourology. The content ranges from basic to futuristic endourology. In 166 chapters, the latest advances in antegrade and retrograde endoscopic nephrostomy, laparoendoscopic single‐site surgery, and robotic procedures as well the newest image‐guided therapies are clearly detailed and illustrated both in photographs and often by instructional video demonstrations. A wise mentor2 once advised me: “You are only as good as tomorrow.” That single sentence should haunt each of us as we arise every morning to provide relief to those

who suffer. To that end, we must seek methods to relieve suffering rather than cause it, to heal without harming, to cure without substituting one malady for another. Endourology empowers each of us to provide all individuals seeking our care with a kinder, gentler solution to their urological problems. In the first part of the twentieth century, Sir William Osler opined: “Diseases that harm require treatments that harm less.”3 A century later, his dictum has been largely realized in the practice of endourology. My heartfelt congratulations go out to Drs Smith, Badlani, Kavoussi, Preminger, and Rastinehad, who have provided a comprehensive guide of immense value to me, to you, and to all of our patients. Read Smith’s Textbook of Endourology well, apply its principles earnestly, and, if opportunity presents, seek to further innovate and build on its contents. The text is not an end in and of itself; rather, it is another paver in the surgical journey in which each of us plays a role — using techniques borne of today’s technology to proceed to further reduce the burden of the “surgical” cure we are obligated to apply.

Ralph V. Clayman, MD Professor of Urology/Dean (Emeritus) School of Medicine University of California, Irvine

Notes 1 Smith AD, Lange PH, and Fraley EE. Letter to the Editor:

applications of percutaneous nephrostomy. New challenges and opportunities in endo‐urology. J Urol 1979;121:382.

2 Arthur D. Smith. 3 Attributed to Sir William Osler (1849–1919).

xli

Preface The cover of this textbook synthesizes the concepts of endourology. In order to perform endoscopic surgery one needs access to the organ and various forms of energy to facilitate access, control bleeding, and obliterate tissues. These goals can only be accomplished with appropriate devices. Fortunately, evolving technology allows the manufacture of improved devices. It is essential for endourologists to keep abreast of these advances. The fourth edition of this book accomplishes this with an update of the existing chapters by the original authors or complete revision by new authors. In 1978 the concept of endourology was launched. It was defined as closed, controlled manipulation within the urinary tract. The word “closed” was used to indicate either a minimal incision or no incision at all and the control was achieved either endoscopically or by noninvasive imaging. Until then, residents had been taught that the only way to have good exposure was through a large incision. Now the ultimate goal is good exposure with no incision at all. This is achieved by utilizing a combination of endoscopy and the new modalities of imaging. There are now relatively few accepted open urological procedures and this has had the gratifying result of a dramatic decrease in the morbidity of our patients undergoing treatment. In this era of fewer working hours for residents, the amount of time that the residents spend in the operating room has decreased dramatically and the necessary skills have to be taught using a combination of additional educational modalities. In addition to books and journals, there are an abundance of videos on surgical techniques, animal laboratories, teaching models, and virtual reality simulators. Fortunately, endourologic techniques are uniquely suited to these modalities and the student can become quite adept by using them before being instructed in the operating room. As the technology has evolved, courses have been organized by the Endourology Society to train not only the residents and fellows, but also the practicing urologist so that their “learning curve” can be accelerated, and

they can then use these techniques with the required expertise. In addition, the Endourology Society has developed the Journal of Endourology and the Journal of Endourology Case Reports to update urologists on the latest technology. The Journal of Endourology allows the members access the Journal of Videourology which features videos of new and established techniques on the computer or tablet. This textbook consists of two volumes. Volume 1 is on stones of the upper tract. Volume 2 is on robotic and laparoscopic surgery and image‐guided diagnostic and therapeutic techniques together with minimally invasive therapy of the lower urinary tract. Volume 1 consists of five sections. Section 1 discusses the basic principles. Section 2 is devoted to percutaneous renal surgery. Section 3 discusses the intricacies of ureteroscopy. Section 4 is on shock‐wave lithotripsy. We are cognizant of the fact that there is no single modality for the treatment of stones and hence Section  5 describes the management of the patient with various stone‐related problems in a composite format. Volume 2 covers robotic and laparoscopic surgery. At present, there is very little difference between the techniques and that which there is is primarily related to technical experience, availability of the robot, and financial considerations. Sections 6 and 7 discuss image‐guided diagnostics and therapeutics. This is an important addition to our Textbook of Endourology, as it is an essential component of the armamentarium of the practicing urologist, particularly as we move into the era of “no incision.” If the procedures described in this section are not performed by urologists, then they will be taken over by radiologists. This in turn will result in the loss of ­continuity of care of our patients. I would like to thank each of the contributors for the many hours they have devoted to writing, illustrating, and creating videos for their chapters. Hopefully, they will be as delighted with the results as the editors and publishers of this textbook. I am also deeply indebted to my co‐editors, who have reviewed, edited, and re‐reviewed chapters countless times. Thanks to their families as well, as the

xlii

Preface

time spent on the book could have been devoted to them. The staff at Wiley Blackwell and the project manager Mirjana Misina have been highly professional and encouraging. When one deals with a large organization, it is reassuring to know that as a book bounces from one stage to the next there has been a “continuity of care throughout the operation.” They are a great team and we appreciate all the help we received from them.

Finally, I would like to thank my wife, Kay, who inspired me to edit this fourth edition and has repeatedly helped me with this and countless other projects throughout my academic career. If I am regarded as the “father” of endourology, she is unquestionably the “mother” who has helped to nurture this field of urology. June 2018

Arthur D. Smith

xliii

About the Companion Website This book is accompanied by a companion website:

www.wiley.com/go/smith/textbookofendourology The website includes: ●● ●●

Over 100 videos showing procedures as described in the book PowerPoints of all figures from the book for downloading

All videos are referenced in the text where you see this icon:

1

SECTION 1 Basic Principles

3

1 Care and Sterilization of Instruments Carol Olsen The Arthur Smith Institute for Urology, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA

­History of sterilization The creation and use of surgical instruments has occurred since prehistoric times. The effects of using instruments that were neither clean nor sterile were not a major concern in past eras. The methods for the care and sterilization of instruments have gone through a huge change and have greatly improved over the last few centuries. It was not until the nineteenth century that the development and recognition of a process for instrument sterilization occurred. During this time the focus on the need to sterilize instruments prior to a surgical proce­ dure developed from the effects of post‐surgery wound management and the need to eliminate the increased infections of these wounds. This recognition led to the evolution and development of the current standard practice of instrument sterilization. Noted in the nineteenth century, surgeons performed operations in their street clothes, which were often dirty, and they also reused instruments without a standard cleaning process. In 1864, Joseph Lister introduced the use of phenol, or carbolic acid, on inanimate objects and surfaces as well as human tissue, in hospital wards and operating rooms which resulted in a dramatic decrease in the incidence of wound infections. The carbolic acid was used in conjunction with other components to dress wounds in an antiseptic manner which prevented bacteria from entering the wound. This led Lister to introduce other methods of asepsis, such as sterilization of surgical instruments by applying heat and carbolic acid and the frequent cleaning of the surgeon’s hands during an operation. After publication of these findings, in the The Lancet in 1867 the “era of antiseptic surgery” was introduced into the field of medicine and surgery. By the year 1875 Lister’s principles of antiseptic surgery were accepted worldwide [1].

The steam autoclave was derived from a steam digester currently known as a pressure cooker invented by a physicist named Denis Papin in the late 1600s. By 1879, Charles Chamberland, a colleague of Louis Pasteur, made improvements to Papin’s invention and invented a porcelain dish with tiny holes that was able to filter microorganisms from liquid that was poured through this dish. This is known as the Chamberland filter or the Chamberland–Pasteur filter and with his further research in 1884 the autoclave was invented. The use of pressur­ ized steam sterilization of instruments with an autoclave was introduced by Ernst von Bergmann in 1886. Ethylene oxide (ETO) was first used in 1938 to preserve spices. In the 1950s, ETO was accepted by the medical device industry as a sterilant after a US army researcher investigated the microbicidal effect of ETO and published his findings [2]. This method of sterilization has been used for heat‐sensitive instruments, such as flexible scopes and lenses. In the early 1900s, urological instruments were sterilized in a formalin sterilizer and disinfected with a carbolic acid solution. The formalin sterilizer exposed instruments to heated formalin vapors for 2 hours and remained in the sterilizer until use [3]. Since the late 1980s other methods of sterilization were developed that were less caustic to instruments, required less process time, are noncarcinogenic, and allowed for sterile instrument availability. These methods have replaced some of the older sterilization methods.

­Instrument processing Any item, such as an instrument or medical device that is intended to be reused in a sterile procedure, must be pro­ cessed in a specific manner, beginning with cleaning and ending with sterilization or high‐level disinfection (HLD).

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

4

Section 1  Basic Principles

In order for sterilization or HLD of an item to be effec­ tive, the following steps must occur in a proper and adequate manner: precleaning, cleaning, decontamination, rinsing, drying, disinfection (includes HLD immersion and rinsing with sterile water) or sterilization, and stor­ age. The necessary type of package or container prepa­ ration the item will be placed in is determined by the method of sterilization, such as a paper peel package or metal container. In some instances the item may be placed in storage until reuse, such as those that require, at the minimum, HLD. Urologic instruments consist of reusable flexible cys­ toscopes, flexible ureteroscopes, flexing instruments for endoscopes, rigid cystoscopes, semi‐rigid ureteroscopes, transurethral resection instruments, rigid nephroscopes, laparoscopic instruments, metal dilators, various metal surgical instruments, and ultrasound probes, both exter­ nal and internal (intracavity, endorectal, or prostate biopsy probes). First the item should be categorized to determine which type of disinfection or sterilization method is recommended for processing. In 1968 Earl H. Spaulding categorized medical instruments and items used for patient care as critical, semicritical, and noncritical based on the degree of risk for infection with the pro­ cessing and reuse of each item. These categories make up the Spaulding scheme or Spaulding classification system, which is a recognized resource when describing the appropriate disinfection and sterilization process for medical instruments and devices [4, 5]. Critical items are instruments which will come in direct contact with ster­ ile tissue, enter the vascular system, or penetrate the skin. They require sterilization by such methods as steam, ETO, hydrogen peroxide gas plasma, or a liquid chemical sterilant such as peracetic acid [6]. Semicritical items are instruments which will come in contact with mucous membranes and require sterilization or at a minimum HLD. These items have been identified as high risk for transmitting infection [7]. Noncritical items are instruments or medical devices, such as a stethoscope or blood pressure cuff, which will come into contact with intact skin only and require intermediate to low‐level disinfection, such as an impregnated antimicrobial wipe. Neglect of low‐level disinfection can lead to cross‐con­ tamination to the healthcare worker’s hands; reuse of the instrument or medical device with another patient also causes cross‐contamination [5, 8–10]. Utilization of a reusable instrument or medical device is a major risk due to the potential introduction of path­ ogenic microorganisms, which can lead to infection. Therefore, adequate cleaning is imperative to successfully eliminate the bioburden or microbes present on an instrument. Cleaning and decontamination of any level of item used in any type of healthcare facility is a mandatory

requirement prior to reuse. Each facility must have a policy and procedure manual in place which identifies the process of cleaning or decontamination, followed by the process for disinfection or sterilization of these items when indicated. Cleaning is the most important step in the process leading to sterilization or HLD and begins with physi­ cally removing microbes in preparation for the next step, which is decontamination [8]. There are different accepted methods for cleaning instruments prior to disinfection or sterilization. These are either manual or automated, which can include a washer/sterilizer, ultra­ sonic cleaner, or washer/decontaminator [11]. Prior to the cleaning process, any healthcare person­ nel must don personal protective equipment (PPE) to protect their eyes, skin, and clothing from splashing or droplet contact from any angle [12]. PPE includes eye protection (goggles or mask with shield), mask, imper­ vious gown with long sleeves, gloves, hair bonnet or cap, and shoe covers to avoid exposure to microorgan­ isms and for personal safety protection [6, 11]. After the cleaning and decontamination process, the PPE must be removed or doffed followed by hand hygiene practice [12]. Manual cleaning involves three components: a low‐ sudsing detergent or enzymatic cleaner, a brush or sponge, and friction [13]. These components will ensure the removal of tissue and debris from an instrument. Manual cleaning of an item begins with immersion in a receptacle or deep sink filled with detergent or enzyme cleaner and warm water solution. Preparation of the detergent or enzymatic cleaner must follow the manufac­ turer’s instructions to ensure the solution is the correct concentration and temperature to maintain its effective­ ness. Many cleaners are designed with a premeasuring pump mechanism; healthcare personnel must make certain a full depression of the pump occurs to ensure appropriate solution concentration. A weak solution may fail to break down proteinaceous tissue or a strong solu­ tion may create sudsy bubbles which form air pockets and can prevent surface contact by the cleaner. To accurately fill the receptacle or sink with the correct amount of water, a fluid depth indicator or line should be placed for guidance of accuracy [13, 14]. An example is shown in Figure  1.1. A visible instruction guide should indicate the correct solution amount to be added to the correct measurement of water; for example 1 ounce of detergent to 1 gallon of water (Figure 1.2). To prevent aerosol for­ mation by microorganisms, the item being cleaned should be kept immersed below the solution level [8]. Prior to immersion, if the item has numerous parts it must be disassembled, and hinged instruments must be kept in the open, unlocked position. Gentle scrubbing of the item with a soft‐bristle brush or sponge will assist in

1  Care and Sterilization of Instruments

Figure 1.1  Example of the fill line of a cleaning receptacle.

Figure 1.2  Visible instructions for preparing an enzymatic cleaner.

removal of bioburden and preservation of the instrument’s functions and effectiveness [11]. The most recent recom­ mendation is to use a disposable, single‐use brush or sponge. The use of disposable brushes or sponges during the cleaning process will help to prevent cross‐contami­ nation to instruments, endoscopes, and medical devices. If a reusable brush is to be used due to cost issues then it must follow undergo HLD between each use [6]. Endoscope manufacturers each have their own select line of various styles and sizes of single‐use brushes, with instructions for use (IFU) guidelines for their specific endoscope models. The correct brush should be used for each instrument; the important components of the brush when selecting which one to use are its length, diameter, design, and material [15]. For example, the proper brush used for a flexible cystoscope should be longer than the scope itself, be the right diameter to easily fit through the internal working channels, be kink‐resistant, and

have a plastic tip on the end to protect the scope internal channel(s). The next step in manual cleaning is to thoroughly rinse the item with cool tap water in a deep sink to allow for ample movement. Following rinsing, sufficient drying time is needed before the item is to be prepared for steri­ lization or HLD. In urology, endoscopes, both flexible and rigid, are a frequently used. They are valuable diagnostic tools that are reusable and require healthcare personnel to follow the guidelines for reprocessing to prevent an outbreak of infection due to improper cleaning. These scopes are introduced into the bladder to examine its appearance and anatomy, as well as the lower urinary tract and pros­ tate gland. Other uses are for urine specimen collection, bladder biopsies, removal of small stones, small foreign objects, or an indwelling ureteral stent. An estimated 4  million or more cystoscopies are performed in the United States each year [16]. When indicated by the manufacturer a leak test should be performed on flexible endoscopes after precleaning and prior to full immersion of the scope in the cleaning solution. This test is done to check the integrity of the outer covering and the internal lining of the scope shaft for any leaks. Before the shaft of the scope is submerged in water, the scope manufacturer leak testing device (which may be manual/hand‐operated or automated) is connected to the flexible scope to allow pressurized air to fill the internal channel. The purpose of this test is to determine if there are any microscopic holes from continued use and reprocessing, which would be a source of contamination due to fluid accu­ mulation. The presence of a leak will be identified if the pressurized scope produces a flow of bubbles when inserted in water. Careful inspection of the flexible endoscope for any visible cracks, tears in the sheath material, or malfunctions of its performance is another vital step in reprocessing [6, 7]. External surfaces should be washed with a soft brush or sponge to remove any visible debris. Careful attention should be focused on the lumens and working channels of all endoscopes. Lumens and working channels should be irrigated with a large syringe or a manufacturer‐spe­ cific irrigating device. This is done first with detergent or enzymatic solution to help remove any residue, followed by a water rinse until it appears clear. Using the appropri­ ate‐size flexible brush will allow for proper cleaning of the lumens and working channels. Once the brush exits the tip of the scope, the bristles should be cleaned before pulling the brush back into the internal channel [6]. Brushes are available in a variety of sizes and shapes to accommodate any manufacturer’s endoscopes, and proper selection is essential for prevention of damage to the endoscope (Figure 1.3). Use of newly prepared cleaning

5

6

Section 1  Basic Principles

(a)

(b)

Figure 1.3  (a) Examples of various cleaning brushes. (b) Examples of brushes and their tips.

solution prior to cleaning of each endoscope is most effective and helps prevent cross‐contamination [13, 14]. A washer/sterilizer is designed to have several cycles, starting with a cold water pre‐rinse, followed by a high‐ temperature wash cycle with an alkaline low‐sudsing detergent, a neutralizing cycle, and then by a final rinse, steam sterilization, and a drying cycle [9, 11]. An ultra­ sonic cleaner functions by cavitation. Ultrasonic energy is passed through a water bath, creating microscopic bubbles that implode. The implosion process creates a suction action that pulls soil and foreign body matter away from instrument surfaces [9, 11]. Instruments that contain plastic or rubber should not be placed in an ultrasonic cleaner. The washer/decontaminator is a single or multi‐chamber unit that cleans using an alka­ line low‐sudsing detergent with a spray force action and heat during the drying cycle. Multi‐chamber units allow multiple single tasks to be performed simultaneously including a cool‐water rinse, pre‐wash with an enzymatic cleaner, wash cycle with detergent, ultrasonic cleaning, pure hot water rinse, and high‐temperature drying [9, 11].

­ rotection, handling, and maintenance P of instruments Protection, proper handling, and maintenance of instru­ ments are vital in maintaining the efficacy of instruments as well as keeping instrument replacement costs down [17]. During and immediately following a procedure, heavily soiled instruments should be immersed in warm water to prevent the onset of corrosion, pitting, and rusting [11, 17]. Precleaning helps to remove debris or bioburden and prevent it from drying on the instrument. If not removed completely debris could cause an obstacle in the next

steps of reprocessing and be a potential source of cross‐ contamination. When using flexible or rigid endoscopes, the working channel should be flushed immediately after use to prevent bioburden from drying inside and the exter­ nal part should be wiped down to remove visible debris [6]. Proper handling of instruments is a crucial part of maintaining an instrument’s function, especially when setting up a procedure and during reprocessing. This step is often overlooked in a careless manner due to one’s haste in preparing for the next procedure. Any delicate instruments such as telescopes, flexible scopes, light cables, and fine instruments such as microinstruments must be handled in a specific manner. During a proce­ dure these instruments should be kept in a separate location on the sterile field/setup to avoid other instru­ ments from being placed on top of them and causing potential damage. When transporting delicate instruments to the soiled processing room they should be placed in a specific labeled biohazard container designed for instrument transport [12]. Flexible scopes and light cables must not be over‐coiled while on the sterile field/ setup or during transport; this will help prevent the internal fiber optics from becoming cracked or broken. After cleaning, instruments should be checked for their function and lubricated when recommended by the manufacturer with a water‐soluble lubricant [4]. Lubrication also helps prevent rusting and maintains the function of any movable piece, such as a Leur Lock part.

­Methods of sterilization Sterilization can be achieved by way of several approved methods. These methods include using steam, ETO gas, peracetic acid, or hydrogen peroxide gas plasma.

1  Care and Sterilization of Instruments

Each method has its advantages and disadvantages along with specific indications for use. The manufacturer’s guidelines and IFU for any instrument must be followed when selecting which method to use to ensure instru­ ment viability and appropriate sterilization [18]. The healthcare setting will determine which method is suit­ able for the facility’s operational workflow. Monitoring and documentation of the effectiveness of any sterilization method is a mandatory requirement and must be fol­ lowed according to your facility’s policy and procedure guidelines. Steam sterilization The process of steam sterilization occurs in a steam autoclave unit designed to produce boiling water at 121 and 132 °C. A pressure of 103.42 kPa further produces steam to penetrate packaged or wrapped instruments or instruments in sterilization containers to kill any micro­ organisms present, including spores [19]. In order for steam sterilization to be successful the following stand­ ards are required: direct exposure to pressurized steam, a specific temperature, and a specific length of time [4]. There are types of cycle in a steam autoclave. One is the gravity‐displacement cycle which removes air by the force of gravity from the top downward. Another method is the prevacuum cycle, in which the air is removed via a vacuum pump; this is also referred to as dynamic air removal [4]. The temperature and exposure time vary depending on the type of autoclave unit and the contents of the load. A common cycle consists of 15 minutes of preheat, 15 minutes of pressurized steam, and 5–15 minutes of cooling [19]. Steam sterilization has been in existence for a long time and it is recognized to be one of the most effective, safe, and economical sterilization tech­ niques [20]. One major disadvantage of steam sterilization is the inability to sterilize heat‐sensitive materials, such as plastic or some rubber materials. Some advantages are that it is a short process, allowing a quick turnaround of packaged items, and it can be used in any healthcare setting due to the availability of various sizes of auto­ clave, including a table‐top version which can be used in an office setting. However, some healthcare systems are moving away from table‐top steam autoclaves due to the age of the technology, and the lack of quality control and biological indicator monitoring. Hence, critical items that need to be sterilized are transported to a hospital facility or a designated outsourced instrument processing facility with free‐standing steam autoclaves. Depending on the cost, outpatient office settings can purchase vari­ ous disposable, one‐time‐use, single instruments or use reusable instruments.

ETO ETO has the ability to sterilize heat‐ and moisture‐sensitive instruments and medical devices, such as ones made of plastic or rubber, flexible scopes, and other instruments with lenses. ETO sterilization is a lengthy process, last­ ing 12 hours or more, which decreases the availability of a center’s instruments. The process must be carried out in an area with proper ventilation, vent‐failure alarms, and a special sterilization chamber. Careful monitoring of ETO concentration must be maintained in work areas to prevent potential injury to healthcare personnel. Due to ETO’s high flammability it is mixed with inert gases, such as carbon dioxide or a fluorinated hydrocarbon, to decrease the risk of fire. In recent years hydrocarbons such as Freon 12, which used to be mixed with ETO for sterilization, have been found to contribute to destruc­ tion of the Earth’s ozone layer. Therefore, since 1998 there has been a significant decrease in the use of ETO for sterilization, since other methods have been intro­ duced [20]. Other disadvantages of ETO are it has the potential to cause harm to healthcare personnel if there is exposure, either acute or chronic. Irritation to the eyes or skin may occur from acute exposure. Chronic expo­ sure may lead to hematologic changes, increased risk of spontaneous abortion, and some forms of cancer [4]. Peracetic acid In 1988 a low‐temperature sterilization method using a peracetic acid compound was introduced for medical and surgical instruments, including endoscopes and instruments with lumens. Peracetic acid is an oxidizing agent composed of acetic acid, hydrogen peroxide, and water but has the disadvantage of being corrosive [21]. To allow for sterilization with peracetic acid, the STERIS Corporation in Mentor, Ohio, USA manufactured a ster­ ilant of 35% peracetic acid and a noncorrosive chemical. This sterilant was packaged in a sealed, single‐dose con­ tainer and was designed to be used in the manufacturer’s table‐top sterilizer. This system was for “just in time” use, and so it did not require instruments to be wrapped or packaged. The table‐top system was equipped with cov­ ered tray inserts to accommodate various sizes of flexible endoscopes, rigid endoscopes, and other instruments. To circulate the sterilant and rinse water through the lumens and working channels of endoscopes, specific connecting tubes were designed to attach to the different styles of scopes. This sterilization process required filtered water of 50 °C to dilute the sterilant to a 2% concentration and the system was designed to empty the liquid concentrated sterilant via a drainage system that had to be connected to the facility’s waste management line. The final phase

7

8

Section 1  Basic Principles

removed excess water by passing clean filtered air through the machine’s chamber, including the tubing connected to the lumens and working channels of the scopes. This table‐top unit was equipped with a com­ puter controlling the cycle’s temperature, duration, and verification of completion status. Another feature of this unit was it allowed a diagnostic cycle to be run before daily use to ensure the unit had full functionality. An  internal sensor would stop the unit and abort the procedure if an error in the process was detected [4, 21]. In December 2009 the US Food and Drug Adminis­ tration (FDA) ceased to allow the use of the original STERIS I system due to it being unable to sterilize instru­ ments as originally intended. The system may not have performed appropriately and therefore caused possible transmission of microorganisms to patients and health­ care workers and improper instrument function [22]. But in April 2010 the FDA approved a newly designed liquid chemical sterilization system known as the Steris System 1E Liquid Chemical Sterilant (SS1E), which uses a peracetic acid‐based germicide to sterilize medical instruments such as flexible endoscopes. The system uses filtered tap water that is exposed to ultraviolet rays to eliminate microorganisms such as fungi, protozoa, and bacteria in the water. Once the process is completed the instrument or device is ready for use or can be placed in storage if not needed. Since this system uses filtered tap water, which is not sterile, critical items are contrain­ dicated for this method [22–24]. Gas plasma The newest method of sterilization is hydrogen peroxide gas plasma sterilization, which has been available in the United States since 1993. This low‐temperature system allows for sterilization of instruments, especially heat‐ sensitive or delicate ones, in just 60–75 minutes, depend­ ing on the model [20]. This technology is based on gas plasma, which has been referred to as the fourth state of matter (i.e. liquids, solids, gases, and gas plasmas) [4]. There are five phases of this process: the vacuum phase, injection phase, diffusion phase, plasma phase, and vent phase. Terminal sterilization occurs after these five phases have been completed. The positive aspects of this system are there are no toxic fumes, no plumbing, no aeration time, and no ventilation system required. The compact, free‐standing system requires a small area and an electrical source [21]. Immediate‐use sterilization Flash sterilization, or immediate‐use steam sterilization (IUSS) [10], is a high‐temperature, high‐moisture pro­ cess used to sterilize wrapped or unwrapped instruments

rapidly for just‐in‐time use. This method is most useful in an emergency situation when an instrument becomes contaminated during a procedure and there is no sterile replacement. Other reasons for using this method may include a low‐volume inventory of specialty instruments that are needed for back‐to‐back procedures, or that a surgeon brings a specialty instrument required for a pro­ cedure that is not available in the healthcare facility. However, these reasons should be resolved by purchas­ ing the appropriate amount of instruments based on the volume of cases and improved communication with sur­ geons in advance if any specialty instruments are needed for the case. These instruments can be brought to the healthcare facility and processed according to the manu­ facturer’s guidelines in a timely manner with the proper communication and planning. During the last 10 years, immediate‐use sterilization in healthcare facilities has come under close scrutiny due to an increase in surgical site infections (SSI) in patients who had an immediate‐use‐sterilized item used or implanted during their procedure [4]. Although it is an approved method of sterilization for immediate use, excluding heat‐and moisture‐sensitive items such as flexible endoscopes or implants, it has become a contro­ versial method. IUSS is not effective if the instrument or device has not been appropriately cleaned, decontaminated, and rinsed according to the manufacturer’s instructions. The cleaned item to be sterilized is placed in an open mesh pan or a specially designed rigid container with a lid that allows for rapid penetration of steam [4]. Once the steri­ lization cycle has been completed the covered, sterile item is transported to the point of use. Ineffective clean­ ing and sterilization can result in a SSI, increased length of hospital stay, increased hospital costs, and liability. As of 2014, the Joint Commission has included in their National Patient Safety Goals a focus on prevention of SSIs, which can be caused by instruments being improp­ erly cleaned and processed by IUSS [25]. Multiple issues need to be considered when approving this method of sterilization in your healthcare facility. A most crucial issue is the location where the instrument will be cleaned prior to sterilization. It is ideal for the instrument to be processed in a designated soiled utility room with negative pressure and 10 air exchanges per hour [26]. If there is no designated soiled utility room within the operating environment then the instrument should be brought to the central sterile processing department for adequate processing. Location of the immediate‐use sterilizer will determine whether pan or container method should be utilized, such as an open pan or a steam‐penetratable container with a lid. With the implementation of IUSS, healthcare facilities are placing intended sterilizers for immediate use in close

1  Care and Sterilization of Instruments

proximity to specific operating or procedure rooms to assist in aseptic transport to the sterile field. Healthcare personnel retrieving containers from the sterilizer and transporting sterilized devices must don heat‐sensitive gloves to avoid the potential risk of burning. Once the item is accepted into the sterile field it must be cool before use to prevent a patient burn injury. If necessary the immediate‐use‐sterilized item should be placed in sterile saline to cool before use. Depending on the type of sterilizer and the composi­ tion of the item to be sterilized for immediate use there are specific guidelines from the American National Standards Institute/Association for the Advancement of Medical Instrumentation (ANSI/AAMI) [24]. The tem­ perature regardless of the sterilizer should always be 132–135 °C. The recommended sterilization exposure time ranges from 3 to 10 minutes and depends on the type of sterilizer and the contents of the load. Drying times of 0–1 minute are recommended for gravity‐dis­ placed sterilizers and will also depend on the item and the sterilizer manufacturers’ instructions [4, 27]. Quality monitoring of the sterilizer’s daily function and each cycle along with documentation is a vital part of the sterilization process. The types of monitoring for include physical, efficacy, chemical, and biological rapid readouts. Any breakdown in the process, such as an incorrect temperature or a positive biological indicator, must be reported immediately to management and the physician for further follow‐up and corrective action. Education of staff and documentation of competence of the procedure for immediate‐use sterilization are other important requirements. Initial and annual training should be provided to all involved healthcare personnel, along with return demonstration by the staff to validate their competency in immediate‐use sterilization [27, 28]. To avoid overuse of immediate‐use sterilization, it is recommended to increase the inventory of high‐volume items that are being sterilized for immediate use, to review the schedule the day before to anticipate instru­ mentation needs, to expedite immediate sterilization after use of surgeon or procedural specialty items to allow for availability of sterile equipment, and to take receipt of implants in a timely manner to allow for a full sterilization process to take place prior to the procedure’s start time [28, 29].

­Other alternatives HLD is the other alternative to sterilization in specific healthcare environments. HLD can be expected to kill all microorganisms, with the exception of a few bacterial spores when a high number is present [4, 6, 19]. The steps

of this process are similar to sterilization but do not include packaging or placement of an item in a steriliza­ tion container. The steps of this process are precleaning, cleaning, rinsing, drying, immersion in disinfectant solution, sterile‐water rinsing, drying, and immediate use or storage. As of March 2015, the FDA approved various agents for HLD: ≥2.4% glutaraldehyde, stabilized hydrogen peroxide, peracetic acid, and ≥0.575% ortho‐ phthalaldehyde (OPA) [5, 30]. Some of these agents may be mixed together at certain strengths to make one ­disinfectant solution. The required soak time and tem­ perature of the solution differs based on the disinfectant used. Aldehyde agents are most commonly used for HLD, especially for the manual process. Glutaraldehyde, which is the most commonly used solution, has an alkaline pH and can be used for 2–4 weeks or 30 days depending on the formula, but must be checked daily for potency [19, 30]. The disinfectant solution to be used for the instrument or medical device must be approved by the instrument or device manufacturer and be stated in the IFU guidelines. Prior to use, healthcare personnel must don a new set of PPE, including a full face shield, impervious gown with sleeves, and nitrile gloves. The chemical disinfectant must be prepared in a well‐venti­ lated area with a low traffic pattern. Depending on the IFU, some flexible endoscopes can be processed in an automatic endoscope reprocessor. This is a closed system that allows the scope’s external surface to be fully exposed to the disinfectant solution. Connection tubing is attached to the lumens, allowing internal channels to be purged with the solution as well. The benefit of this closed system is it lessens the chance for exposure to the chemical disinfectant solution [6]. With a shift of hospital procedures to outpatient healthcare facilities, there is an ever‐present concern about HLD and sterilization of semicritical and critical instruments and medical devices. Nationwide in the United States there is an awareness of neglect in the required guidelines for processing of semicritical items by HLD, especially all flexible endoscopes, including cystoscopes. Healthcare‐associated infections are on the rise and connected to contaminated endoscopes due to improper reprocessing [10, 31]. In September 2015 major regulatory organizations of the Department of Health and Human Services  –  the Centers for Disease Control (CDC) and the FDA – communicated an alert to healthcare staff regarding the importance of properly processing (cleaning, disinfecting, decontam­ ination, and sterilization) semicritical and critical medical instruments and devices. The FDA recom­ mended that any instrument or medical device that passes through an endoscope and comes into contact with sterile tissue, such as a biopsy forceps, must be sterilized prior to use [7, 31].

9

10

Section 1  Basic Principles

There are two factors that must be in place to ensure the proper process for cleaning and disinfecting instru­ ments or medical devices prior to HLD or sterilization. One is the physical area or layout and the second is training and education of the staff preparing instruments for HDL or sterilization. The physical layout should consist of two separate work areas regardless of the healthcare setting, allowing a dirty‐to‐clean flow from one room to the other. An instrument processing room (dirty) receives the soiled instruments for cleaning and decontamination. A HLD system can be found in this room as well. The purpose of the adjacent room (clean) is for instrument preparation, sterilization, and storage of disinfected flexible scopes when necessary. Instru­ ments stored in this room must be either sterile or HLD, and ready for use. Ideally, a third room for instrument storage would be beneficial to allow the clean room to be utilized just for instrument processing and sterilization. In some outpatient healthcare facilities there can be a substerile room adjacent to the procedure room that accommodates a free‐standing steam sterilizer. This is for any instruments that can be sterilized as per the man­ ufacturer’s IFU, such as flexible instruments, vasectomy trays, or rigid cystoscopes. In the instrument processing room there should a designated dirty sink, a clean sink, and a hand‐washing sink. A double sink should be desig­ nated as either dirty or clean and therefore there must be yet another two sinks, one for dirty or clean and the other for hand washing. The latter should have an eyewash station attached, in case there is exposure of the eyes to bodily fluids or any chemicals used in this area. Designating a clean and dirty sink is to help prevent the possibility of cross‐contamination while cleaning the instruments or medical devices. Due to certain circum­ stances some outpatient healthcare facilities may only be able to have a double sink, with one used for cleaning and the other for rinsing. These sinks must be wiped down in between uses with a bleach‐based Environmental Protection Agency (EPA)‐registered hospital‐grade surface disinfectant after cleaning dirty instruments and before rinsing. The sinks should be equipped with a gooseneck‐style faucet with winged handle controls to allow for proper water temperature adjustment. Sensor‐ controlled faucets are not recommended as it is difficult to obtain a precise water temperature that is adequate for cleaning and decontamination of instruments or medical devices [32]. Before placement in the disinfectant solution all items must be rinsed thoroughly to remove any residual deter­ gent and dried completely to prevent dilution of the disinfectant solution once an instrument is immersed [9]. Once an instrument is fully immersed, if it has lumens or working channels the disinfectant solution must be flushed through with a syringe three times for internal

exposure. The syringe must remain in place for the full indicated soak time [32, 16]. Exposure time ranges from 10 to 45 minutes with a solution temperature of 20–25 °C [5]. After the recommended exposure time, the instrument is transferred to an adjacent basin filled with sterile water. The instrument is fully immersed in sterile water and the external surfaces are wiped with a lint‐free cloth. If the instrument has lumens or working channels the sterile water must be flushed through three times to remove any residual disinfectant solution. The final step before use or storage is to thoroughly dry the instrument and, if it has lumens or working channels, air is to be forced through with a large sterile syringe. For use in a proce­ dure the instrument should be transferred to a sterile sheet or drape, covered in a sterile manner and trans­ ported to the point of use. If a scope is to be placed in storage it is recommended that it be hung in a well‐ ventilated drying cabinet that supplies forced air in cycles. Scopes are hung in a vertical position and con­ nected to plastic tubing which enables the transport of forced air. This drying process prevents recontamination from residual fluid that may stay dormant in the scope and harbor bacterial growth, further promoting thorough drying of the internal channels of the endoscope [5]. The drying process can be enhanced with filtered, low‐­ pressure medical air, a large syringe filled with air, or by flushing with 70% alcohol according to the manufacturer’s guidelines or IFU. If the scope has detachable pieces they are to be removed prior to storage to stop residual mois­ ture from flowing into the inner channel and aiding in growth of microorganisms [6, 7, 10, 12, 32, 33]. Monitoring of the room’s temperature and humidity with a traceable digital meter is recommended by the CDC when storing flexible endoscopes [12]. According to the Association of Operating Room Nurses (AORN), the safest practice in the disinfection of endoscopes is to disinfect at the end of each day’s use, again before the first use of the next day, and again before each use throughout the day [34]. Any healthcare facility that utilizes chemical disinfec­ tion must provide a safe environment for the setup and for the protection of their healthcare personnel. The solution, once activated and dispensed, must be kept in a covered container with a tight‐fitting lid in a well‐­ ventilated area. A free‐standing or vented chemical fume hood is recommended for aldehyde solutions. With a free‐standing fume hood, a carbon filter should be installed and must be changed and disposed of according to the manufacturers’ instructions [9]. Fume hoods are available in various sizes and designs to accommodate your needs (Figures 1.4 and 1.5). A spill kit must be read­ ily available in the event of a spillage of the chemical solution. Disposal of the chemical solution once deemed ineffective or on expiration must follow state and local

1  Care and Sterilization of Instruments

Figure 1.4  Table‐top and wall‐mounted fume hoods for aldehyde solutions.

Figure 1.5  Table‐top fume hood for aldehyde solutions.

regulations. A neutralizing agent should be added to the solution to deactivate its potency. This can take from 5 to 15 minutes before disposal of the neutralized solution can occur [6]. In 2014, The American Urological Association (AUA) and the Society of Urologic Nurses and Associates (SUNA) published a joint white paper on the reprocessing of flexible cystoscopes. This is an excellent resource for any healthcare facility that utilizes flexible cystoscopes and it includes an “In‐Office Disinfection of Flexible Cystoscopes Quick Reference Tool” which can help guide the instrument processing team [6]. OPA is a newer high‐level disinfectant that was approved by the FDA in 1999. It is less potent than glutaraldehyde, is not an irritant to the eyes and nasal passages, and has a soak time of just 12 minutes. Prior to 2004 this chemical was ideal for the HLD of flexible cystoscopes, but due to reports of patients with bladder cancer experiencing an

anaphylaxis‐like reaction after cystoscopy utilizing scopes processed with OPA, this chemical disinfectant is cur­ rently contraindicated for cystoscopes and any urologi­ cal instruments that will have contact with the bladder, according to the CDC and the manufacturer [6]. OPA is the disinfectant of choice for an ultrasound rectal probe, a semicritical device, which is used for guidance during a prostate needle biopsy procedure or for prostate measurement. Prior to the immersion and soak time, an  ultrasound probe must be cleaned, wiped, rinsed, and dried according to the manufacturer’s guidelines. A  newer, alternative method of HLD for intracavity ultrasound probes is a 35% hydrogen peroxide mist system that is now available and approved by the FDA. This system not only disinfects the part of the probe (the head) that has contact with mucous membranes but it also disinfects the part of the probe used by the physi­ cian’s hand to position the probe (the handle) and which therefore has the potential for contamination due to its function [33, 35, 36]. Documentation of the HLD process includes several factors. The initial setup of the HLD solution must be tested for its efficacy and level of concentration, known as minimal effective concentration (MEC). If the MEC fails the check before the intended expiration date the solution must be discarded [6]. The solution is tested every day with a reagent strip made by the solution’s manufacturer, and the solution is also tested before use. The result is documented in a log book. When an item is intended for use the following information must be documented in the log: date, test strip result for effective solution concentration (positive or negative), tempera­ ture of the solution, name of the semicritical item, serial number if applicable, time it was placed in the solution, time it was removed, patient medical record number, cleaning method (manual or automated), soak station number if there is more than one on site, and name of person performing the HLD [6]. Each healthcare facility will determine which method of sterilization is best for their practice. In a hospital setting, steam, gas plasma, and peracetic acid are preferred. Some ambulatory healthcare facilities have a steam autoclave, and also use gas plasma and/or peracetic acid for sterilization methods. As for HLD semicritical items, aldehydes are used primarily to carry out this process. Several organizations have developed guidelines for sterilization and disinfection of instruments and medical devices. The AAMI developed recommended practices for steam sterilization in healthcare facilities. The CDC put together guidelines for disinfection and sterilization in healthcare facilities and guidelines to prevent surgical infections. The AORN have recommended practices for cleaning and caring for surgical instruments, steriliza­ tion, the use and care of endoscopes and HLD in the

11

12

Section 1  Basic Principles

perioperative setting. The Joint Commission has standards (IC.02.02.01) to reduce the risk of infection associated with medical equipment, devices, and supplies; this includes cleaning, disinfection, sterilization, and storage [37]. In 2013, this standard was identified as one of the top five least‐adhered‐to requirements for all healthcare facilities. It fell into the category of an immediate threat to life due to a break in technique of sterilization and HLD of instruments and medical devices [29]. When surveying a healthcare facility the surveyors are looking for documentation of staff orientation, training, and competency of the relevant processes. Other require­ ments that they will focus on are quality monitoring and adherence to the manufacturers’ IFU when processing medical devices or instruments. These organizations’ recommendations serve as a resource for your policy and procedure manuals and a guide to provide best practice in your healthcare facility. Education and the training of staff is a current focus in healthcare facilities that carry out HLD and steriliza­ tion processes. In the hospital setting the staff in the central sterile department maintain certification for instrument technicians after staff have received the required training and acquired their certification. Those who work in nonhospital settings and who are not certified should receive appropriate hands‐on train­ ing and education sessions to ensure they understand all aspects of the cleaning, decontamination, disinfec­ tion, and sterilization processes, including the safe use

of all equipment involved. All trained staff should have a documented initial and annual competency kept in their employee departmental file for each process and piece of equipment used [15].

­Conclusion The ultimate goals of instrument sterilization and HLD are to maintain a safe patient environment, provide quality patient care, and positive surgical or procedural outcomes with no evidence of infections. It is the responsibility of the healthcare facility to develop policy and procedures and evidence‐based guidelines for the reprocessing of all critical and semicritical patient care items. These policies and guidelines should identify whether disinfection or sterilization is indicated as per the manufacturer’s guidelines and the Spaulding classi­ fication system. The healthcare personnel responsible for the full cycle of reprocessing of these items should be trained and certified to perform all aspects of this task. In the physician office setting there should be desig­ nated personnel who have been trained and deemed competent to carry out the tasks of reprocessing patient care items based on the availability of soiled and clean work areas. Continuing education should occur to keep the trained and certified personnel informed of any changes in process or equipment use, and as an annual scheduled event.

­References 1 New world encyclopedia. Biography.Lister, Joseph,

7 Rutala WA and Weber DJ. Reprocessing semicritical

2

8

3

4

5

6

1st baron Lister. http://www.newworldencyclopedia.org/ entry/Joseph_Lister The future of gas sterilization. Ethylene oxide (EtO or EO) sterilization in healthcare facilities. http://www. anpro.com/support/indexeto.htm Pilcher PM. Historical clinical perspective from 1911. Practical cystoscopy: Care of the instruments and preparation for a cystoscopic examination. Urol Nurs 2004 Apr;24(2):120–124. Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. http://www.cdc.gov/hicpac/pdf/guidelines/ Disinfection_Nov_2008.pdf Rutala WA and Weber DJ. Disinfection and sterilization in health care facilities: what clinicians need to know. Clin Infect Dis 2004:39:702–709. American Urological Association. Reprocessing of flexible cystoscopes. Joint AUA/SUNA White Paper 2014;1–17.

9

10

11

12 13

items: current issues and new technologies. Am J Infect Control 2016;(44):e53–e60. Drummond DC and Skidmore AG. Sterilization and disinfection in the physician’s office. Can Med Assoc J 1991;145(8):937–943. Association of peri‐Operative Registered Nurses. Recommended practices for high‐level disinfection. AORN J 2005 Feb;81(2):402–412. Rutala WA and Weber DJ. Disinfection, sterilization, and control of hospital waste. In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 8e, vol. 2, 3294–3309. Elsevier. Association for peri‐Operative Registered Nurses. Recommended practices for cleaning and caring for surgical instruments and powered equipment. AORN Journal March 2002;75(3):727–741. Klacik S. New AAMI standard for endoscope reprocessing. OR Manager 2015 Sep;31(9):18–21. Thomas LA, Essentials for endoscopic equipment. Gastroenterol Nurs 2005 January;26(6):512–513.

1  Care and Sterilization of Instruments

14 Hutchisson B and LeBlanc C. The truth and

15

16

17 18

19 20

21

22

23

24

25

consequences of enzymatic detergents. Gastroenterol Nurs 2005 March;28(5):372–376. Dimon VJ. The evolution solution. For best outcomes, utilize, standardize, recognize your SPD. 2016 SPD Equipment &Technology Guide. Healthcare Purchasing News 2016 May;34–42. Rutala WA, Gergen MF, Bringhurst J, and Weber DJ. Effective high‐level disinfection of cystoscopes: is perfusion of channels required? Infect Control Hosp Epidemiol 2016 Feb;37(2):228–229. Vrancich, A. Instrumental care. Mater Manag Health Care 2003 Mar;12:22–25. Aiello AE, Larson EL, and Sedlak, R. Hidden heroes of the health revolution sanitation and personal hygiene. Am J Infect Control 2008;36:S128–S151. Sebben JE. Avoiding infection in office surgery. J Dermatol Surg Oncol 1982 June;8:6. Chobin N and Trattler B. Perspectives from sterile processing and perioperative services. Mater Manag Health Care 2003 February:12:23–25. Crow,S. Peracetic acid sterilization: a timely development for a busy healthcare industry. Control Hosp Epidemiol 1992;13:111–113. US Food and Drug Administration. Steris system 1 processor: FDA notice and recommendations. http:// www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts (accessed 16 April 2018). Mattke S. Letter to the editor: sterilization of endoscopic instruments. Reply: Rutala WA and Weber DJ. J Am Med Assoc 2015 Feb;313(5):524. US Food and Drug Administration. Steris 1E (SS1E) liquid chemical sterilant –K090036. http://www.fda. gov/MedicalDevices/ProductsandMedicalProcedures/ DeviceApprovalsandClearances/Recently‐ ApprovedDevices (accessed 16 April 2018). Foster S, Cox Sullivan S, Brandt J et al. Code flash: how an interdisciplinary team eradicated immediate‐use steam sterilization. Infect Control Hosp Epidemiol 2015 Jan;36(1):112–113.

26 Leonard Y, Speroni KG, Atherton M and Corriher J.

27 28 29

30

31

32

33

34 35

36

37

Evaluating use of flash sterilization in the OR with regard to postoperative infections. AORN J 2006 Mar;83(3):672–680. Satkowski LK. OR sheds light on a sterilization dilemma. Mater Manag Health Care 1995 Oct;4(10):60–64. Carlo A. The new era of flash sterilization. AORN J 2007 Jul;86(1):58–68. The Joint Commission, Division of Health Care Improvement. Improperly sterilized or high‐level disinfected equipment. QuickSafety 2014 May;2:1–2. US Food and Drug Administration. FDA‐cleared sterilants and high level disinfectants with general claims for processing reusable medical and dental devices. September 2015. http://www.fda.gov/ MedicalDevices/DeviceRegulationandGuidance/Repro cessingofReusableMedicalDevices/ucm437347.htm Rutala WA and Weber DJ, New developments in reprocessing semicritical items. Am J Infect Control 2013;(41):S60–S65. Bringhurst J. Special problems associated with reprocessing instruments in outpatient care facilities. Am J Infect Control 2016;44:e63–e67. Rutala WA and Weber DJ, Disinfection and sterilization in health care facilities: an overview and current issues. Infect Dis Clin N Am 2016;30:609–631. Fogg D. High‐level disinfection, endoscope disinfection. AORN J 2000 Feb;71(2):398–403. Rutala WA,Gergen MF, and Sickbert‐Bennett EE. Effectiveness of a hydrogen peroxide mist (Trophon) system in inactivating healthcare pathogens on surface and endocavity probes. Infect Control Hosp Epidemiol 2016 May;37(5):613–614. Alfa MJ. Intra‐cavitary ultrasound probes: cleaning and high‐level disinfection are necessary for both the probe head and handle to reduce the risk of infection transmission. Infect Control Hosp Epidemiol 2015 May;36(5):585–586. The Joint Commission, Division of Health Care Improvement. Superbug reveals challenges with high‐ level disinfection. QuickSafety 2015 March;11:1–2.

13

14

2 Radiation Safety During Diagnosis and Treatment Yasser A. Noureldin1,2 & Sero Andonian2 1 2

Department of Urology, Benha Faculty of Medicine, Benha University, Benha, Egypt Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada

­Introduction According to a 2009 National Council on Radiation Protection and Measurements (NCRP) report, the total ionizing radiation exposure to United States citizens had almost doubled over the previous two decades [1]. The report attributed this to increased exposure from computed tomography (CT) scans, image‐guided fluoroscopic procedures, and nuclear medicine studies, which were estimated at 67 million, 17 million, and 18 million, respectively. During 2006, these imaging modalities constituted 89% of the total annual radiation exposure [1, 2]. On the other hand, recent studies have shown significant worldwide increase in the prevalence of stone disease [3,  4]. In the United States, prevalence increased from 5.2% in 1994 to 8.8% in 2010 [5]. Similarly, in the United Kingdom, renal colic episodes increased by 63% from 2000 to 2010 [5]. This was associated with marked decline by 83% in open surgeries and a marked increase in minimally invasive endourologic procedures such as shock‐ wave lithotripsy (SWL), which increased by 55%, and ureteroscopy, which increased by 127% [5]. The increase in the incidence of stone disease and management with endourologic procedures is not without risks. Since ionizing radiation is not only an integral part of modern endourologic interventions but also constitutes the basis for diagnosis, preoperative planning, and post‐operative follow‐up, it is important for the urologists to have an intimate knowledge of radiation safety measures and to minimize ionizing radiation as much as possible to themselves, operating room personnel, and most importantly to their patients. This chapter discusses the state of the art in radiation safety measures during diagnosis, treatment, and follow‐up. To follow radiation safety measures, one needs to understand how ionizing radiation is generated in the first place. Therefore, this chapter will start by

explaining the anatomy of the X‐ray tube and the generation of X‐rays. It will then go through potential hazards of ionizing radiation. At the end of this chapter, readers will have developed strategies in lowering radiation exposure during diagnosis, treatment, and follow‐up of their patients requiring endourologic procedures.

­ asic terminology and International B System of Units in radiology According to the International System of Units (SI), the absorbed dose, measured in Grays (Gy) or joules/kg, is the amount of energy absorbed per mass of tissue [6, 7]. To measure the biological effect of radiation on human tissue, the mean absorbed dose in an organ or tissue is multiplied by radiation weighting factor to calculate the “equivalent dose.” The radiation weighting factor differs according to the type of radiation. For X‐ray imaging (photons), it equals 1. Therefore, the mean absorbed dose and the equivalent dose are numerically equal. The SI unit for equivalent dose is the Sievert (Sv). Thus, 1 Gy equals 1 Sv. As the doses used for radiographic imaging are generally very low, milliSieverts (mSv) is used as a standard nomenclature describing doses administered [8]. The probability and severity of harmful effects from the same value of equivalent dose of radiation differ among different body organs and tissues. The International Commission on Radiological Protection (ICRP) refers to the combination of probability and severity of harm as “detriment.” In order to determine the combined detriment from stochastic effects due to the equivalent doses in all body organs and tissues, the “effective dose” is described. It is calculated by multiplying the equivalent doses in each organ by a tissue weighting factor (W T), and the results are summed

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

2  Radiation Safety During Diagnosis and Treatment

Source of radiation (Inside or outside the body)

Radiation emission

der (KUB) film to 18 mSv for a CT scan, depending upon device settings and body habitus. Even with relatively low radiation doses, the concern over excessive radiation exposure has grown recently due to the exponential rate at which medical imaging is used [14].

­How are X‐rays generated? Organs Absorbed doses (Gy)

Radiation weighting factors

Organs Equivalent doses (Sv)

Tissue weighting factors and summation

Whole body Effective doses (Sv)

Figure 2.1  The relationship between absorbed dose, equivalent dose, and effective dose. Reproduced with permission of Sage Publications Ltd.

over the whole body [8] (Figure  2.1). The SI unit for effective dose is also the Sievert (Sv). The weighting factors vary according the radiosensitivity of each organ and are determined by the ICRP. For example, a W T of 0.12 was described for red bone marrow, colon, lung, stomach, breast, kidney, pancreas, and prostate, a W T of 0.08 for gonads, and W T of 0.04 for the skin and brain [8]. Another factor used for estimation of radiation exposure is the dose area product (DAP), which is calculated from the radiation dose to air multiplied by the area of the X‐ray field. It is expressed in Gy/cm2 and it could be reliably used to estimate the effective dose by combining the DAP with the appropriate coefficient (which varies for the irradiated portion of body and the protocol used) derived from Monte Carlo simulations with anthropomorphic digital phantoms [9–11]. The size‐specific dose estimate is considered as a novel method of reporting a patient’s radiation dose. It is calculated by multiplying CT dose index volume (CTDIvol) by a size‐dependent conversion factor. It accounts for patient size in a way that the increase in patient size decreases the size of specific dose estimates [12, 13]. The average medical imaging exposure ranges from 0.7 mSv for a single plain kidney‐ureter‐blad-

Prior to understanding the hazards of radiation and methods of protection, it is wise to briefly consider the principles of radiation production. The basic components required for X‐ray generation are (i) rotating anode (usually made of tungsten which is capable of handling a high heat load without warping or vaporizing), (ii) cathode (source of electrons), (iii) high voltage source, (iv) X‐ray vacuum glass tube, (v) housing (steel casing which provides shielding to prevent leakage of stray X‐rays), and (vi) collimator (which specifies the X‐ray field). Within the shielded housing, X‐rays are generated when a high voltage is applied between the cathode and the rotating anode. The amount of electrons liberated from the cathode is directly proportional to the amount of current applied in milliamps (mAs). A large voltage potential (kVp) in the range of 50–120 kVp is usually required. Higher energy X‐rays will penetrate deeper into tissues and penetrability of X‐ray photons is directly proportional to the average energy of the photons generated. Hence, obese patients are expected to receive higher doses of radiation to obtain appropriate image quality compared with thinner ones. Therefore, the potential energy is adjusted to compensate for differences in patient body mass index (BMI). X‐rays exit the housing through a narrow beryllium window, which permits the passage of only focused X‐rays. Lead collimators further restrict the area of exposure, limiting the radiation area and, in turn, the amount of scattered radiation from the patient to operating room personnel (Figure 2.2) [6, 7]. The amount of X‐ray photons, or radiation, generated by individual electrons varies depending on the proximity to the target material’s nucleus. Therefore, a direct impact transfers a large quantity of kinetic energy and generates maximum energy X‐ray photons, while a more distant interaction generates weaker X‐ray photons. The X‐ray photons produced is termed bremsstrahlung, which translates to “braking radiation.” The variability of distance from the nucleus therefore creates a spectrum of energy emitted from the X‐ray tube, the bremsstrahlung spectrum. The mean energy of the photons across the spectrum is typically equal to one‐third the total potential difference generated by the voltage. The energy of photons is an important consideration because the higher the energy of the photon, the more

15

16

Section 1  Basic Principles Display monitors

TV camera

Image intensifier (detector) C-arm motion Tabletop to detector

Tabletop

Source to tabletop

X-ray tube (source)

Linear collimator

Iris collimator

Figure 2.2  X‐ray generator set‐up. Adapted from Wheeler AH. Therapeutic injections for pain management. http://emedicine.medscape. com/article/1143675‐overview#a3 (accessed 15 July 2016).

shielding is required and the more readily the photon will penetrate tissue. Shielding for the X‐ray housing is restricted to less than 100 mrad/hour at 1 m to prevent excessive leakage rates while the tube is operating at maximum potential difference and current. Photons leave the tube through a small opening in the shielding and are directed towards the area of interest (Figure 2.2). Filters are then generally applied to these diagnostic X‐ray beams. These filters attenuate the lower‐energy photons which do not have sufficient energy to reach the detector and therefore are not of clinical benefit. The electrons with energy high enough to penetrate through the filters are focused by the collimators through the tissue area of interest. Typically, the collimators further restrict exposure to the patient and the operator by eliminating radiation exposure outside the area of interest (Figure 2.2). The quality of the image obtained is significantly reliant on the energy level and quantity of the electrons reaching the detector. X‐ray photons need to be of high energy enough to penetrate through the tissue but low energy enough to limit "over‐exposure" of the detector.

Therefore, the most controllable aspects of diagnostic imaging equipment are (i) the potential difference (kVp), which determines the amount of energy in X‐ray photons, (ii) the current (milliamps), which determines the number of electrons that create photons for a given time period, and (iii) exposure time, which combines with the current to determine the total quantity of X‐rays produced. Because radiation exposure is proportional to the square of kVp and linearly related to milliamps, ideally it is better to increase kVp prior to increasing milliamps to enhance image quality. Conversely, if an initial image is “over‐exposed,” reducing current will greatly reduce radiation dose. Emitted X‐rays have three potential fates as they interact with living tissue: (i) some X‐rays are absorbed by dense tissues such as bones, (ii) others penetrate soft ­tissues to reach the image intensifier, and (iii) 0.1% of X‐rays are scattered 90° to the incident radiation, exposing bystanders. By placing the image intensifier above the patient and the source below the patient, the amount of  scattered radiation exposure to the surgeon can be

2  Radiation Safety During Diagnosis and Treatment

minimized. Furthermore, leakage from the tube itself is shielded and is further away from the operating surgeon’s head and body (Figure 2.2). Understanding the basic principles and mechanisms of X‐ray generation provides a foundation for the understanding of radiation protection. Proper equipment maintenance and inspection of shielding and filters are requisite requirements for operators of imaging equipment. Fluoroscopy units in hospitals are usually inspected and maintained annually by biomedical engineers. Nonetheless, it is important for the urologist to understand the basic electrical parameters (kVp and current) and their effects on X‐ray generation leading to optimization of the image quality while minimizing dose to patients and operators. Finally, the use of collimation to limit the exposure field to precisely target the tissue area of interest can greatly restrict unnecessary exposure.

­ otential hazards of excessive P radiation exposure There are two broad categories describing the risks from radiation exposure; namely, deterministic and stochastic. Deterministic effects These generally refer to a direct cell death resulting from direct exposure of a biologic tissue to high doses of radiation. This type of tissue reaction needs a threshold dose to occur; below this threshold nothing will happen and the degree of tissue response correlates with the intensity of radiation dose above the threshold. An example is the opacification of the lens of the eye or cataract formation at a threshold of 200 rad, skin erythema and depilation at a threshold of 300–600 rad, and even skin ulceration and necrosis at a threshold of 1500–2000 rad [1, 8]. Stochastic effects These refer to events that are likely to occur by chance irrespective of the threshold levels of radiation, and likelihood of occurrence increases with dose. However, there is no relationship between severity of the event and the dose. The stochastic risks of greatest concern are hematologic and solid organ malignancy. The proposed explanation of these carcinogenic hazards is that X‐rays, as a type of ionizing radiation, possess enough energy to overcome the binding energy of the electrons orbiting atoms. Thus this energy can knock electrons out of their orbits and create ions. In biologic material, X‐rays can either ionize DNA directly or produce hydroxyl (OH) radicals from the interaction with water molecules. These hydroxyl radicals in turn interact with nearby DNA and

cause epigenetic responses in the form of radiation‐ induced genomic instability or bystander signaling, base damage, or strand breaks. While most X‐ray‐induced DNA damage undergoes rapid repair by different intracellular mechanisms, occasional problems in DNA repair may happen resulting in chromosomal translocations or point mutations which may lead to induction of carcinogenesis, especially in growing cells such as in infants and children [14]. Whereas a correlation between excessive radiation exposure and deterministic dermal and ocular effects exists, models used to calculate the stochastic effects associated with radiation exposure are still debated [15]. Two recent studies assessing the risks of cancer following repeated or protracted low‐dose radiation exposure among 308  297 radiation‐monitored workers from United States, France, and United Kingdom [16] showed that there was a linear increase in the rate of cancer with increasing radiation exposure. Workers were selected for monitoring based on conditions of being employed for at least 1 year by the Departments of Energy and Defence in the United States, the Atomic Energy Commission or the National Electricity Company in France, and nuclear industry employers included in the National Registry for Radiation Workers in the United Kingdom. After exclusion of chronic lymphocytic leukemia, there was an excess relative risk of mortality from leukemia of 2.96 per Gy with marked association between the radiation dose and mortality from chronic myeloid leukemia (excess relative risk per Gy 10.45) and doses were accumulated at very low rates (mean of 1.1 mGy/year) [16]. Another study revealed a direct estimate of the association between solid cancer mortality and protracted low‐dose exposure to ionizing radiation [17]. Another international study with 407 391 nuclear industry workers from 15 countries estimated the oncologic risks following prolonged low doses of ionizing radiation exposure. The authors found significant association between the radiation dose and all cancer mortality, with excess relative risk per Sievert (ERR/Sv) of 0.97 (90% confidence interval [CI] 0.28–1.77; 5233 deaths). Furthermore, duration of employment had a large effect on the ERR/Sv and lung cancer was the only type which had a significant association among 31 malignancies studied (ERR/Sv = 1.86 [90% CI 0.49–3.63; 1457 deaths]) [18]. In another study, the risk of cancer from diagnostic X‐ray in 14 developed countries was 0.6–1.8% compared with more than 3% in Japan, which has the highest ­estimated worldwide annual exposure [19]. Eisenberg and co‐investigators studied the risk of cancer in 82 861 patients without previous history of cancer and undergoing diagnostic or therapeutic imaging following acute  myocardial infarction from 1996 to 2006 [20]. The  cumulative radiation exposure was found to be

17

18

Section 1  Basic Principles

5.3 mSv/patient/year. Over a median follow‐up of 5 years, a total of 12 020 incident cancers were diagnosed. Every 10 mSv of low‐dose ionizing radiation was associated with a 3% increase in the risk of age‐ and sex‐adjusted cancer with a hazard ratio of 1.003 per mSv (95% CI 1.002–1.004) [20]. Additionally, Berrington de González and coworkers estimated future cancers attributable to ionizing radiation from CT scans to be 29 000 cases in the United States in 2007. Of these, 66% were females and the largest contribution (14 000) was from abdominopelvic CTs [21]. Furthermore, Smith‐Bindman and co‐ investigators reported that 1/600 men and 1/270 women patients who underwent CT coronary angiography at the age of 40 are at risk of cancer and this risk is halved for those who were in their sixties and doubled for those who were in their twenties [22].

­ ources of ionizing radiation S encountered in urology Diagnostic imaging There is no doubt that most medical diagnoses are based on ionizing radiation. However, diagnostic modalities such as ultrasound and magnetic resonance imaging (MRI) are free from radiation. Plain radiography, fluoroscopy, CT, and nuclear medicine studies are associated with various doses of ionizing radiation. Traditionally, plain radiography such as KUB films was the initial imaging modality for patients with suspected nephrolithiasis with a sensitivity of 59% and specificity of 71% [23]. This low accuracy is due to the failure of plain radiographs to detect uric acid stones. Furthermore, identification of stones might be masked by the overlying bowel gases. Advantages of KUB include low cost which rendered it  available worldwide and lower radiation exposure compared to other modalities (effective radiation dose of 0.2–0.7 mSv) [23, 24]. Intravenous urography (IVU) has additional advantages over KUB such as demonstration of the anatomical and functional status of the urinary system. It is associated with higher effective radiation dose ranging from 0.7 to 3.7 mSv, depending on the number of images [24, 25]. However, IVU is time‐consuming and necessitates the use of intravenous contrast materials with the risk of allergic reactions and contrast‐induced nephropathy Since being invented in 1970s, CT has been largely used in medical diagnosis and intervention. During a CT scan, multiple cross‐sectional two‐dimensional images of a specific area are produced by a rotating source passing X‐rays through the patient’s body. Later on, ­ these two‐dimensional images can be digitally combined to yield three‐dimensional images  [26]. In urologic

practice, CT scans play a vital role in preoperative ­ lanning of percutaneous nephrolithotomy (PCNL) and p SWL. For PCNL, it provides an orientation of the pyelocalyceal system and the relationship of the kidney to the surrounding organs such as the colon, liver, and spleen. In addition, preoperative non‐contrast CT (NCCT) scanning forms the basis of calculating different scoring systems assessing PCNL complexity such as the S.T.O.N.E. and Seol scoring systems [27, 28]. Regarding SWL, CT is very important for calculating the skin‐to‐ stone distance to determine whether shock waves can reach the stone. For both SWL and PCNL, it detects postprocedural complications and presence of residual stones [29, 30]. Furthermore, it is ideal for diagnosis, staging, and follow‐up of most urologic malignancies [31, 32]. In addition, NCCT is the imaging modality of choice for initial evaluation of patients with suspected urolithiasis with reported diagnostic sensitivity up to 98% and specificity up to 100% [33]. It is worth mentioning that the stone protocol CT scans performed for diagnosis and follow‐up of urolithiasis patients have scan acquisition parameters that differ from traditional abdominopelvic CT scans. Therefore, patients presenting with suspected stone disease to the emergency department undergo NCCT scans with acquisition parameters different from those used in the normal stone protocol CT scans to allow emergency physicians to diagnose pathologies other than stones [34, 35]. With the exception of stones encountered in patients undergoing indinavir therapy and pure matrix stones, NCCT scan can diagnose all types of urolithiasis such as calcium, uric acid, xanthine, and cystine stones [36, 37]. Furthermore, it detects other renal and abdominal pathologies which present with acute abdominal pain resembling renal colic such as diverticulitis, appendicitis, or ovarian torsion. Therefore, it is not surprising that 10–14% of NCCTs performed in the emergency departments for renal colic were associated with alternative diagnoses [38–43]. In addition to determination of stone burden, location, multiplicity, density (Hounsfield unit), and associated hydronephrosis, dual‐energy CT (DECT) technology, which has been introduced in the past decade, seems to possess the potential ability for accurate determination of stone composition [44–47]. It includes dual‐energy simultaneous scanning using two different energies, which permits tissue characterization. There are two currently available DECT systems: single‐source DECT (ssDECT) and dual‐source DECT (dsDECT). While ssDECT is assembled with one X‐ray tube with rapid kV switching between high (140  kVp) and low energy (80 kVp), dsDECT is assembled with two X‐ray tubes (140 and 80 kVp) and two detectors on a single gantry perpendicular to each other [48]. Several in vitro and

2  Radiation Safety During Diagnosis and Treatment

in  vivo studies have validated DECT technology for detection of stone composition using both dsDECT and ssDECT. It allows detection of stone composition based on the variation in attenuation characteristics of stones at different X‐ray energies with up to 100% sensitivity and accuracy in distinguishing non‐uric acid and uric acid stones, regardless of the size of stones [44, 46, 49, 50]. Furthermore, with evolving DECT algorithms, there is an application for accurate subcategorization of renal stones [49, 51]. To reduce radiation exposure, the current DECT protocol for renal stones includes the use of single‐energy mode at a low dose covering the abdomen and pelvis, to recognize possible calculi in the urinary tract. Once the urinary stone is detected, a dual‐energy acquisition targeted to the anatomical area of the stone is performed [37]. It should be noted that obese patients are at higher risk of more radiation exposure from CT [52]. In a recent study by Wang and coworkers, they found that obese patients are at more than threefold‐ increased risk of radiation exposure compared with nonobese patients during the stone‐protocol CT employing automatic tube current modulation (10.22 vs. 3.04 mSv; P < 0.0001) [53]. Disadvantages of CT include the high cost which limits worldwide availability, and the high radiation exposure, with effective radiation doses of 4.5–18 mSv [25]. In a study by John and colleagues, patients who underwent a CT were exposed to 14.46 mSv [54]. Furthermore, the median effective radiation dose (ERD) associated with an acute stone episode and 1 year of follow‐up at two American academic centers was 29.7 mSv [55]. Moreover, it was found that 20% of patients received over 50 mSv with an average of 3.5 CTs [55]. In a similar study by Fahmy et  al. assessing the ERD to which urolithiasis patients are exposed during the evaluation and follow‐up over the first and second year following the acute stone episode, they found that the average ERD per CT scan was 23.16 mSv (range 4.94–72.77 mSv). Furthermore, they found that 17.3% of patients exceeded 50 mSv during the first follow‐up year with mean ERD of 29.29 mSv (1.7–77.27 mSv) [56]. Another study reported that a case of acute kidney stone episode that may require radiological imaging in the form of one or two KUBs, one or two abdominopelvic CT, and one IVU during the first year of follow‐up may be exposed to a total effective dose between 20 and 40 mSv [24]. In addition, it has been calculated that the effective dose from CT scan of the abdomen in adult patient is roughly equivalent to effective dose from 400 chest X‐rays [25]. Even some surveillance protocols using CTs have been  shown to be associated with significant radiation exposure and the risk of developing cancers. Tarin and colleagues assessed the estimated cancer risks associated with the 5‐year surveillance protocol of stage I

non‐seminomatous germ cell tumors of the testis, as ­recommended by the National Comprehensive Cancer Network. They reported a lifetime cancer risk of 1.5% for different age groups with lung and colon cancer accounting for most of the risk [57]. Nuclear medicine imaging procedures such as position emission tomography CT (PET CT) scans and renal scintigraphy (renal scanning) entails the use of a radioactive material, called a radiotracer or radiopharmaceutical, which is introduced into the human body by injection, swallowing, or inhalation. This radiotracer accumulates in the area of the body being examined, where it gives off a small amount of energy that can be detected by gamma camera and provides details on both the function and structure of tissues and organs being examined. These radiotracers stay within the tissues for a period of time and liberate radiation. However, unlike other sources of ionizing radiation with a source of external radiation, nuclear studies represent a source of internal radiation. These studies are of special importance for identifying the function of organs such as the differential renal function which especially important in children with congenital renal anomalies. The ICRP reported a total of 18 million nuclear studies in the United States in 2006. Furthermore, the doubling of ionizing radiation exposure in United States over the last two decades was largely attributable to increased imaging from CT, interventional fluoroscopy, and nuclear medicine [26]. According to the US NCRP, CT scans, fluoroscopy‐ guided procedures, and nuclear medicine studies represent approximately 26% of the annual imaging procedures. Nonetheless, they cause 89% of the total annual radiation exposure [1, 26]. Interventional imaging The main interventional endourologic procedures such as SWL, ureteroscopy, and PCNL use fluoroscopic guidance. The increase in the number of these procedures over the past few decades has raised concerns regarding the amount of radiation exposure associated with these interventions. For example, in the United States, per‐ capita radiation exposure from medical sources increased about 600% (from 0.54 to 3.0 mSv) between 1982 and 2006 [25]. In terms of radiation exposure associated with each procedure, a study by Safak et al. found a mean ERD of 9.2 mSv (0.82–26.0 mSv) for PCNL [58]. These results were similar to the mean ERD reported by the Mancini group (9.09 mSv) [59]. Higher ERD was associated with higher BMI, larger stone burden, non‐branched stone configuration, and higher number of percutaneous access (PCA) tracts [59]. Furthermore, increased stone burden, prolonged operative time, multiple access tracts, and blood loss >250 cm3 have been associated with

19

20

Section 1  Basic Principles

s­ignificantly prolonged fluoroscopy time (FT) [60, 61]. Concerning ureteroscopy, the mean ERD has been recently reported as 1.13 mSv, which is equivalent to that of an abdominopelvic X‐ray [62]. This was lower than older studies which reported a mean ERD of 2.5 mSv [63]. The use of recent fluoroscopy devices might explain the cause behind the lower ERD in the more recent study. Predictors of prolonged FT during ureteroscopy were found to be urology trainees, male gender, ureteral balloon dilation, residual stones, use of access sheath, surgeon/trainee behavior, longer duration of the procedure (14 seconds per 10 minutes), and higher BMI [64–66]. Furthermore, the use of flexible ureteroscopes or both flexible and semi‐rigid ureteroscopes in the same setting was associated with higher radiation exposure compared with semi‐rigid ureteroscopy alone [63]. Regarding SWL, precise stone localization necessitates the use of fluoroscopy. SWL is associated with mean radiation exposure of 1.63 mSv [67]. Higher radiation exposures are associated with higher stone burden, higher BMI, ureteral stones locations, physician inexperience, and higher number of shocks delivered [67–69]. Moreover, radiation is used to follow‐up patients with post‐SWL. Recently, Kaynar and coworkers evaluated ERD of 129 patients during the first follow‐up year following SWL. They reported a mean ERD of 15.91 mSv following SWL of kidney stones, 13.32  mSv following SWL of ureteral stones, and 27.02 mSv following SWL for multiple stone locations. Furthermore, SWL for multiple stone locations was associated with significantly higher radiation exposure during the first follow‐up year compared with SWL of solitary renal or ureteral stones [70].

­ ccupational radiation exposure O for urologists Until recently, there was paucity in the literature in terms of the amount of radiation to which urologists are exposed and its impact on their health. The 2007 ICRP guidelines recommend 50  mSv (5000  milliroentgen equivalent man or mrem) as an occupational dose limit per year or 100 mSv (10 000 mrem) averaged over 5 years [6]. Furthermore, the United States regulations (Title 10, part 20 of the Code of Federal Regulations) mandate a  yearly accepted limit of 5000 mrem as deep‐dose equivalent, 15 000 mrem as lens dose equivalent, and 50 000 mrem as shallow‐dose equivalent. To ensure practitioners are within these guidelines, there exists a need for a controlled measurement of radiation exposure experienced by practicing urologists over a period of time. Therefore, urologists are recommended using a dosimeter to monitor their radiation exposure. A single‐center prospective German study measured the

radiation exposure in 12 urologists by placing two thermoluminescent dosimeters (one on the forehead and the other on the ring finger). A total of 188 patients underwent 235 endourologic procedures including 51 ureteral stent changes (USCs), 67 ureteral stent placements (USPs), 67 percutaneous stent changes (PSCs), 39 ureteroscopies, and 11 PCNLs. The authors recorded an average value of 0.04 mSv during USP and USC, 0.03 mSv during PSC, 0.18 mSv during PCNL, and 0.1 mSv during ureteroscopy using the forehead dosimeter and average values of 0.13, 0.21, 0.20, 4.36, and 0.15 mSv during USP, USC, PSC, PCNL, and ureteroscopy, respectively using a dosimeter positioned at the ring finger [71]. Furthermore, a study from North America measured the fluoroscopic radiation exposure of an experienced urologist over 9 months using a thermoluminscent dosimeter installed outside the thyroid shield. The total radiation exposure over 9  months was 87  mrems deep‐dose equivalent, 293 mrem lens dose equivalent, and 282 mrem for shallow‐dose equivalent [72]. Therefore, these studies showed that radiation exposure for urologists was below the annual accepted limits. Nevertheless, radiation safety protocols and recommendations should be followed to  guard against the potential hazards from ionizing radiation.

­Dose‐reduction strategies Over the past two decades, reports have highlighted the increasing use of radiation in medicine. During 2000, a report from the United Nations Scientific Committee on  the Effects of Atomic Radiation (UNSCEAR) found that radiation used for medical purposes accounts for more than 95% of human‐made radiation exposure. Furthermore, radiological diagnostic procedures equaled or exceeded one per each individual of the population per year. It has been reported that a person who lives in United States is exposed yearly to an average of 6.2 mSv radiation from ambient sources such as cosmic rays, radon, and medical procedures [73]. While the recommended occupational radiation exposure to medical personnel should be limited to 50 mSv/year, there is no dose threshold for developing stochastic hazards [73]. According to the linear‐no‐threshold model (or LNT), which is used to quantify radiation exposure and set the regulatory limits for radiation protection, there is no safe dose of radiation and cancer can occur in 1/1000 individuals following exposure to an effective dose as low as 10 mSv [74]. This is because some organs such as the gonads and the eyes are more sensitive than others, such as the extremities. Thus the recommended exposure limits vary according to the body part. In addition, there are variations in radiation exposure among healthcare

2  Radiation Safety During Diagnosis and Treatment

centers in terms of ERD for the same diagnostic procedure [75]. According to a study by Smith‐Bindman and colleagues, there were wide variations among radiation doses reported for different types of medical imaging studies. For example, a mean 13‐fold variation was reported between the lowest and highest dose of CT scans for adult patients across and within institutions in the San Francisco Bay area [22]. Therefore, different groups including the American Association of Physicists in Medicine, the American College of Radiology, and NCRP, together with the US Food and Drug Administration (FDA), have worked to establish nationally recognized diagnostic reference levels (DRLs) for different imaging procedures [76]. The ICRP recommended three basic principles for reducing radiation exposure. First is the principle of justification, which is defined as “Any decision that alters the radiation exposure situation should do more good than harm,” refers to avoidance of unnecessary studies and replacing procedures associated with higher radiation with others that may play the same role, whenever appropriate. Second is the principle of optimization, which is defined as “The likelihood of incurring exposure, the number of people exposed, and the magnitude of their individual doses should all be kept as low as reasonably achievable (ALARA), taking into account economic and societal factors,” entails performing the diagnostic or interventional procedure with an acceptable quality and lowest radiation exposure. Third, Application of dose limits, is defined as “The total dose to any individual from regulated sources in planned exposure situations other than medical exposure of patients should not exceed the appropriate limits specified by the Commission” [6]. Principle of justification Justification is a key principle for radiation safety during diagnosis and treatment using ionizing radiation. It entails several items that should be addressed. First, it is mandatory that any ionizing radiation examination prescribed by the referring clinician is required for an individual patient and that the examination has a specific objective, is risk‐effective, reliable, and anticipated to influence the decision‐making, patient treatment, and final outcome, and that the necessary information cannot be obtained by other modalities with lower risk. Furthermore, a single person should be responsible for the examination and this person is normally a radiologist who is trained in radiological techniques and radiological protection as certified by a competent authority. In addition, a documented request including patient’s clinical information, signed or endorsed by a referring clinician, should be available before an examination is performed. In the case of a female patient in the c­ hildbearing period

the potential that she may be pregnant should always be kept in mind and date of the last menstrual period should be documented and pregnancy test should be ordered in case of doubt in pregnancy [8, 77]. Furthermore, all biomedical research projects that involve the use of ionizing radiation should be institutionally approved by ethics review boards and radiation protection committees. Principle of optimization Following justification of the examination or the image‐ guided intervention, optimization is the next step towards radiation protection. Optimization of protection is considered a forward‐looking iterative process directed to performing the procedure with an acceptable quality while keeping radiation exposure as low as reasonably achievable (ALARA). It takes into account both technical and socioeconomic factors. Therefore, it is a process of “frame of mind” that always questions whether all that is reasonable has been done to reduce doses. The concept of ALARA or “as low as reasonably achievable” was described as a fundamental part of the optimization process. The basis of ALARA principles is that these measures have been compiled to minimize radiation exposure. They are cost‐effective to increase compliance. They do not cause unnecessary delay to procedure, do not hinder the performance nor affect the outcome of the procedure. The three basic principles for ALARA are time, distance, and shielding. ALARA principles Time (minimize time)

One of the most effective methods to reduce radiation exposure to patients and healthcare personnel is to limit the time of radiation exposure. This is particularly important during fluoroscopy where shortening of the FT leads to substantial decrease in radiation exposure. This could be achieved by multiple avenues. (i) Substitute fluoroscopy with other imaging modalities such as ultrasound‐guided PCA during PCNL or totally ultrasound‐ guided PCNL. (ii) Use digital fluoroscopy. (iii) Use “last‐image‐hold” technology which has been shown to reduce radiation exposure dose by almost 10‐fold (from 3000 to 400 mGy). (iv) Use pulsed fluoroscopy with fewer frames per second (such as 1 or 4 frames per second) rather than standard fluoroscopy at 30 frames per second. (v) Fluoroscopy should be turned on/off by the surgeon only during absolute key points rather than continuous stretches. (vi) Keep tracking the FT. (vii) Document the FT after each procedure [78–82] (Box 2.1). Distance (maximize distance)

Increasing the distance is considered the cheapest and most effective way to reduce radiation to operating room personnel. It is of particular importance for healthcare

21

22

Section 1  Basic Principles

Box 2.1  Take‐home messages in radiation safety measures. 1 2 3 4 5 6 7 8 9 10 11 12

Practice ALARA principles (minimize time, maximize distance, and always use shields). Use modern equipment with digital fluoroscopy with last‐image hold technology. Stand as far as possible from the patient to avoid scattered radiation. Place the image intensifier as close as possible to the patient to minimize scatter radiation. Minimize the area of radiation exposure by using collimators to narrow the field. Use pulsed fluoroscopy with 4 frames per second. Control the foot pedal and movement of the C‐arm. Limit the time of fluoroscopic exposure to a minimum during absolute key points rather than continuous stretches. Track and document the amount of radiation used for each procedure. Check each fluoroscopy unit annually. Invest in custom‐made lightweight aprons and examine each apron annually for defects. Whenever possible, order imaging studies associated with lower radiation exposure such as ultrasound/KUB or low‐dose CT.

personnel. As radiation exposure has an inverse relationship with the square of the distance, doubling the distance reduces radiation to one‐quarter and at a distance of 3 m  the radiation dose becomes similar to background levels. Healthcare providers can increase the distance by  avoiding being in the room during the procedure, whenever possible such as when performing kidney– ureter–bladder (KUB) plain radiographs, intravenous pyelography, or computed tomography (CT). Also, the use of lens‐mounted video cameras decreases the distance of the surgeon from the radiation source [7, 82] (Box 2.1). Shielding (always use shields)

Shielding is the third line of defense, especially for personnel who have to be in the radiation field. Shielding is made of heavy metals, most commonly lead which is capable of attenuating radiation. Examples of shields are lead‐impregnated eye glasses, gloves, thyroid shields, chest and pelvic aprons, and ceiling‐mounted shields. Lead aprons vary in thickness; most are 0.5 mm lead equivalent that attenuate radiation by 96.5–99.5%. Thus shielding does not provide 100% protection from radiation. Therefore, it should not be considered a substitute for other principles of ALARA [7, 83]. Lead aprons should be inspected annually for cracks. In one study, thyroid shields were found to decrease radiation exposure 23 times (from 46 to 0.02 mSv), thereby reducing radiation exposure to background levels [84]. Despite the major benefits of shielding in reducing radiation exposure, the weight of chest and pelvic aprons are associated with orthopedic problems. In 2011, Elkoushy and Andonian surveyed compliance with radiation safety measures and the prevalence of orthopedic complaints among members of the Endourological Society. Almost 64% of respondents reported orthopedic complaints in the form of back problems in 38.1%, neck problems in 27.6%, hand problems in 17.2%, and hip and knee problems in 14.2% [85]. Although there was good compliance

(97%) in wearing chest and pelvic aprons, compliance with thyroid shields was only 68%. In addition, only 34.3% of respondents used dosimeters, 17.2% used lead‐ impregnated glasses, and 9.7% used lead‐impregnated gloves [85]. Similarly, other national and international surveys have shown the lack of radiation exposure monitoring in the United States, Europe, India, Brazil, and Turkey [86–89]. Therefore, all of those studies recommended regular radiation safety courses for trainees and urologists. Radiation safety courses have been successful in reducing radiation dose with the implementation of a “radiation awareness program,” where focus was placed on taking fewer “snapshots” during SWL [90]. In another study, after implementing a radiation safety education initiative, a significant decrease in dose area product and FT was achieved during pediatric procedures [82, 91] (Box 2.1). Principle of application of dose limits This limit entails that the effective dose or the equivalent dose values prescribed to individuals should not be exceeded during planned exposure situations. This applies only during occupational exposure. For example, the dose limit for a surgeon or the technician should not exceed 50 mSv per year. However, limiting the dose to individual patients is not recommended because it may impact the effectiveness of the patient’s diagnosis or treatment. For example, dose limits cannot be applied for patients undergoing radiotherapy, where a target is needed irrespective of the dose of radiation. Therefore, for patients, only the principles of justification and optimization apply [6]. During 2010, the FDA launched a collaborative initiative aimed at reducing unnecessary radiation exposure from medical imaging. This initiative focused on CT, fluoroscopy, and nuclear medicine as the three medical imaging modalities that are associated with highest radiation [1]. The measures included

2  Radiation Safety During Diagnosis and Treatment

promotion of safe use of medical imaging devices through (i) establishing requirements for manufacturers of CT and fluoroscopic devices to include additional safeguards into the equipment design and developing nationwide recognized DRLs, (ii) supporting informed clinical decision making by adding requirements for manufacturers of fluoroscopy and CT devices to record radiation dose information for use in patient medical records; this may allow the physician together with the patient and the radiologist to further justify procedures which necessitate ionizing radiation, and (iii) increase patient awareness and provide them with tools to track their personal medical imaging history such as using a patient medical imaging record card [1]. During 2014, the government of Germany hosted an international conference sponsored by the International Atomic Energy Agency and the World Health Organization calling for action on radiation protection in medicine in the next decade. This conference was coined the “Bonn Call for Action” [92]. The conference recommended 10 main actions: (i) enhancing the implementation of the principle of justification by applying the 3 As (awareness, appropriateness, and audit), (ii) enhancing the implementation of the principle of optimization by ensuing the use of the DRLs for imaging procedures and strengthening the establishment of quality assurance programs for medical exposure, (iii) strengthening the manufacturers’ role in contributing to the overall safety regime, (iv) strengthening radiation protection education, (v) shaping and promoting a strategic research agenda for medical radiation protection, (vi) increasing the availability of information on medical exposure, (vii) improving the prevention of medical radiation accidents and incidents, (viii) provoking the radiation safety culture in healthcare, (ix) fostering an improved radiation risk‐benefit dialogue among health professionals, patients, and the public, and (x) strengthening global implementation of radiation safety requirements [92].

­Dose‐reduction strategies during diagnosis While CT is considered the workhorse in evaluation of most non‐emergent and emergent medical situations, it is the imaging modality that is associated with highest potential for radiation exposure (Table 2.1) [13, 14, 93]. Therefore, it constitutes a major concern for healthcare professionals and patients especially those who are recurrent stone‐formers and are at risk of undergoing repeated CTs with the associated risks of cumulative radiation exposure [14, 56, 94, 95]. Katz et al. reported a cumulative radiation dose associated with repeated CT scans between 8.5 and 154  mSv [96]. Furthermore, reports by NRCP reported a yearly increase in the

Table 2.1  Effective dose associated with different imaging and image‐guided interventions.

Procedure

Mean effective dose (mSv)

KUB [24, 55, 94, 111]

0.7–1.1

IVU [24, 55, 94, 111]

1.5–3.5

Standard‐dose CT, abdomen [24, 55, 95]

5–10

Standard‐dose CT, pelvis [55, 95]

5–10

Standard‐dose CT, urogram [22, 24]

10–31

Low‐dose CT, abdomen/pelvis [94, 102]

2.0–3.5

Ultra low‐dose CT, abdomen/pelvis [109]

0.5–1.5

PET CT scan [24]

14.1

Diuretic renal scan [24]

2.6

Bone scan [24]

6.3

Cystography [24]

1.8

Nephrostomy tube placement [24]

3.4

SWL [127, 128]

1–8

Ureteroscopy [128, 159]

1–7

PCNL [59, 62]

3–18

number of CTs performed in the United States of about 10% between 1993 to 2006 with estimated 62 million CT examinations performed during 2006 alone [2]. Given the importance of CT as a first‐line choice for diagnosis of different urological diseases especially stone disease, and the potential hazards of the high doses of radiation associated with CT, several strategies were proposed for lowering radiation exposure. These strategies depend on either modifying the basic design of scanners and their components or the technical parameters such as slice thickness, pitch, and tube current modulation. In addition, appropriate patient centering on the gantry has been reported to decrease the dose by 20% by decreasing z‐axis coverage. Pitch is the speed at which the table moves through the scanner gantry and increasing pitch results in radiation dose reduction. In a study by McCollough and colleagues, increasing the pitch from a standard of 1 to 1.5 resulted in 33% reduction in effective dose while still maintaining adequate image quality from a single‐slice helical CT [97]. However, these results could not be achieved with multi‐slice CT [98]. Furthermore, optimization of slice thickness was accompanied by reduction in radiation dose without compromising diagnostic accuracy. While slices at 0.5 mm detected stones at 70% higher than slices at 5 mm, it was associated with significantly higher radiation exposure in single‐detector CT scanners [99]. Therefore, optimization of slices at 2.5 mm was proposed and it would detect most clinically relevant stones with  single‐detector CT scanners. However, the latest

23

24

Section 1  Basic Principles

multi‐detector CT (MDCT) scanners presented the ­possibility of decreasing the slice thickness without increasing radiation exposure. For example, there was no change in radiation dose among different slice thicknesses using the 64‐MDCT scanner [100]. Furthermore, radiation exposure could be further decreased while maintaining an appropriate image quality by obtaining slices of 5 mm and complementing it with 3 mm coronal/ sagittal reformatted images [34, 35]. Reducing the tube current has been found to be the most effective method of reducing radiation exposure. There is linear relationship between radiation dose and tube current. Therefore, a 50% reduction in tube current leads to a 50% reduction in the radiation dose. The tube current can be adjusted either manually using manual selection of a lower fixed tube current or automatically using automatic tube current modulation, optimizing the dose according to the density of tissues penetrated by  radiation and patient body habitus. This could be achieved by incorporating software that uses the scout image to make adjustments in radiation output according to the patient’s BMI and the tissues examined. However, reduction in tube current results in increased “noise,” which is acceptable in certain situations such as stone disease. These recommendations are based on several studies that showed comparable accuracy between low‐ dose CT (LDCT) and standard‐dose CT (SDCT) in detection of renal calculi. In one study, simulated CT reconstructions at 50 and 75% reductions from the original dose had comparable sensitivities compared with the SDCT in detection of stones >3 mm [101]. In another study by Polletti and coworkers, the accuracy in detecting ureteral calculi was comparable between LDCT and SDCT in patients with a BMI of less than 30 kg/m2 with significant reduction in radiation exposure (9.6 vs. 1.6 mSv in men and 12.6 vs. 2.1 mSv in women). However, in patients with a BMI of ≥30 kg/m2, the sensitivity of LDCT to detect ureteral calculi was only 50% [102]. In addition, according to a recent systematic review, LDCT scans resulted in radiation exposure ranging from 0.5 to 2.8 mSv, and had a sensitivity of 90–97% and a specificity of 86–100% for diagnosing stone disease. However, this technique may miss small ureteral stones (30 kg/m2) [103]. Several studies confirmed the lower accuracy of LDCT for detection of ureteral calculi in obese patients [102, 104, 105]. Since 1998, MDCT scanners have been used in diagnosis and planning of treatment for patients with renal stones. It has the ability to perform three‐dimensional reconstructions and multi‐planar reformatting while obtaining slices down to 1 mm thick [34, 35]. In one study, using a 16‐MDCT with tube current modulation, there was comparable accuracy between LDCT and SDCT in detection of urolithiasis in both non‐obese and

obese patients [106]. While LDCT using MDCTs was  associated with relatively higher radiation dose (1.41 mSv), this radiation dose was still significantly lower than the SDCT (2.89 mSv) [106]. Furthermore, the positive correlation which was noted between ERD and BMI (r=0.86) was congruent with the hypothesis that radiation exposure is higher in obese patients [106]. In a recent study by Abou El‐Ghar and colleagues, the use of automatic tube current modulation that is available in modern multi‐slice CT scanners such as 64‐MDCT made it possible to use LDCT with comparable results to SDCT even in obese patients [107]. Moreover, employing LDCT was equally sensitive to SDCT in detecting uric acid stones at very low radiation doses. Therefore, ultra‐low dose protocols have demonstrated a high sensitivity and specificity (97 and 95%, respectively) in detecting calculi while reducing radiation exposure [37, 108, 109]. In a meta‐analysis by Niemann and colleagues, LDCT reported to detect urolithiasis with a sensitivity of 97% and specificity of 95% [32]. Therefore, LDCT should be preferred to SDCT and be considered the first‐line imaging modality in acute renal colic [32]. Based on these data, LDCT is now recommended by the American and European Urological Association guidelines as the first‐line imaging modality for evaluation of non‐obese (BMI 3 mm and was associated with significantly lower radiation exposure ­compared with the SDCT (0.48±0.07 vs. 4.43±3.14 mSv; P 75 years

Moderate (consider bridging based on patient and surgery‐specific factors; 5–10% annual risk of thromboembolism)

Severe thrombophilia Protein C, protein S, or antithrombin deficiency ●● Antiphospholipid antibodies ●● Multiple abnormalities ●●

VTE within the past 3–12 months Non‐severe thrombophilia: ●● Heterozygous factor V Leiden ●● Prothrombin gene mutation

Recurrent VTE Active cancer (treated within 6 months or palliative) VTE >12 months and no other risk factors Low (no bridging needed; benefit Delay surgery

Proceed with surgery

Risk > benefit Delay surgery

Discontinue DAPT if risk of delayed surgery > risk of thrombosis

Discontinue DAPT, proceed with surgery

Figure 5.2  2016 ACC/American Heart Association treatment algorithm for timing of elective noncardiac surgery in patients with coronary stents [23]. DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention.

79

80

Section 1  Basic Principles

therapeutic‐dose LMWH 48–72  hours after surgery instead of resuming LMWH within 24 hours after surgery. If the surgery poses a low risk of significant hemorrhage, resuming therapeutic‐dose LMWH approximately 24 hours after surgery is recommended [8, 23].

­ ntiplatelet and anticoagulant use A in urological surgery There is very limited evidence‐based literature on the perioperative management of patients who are scheduled for urological surgery. In deciding on a management scheme for interrupting and resuming antiplatelets and anticoagulation during elective urological surgery, ­certain patient and procedural risk factors need to be considered. The risk of thromboembolic event or stent stenosis needs to be considered along with comorbid conditions. Patients with severe coronary artery disease with multiple stents, stent re‐stenosis, poor ejection fraction, and renal failure need to be weighed against the risk of bleeding or significant hemorrhage associated with the planned surgery. Consultation and comanagement with the patient’s cardiologist and hematologist, as well as the anesthesiologist, is necessary to minimize the risk of adverse outcomes. In Table 5.2 the most common types of urological surgery are categorized according to bleeding risk. Table 5.2 categorizes the patients into low‐, moderate‐, and high‐ risk groups according to the ACC and ACCP guidelines. For most cases, aspirin can be continued perioperatively in patients with intracoronary stenting, as prematurely interrupting aspirin is a risk factor for acute coronary syndrome and stent thrombosis. However, if the risk of bleeding is considered to be severe, aspirin should be interrupted for the surgery and then resumed as soon as the window for severe bleeding has elapsed. Several studies of perioperative aspirin and anticoagulation use during transurethral resection of the prostate have demonstrated an increased rate of postoperative bleeding, likewise for transurethral laser enucleation techniques

[24–29]. However, for transurethral vaporization techniques, there does not appear to be a significantly increased risk of bleeding for patients receiving clopidogrel, aspirin, or warfarin compared to controls [24–29]. Pregnancy and uncorrected coagulopathy are the two absolute contraindications for shock‐wave lithotripsy. It can carry a high risk of hemorrhagic complications including postoperative perirenal hematomas and life‐ threatening renal hemorrhage, resulting in transfusion, renal embolization, and nephrectomy. The rate of asymptomatic perirenal hematomas can be as high as 25% when sensitive abdominal computed tomography scanning is used postoperatively, and rate of symptomatic hematomas have been reported to be 0.7% [30–32]. Patients that cannot discontinue anticoagulants and antiplatelets are usually managed with other modalities [33–36]. Several series have reported results of the use of the anticoagulants and antiplatelets in conjunction with shock‐wave lithotripsy, some with catastrophic outcomes [37]. In patients undergoing transrectal ultrasound‐guided prostate biopsy (TRUS Bx) there is an increased the risk of prolongation of rectal bleeding, hematuria, and hematospermia in association with antiplatelets and anticoagulants use [29, 38–40]. A prospective randomized trial published in 2007 found that the median duration of hematuria and rectal bleeding was statistically significantly greater in uninterrupted aspirin use (group 1) and interrupted but bridged with LMWH (group 2) compared to interrupted aspirin (group 3): 6, 4, and 2 days and 3, 2, and 1 days, respectively. The number of patients still reporting hematospermia at 30 days after TRUS Bx was 21.4, 18.5, and 9.3% in groups 1, 2, and 3, respectively [38]. Ureteroscopy is considered safe in the face of anticoagulation and antiplatelets. Turna et  al. published a ­retrospective case‐control study of flexible ureteroscopy and holium:YAG laser lithotripsy [41]. They identified 37 patients on warfarin (38%), clopidogrel (13%), or ­aspirin (49%) who underwent surgery without interruption of antithrombotic therapy. There were no bleeding‐ related complications in either group [41].

Table 5.2  Bleeding risk categories for common urological surgeries. Low risk

Moderate risk

High risk

Cystoscopy

Laser enucleation of prostate

Cystectomy

Ureteroscopy/renoscopy

Transurethral resection of prostate

Partial and total nephrectomy

Laser lithotripsy

Transurethral resection of bladder

Prostatectomy

Laser vaporization of prostate

Transrectal biopsy of prostate

Penile prosthesis

Urethral bulking

Urethral sling and sphincter placements

Penectomy

Prolapse repair

Shockwave lithotripsy

5  Management of the Anticoagulated Patient

Several series have also been published on use of aspiring during other high‐risk procedures [42, 43]. Leyh‐Bannurah et al. reported on a retrospective series of 137 open retropubic and robot‐assisted radical prostatectomy (RARP) in patients on uninterrupted aspirin ­therapy ­compared to controls matched by propensity score. The authors did not observe a statistically significant increase in blood loss in the aspirin group. However, they did observe that aspirin was an independent predictor of blood transfusion [42]. Likewise for robot‐ assisted laparoscopic radical nephrectomy (RALRN) and RALRP, Parikh et  al. reported on 51 patients who underwent RARP while continuing aspirin compared to 44 controls. There was no significant difference in estimated blood loss, and there were no transfusions in either group. Results were similar for the RALRN group which had 14 patients with uninterrupted aspirin versus 12 controls [44]. In contrast to aspirin, clopidogrel, cilostazol, and warfarin were associated with an increased risk of thrombotic events postoperatively in patients undergoing open or laparoscopic partial nephrectomy in a retrospective series of 47 chronically anticoagulated patients who had the anticoagulation interrupted [45]. In that series, the

transfusion rates were similar to the matched control group. Similar findings were observed in patients with a percutaneous nephrolithotomy [46]. However, a recent series of uninterrupted aspirin therapy in patients undergoing percutaneous nephrolithotomy did not show an difference in bleeding complications compared to ­controls [47].

­Conclusion With the increasing prevalence of patients with coronary stents and who are on antiplatelet therapy or anticoagulation, urologists are increasingly more likely to be needed to perform surgeries. Sometimes the underlying indication for surgery can be life threatening, creating an incredibly complex set of difficult medical choices. Taken together, the evidence base upon which to draw conclusions and guide management is sparse and of suboptimal quality. It thus becomes imperative to categorize the patient’s risk group and to balance the risk of hemorrhagic consequences with the risk of thromboembolic events. A multidisciplinary approach is essential for optimal management of these patients.

­References 1 Centers for Disease Control and Prevention. Fact Book, 7. 2 3

4

5

6

7

8

Atlanta, GA: CDC, 1994. Changing patterns of infectious disease. Cohen ML Nature406p762‐7(2000 Aug 17) World Health Statistics. Monitoring health for the SDGs. http://www.who.int/gho/publications/world_ health_statistics/2016/en/(accessed 8 August 2016). Ward BW, Schiller JS, and Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis 2014;11:E62. Gerteis J, Izrael D, Deitz D et al. Multiple chronic conditions chartbook. http://www.ahrq.gov/sites/default/ files/wysiwyg/professionals/prevention‐chronic‐care/ decision/mcc/mccchartbook.pdf (accessed 8 August 2016). http://www.imshealth.com/files/web/Corporate/News/ Top‐Line%20Market%20Data/Top_20_Global_Therapy_ Areas_2015.pdf (accessed 8 August 2016). Roger VL, Go AS, Lloyd‐Jones DM et al. Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation 2012;125:e2–e220. Douketis JD, Spyropoulos AC, Spencer FA et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence‐ Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e326S–350S.

9 Iakovou I, Schmidt T, Bonizzoni E et al. Incidence,

10

11

12

13

14

15

predictors, and outcome of thrombosis after successful implantation of drug‐eluting stents. JAMA 2005;293:2126–2130. Kałuza GL, Joseph J, Lee JR et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000;35:1288–1294. Ferreira JL and Wipf JE. Pharmacologic therapies in anticoagulation. Med Clin North Am 2016;100:695–718. Walker CP and Royston D. Thrombin generation and its inhibition: a review of the scientific basis and mechanism of action of anticoagulant therapies. Br J Anaesth 2002;88:848–863. Stacy ZA, Call WB, Hartmann AP et al. Edoxaban: a comprehensive review of the pharmacology and clinical data for the management of atrial fibrillation and venous thromboembolism. Cardiol Ther 2016;5:1–18. Chen JY, Zhang AD, Lu HY et al. CHADS2 versus CHA2DS2‐VASc score in assessing the stroke and thromboembolism risk stratification in patients with atrial fibrillation: a systematic review and meta‐ analysis. J Geriatr Cardiol 2013;10:258–266. Lip GY, Nieuwlaat R, Pisters R et al. Refining clinical risk stratification for predicting stroke and

81

82

Section 1  Basic Principles

16

17

18

19

20

21

22

23

24

25

thromboembolism in atrial fibrillation using a novel risk factor‐based approach: the Euro Heart Survey on atrial fibrillation. Chest 2010;137:263–272. Abu‐Assi E, Otero‐Raviña F, Allut Vidal G et al. Comparison of the reliability and validity of four contemporary risk stratification schemes to predict thromboembolism in non‐anticoagulated patients with atrial fibrillation. Int J Cardiol 2013;166:205–209. Lip GY, Frison L, Halperin JL et al. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS‐BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol 2011;57:173–180. Agnelli G and Becattini C. Treatment of DVT: how long is enough and how do you predict recurrence. J Thromb Thrombolysis 2008;25:37–44. Levine MN, Hirsh J, Gent M et al. Optimal duration of oral anticoagulant therapy: a randomized trial comparing four weeks with three months of warfarin in patients with proximal deep vein thrombosis. Thromb Haemost 1995;74:606–611. Nishimura RA, Otto CM, Bonow RO et. al. 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2014;148:e1–e132. Moses JW, Leon MB, Popma JJ et al. Sirolimus‐eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315–1323. Stone GW, Ellis SG, Cox DA et al. One‐year clinical results with the slow‐release, polymer‐based, paclitaxel‐eluting TAXUS stent: the TAXUS‐IV trial. Circulation 2004;109:1942–1947. Levine GN, Bates ER, Bittl JA et al. 2016 ACC/AHA Guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016;68:1082–1115. Taylor K, Filgate R, Guo DY et al. A retrospective study to assess the morbidity associated with transurethral prostatectomy in patients on antiplatelet or anticoagulant drugs. BJU Int 2011;108, Suppl 2:45–50. Ong WL, Koh TL, Fletcher J et al. Perioperative management of antiplatelets and anticoagulants among patients undergoing elective transurethral resection of the prostate‐‐a single institution experience. J Endourol 2015;29:1321–1327.

26 Bishop CV, Liddell H, Ischia J et al. Holmium laser

27

28

29

30

31

32

33

34

35

36

37

38

39

enucleation of the prostate: comparison of immediate postoperative outcomes in patients with and without antithrombotic therapy. Curr Urol 2013;7:28–33. Netsch C, Magno C, Butticè S et al. Thulium vaporesection of the prostate and thulium vapoenucleation of the prostate in patients on oral anticoagulants: a retrospective three‐centre matched‐ paired comparison. Urol Int 2016;96:421–426. Netsch C, Stoehrer M, Brüning M et al. Safety and effectiveness of thulium vapoenucleation of the prostate (ThuVEP) in patients on anticoagulant therapy. World J Urol 2014;32:165–72. Ruszat R, Wyler S, Forster T et al. Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation. Eur Urol 2007;51:1031–1041. Dhar NB, Thornton J, Karafa MT et al. A multivariate analysis of risk factors associated with subcapsular hematoma formation following electromagnetic shock wave lithotripsy. J Urol 2004;172:2271–2274. Kaude JV, Williams CM, Millner MR et al. Renal morphology and function immediately after extracorporeal shock‐wave lithotripsy. AJR Am J Roentgenol 1985;145:305–313. Rubin JI, Arger PH, Pollack HM et al. Kidney changes after extracorporeal shock wave lithotripsy: CT evaluation. Radiology 1987;162:21–24. Sare GM, Lloyd FR, and Stower MJ. Life‐threatening haemorrhage after extracorporeal shockwave lithotripsy in a patient taking clopidogrel. BJU Int 2002;90:469. Zanetti G, Kartalas‐Goumas I, Montanari E et al. Extracorporeal shockwave lithotripsy in patients treated with antithrombotic agents. J Endourol 2001;15:237–241. Ruiz H and Saltzman B. Aspirin‐induced bilateral renal hemorrhage after extracorporeal shock wave lithotripsy: implications and conclusions. J Urol 1990;143:791–792. Knorr PA and Woodside JR. Large perirenal hematoma after extracorporeal shock‐wave lithotripsy. Urology 1990;35:151–153. Katz R, Admon D, and Pode D. Life‐threatening retroperitoneal hematoma caused by anticoagulant therapy for myocardial infarction after SWL. J Endourol 1997;11:23–25. Giannarini G, Mogorovich A, Valent F et al. Continuing or discontinuing low‐dose aspirin before transrectal prostate biopsy: results of a prospective randomized trial. Urology 2007;70:501–505. Halliwell OT, Yadegafar G, Lane C et al. Transrectal ultrasound‐guided biopsy of the prostate: aspirin increases the incidence of minor bleeding complications. Clin Radiol 2008;63:557–561.

5  Management of the Anticoagulated Patient

40 Maan Z, Cutting CW, Patel U et al. Morbidity of

transrectal ultrasonography‐guided prostate biopsies in patients after the continued use of low‐dose aspirin. BJU Int 2003;91:798–800. 41 Turna B, Stein RJ, Smaldone MC et al. Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol 2008;179:1415–1419. 2 Leyh‐Bannurah SR, Hansen J, Isbarn H et al. Open and 4 robot‐assisted radical retropubic prostatectomy in men receiving ongoing low‐dose aspirin medication: revisiting an old paradigm? BJU Int 2014;114:396–403. 3 Mortezavi A, Hermanns T, Hefermehl LJ et al. 4 Continuous low‐dose aspirin therapy in robotic‐ assisted laparoscopic radical prostatectomy does not

44

45

46

47

increase risk of surgical hemorrhage. J Laparoendosc Adv Surg Tech A 2013;23:500–505. Parikh A, Toepfer N, Baylor K et al. Preoperative aspirin is safe in patients undergoing urologic robot‐ assisted surgery. J Endourol 2012;26:852–856. Kefer JC, Desai MM, Fergany A et al. Outcomes of partial nephrectomy in patients on chronic oral anticoagulant therapy. J Urol 2008;180:2370–2374. Kefer JC, Turna B, Stein RJ et al. Safety and efficacy of percutaneous nephrostolithotomy in patients on anticoagulant therapy. J Urol 2009;181:144–148. Leavitt DA, Theckumparampil N, Moreira DM et al. Continuing aspirin therapy during percutaneous nephrolithotomy: unsafe or under‐utilized? J Endourol 2014;28:1399–1403.

83

85

SECTION 2 Percutaneous Renal Surgery

87

Part 1  Perioperative Considerations

6 Surgical Anatomy of the Kidney for Endourological Procedures Francisco J.B. Sampaio Urogenital Research Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil

­General anatomy The kidneys are paired organs lying retroperitoneally on the posterior abdominal wall. Each kidney has a characteristic shape, with a superior and an inferior pole, a convex border placed laterally, and a concave medial border. The medial border has a marked depression, the hilum, containing the renal vessels and renal pelvis. Renal morphometry In adults, the left kidney is larger than the right, and this agrees with morphometric findings in fetal kidneys [1]. The right kidney has a mean length of 10.97 cm and 3.21 cm mean thickness at the hilum, in comparison to 11.21 cm and 3.37 cm, respectively, for the left kidney [2]. An interesting finding is that the superior pole has a greater width (mean, 6.48 cm) than the inferior pole (mean, 5.39 cm). Also, there is a statistically significant correlation between kidney length and an individual’s stature [2]. Position of the kidneys Because the kidneys lie on the posterior abdominal wall, against the psoas major muscles, their longitudinal axis parallels the oblique course of the psoas (Figure  6.1). Moreover, since the psoas major muscle has a cone shape, the kidneys also are dorsally inclined on the longitudinal axis. Therefore, the superior poles are more medial and more posterior than the inferior poles (Figure 6.1). Also, because the hilar region is rotated anteriorly on the psoas muscle, the lateral borders of both kidneys are posteriorly positioned. This means the kidneys are angled 30–50° behind the frontal (coronal) plane (Figure 6.2) [3].

Perirenal coverings The kidney surface is enclosed in a continuous covering of fibrous tissue, the renal capsule (“true renal capsule”). Each kidney within its capsule is surrounded by a mass of adipose tissue, lying between the peritoneum and the posterior abdominal wall (Figures 6.2 and 6.3). This perirenal fat is enclosed by the renal fascia (the so‐called fibrous renal fascia of Gerota). The renal fascia is enclosed anteriorly and posteriorly by another layer of adipose tissue, the pararenal fat, which varies in thickness (Figure 6.3). The renal fascia is made up of a posterior layer (a well‐ defined and strong structure) and an anterior layer (a more delicate structure, which tends to adhere to the peritoneum) (Figures  6.2 and 6.3). The anterior and ­posterior layers of the renal fascia (fascia of Gerota) subdivide the retroperitoneal space into three potential compartments: (i) the posterior pararenal space, which contains only fat; (ii) the intermediate perirenal space, which contains the suprarenal glands, kidneys, and proximal ureters, together with the perirenal fat; and (iii) the anterior pararenal space, which unlike the posterior and intermediate spaces, extends across the midline from one side of the abdomen to the other. This latter space contains the ascending and descending colon, the duodenal loop, and the pancreas [3] (Figure 6.4). Inferiorly, the layers of the renal fascia end weakly fused around the ureter (Figures 6.3 and 6.5). Superiorly, the two layers of the renal fascia fuse above the suprarenal gland and end fused with the infradiaphragmatic fascia (Figure 6.5). An additional fascial layer separates the suprarenal gland from the kidney (Figure 6.5). Laterally, the two layers of the renal fascia fuse behind the ascending and descending colons. Medially, the posterior fascial layer is fused with the fascia of the spine muscles. The anterior fascial layer merges into the connective tissue of the great vessels (aorta and inferior vena cava) (Figures 6.2 and 6.4).

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

88

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

Pe

k P A

Figure 6.1  Schematic of an anterior view of the kidneys in relation to the skeleton showing that the longitudinal axes of the kidneys are oblique (arrows), with the superior poles more medial than the inferior poles. The dashed lines mark the longitudinal axis of the body. It can also be seen that usually the posterior surface of the right kidney is crossed by the 12th rib and the left kidney by the 11th and 12th ribs.

These anatomic descriptions of the renal fascia show that the right and left perirenal spaces are potentially separated and, therefore, it is exceptional that a complication of an endourologic procedure, e.g. hematoma, urinoma, or perirenal abscess, involves the contralateral perirenal space [3]. Relationship of kidneys to the diaphragm, ribs, and pleura The kidneys lie on the psoas and quadratus lumborum muscles. Usually, the left kidney is higher than the right kidney, with the posterior surface of the right kidney

Figure 6.3  Schematic of a lateral view of a longitudinal section through the retroperitoneum showing the posterior (P) and anterior (A) layers of the renal fascia. Pe, peritoneum; k, kidney.

crossed by the 12th rib and the left kidney crossed by the 11th and 12th ribs (Figure 6.1). The posterior surface of the diaphragm attaches to the extremities of the 11th and 12th ribs (Figure 6.6). Close to the spine, the diaphragm is attached over the posterior abdominal muscles, and forms the medial and lateral arcuate ligaments on each side (Figure 6.6). In this way, the posterior aspect of the diaphragm (posterior leaves) arches in a dome above the superior pole of the kidneys, on each side. Therefore, when performing an intrarenal access by puncture, the endourologist may consider that the diaphragm is traversed by all intercostal punctures, and possibly by some punctures below the 12th rib (Figure 6.7). Also, it can be FA

RA

RA

Figure 6.2  Schematic of a superior view of a transverse section of the kidneys at the level of the second lumbar vertebra showing that the kidneys are angled 30–50° behind the frontal (coronal) plane of the body (FA). RA, renal frontal (coronal) axis.

6  Surgical Anatomy of the Kidney for Endourological Procedures

Figure 6.4  Schematic of a superior view of a transverse section of the kidneys at the level of the second lumbar vertebra showing the three compartments of the retroperitoneal space. P, posterior pararenal space, which contains only fat; I, intermediate perirenal space, which contains the suprarenal glands, kidneys, and proximal ureters, together with the perirenal fat; and A, anterior pararenal space, which unlike the posterior and intermediate spaces, extends across the midline from one side of the abdomen to the other, and contains the ascending and descending colons, duodenal loop, and pancreas.

A I P

D

M

L

ql

Figure 6.5  Schematic of an anterior view of the renal fascia (Gerotas’ fascia) and kidneys. This shows that the two layers of the renal fascia fuse above the suprarenal gland and end fused with the infradiaphragmatic fascia (long arrow). Note a dependence of the fascia separating the suprarenal gland from the kidney (short arrow). D, diaphragm muscle.

expected that the pleura is transversed without symptoms in most intercostal approaches [4]. Generally, the posterior reflection of the pleura extends inferiorly to the 12th rib; nevertheless, the lowermost lung edge lies above the 11th rib (at the 10th intercostal space) (Figure 6.7). Regardless of the degree of respiration (mid or full expiration), the risk of injury to the lung from a 10th intercostal percutaneous approach to the kidney is prohibitive [4]. Any intercostal puncture should be made in the lower half of the intercostal space, in order to avoid injury to the intercostal vessels above.

pm

Figure 6.6  Schematic of an inferior view of the diaphragmatic dome. The arrows point to the diaphragmatic attachments to the extremities of the 11th and 12th ribs. M, medial arcuate ligament; L, lateral arcuate ligament; ql, quadratus lumborum muscle; pm, psoas muscle.

Relationship of kidneys to the liver and spleen The liver on the right side and the spleen on the left may be posterolaterally positioned at the level of the suprahilar region of the kidney, because at this point these organs have their largest dimensions (Figure  6.8). Therefore, it should be remembered that a kidney puncture performed high in the abdomen will allow little space for the needle entrance [4]. If the intrarenal puncture is performed when the patient is in mid or full inspiration, the risk of injury to the liver and spleen is increased [4]. This knowledge is particularly important in patients with hepatomegaly or splenomegaly, in whom a computed tomography (CT) scan should be performed before puncturing the kidney.

89

90

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

Relationship of kidneys to the ascending and descending colons X

L XI

XII K PR

The ascending colon runs from the ileocolic valve to the right colic flexure (hepatic flexure), where it passes into the transverse colon. The hepatic colic flexure (hepatic angle) lies anteriorly to the inferior portion of the right kidney. The descending colon extends inferiorly from the left colic flexure (splenic flexure) to the level of the iliac crest. The left colic flexure lies anterolateral to the left kidney. It is important to consider the position of the retroperitoneal ascending and descending colons. Occasionally, in the course of a routine abdominal CT scan, the retroperitoneal colon has been observed to lie in a posterolateral or even a retrorenal position [5], and in these cases, there is a great risk of kidney injury with the intrarenal percutaneous approach. A retrorenal colon is more common in the area of the inferior poles of the kidneys (Figure 6.9). Retrorenal colon was found on CT scan in 1.9% of patients in the supine position, but 10% when the prone position (the more commonly adopted position for percutaneous access to the kidney) was assumed [5]. Therefore, with the patient in the prone position and before any invasive percutaneous renal procedure, retrorenal colon should be looked for, especially around the inferior poles of the kidney, using fluoroscopy [5]. Intrarenal vessels Intrarenal arteries

Figure 6.7  Schematic of a lateral view of the kidney and its relationships with the diaphragm, ribs, pleura, and lung. PR, posterior reflection of the pleura, L, lower edge of the lung; K, kidney; X, 10th rib; XI, 11th rib; XII, 12th rib.

Generally, the main renal artery divides into an anterior and a posterior branch after giving off the inferior suprarenal artery. Whereas the posterior branch (retropelvic artery) proceeds as the posterior segmental artery to

(a)

(b)

Figure 6.8  (a) Inferior view of a transverse section through a cooled cadaver at the level of the suprahilar region of the kidney. This shows that the liver (L) and spleen (S) are posterolaterally positioned in relation to the right (RK) and left (LK) kidneys. (b) Similar section to (a) at the level of the infrahilar region. This shows that inferiorly the liver (L) and spleen (S) are more laterally positioned in relation to the right (RK) and left (LK) kidneys.

6  Surgical Anatomy of the Kidney for Endourological Procedures aa

ia

L

sa

AC

S R

RA

DC

Figure 6.9  Superior view of a transverse section through a cooled cadaver at the level of the inferior poles of the kidney. This shows the ascending (AC) and descending (DC) colons lying in a posterolateral position in relation to the right (R) and left (L) kidneys. S, spine.

supply the homonymous segment without further significant branching, the anterior branch of the renal artery provides three or four segmental arteries. The segmental arteries divide before entering the renal parenchyma into the interlobar arteries (infundibular arteries), which progress adjacent to the calyceal infundibula and the minor calyces, entering the renal columns between the renal pyramids (Figures 6.10 and 6.11) [6]. As the interlobar arteries progress, near the base of the pyramids, they give origin (usually by dichotomous ­division) to the arcuate arteries (Figures 6.10 and 6.11). The arcuate arteries give off the interlobular arteries, which run to the periphery, giving off the afferent arterioles of the glomeruli (Figure 6.11) [6].

Figure 6.10  Schematic of an anterior view of a right kidney. This shows the branching of the renal arteries and their official nomenclature according to kidney region. RA, renal artery; sa, segmental artery; ia, interlobar (infundibular) artery; aa, arcuate artery.

af. il.a aa

Intrarenal veins

The intrarenal veins, unlike the arteries, do not have a segmental model. Moreover, in contrast to the arteries, there is free circulation throughout the venous system, with ample anastomoses between the veins. These anastomoses, therefore, prevent parenchymal congestion and ischemia in case of venous injury [7]. The small veins of the cortex, called stellate veins, drain into the interlobular veins that form a series of arches (Figure 6.12). Within the kidney substance, these arches are arranged in arcades, which lie mainly in the longitudinal axis. There are usually three systems of longitudinal anastomotic arcades and the anastomoses occur at different levels: between the stellate veins (more peripherally), between the arcuate veins (at the base of the pyramids), and between the interlobar (infundibular) veins (close to the renal sinus) (Figure  6.12). We have named these anastomoses as first order, second order, and third order, from periphery to center [7]. In early studies, we found three trunks (53.8%) and two trunks

ia

Figure 6.11  Schematic of two adjacent pyramids and minor calyces. This shows the renal vasculature from the level of the interlobar arteries to the glomerular level. ia, interlobar (infundibular artery); aa, arcuate artery; il.a, interlobular artery; af., afferent arteriole of the glomerulus.

(28.8%) joining each other to form the main renal vein. Less frequently, we found four trunks (15.4%) and five trunks (1.9%) [7]. A detailed description of the kidney collecting system (the pelviocalyceal system), as well as the anatomic relationships between the intrarenal arteries and veins with

91

92

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

(a)

(b)

3

RV 1

2

Figure 6.12  (a) Anterior view of a left kidney endocast of the pelviocalyceal system together with the venous vascular tree. This shows the three systems of longitudinal anastomotic arcades; from lateral (periphery) to medial (hilar): stellate veins (curved arrow), arcuate veins (short arrow), and interlobar veins (long arrow). RV, renal vein. (b) Schematic showing the three orders of arcades: 1, first‐order arcade; 2, second‐order arcade; 3, third‐order arcade.

the kidney collecting system, which are of utmost importance for endourology, is given below.

­Pelvicocalyceal system: endourologic implications Anatomic classification Recent advances in endourology have revived interest in collecting system anatomy, since a full understanding of such anatomy is necessary to perform reliable endourologic procedures as well as uroradiologic analysis [8–10]. We have proposed a pelviocalyceal classification, including all morphologic types of collecting systems, which we believe is helpful for standardizing patients and procedures [9]. This classification was derived from the analysis of 140 three‐dimensional (3D) polyester resin corrosion endocasts of the pelviocalyceal system (Figure 6.13), obtained from 70 fresh cadavers according to a technique described previously [8]. Basic intrarenal anatomy

The renal parenchyma basically consists of two kinds of tissue, the cortical tissue and medullar tissue. On a longitudinal section (Figure 6.14), the cortex forms the external layer of renal parenchyma. The renal medulla is formed by several inverted cones, surrounded by a layer

of cortical tissue on all sides (except at the apices). As in longitudinal sections, a cone assumes the shape of a pyramid (Figure 6.14) and the established term for the medullar tissue is renal pyramid; the apex of this pyramid is termed the renal papilla. The layers of cortical tissue between adjacent pyramids are termed renal columns (cortical columns of Bertin; Figure 6.14) [8, 10]. The cortical tissue is made up of the glomeruli with proximal and distal convoluted tubules. The renal pyramids are made up of loops of Henle and collecting ducts; these ducts join to form the papillary ducts (about 20), which open at the papillary surface (area cribosa; Figure  6.15) and drain urine into the collecting system (into the fornix of a minor calyx). A minor calyx is defined as the calyx that is in immediate apposition to a papilla (Figures  6.14 and 6.15). The renal minor calyces drain the renal papillae and range in number from 5 to 14 (mean, 8); we have found 70% of kidneys to have 7–9 minor calyces [8]. A minor calyx may be single (drains one papilla) or compound (drains two or three papillae) (Figures 6.13 and 6.15). The polar calyces are often compound, markedly in the superior pole (Figure 6.13). The minor calyces may drain straight into an infundibulum or join to form major calyces, which subsequently will drain into an infundibulum (Figures  6.13 and 6.15). Finally, the infundibula, which are considered the primary divisions of the pelviocalyceal system, drain into the renal pelvis.

6  Surgical Anatomy of the Kidney for Endourological Procedures

(a)

(b) sc

cc i mc

Mc

P

f

Figure 6.13  (a) Anterior view of a pelviocalyceal endocast from a left kidney, obtained according to the injection–corrosion technique. (b) Schematic of the endocast shown in (a). This shows the essential elements of the kidney collecting system. cc, compound calyx; sc, single calyx; mc, minor calyx; Mc, major calyx; f, calyceal fornix; i, infundibulum; P, renal pelvis. Reproduced with permission of Georg Theim Verlag KG. pd rc

p

c ac

P Mc mc

imc

Mc

mc i rp p

Figure 6.14  Schematic of a longitudinal section of the kidney. This shows the intrarenal structures. c, renal cortex; rc, renal column (cortical column of Bertin); rp, renal pyramid; p, renal papilla; mc, minor calyx; Mc, major calyx; P, renal pelvis. Reproduced with permission of Georg Theim Verlag KG.

Figure 6.15  Schematic representation of the possible minor calyx (mc) arrangements. A single mc drains only one papilla and a compound mc drains two or three papillae. p, renal papilla; pd, papillary ducts; ac, area cribosa; Mc, major calyx; imc, infundibulum of a mc (calyceal neck); i, infundibulum. Reproduced with permission of Georg Theim Verlag KG.

93

94

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

Classification of the pelviocalyceal system

●●

The analysis of 140 endocasts led us to a division into two major groups (with two intermediate varieties in each major group). This division was based on superior pole, inferior pole, and kidney midzone (hilar) calyceal drainage. Group A is composed of pelviocalyceal systems that have two major calyceal groups (superior and inferior) as a primary division of the renal pelvis and a midzone calyceal drainage dependent on these two major groups (62.2%) (Figure  6.16). Group A includes two different types of pelviocalyceal system: ●●

●●

Type A‐I (45%): the kidney midzone is drained by minor calyces that are dependent on the superior and/ or inferior calyceal groups (Figure 6.16a). Type A‐II (17.2%): the kidney midzone is drained simultaneously by crossed calyces, one draining into the superior calyceal group and the other draining into the inferior calyceal group (Figure  6.16b). When we analyzed the endocasts with crossed calyces in the kidney midzone, we observed that the crossed calyces (laterally) and the renal pelvis (medially) bound a region (space) that we designated the “interpelviocalyceal” (IPC) region (space) (Figure 6.16b).

Group B is composed of pelviocalyceal systems with kidney midzone (hilar) calyceal drainage independent of both the superior and inferior calyceal groups (37.8%) (Figure  6.17). This group also includes two different types of pelviocalyceal system: ●●

Type B‐I (21.4%): the kidney midzone is drained by a major calyceal group, independent of both the superior and the inferior groups (Figure 6.17a).

(a)

Type B‐II (16.4%): the kidney midzone is drained by minor calyces (one to four) entering directly into the renal pelvis (Figure 6.17b). Such calyces are independent of both the superior and inferior calyceal groups.

The kidney collecting system is very variable and is not symmetrical. We found pelviocalyceal systems with morphologic bilateral symmetry in the same individual in only 37.1% of the cases (26 pairs of kidneys). Although our pelviocalyceal classification includes all morphologic types of calyces and renal pelvices, in performing endourologic procedures it is important to be aware that the collecting system anatomy is very variable. The endocast in Figure 6.18a, for example, reveals a very long and thin superior calyceal infundibulum; this anatomic formation will certainly cause difficulties in the introduction and manipulation of a nephroscope into the superior pole collecting system. The endocast in Figure 6.18b shows just the opposite aspect (both superior and inferior calyceal infundibula are short and thick); this anatomic formation will certainly make it easier to introduce and manipulate a nephroscope within the superior and inferior collecting systems. Comparative analysis between pyelograms and the corresponding 3D collecting system endocasts Since standard urograms (pyelograms) show the collecting system in only one plane, it is extremely difficult for the practitioner to visualize and imagine this system in three dimensions. A full understanding of pelviocalyceal anatomy is a prerequisite for successful endourologic

(b)

IPC

S

S I

I

Figure 6.16  View of the two morphologic types of pelviocalyceal systems that compose Group A. (a) Type A‐I: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by calyces dependent on the superior (S) and inferior (I) calyceal groups. (b) Type A‐II: anterior view of a right pelviocalyceal cast shows the kidney midzone drained by crossed calyces, dependent simultaneously on the superior (S) and inferior (I) calyceal group. This endocast shows the interpelviocalyceal (IPC) space. Reproduced with permission of Georg Theim Verlag KG.

6  Surgical Anatomy of the Kidney for Endourological Procedures

(a)

(b)

S

S

M

M I

I

Figure 6.17  View of the two morphologic types of pelviocalyceal systems that comprise Group B. (a) Type B‐I: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by a hilar major calyx (M), independently of the superior (S) and inferior (I) major calyces. (b) Type B‐II: anterior view of a left pelviocalyceal endocast shows the kidney midzone drained by minor calyces (M) entering directly into the renal pelvis, independently of both the superior (S) and inferior (I) calyceal groups. Reproduced with permission of Georg Theim Verlag KG.

interventions in the upper urinary tract, as well as for interpreting fluoroscopy pyelograms and other imaging examinations. To assist endourologists in forming a mental image of the collecting system in three dimensions and learning the exact spatial position of the calyces, before obtaining the pelviocalyceal system endocast, iodinated contrast was injected into the ureter of 40 of our cases to opacify the collecting system to obtain a pyelogram. After radiography, the contrast was removed and the collecting system was filled with a polyester resin to obtain a 3D endocast. These 40 kidneys enabled a comparative study between the radiographic images and their corresponding 3D endocasts. This identified some remarkable ­anatomic aspects of the kidney collecting system that need to be considered during endourologic procedures. Presence of perpendicular minor calyces

In 11.4% of the endocasts (16 of 140) we found a perpendicular minor calyx draining directly into the renal pelvis or into a major calyx (Figure  6.19). The minor calyces perpendicular to the surface of the collecting system, which are seen in the endocasts, can be superimposed on other structures, which means their visualization radiographically can be difficult (Figure 6.20). Stones in such

minor calyces viewed on standard anteroposterior radiographic images can appear as if they were placed in the pelvis or a major calyx. Thus, this anatomic detail must be considered in cases of stones that do not alter renal function and can appear as if they are in the renal pelvis or a major calyx. In this situation, a complementary ­radiologic study with lateral and oblique films must be performed to determine accurately the position and extent of the stones [11, 12]. When a stone is located in a perpendicular minor calyx (Figure 6.19), its removal presents additional difficulties for both extracorporeal shock‐wave lithotripsy (ESWL) and percutaneous nephrolithotripsy (PCNL). Patients with stones in such calyces are not good candidates for ESWL because these calyces invariably present narrow infundibula (50% in different positions), we believe that precise determination of calyceal position is difficult with the common radiologic methods, even using oblique and lateral views [9, 11]. To solve this problem quickly and inexpensively, during endourologic procedures, with the patient in the prone position, room air should be injected into the collecting system and this will rise to the more posterior portions of the collecting system, determining which calyces are located posteriorly (radiolucent contrast) [11, 12, 16].

97

98

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

(a)

(b)

(c)

S

S

S I

I I

Figure 6.21  Anterior view of right pelviocalyceal endocasts. This shows the different shapes that the interpelviocalyceal (IPC) space may assume: (a) small and round IPC space (arrow); (b) lozenge‐like IPC space (most common shape) (asterisk); (c) long and narrow IPC space (curved arrow). S, superior calyceal group; I, inferior calyceal group. Reproduced with permission of Georg Theim Verlag KG.

(a)

Figure 6.22  Comparative study between a retrograde pyelogram of a left kidney and its corresponding 3D endocast of the pelviocalyceal system. (a) Anterior view of a retrograde pyelogram shows the radiographic image of the interpelviocalyceal (IPC) region (arrow). (b) Anterior view of the corresponding 3D endocast. The arrow points to the calyx which is draining into the inferior calyceal group in the ventral position (87.7% of the endocasts of the IPC space). S, superior calyceal group; I, inferior calyceal group. Reproduced with permission of Georg Theim Verlag KG.

(b)

S

I

Position of the calyces relative to the polar regions and kidney midzone

The superior pole was drained by a midline calyceal infundibulum in 98.6% of the endocasts (Figure  6.26). The midzone (hilar) was drained by paired calyces that were arranged in two rows (anterior and posterior) in 95.7% of the endocasts (Figure  6.26). The inferior pole

was drained by paired calyces arranged in two rows in 81 endocasts (57.9%) (Figure 6.26a) and by a single midline calyceal infundibulum in 59 endocasts (42.1%) (Figure 6.26b). With regard to the calyceal drainage of the kidney polar regions, many investigators have affirmed that there usually is only one calyceal infundibulum draining

6  Surgical Anatomy of the Kidney for Endourological Procedures

Figure 6.23  Position of the calyces relative to the lateral margin of the kidney. (a) Anterior view of a right pelviocalyceal endocast, which shows the anterior calyces have a more lateral (peripheral) position than the posterior calyces (arrows). This means that the posterior calyces are located medially. (b) Schematic of the endocast shown in (a). This shows the peripheral calyces in the anterior plane and the medial calyces (arrows) in the posterior plane. Reproduced with permission of Georg Theim Verlag KG.

(a)

(b)

Figure 6.24  Position of the calyces relative to the lateral margin of the kidney. (a) Anterior view of a right pelviocalyceal endocast. This shows that the posterior calyces (arrows) have a more lateral (peripheral) position than the anterior calyces. (b) Schematic of the endocast shown in (a). This shows the peripheral calyces in the posterior plane (arrows) and the medial calyces in the anterior plane. Reproduced with permission of Georg Theim Verlag KG.

(a)

(b)

each pole [3, 10, 14]. In our study, the superior pole was drained by only one midline calyceal infundibulum in 98.6% of the endocasts. However, the inferior pole was drained by paired calyces arranged in two rows in 81 of the 140 endocasts (57.9%) and by one midline calyceal infundibulum in 59 endocasts (42.1%) (Figure  6.26). These results are important in endourology; it will be easier to access endoscopically a polar region drained by a single infundibulum, which usually has a suitable

­ iameter, rather than a polar region drained by paired d calyces (Figure 6.26). Because the inferior pole is drained by paired calyces in 57.9% of the endocasts, this anatomic detail must be kept in mind, both to plan and perform the intrarenal access and endoscopic procedures in the inferior pole. The calyceal drainage of superior and inferior poles is also of utmost importance in ESWL [13, 17]. Concerning the kidney midzone (hilar) drainage, our results show that this region is drained by paired calyces

99

100

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

(a)

(b)

Figure 6.25  Position of the calyces relative to the lateral margin of the kidney. (a) Anterior view of a right pelviocalyceal endocast, and (b) schematic of this endocast. The calyces in the anterior plane (arrows) are located alternately relative to the lateral margin of the kidney, i.e. in one region they are more lateral and in another they are more medial. Reproduced with permission of Georg Theim Verlag KG.

(a)

(b)

Figure 6.26  Position of calyces relative to the polar regions and kidney midzone. (a) Lateral view of a left pelviocalyceal endocast. The superior pole is drained by a single midline calyceal infundibulum (arrowhead). The midzone (hilar) is drained by paired calyces arranged in two rows (short arrow); anterior and posterior. The inferior pole is drained by paired calyces arranged in two rows (long arrow). (b) Lateral view of a right pelviocalyceal endocast. The superior pole is drained by a single midline calyceal infundibulum (arrowhead). The midzone is drained by paired calyces arranged in two rows (short arrow); anterior and posterior. The inferior pole is drained by only one midline calyceal infundibulum (long arrow). Reproduced with permission of Georg Theim Verlag KG.

6  Surgical Anatomy of the Kidney for Endourological Procedures

arranged in two rows (anterior and posterior) in 95.7% of the endocasts (Figure  6.26), which is of relevance to endourologists accessing and treating the mid kidney.

­ natomic relationship of intrarenal A vessels (arteries and veins) with the kidney collecting system: importance for puncture intrarenal access Percutaneous nephrostomy is the procedure of choice for temporary drainage of urine and for gaining access to the kidney during numerous endourologic and interventional procedures. The development of new percutaneous techniques, as well as a variety of instruments, has enabled the replacement of several open surgeries by percutaneous therapy (renal abscess, calyceal diverticulum, infundibular stenosis, ureteropelvic junction obstruction, some cases of upper tract urothelial tumors, etc.) [18–20]. Percutaneous procedures are relatively invasive and complications may occur. One of the most significant complications is vascular injury that occurs when the urologist is obtaining intrarenal access. This problem may have several consequences, including intraoperative hemorrhage, hypotension, loss of functioning renal parenchyma, arteriovenous fistula, and pseudoaneurysm [21–25]. The goal of this section is to offer a detailed anatomic depiction of the intrarenal vessels and their relationships to the collecting system, and show how to perform safe percutaneous intrarenal access by keeping as many renal vessels as possible intact during puncture. We analyzed 62 retrograde pyelograms and their corresponding 3D polyester resin corrosion endocasts of Figure 6.27  (a) Anterior view of a retrograde pyelogram from a right kidney showing the superior pole (s), mid kidney (m), and inferior pole (i) punctures. These punctures were performed after polyester resin injections into the arterial and venous systems, while the resins were still in the gel state. Note that the injected resins are not opaque to X‐rays. (b) Posterior view of the corresponding corrosion endocast obtained after contrast removal and pelviocalyceal system injection with resin. The needles are maintained in their original places. s, superior pole puncture; m, mid kidney puncture; i, inferior pole puncture. The arrowheads show the tracts of the needles. A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

the kidney collecting system, together with the intrarenal arteries and veins, obtained from fresh cadavers. The kidneys were punctured under fluoroscopic guidance and the endocasts obtained with needles positioned at the site of puncture (Figure  6.27). For comparative analysis, we studied kidneys that had been punctured through a calyceal infundibulum and kidneys punctured through a calyceal fornix. Intrarenal access through an infundibulum Figure 6.13 shows the basic anatomy of the renal collecting system. Keeping those anatomic landmarks in mind, note that a puncture through an infundibulum (in any region of the kidney) presents clear hazards [26]. Superior pole

Puncture is most dangerous through the upper pole infundibulum because this region is surrounded almost completely by large vessels (Figure  6.28). Infundibular arteries and veins course parallel to the anterior and posterior aspects of the upper pole infundibulum. In our series, injury to an interlobar (infundibular) vessel was a common consequence of puncturing the upper pole infundibulum (67% of kidneys) (Figure 6.29); the injured vessel was an artery in 26% of those cases. The most serious vascular accident in upper infundibulum puncture is lesion of the posterior segmental artery (retropelvic artery). This event may occur because this artery was crossed by and is related to the posterior ­surface of the upper infundibulum in 57% of the endocasts (Figure 6.30) [27]. Figure 6.31 shows an upper infundibulum puncture in which the needle tract produced complete laceration of the posterior segmental artery.

(a)

(b) S

s A

V

m

u

m

i

i

101

102

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

A A

V V

u

u

Figure 6.28  Oblique medial view of an endocast of arterial (A), venous (V), and pelviocalyceal systems from a left kidney. This shows the upper infundibulum almost completely encircled by infundibular arteries and veins. This anatomic arrangement makes upper pole infundibular puncture especially dangerous. A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

(a)

Figure 6.30  Posterior view of an endocast from a right kidney. This shows the posterior segmental artery (retropelvic artery) crossing the posterior surface of the upper infundibulum (arrow). A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

(b)

A

u

V

Figure 6.29  (a) Posterior view of a retrograde pyelogram from a left kidney. Puncture performed through the upper infundibulum has injured an infundibular vein (curved arrow). Note the contrast in the retropelvic vein (short arrows). (b) Posterior view of the corresponding endocast reveals the site of the lesion (arrow). Arrowheads show the needle tracts. A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

6  Surgical Anatomy of the Kidney for Endourological Procedures

Figure 6.31  (a) Posterior view of a retrograde pyelogram from a left kidney. This shows contrast extravasation, and contrast in the arterial system and main trunk of the renal artery (short arrows). The retropelvic artery was injured by the needle (needle tracts shown by the arrowheads). The curved arrow points to the site of the lesion; the long arrow points to the retropelvic artery filled with contrast extravasated from the collecting system. (b) Posterior view of the corresponding endocast. This shows the divided retropelvic artery (arrow) and the needle (arrowheads) responsible for the lesion (curved arrow). A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

(a)

(b)

A

V u

Because the posterior segmental artery (retropelvic artery) may supply up to 50% of the renal parenchyma, injury to it may result in significant loss of functioning renal tissue, as well as causing hemorrhage [28]. Middle kidney

Intrarenal access through the mid kidney infundibulum caused arterial lesion in 23% of the kidneys studied. The middle branch of the posterior segmental artery was injured more often than any other vessel. Inferior pole

The posterior aspect of the lower pole infundibulum is widely presumed by endourologists and interventional radiologists to be free of arteries. It is considered, therefore, to be a safe region through which to gain access to the collecting system and to place a nephrostomy tube. In about 38% of the kidneys examined, however, an infundibular artery was found in this region [27]. Thus, significant complications may develop as a consequence of a posterior approach through the supposedly vessel‐ free lower infundibulum [22, 25, 26]. We found an arterial injury in 13% of kidneys we had punctured ­ through the lower pole infundibulum. Concerning the veins, we found large venous anastomoses, similar to collars, around the calyceal infundibula (the so‐called calyceal necks) in many of the kidneys we studied [7]. Puncture through the lower pole infundibulum therefore also risks injury to a venous arcade (Figure 6.32). A venous lesion usually heals spontaneously, but consequent hemorrhage may be problematic during the procedure. Our findings clearly demonstrate that percutaneous nephrostomy through an infundibulum of a calyx is not a

safe route, because this type of access poses an important risk of significant bleeding from interlobar (infundibular) vessels. Infundibular puncture also creates the hazard of through‐ and‐through (two‐wall) puncture of the collecting system (Figure  6.33). Because major segmental branches of the renal artery, as well as major tributaries of the renal vein, are positioned on the anterior surface of the renal pelvis, marked hemorrhage may occur as a result of an anterior through‐and‐through perforation. In addition, effective tamponade of injured anterior vessels is difficult because they lie distantly in the nephrostomy tract [24, 26, 29]. Although infundibular access is feasible in some ­circumstances and must be considered in specific situations (e.g. some difficult anatomic cases), the surgeon must evaluate the risk of an arterial lesion, primarily in the superior pole and in the mid kidney [24]. Intrarenal access through the renal pelvis Direct puncture of the renal pelvis for endourologic surgery should never be performed. Besides the fact that the nephrostomy tube inserted at this site is easily dislodged and difficult to reintroduce during the operative maneuvers, renal pelvis puncture has a prohibitive and unnecessary risk of injuring a retropelvic vessel (artery and/or vein) [7, 22, 27]. Intrarenal access through a calyceal fornix When we made a puncture through a fornix of a calyx, venous injury occurred in fewer than 8% of the kidneys. These injuries occurred indiscriminately in the upper

103

104

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

(a)

(b)

A

Figure 6.32  (a) Posterior view of a retrograde pyelogram from a left kidney. This shows a puncture performed through the inferior infundibulum. A venous lesion and the contrast in a large venous arcade draining to the retropelvic vein (arrows) can be seen. The arrowheads show the tract of the needle. (b) Posterior view of the corresponding endocast reveals the site of the lesion in the venous arcade (arrows). The arrowheads show the tracts of the needles. A, renal artery; V, renal vein; u, ureter. Reproduced with permission of Elsevier.

V u

(a)

(b)

u

pole, mid pole, and lower pole calyces. We did not detect any arterial lesions as a consequence of a forniceal ­puncture [24]. Where to puncture for intrarenal access In conclusion, the high rate of vascular injury and the possibility of associated complications mean that a nephrostomy tube should not be placed through an infun-

Figure 6.33  (a) Posterior view of a retrograde pyelogram from a right kidney reveals superior, middle, and inferior punctures (short arrows) and contrast in the superior and inferior infundibular arteries (arrows). (b) Posterior view of the corresponding endocast reveals injury to an upper infundibular artery (black arrow). The mid kidney puncture (white arrow) was a through‐and‐through (two‐wall) puncture and injured an anterior segmental artery. The injured vessel furnished the posteroinferior branch filled with contrast on the pyelogram. The arrowheads show the tracts of the needles. u, ureter. Reproduced from Sampaio et al. [24] with permission.

dibulum of a calyx (Figure 6.34). On the other hand, and regardless of the region of the kidney, puncture and placement of a nephrostomy tube through a fornix of a calyx is safe and should be the site chosen by the operator (Figure 6.35). Even in the superior pole, intrarenal puncture through a calyceal fornix is harmless (Figure 6.36). In addition, when puncturing through a fornix of a calyx, in case of lesion, injury is always to a peripheric vessel, such as a small venous arcade (Figure 6.37).

6  Surgical Anatomy of the Kidney for Endourological Procedures

Figure 6.34  (a) Schematic of a posterior view of a longitudinal section of a right kidney showing an intrarenal puncture performed through a calyceal infundibulum (arrow). This type of puncture should not be performed because it carries a high risk of vascular injury. (b) Schematic of a superior view of a transverse section of a kidney also shows an intrarenal puncture through a calyceal infundibulum (arrow); again this is not a recommended route. V, ventral region; D, dorsal region.

(a)

(b) V

D

Figure 6.35  (a) Schematic of a posterior view of a longitudinal section of a right kidney showing an intrarenal puncture performed through a calyceal fornix (arrow). This type of puncture is safe and is associated with a very low incidence of vascular injury. (b) Schematic of a superior view of a transverse section of the kidney shows an intrarenal puncture through a calyceal fornix (arrow), a route that is strongly recommended. V, ventral region; D, dorsal region.

(a)

(b) V

D

105

106

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

P

u

Figure 6.37  Posterior view of an endocast from a right kidney with an inferior puncture performed through a fornix of a calyx. The arrows point to a lesion in a small peripheric venous arcade. The arrowheads show the needle tract. P, renal pelvis; u, ureter. Figure 6.36  Superior view of an endocast from a left kidney shows that, even in the superior pole, a puncture through the fornix of a calyx (arrow) is safe.

­References 1 Sampaio FJB. Analysis of kidney volume growth during 2

3 4

5

6

7

the fetal period in humans. Urol Res 1992;20:271–274. Sampaio FJB and Mandarim‐de‐Lacerda CA. Morphométrie du rein. Etude appliquée à l’urologie et à l’imagerie. J Urol (Paris) 1989;95:77–80. Sampaio FJB. Renal anatomy: endourologic considerations. Urol Clin North Am 2000;27:585–607. Hopper KD and Yakes WF. The posterior intercostal approach for percutaneous renal procedures: risk of puncturing the lung, spleen, and liver as determined by CT. AJR Am J Roentgenol 1990;154:115–117. Hopper KD, Sherman JL, Luethke JM, and Ghaed N. The retrorenal colon in the supine and prone patient. Radiology 1987;162:443–446. Sampaio FJB. Relationships of intrarenal arteries and the kidney collecting system. Applied anatomic study. In: Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology (ed. FJB Sampaio and R Uflacker), 23–32. New York: Thieme Medical Publishers, 1993. Sampaio FJB and Aragão AHM. Anatomical relationship between the renal venous arrangement and the kidney collecting system. J Urol 1990;144:1089–1093.

8 Sampaio FJB. Anatomic classification of the pelviocaliceal

9

10 11

12

13

system. Urologic and radiologic implications. In: Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology (ed. FJB Sampaio and R Uflacker), 1–5. New York: Thieme Medical Publishers, 1993. Sampaio FJB and Mandarim‐de‐Lacerda CA. Anatomic classification of the kidney collecting system for endourologic procedures. J Endourol 1988;2:247–251. Kaye KW and Goldberg ME. Applied anatomy of the kidney and ureter. Urol Clin North Am 1982;9:3–13. Sampaio FJB and Mandarim‐de‐Lacerda CA. 3‐ Dimensional and radiological pelviocaliceal anatomy for endourology. J Urol 1988;140:1352–1355. Sampaio FJB. Basic anatomic features of the kidney collecting system. Three‐dimensional and radiologic study. In: Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology (ed. FJB Sampaio and R Uflacker), 7–15. New York: Thieme Medical Publishers, 1993. Sampaio FJB and Aragão AHM. Inferior pole collecting system anatomy. Its probable role in extracorporeal shock wave lithotripsy. J Urol 1992;147:322–324.

6  Surgical Anatomy of the Kidney for Endourological Procedures

14 Sampaio FJB. Renal collecting system anatomy: its

22 Clayman RV, Surya V, Hunter D et al. Renal vascular

15

23

16 17

18

19

20

21

possible role in the effectiveness of renal stone treatment. Curr Opin Urol 2001;11:359–366. Kaye KW and Reinke DB. Detailed caliceal anatomy for endourology. J Urol 1984;132:1085–1088. Weyman PJ. Air as a contrast agent during percutaneous nephrostomy. J Endourol 1986;1:16–17. Sampaio FJB and Aragão AHM. Limitation of extra corporeal shock wave lithotripsy in lower caliceal stones: anatomical insight. J Endourol 1994;8:241–247. Elliott DS, Segura JW, Lightner D et al. Is nephroureterectomy necessary in all cases of upper tract transitional cell carcinoma? Long‐term results of conservative endourologic management of upper tract transitional cell carcinoma in individuals with a normal contralateral kidney. Urology 2001;58:174–178. Murphy DP, Gill IS, and Streem SB. Evolving management of upper‐tract transitional‐cell carcinoma at a tertiary‐care center. J Endourol 2002;16:483–487. Auge BK, Munver R, Kourambas J et al. Neoinfundibulotomy for the management of symptomatic caliceal diverticula. J Urol 2002;167:1616–1620. Segura JW. The role of percutaneous surgery in renal and ureteral stone removal. J Urol 1989;141:780–781.

24

25

26 27

28

29

complications associated with the percutaneous removal of renal calculi. J Urol 1984;132:228–230. Lee WJ, Smith AD, Cubelli V et al. Complications of percutaneous nephro‐lithotomy. AJR Am J Roentgenol 1987;148:177–180. Sampaio FJB, Zanier JFC, Aragão AHM, and Favorito LA. Intrarenal access: 3‐dimensional anatomical study. J Urol 1992;148:1769–1773. Sampaio FJB. Intrarenal access by puncture. Three‐ dimensional study. In: Renal Anatomy Applied to Urology, Endourology, and Interventional Radiology (ed. FJB Sampaio and R Uflacker), 68–76. New York: Thieme Medical Publishers, 1993. Sampaio FJB. How to place a nephrostomy, safely. Contemp Urol 1994;6:41–46. Sampaio FJB and Aragão AHM. Anatomical relationship between the intrarenal arteries and the kidney collecting system. J Urol 1990;143:679–681. Sampaio FJB, Schiavini JL, and Favorito LA. Proportional analysis of the kidney arterial segments. Urol Res 1993;21:371–374. Clayman RV, Hunter D, Surya V et al. Percutaneous intrarenal electrosurgery. J Urol 1984;131:864–867.

107

108

7 Nephrolithometric Scoring Systems for Percutaneous Nephrolithotomy Roshan Patel,1 Daniel J. Lama,2 & Zhamshid Okhunov1 1 2

Department of Urology, University of California, Irvine, CA, USA Division of Urology, University of Cincinnati School of Medicine, Cincinnati, OH, USA

­Introduction Kidney stone disease is common and affects nearly 1 in 11 individuals in the United States [1]. The majority of stones pass spontaneously; however, up to 10–20% of stones require surgical intervention. Ureteroscopy and shock‐wave lithotripsy are the primary surgical methods for treating small stones while percutaneous nephrolithotomy (PCNL) is the gold standard for stones larger than 2.0 cm [2]. There are several patient‐ and stone‐ related factors that dictate the feasibility of PCNL. Stone characteristics have a significant impact on surgical outcomes and features such as size, the extent of calyceal involvement, and stone density play an important role in the decision‐making process. Additional factors that should be considered are the tract length, degree of obstruction of the collecting system, pelvicalyceal anatomy, and anatomical malformations [3–7]. Efforts have been made by several groups to characterize renal stones in a standard and reproducible fashion. The importance of establishing scorings systems is twofold. First, preoperative patient counseling necessitates the development of an integrated scoring system to assess and quantify stone complexity for optimal decision‐making. Second, it allows a way to account for the methodological differences among studies reporting outcomes of PCNL. Nephrolithometry scoring systems (NLSS) aim for preoperative prediction of stone‐free status (SFS) and complications through assessment of the complexity of stones before performing a PCNL. The S.T.O.N.E. nephrolithometry, the Guy’s stone score (GSS), the Clinical Research Office of the Endourology Society (CROES) nomogram, and the Seoul National University Renal Stone Complexity (S‐ReSC) score are the four most common NLSS used today (Table  7.1) [8–11]. These NLSS

not only consider imaging criteria of stones and renal anatomy but may also use relevant patient characteristics such as body mass index (BMI), previous renal surgery, and surgeon experience. This chapter provides a comprehensive review of NLSS used today. Their individual advantages and disadvantages will be presented along with their commonalities. Despite validation of the NLSS discussed in this chapter over 10% of members of the Endourological Society were not aware of their existence and over 85% did not use them in clinical practice [12]. An understanding of the various NLSS is critical in overcoming the methodological differences among studies that look at outcomes of PCNL and the judicious use of such systems may improve stone‐ free rates and reduce morbidity associated with PCNL.

­ tone scoring tools: descriptions S and assessments S.T.O.N.E. nephrolithometry: development, reproducibility, and validation S.T.O.N.E. nephrolithometry was developed in 2013 as a means to quantitate kidney stone complexity in a standardized and reproducible manner. The scoring system consists of the five most reproducible variables obtained from preoperative imaging. These are Stone size, Tract length, Obstruction/hydronephrosis, Number of involved calyces, and Essence of stone density measured by Hounsfield units (Table 7.2). Stone size is determined by measuring and multiplying the vertical length by the greater of the two measurements, width or length, resulting in a size in square millimeters. The tract length is defined as the distance from the center of the stone to the surface of skin measured at a 45° angle on a supine

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

7  Nephrolithometric Scoring Systems

Table 7.1  The overview of most common NLSSs. Scoring system

Categorization

Method of derivation

Guy’s stone score [11]

Grade I: a solitary stone in the mid/lower pole, or renal pelvis with simple anatomy Grade II: a solitary stone in the upper pole with simple anatomy, multiple stones in a patient with simple anatomy, or any solitary stone in a patient with abnormal anatomy Grade III: multiple stones in a patient with abnormal anatomy, stones in a caliceal diverticulum, or partial staghorn calculus Grade IV: staghorn calculus or any stone in a patient with spina bifida or spinal injury

Literature review, expert opinion, iterative process

CROES nomogram [10]

A: stone burden, calculated as follows:

Multiple logistic regression analysis

1)  Measure the maximum length of each stone in millimeters 2)  Measure the maximum width of each stone in millimeters 3)  Calculate the stone burden for each stone = 0.785 × length × width 4)  Add individual stone burdens if multiple stones B: calyceal location: position in renal pelvis or multiple calyces involved, including staghorn calculi C: stone count: single or multiple D: case volume S.T.O.N.E. nephrolithometry

Scoring based on five variables from preoperative noncontrast computed tomography stone size: S = stone size

Systematic review

1)  0–399 mm2 2)  400–799 mm2 3)  800–1599 mm2 4)  >1600 mm2 T = tract length 1)  100 mm O = obstruction 1)  No or mild dilatation 2)  Moderate to severe dilatation N = number of involved calyces 1)  1 calyx involved 2)  2–3 calyces involve 3)  Full staghorn calculus E = essence (stone density) 1)  950 HU Seoul National University Renal Stone Complexity (S‐ReSC) score [8]

Identify number of preselected pelvicalyceal locations involved: each of the nine locations is worth 1 point; total score 5 cumulative number of locations involved

computed tomography (CT) film. The tract length is subdivided into two scores: ≤100 mm is one point and >100 mm is two points. The obstruction component of the scoring system evaluates the degree of hydronephrosis according to the dilation of the collecting system

Not reported

viewed on CT imaging. Assigning a score for this variable is dependent on the user’s familiarity with recognizing hydronephrosis in axial imaging. None or mild hydronephrosis is given a score of 1 while moderate to severe hydronephrosis is scored as 2. The number of

109

110

Section 2  Percutaneous Renal Surgery: Perioperative Considerations

Table 7.2  The overview of the S.T.O.N.E. nephrolithometry [9]. Score Variable

1

2

3

4

Stone size (mm2)

0–399

400–799

800–1599

>1600

Tract length (mm)

100

Obstruction

None

Severe

Calyces

1–2

3

Essence

950 HU

Staghorn

calyces evaluates the extent of calyces infiltrated by the stone. This component is highly dependent on the user’s understanding of renal cross‐sectional anatomy [2]. If one or two calyces are involved the score of 1 is given, if three calyces are involved the score is 2, and if it is a staghorn stone the highest score of 3 is assigned. The essence component of the scoring system evaluates the stone density measured in Hounsfield units (HU) for a circular region of interest (ROI). Due to the heterogeneity of stone shape, this measurement is made by creating a circular ROI that encompasses the most stone possible while minimizing adjacent soft tissue. It is important to capture as large an area of the stone as possible in order to appreciate the average density of the stone. As most stones are lamellate in their composition, density will vary considerably from the center to the outer edges of the stone. It is important to evaluate the average density of the entire stone for the sake of reproducibility. This variable is scored based on radiodensity threshold of 950 HU. Stones greater than 950 HU are scored 2 and those less than 950 HU are scored 1. The parameters used for the S.T.O.N.E. score are easy to calculate, do not require specialized software, and are derived from noncontrast‐enhanced CT images. The methodology for choosing the associated variables were identified via a literature review of English language studies from 1976 to 2012 on MedLine to identify the most clinically relevant and reproducible variables that had been shown to impact outcomes following PCNL. The scoring system was subsequently validated in a cohort of 117 PCNL patients to evaluate the predictive value of the S.T.O.N.E. nephrolithometry. A “low” score of 4–5 demonstrated a correlation with SFS of 94–100%, a “moderate” score of 6–8 correlated with a SFS of 83–92%, and “high” scores of 9–13 correlated with SFS ranging from 27 to 64% [9]. A subsequent study demonstrated interobserver reliability, although the degree of training and levels of expertise with CT imaging clearly impacted the accuracy of grading and assessment of stone complexity. The authors found that quantifying the

stone size and number of involved of calyces were least reproducible overall [13]. S.T.O.N.E. nephrolithometry has been externally validated in a number of studies. Akhavein and colleagues validated the system as a reproducible and predictive model for treatment success in 122 patients [14]. A multi‐institutional study of 850 patients confirmed that the model was significantly associated with SFS, overall complications, estimated blood loss (EBL), operation time, and length of stay [15]. Studies by Labadie and Noureldin showed that the system was correlated with EBL, operative time, and length of hospital stay [16–18]. A study by Kumsar and colleagues showed that this system is effective in predicting postoperative complications [19]. This NLSS when compared to the Guy’s and CROES nomogram also had more predictive ability in a retrospective review of 217 patients at a single institution [20]. S.T.O.N.E. has also been validated among a pediatric population, correlating with SFS, length of hospitalization, and complications [21]. Strengths and weaknesses

The GSS and CROES nomograms, which are discussed later in this chapter, were initially developed using abdominal plain films, whereas S.T.O.N.E. nephrolithometry was developed on the basis of CT findings. Furthermore, because it stratifies patients into low‐, moderate‐, and high‐risk groups, it is clinically practical for decision‐making and surgical planning. Notably, S.T.O.N.E. can be calculated using only a preoperative CT, making it ideal for building a retrospective database with limited clinical information. Additionally, the score would benefit from greater refinement of the methods used to score each of the factors to take into account their relative predictive power. It is not clear that the cutoffs used for tract length and stone density are optimal. Furthermore, the authors acknowledge the need for a standardized method to measure stone size and number of calyces involved in order to improve predictive value. A standardized definition of calyx as well as the imaging plane used to enumerate calyceal involvement would improve reproducibility. Additionally, the score assigned by degree of hydronephrosis is subjective and would benefit from stricter criteria. Guy’s stone score: development, reproducibility, and validation The GSS was developed to be quick, simple, and reproducible with good correlation with SFS and complication rates so that it could be used in everyday practice. An analogy might be the use of the American Society of Anesthesiologists score, which is widespread in clinical practice [22]. It was created using evidence from

7  Nephrolithometric Scoring Systems

­ ublished data combined with knowledge and experip ence of senior endourologists at a single institution [11]. It consists of four grades based on stone burden and patient anatomy (Figure 7.1). The score was refined using an iterative process after evaluating 10 consecutive cases. The score was prospectively validated in 100 patients

who underwent PCNL procedures in a tertiary stone center. The authors used abdominal radiography preoperatively and CT and abdominal radiography to determine SFS as defined as no stones visible or presence of  clinically insignificant residual fragments 2 mm in size. Ganpule et  al. identified 187 patients with RFs after PCNL (mean RF size 38.6 mm2) and found that 45% of RFs passed spontaneously, most within three months [34]. No RF >100 mm2 cleared without intervention, and RF size correlated inversely with spontaneous passage rates. On the other hand, Altunrende et  al. found that among 38 patients with ≤4 mm RFs after PCNL and a minimum follow‐up of 24 months (mean 28.4 months), only 8% spontaneously passed their fragments  [35]. Additionally, although no patient required surgical intervention, 26% experienced symptoms (pain or hematuria), and 21% demonstrated growth of the RFs. Osman et al. also reviewed the outcomes of 75 patients with ≤5 mm RFs after PCNL (mean RF size 4.7 mm) [36]. At a mean follow‐up of 36 months, a third of patients had apparently passed their RFs spontaneously (presumably asymptomatically), 29% retained stable, asymptomatic RFs, a third demonstrated growth of the RFs, and 4% had an RF pass into the ureter. All of the 25 patients demonstrating growth of RFs and the three patients presenting with ureteral stones underwent surgical intervention. On multivariate analysis, only RF size >3 mm correlated with stone growth or symptomatic passage into the ureter (OR 1.882, 95% CI 0.919–3.854, P = 0.05).

0003948260.indd 446

Olvera‐Posada et  al. identified 44 patients with RFs (median size 5.5 mm) among 202 patients who underwent CT imaging post PCNL and had at least 12 months of follow‐up [37]. At a mean follow‐up of 57.9 months, 45.5% of patients remained asymptomatic while 54.5% of patients became symptomatic (pain or UTI) and 72.7% of patients underwent surgical intervention (electively or urgently). Overall, 84% of patients demonstrated growth of RFs at last follow‐up. By Kaplan–Meier analysis, the 1‐ and 5‐year probability of remaining intervention‐free with the RFs was 91% and 29%, respectively. Furthermore, the likelihood of requiring intervention was significantly greater in patients with RFs >4 mm compared to those with RFs ≤4 mm. Of note, the likelihood of a symptomatic event was unrelated to RF size. Predictors of an SRE in multivariable models included RF size >2 mm [33], >3 mm [36], >4 mm [37], stone location in the renal pelvis [33] or ureter [33], or no associated factors [37]. Larger stone size has consistently been shown to predict need for retreatment [33, 37, 38], but stone composition (notably struvite/apatite) may additionally correlate [37, 38]. Raman et  al. showed that patients with RFs >2 mm had a 53% retreatment rate compared to 8% in those with RFs ≤2 mm [33]. In the longest follow‐up study evaluating retreatment after PCNL, Portis et  al. reviewed 150 patients undergoing 160 PCNL procedures to determine need for repeat surgical intervention [38]. At a median follow‐up of 5.4 years, after controlling for stone composition, renal units with RFs were found to be 7.87 times more likely to require retreatment than those rendered stone free (95% CI 2.21–28.0, P = 0.001). By Kaplan–Meier survival analysis, cumulative retreatment rates at 7 years were 4.1% in those with no RF (95% CI 0–8.7), 33.3% in those with RF ≤4 mm (95% CI 6.1–60.5) and 29.8% in those with RF >4 mm (95% CI 12.1–47.5). Furthermore, non‐calcium‐ containing RFs had a greater likelihood of requiring retreatment compared to calcium‐containing RFs (56% vs. 23%, respectively). Overall, among these series, stone growth occurred in 45%, symptoms developed in 42%, and surgical intervention was needed in 43% of patients (Table 37.3). Because of this, there is compelling evidence to support SLFN after PCNL to retrieve RFs. However, SLFN is costly and associated with additional morbidity, hospital length of stay, and cost. Raman et al. performed a cost effectiveness analysis to compare the cost of SLFN with the cost of expectant management in patients with RFs, taking into account the cost of the additional procedure and hospital length of stay for SLNF and the cost of additional ED visits and need for retreatment arising from observation of RFs [39]. Based on rates of RFs and need for surgical intervention obtained from the literature, the cost of observing RFs ≤4 mm was estimated at US$1743

12/5/2018 10:16:35 AM

Table 37.3 Outcomes of residual fragments after percutaneous nephrolithotomy.

Author (year)

No. of patients

RF size

Mean follow‐up

Stone composition

Asymptomatic

Passed

Stone growth

Symptomatic

Intervention

Raman (2009) [33]

42

Median 2 mm (range 1–12 mm)

41 months

48% CaOx mono 26% hydroxyap 12% brushite 10% CaOx di 5% cystine

–

–

–

43.0% (18/42)

26.0% (11/42)

Altunrende (2011) [35]

38

≤4 mm

28.4 months (median)

81% CaOx mono 5% uric acid 13% struvite

–

7.9% (3/38)

21.1% (8/38)

26.3% (10/38)

–

Osman (2013) [36]

75

Mean 4.7 mm (range 2–5 mm)

36.2 months (median)

–

29.4% (22/75)

33.3% (25/75)

33.3% (25/75)

–

34.7% (26/75)

Olvera‐Posada (2016) [37]

44

Median 5.5 mm (IQR 3.25–8 mm)

57.9 months

39% CaOx mono 7% CaOx di 27% uric acid 14% CaPhos 9% struvite

6.8% (3/44)

9.1% (4/44)

84.0%

54.5% (24/44)

72.7% (32/44)

–

–

–

21.0%

20.4%

44.6%

42.0%

42.8%

Total

199

RF, residual fragment; IQR, interquartile range.

448

Section 2  Percutaneous Renal Surgery: Exit Strategy and Complications

and the cost of observing RFs >4 mm was US$4674. With a cost of SLFN in 2009 of US$2475, the model predicted that SLFN was cost‐advantageous for RFs >4 mm, not cost‐beneficial for ≤2 mm RFs, and only marginally cost‐ advantageous for RFs 3–4 mm in size [39]. Therefore, using the outcomes defined by prior work, SLFN should be strongly considered when RFs >2 mm remain after PCNL.

­ esidual fragments in the pediatric R population Few studies have evaluated the outcomes of RFs after minimally invasive and noninvasive stone procedures in children. With evidence suggesting a growing prevalence of nephrolithiasis in children [40] and the longer time period of observation in this population, knowledge of the potential adverse effects of RFs is all the more important when selecting a treatment modality. In the only series to evaluate the outcomes of RFs after SWL in children, Afshar et  al. reviewed 26 children (mean age 7 years) with ≤5 mm RFs followed for a mean of 46 months [41]. Only 15% of RFs passed spontaneously, while 35% of patients experienced a symptomatic episode and 35% demonstrated stone growth. Of note, the only significant predictors of adverse outcomes in this population were the presence of a metabolic disorder and growth of RFs. Dincel et  al. reviewed the outcomes of 85 children (mean age 9 years) with ≤4 mm RFs after PCNL and found a rate of spontaneous passage of 26%, growth of RFs in 21%, and need for secondary intervention in 29% of patients at a mean follow‐up of 22 months [42]. Likewise, El‐Assmy et  al. identified 61 children (mean age 6 years) with RFs (median size 4 mm, range 2–5 mm) after PCNL who had a mean follow‐up of 18 months, and found comparable rates of spontaneous passage (26%), stone growth (25%), and need for intervention (23%) [43]. The only predictor of reintervention in this series was a history of stone disease.

­Medical therapy Historically, dissolution therapy, particularly for stones composed of struvite and uric acid, was utilized after open stone surgery if RFs remained [44, 45]. With technological advances in endoscopic management of stones and better patient selection for SWL, such interventions are now only of historical interest. However, in vitro studies have demonstrated that even normal urine parameters can induce growth of RFs after intervention

0003948260.indd 448

[46], and inhibitors of crystallization, such as phytate and citrate, can impede this process [47, 48]. Because of this, the ability to medically manage RFs after intervention is a promising area of study. Cicerello et al. investigated the use of potassium citrate in patients with 2 cm: a systematic review and meta‐analysis. J Endourol 2012;26(10):1257–1263. Donaldson JF, Lardas M, Scrimgeour D et al. Systematic review and meta‐analysis of the clinical effectiveness of shock wave lithotripsy, retrograde intrarenal surgery, and percutaneous nephrolithotomy for lower‐pole renal stones. Eur Urol 2015;67(4):612–616. Somani BK, Giusti G, Sun Y et al. Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study. World J Urol 2017;35(4):675–681.

561

562

49 Diagnostic Ureteroscopy Hendrik Heers1 & Benjamin W. Turney2 1 2

Department of Urology, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK

­Indications From the advent of ureteroscopy (URS) the procedure has been used for diagnostic purposes [1–3]. As the early instruments lacked a working channel, diagnosis was actually its initial primary function. The equipment has experienced significant innovation ever since, broadening indications and refining results. Diagnostic URS is still not perfect and should only be seen as one step in a suite of investigations along with ultrasound, computed tomogra­ phy (CT), or magnetic resonance imaging (MRI), and urine‐ based diagnostics, when looking at the upper urinary tract. The main purpose of diagnostic URS has always been the detection of upper urinary tract urothelial cancer (UTUC). Established indications are hence derived from surrogate markers of this disease. Every patient presenting with visible hematuria or persistent nonvis­ ible hematuria warrants a urological workup. Besides urine dipstick and culture, cystoscopy is performed to evaluate the lower urinary tract. The upper tract is usually primarily assessed with radiological techniques: ultrasound, CT kidney–ureter–bladder (KUB), and CT urogram, and – in select cases – intravenous pyelogram (IVP). Stones as a source of hematuria can be reliably identified this way. If any of these investigations shows abnormalities suspicious of a tumor, diagnostic URS is recommended prior to any treatment. However, as all these investigations have limited sensitivity, a diagnos­ tic URS should still be considered in the absence of radiological abnormalities if there is a strong clinical suspicion of UTUC (e.g. persistent hematuria in a patient with a history of bladder tumors or positive urine cytology with normal cystoscopy) or in situa­ tions where early diagnostic accuracy is paramount (e.g. solitary kidney).

Classical findings suggestive of UTUC are hydrone­ phrosis in the absence of ureteric calculi (differential diagnoses: ureteric stricture, pelviureteric junction [PUJ] obstruction, compression of the ureter) on CT KUB and contrast‐filling defects on CT or IVP. Only tumors of a certain size are directly visualized on CT or ultrasound at which stage they are often invasive. This is the case for 60% of UTUC at primary diagnosis [4]. Other indications for diagnostic URS are follow‐up after organ‐sparing treatment of UTUC and in individual cases after radical cystectomy for transitional cell carci­ noma (TCC) of the bladder, for example if a cutaneous ureterostomy has been established. The procedure may also be used to investigate ureteric strictures, cases of suspected ureteric endometriosis, and other rare changes of the upper urinary tract (e.g. amyloidosis).

­Patient preparation The preparation for diagnostic ureteroscopy should be even more vigorous than for other endourological procedures due to its delicate nature and susceptibility to confounding factors. All patients must have their urine cultured prior to the intervention and any urinary tract infection should be treated with antibiotics. Indwelling ureteric stents should be removed at least 3 weeks ahead if possible as they can provoke inflammatory changes rendering an endoscopic diagnosis of smaller lesions impossible. The consenting process should include injuries to the lower urinary tract and ureter requiring open surgical repair, formation of strictures, hydronephrosis, and the necessity to insert a ureteric stent. Any intended simulta­ neous therapeutic procedure must also be addressed.

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

49  Diagnostic Ureteroscopy

All patients with suspected UTUC should be assessed with CT urogram (or MRI urogram in cases of impaired kidney function or allergy to iodine‐containing contrast agents) prior to endoscopy in keeping with the European guidelines, whereas the American National Compre­ hensive Cancer Network guidelines do not make specific recommendations on the sequence [4, 5]. If a tumor is detected, a diagnostic URS should be performed prior to nephroureterectomy. Not only should a histological diagnosis be obtained but there is also a cohort of patients with small low‐grade lesions who might benefit from organ‐sparing treatment. Up to 42% of patients would receive unnecessary over treatment without diagnostic URS [6]. Diagnostic URS should not be considered for atrophic kidneys as this is an indication for nephrectomy. If the radiological findings are suggestive of a nonfunctioning kidney, a MAG3 or 99mTc‐labeled dimercaptosuccinic acid (DMSA) renogram should be considered for confirmation. Single‐shot antibiotic prophylaxis for diagnostic URS is currently a point of discussion. In the absence of risk factors, it can be omitted as the incidence of sepsis is very low [7].

­Instruments It is important to use as little equipment as possible in order to visualize the ureter and collecting system in its original state, avoiding artificial injuries interfering with the inspection. Semirigid and flexible ureteroscopes are available, typically with a diameter between 6 and 10 Fr. They have either one or two working channels. Due to the high maintenance costs and frequent need for repair of flexible ureteroscopes, disposable instru­ ments have been introduced to the market recently. Furthermore, although fibre‐optics have traditionally been used for flexible ureteroscopy, the advancements in digital optics (“chip on the tip”) offer better image quality. Their use has systematically been validated in URS for stone removal. While stone‐free rates and complications are comparable to fibre‐optic scopes, the duration of procedures has significantly been reduced [8, 9]. Despite a lack of literature, it may be expected that the diagnostic accuracy of the new digital instruments is superior thanks to their enhanced image quality. A plethora of auxiliary equipment is available for ureteroscopy: guidewires of variable stiffness both hydro­ philic and nonhydrophilic, ureteric catheters, balloon dilatation catheters and other devices to facilitate entrance into and passage through the ureter, as well as therapeutic devices which may be applied during diag­ nostic URS, including baskets, biopsy forceps, and laser

fibres. Balloon dilatation catheters bear a significant risk of injury to the ureter and can even result in tumor spillage if a perforation arises, so their application needs to be considered very carefully in diagnostic URS. If no access to the ureter can be obtained, it might be the better option to insert a ureteric stent and bring back the patient for a second look after 1 or 2 weeks.

­Technique Every diagnostic URS begins with a close inspection of the urethra and bladder to rule out concomitant lower urinary tract lesions such as bladder tumors or promi­ nent vessels in the prostatic urethra. Subsequently, the ureteric orifices (UOs) are identified and closely moni­ tored for uni‐ or bilateral hematuric urine ejaculation. After exclusion of tumors, bilateral upper tract hematuria is suggestive of a glomerular cause which should be evaluated by a nephrologist. If the UOs cannot be identified due to inflammatory changes to the mucosa, bleeding, or a large prostate, a rigid cystoscope with an angulated optic should be used. It might be sufficient to fill up the bladder in order to bring the UOs into view. The use of intravenous methylene blue should be omitted as it will impair the diagnostic quality upon entry into the ureter. A semirigid ureteroscope should be used for inspec­ tion of the ureter to the PUJ. An experienced surgeon is often able to intubate the UO without using a guidewire. This has the advantage of omitting mucosal lacerations by the wire but bears an increased risk of injury to the ureteric wall. The risks and benefits in the individual situation must be outweighed against each other. The authors advocate using a hydrophilic guide­ wire routinely. Due to the shape of the ureteroscope’s tip it is advisable to twist the instrument by 180° (clockwise for a right‐ handed surgeon) to obtain an atraumatic intubation with fully opened irrigation. In this position, by lowering the tip, the UO can be widened slightly. Once the tip of the scope is passed into the distal ureter, it is twisted back into its original orientation. If the UO is too tight to allow direct entrance, a hydro­ philic guidewire should be used in the same technique. In case this is not sufficient, a ureteric catheter can be used instead as it has the advantage of higher rigidity. Any dilating devices such as balloon catheters or access sheaths can potentially injure the ureter and should be avoided wherever possible during diagnostic URS. If any of these devices is used, a guidewire should always be placed into the mid ureter. Hydrophilic guidewires are preferential as they are less traumatic. A guidewire with a hydrophilic tip and a more rigid body is a good

563

564

Section 3  Ureteroscopy: General Principles

compromise between preserving the mucosa and assist­ ing with the passage of the instrument. Fluoroscopy for orientation is highly recommended. Any forced movements must strictly be avoided as they can result in a discontinuing injury of the ureter already in its intramural portion. If a bladder tumor occludes the UO or if there is a stenosis following a transurethral resection, it may be necessary to perform another resection first before obtaining access to the ureter. This maneuver has a risk of ongoing vesicoureteric reflux and perforation. In almost all cases however, the UO can be intubated with­ out problems, even with a flexible ureteroscope [10, 11]. With the scope in the distal ureter, a retrograde uret­ eropyelogram should be performed. Air bubbles in the syringe must be avoided. Any filling defects are noted. The images help during the navigation, especially inside the kidney. It is important to inject the adequate amount of contrast agent, allowing complete visualization of the ureter and collecting system but avoiding extravasation and bleeding of small vessels. To improve the diagnostic quality when looking for UTUC, several urine cytologies should be taken, usually from the bladder, on three levels of the ureter, and subse­ quently in all portions of the kidney as well as targeted on any suspicious lesions. Cytology has limited sensitivity, particularly for low‐grade tumors, but high specificity. When advancing the ureteroscope, the ureteric lumen must remain central in the field of view so that the entire circumference of the wall can be inspected. Any obsta­ cles such as kinks can usually be passed with the help of a (hydrophilic) wire or if necessary a ureteric catheter. Major kinks in a chronically ectatic ureter can some­ times be resolved by positioning the patient head down for a short while. Increasing the irrigation pressure can also be helpful but should be used sparingly to avoid overdistension with subsequent urothelial bleeding. Extrinsic filling defects can often be determined visually with the appearance of compression of the ureter in the absence of any intrinsic mass in the ureteral lumen. When the ureter is extrinsically compressed by a venous struc­ ture, the ureteral lumen is distensible during ureteroscopic inspection, whereas extrinsic compression from an artery often results in visible pulsations. Ureteral strictures and PUJ obstructions also may be visually confirmed. The semirigid ureteroscope can be used until gaining entrance to the renal pelvis. The instrument of choice for inspection of the proximal ureter and the collecting sys­ tem is the flexible ureteroscope. Thus, a hydrophilic guidewire is placed through the semirigid instrument into the renal pelvis under vision. The ureter can usually be inspected more effectively when slowly drawing back the scope, rather than during the advancement. After removing the semirigid scope, a flexible instrument

is inserted via the guidewire which can subsequently be removed. Using the previously performed retrograde pyelogram for guidance, the entire collecting system is carefully inspected. Again, urine cytologies should be obtained from several sites in the kidney. Towards the end of the procedure, the flexible uret­ eroscope is removed, allowing for a final inspection of the ureter. After an uneventful diagnostic URS, a ureteric stent is usually not required. If there is a risk of obstruc­ tion or significant bleeding, a stent may be inserted.

­Diagnosis of upper tract urothelial cancer Some 5% of TCCs are localized in the upper tract, more commonly in the ureter than in the collecting system, in keeping with the relative amount of urothelial surface. Tumors in the upper tract have an appearance similar to bladder tumors: they are mostly exophytic and papillary but there can also be flat reddish lesions, especially when carcinoma in situ is present. These are easily missed on inspection, especially with older instruments and optics. Many patients with TCC have multifocal disease. After nephroureterectomy, further lesions are reported after histology that were not detected on URS in 25% of patients [12]. Figures  49.1 and 49.2 show examples of TCC in the renal pelvis. Fibroepithelial polyps, while often long and papillary, can be distinguished from upper urinary tract TCC as they frequently have a smooth, normal‐appearing urothe­ lial surface whereas TCC often show hypervascularization and in later stages can be necrotic. The location of any tumor should be documented as exactly as possible to optimize further treatment planning. Every suspicious lesion should be biopsied. As every diagnostic component for UTUC has its own flaws, only the combination of imaging, endoscopic inspection, cytology, and biopsy is adequate. The pres­ ence of hydronephrosis, positive cytology, and high‐ grade tumor on biopsy correlate with ≥ pT3 disease [13]. Biopsies can be obtained with forceps or stone baskets. Forceps are useful for flat lesions whereas baskets can be helpful for exophytic tumors which can be completely removed if the basket is placed around the stem. If for­ ceps are used, multiple biopsies should be taken as the volume with each biopsy is very small. The histological sample should include muscular tissue but, at the same time, a perforation should be avoided as it can lead to tumor spillage. If reasonable, a basket should be used as it harvests better results in terms of successfully obtain­ ing a representative tissue sample and correctly grading a tumor [14]. Video 49.1 shows an example of a basket biopsy of TCC recurrence in the renal pelvis of a patient with ileal conduit.

49  Diagnostic Ureteroscopy

Figure 49.1  Ureteroscopic impression of exophytic TCC in the renal pelvis. Images courtesy of Mr Oliver Wiseman, Cambridge, UK.

­ ndoscopic treatment of upper tract E urinary cancer

Figure 49.2  Further tumor material in the same patient. Image courtesy of Mr Oliver Wiseman, Cambridge, UK.

While tumor grading with biopsies is 79–93% accu­ rate, assessing the local stage is problematic [15–18]. Many tumors are upstaged following nephroureterec­ tomy. High‐grade tumors on biopsy are suggestive of invasive stages (≥pT2), which are found in around 60% of cases.

Upper tract TCC can be treated endoscopically with either diathermy resection using a special ureteric resectoscope or preferably a holmium laser. Nephro­ ureterectomy remains the gold‐standard therapy but in select patients an organ‐preserving treatment regimen may be selected. This is the case in patients with low‐ grade and low‐stage disease, a solitary kidney, severely impaired kidney function, bilateral tumors in the upper tract, and patients unfit for major surgery. For tumors of the renal collecting system, a percutane­ ous approach is feasible, however this bears the risk of tumor cell spillage. Thus, ureteroscopic treatment is often preferred. If nephroureterectomy is indicated, ureteroscopic management should only be offered to patients with small, low‐grade tumors. The patient must be informed about the potential undergrading and understaging through biopsy (see above) and that a purely endoscopic treatment requires a rigid follow‐up with semi‐annual ureteroscopies as there are higher recurrence rates than with radical surgery. Adjuvant treatment with mitomy­ cin and BCG has been described but is not the standard of care. For an adequately selected patient group, the rate of secondary nephroureterectomy has been reported to be around 20% [19].

565

566

Section 3  Ureteroscopy: General Principles

The use of a holmium:YAG laser for tumor ablation is the option of choice as its penetration into tissue is only 0.4 mm, thus the risk for perforation is comparatively low. Papillary tumors can be removed and subsequently the surface is coagulated for hemostasis. Neodymium:YAG lasers may also be used for larger tumors. They penetrate deeper (2–5 mm) and have a larger extent of thermic tissue destruction.

­Other causes for hematuria If tumors and stones are ruled out, other causes for hematuria have to be considered. Bilateral ureteric hematuria is usually a glomerular problem. Other benign causes of hematuria are hemangioma and arteriovenous malformations. The term “nutcracker syndrome” des­ cribes a compression of the renal vein by other structures resulting in a rising intravenous pressure that subse­ quently leads to glomerular hematuria. Angiography with measurement of the intravasal pressure may be necessary for its diagnosis.

­New technologies and perspectives Due to the limitations of diagnostic ureteroscopy that have already been described in this chapter there is an increasing number of auxiliary technologies on trial to enhance the diagnostic value. ●●

Photodynamic diagnosis (PDD) has been established for the diagnosis of bladder TCC for years. Hexa‐ aminolaevulinic acid (5‐ALA) is instillated into the bladder prior to endoscopy. It intercalates with repli­ cating DNA and thus accumulates in malignant (and inflammatory) tissue. Light waves with a length of 400 nm excite the electrovibrational state of the fluorochrome. Upon relaxation to the ground state, a

●●

●●

●●

●●

photon is emitted (wavelength 590–700 nm), permit­ ting optical diagnosis of tumors. For the purpose of upper tract diagnostics, 5‐ALA can be administered through a ureteric catheter or orally. Episodes of hypo­ tension have been described as a side effect. Some authors describe enhanced sensitivity but the tech­ nique has limitations. PDD works best with a perpen­ dicular view onto the tissue. On tangential visualization as in ureteroscopy, it can lead to false‐positive results [20, 21]. Optical coherence tomography (OCT) has first been employed in ophthalmology. It employs a similar principle to ultrasound but uses light waves and cov­ ers a depth of up to 2 mm. The measurement of the attenuation coefficient μOCT allows for differentiation of tissues. Only few data on its use in diagnostic URS is available yet [22]. Confocal laser endomicroscopy (CLE) is another tech­ nique using fluorescence, in this case by injecting flu­ orescein intravenously. It allows ultra‐high‐resolution imaging of tissue microarchitecture but only has a depth of up to 400 µm. A drawback is the susceptibil­ ity to motion artefacts. Further studies are needed to prove an enhanced diagnostic value [20, 23]. Narrow‐band imaging (NBI) relies on the absorption of light at specific wavelengths by hemoglobin; hence microvessels are better visualized. Apparently, this improves sensitivity up to 23%, but again, further studies are required [20, 24]. SPIES® (Storz professional image enhancement system) uses spectral separation by digital filters in order to enhance contrast. There is no literature on its applica­ tion in the upper tract available yet [20].

In conclusion, diagnostic URS is an important step in the workup for UTUC and other pathologies of the upper urinary tract. The current technological advancements in optics, endoluminal imaging, and image processing offer promising enhancements to further the sensitivity and specificity of upper urinary tract endoscopy.

­References 1 Aso Y, Ohtawara Y, Suzuki K et al. Usefulness of

fiberoptic pyeloureteroscope in the diagnosis of the upper urinary tract lesions. Urol Int 1984;39(6):355–357. Bagley DH, Huffman JL, and Lyon ES. Combined rigid 2 and flexible ureteropyeloscopy. J Urol 1983;130(2):243–244. Bagley DH and Rivas D. Upper urinary tract filling 3 defects: flexible ureteroscopic diagnosis. J Urol 1990;143(6):1196–1200.

4 Roupret M, Babjuk M, Comperat E et al. European

Association of Urology Guidelines on upper urinary tract urothelial cell carcinoma: 2015 update. Eur Urol 2015;68(5):868–879. 5 Clark PE, Agarwal N, Biagioli MC et al. Bladder cancer. J Natl Compr Canc Netw 2013;11(4):446–475. 6 Golan S, Nadu A, and Lifshitz D. The role of diagnostic ureteroscopy in the era of computed tomography urography. BMC Urol 2015;15:74.

49  Diagnostic Ureteroscopy

7 Martov A, Gravas S, Etemadian M et al. Postoperative

8

9

10

11

12

13

14

15

infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: a matched case‐control analysis on antibiotic prophylaxis from the CROES URS global study. J Endourol 2015;29(2):171–180. Somani BK, Al‐Qahtani SM, de Medina SD, and Traxer O. Outcomes of flexible ureterorenoscopy and laser fragmentation for renal stones: comparison between digital and conventional ureteroscope. Urology 2013;82(5):1017–1019. Binbay M, Yuruk E, Akman T et al. Is there a difference in outcomes between digital and fiberoptic flexible ureterorenoscopy procedures? J Endourol 2010;24(12):1929–1934. Hudson RG, Conlin MJ, and Bagley DH. Ureteric access with flexible ureteroscopes: effect of the size of the ureteroscope. BJU Int 2005;95(7):1043–1044. Johnson GB, Portela D, and Grasso M. Advanced ureteroscopy: wireless and sheathless. J Endourol 2006;20(8):552–555. Yamany T, van Batavia J, Ahn J et al. Ureterorenoscopy for upper tract urothelial carcinoma: how often are we missing lesions? Urology 2015;85(2):311–315. Brien JC, Shariat SF, Herman MP et al. Preoperative hydronephrosis, ureteroscopic biopsy grade and urinary cytology can improve prediction of advanced upper tract urothelial carcinoma. J Urol 2010;184(1):69–73. Kleinmann N, Healy KA, Hubosky SG et al. Ureteroscopic biopsy of upper tract urothelial carcinoma: comparison of basket and forceps. J Endourol 2013;27(12):1450–1454. Clements T, Messer JC, Terrell JD et al. High‐grade ureteroscopic biopsy is associated with advanced pathology of upper‐tract urothelial carcinoma tumors at definitive surgical resection. J Endourol 2012;26(4):398–402.

16 Rojas CP, Castle SM, Llanos CA et al. Low biopsy

17

18

19

20

21

22

23

24

volume in ureteroscopy does not affect tumor biopsy grading in upper tract urothelial carcinoma. Urol Oncol 2013;31(8):1696–1700. Straub J, Strittmatter F, Karl A et al. Ureterorenoscopic biopsy and urinary cytology according to the 2004 WHO classification underestimate tumor grading in upper urinary tract urothelial carcinoma. Urol Oncol 2013;31(7):1166–1170. Wang JK, Tollefson MK, Krambeck AE et al. High rate of pathologic upgrading at nephroureterectomy for upper tract urothelial carcinoma. Urology 2012;79(3):615–619. Cutress ML, Stewart GD, Zakikhani P et al. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int 2012;110(5):614–628. Bus MT, de Bruin DM, Faber DJ et al. Optical diagnostics for upper urinary tract urothelial cancer: technology, thresholds, and clinical applications. J Endourol 2015;29(2):113–123. Kata SG, Aboumarzouk OM, Zreik A et al. Photodynamic diagnostic ureterorenoscopy: A valuable tool in the detection of upper urinary tract tumour. Photodiagnosis Photodyn Ther 2016;13:255–260. Bus MT, Muller BG, de Bruin DM et al. Volumetric in vivo visualization of upper urinary tract tumors using optical coherence tomography: a pilot study. J Urol 2013;190(6):2236–2242. Villa L, Cloutier J, Cote JF et al. Confocal laser endomicroscopy in the management of endoscopically treated upper urinary tract transitional cell carcinoma: preliminary data. J Endourol 2016;30(2):237–242. Traxer O, Geavlete B, de Medina SG et al. Narrow‐ band imaging digital flexible ureteroscopy in detection of upper urinary tract transitional‐cell carcinoma: initial experience. J Endourol 2011;25(1):19–23.

567

568

50 Ureteroscopic Diagnosis and Treatment of Upper Urinary Tract Neoplasms Scott G. Hubosky & Demetrius H. Bagley Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA, USA

Ureteroscopy is an essential technique in the diagnosis, treatment, and surveillance of upper tract neoplasms. The introduction of fiber‐optic illumination, imaging, and small rigid and flexible ureteroscopes in the early 1980s provided access to the entire upper collecting sys­ tem. This combination with devices for tissue sampling and ablation has made accurate diagnosis and treatment possible. Other diagnostic studies including radiologic, cytologic, and molecular techniques can provide initial or supportive diagnostic information, yet remain secondary to endoscopy as the definitive study. Upper tract neoplasms are rare and upper tract urothelial carcinoma (UTUC) accounts for 5% of all urothelial carcinomas [1]. UTUC is more common in patients with a previous history of carcinoma of the bladder [2, 3]. The most common presentation is hema­ turia, either gross or microscopic, in approximately 80% of patients [1, 4, 5]. UTUC is an incidental finding in 10–15% of patients but flank pain can be seen in up to 30% of patients. Physical findings are rare, unless the patient has metastatic tumor or hydronephrosis sec­ ondary to obstruction. Radical nephroureterectomy (RNU) with removal of a bladder cuff has been considered the standard for treatment of UTUC [6]. The application of endo­ scopic techniques to these lesions initially in patients with a solitary kidney or compromised contralateral kidney, which have been considered imperative indi­ cations, have shown the feasibility of this treatment. Consequently, it has been performed increasingly in patients with a normal contralateral kidney [7, 8]. Evidence of progressive functional renal loss in patients undergoing nephrectomy for renal cell carcinoma can also be expected in patients losing their kidney to nephroureterectomy and is a stimulus for nephron‐ sparing surgery [9].

­Noninvasive diagnosis Radiologic studies, including intravenous contrast stud­ ies to outline the collecting system with excretory urog­ raphy or computed tomography (CT) urography are the most useful noninvasive diagnostic techniques. A filling defect is the most common finding, which may indicate an upper tract urothelial neoplasm. The differential diagnosis includes blood clot, lucent calculus, air bubble, fungus ball, sloughed papilla, external compression with a crossing vessel, or benign inflammatory or neoplastic lesion. One series using a multidetector CT scanner for CT urography in patients with gross hematuria demon­ strated a very high sensitivity, specificity, and accuracy [10]. In some patients with a severe contrast allergy with nonvisualization of the collecting system, retrograde ureteropyelography may be indicated. However, this suf­ fers from low accuracy [4, 11]. Renal ultrasound can define intrarenal calculi, hydro­ nephrosis, and renal masses accurately but is less useful to define small intraluminal soft tissue masses. In con­ trast, CT can accurately distinguish calculi from soft tis­ sue masses. It is also helpful in demonstrating masses extending beyond the collecting system or enlarged lymph nodes. Inclusion of a pyelographic phase with reconstruction of the excretory system or an abdominal radiograph taken after the administration of contrast as an anteroposterior ureteropyelogram may be most useful in demonstrating intraluminal lesions [10, 12]. Magnetic resonance imaging has similar limitations, especially in the cross‐sectional mode [13]. The magnetic resonance urogram designed to image the fluid of a distended collect­ ing system may be helpful in some patients with nonfunc­ tioning kidneys or severe contrast allergies. Cytologic study of voided urinary samples is of limited value because of the frequent equivocal and false negative

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

findings. It can be useful in detecting high‐grade tumors, which shed obviously malignant cells in the urine. The sensitivity of voided urinary cytology increases with an increasing grade, ranging from 11% for Grade 1 to 83% for Grade 4 lesions [14]. Elective ureteral catheterization for a specific and localized upper tract urinary sample for cytologic study is occasionally indicated in patients with positive cytology without radiographic findings and with normal cystoscopy and bladder biopsy. However, routine ureteral catheterization to collect urine from a radiographically abnormal area is no longer indicated if ureteroscopy can be performed. Similarly, fluoroscopic guided brush biopsy is rarely indicated when ureteros­ copy is available. Fluorescence in situ hybridization (FISH) has been used to detect genetic aberrations in chromosomes 3, 7, 9, and 17 and improves the sensitivity of voided urine cytology for all bladder lesions, including low grade, from 25 to 53% [15, 16]. The appeal of FISH would be to utilize it in voided urine specimens to detect UTUC without the invasiveness of ureteros­ copy. The largest published reports of FISH in UTUC detection using voided urine specimens demonstrate increased sensitivity compared to voided cytology but it is still not sensitive enough to forgo ureteroscopic visualization for diagnosis [17–19].

­Endoscopic diagnostic techniques Endoscopic evaluation of an abnormality in the upper urinary tract suspicious for a neoplasm includes inspec­ tion of the entire bladder and involved collecting system. Cystoscopy is an essential evaluation of the patient with hematuria and/or filling defects because of the risk of associated bladder tumors and to provide access to the ureter for retrograde pyelography and ureteroscopy. A retrograde ureteropyelogram may give more informa­ tion regarding the extent of the filling defect or suspi­ cious lesion or ureteral abnormalities, which might affect access for treatment. A cone‐tipped retrograde injection most efficiently outlines the entire collecting system without traumatizing the ureter itself. Care should be taken to prevent overfilling of the collecting system, which can obscure filling defects. Initial ureteral cathe­ terization without contrast study should be avoided since it can traumatize the specific lesion of interest and the otherwise normal ureteral mucosa. A “no‐touch technique” should be employed to exam­ ine the involved upper collecting system. The distal ureter is first inspected either with a small rigid endo­ scope, preferably one small enough to pass into the ori­ fice without other dilation, or with a flexible ureteroscope that can be passed into the ureter without dilation [20].

In this way, the ureter can be inspected without prior instrument trauma. When using a semirigid uretero­ scope, it is passed as far as possible into the lumen before leaving a guidewire in place as the endoscope is removed. The guidewire is passed only to the level of the ureter that has been inspected with the semirigid ureteroscope and should not be passed into the intrarenal collecting system where the tip of the wire can traumatize the calyx or the renal pelvis and obscure subsequent visual inspec­ tion. The smallest flexible ureteroscope is then passed over the guidewire into the ureter. If a small flexible ureteroscope can be passed directly into the ureter, then the steps of semirigid ureteroscopy and wire placement can be avoided. The flexible ureteroscope is used to inspect the more proximal portions of the ureter not previously seen and the intrarenal collecting system. Inspection at that level should be systematic going from the renal pelvis to the upper infundibula and calyces to the mid and then the lower pole. In this way, the risk of trauma to the mucosa with the endoscope is minimized. Continuous irrigation with saline is maintained through the working channel of the ureteroscope to clear the field of view. Iodinated contrast medium can be used in the irrigant to outline the collecting system for fluoroscopic monitoring. Positioning of the flexible ureteroscope throughout the collecting system can then be confirmed fluoroscopically. Care must be taken to avoid overfilling the collecting system, since this can induce submucosal hemorrhage and rupture of the for­ nices. When adding contrast through the endoscope within the collecting system, the irrigant present should be removed. Lines of refraction will be visible as fluids of two different densities mix. This can be avoided by minimizing the mixing. If there is a specific lesion to be examined, such as a filling defect or a point of obstruction, then the distal portion of the urinary tract should be inspected first, followed by the lesion itself in order to inspect it within a clear visual field without other manipulation that may cause bleeding and obscure the field of view. In many cases, visual inspection alone can provide a diagnosis [21–24]. For example, the appearance of a calculus will readily distinguish it from a low‐grade papillary tumor. Irrigant with contrast should be used so that fluoroscopy can demonstrate the tip of the ureteroscope at the filling defect. In this way, correct visualization and identifica­ tion of the lesion can be confirmed. Epithelial neoplasms may have totally different appear­ ances. Low‐grade UTUC has a typical papillary appearance, similar to the same lesions in the bladder (see Videos 50.1, 50.2a,c, and 50.3 ). High‐grade UTUC may be more ses­ sile and less papillary, often with necrotic or inflamma­ tory debris on the surface. However, these differences

569

570

Section 3  Ureteroscopy: General Principles

are not consistent. El‐Hakim and colleagues [25] found an accuracy of only 70% in determining the grade of an upper tract neoplasm by appearance alone. Benign lesions can often be diagnosed endoscopically. Fibroepithelial polyps located within the pelvis and inverted papillomas throughout the upper collecting sys­ tem have been seen to have a smooth, rounded surface [26]. There may be an impression of an intact epithelial layer in the appearance. These differences have not been prominent enough to allow visual identification, but they have been strongly suggestive. All benign lesions observed, including fibroepithelial polyps, inverted pap­ illomas, and hemangiomas located in the ureter or the ureteropelvic junction can be narrow, elongated, and worm‐like. In many instances, visual inspection alone may not be adequate for diagnosis. High‐grade UTUC can be con­ fused with inflammatory lesions or may be obscured by tumor growing submucosally or proximal to obstructive edema. There may be calculus material on the surface of a neoplasm with the resultant appearance of a solid cal­ culus. Other tumors with a necrotic surface can appear the same as a soft, infection stone covered with inflam­ matory debris. In these and many other situations, visual inspection alone is not adequate for diagnosis. Aids to visual diagnosis of neoplasms such as narrow‐ band imaging (NBI) and confocal laser endomicroscopy have been used in the bladder to detect carcinoma in situ or additional exophytic tumors. NBI is an optical image‐ enhancement system that makes use of blue and green wavelengths of light, which are readily absorbed by hemoglobin to enhance surface tumor detection by pro­ viding contrast between normal mucosa and microvas­ culature. Since malignant lesions tend to have a rich vascular component, they appear dark brown or green against white mucosa thus enhancing lesion detection. One report of NBI for use in cases of UTUC found a 23% improved detection rate among 27 patients in which additional tumors were seen or borders of tumors were enhanced and noted to extend beyond what was observed with white light alone [27]. NBI also has value in differ­ entiating benign inflammation, as seen from indwelling stents, from subtle malignant luminal lesions [28]. Unlike photodynamic diagnosis modalities, NBI requires no extrinsic fluorochrome, an attractive aspect for use in the upper tracts.

­Endoscopic biopsy technique Ureteroscopic biopsy is necessary to sample neoplasms in the upper urinary tract to determine the presence of malignancy, and to determine the grade. The rate‐limit­ ing step of ureteroscopic biopsy is the size of the working

channel within the ureteroscope, which dictates the size of the biopsy instrument that can be used. For example, a piece of tissue obtained with a 3 Fr cup biopsy forceps is less than 1 mm in diameter and is usually too small to be prepared for histologic study using standard techniques. It is often lost in the process (see Video 50.1a). In ­contrast, it is a relatively large fragment of tissue for cytologic techniques. It can be prepared as a cell block and stained and examined as a histologic preparation to give a diag­ nosis and possibly grade. Several different biopsy instruments and techniques are available. Abdel‐Razzak and colleagues [29] evalu­ ated samples from 55 procedures in 44 patients with a possible diagnosis of UTUC. They compared the diag­ nostic yield, considering only those samples that were specifically positive or negative for malignancy, exclud­ ing those that were “suggestive” or equivocal. The tech­ niques compared aspiration of urine at the level of the lesion, wash and aspiration with saline solution at the area of the lesion, and direct tissue sampling with brush, basket, or biopsy forceps. The tissue sampling techniques gave the best yield, particularly the flat wire basket for large friable tumors and the cup forceps for more sessile lesions. The brush was less effective, and under endoscopic vision was observed to move the more flexible tissue without removing fragments. It may be more useful with flat or sessile lesions. Aspiration and wash proved to be valua­ ble in providing a diagnosis for some patients in whom the other sampling techniques were inconclusive. A flat wire basket is quite effective for removing large fragments of papillary tissue with a small‐diameter ure­ teroscope (see Videos 50.2a–c and 50.6 ). We highly recommend this instrument for biopsy of UTUC when­ ever applicable since it has been shown to be superior to the 3 Fr cup biopsy forceps in securing a diagnosis of UTUC in suspected lesions [30]. Under endoscopic vision, the basket is placed on the tumor and partially closed. The entire unit consisting of tumor sample, bas­ ket, and ureteroscope is then removed from the ureter and bladder. This can often remove a large sample even up to 1 cm in diameter, which is adequate for cytologic or histologic study. The ureteroscope is then replaced to repeat the inspection and biopsy or treat the ­neoplastic lesion. The most important steps in handling the tissue for pathologic diagnosis is to work closely with the cyto­ pathologist [31–34]. Samples are examined with both a smear and cytospin preparation. If there is any macro­ scopically visible tissue in the sample, a cell block is also prepared. This sample often demonstrates both the architecture of the neoplasm and the individual cells to allow grading of UTUC in many of the samples adequate for cell block. Multiple samples of the lesion are taken.

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

Box 50.1  Specimens for cytology. Bladder urine Aspirate at tumor Biopsy Aspirate after biopsy Aspirate after treatment

In addition, urine and saline wash samples of the lesion before and after biopsy and/or treatment are also obtained (Box 50.1).

­Grading with ureteroscopy Grading of UTUC is important in determining progno­ sis and directing therapy. Grade obtained from uretero­ scopic biopsy has been shown to reflect the grade of the overall tumor with reasonable accuracy. In 42 patients, Keeley and colleagues [35] found that the grade seen on a ureteroscopic biopsy prior to surgical treatment matched that in the final pathologic specimen in 38/42 (90%) of cases. Daneshmand and colleagues [36] showed an overall accuracy of 90% in patients who had surgery early after biopsy and in those who had surgery within 2 months of ureteroscopic diagnosis. In a larger, more recent series, Brown et al. demonstrated ureteroscopic grading accuracy in 112/119 (94%) of patients [37]. Other groups, however, have expressed concern over grade discordance between ureteroscopic and surgical specimens such that 23/24 (96%) of grade 1 lesions and 23/57 (40%) of grade 2 lesions were upgraded [38]. This exceptional finding is likely explained by the use of multiple grading systems for urothelial carcinoma used over the years, which are not simply interchangeable. In the surgical pathology literature, grade 2 UTUC lesions as defined by the 1973 World Health Organization (WHO) classification have demonstrated significant heterogeneity such that up to 50% of them would qualify as high‐grade lesions according to the 1998 WHO system [39, 40]. This is very important to consider whenever interpreting studies involving the ureteroscopic treat­ ment of UTUC over time since most studies are retro­ spective single institutional experiences taking place over many years in which the grading systems had changed. To consider all 1998 “low‐grade” UTUCs as 1973 grade 1 cases would certainly explain the high rate of grade 1 upgrading to grade 2 in the 2012 Mayo series. Nevertheless, the possibility of UTUC tumors being heterogeneic in regard to grade must be considered, especially in view of the findings with urothelial carci­ noma of the bladder in which up to 29% of primarily low‐grade non‐muscle invasive tumors had a high‐grade

component of at least 5% tumor volume [41]. The het­ erogeneity of grade 2 lesions also explains the benefit of combining site‐specific cytology with ureteroscopic biopsy in patients with grade 2 UTUC to provide a more accurate diagnosis [42].

­Staging Pathological stage has been shown to be the best predictor of prognosis in patients undergoing treatment for UTUC [43, 44]. Many factors are responsible for unreliable UTUC staging with ureteroscopic biopsy techniques including small specimen size due to limits of instru­ ment size, relative thinness of the ureteral wall which could lead to extravasation with aggressive biopsy and the variable morphologies of the intrarenal collecting system resulting in “hard‐to‐reach” lesions. It is impos­ sible to expect reliably complete excisional biopsies in the upper tract. Contemporary series report stage concordance rates of only 49–68% with the overwhelm­ ing trend demonstrating understaging of ureteroscopic biopsies [42, 45, 46]. Reliably determining the depth of invasion of the primary tumor or other simultaneous lesions remains difficult. One series advocated multiple deep biopsies with cup forceps in an attempt to deter­ mine the presence of tumor in the lamina propria [47]. Most series have not reported accuracy in determining the depth of invasion. The grade of the primary tumor has often been asso­ ciated with stage, but it cannot be considered truly accurate staging. In Keeley’s series [35], increasing stage was noted with increasing grade seen on ureteroscopic biopsy. Brown and colleagues also found that the grade on endoscopic biopsy correlated with the final patho­ logic stage in nephroureterectomy specimens [37]. Findings from these two studies demonstrated that low‐ grade UTUC on ureteroscopic biopsy correlated with noninvasive stage (pT2) in 66%. Other series of patients treated surgically have also demonstrated the relationship of increasing stage with increasing grade [48]. Cross‐sectional imaging is essential for determining the presence of overtly metastatic disease but histori­ cally has not been very accurate in predicting subtly invasive disease (pT2–pT3). Favaretto et  al. recently presented a model which combines ureteroscopic biopsy results with cross‐sectional imaging and pre­ pT2 disease with an accuracy of 71% [49]. dicts >  Endoluminal ultrasound has been used in two series in an attempt to determine the depth of invasion [50, 51]. It has shown some value but is severely limited by the availability of the instruments.

571

572

Section 3  Ureteroscopy: General Principles

Optical coherence tomography (OCT) is a new tech­ nological advancement that makes use of backscat­ tered light to produce micrometer‐level resolution cross‐sectional images such that layered tissue anat­ omy can be appreciated. A 2.7 Fr probe can be placed through the lumen of a flexible or semirigid uretero­ scope at the level of a urothelial lesion for cross‐sec­ tional imaging. Depth of imaging is reported at 2 mm and OCT staging is binary such that invasive disease is classified as > pT1. An early validation study compared OCT stage to surgical stage after RNU and demon­ strated 100% concordance in seven cases using the binary classification [52]. One case could not be staged due to tumor thickness going beyond OCT imaging depth. More experience is needed before the utility of this modality is fully appreciated.

Ureteroscopic biopsy is of value in any patient with an upper tract filling defect in whom the diagnosis is in question, such as those with a filling defect and voided urinary cytology without a definitive (positive) diagnosis for malignant cells. The presence of individually malig­ nant‐appearing cells (positive cytology) indicates either carcinoma in situ or a high‐grade neoplasm. Biopsy may be avoided in patients with cytology that is definitively positive for malignant cells and who have a large irregu­ lar upper tract filling defects, which can be considered classic for UTUC. Even these patients should have endoscopy to rule out associated bladder tumor.

­ atural history and prognosis after N extirpative surgery

­Complications of biopsy There remains some concern that ureteroscopic biopsy of UTUC can disseminate tumor cells locally or systemically. The possibility of pyelovenous or pyelolymphatic backflow has been cited as a possible mechanism. In a single case report, tumor cells were found outside the kidney in a nephroureterectomy specimen after ureteroscopic biopsy [53]. However, in a review of 13 nephroureterectomy specimens follow­ ing ureteroscopic biopsy, no unusual metastatic pattern was seen [54]. In a well‐controlled study of 96 patients, Hendin and colleagues [55] found no difference in long term or disease specific survival in patients with UTUC who had surgical treatment preceded either with or without ureteroscopic biopsy (Table  50.1). Hara and colleagues [56] reported the usefulness of ureteroscopic biopsy and added 50 patients to those who have had ureteroscopic biopsy without develop­ ment of metastatic disease. These series have con­ cluded that ureteroscopic biopsy can be a safe and very valuable procedure without any documented evi­ dence of tumor dissemination.

The rationale for conservative endoscopic therapy of UTUC was based initially on the success of other con­ servative treatment modalities and the natural history of this neoplasm. The behavior and prognosis of UTUC, in both the ureter and the intrarenal collecting system, has repeatedly been shown to be related to the grade and stage of the lesion. In many early, published series of extirpative surgery for UTUC, the vast majority of cancer‐related deaths were in those with high‐grade disease, in whom muscle invasion was also frequently present. Survival of 49 patients with Grade I UTUC of the ureter or renal pelvis collected at the Mayo Clinic over a 22 year period was identical to that of an age‐ matched control group [57]. In contrast, the survival with higher‐grade UTUC correlated with tumor stage and grade and was consistently lower than a control group [58]. Lymph node‐positive disease also was dependent on tumor grade. In a series by Charbit and colleagues [48], lymphadenectomy was negative in all patients with low‐grade tumors in whom it was performed while 39% of those in patients with higher‐grade tumors were positive. Endoscopic therapy

Table 50.1  Effect of ureteroscopic biopsy. Biopsy

None

No. of patients

48

48

Metastases

12.6%

18.8% (NS)

Died with recurrence

10.4%

10.4% (NS)

Data from Hendin et al. [55]. NS, not significant.

­Selection of patients for ureteroscopic biopsy

Endoscopic therapy in the upper tracts for UTUC treat­ ment is a natural extension of the well‐accepted tech­ niques for treating lesions in the bladder, only with smaller instruments imparting some unique limitations. The neo­ plasm itself, including its diagnosis, grade, location, and size, must be considered in any decision for endoscopic treatment in an individual patient (Table 50.2). There are several ureteroscopic techniques for the treatment of

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

Table 50.2  Selection of patients for ureteroscopic treatment. Tumor factor

For

Against

Size

Small

Large

Configuration

Papillary

Sessile

Number

Solitary

Multiple

Distribution

Single

Circumferential or extensive

Grade

Low

High

Cytology

Negative

Positive

UTUC and they include mechanical removal, electrosur­ gical resection, fulguration, and laser therapy. The techniques used for the ureteroscopic biopsy of tumors result in the removal of tissue volume. A flat wire basket can remove several millimeters of papillary tumor with each application (see Video 50.6). Although the cup  biopsy forceps removes a small volume with each bite, repetitive sampling can remove a small tumor (see Video 50.1a). The base of the tumor can then be coagu­ lated with one of the other instruments (see Video 50.1b). Electrosurgical techniques similar to those used in the bladder have been applied for small distal ureteral neo­ plasms using longer, small‐diameter endoscopes. Over time, this tedious procedure has been superseded by other more efficient techniques. Ureteroscopic electrocoagulation of UTUC is possible using 2 or 3 Fr probes which can be passed through the channels of small‐diameter rigid or flexible uretero­ scopes. Care should be maintained to avoid fulgurating large areas of the ureter, which can result in stricture formation. This electrocautery technique is also useful for lesions within the intrarenal collecting system often in the lower pole medially where laser fibers may limit deflection of the ureteroscope. The 2 Fr electrode is slightly more flexible and can fulgurate with lateral con­ tact rather than directly forward approach needed for a laser (see Video 50.5b ). Laser techniques have been applied safely and effi­ ciently for UTUC treatment. Small fibers of 200–400 µm core diameter can be passed through the flexible uretero­ scope. The two most commonly utilized lasers presently available can effectively treat UTUC with coagulation, ablation and resection. The neodymium:YAG laser was first used for treatment of bladder tumors and for renal pelvic and ureteral neoplasms in open surgical proce­ dures achieving long‐term cures [59]. It was subsequently used ureteroscopically to ablate urothelial carcinoma of the ureter [60]. In a comparative series, Schmeller and Hofstetter [61] demonstrated the success of laser ablation of upper tract tumors with the development of fewer ure­ teral strictures than after electrocoagulation.

The neodymium:YAG laser can penetrate up to 5 mm into tissue after several seconds of exposure. This can be controlled by positioning the fiber onto the tumor without directly aiming it toward the wall of the ureter and by mov­ ing the fiber across the surface of the tissue to avoid pro­ longed exposure. Ureteral damage may be limited by aiming the fiber and the beam parallel to the surface of the ureter. Within the kidney, especially the renal pelvis, where there is a greater surface area and less risk of scarring and stricturing, the neoplasm can be coagulated safely with the neodymium:YAG laser [62] (see Video 50.3). The laser is activated at 20–30 W on continuous mode and moved over the surface to coagulate the tissue. The effect can be seen as the color of the tissue changes to white. The laser fiber will char if it is activated in contact with tissue. For a relatively large lesion obstructing the ureter or an infundibulum, it may be necessary to remove some of the coagulated tissue with a basket or grasper to determine whether viable tumor remains. Since the laser can penetrate to a depth of approx­ imately 5 mm, it may not affect the entire depth of the tumor. There have been no reports of significant renal or vascular injury or damage to associated organs from for­ ward scatter of the neodymium:YAG laser that has been used in the renal pelvis. The holmium:YAG laser has been widely applied for urologic indications. It is a solid‐state pulsed laser that can fragment calculi and can coagulate and ablate tissue. This laser produces light at a wavelength of 2100 nm car­ ried along a low‐water‐content fiber. The laser energy is absorbed within less than 0.5 mm of tissue or fluid and has essentially no risk of forward scatter. The effect observed is the only tissue effect achieved. It is particu­ larly useful for ureteral lesions since it can ablate and remove a visually occlusive neoplasm to open the lumen for access [63–65] (see Video 50.4 ). In use, the laser fiber must be placed in contact with or very close to the tissue to be treated. The laser is then activated at energies from 0.5 to 1 J at a frequency of 6–10 or even 15 Hz. Irrigation is maintained to clear the visual field of tissue debris. It is often necessary to dis­ continue treatment to allow the field to clear, since con­ siderable debris is formed during treatment. Bleeding occurs occasionally and can be controlled better at lower energies or by moving the fiber slightly away from the tissue to diffuse the laser beam and improve coagulation. There is also clinical evidence that using longer pulse duration such as 700 microseconds, rather than the 350 microseconds often used for lithotripsy, will also improve coagulation (see Video 50.5a). The very limited penetration allows precise control and the laser, thus, can be used for ureteral lesions located at the level of the iliac vessels and the renal pelvis near the renal vessels. Great care is employed to avoid ablation and resection through the wall of the ureter or renal pelvis itself.

573

574

Section 3  Ureteroscopy: General Principles

These lasers are best used in synergistic combination. The effects of the neodymium:YAG and holmium:YAG lasers are complimentary. The neodymium:YAG laser can be used to coagulate the major volume of tumor since it penetrates several millimeters and can achieve coagulation effect within the depth of the tissue. (a)

(d)

The coagulated tissue can then be removed mechani­ cally or even more effectively with the holmium:YAG laser. The holmium:YAG is used to resect the tissue to the level of the wall of the ureter or renal pelvis. Thus, the benefits of each device can be used to the best advantage (Figure 50.1).

(b)

(c)

(e)

Figure 50.1  (a) Digital flexible ureteroscopic image of a low‐grade UTUC of the renal pelvis prior to laser resection. (b) Coagulation of the papillary tumor with the neodymium:YAG laser. (c) Complete ablation of the coagulated tumor which was resected with the holmium:YAG laser reveals the normal contour of the collecting system. (d) Fluoroscopic view of the left collecting system with contrast irrigation demonstrates a large papillary lesion in the renal pelvis with extension to a lower pole infundibulum. (e) Fluoroscopic view of the collecting system after ureteroscopic laser resection demonstrates the absence of masses and no evidence of extravasation. Moderately sized lesions can be effectively treated with the combination Nd and holmium:YAG laser which allows for less luminal bleeding and better visualization.

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

­Results of treatment Ureteroscopic treatment of UTUC has been employed and studied for well over 30 years. There are many small retro­ spective series with variable tumor characteristics treated with non‐uniform techniques and follow‐up protocols. These are reported with various endpoints such as cancer‐ specific survival (CSS), local recurrence rates in the upper tract and bladder, renal preservation rate, and progression of disease defined in many different ways. Reports of metastatic disease are not uniformly presented, likely representing underreporting. Cohorts describing short‐ to intermediate‐ term results are plentiful while larger series with longer follow‐up approaching 5 years have been published more recently. The indications for ureteroscopic treatment of UTUC have expanded from small low‐grade lesions in patients with imperative indications to medium‐ and larger‐ sized lesions in patients with normal contralateral kidneys. Generally, recurrence rates become higher with longer follow‐up, and treatment of larger, and high‐grade, lesions. Non‐malignant ureteral strictures are not uncommon as a result of repetitive manipulations over time.

­Recurrences UTUC recurs at significant rates similar to locally treated bladder tumors. It is impossible to determine whether these new neoplasms are the result of implantation of

cells from the original tumor or if it is related to a field change in the urothelium. Successful treatment depends on several factors A meta‐analysis by Cutress et al. sum­ marize the local recurrence rates and CSS of 20 contem­ porary ureteroscopic series in the treatment of UTUC [66]. Clearly, this is influenced by the grade of the origi­ nal lesion with rates between 48 and 54% for low‐ to intermediate‐grade lesions and as high as 60–76% for high‐grade lesions. The grade of the original lesion also affects CSS with most series reporting rates of 86–100% with mean follow‐up of 5 years or less (Table  50.3). Equally important are the length of follow‐up and the size of lesions being treated. These factors vary widely from series to series but in general, local recurrence rates increase with longer follow‐up and larger sized lesions. When considering the more recent series in Table 50.3, local recurrence rates of 77–90% are seen with series of more than 48 months follow‐up [75, 77–79]. An excep­ tion to this trend was noted in the 2008 Mayo series with a 55% local recurrence rate with 59 month follow‐up but the average lesion size treated in this series was only 8 mm [74]. In general, these recurrent lesions are small and can be treated endoscopically. A notable exception is when there is progression in grade from low‐ to a newly developed high‐grade lesion. The rate of such grade progression has been defined by Grasso et al. as 15% at a  mean of 38.5 months. This should be mentioned to patients considering ureteroscopic treatment for UTUC during initial consultation [78].

Table 50.3  Recurrence after ureteroscopic treatment of upper urinary TCC. Series

Martinez‐Piniero et al. [68] Tawfiek and Bagley [69]

a

DSSa

Mean follow‐up (months)

Recurrence (%)

28

31

29

205

NS

31.7

NS 100

93

Keeley et al. [70]

41

35

28

Elliot et al. [67]

44

60

38

Chen and Bagley [7]

23

30

65

100

Daneshmand et al. [36]

26

31

88

100

86.5

Suh et al. [71]

18

21

37.5

100

Johnson et al. [72]

35

32

68

100

Sowter et al. [73]

35

42

74

100

Thompson et al. [74]

86

59

55

100

Pak et al. [75]

57

53

90

95

Cornu et al. [76]

35

24

60

100

Gadzinski et al. [77]

34

58

84

100/86b

Grasso et al. [78]

66

52

77

87

Cutress et al. [79]

73

54

68

90

 Disease‐specific survival.  High‐grade patients.

b

No. of patients

575

576

Section 3  Ureteroscopy: General Principles

Box 50.2  Factors related to increased risk of tumor recurrence.

Table 50.4  New or recurrent bladder tumors: after ureteroscopic treatment of UTUC. Reference

Multifocality Tumor grade Tumor size Abnormal cytology Previous bladder tumor ? Tumor location

Several characteristics of primary UTUC appear to be related to the risk of recurrence (Box  50.2), some of which are similar for those of bladder tumors. Recurrent disease is more likely for tumors over 1.5 cm in diameter than smaller lesions. There is also a higher risk of recur­ rence for high‐grade tumors treated either ureteroscopi­ cally or by open surgery. There is evidence that positive urinary cytology at the time of treatment is a poor prog­ nostic sign. The effect of the location of the primary tumor, whether in the intrarenal collecting system or ureter, has been inconsistent with some series reporting a higher rate for intrarenal neoplasms and others finding no difference or more frequent recurrence after ureteral primaries. However, multifocal lesions have consistently been seen to be associated with more frequent recur­ rences, both in the upper tract and in the bladder.

­Bladder tumors There is significant risk of new bladder tumors develop­ ing in patients with upper tract neoplasms. The simulta­ neous initial presentation of urothelial carcinoma of the upper tract and bladder has been observed to be 17% in patients without prior history of bladder tumors [80]. The vast majority of bladder recurrences (80–90%) develops within the first 2–3 years of UTUC treatment [80] and tends to be nonmuscle‐invasive in 88–95% of cases [81, 82]. In a recent meta‐analysis including 8275 patients from 18 international centers undergoing RNU for UTUC between 2007 and 2014, Seisen et al. reported a pooled intravesical recurrence rate of 29% (range 21.5– 46.9%) at median time 22.2 months with median follow‐ up of 43.8 months [83]. In contrast, Cutress et  al. reported data on 22 ureteroscopically treated UTUC cohorts and noted a collective rate of intravesical tumor recurrence in 34% of patients with mean follow‐up ranging between 14 and 73 months in another recent meta‐analysis [66]. In two series specifically noting patients without previous bladder tumors, the rate was 34 and 33% [73, 76] (Table 50.4). In series with extended follow‐up, the rate of bladder tumor occurrence is

Bladder tumor

Percentage

Sowter et al. [73]a

12/35

34.3

Thompson et al. [74]

37/83

44.6

6/30

20.0

Daneshmand et al. [36] Chen and Bagley [7]

b

41/101

40.5

Cornu et al. [76]

14/35

40.0

Cutress et al. [79]

31/73

42

Grasso et al. [78]

40/66

61

Combined

181/423

42.8

a

 No history of bladder tumor.  Reviewed series to 2001.

b

higher. Cutress et al. noted a 42% rate of bladder recur­ rences with mean follow‐up of 52 months in 73 patients [79] while Grasso et al. noted 61% of 66 ureteroscopi­ cally treated patients developed bladder lesions with mean follow‐up of 52 months [78]. It is difficult to compare patients treated ureteroscopi­ cally or surgically because of selection bias in treating patients. The endoscopically treated patients have lower‐ risk tumor characteristics but bladder tumor occurrence is similar in both groups. This fact highlights the need for diligent cystoscopic surveillance for UTUC patients regardless of primary treatment modality. Furthermore, this also raises the question for the need of postoperative intravesical chemotherapy in ureteroscopically treated UTUC patients even without the immediate simultane­ ous presence of a bladder tumor. As seen in the ODMIT trial with bladder tumor‐naïve UTUC patients undergo­ ing RNU, the rate of new bladder tumor development within the first postoperative year was lower in those receiving a one‐time dose of intravesical mitomycin (16%) versus those who did not (27%) [84].

­Large tumors Large neoplasms of the upper tract can be treated suc­ cessfully ureteroscopically in some patients. It may be necessary to stage treatment at intervals of approxi­ mately 6 weeks. A combination of neodymium:YAG laser, coagulation, or electrocoagulation with holmium laser resection is effective. If visibility deteriorates with bleeding or tumor debris, it may be impossible to dis­ tinguish the margin of the tumor. The second resection may allow more precise treatment. Some tumors that regrow too rapidly or are too large to be treated uretero­ scopically may require a percutaneous nephroscopic procedure or even nephroureterectomy.

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

­High‐grade tumors Numerous reports have correlated the presence of high‐ grade UTUC with invasive disease on extirpative surgi­ cal specimens [35, 37]. Therefore, the presence of high‐grade UTUC precludes the employment of ureter­ oscopy as primary treatment with the intent to cure. Endoscopic treatment for high‐grade UTUC is reserved for those patients medically unfit for extirpative surgery, those with renal insufficiency or those with solitary renal units unfit for conservative extirpative surgery who would otherwise need dialysis but are unwilling to commit to it. In these situations, ureteroscopic manage­ ment should be considered palliative with the goal of stopping gross hematuria and limiting the need for hos­ pitalizations. The same ureteroscopic techniques would be employed with focus on coagulation of bleeding tumors and ablation of obstructing tumors whenever possible. In certain cases, stent dependence is accepted in order to maximize drainage especially if malignant obstructing tumors are present and require extensive coagulation, which may lead to ureteral stricture forma­ tion. Patients undergoing ureteroscopic treatment for high‐grade UTUC should be counseled on the very high probability of eventual development of metastatic dis­ ease, end‐stage renal disease, or both. Although there have been rare reported cases of successful long‐term ureteroscopic treatment of high‐grade cases [71], the median overall survival for such patients typically has been noted to be 29.2 months (range 6–52 months) [78].

­Surveillance Surveillance after ureteroscopic treatment of upper tract neoplasms is essential because of the high local recur­ rence rate in the ipsilateral renal unit and the bladder. Almost every paper reviewing experience with this treat­ ment has cautioned that endoscopic surveillance is neces­ sary. Similar to surveillance for bladder cancer, cystoscopy in UTUC patients is performed every 3 months for the first year, every 6 months for the second year, and yearly thereafter. Evaluation of the upper tracts for new or recur­ rent tumors can be maintained radiographically or with diagnostic ureteroscopy. It is important to note that uret­ eroscopy is the most sensitive technique to evaluate the upper tract and should be used routinely in follow up surveillance. Keeley and colleagues [70] found that the sensitivity of retrograde ureteropyelography for detecting recurrent upper tract tumors was only 25% in patients with UTUC history undergoing strict ureteroscopic sur­ veillance. In another series [85], urinalysis, voided cytology, and retrograde ureteropyelography were compared in

patients with ureteroscopically visualized and treated tumors. None of those tests could accurately and routinely detect tumors as well as endoscopic findings, which were defined as the gold standard. There was a high specificity of bladder urine cytology and urinalysis, which do support their use. If they are abnormal, earlier endoscopy should be undertaken. At this time, the role of FISH in detecting recurrent UTUC appears to be minimal. Various surveillance protocols have been proposed. Some authors recommend excretory urography or ret­ rograde ureteropyelography at intervals of 3–6 months with ureteroscopy reserved only when specifically indicated. However, the greater sensitivity of direct endoscopic inspection must be recommended as the preferred technique for surveillance. Ureteroscopy is continued at intervals of 3 months until the upper tract is clear, at which time the patient is examined uretero­ scopically at 6 month intervals. Cystoscopy and cytology with urinalysis are continued at intervals of 3 months during the first 2 years (Table  50.5). Evaluation of the contralateral collecting system with retrograde pyelog­ raphy should be performed at least yearly and possibly at each 6 month interval. Cross‐sectional imaging with contrast, as tolerated by the patient’s renal function, should be performed yearly to rule out locally advanced, extra‐luminal disease.

­Complications Complications can occur with any ureteroscopic proce­ dure but there are some that appear to be specific to ureteroscopic tumor treatment. Many of the problems related to dilation of the ureterovesical junction can be avoided by the use of small‐diameter rigid and flexible ureteroscopes. Electroresection is rarely used, and there­ fore the complications inherent in that procedure are avoided. With any of the techniques commonly used, electrocoagulation, laser coagulation, or resection with a neodymium:YAG or holmium:YAG laser, there remains Table 50.5  Surveillance. Interval

Action

3 month intervals

Cystoscopy Cytology

6 month intervals (after tumor‐free)

Ureteroscopy

6 or 12 month intervals

Imaging of contralateral kidney (IVP or retrograde)

12 month intervals

Cross‐sectional imaging (CT or MRI)

577

578

Section 3  Ureteroscopy: General Principles

Table 50.6  Strictures after ureteroscopic treatment of UTUC. Reference

No. of patients

Stricture

%

Suh et al. [71]

16

2

12.5

Daneshmand et al. [36]

30

5

16.7

Johnson et al. [72]

35

3

 8.5

Sowter et al. [73]

40

4

10.0

Chen et al. [86]

139

19

13.7

Overall

260

33

12.7

a

a

 Combined series to 2001.

a risk of stricture from scarring of the ureter or an infun­ dibulum. A review of complications from published series of ureteroscopic treatment of upper tract tumors indicates a ureteral stricture rate of 13% which is consid­ erably higher than the less than 1% seen for stone treat­ ment [86]. This may be an inherent risk of ureteroscopic tumor treatment, since the ureter itself is specifically traumatized with the treatment of the neoplasm. In comparison, damage to the ureteral wall during stone treatment is diligently avoided (Table 50.6). Perforation remains a strong theoretical risk. However, reported series have not shown any strong propensity toward intraluminal tumor dissemination, implantation, extraluminal tumor, or tumor extension [55].

­Adjuvant therapy Adjuvant chemotherapy or immunotherapy is an attrac­ tive option in the treatment of UTUC particularly because of the high recurrence rate. Due to the rarity of UTUC, no prospective, randomized trials have ever proven the efficacy of Bacille–Calmette–Guerin (BCG) or mitomycin C (MMC) as intraluminal adjuvant ther­ apy following endoscopic management. Thus far, the literature offers mostly retrospective, single‐institution, non‐randomized case control studies containing relatively small numbers of patients with heterogeneous tumors with both ureteroscopic and percutaneous treatment approaches. Furthermore, no method of delivery to the upper tract has ever been standardized and these range from slow infusions via PCN tubes and ureteral catheters to passive application to the upper tract by bladder infu­ sion with a stent. Two of the largest retrospective series published to date showed no benefit in terms of local recurrence rates in those given MMC with up to 63 months’ mean follow‐up [79] and those given BCG with up to 61 months’ mean follow‐up [87]. Thus, adju­ vant therapy with either BCG or MMC has been seen to be feasible, with relatively low side effects, but efficacy

has not been demonstrated. The safety and potential advantages of adjuvant therapy have been suggested in several short series but this treatment has no proven role.

­Cost of treatment The application and the need for endoscopic resection and surveillance for upper tract tumors have raised concerns regarding the costs of this management. Pak and colleagues [75] examined the direct costs of renal‐ sparing conservative measures versus nephroureterec­ tomy and subsequent chronic kidney disease or end‐stage renal disease. In a cohort of 57 patients with a minimum follow‐up of 2 years, renal preservation was 81% with CSS of 94.7%. On examination of Medicare payments, even the worst‐case scenario of a solitary kidney with recurrences at each follow‐up for 5 years versus nephro­ ureterectomy and dialysis for the same period would save over US$250 000. This same savings could alleviate the expense of five cadaveric renal transplantations.

­ amilial neoplasm of the upper F urinary tract Hereditary nonpolyposis colorectal cancer syndrome (HNPCC), also known as Lynch syndrome (LS), is an autosomal dominant genetic disorder which is charac­ terized by germ‐line mutations in DNA mismatch‐repair genes, including MSH‐2, MLH‐1, MSH-6, and PMS‐2. The syndrome is associated with predisposition to colo­ rectal cancer and extracolonic tumors, especially the endometrium, but also including the breast, the ovary, and the upper urinary tract. An international retrospec­ tive cohort study performed by the world’s largest LS research centers determined the lifetime risk of UTUC development in LS carriers was 8.4% but on further risk stratification was noted to be as high as 28% in men with MSH‐2 mutations with peak age of diagnosis between 50 and 70 years of age [88]. Observational studies suggest that the clinical behav­ ior of UTUC in LS patients differs from sporadic cases of UTUC. Crockett et al. examined the Creighton University HNPCC database and found 39 patients with UTUC, the majority of who had confirmed mutational analysis [89]. When compared to sporadic UTUC cases, LS patients with UTUC present were on average 8 years younger, had a greater tendency towards ureteral tumor location versus intrarenal location, and had a slight female preponderance. A series of UTUC patients with MSH‐2 mutations treated with ureteroscopy and laser ablation has been reported [90]. Similar to Crockett’s report,

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

these patients were relatively young at presentation at a mean age of 56.5 years and demonstrated a greater tendency for ureteral lesions. This series had a notable rate of metachronous bilateral UTUC (6/13) with a mean time of 49 months between eventual bilateral UTUC development. Although selection bias in this small series must be taken into account, the risk for bilateral disease in this population must be seriously considered. Further­ more, given the relatively younger age at presentation, conservative management with endoscopic treatment should be entertained as first line therapy whenever clinically feasible [89–91]. Panel recommendations have been put forth suggesting annual urinary analysis in LS carriers with three or more red blood cells per high‐pow­ ered field as an initiator for further work‐up. Although routine imaging was not recommended in every case, strong consideration should be given to CT urogram, particularly in those patients already undergoing peri­ odic cross‐sectional imaging for other malignancies especially when MSH‐2 carrier status exists or family history of UTUC is present [92].

­Benign neoplasms Benign urothelial neoplasms are rare in the renal pelvis and ureter. Many individual cases or short series have been reported and include fibroepithelial polyps, inverted papillomas, and hemangiomas as well as the more com­ monly noted ureteritis cystica. Fibroepithelial polyps (FEPs) are mostly benign ureteral luminal lesions originating from the mesodermal com­ ponents of the ureteral wall and are covered in otherwise normal urothelial epithelium. Very rarely they are asso­ ciated with UTUC [93] and therefore routine pathologic analysis is required for a complete evaluation. FEPs typi­ cally appear in young patients as a smooth pedunculated mass in the upper urinary tract, often occurring at the ureteropelvic junction with polyp length ranging from 0.5 to 4 cm [94], although longer FEPs have been reported. Historically, these lesions have been treated by open surgical resection. However, the availability of small ureteroscopes and appropriate biopsy or resection

devices, such as used for UTUCs have permitted ureter­ oscopic diagnosis and treatment. With increasing use of flexible digital ureteroscopes, the stalks of these FEPs are more clearly appreciated than ever, allowing for laser resection with holmium laser and complete removal with minimal trauma to the ureteral surface [95]. Follow‐ up after treatment is required only to confirm healing without significant stricture. Inverted papillomas have also been considered a benign lesion, although there has been concern because of the association with UTUC and the difficult histo­ pathologic diagnosis. The most common presentation has been with hematuria [96]. However, they can also cause obstruction with hydronephrosis. Endoscopically, they appear as a smooth mucosal based neoplasm. Often, there is a relatively narrow base encompassing less than one‐quarter circumference of the ureter. The lesions lack the papillary configuration of low‐grade UTUC, but can be confused with a higher‐grade lesion. Endoscopic biopsy is a crucial diagnostic study. It is particularly help­ ful to excise the entire lesion [97]. Follow‐up should be maintained both to confirm the patency of the urinary tract and because of the possible association with new UTUC. These neoplasms can be treated adequately ureteroscopically.

­Conclusion Ureteroscopy plays a central role in the diagnosis and treatment of UTUC. Larger lesions may require a percu­ taneous approach. Lesions that are more extensive, high‐ grade, or unable to be controlled endoscopically require nephroureterectomy, which can usually be performed laparoscopically.

­Acknowledgments The authors would like to acknowledge the assistance of Kelly A. Healy, MD, in the production of the videos for this chapter.

­References 1 Batata M and Grabstald H. Upper urinary

tract urothelial tumors. Urol Clin North Am 1976;3:79–86. 2 Shinka T, Uekado Y, Aoshi H et al. Occurrence of uroepithelial tumors of the upper urinary tract after the initial diagnosis of bladder cancer. J Urol 1988;140:745–748.

3 Rabbani F, Perrotti M, Russo P, and Herr HW. Upper

tract tumors after an initial diagnosis of bladder cancer: argument for long term surveillance. J Clin Oncol 2001;19:94–100. 4 Murphy DM, Zincke H, and Furlow WL. Management of high grade transitional cell cancer of the upper urinary tract. J Urol 1981;125:25–29.

579

580

Section 3  Ureteroscopy: General Principles

5 Bloom NA, Vidone RA, and Lytton B. Primary

6

7

8

9

10

11

12

13

14

15

16

17

carcinoma of the ureter. A report of 102 cases. J Urol 1970;103:590–598. Libertino JA, Bosco PJ, Ying CY et al. Renal revascularization to preserve and restore renal function. J Urol 1992;147:1485–1487. Chen GL and Bagley DH. Ureteroscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. J Urol 2000;164:1173–1176. Elliott DS, Segura JW, Lightner D et al. Is nephroureterectomy necessary in all cases of upper tract transitional cell carcinoma? Long‐term results of conservative endourologic management of upper tract transitional cell carcinoma in individuals with a normal contralateral kidney. Urology 2001;58:174–178. Huang, WC, Levey AS, Serio AM et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006;7:735–740. Wang LJ, Wong YC, Chuang CK et al. Diagnostic accuracy of transitional cell carcinoma on multidetector computerized tomography urography in patients with gross hematuria. J Urol 2009;181:524–531. Chen GL, El‐Gabry EA, Bagley DH. Surveillance of upper urinary tract transitional cell carcinoma: The role of ureteroscopy, retrograde pyelography, cytology and urinalysis. J Urol 2000;165:1901–1904. McCoy JG, Honda H, Reznicek M, and Williams RD. Computerized tomography for detection and staging of localized and pathologically defined upper tract urothelial tumors. J Urol 1991;146:1500–1503. Milestone B, Friedman AC, Seidmon EJ et al. Staging of ureteral transitional cell carcinoma by CT and MRI. Urology 1990;36(4):346–350. Zincke H, Aguillo JJ, Farrow GM et al. Significance of urinary cytology in the early detection of transitional cell cancer of the upper urinary tract. J Urol 1976;116:781–783. Placer J, Espinet B, Salido M et al. Clinical utility of a multiprobe FISH assay in voided urine specimens for the detection of bladder cancer and its recurrences, compared with urinary cytology. Eur Urol 2002;42:547–552. Fadl‐Elmula I, Gorunova L, Mandahl N et al. Cytogenetic analysis of upper urinary tract transitional cell carcinomas. Cancer Genet Cytogenet 1999;115:123–127. Marin‐Aguilera M, Mengual L, Ribal MJ et al. : Utility of fluorescence in situ hybridization as a noninvasive technique in the diagnosis of upper urinary tract urothelial carcinoma. Eur Urol 2007;51(2):409–415. discussion 15.

18 Chen AA and Grasso M. Is there a role for FISH in the

19

20

21

22

23

24

25

26

27

28

29

30

31

32

management and surveillance of patients with upper tract transitional cell carcinoma? J Endourol 2008;22:1371–1374. Johannes JR, Nelson E, Lepchuk B et al. Voided urine FISH testing in upper tract urothelial carcinoma surveillance. J Urol 2010;184:879–882. Grasso M and Bagley DH. A 7.5/8.2 F actively deflectable, flexible ureteroscope: a new device for both diagnostic and therapeutic upper urinary tract endoscopy. Urology 1994;43:435–441. Streem SB, Pontes JE, Novick AC et al. Ureteropyeloscopy in the evaluation of upper tract filling defects. J Urol 1986;136:383–385. Bagley DH and Rivas D. Upper urinary tract filling defects: flexible ureteroscopic diagnosis. J Urol 1990;143:1196–2000. Kavoussi L, Clayman RV, and Basler J. Flexible, actively deflectable fiberoptic ureterorenoscopy. J Urol 1989;142:949–954. Blute ML, Segura JW, Patterson DE et al. Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol 1989;141:1298–1301. El‐Hakim A, Weiss GH, Lee BR et al. Correlation of ureteroscopic appearance with histologic grade of upper tract transitional cell carcinoma. Urology 2004;63:647–650. Bagley DH, McCue P, Blackstone AS. Inverted papilloma of the renal pelvis: flexible ureteroscopic diagnosis and treatment. Urology 1990;36:336–338. Traxer O, Geavlete B, diez de Medina SG et al. Narrow‐band imaging digital flexible ureteroscopy in detection of upper urinary tract transitional cell carcinoma: initial experience. J Endourol 2011;25:19–23. Geavlete P, Georgescu D, Multescu R et al. Improving the diagnosis of upper urinary tract tumors: narrow band imaging technology. J Endourol B VideoUrology 2013;27: doi: 10.1089/vid.2012.0063. Abdel‐Razzak OM, Ehya H, Cubler‐Goodman A, and Bagley DH. Ureteroscopic biopsy in the upper urinary tract. Urology 1994;44:451–457. Kleinmann N, Healy KA, Hubosky SG et al. Ureteroscopic biopsy of upper tract urothelial carcinoma: comparison of basket and forceps. J Endourol 2013;27:1450–1454. Bian Y, Ehya H, and Bagley DH. Cytologic diagnosis of upper urinary tract neoplasms by ureteroscopic sampling. Acta Cytol 1995;39:733–740. Bagley DH, Kulp DA, and Bibbo M. Ureteroscopic biopsy optimized by cytopathologic techniques. J Urol 1994;151:387A.

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

33 Low RK, Moran ME, and Anderson KR. Ureteroscopic

34

35

36

37

38

39

40

41

42

43

44

45

46

cytologic diagnosis of upper tract lesions. J Endourol 1993;7:311–314. Tawfiek ER, Bibbo M, and Bagley DH. Ureteroscopic biopsy: technique and specimen preparation. Urology 1997;50:117–119. Keeley FX, Kulp DA, Bibbo M et al. Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J Urol 1997;157:33–37. Daneshmand S, Quek MD, and Huffman JL. Endoscopic management of upper urinary tract transitional cell carcinoma: long term experience. Cancer 2003;98:55–60. Brown GA, Matin Surena, Buzby JE et al. Ability of clinical grade to predict final pathologic stage in upper urinary tract transitional cell carcinoma: implications for therapy. Urology 2007;70:252–256. Wang JK, Tollefson MK, Krambeck AE et al. High rate of pathologic upgrading at nephroureterectomy for upper tract urothelial carcinoma. Urology 2012;79:615–619. Genega EM, Kapali M, Torres‐Quinones M et al. Impact of the 1998 World Health Organization/ International Society of Urological Pathology classification system for urothelial neoplasms of the kidney. Modern Pathol 2005;18:11–18. Montironi R, Lopez‐Beltran A. The 2004 WHO Classification of Bladder Tumors: a summary and commentary. Int J Surg Pathol 2005;13:143–153. Cheng L, Neumann RM, Nehra A et al. Cancer heterogeneity and its biologic implications in the grading of urothelial carcinoma. Cancer 2000;88:1663–1670. Skolarikos A, Griffiths TRC, Powell PH et al. Cytologic analysis of ureteral washings is informative in patients with grade 2 upper tract TCC considering endoscopic treatment. Urology 2003;61:1146–1150. Hall MC, Womack S, Sagalowsky AI et al. Prognostic factors, recurrence and survival in transitional cell carcinoma of the upper urinary tract: a 30‐year experience in 252 patients. Urology 1998;52:594–601. Margulis V, Shariat SF, Matin SF et al. Outcomes of radical nephroureterectomy: a series from the upper tract urothelial carcinoma collaboration. Cancer 2009;115:1224–1233. Vashistha V, Shabsigh A and Zynger DL. Utility and diagnostic accuracy of ureteroscopic biopsy in upper tract urothelial carcinoma. Arch Pathol Lab Med 2013;137:400–407. Smith AK, Stephenson AJ, Lane BR et al. Inadequacy of biopsy for diagnosis of upper tract urothelial carcinoma: implications for conservative management. Urology 2011;78:82–86.

47 Guarnizo E, Pavlovich CP, Seiba M et al. Ureteroscopic

48

49

50

51

52

53

54

55

56

57

58

59

60

61

biopsy of upper tract urothelial carcinoma: improved diagnostic accuracy and histopathological considerations using a multi‐biopsy approach. J Urol 2000;163:52–55. Charbit L, Gendreau M‐C, Mee S et al. Tumors of the upper urinary tract: 10 years of experience. J Urol 1991;146:1243–1246. Favaretto RL, Shariat SF, Savage C et al. Combining imaging and ureteroscopy variables in a multivariable model for prediction of muscle‐invasive and non‐organ confined disease in patients with upper tract urothelial preoperative carcinoma. BJU Int 2011;109:77–82. Liu JB, Bagley DH, Conlin MJ et al. Endoluminal sonographic evaluation of ureteral and renal pelvic neoplasms. J Ultrasound Med 1997;16:515–521. Matin SF, Kamat AM, and Grossman HB. High‐ frequency endoluminal ultrasonography as an aid to the staging of upper tract urothelial carcinoma. J Ultrasound Med 2010;29:1277–1284. Bus MT, Muller BG, de Bruin DM et al. Volumetric in vivo visualization of upper urinary tract tumors using optical coherence tomography: a pilot study. J Urol 2013;190:2236–2242. Lim DJ, Shattuck MO, and Cook WA. Pyelovenous lymphatic migration of transitional cell carcinoma following flexible ureterorenoscopy. J Urol 1993;149:109–111. Kulp DA and Bagley DH. Does flexible ureteropyeloscopy promote local recurrence of transitional cell carcinoma. J Endourol 1994;8:111–113. Hendin BN, Streem SB, Levin HS et al. Impact of diagnostic ureteroscopy on long term survival in patients with upper tract transitional cell carcinoma. J Urol 1999;161:783–785. Hara I, Hara S, Miyake H et al. Usefulness of ureteropyeloscopy for diagnosis of upper urinary tract tumors. J Endourol 2001;15:601–605. Murphy DM, Zincke H, and Furlow WL. Primary grade I transitional cell carcinoma of the renal pelvis and ureter. J Urol 1981;123:629–631 Murphy DM, Zincke H, and Furlow WL. Management of high grade transitional cell cancer of the upper urinary tract. J Urol 1981;125:25–29. Malloy TR: Laser treatment of ureter and upper collecting system. In Lasers in Urologic Surgery (ed. JA Smith), 82–93. Chicago, IL: YearBook Medical Publishers, 1985. Blute ML, Segura JW, Patterson DE et al. Impact of endourology on diagnosis and management of upper urinary tract urothelial cancer. J Urol 1989;141:1298–1301. Schmeller NT and Hofstetter AG. Laser treatment of ureteral tumors. J Urol 1989;141:840–843.

581

582

Section 3  Ureteroscopy: General Principles

62 Bagley DH. Ureteroscopic laser treatment of upper

63

64

65 66

67

68

69 70

71

72

73

74

75

76

77

urinary tract tumors. J Clin Lasers Surg Med 1998;16:55–59. Johnson DE. Use of the Holmium:YAG laser for treatment of superficial bladder carcinoma. Lasers Surg Med 1994;14:213–218. Razvi HA, Chun SS, Denstedt JD, and Sales JL. Soft‐ tissue applications of the Holmium:YAG laser in urology. J Endourol 1995;9:387–390. Bagley DH and Erhard M. Use of the holmium laser in the upper urinary tract. Tech Urol 1995;1:25–30. Cutress ML, Stewart GD, Zakikhani P et al. Ureteroscopic and percutaneous management of upper tract urothelial carcinoma (UTUC): systematic review. BJU Int 2012;110:614–628. Elliott DS, Blute ML, Patterson DE et al. Long‐term follow up of endoscopically treated upper urinary tract transitional cell carcinoma. Urology 1996;47:819–825. Martinez‐Pineiro JA, Garcia Matres MG, and Martinez‐Pineiro L. Endourological treatment of upper tract urothelial carcinomas:analaysis of a series of 59 tumors. J Urol 1996;156:377–385. Tawfiek ER, Bagley DH. Upper‐tract transitional cell carcinoma. Urology 1997;50(3):321–329. Keeley FX, Bibbo M, and Bagley DH. Ureteroscopic treatment and surveillance of upper tract transitional cell carcinoma. J Urol 1997;157:1560–1565. Suh RS, Faerber GJ, and Wolf JS. Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma. J Urol 2003;170:2209–2216. Johnson G, Fraiman M, and Grasso M. Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies. BJU Int 2005;95 Suppl 2:110–113. Sowter SJ, Ilie CP, and Efthimiou I. Endourologic management of patients with upper tract transitional cell carcinoma: long term follow up in a single center. J Endourol 2007;21:1005–1009. Thompson RH, Krambeck AE, and Lohse CM. Endoscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys. Urology 2008;71:713–717. Pak R, Moskowitz E, and Bagley DH. What is the cost of maintaining a kidney in upper tract transitional cell carcinoma. J Endourol 2009;23:341–346. Cornu TN, Roupret M, Carpentier X et al. Oncologic control obtained after exclusive flexible ureteroscopic management of upper urinary tract urothelial cell carcinoma. World J Urol 2010;28:151–156. Gadzinski AJ, Roberts WW, Faerber GJ et al. Long‐ term outcomes of nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma. J Urol 2010; 183:2148–2153.

78 Grasso M, Fishman AI, Cohen J et al. Ureteroscopic

79

80

81

82

83

84

85

86

87

88

89

90

and extirpative treatment of upper urinary tract urothelial carcinoma: a 15‐year comprehensive review of 160 consecutive patients. BJU Int 2012;110:1618–1626. Cutress ML, Stewart GD, Wells‐Cole S et al. Long‐term endoscopic management of upper tract urothelial carcinoma: 20‐year single‐centre experience. BJU Int 2012;110:1608–1617. Cosentino M, Palou J, Gaya JM et al. Upper urinary tract urothelial cell carcinoma: location as a predictive factor for concomitant bladder carcinoma. World J Urol 2013;31:141–145. Kang CH, Yu TJ, Hsieh HH et al. The development of bladder tumors and contralateral upper urinary tract tumors after primary transitional cell carcinoma of the upper urinary tract. Cancer 2003;98:1620–1626. Raman JD, Ng CK, Boorjian SA et al. Bladder cancer after managing upper urinary tract transitional cell carcinoma: predictive factors and pathology. BJU Int 2005;96:1031–1035. Seisen T, Granger B, Colin P et al. A systematic review and meta‐analysis of clinicopathologic factors linked to intravesical recurrence after radical nephroureterectomy to treat upper tract urothelial carcinoma. Eur Urol 2015:1122–1133. O’Brien T, Ray E, Singh R et al. Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma: a prospective, multicenter, randomized clinical trial of a single postoperative dose of Mitomycin C (the ODMIT‐C Trial). Eur Urol 2011;60:703–710. Chen GL, El‐Gabry EA, and Bagley DH. Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinalysis. J Urol 2000;165:1901–1904. Chen GL and Bagley DH. Ureteroscopic surgery for upper tract transitional cell carcinoma: complications and management. J Endourol 2001;15:399–404. Rastinehad AR, Ost MC, VanderBrink BA et al. A 20‐year experience with percutaneous resection of upper tract transitional carcinoma: is there an oncologic benefit with adjuvant Bacillus Calmette Guerlin Therapy? Urology 2009;73:27–31. Watson P, Vasen HF, Mecklin JP et al. The risk of extra‐colonic, extra‐endometrial cancer in the Lynch Syndrome. Int J Cancer 2008;123:444–449. Crockett DG, Wagner DG, Holmang S et al. Upper urinary tract carcinoma in Lynch Syndrome cases. J Urol 2011;185:1627–1630. Hubosky SG, Boman BM, Charles S et al. Ureteroscopic management of upper tract urothelial carcinoma (UTUC) in patients with Lynch Syndrome

50  Diagnosis and Treatment of Upper Urinary Tract Neoplasms

(hereditary nonpolyposis colorectal cancer syndrome). BJU Int 2013;112:813–819. 91 Pradere B, Lotan Y, and Roupret M. Lynch Syndrome in upper tract urothelial carcinoma: significance, screening, and surveillance. Curr Opin Urol 2017; 27:48–55. 2 Mork M, Hubosky SG, Roupret M et al. Lynch 9 syndrome: a primer for urologists and panel recommendations. J Urol 2015;194:21–29. 3 Zervas A, Rassidakis G, Nakopoulou L et al. 9 Transitional cell carcinoma arising from a fibroepithelial ureteral polyp in a patient with duplicated urinary tract. J Urol 1997;157:2252–2253.

94 Childs MA, Umbreit EC, Krambeck AE et al.

Fibroepithelial polyps of the ureter: a single‐ institution experience. J Endourol 2009;23:1415–1419. 95 Hubosky SG and Bagley DH. Laser resection of fibroepithelial polyps with digital ureteroscopy. J Endourol Case Reports 2015;1:36–38. 6 Witjes JA, van Ballen MR, van de Koa CA. The 9 prognostic value of a primary inverted papilloma of the urinary tract. J Urol 1997;158:1500–1505. 97 Bagley DH, McCue P, and Blackstone AS. Inverted papilloma of the renal pelvis: flexible ureteroscopic diagnosis and treatment. Urology 1990;36:336–338.

583

584

Part 2  Ureteroscopic Management of Ureteral Obstruction

51 Retrograde Endopyelotomy Weil R. Lai & Raju Thomas Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA

­Introduction

­History

Advances in technology, instrumentation, and techniques have changed the practice of urology, especially over the past two decades. One of the areas of major impact has been the treatment of ureteropelvic junction obstruction (UPJO), which is defined as an anatomic or functional impedance of urine flow from the renal pelvis into the ureter [1] (Figure 51.1). This condition can be congenital or acquired, the congenital form being the more common. UPJO, although relatively uncommon, warrants prompt attention to alleviate symptoms and prevent deterioration of renal function. Several factors can play roles in the development of UPJO, including intrinsic aperistalsis of the involved ureteral segment, crossing aberrant vessels causing direct compression of the ureter, renal stone disease, and previous surgical or endourologic manipulation. The advent of smaller‐caliber endoscopes [2], and development of laparoscopic reconstructive techniques, laser technology, and robotics has diversified the treatment options for this condition. Although the efficacy, and decreased morbidity, hospital stay, and need for analgesia with endopyelotomy have been clearly demonstrated, several issues have still not been completely resolved. Should patients be managed initially by the ureteroscopic approach? What are the exclusion criteria for these endoscopic procedures? What are the relative merits of antegrade versus retrograde approaches? In the era of minimally invasive laparoscopy and robot‐assisted surgery, is there still a role for retrograde ureteroscopic endopyelotomy? In this chapter we discuss the technique and results at our institution for retrograde ureteroscopic endopyelotomy for the treatment of UPJO.

Several reconstructive procedures have been described for the management of UPJO since Trendelenburg’s first description of such a procedure in 1886. Open surgical correction was the only mode of treatment for this condition before the introduction of endoscopic and laparoscopic techniques, and has been considered the gold standard of treatment for this condition, with success rates of over 90% [3]. However, associated morbidity is not unusual with open surgery. Specifically, there is fistula formation in 2.6% of patients, stricture of the ureteropelvic junction (UPJ) in 2.4%, and the need for nephrectomy in 3.2% [4]. The present‐day endourologic approach to the management of UPJO can be traced back to the original descriptions of Albarran, Keyes, and Davis. Albarran did the first endosurgical repair of the UPJO in 1903, which actually described a ureterotome externe [5]. Keyes performed a similar procedure successfully in 1915 [6]. Both the antegrade and retrograde endopyelotomy follow the concept of Davis’s intubated ureterotomy, first described by Davis in 1943. In 1985, Bagley et  al. reported a combined percutaneous and flexible ureteroscopic approach for the management of an obliterated UPJ [7]. Wickham and Kellet described the first ureteroscopic pyelolysis of the UPJ in 1983 [8], and this was repeated by Inglis and Tolley in 1986 [9]. Thomas et al. described their experience of ureteroscopic endopyelotomy in which pre‐stenting was performed to facilitate ureteroscopy in 1996 [10]. A single‐setting, one‐stage procedure was subsequently described by Soroush and Bagley in 1998 [11]. There are now multiple different options for the treatment of UPJO, including antegrade nephroscopic

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

51  Retrograde Endopyelotomy

is less invasive, requires less operating room time, enables the procedure to be performed on an outpatient basis or with a very short hospital stay, and is associated with a shorter convalescence period [1, 13, 25–29]. Also, the initial report of ureteral stricture formation because of thermal injury from transmission of the electrocautery current has been eliminated with the use of insulated ureteroresectoscopes and electrocautery and rigid or flexible ureteroscopes with holmium laser fibers [30]. With the miniaturization of ureteroscopes, the use of the rigid resectoscope is no longer advised.

­ atient selection and preoperative P preparation

Figure 51.1  Intravenous pyelogram of a right ureteropelvic junction obstruction (arrow).

endopyelotomy, retrograde ureteroscopic endopyelotomy, Acucise™ (Applied Medical, Rancho Santa Margarita, CA, USA), and laparoscopic and robot‐assisted pyeloplasty, as well as the traditional open surgical pyeloplasty [12]. As mentioned above, open surgical dismembered pyeloplasty has been considered the gold standard for the treatment of UPJO, with success rates of over 90%. However, many institutions have considered endopyelotomy a possible first‐line therapy option for the treatment of this condition [13–16]. Currently, a retrograde endopyelotomy can be performed in three ways: (i) using a rigid ureteroscope and a cold‐knife, electrocautery, or holmium laser incision; (ii) using a flexible ureteroscope and electrocautery or laser incision; and (iii) in rare select cases, using a balloon with a cutting wire (Acucise) [15]. The technique of dilation and cold‐cut incision with a peripheral cutting balloon, which was originally designed for angioplasty, had been reported mainly for ureteral strictures other than UPJO [17–19]. For UPJO, a recent retrospective case series was described in infants under 18 months of age [20]. This has not yet been reported in literature for adult patients with UPJO. It must be mentioned that the use of Acucise is not recommended for primary UPJO because of incidences of hemorrhage following use of this device. Different series have reported success rates for retrograde ureteroscopic endopyelotomy to be in the range of 73–90% [10, 11, 21–24]. As compared with other treatment options, ureteroscopic retrograde endopyelotomy

The presumptive clinical diagnosis of UPJO can be evaluated and/or confirmed with a renal ultrasound, intravenous pyelogram (IVP), diuretic renal scan, retrograde pyelogram, computed tomography (CT) scan, Whitaker test, or with a combination of these, as is clinically indicated. The renal scan, besides aiding in the diagnosis of a UPJO, gives a quantitative differential renal function, which can be used to choose the best treatment option and, further, to allow for follow‐up evaluation of the renal function. A high‐resolution spiral CT angiography is highly recommended to assess for the presence of an aberrant crossing vessel. For practitioners with experience and access to endoluminal ultrasound equipment, it can also be used to identify crossing vessels [31]. The UPJ area can also be evaluated ureteroscopically for the presence of pulsations before performing the endopyelotomy incision. Although ureteroscopic retrograde endopyelotomy is applicable to most patients with UPJO, there are some absolute and relative exclusion criteria. Among the absolute contraindications are patients with active infection and bleeding diathesis. Patients with concurrent renal calculi and UPJO, and patients with a nephrostomy tube in place, should be treated with an antegrade approach so that both the renal stone and the UPJO can be managed in a one‐stage procedure. Patients with a relatively long length of obstruction, usually greater than 2 cm, are best managed either with open surgical, laparoscopic, or robot‐assisted techniques. Patients with ipsilateral differential renal function of less than 20% and severely decreased parenchymal thickness can be given a trial of drainage and re‐evaluation [15] or should be offered a laparoscopic simple nephrectomy for a poorly functioning or nonfunctioning kidney. Patients with massive hydronephrosis should be treated with dismembered pyeloplasty, either open surgical, laparoscopic, or robot‐assisted,

585

586

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

because of the need for trimming and reduction of the redundant renal pelvis. Controversy exists with regard to patients with high insertion of the UPJ and crossing vessels. Although once considered a contraindication because of poor results, published series report that the type of ureteral insertion has no significant impact on the outcome of endopyelotomy [32], and that patients with crossing vessels had long‐term success with retrograde endopyelotomy [14]. We routinely perform laparoscopic robot‐assisted pyeloplasty in both cases with a high insertion UPJO or a known crossing vessel [12]. In the case of recurrent UPJO after pyeloplasty in adult patients, a trial of retrograde endopyelotomy should be considered as it has been noted to have success rates greater than 80% in such cases [33]. Lastly, patients with known intractable stent intolerance should be considered candidates for either an antegrade endopyelotomy or an open pyeloplasty with a nephrostomy tube, and not for ureteroscopic endopyelotomy. Once the surgeon and patient have decided on the retrograde approach for management of a UPJO, an indwelling ureteral stent is usually placed to drain the obstructed renal unit for 1–2 weeks. This procedure not only drains the obstructed renal unit, but also stabilizes its renal function, dilates and straightens the UPJ, and facilitates subsequent passage of the ureteroscope into the renal pelvis. Above all, preoperative placement of the stent allows evaluation of any degree of stent intolerance and may identify improvement of renal function after drainage. Informed consent On the day of the scheduled endopyelotomy, any final questions are answered, and an informed consent is obtained after explaining and discussing with the patient the expected outcomes and benefits of the procedure (e.g. improved renal drainage, preservation of renal function, diminished risk of calculus and infection, minimally invasive procedure), its associated risks or complications (bleeding, infection, possibility of conversion to open surgery, recurrence, etc.), and the other minimally invasive treatment options available. Patients are informed that postoperative evaluations may show some residual pelvicaliectasis, especially in those with long‐standing UPJO.

Table 51.1  Required instrumentation. Holmium laser ureteroscopic endopyelotomy

7.5 Fr rigid and/or flexible ureteroscope 200 or 365 µm holmium laser fiber at the following settings: ●● 1.5–2.5 J, ●● 10–15 Hz. Super‐stiff guidewire (0.038 inch) Single Action Pumping System (Boston Scientific, Marlborough, MA, USA) Endopyelotomy stent (Boston Scientific or Applied Medical, Rancho Santa Margarita, CA, USA) Routine cystoscopy and fluoroscopy setup

Ureteroscopic endopyelotomy with electrocautery

11.5 Fr ureteroresectoscope (Karl Storz, Culver City, CA, USA; Richard Wolf, Rosemont, IL, USA) (Figure 51.2): ●● insulated electrocautery knife, ●● cold knife, ●● electrocautery attachments. Single Action Pumping System (Boston Scientific) Super‐stiff guidewire (0.038 inch) 5 Fr open‐ended catheter Endopyelotomy stent (Boston Scientific or Applied Medical) Routine cystoscopy and fluoroscopy setup

(a)

(b)

­Step‐by‐step operative technique The required instrumentation is listed in Table  51.1. After either a general or a spinal anesthesia, the patient is placed in the lithotomy position. Caution is taken so that all pressure points are well cushioned, and antiembolic

Figure 51.2  (a) 11.5 Fr Ureteroresectoscope with insulated tip. (b) Close‐up view of ureteroresectoscope shows insulated cutting electrode in place (arrow).

51  Retrograde Endopyelotomy

stockings are used in high‐risk patients. With the use of a cystoscope, and under fluoroscopic guidance, a retrograde pyelogram is performed to confirm the length of the UPJO segment, and subsequently a super‐stiff guidewire is passed and coiled into the renal pelvis. If the patient had a previously placed indwelling ureteral stent, it is removed and used to pass the guidewire prior to removing the stent. A retrograde pyelogram can assess for any resolution of hydronephrosis and can be used as a prognostic indicator. The next step varies depending on whether the endopyelotomy is done with electrocautery through a ureteroresectoscope or whether a holmium laser is used through a modern rigid, semirigid, or flexible ureteroscope. In regions where the holmium laser is not available, an insulated electrocautery electrode can be used to incise using the cutting current.

­ olmium:YAG laser ureteroscopic H endopyelotomy A 7.5 Fr self‐dilating rigid, semirigid, or flexible ureteroscope is passed alongside the super‐stiff guidewire using generally accepted ureteroscopic techniques. A balloon dilator can be passed over the guidewire and the ureteral orifice dilated in the case of difficulty advancing the ureteroscope within the ureter. If necessary, another guidewire can be passed through the ureteroscope and the narrow area subsequently balloon dilated. Once at the UPJ, this is first inspected for the presence of any transmitted pulsations. A 365 µm holmium laser fiber, when using a rigid or semirigid ureteroscope, or a 200 µm fiber in the case of a flexible ureteroscope, is passed through the working channel of the ureteroscope. At a setting of 1.5–2.5 J and a frequency of 10–15 Hz, the UPJ is incised under direct vision either laterally or posterolaterally to avoid the risk of injuring any unsuspected crossing vessel. The incision is carried on until periureteral fat is seen and the UPJ is wide enough to permit easy passage of the ureteroscope into the renal pelvis (Figure 51.3). After hemostasis of any venous bleeding is performed, the laser fiber and ureteroscope are removed. The UPJ area is dilated up to 24 Fr using a balloon dilator under fluoroscopic guidance. The concept of balloon dilation of the UPJ is based on Davis’ intubated ureterotomy, in which the incised and dilated ureteral fibers regenerate around the ureteral stent over a 6 week period [6] (Figure 51.4). The balloon dilator is then removed. An endopyelotomy stent is placed under fluoroscopic control, leaving the 14 or 10 Fr end at the UPJ (depending on the stent

Figure 51.3  Periureteral fat seen after the ureteropelvic junction was incised with a holmium laser.

Preincision

Step 1: Incision

Step 2: Balloon dilation

Step 3: Regenerating tissue

Stent

Figure 51.4  Tissue regeneration after incision and balloon dilation.

587

588

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Figure 51.5  Endopyelotomy indwelling stent in place after ureteropelvic junction obstruction incision.

used) and the 7 Fr end coiled in the bladder (Figure 51.5). Alternatively, a 7 or 8 Fr double‐J ureteral stent can be left in place. The authors recommend using a ureteral stent one size longer than anticipated to prevent downward migration of the renal coil into the incised UPJ. If the stent is malpositioned, this can lead to leakage of urine into the retroperitoneal space with formation of a urinoma. As the ureteral stent can reflux urine from the bladder to the incised UPJ, an indwelling Foley catheter is placed to drain the bladder for 48 hours. This helps to maintain a low‐pressure system in the urinary uract and to prevent urinary reflux through the ureteral stent into the incised UPJ, which also may leak into the retroperitoneal space, possibly causing formation of a urinoma.

­Ureteroscopic endopyelotomy with electrocautery A 5 Fr open‐ended catheter is passed over the super‐stiff wire. The open‐ended catheter works as an insulator, preventing contact with the electrocautery element, and avoiding transmission of current along the length of the guidewire if contact is made. Also, once the wire is

removed, the open‐ended catheter may serve to continuously drain the renal pelvis of the irrigant used during the procedure. The 11.5 Fr ureteroresectoscope is passed directly alongside the insulated guidewire with the cold knife in place. The electrocautery element is right‐angled and would impede vision if placed during the insertion of the ureteroresectoscope [1]. If there is difficulty accessing the ureteral orifice or the intramural ureter, a balloon dilator can be passed over the guidewire to dilate the area. If there is resistance advancing the ureteroresectoscope along the ureter proximal to the UPJO, a smaller self‐dilating ureteroscope can be passed to passively dilate the ureter and to inspect for the cause of the narrow area. If necessary, another guidewire can be passed through the self‐dilating ureteroscope and the narrow area is balloon dilated. Once at the UPJ, the cold‐knife working element is exchanged for the electrocautery element. Either water or 1.5% glycine solution is used as the irrigant during monopolar electrocautery for incision. The UPJ is first inspected for the presence of any transmitted pulsations, and then incised laterally, between 8 and 9 o’clock on the right and between 3 and 4 o’clock on the left. Short and shallow strokes should be performed, and aggressive and deep incisions should be avoided. Any bleeding site is controlled by means of spot electrocoagulation. The incision is carried down until periureteral fat is seen, and the ureteroresectoscope enters the renal pelvis with ease. The ureteroresectoscope and the open‐ended catheter are removed. The rest of the subsequent steps, balloon dilation, stenting, and Foley catheter drainage, are the same as described above for the holmium:YAG laser endopyelotomy. As mentioned above, if the holmium laser is not available, then a flexible insulated electrocautery electrode can be used instead. Postoperative care The vast majority of patients are discharged either the same day or within the first 24 hours following the procedure. Oral antibiotics, usually fluoroquinolones, are given for 3–5 days. Oral antispasmodics and/or oral anticholinergics are given as needed in case of irritative bladder symptoms. The Foley catheter is removed, often by the patient, after 48 hours. The ureteral stent is removed cystoscopically in clinic in 6 weeks. Diuretic MAG3 renal scans or IVP are performed 4 weeks after ureteral stent removal. Patients are followed‐ up with renal ultrasound or renal scan every 4–6 months during the first year and yearly thereafter or as needed. Success following endopyelotomy is measured by evaluating improvement of the function and drainage of the

51  Retrograde Endopyelotomy

involved kidney and alleviation of symptoms. After correction of the obstruction at the UPJ, postoperative radiographic images from an IVP or CT scan often show residual pelvicaliectasis resulting from long‐standing obstruction and dilation that may not completely resolve. Results We analysed the outcome of 139 consecutive patients who underwent retrograde ureteroscopic endopyelotomy at Tulane University Health Sciences Center between 1989 and 2002. These patients included seven pediatric patients, four solitary kidneys, two horseshoe kidneys, and one ptotic kidney. The average postoperative hospital stay was less than 24 hours. Seventy‐nine percent of the patients were discharged home on the same day, and 97% of them within 24 hours. Of the 139 patients, 32 (23%) required subsequent procedures to treat recurrence of obstruction, showing an overall long‐term success rate for retrograde ureteroscopic endopyelotomy of 77%. Fourteen of these patients (10%) required major open or laparoscopic surgical intervention, including nephrectomies for severe hydronephrosis and nonimprovement in renal function in three (2%) cases, emergent nephrectomy for severe bleeding in one (0.7%), dismembered pyeloplasties in eight (5.7%), and spiral flap pyeloplasties in two (1.4%). Eighteen (12.9%) patients required minor procedures, which included cystoscopy and balloon dilation of the UPJ in 13 (9.3%), repeated retrograde endopyelotomy in four (2.8%), and long‐term indwelling stent exchange in one (0.7%). There were no ureteral strictures secondary to manipulation or the earlier use of the larger ureteroresectoscope in our series. After analysing the failures of treatment in this series, two factors were obviously associated with poor results (no improvement of symptoms, drainage, and function after endopyelotomy): (i) a long‐standing obstruction with a decrease in ipsilateral renal function of less than 20% of the total renal function and (ii) a severely dilated renal pelvis, which did not improve on drainage with an indwelling ureteral stent. After evaluation of these results, we conclude that patients with patulous redundant renal pelvis and borderline salvageable renal function should be considered candidates for alternative treatment modalities, such as open or laparoscopic/robotic pyeloplasty or nephrectomy, rather than endopyelotomy. Complications Since its initial description by Young in 1912, retrograde ureteroscopy has come a long way and has gained widespread acceptance as an option for the treatment

of multiple pyeloureteric conditions. Further advances in technology have led to the introduction of smaller‐ caliber ureteroscopes with the capacity to accommodate accessory instruments necessary to perform diagnostic and therapeutic upper urinary tract procedures. As with ureteroscopy, the complications and adverse events associated with retrograde ureteroscopic manipulation of the ureter have decreased dramatically in the past two decades. Smaller‐caliber ureteroscopes, the advent of laser technology, improved paraphernalia, and, above all, experience in the procedures, should be given credit. Although these advances have decreased the need for open ureteral surgery, iatrogenic injury can still occur with the endoscopic technique. Possible iatrogenic complications of ureteroscopy include ureteral perforation, stricture, false passage, ureteral avulsion, bleeding from the ureteral mucosa or adjacent structures, infection, and sepsis. Multiple studies have reported the overall complication rate of ureteroscopy to fluctuate between 1 and 15% [34–36]. Complication rates have substantially decreased following introduction of smaller‐caliber rigid and flexible ureteroscopes. The reported incidences of pain, fever, false passage, and urinary tract infection were 5.5, 1.4, 0.4, and 1.6%, respectively, in one large ureteroscopy series [37]. Other complications associated with incision of the UPJ can include bleeding from adjacent aberrant vessels, stent migration through the UPJ incision, and UPJO recurrence. Significant bleeding requiring emergent nephrectomy or selective angioembolization is another possible complication that justifies the need for vascular or three‐ dimensional (3D) radiographic studies to identify aberrant vessels. The use of a complete lateral incision at the UPJ helps to prevent injuries to those vessels, based on detailed anatomical studies of renal vascular anatomy [38]. Minor complications of retrograde ureteroscopic endopyelotomy include proximal stent migration, stent intolerance, minor bleeding, and urinary tract infection after manipulation. Most of these complications are alleviated after removal of indwelling ureteral stents. The routine use of antispasmodic and anesthetic drugs after surgery improves tolerance to the stent and decreases complaints from the patient. Current role of retrograde endopyelotomy With the proliferation of robotic technology, robotic pyeloplasty has replaced ureteroscopic endopyelotomy as the primary treatment option for UPJO. In these institutions, retrograde endopyelotomy is reserved for initial management of any UPJO recurrence following robotic pyeloplasty. However, the indications for retrograde endopyelotomy have not changed in institutions where laparoscopic and robotic pyeloplasty are unavailable.

589

590

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

­Comparison of treatment approaches and conclusions Multiple endourologic and open surgical techniques are now available for the treatment of UPJO. The choice of technique relies primarily on the urologist’s experience with each procedure, available equipment, and the need to perform another concomitant procedure. Antegrade endopyelotomy requires expertise in ­percutaneous renal surgery, with detailed knowledge of the intrarenal anatomy and adequate experience in “realtime” two‐dimensional fluoroscopic imaging. This is the preferred technique when treating concomitant intrarenal calculi, but it is also associated with a larger potential for complications and morbidity. The occurrence of pneumothorax, adjacent organ trauma (i.e. bowel, spleen, liver), and hydrothorax are possibilities that need to be explained to the patient prior to the surgery. Antegrade and retrograde endopyelotomy share the potential for hemorrhage from injury to aberrant crossing vessels; however, antegrade access may also be associated with hemorrhage from the percutaneous renal tract and with a higher risk of infection owing to external urinary drainage through the percutaneous nephrostomy tube. Acucise retrograde endopyelotomy is no longer popular, but, if performed, relies on fluoroscopic imaging and not on direct visualization during cutting of the UPJ. High‐quality fluoroscopic imaging is critical for optimal electrode placement. Short‐term success rates of this procedure have been comparable to those obtained with retrograde ureteroscopic endopyelotomy and range from 66 to 84% [39]. Extreme caution should be exercised when using this technique in the presence of aberrant crossing vessels. Preoperative CT scan with angiographic phase and 3D reconstruction has been shown to be adequate to collect information regarding periureteral

vasculature at the level of the obstruction [40]. Incision at the lateral position of the UPJ should minimize the risk of vascular injury while performing this procedure. Use of this technique has dramatically decreased because of lower success rates noted with long‐term follow‐up [41]. Multiple different indwelling stents can be used to maintain patency of the UPJ after an endopyelotomy. At our institution we use a 7 or 8 Fr double‐J ureteral stent with postoperative results similar to those obtained with endopyelotomy stents. It is always important to use an indwelling stent one size longer than anticipated in order to avoid downward migration of the stent that could compromise endopyelotomy healing.In many high‐volume centers, laparoscopic and robotic pyeloplasty has supplanted retrograde ureteroscopic endopyelotomy as the first‐line treatment for UPJO because of good long‐term outcomes (i.e. greater than 90%), comparable to those of open pyeloplasty. While robotic pyeloplasty has replaced retrograde ureteroscopic endopyelotomy as our first‐line treatment for most symptomatic UPJO, it is our belief that retrograde ureteroscopic endopyelotomy continues to have a place in providing a safe and adequate treatment for patients suffering from a short‐segment UPJO with good renal function and non‐patulous renal pelvis. With the advent of smaller scopes and devices, this technique has evolved to include larger children as possible patients. Adherence to strict endourologic principles and direct visualization makes retrograde ureteroscopic endopyelotomy a safe and effective treatment modality. Furthermore, this procedure has a short learning curve and can be performed in almost all general hospitals where ureteroscopy is performed. Lastly, this procedure should always be part of a urologist’s treatment armamentarium, because adult patients who have failed laparoscopic, robotic, or open surgical pyeloplasty can be managed with ureteroscopic retrograde endopyelotomy as a secondary procedure.

­References 1 Thomas R and Monga M. Endopyelotomy. Retrograde

6 Davis DM, Strong GH, and Drake WM. Intubated

2

7

3

4

5

ureteroscopic approach. Urol Clin North Am 1998;25(2):305–310. Boylu U, Oommen M, Thomas R, and Lee BR. In vitro comparison of a disposable flexible ureteroscope and conventional flexible ureteroscopes. J Urol 2009;182(5):2347–2351. Murphy LJT. The kidney. In: The History of Urology (ed. LJT Murphy and E Desnos), 197. Springfield, IL: Thomas, 1972. Scardino PT and Scardino PL. Obstruction at the ureteropelvic junction. In: The Ureter (ed. H Bergman), 697. New York: Springer‐Verlag, 1981. Albarran J. Operations plastiques et anastomoses dans la traitment des retentions de weim. Thesis, Paris, 1903.

8 9

10

ureterotomy; experimental work and clinical results. J Urol 1948;59(5):851–862. Bagley DH, Huffman J, Lyon E, and McNamara T. Endoscopic ureteropyelostomy: opening the obliterated ureteropelvic junction with nephroscopy and flexible ureteropyeloscopy. J Urol 1985;133(3): 462–464. Wickham JE and Kellet MJ. Percutaneous pyelolysis. Eur Urol 1983;9(2):122–124. Inglis JA and Tolley DA. Ureteroscopic pyelolysis for pelviureteric junction obstruction. Br J Urol 1986;58(3):250–252. Thomas R, Monga M, and Klein EW. Ureteroscopic retrograde endopyelotomy for management of

51  Retrograde Endopyelotomy

11 12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

ureteropelvic junction obstruction. J Endourol 1996;10(2):141–145. Soroush M and Bagley DH. Ureteroscopic retrograde endopyelotomy. Tech Urol 1998;4(2):77–82. Boylu U, Oommen M, Lee BR, and Thomas R. Ureteropelvic junction obstruction secondary to crossing vessels‐to transpose or not? The robotic experience. J Urol 2009;181(4):1751–1755. Danuser H, Ackermann DK, Bohlen D, and Studer UE. Endopyelotomy for primary ureteropelvic junction obstruction: risk factors determine the success rate. J Urol 1998;159(1):56–61. Ferraro RF, Abraham VE, Cohen TD, and Preminger GM. A new generation of semirigid fiberoptic ureteroscopes. J Endourol 1999;13(1):35–40. Nakada SY and Johnson M. Ureteropelvic junction obstruction. Retrograde endopyelotomy. Urol Clin North Am 2000;27(4):677–684. Van Cangh PJ, Nesa S, and Tombal B. The role of endourology in ureteropelvic junction obstruction. Curr Urol Rep 2001;2(2):149–153. Steiner D, Johns‐Putra L, and Lyon S. Ureteroplasty with a cutting balloon: a novel approach to ureteric anastomotic strictures. Australas Radiol 2007;51(2):143–146. Atar E, Bachar GN, Bartal G et al. Use of peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures. J Vasc Interv Radiol 2005;16(2 Pt 1):241–245. Boylu U, Oommen M, Raynor M et al. Ureteroenteric anastomotic stricture: novel use of a cutting balloon dilator. J Endourol 2010;24(7):1175–1178. Parente A, Perez‐Egido L, Romero RM et al. Retrograde endopyelotomy with cutting balloon™ for treatment of ureteropelvic junction obstruction in infants. Front Pediatr 2016;4:72. Badlani G, Karlin G, and Smith AD. Complications of endopyelotomy: analysis in series of 64 patients. J Urol 1988;140(3):473–475. Conlin MJ and Bagley DH. Ureteroscopic endopyelotomy at a single setting. J Urol 1998;159(3): 727–731. Hibi H, Yamada Y, Mizumoto H et al. Retrograde ureteroscopic endopyelotomy using the holmium:YAG laser. Int J Urol 2002;9(2):77–81. Meretyk I, Meretyk S, and Clayman RV. Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Urol 1992;148(3):775–82; discussion 782–783. Brooks JD, Kavoussi LR, Preminger GM et al. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 1995;46(6):791–795. Gerber GS and Kim JC. Ureteroscopic endopyelotomy in the treatment of patients with ureteropelvic

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

junction obstruction. Urology 2000;55(2):198–202; discussion 203. Giddens JL and Grasso M. Retrograde ureteroscopic endopyelotomy using the holmium:YAG laser. J Urol 2000;164(5):1509–1512. Shalhav AL, Giusti G, Elbahnasy AM et al. Adult endopyelotomy: impact of etiology and antegrade versus retrograde approach on outcome. J Urol 1998;160(3 Pt 1):685–689. Delvecchio FC and Preminger GM. Endourologic management of upper urinary tract strictures AUA Update Series 2000;19:250–255. Thomas R. Endopyelotomy for ureteropelvic junction obstruction and ureteral stricture disease: a comparison of antegrade and retrograde techniques. Curr Opin Urol 1994;4:174–179. Hendrikx AJ, Nadorp S, De Beer NA et al. The use of endoluminal ultrasonography for preventing significant bleeding during endopyelotomy: evaluation of helical computed tomography vs endoluminal ultrasonography for detecting crossing vessels. BJU Int 2006;97(4):786–789. Shalhav AL, Giusti G, Elbahnasy AM et al. Endopyelotomy for high‐insertion ureteropelvic junction obstruction. J Endourol 1998;12(2):127–130. Patel T, Kellner CP, Katsumi H, and Gupta M. Efficacy of endopyelotomy in patients with secondary ureteropelvic junction obstruction. J Endourol 2011;25(4):587–591. Blute ML, Segura JW, Patterson DE et al. Impact of endo­urology on diagnosis and management of upper urinary tract urothelial cancer. J Urol 1989;141(6):1298–1301. Fasihuddin Q and Hasan AT. Ureteroscopy (URS): an effective interventional and diagnostic modality. J Pak Med Assoc 2002;52(11):510–512. Low RK, Moran ME, and Anderson KR. Ureteroscopic cytologic diagnosis of upper tract lesions. J Endourol 1993;7(4):311–314. Grasso M and Bagley D. Small diameter, actively deflectable, flexible ureteropyeloscopy. J Urol 1998;160(5):1648–1653; discussion 1653–1654. Sampaio FJ. The dilemma of the crossing vessel at the ureteropelvic junction: precise anatomic study. J Endourol 1996;10(5):411–415. Nakada SY, Pearle MS, and Clayman RV. Acucise endopyelotomy: evolution of a less‐invasive technology. J Endourol 1996;10(2):133–139. Quillin SP, Brink JA, Heiken JP et al. Helical (spiral) CT angiography for identification of crossing vessels at the ureteropelvic junction. AJR Am J Roentgenol 1996;166(5):1125–1130. Biyani CS, Minhas S, el Cast J et al. The role of Acucise endopyelotomy in the treatment of ureteropelvic junction obstruction. Eur Urol 2002;41(3):305–310; discussion 310–311.

591

592

52 Endoscopic Management of Mid‐ureteral Obstruction Samuel Abourbih & D. Duane Baldwin Loma Linda University Medical Center, Loma Linda, CA, USA

­Introduction Strictures of the ureter are challenging to diagnose, techni­ cally difficult to treat once diagnosed, and associated with significant psychological overlay due to their frequent iatrogenic etiology. Although sometimes successfully treated with a single endoscopic procedure, mid‐ureteral strictures tend to recur, and may lead to renal loss if the obstruction is not expeditiously diagnosed and relieved. Mid‐ureteral strictures are anatomically, physiologically, and surgically distinct from both proximal and distal ure­ teral strictures. Therefore, the endourologist must possess an intimate understanding of ureteral anatomy and physi­ ology to avoid injury to the ureter, and to provide definitive management for these injuries when they do occur. This chapter will review strictures of the mid ureter, including the anatomy, prevention, diagnosis, and treatment.

­Anatomy The adult ureter is 25–30 cm long and 1.5–6 mm wide in its unobstructed, physiologic state [1]. The course of the ureter in the retroperitoneum is relatively constant, and is generally found just lateral to the transverse processes of the lumbar vertebrae (Figure 52.1). Knowledge of the anatomical relationships of the ureter may prevent iatro­ genic injury [1]. Posterior to the proximal ureter, the genitofemoral nerve runs along the psoas muscle [2, 3]. Anteriorly, at the level of the kidney lower pole, the ureter is crossed by the gonadal vessels. In close proximity to the abdominal ureter is the sigmoid mesocolon [4]. Just below the pelvic brim, the ureter crosses over the common iliac artery near its bifurcation. The iliac artery pulsations may serve as an important ureteroscopic

landmark. The ureters then course inferoposteriorly, along the pelvic sidewall, anterior to the internal iliac artery and outside of the parietal peritoneum. The ureters then run anteromedially into the bladder [5]. The ureter is divided into three anatomic portions, with the middle portion overlying the bony pelvis. The ureter also has three anatomic narrowings including the uret­ eropelvic junction, the level where the ureter crosses the common iliac artery, and the intramural ureter [6]. Familiarity with the ureteral blood supply may prevent inadvertent devitalization during ureteral dissection. The ureter has a segmental blood supply from the aorta and renal, gonadal, common iliac, and internal iliac arteries. Above the pelvic brim, the arterial supply originates medially while it originates laterally below the brim [6]. Histologically, from inner to outer, the ureteral layers are the urothelium, mucosal vascular plexus, muscular layer, and adventitia. In the upper ureter, the inner mus­ cular layer parallels the long axis of the ureter. The outer muscular layer has a circular or oblique orientation. The mid and distal ureter have an additional outer longitudi­ nal layer. The adventitia contains vertically arranged arteries supplying the ureteric wall [6]. Dissection of the ureter should proceed outside these vessels to avoid compromising its blood supply. Preservation of these vessels will allow collateralization from other levels even if some blood supply must be sacrificed [7]. The venous drainage parallels the arterial supply. The lymphatic drainage of the ureter consists of the lateral aortic (lumbar), common iliac, external iliac, and inter­ nal iliac lymph nodes. The nervous supply of the ureter arises from adjacent renal, aortic, and hypogastric auto­ nomic plexuses. Pain fibers enter the spinal ganglia and the spinal cord at segments T11 through L1 or L2, taking the same course as the sympathetic fibers [5].

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

52  Endoscopic Management of Mid‐ureteral Obstruction

Gonadal vessels

Proximal ureter

Common iliac artery

Mid ureter

Genitofemoral nerve Distal ureter Sacroiliac joint

Figure 52.1  Anatomical relationships of the ureter.

­Classification and etiology of strictures A ureteral stricture is a pathologic narrowing of the ure­ ter, resulting in dilation of the urinary system proximal to that point with resultant delayed urine transit. Strictures may be extrinsic, intrinsic, or intraluminal. This classi­ fication system is valuable since the different types of obstruction may be treated differently. For e­xample, ­intraluminal obstruction may be successfully treated by endoscopic ablation or removal of the obstructing agent, while extrinsic obstruction is difficult to treat endoscopi­ cally and requires drainage and treatment of the extrinsic etiology of the obstruction. Strictures can also be classified as ischemic or non‐ ischemic. This definition is also clinically relevant because

ischemic strictures may not respond as well to endoscopic procedures [8]. Strictures have also been classified as inflammatory versus non‐inflammatory [9], but it is unclear if there is any clinical relevance to this classifi­ cation system [10]. Table  52.1 lists the etiologies and classifications of ureteral obstruction. Strictures often arise iatrogenically due to surgery, by clipping, suture ligation, thermal injury, or devascu­ larization. Gynecological surgery is the most common cause of iatrogenic ureteral injury and hysterectomy is the leading procedural cause, occurring at a rate of 0.5–1.5% [10, 11]. Abdominal hysterectomy is more likely to lead to ureteral injury (2.2%) compared to vaginal hysterectomy (0.03%) [10]. Unfortunately only 13–66% of injuries are detected intraoperatively, with the remainder diagnosed postoperatively [10].

Table 52.1  Etiologies of mid‐ureteral strictures according different classifications. Ischemic

Non‐ischemic

Extrinsic

Intrinsic

Intraluminal

Inflammatory

Radiation

Impacted stone

Iatrogenic ligation

Bilharziasis

Fungus ball

Tuberculosis

Surgery

Idiopathic

Retroperitoneal malignancy

Endometriosis

Sloughed papilla

Retroperitoneal fibrosis

Primary ureterovesical junction obstruction

Aneurysm

Fibrosis

Stone

Schistosomiasis

Submucosal stone

Transitional cell carcinoma

Neoplasm

Postendoscopy

Iatrogenic injury

593

594

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

The incidence of ureteral injury from colon and rectum surgery is on the rise [4, 12]. The types of colorectal surgery most likely to injure the ureter are transverse colectomy (0.05%), right hemicolectomy (0.08%), proc­ tocolectomy (0.26%), left hemicolectomy (0.28%), sig­ moidectomy (0.33%), subtotal/total colectomy (0.35%), anterior resection (0.58%), and abdominoperineal resec­ tion (0.76%) [12]. Rectal cancer is the most common underlying disease associated with ureter injury at the time of colorectal surgery [12]. Urological surgery is another well‐recognized cause of ureteral stricture. In the initial experience of endoscopic stone treatment, large‐caliber ureteroscopes [13] and lithotrites like the electrohydraulic probe led to a major complication rate (defined as perforation, avulsion, or stricture) of 6.6% [14]. In the modern era, with the advancement of technology to include smaller, tapered, and more flexible ureteroscopes and instruments the stricture rate for uncomplicated ureteroscopy is 0.3–0.6% while the perforation rate for intact extraction of stones is 4% [15, 16]. The danger arises when these injuries are not recognized intraoperatively, and are associated with silent obstruction, risking renal loss. This concern has led the American Urological Association to recommend routine ultrasound of upper tracts following uretero­ scopic manipulation for stone removal [17]. A long‐standing, impacted, ureteral stone can also lead to ureteral wall damage and stricture formation (Figure 52.2). Roberts et al. reviewed 21 patients with long‐standing ureteral stones (mean 8 months) [18].

After treatment, 24% developed strictures. The authors identified longer duration of impaction and iatrogenic ureteral perforation during ureteroscopy as risk factors for future stricture formation [18]. An entity called congenital mid‐ureteral stricture represents a rare cause of mid‐ureteral obstruction and may be confused with either ureteropelvic junction or ureterovesical junction obstruction. This highlights the importance of retrograde pyelography prior to treatment of ureteral strictures [19, 20]. Segmental excision is cura­ tive and the etiology may be chronic in utero ischemia at the level of the mid ureter because of the vascular water­ shed between the aorta and iliac vessels.

­Presentation An injury to the mid ureter may present clinically in a variety of ways. In the case of acute iatrogenic ureteral transection the patient may be acutely septic while in the case of a ligated but intact ureter, the patient may present with ipsilateral flank pain, recurrent pyelonephritis, and/or an unexplained rise in serum creatinine. Urine extravasating into the peritoneal cavity may cause peri­ toneal irritation and findings of an acute abdomen. In contrast an incomplete stricture may be asymptomatic, and identified incidentally only upon abdominal imag­ ing. In an international review of almost 2000 ureteros­ copy patients, the majority of strictures were symptomatic but three (0.15%) were asymptomatic. The presence of pain after stent removal had a 64.3% positive predictive value and a 99.8% negative predictive value for stricture.

­Diagnosis

Figure 52.2  Impacted ureteral stone. Note mucosal edema and ingrowth around stone.

There are several methods available to assist the urolo­ gist in the evaluation of strictures (Table 52.2). One of the simplest and least invasive initial studies is ultra­ sonography. B‐mode ultrasound will detect dilation of the renal pelvis and/or calyces although ureteral dilation is sometimes obscured by overlying structures or bowel gas. Using Doppler sonography the resistive index (RI), defined as [peak systolic velocity − end diastolic velocity]/ peak systolic velocity, is generally less than 0.7 in an unobstructed system [21]. Although a RI above 0.75 is correlated with obstruction, compared to normal kidneys (RI 0.6) and healthy controls (0.58; P < 0.05) [22], a threshold RI of 0.7 has only a 44% sensitivity and 82% specificity for diagnosis of ureteral obstruction [23]. Historically intravenous pyelography was employed in the diagnosis of suspected ureteral injuries (Figure 52.3). This modality is still available in many centers, although

52  Endoscopic Management of Mid‐ureteral Obstruction

Table 52.2  Diagnostic modalities used to evaluate mid‐ureteral strictures. Costs are listed in US dollars. Modality

Advantages

Disadvantages

Sensitivity

Specificity

Cost

Computed tomographic (CT) urography

Superior spatial resolution Non‐invasive

Significant radiation source Contrast reactions

High

High

$1565

Magnetic resonance (MR) urography

No radiation Ideal for diagnosing extrinsic causes

Poor ability to diagnose stones Nephrogenic systemic fibrosis Expensive, time‐consuming

High

High

$2048

Diuretic renography

Provides split function Provides functional information regarding obstruction

Subjective interpretation Inconsistent results

High

Medium to high

$1138

Ultrasonography

No ionizing radiation No need for intravenous contrast medium

Operator dependent Image quality dependent on body habitus and overlying structures

Med to High

High

$410

Whitaker test

Provides objective information regarding obstruction Can identify bladder pressure abnormalities

Invasive Unfamiliar to many radiologists

Medium

Low to medium

Variable

Figure 52.3  Intravenous pyelogram showing abrupt narrowing of contrast at the level of the mid ureter. Courtesy Dr Mohamed Keheila and Dr Waleed Elsayed.

the results are not as sensitive or as specific as computed tomographic (CT) urography [24]. CT imaging represents the most common modality employed to evaluate ureteral obstruction. Unenhanced

CT scanning is the gold standard for the initial evaluation of suspected nephrolithiasis [17], but does not reliably determine non‐stone‐related causes of ureteral obstruc­ tion. In such instances, CT urography provides superior spatial and contrast resolution by opacification of the col­ lecting system [25] enabling it to detect stones, urothelial tages of masses, and congenital anomalies. Disadvan­ CT urography include the need for intravenous contrast, which can lead to nephropathy (defined as a rise in serum creatinine of 0.5 mg/dl or 25%) and contrast allergy [26]. Risk factors for contrast nephropathy include renal impairment, diabetes, age, congestive heart failure, dehy­ dration, multiple myeloma, and high‐osmolality agents [26], and these risk may be mitigated by hydration, discon­ tinuation of nephrotoxic agents, reduced contrast dose, N‐acetylcysteine, and use of iso‐osmolar or low‐osmolal­ ity contrast medium. When precise anatomical details are required and intravenous contrast is contraindicated, CT pyelography can be performed by injecting contrast through a nephrostomy, or by direct needle puncture of the col­ lecting system. In a study by Ghersin et al., CT pyelogra­ phy successfully detected the cause of ureteral obstruction in 20/20 patients who failed first‐line imaging [25]. Diuretic renography provides objective evidence regard­ ing ureteral obstruction. In this procedure the patient is hydrated and challenged with furosemide (usually 40 mg intravenously), administered when the tracer peaks in the affected system. Obstruction is defined as the time required to clear half of the radionuclide (T½) greater than 20 minutes, while a T½ of 22 cmH2O [32]. This test may underdiagnose obstruction in the face of massive hydro­ nephrosis [33]. Usually, the Whitaker test is performed when there is disagreement between other imaging modalities leading to ambiguity in the diagnosis [32]. Intraluminal ultrasound using a 12.5–30.0 MHz probe deployed in the ureter may provide information regard­ ing the nature of the ureteral wall and periureteral tissues, and information regarding any associated foreign body (stone) within the ureter or periureteral tissues [34]. Also, a mixture of indocyanine green injected in a retro­ grade manner into the collecting system may help iden­ tify the location of a stricture and help to identify the diseased ureter (remains dark) from the healthy fluo­ rescing ureter during robotic ureteroureterostomy [35].

­Stricture prevention The best way to prevent mid‐ureteral stricture disease is to use immaculate surgical technique and to preserve a robust ureteral blood supply. During ureteroscopy, the

Figure 52.4  Antegrade nephrostogram showing complete ureteral obliteration at the mid ureter.

mid ureter is the most susceptible region for major ureteral complications including the highest rates of ureteral avulsion (0.3%) and perforation (1.6%) [36]. Small‐caliber ureters occurring in small patients, chil­ dren, young males, duplicated systems, and following radiation or inflammatory processes are at the highest risk for injury [37, 38]. In these situations prestenting may allow passive ureteral dilation for 1–2 weeks and reduce this risk [39]. Prestenting may also be beneficial prior to complicated abdominal or pelvic surgery where extrinsic pathology and inflammation may make ureteral identification difficult [40, 41]. Fluoroscopic stone identification over the dense bony pelvis is more difficult. Also, in men the deep pelvis and the angulation as the ureter crosses the iliac artery make semirigid ureteroscopy more challenging and potentially dangerous. Attempting to force the semirigid uretero­ scope past the iliac vessels may result in flap creation or ureteral perforation. In addition, pulsations from the iliac artery can cause inadvertent injuries during

52  Endoscopic Management of Mid‐ureteral Obstruction

lithotripsy. Use of flexible ureteroscopy will decrease the risk of perforation in this region. Cases of “scabbard”‐ type ureteral avulsion have been reported when semi­ rigid ureteroscopes have been used in tight ureters [42]. This type of avulsion occurs when the ureter is com­ pletely transected between two points, and is removed intact with the ureteroscope. Blind basket extraction in the ureter should be avoided, as it has been linked with cases of ureteral entrapment and avulsion [43]. When performing laser lithotripsy, one should avoid firing directly adjacent to the mucosa, utilize the lowest possible power settings that will achieve efficient frag­ mentation, and use caution when advancing the uret­ eroscope and fiber. If a significant perforation occurs, it is prudent to terminate the procedure immediately and leave a double‐J stent to prevent submucosal stone fragment migration or enlargement of the injury. It is uncertain whether routine stenting reduces the ureteral stricture rate following uncomplicated ureteroscopy [14, 44, 45]. However, stent placement following ureter­ oscopy complicated by residual fragments, a urothelial flap, use of a ureteral access sheath, or a long‐term stone may minimize the risk of subsequent stricture [46]. Any patients undergoing intact stone extraction who have residual pain or dilation on renal ultrasound should be evaluated with a CT urogram to evaluate for stricture [17].

­Management of mid‐ureteral stricture disease There are many options for the treatment of a mid‐ ureteral stricture including observation, endoscopic approaches (stenting, balloon dilation, and endoscopic incisional procedures), and more complicated open and minimally invasive reconstructive approaches (uretero­ ureterostomy, ureteroneocystostomy with psoas hitch, Boari flap, transureteroureterostomy, and ileal ureter). The least invasive option for the management of a mid‐ureteral stricture is serial observation. Ureteral strictures that are not accompanied by pain and are not resulting in urinary tract infections, stone formation from urinary stasis, or renal deterioration on nuclear renography may be closely monitored to ensure progres­ sion of the disease does not occur [47]. However, poor follow‐up may jeopardize renal function and the deci­ sion for observation must consider many subtle factors. For example, if diuretic renography shows obstruction in an asymptomatic patient but the function is preserved, the surgeon may choose observation. In contrast the surgeon may intervene in a symptomatic patient with a borderline T½ on diuretic renography, and decreasing function. All treatments should be embarked upon with restraint, after extensive counseling including all

the options and following a carefully documented and detailed informed consent in order to avoid medicolegal complications. Once the surgeon decides to intervene, the next decision is the optimal timing for the operation. In the 13–66% of patients presenting with intraoperative ureteral injury the treatment should be embarked upon immediately. In patients who are medically unstable or with com­ plications following their ureteral injury, a period of 6–12 weeks with a nephrostomy tube or stent to allow inflammation to resolve is reasonable [48].

­Retrograde and antegrade stenting Immediate temporary renal decompression can be accomplished in either an antegrade or retrograde fashion and the approach of choice may vary depending upon the clinical presentation. In patients presenting with acute hydronephrosis, refractory pain, or infection the initial evaluation and management is cystoscopy, retrograde pyelography, and ureteral stent placement. Stent placement bypasses the obstruction while pre­ serving renal function and is also sometimes therapeutic. Antegrade or retrograde stenting has been shown to durably resolve ureteral strictures occurring in the transplant setting in up to 75% of cases [49]. Similarly, stenting of short‐segment strictures due to irritation, edema, or inflammation (i.e. tuberculosis) while the underlying cause is corrected may resolve strictures in 49% of patients [50]. The limitations of retrograde stent­ ing include discomfort, migration, infection, decreased effectiveness with extrinsic compression, and encrusta­ tion [51, 52]. Although changing stents every 3 months avoids encrustation, it is a less desirable long‐term management strategy. Newer metallic and coiled wire stent designs have attempted to improve drainage with extrinsic compression with a 65% success rate at a 5 month mean follow‐up [53, 54]. Retrograde stenting (double‐J) has the advantage of being completely intracorporeal, while a nephrostomy tube has both an intracorporeal and an external compo­ nent, making the nephrostomy more prone to inadvertent dislodgement. Another advantage of a retrograde ureteral stent is that the strictured lumen is stented open to prevent a dry ureter. In contrast the nephrostomy has the advantage of bypassing virtually any downstream obstruction and can allow for antegrade studies or thera­ pies. The nephrostomy tube, however, by diverting the urine, may convert a partial to a complete ureteral obstruction due to a dry ureter. Song et al. reviewed retrograde stenting in a series of patients with gynecologic malignancy and found an initial 81% success rate. However, 37% eventually received

597

598

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

nephrostomy drainage at a mean 9.1 month follow‐up [55]. Factors associated with stent failure on multivariate analysis were preoperative serum cystatin C levels >2.5 mg/l and stricture length longer than 3 cm [55]. Unlike previous studies [56], bladder invasion did not predict stent failure. Due to the high failure risk of an indwelling double‐J stent, many authors advocate for nephrostomy drainage in cases with extrinsic compres­ sion. Park et al. [57] reviewed a small patient series with metastatic nongenitourinary cancer and determined that ureteral stenting failed in each case, but nephros­ tomy successfully relieved each obstruction. In a larger study by Ku et  al. [58], patients with advanced malig­ nancy and ureteral obstruction were approximately ten times more likely to fail indwelling ureteral compared with nephrostomy drainage. One longer‐term stent option to relieve ureteral obstruction is the thermoexpandable metallic stents that have been employed for the treatment of benign and malignant obstruction. In one of the largest series to date, Agrawal et al. described their long‐term experience [59]. At a mean follow‐up of 16 months, 14 of 55 patients (25%) required stent replacement, mostly due to stent migration, but only three patients had stricture progres­ sion that required a stent change. When decompression is needed for a benign etiology (most commonly a stone), a randomized German study found superior outcomes across all variables in the nephrostomy group compared with the double‐J stent group [60]. In another study, Pearle et  al. randomized patients with septic obstructing stones to stent versus nephrostomy. In contrast to the prior study, there was no difference in efficacy or duration of analgesia, but retrograde stent placement was twice as costly [51]. Ultimately, the decision for nephrostomy or double‐J stent depends upon a number of factors including the etiology, the likelihood of success with each procedure, the need for future therapies, the availability of the facili­ ties and staff, and  –  perhaps most importantly  –  the patient’s wishes.

­Balloon dilation Initially developed for coronary arteries, balloon cathe­ ters have been shown to cause linear tears in the ureter, in a manner similar to an endoureterotomy [61, 62]. Both retrograde and antegrade balloon dilation are possible, but a retrograde approach is favored when the urethra, bladder, and ureter are in continuity. In this procedure a 5 or 6 Fr open‐ended catheter is employed to perform a high‐quality retrograde pyelography. Next, a flexible‐ tipped lubricious wire is passed via an open‐ended catheter past the stricture and into the renal pelvis.

Figure 52.5  An 18 Fr, 10 cm balloon is shown here dilating a proximal to mid‐ureteral stricture.

The endhole catheter is then pushed above the stricture and the lubricious wire is converted to a standard or stiff guidewire. Alternatively, a single hybrid wire could be utilized. Next, the appropriate diameter (12–24 Fr) and length (4–10 cm) balloon catheter is inserted using fluor­ oscopic localization ensuring that the two radiopaque markers are straddling the stricture (Figures  52.5 and 52.6). Using half‐strength contrast the balloon is inflated and held for 1–2 minutes. Optionally ureteroscopy can be performed to ensure complete dilation. A 6 Fr ureteral stent is routinely left in place for 4–6 weeks following the dilation (See Video 52.1). Reported short‐term ­success rates of ureteral balloon dilation for short‐length strictures are usually 48–55% [61, 63].

­Endoureterotomy Endoureterotomy is a relatively simple procedure where a full‐thickness incision is made in the ureter to open a stricture [8]. It may be accomplished using different methods including a variety of electrified or nonelec­ trified cutting instruments and is frequently employed with balloon dilation. Since the earliest descriptions, the principles of endoureterotomy have changed little, except for the method of making the incision. The heter­ ogeneity of studies (size and type of laser fiber, combina­ tion with balloon dilation, renal function, presence of crossing vessels, degree of hydronephrosis, and size and duration of stent) makes it difficult to compare studies

52  Endoscopic Management of Mid‐ureteral Obstruction

Figure 52.6  A 24 Fr, 4 cm balloon is shown here dilating a proximal to mid‐ureteral stricture.

energy is to be used an insulated wire should be employed. Next, a balloon catheter is used to dilate the stricture. Following this, a full‐thickness incision of the ureteral stricture is created, directed away from the blood supply and extending 5–10 mm above and below the stricture. Currently, the most widely used and best‐described instrument for incision is the holmium laser due to its shallow tissue penetration (2 cm, and stricture due to endome­ triosis [65, 66]. Despite these limitations, the European Association of Urology state in the Laser guidelines that “Retrograde endoureterotomy is considered a first‐line treatment option for ureteral strictures,” with a Grade C recommendation [67]. Most endoureterotomy failures occur 3–9 months after the procedure [68, 69], although some failures occur as late as 18 months after endouret­ erotomy [70]. This underscores the need for extended surveillance in all patients undergoing endoscopic treat­ ment of ureteral strictures. A special subtype of endoureterotomy is the hot‐wire balloon (Acucise™) endopyelotomy [71]. This device was not frequently used for mid‐ureteral strictures due to the risk of iliac artery injury if the balloon was not positioned correctly [72]. Although initially very popu­ lar, this technique has fallen out of favor due to difficulty controlling the cutting action, the risk of hemorrhage, and the much higher success rates seen with techniques employing direct vision and laparoscopic and robotic procedures [73].

­Rendezvous procedures

Figure 52.7  Endoscopic view of a very narrow mid‐ureteral stricture, with a safety wire passing through the stricture.

or identify a gold‐standard technique for the performance of endoureterotomy. The first step of endoureterotomy is to perform a ­retrograde pyelogram to delineate the stricture. Next a safety wire is placed across the stricture and a uretero­ scope is used to evaluate the stricture site to exclude neoplasm or submucosal stone (Figure 52.7). If electrical

One dreaded potential iatrogenic complication is complete ureteral transection. This type of injury, when not detected intraoperatively, can lead to sepsis and the potential for renal loss. Diagnostic imaging will demon­ strate no ureteral continuity (Figure 52.8 and Video 52.2). These injuries, when occurring in the mid ureter, are best treated by a reconstructive procedure like a Boari flap or psoas hitch since a blind puncture or cut outside the mid ureter may result in iliac injury. If there are con­ traindications to such techniques and the length of the stricture is less than 3 cm, one endoscopic approach that may be attempted is the “rendezvous” technique or endoscopic realignment. This technique involves feed­ ing a wire antegrade into the retroperitoneum, then

599

600

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Figure 52.8  Endoscopic view of a completely obliterated ureter.

grasping this wire with a semirigid ureteroscope from below to establish through‐and‐through access [74]. Alternatively use of a flexible ureteroscope from above and a semirigid ureteroscope from below provides the surgeon with greater control [75]. Using the latter technique Liu et  al. achieved a 75% success rate at a mean of 21.5 months of follow‐up. Tsai et al. achieved 100% success in 10 patients treated using this tech­ nique at a mean of 16 months of follow‐up [76].

­Laparoscopic and robotic approaches While more invasive than endoscopy, laparoscopic and robotic approaches have the advantage of removing the diseased ischemic tissue and creating a widely spatulated, tension‐free mucosa‐to‐mucosa seal of the urothelium. In the mid ureter a laparoscopic or robotic ureterouret­ erostomy may be performed. The patient is positioned in a dorsal lithotomy position with moderate to steep Trendelenburg. Next, the ureter is mobilized above and below the stricture, and the pathologic segment is excised and sent for pathologic analysis. The ureter is then spat­ ulated at both ends for a distance of at least 5–15 mm. The posterior anastomosis is performed using a 4‐0 Vicryl suture, in either a running or interrupted fashion. Once the posterior portion is complete, a double pigtail stent is inserted across the repair, and the anastomosis is then completed. A drain is left postoperatively and the stent is left indwelling for 6 weeks [77].

Buffi et al. reported their experience with five lumbar and iliac ureteral strictures ranging from 5 to 30 mm long that were treated with a robot‐assisted laparoscopic approach [78]. In all cases intraoperative flexible ureter­ oscopy was used to identify the stricture margins and there were no recurrences. Complete mobilization of the kidney can be performed if necessary to obtain addi­ tional length for the anastomosis. Overall, outcomes for laparoscopic and robotic ureteroureterostomy are good, although sample sizes in the majority of studies are small. Mid‐ureteral strictures longer than 3 cm may be treated with a high psoas hitch or Boari flap or more traditional approaches including an ileal ureter, auto­ transplantation, and transureteroureterostomy. The steps of a robotic ureteral reimplant for a stricture at the junction of the mid and distal ureter are demon­ strated in Video 52.3. When faced with longer‐length strictures, excisional techniques are insufficient. Traditionally, long ureteral strictures have been treated by Boari flap, ileal ure­ ter  substitution, or autotransplantation. Each of these techniques have been reported using a robotic approach and for more details of these surgeries we refer the reader to Chapter 103. One group has looked at reduc­ ing the invasiveness of repairing long‐length ureteral strictures by applying the buccal mucosal graft used in urethral reconstruction [79]. The authors noted a 100% success rate in three patients at a median 15‐month ­follow‐up. Other groups have experimented with dif­ ferent types of grafts, including lingual mucosa grafts and tubularized peritoneal flaps with varying success [80, 81]. Duty et al. reported on the use of appendix as an onlay flap for laparoscopic reconstruction of proxi­ mal and mid‐ureteral strictures [82]. This approach has some drawbacks compared to the buccal mucosal graft as it enters the digestive tract, and two out of six patients required reoperation, including one nephro­ ureterectomy. Laparoscopic ileal ureter has been described but should not be required for most mid‐ ureteral strictures [83]. In this chapter we have discussed the presentation, diagnosis, prevention, endoscopic incisional and lapa­ roscopic and robotic excisional techniques for manage­ ment of mid‐ureteral strictures. Endoscopic management offers a minimally invasive solution to about half of patients presenting with mid‐ureteral strictures. Following appro­ priate patient counseling it is reasonable to offer one or two trials of endoscopic management in short‐length strictures (7 mm. It can be divided into subsets of obstructive megaureter and refluxing megaureter. Obstructive megaureter is thought to arise from a malfor­ mation of the distal ureter at the ureterovesical junction (UVJ), with an aperistaltic segment leading to a small distal portion of stenotic or normal‐caliber ureter with proximal hydroureter [38, 39]. See Figure 53.13. Ureteral meatal stenosis is a congenital pinpoint orifice without previous instrumentation or stone impaction. The ureteral orifice is naturally the narrowest ureteral point of the ureter with an estimated 6 Fr lumen size. If this stenosis is functionally affecting drainage a simple meatatomy or dilation is adequate treatment. A ureterocele is a cystic outpouching of the terminal ureter occuring in 1 in 4000 children, predominantly females. Some 80% are in ectopic locations, ranging from the bladder to the urethra; 80% are associated with a dysplastic or poorly functioning duplicated upper pole system. Obstructive symptoms in ureteroceles varies in patients and can range from being asymptomatic to having recurrent urinary tract infections (UTIs), hydro­ nephrosis, and renal failure. Ureteroceles cause obstruc­ tion due to a stenotic ureteral orifice; however, in severely dysplastic ureteroceles they can also prolapse and cause bladder neck obstruction [40, 41]. Acquired strictures Acquired strictures fall into several broad categories: benign, malignant, iatrogenic, and idiopathic. In a review by Tyritzis and Wiklund, 35% of strictures were iatro­ genic in nature, 35% had benign causes, 20% idiopathic, and 10% malignant [42]. Open or endoscopic procedures can result in iatrogenic mechanical and vascular damage to the ureter with an estimated occurrence of 0.3–2.5% in pelvic and endo­ scopic surgery [43]. With the increased volume of mini­ mally invasive laparoscopic and robotic procedures, the overall incidence has increased 30% since 2000, attributed to increased difficulty in visualization and the inability to palpate the ureter compared to open surgery [44].

615

616

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

(a)

(c)

(b)

(d)

Figure 53.13  (a) The appearance of a congenital obstructive megaureter. The distal obstructed lumen was incised with a cold‐knife endoureterotome. (b) Obstructive megaureter after treatment, note the dilation of the left distal ureter, (c) Sluggish ureteral jet on the left due to poor peristalsis rather than obstruction. (d) Strong ureteral jet on the contralateral side.

Injury can range from thermal mucosal damage to perfo­ ration to partial or complete transection. In each case, the ureter or its end vasculture is intrisically damaged, leading to fibrosis and stricture. The type of surgery responsible for ureteral injuries varies considerably by study. Gynecologic procedures account for 45–74% of ureteral injuries. The injury most commonly seen during hysterectomies occurs in the ureter distal to the crossing of the uterine artery. General surgical injuries account for 4–17%, mostly during colectomies; this is estimated at a rate of 0.3–10% of

distal colectomies with the remaining occuring in vascular cases [45]. Urologic surgery accounts for the remaining iatrogenic injuries, estimated at 8–44% of all ureteral injuries dur­ ing both endoscopic and open surgery. Ureteroscopic injuries are relatively rare, at a rate of 1–3% postinstru­ mentation. Passage of flexible or semirigid ureteroscopes can cause intraluminal trauma through shear forces, especially if the ureter is insufficiently dilated. A study by Karakan et  al. [46] reported higher rates of injury with balloon dilation of the ureter and preoperative UTI.

53  Endoscopic Management of Distal Ureteral Strictures

Insertion of a ureteral access sheath can be associated with iatrogenic ureteral wall injury, especially in unstented narrow lumens. This is due to inserting a larger‐diameter device, causing intraluminal shear forces. Holmium laser lithotriposy can cause iatrogenic damage but with pene­ tration of only a few millimeters the damage is less than with Nd:YAG lasers. Nevertheless, accidental energy application, mechanical pressure, and stone fragments can cause localized ischemia and scar tissue. Use of a basket during treatment of stones can result in complete avulsion of the ureter [47]. Fam et  al. reported on 77 patients treated endoscopically for impacted ureteral stones, and following the operation found a stricture rate of 7.8% [48]. Iatrogenic ureteral strictures occurring after open urologic procedures such as cystectomy and kidney transplantation are almost always the result of ureteral reimplantation or urinary diversion. Cystectomy has a ureteral anastomosis stricture rate of 2.7–8.8% [49]. In a review by Mano et al. of 1004 renal transplant recipients between 2000 and 2010, 2.6% developed ureterovesical anastomotic strictures [50]. The pathogenesis of uret­ erointestinal strictures is multifactorial and likely due to ischemia and postsurgical fibrosis [51]. Benign strictures Impacted calculi are responsible for up to 65% of benign strictures. The causes of stricture in these patients are multifactorial and intrinsic in nature. Persistent pressure of the stone against the ureteral mucosa and the resulting immune reaction to the stone itself can cause localized ischemia, leading to fibrosis and stricture [52]. Longer stone impaction leads to increased risk: Roberts et  al. reported that ureteral stone impaction for longer than 2 months harboured a 24% chance of ureteral stricture, ureteral edema, and epithelial hypertrophy [53]. The edematous mucosa is more fragile and limits endoscopic work space, increasing the chance of mucosal damage [48]. Retroperitoneal fibrosis is a rare, commonly bilateral idiopathic and autoimmune disorder characterized by inflammation and fibrosis around an abdominal aortic aneurysm and surrounding retroperitoneal structures, and it can often cause external ureteral compression [54]. Retroperitoneal fibrosis typically develops as a plaque between the renal arteries and the pelvic brim with rare sacral involvement. As such, the distal ureter is usually unaffected. Retroperitoneal fibrosis accounts for roughly 15% of benign strictures [55] with the majority in the mid and upper ureter with medial deviation. The extrinsic compression leads to a narrow lumen, giving a classicstring‐like appearance. The immediate segment above and the pelvicalyceal system are significantly dilated. This process is commonly bilateral.

Endometriosis is the presence of endometrial tissue outside of the uterine cavity and is a chronic inflamma­ tory process stimulating surrounding angiogenesis. Chronic inflammation results in extensive adhesions, distortion, or compression of the ureter in less than 1% of cases [56]. Pelvic lipomatosis can cause compression of the bladder and is associated with possible displacement and narrow­ ing of the distal ureters.

­Infection, trama, and malignancy Infectious causes of ureteral strictures are rare (1 cm, the use of a stent >12 Fr and injection of triamcilinone improved outcomes.

Chandhoke et  al. reported on the Acucise cutting balloon catheter on 28 patients with UPJ or ureteral obstruction, including five in the distal ureter. The symptomatic success rate was 80% in the distal ureter at 3 month follow‐up [105]. Cohen et al. reported 29 month follow‐up success, defined as radiographic resolution or symptom relief, in 80% of the distal strictures [106]. Preminger et  al. reported on a multicenter trial on 40 ureteral strictures with a patency rate of 58% in the dis­ tal ureter [32]. Singal et al. reported use of holmium laser followed by balloon dilation on 12 ureteral strictures with a success rate of 78% at 9 months [107]. In a study by Ibrahim et al., 55 patients with a mean stricture length of 1.92 cm under­ went retrograde laser endoureterotomy. Patients were randomized into single ureteral stent or double ureteral stent for 8 weeks after therapy. They found an overall successful treatment rate of 67%, and for strictures >1.5 cm the double ureteral stent had a success rate of 82% compared to 39% for a single ureteral stent [97, 108]. Eshghi and Schwalb reported on 61 strictures treated with a cold‐knife endoureterotome and endoureterot­ omy scissors with no immediate side effect and 96% success at 24 months [99]. Ureterointestinal anastomotic strictures treated with cold‐knife endoureterotomy and stent placement showed success rates at 1, 2, and 3 year follow‐up of 86, 67, and 60% respectively [109]. See Table 53.3. YAG laser In a study of five patients treated with YAG laser endoureterotomy for anastomotic stricture in trans­ planted kidneys, 100% had resolution of stricture at a median follow‐up of 52 months [111]. Gnessin et  al. reported on 35 patients with benign strictures treated with YAG laser endoureterotomy: 14 had distal ureteral strictures at 27 months and 78% had resolution of stric­ ture. Most failures occurred within less than 9 months of surgery [112]. Mano et al. treated nine patients with ureterovesicular strictures posttransplantation with either cold‐knife or YAG endoureterotomy with a suc­ cess rate of 83% at 44 months [50]. Han et al. reported a success rate of 76.5% out of 77 patients over a median of 19.6 months. Stone disease, positive presenting symp­ toms, and short length of the stricture were identified as variables with a good predictor [113].

­Summary and conclusions The most essential aspect of endoscopic and endourologic management of distal ureteral stricture is an initial thor­ ough assessment of cause, severity, length, and vascular

53  Endoscopic Management of Distal Ureteral Strictures

Table 53.3  Endoureterotomy for benign ureteral strictures. Study

No. of strictures total (distal)

Technique

Success rate total (distal), %

Follow‐up (months)

Lopatkin et al. [104]

  7 (4)

Cold knife

86 (100)

22

Schneider et al. [110]

12 (12)

Cold knife

83 (83)

15

Chandhoke et al. [105]

  8 (5)

Acucise

75 (80)

 4

Cohen et al. [106]

  8 (5)

Acucise

75 (80)

29

Preminger et al. [32]

40

Acucise

55 (58)

 9

Wolf et al. [64]

38 (29)

Cold knife

82 (78)

28

Singal et al. [107]

10 (12)

Holmium laser

67 (70)

11

Eshghi and Schwalb. [99]

61

Cold knife

98

24

viability of the stricture. The coexisting risk factors and comorbidities will further define the path towards the treatment. An adequate training in endoscopic and inter­ ventional techniques along with a wide variety of instru­ ments are basic requirements for treating challenging cases with altered anatomies. As a rule, once access has been secured across a stenotic area in most cases balloon dilation with 3–6 weeks of stenting provides an acceptable success rate. In more complicated cases staged procedures

and use of dedicated instruments such as the cold‐knife endoureterotome is recommended for better results. The dilemma is that, similar to other entities such as renal ureteropelvic tumors there are no standardized techniques or protocols to provide an adequate number of cases with level 1 evidence to allow definitive state­ ments about some of these treatment modalities. With more time and expanded use of these techniques such recommendations will come to fruition.

­References 1 Wein AJ et al. Campbell‐Walsh Urology. Elsevier, 2016. O’Rahilly R and Muller F. Basic Human Anatomy. WB 2

12 Mescher AL. The urinary system. In Junqueira’s Basic

3

13

4

5 6 7 8

9

10

11

Saunders, 1982. Drake R et al. Gray’s Anatomy For Students, 3e. Elsevier, 2014. Zelenko N et al. Normal ureter size on unenhanced helical CT. AJR Am J Roentgenol 2004. 182(4):1039–1041. Butler P et al. Applied Radiological Anatomy. Cambridge UniversityPress, 2012. Woodburne RT and Burkel W. Essentials of Human Anatomy. Oxford University Press, 1988. Eshghi M. Endoscopic Surgery of the Urinary Tract, Part 1. Monographs in Urology. Merck & Co, 1991. Lapides J and Woodburne RT. Configuration of ureteral lumen during peristalsis. J Urol 1972;108(2): 234–237. Vahidi B et al. A mathematical simulation of the ureter: effects of the model parameters on ureteral pressure/ flow relations. J Biomech Eng 2011;133(3):031004. Schwalb DM et al. Morphological and physiological changes in the urinary tract associated with ureteral dilation and ureteropyeloscopy: an experimental study. J Urol 1993;149:1576–1585. Lowe AS and James S. Human Histology, vol. 3. Elsevier Mosby, 2005.

14

15 16

17

18 19 20 21

Histology: Text and Atlas, 12e (ed. L Anthony), chapter 19. McGraw‐Hill Medical, 2010. Cohen SJ. Ureterozystoneostomie. Eine neue antirefluxtechnik. Akt Urol 1975;6(18):1–8. Wallis MC et al. A novel technique for ureteral catheterization and/or retrograde ureteroscopy after cross‐trigonal ureteral reimplantation. J Urol 2003;170(4):1664–1666. Gil‐Vernet JM. A new technique for surgical correction of vesico ureteral reflux. J Urol 1984;131:456–458. Politano VA and Leadbetter WF. An operative technique for the correction of vesicoureteral reflux. J Urol 1958;79:932–941. Paquin AJ Jr. Ureterovesical anastomosis: the description and evaluation of a technique. J Urol 1959;82:573–583. Gregoire W. Le traitement chirugical du reflux vesico‐ ureteral congenital. Acta Chir Belg 1964;63:431–439. Lich RJ, Howerton L., Davis LA. Recurrent urosepsis in children. J Urol 1961;86:554–558. Glenn JF and Anderson EE. Distal tunnel ureteral reimplantation. J Urol 1967;97(4):623–626. O’Donnell B and Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. BMJ Clin Res 1984;289(6436):7–9.

625

626

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

22 Schwalb DM and Eshghi M. Techniques to negotiate 23

24 25

26

27

28

29 30

31

32

33

34

35

36

37

38

the tortuous ureter. J Urol 1994;151(4):939–942. Liguori G. Comparative experimental evaluation of guidewire use in urology. Urology 2008;72(2):286–289. Eshghi M. Endoscopic incisions of the urinary tract. Part II. AUA Update Series 1989;8: lesson 38 Cheng EY. Endoscopic incision of ureteroceles. In: Hinman’s Atlas of Urologic Surgery (ed. J Smith), 345–346. Elsevier, 2012. Schwalb DM et al. Morphological and physiological changes in the urinary tract associated with ureteral dilation and ureteropyeloscopy: an experimental study. J Urol 1993;149(6):1576–1585. Brooks JD et al. Comparison of open and endourologic approaches to the obstructed ureteropelvic junction. Urology 1995;46(6):791–795. Gelet A et al. Endopyelotomy with the Acucise cutting balloon device. Early clinical experience. Eur Urol 1997;31(4):389–393. Kim FJ et al. Complications of acucise endopyelotomy. J Endourol 1998;12(5):433–436. Kim H et al. Use of new technology in endourology and laparoscopy by American urologists: internet and postal survey. Urology 2000;56:5. Nadler RB et al. Acucise endopyelotomy: assessment of long‐term durability. J Urol 1996;156(3):1094–1097; discussion 1097–1098. Preminger GM et al. A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol 1997;157:1625–1629. Faerber GJ et al. Retrograde treatment of ureteropelvic junction obstruction using the ureteral cutting balloon catheter. J Urol 1997;157:454–458. Minardi D et al. Efficacy of tigecycline and rifampin alone and in combination against Enterococcus faecalis biofilm infection in a rat model of ureteral stent. J Surg Res 2012;176(1):1–6. Zelichenko G et al. Prevention of initial biofilm formation on ureteral stents using a sustained releasing varnish containing chlorhexidine. J Endourol 2013;27(3):333–337. Cadieux PA et al. Use of triclosan‐eluting ureteral stents in patients with long‐term stents. J Endourol 2009;23(7):1187–1194. Venkatesh R et al. Impact of a double‐pigtail stent on ureteral peristalsis in the porcine model: initial studies using a novel implantable magnetic sensor. J Endourol 2005;19(2):170–176. Pirker ME et al. Prenatal and postnatal neuromuscular development of the ureterovesical junction. J Urol 2007;177(4):1546–1551.

39 Gimpel C et al. Complications and long‐term outcome

40 41

42

43

44

45

46

47

48

49

50

51

52

53

54 55

of primary obstructive megaureter in childhood. Pediatr Nephrol 2010;25(9):1679–1686. Monfort G et al. Endoscopic treatment of ureteroceles revisited. J Urol 1985;133(6):1031–1033. Shimada K et al. Surgical treatment for ureterocele with special reference to lower urinary tract reconstruction. Int J Urol 2007;14(12):1063–1067. Tyritzis SI and Wiklund NP. Ureteral strictures revisited. Trying to see the light at the end of the tunnel: a comprehensive review. J Endourol 2015;29(2):124–136. Parpala‐Sparman T et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J Urol Nephrol 2008;42(5):422–427. Basic D et al. Iatrogenic ureteral trauma: a 16‐year single tertiary centre experience. Srp Arh Celok Lek 2015;143(3–4):162–168. Tebala GD. The “left ureteral triangle” as an anatomic landmark for the identification of the left ureter in laparoscopic distal colectomies. Surg Laparosc Endosc Percutan Tech 2016;26(5):e100–e102. Karakan T et al. Evaluating ureteral wall injuries with endoscopic grading system and analysis of the predisposing factors. J Endourol 2016;30(4):375–378. Traxer O and Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189(2):580–584. Fam XI et al. Ureteral stricture formation after ureteroscope treatment of impacted calculi: a prospective study. Korean J Urol 2015;56(1):63–67. Kim BK et al. Neovesical‐urethral anastomotic stricture successfully treated by ureteral dilation balloon catheter. Korean J Urol 2010;51(9):660–662. Mano R et al. Retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant kidneys after failed antegrade balloon dilation. Urology 2012;80(2):255–259. Richards KA et al. The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy. Urol Oncol 2015;33(2):65 e1–e8. Devarajan R et al. Holmium: YAG lasertripsy for ureteric calculi: an experience of 300 procedures. Br J Urol 1998;82(3):342–347. Roberts WW et al. Ureteral stricture formation after removal of impacted calculi. J Urol 1998; 159(3):723–726. Vaglio A et al. Retroperitoneal fibrosis. Lancet 2006;367(9506):241–251. Bjorndalen H and Hastings RA. Ureteric obstruction secondary to retroperitoneal fibrosis leading to acute kidney injury. BMJ Case Rep 2013;2013.

53  Endoscopic Management of Distal Ureteral Strictures

56 Nezhat C et al. Silent loss of kidney seconary to ureteral 57

58 59

60

61

62 63

64

65

66

67

68

69

70 71

72

73

endometriosis. JSLS 2012;16(3):451–455. Wagaskar VG et al. urinary tuberculosis with renal failure: challenges in management. J Clin Diagn Res 2016;10(1):PC01–PC03. Khalaf I et al. Urologic complications of genitourinary schistosomiasis. World J Urol 2012;30(1):31–38. Al‐Shukri S, Alwan MH, and Nayef M. [Ureteral strictures caused by bilharziasis]. Z Urol Nephrol 1987;80(11):615–624. Liatsikos EN et al. Ureteral metal stents: 10‐year experience with malignant ureteral obstruction treatment. J Urol 2009;182(6):2613–2617. Elliott SP and Malaeb BS. Long‐term urinary adverse effects of pelvic radiotherapy. World J Urol 2011;29(1):35–41. deVries CR and Freiha FS. Hemorrhagic cystitis: a review. J Urol 1990;143(1):1–9. Tran H et al. Evaluation of risk factors and treatment options in patients with ureteral stricture disease at a single institution. Can Urol Assoc J 2015;9(11–12): E921–E924. Wolf JS Jr et al. Long‐term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997;158(3 Pt 1):759–764. Adorisio O et al. Effectiveness of primary endoscopic incision in treatment of ectopic ureterocele associated with duplex system. Urology 2011;77(1):191–194. Arrabal‐Martin M et al. Endoscopic treatment of ureterovesical junction obstructive pathology: a description of the oblique meatotomy technique and results. Can Urol Assoc J 2013;7(11–12):E728–E731. Kerbl K et al. Effect of stent duration on ureteral healing following endoureterotomy in an animal model. J Urol 1993;150(4):1302–1305. Oppenheimer R and Hinman F. Ureteral regeneration: contraction vs hyperplasia of smooth muscle. J Urol 1955;476–484. Badlani G et al. Percutaneous surgery for ureteropelvic junction obstruction (endopyelotomy): technique and early results. J Urol 1986;135(1):26–28. Kumar R et al. Optimum duration of splinting after endopyelotomy. J Endourol 1999;13(2):89–92. Tong A and Gilet A. Virtual ureteroscopy of upper tract for urothelial tumor. In: Urothelial Malignancies of the Upper Tract (ed. M Eshghi), 55–62. Springer International, 2018. Corcoran AT et al. Management of benign ureteral strictures in the endoscopic era. J Endourol 2009;23(11):1909–1912. Moon YT et al. Evaluation of optimal stent size after endourologic incision of ureteral strictures. J Endourol 1995;9(1):15–22.

74 Radecka E et al. Survival time and period of

75

76

77

78

79

80

81

82

83

84 85

86

87

88

89

catheterization in patients treated with percutaneous nephrostomy for urinary obstruction due to malignancy. Acta Radiol 2006;47(3):328–331. Kachrilas S et al. Current status of minimally invasive endoscopic management of ureteric strictures. Ther Adv Urol 2013;5(6):354–365. Ganatra AM and Loughlin KR. The management of malignant ureteral obstruction treated with ureteral stents. J Urol 2005;174(6):2125–2128. Chitale SV et al. The management of ureteric obstruction secondary to malignant pelvic disease. Clin Radiol 2002;57(12):1118–1121. Kim M et al. Long‐term outcomes of double‐layered polytetrafluoroethylene membrane‐covered self‐ expandable segmental metallic stents (Uventa) in patients with chronic ureteral obstructions: is it really safe? J Endourol 2016;30(12):1339–1346. Rosevear HM et al. Retrograde ureteral stents for extrinsic ureteral obstruction: nine years’ experience at University of Michigan. Urology 2007;70(5):846–850. Chung SY et al. 15‐year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol 2004;172(2):592–595. Richter F et al. Endourologic management of benign ureteral strictures with and without compromised vascular supply. Urology 2000;55(5):652–657. Yossepowitch O et al. Predicting the success of retrograde stenting for managing ureteral obstruction. J Urol 2001;166(5):1746–1749. Ku JH et al. Percutaneous nephrostomy versus indwelling ureteral stents in the management of extrinsic ureteral obstruction in advanced malignancies: are there differences? Urology 2004;64(5):895–899. Wenzler DL et al. Success of ureteral stents for intrinsic ureteral obstruction. J Endourol 2008;22(2):295–299. Tal R et al. Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer. J Urol 2007;178(2):538–542. Slavis SA et al, Wilson RW, Jones RJ, Swift C. Long‐ term results of permanent indwelling wallstents for benign mid‐ureteral strictures. J Endourol 2000;14(7):577–581. Reinberg Y, Ferral H, Gonzalez R, et al. Intraureteral metallic self‐expanding endoprosthesis (Wallstent) in the treatment of difficult ureteral strictures. J Urol 1994;151(6):1619–1622. Clayman RV et al. Experimental extensive balloon dilation of the distal ureter: immediate and long‐term effects. J Endourol 1987;1(1):19–22. Ravery V et al. Balloon catheter dilatation in the treatment of ureteral and ureteroenteric stricture. J Endourol 1998;12(4):335–340.

627

628

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

90 Byun SS, Kim JH, Oh SJ, Kim HH. Simple retrograde

91

92

93 94

95 96

97

98

99

100

101

102

balloon dilation for treatment of ureteral strictures: etiology‐based analysis. Yonsei Med J 2003;44(2):273–278. Chang R et al. Percutaneous management of benign ureteral strictures and fistulas. J Urol 1987;137(6): 1126–1131. Johnson CD et al. Percutaneous balloon dilatation of ureteral strictures. AJR Am J Roentgenol 1987. 148(1):181–184. O’Brien WM et al. Ureteral stricture: experience with 31 cases. J Urol 1988;140(4):737–740. Kramolowsky EV et al. Management of benign ureteral structures: open surgical repair or endoscopic dilation? J Urol 1989;141(2):285–286. Netto NR Jr et al. Endourological management of ureteral strictures. J Urol 1990;144(3):631–634. Hafez KS and Wolf JS Jr. Update on minimally invasive management of ureteral strictures. J Endourol 2003;17(7):453–464. Papadopoulos GI et al. Use of Memokath 051 metallic stent in the management of ureteral strictures: a single‐center experience. Urol Int 2010;84(3):286–291. McIntyre JF et al. Ureteral stricture as a late complication of radiotherapy for stage IB carcinoma of the uterine cervix. Cancer 1995;75(3):836–843. Eshghi M and Schwalb D. Post‐surgical ureteral stenosis. In Current Therapy in Genitourinary Surgery (ed. M Resnick and E Kursh), 216–228. Mosby, 1991. Liatsikos E et al. Ureteral obstruction: is the full metallic double‐pigtail stent the way to go? Eur Urol 2010;57(3):480–486. Selmy G et al. Effect of balloon dilation of ureter on upper tract dynamics and ureteral wall morphology. J Endourol 1993;7(3):211–219. Kwak S et al. Percutaneous balloon catheter dilatation of benign ureteral strictures: effect of multiple dilatation procedures on long‐term patency. AJR Am J Roentgenol 1995;165(1):97–100.

103 Kuntz NJ et al. Balloon dilation of the ureter: a

104

105

106

107

108

109

110

111

112

113

contemporary review of outcomes and complications. J Urol 2015;194(2):413–417. Lopatkin NA et al. An endourologic approach to complete ureteropelvic junction and ureteral strictures. J Endourol 2000;14(9):721–726. Chandhoke PS et al. Endopyelotomy and endoureterotomy with the acucise ureteral cutting balloon device: preliminary experience. J Endourol 1993;7(1):45–51. Cohen TD et al. Long‐term follow‐up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology 1996;47(3):317–323. Singal RK et al. Holmium:YAG laser endoureterotomy for treatment of ureteral stricture. Urology 1997;50(6):875–880. Ibrahim HM et al. Single versus double ureteral stent placement after laser endoureterotomy for the management of benign ureteral strictures: a randomized clinical trial. J Endourol 2015;29(10):1204–1209. Poulakis V et al. Cold‐knife endoureterotomy for nonmalignant ureterointestinal anastomotic strictures. Urology 2003;61(3):512–517; discussion 517. Schneider AW et al. The cold‐knife technique for endourological management of stenoses in the upper urinary tract. J Urol 1991;146(4): 961–965. Gdor Y et al. Holmium:yttrium‐aluminum‐garnet laser endoureterotomy for the treatment of transplant kidney ureteral strictures. Transplantation 2008;85(9):1318–1321. Gnessin E et al. Holmium laser endoureterotomy for benign ureteral stricture: a single center experience. J Urol 2009;182(6):2775–2779. Han PK et al. The short‐term outcome of laser endoureterotomy for ureteric stricture. Med J Malaysia 2013;68(3):222–226.

629

54 Endoscopic Management of Ureteroenteric Strictures Thomas Masterson & Robert Marcovich Department of Urology, University of Miami Miller School of Medicine, Miami, FL, USA

­Introduction Ureteroenteric strictures (UES) represent an uncommon, but potentially devastating and difficult to treat compli­ cation of urinary diversion. UES may occur in 4–8% of cases [1, 2]. Open surgical repair is the gold‐standard therapy, with reported long‐term success rates of up to 80%, but it can be very difficult, with greater morbidity due to scarring and intra‐abdominal adhesion formation [3–6]. The decreased morbidity of primary endoscopic management, as well as the continued refinement of endourologic equipment and techniques, has led to increased interest in this approach despite inferior outcomes compared to open revision. Uniformly, endo­ scopic treatments result in lower blood loss and length of hospital stay, as well as rapid recovery [7]. Initially felt to be suitable only for those unfit for open repair, endourologic management is now typically offered as first‐line treatment. Due to the relatively low incidence of UES, most studies evaluating primary endoscopic therapy are small, which impairs direct comparison of modalities. Often, patients with UES are eliminated from larger studies evaluating the utility of endoscopic techniques for benign stricture disease. Additionally, no randomized studies comparing open and endoscopic management exist. In this chapter we examine the current literature and published techniques pertaining to endoscopic manage­ ment of UES.

­Background Most nonmalignant strictures manifest within 2 years of the initial urinary diversion [8] and multiple factors are believed to contribute to their occurrence. Benign UES

have been reported in all types of urinary diversions and are thought to be associated with ischemic changes in the ureter [9]. Multiple studies have noted an increased stricture rate on the left side, possibly related to the greater degree of ureteral dissection, as well as tunneling and kinking of the ureter through the mesentery [4,  8–11]. Several studies have investigated effects of technical variations at the time of diversion, although some are contradictory or provide results that do not reach significance due to a lack of subjects and statistical power. A running suture at the anastomosis may increase the incidence of strictures [12]. Use of a nonrefluxing anastomosis has been shown to raise the rates of stric­ ture formation in comparison to a refluxing anastomosis [13]. The most studied technical consideration has been comparison of the Wallace (adjoined ureters implanted end to end) and Bricker (individually implanted) ureteral anastomoses, which has generally shown no difference in stricture frequency [10, 14]. The use of ureteral stents at the time of anastomosis is also controversial. Historically believed to assist in healing and alignment, and decrease the risk of urine leak, other studies have associated ure­ teral stenting with a greater likelihood of infection, and possible increased stricture formation [15–17]. Body mass index of >30 kg/m2 and prior pelvic radiation [10] are also thought to influence the risk of developing a stricture.

­Presentation and diagnosis Signs and symptoms of UES can include flank pain, malaise, failure to thrive, pyelonephritis, sepsis, hematu­ ria, and worsening renal function [18, 19]. Some patients may develop strictures slowly and remain asymptomatic with only a rising creatinine level. This heterogeneity in

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

630

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

facilitates antegrade diagnostic studies to assist in stricture localization, characterization, and surgical planning.

­Endourologic techniques

Figure 54.1  Coronal CT scan showing bilateral hydronephrosis in a patient with bilateral uretero‐ileal anastomotic strictures following radical cystectomy.

presentation necessitates routine laboratory and radio­ graphic surveillance and close clinical follow‐up [20]. Initial evaluation generally consists of serum chemistries and radiographic imaging. Renal ultrasound or computed tomography (CT) are most frequently utilized in the screening of hydronephrosis (Figure 54.1). Since reflux can mimic obstruction, it should be ruled out with other anatomic or functional studies. Free reflux of contrast into the ureter on loopography essentially excludes anas­ tomotic stricture. If no reflux is seen on loopogram and renal function is adequate, renal scintigraphy can aid in the diagnosis of obstruction. Antegrade contrast studies such as intravenous urography, CT urography, and ante­ grade nephrostogram can also help diagnose a stricture and characterize its length and location as well as evaluate for filling defects that may herald recurrence of malignancy. Such a recurrence is relatively rare in com­ parison to benign etiologies of stricture, but should be considered if appearing at more than 6 months after initial diversion [21–23]. Urine cytology and biopsy may be indicated before definitive treatment of the stricture.

­Indications for therapy Patients who develop symptomatic strictures gener­ ally require early relief of obstruction. Asymptomatic patients also benefit from decompression, as poorer treatment outcomes have been observed with an ipsi­ lateral renal function of less than 25% [24]. Indications for urgent intervention include intractable flank pain, obstructive pyelonephritis, rising creatinine, and impending sepsis. Due to the inherent difficulty of ­retrograde approaches in patients with urinary diver­ sions, percutaneous nephrostomy is most often utilized to relieve obstruction. Placing a nephrostomy tube also

Treatment of UES has largely developed from techniques used for ureteral stricture disease. Approaches can be retrograde, antegrade, or a combination of both. Because initial management of UES involves decompression of the collecting system with a percutaneous nephrostomy, this, in combination with the technical challenges of identifying the ureteral anastomosis in a conduit or neobladder, make an antegrade approach preferred. Since the key manipulations required to treat UES occur in the distal ureter, it is important to have a percutaneous access which will allow easy passage of instruments to this area. Therefore, upper pole or upper interpolar renal access is preferable to lower pole access. If the patient has a lower pole nephrostomy tube that was previously placed simply to drain the kidney, strong consideration should be given to relocating the access to the upper or mid collecting system. If the patient does not have a nephrostomy tube at the time of definitive management, access is usually obtained with ultrasound guidance and confirmed with fluoroscopy. A urine culture should be obtained and any bacteriuria treated prior to definitive endoscopic treatment of a UES. Video 54.1 demonstrates endoscopic treatment of UES in detail. After induction of general anesthesia, patients with ileal conduits are placed in flank position to provide easy access to the nephrostomy as well as the urostomy, and both the flank and abdomen are sterilely prepared and draped. For left‐sided strictures, which are most common, the patient is placed in the right lateral decubitus position and for right‐sided strictures the patient is positioned in left lateral decubitus. Standard cushioning done for flank approaches, including an axillary role, is utilized. Patients with neobladders are positioned prone with a urethral catheter in place. The technique used for a patient with a neobladder is similar to that used for a benign ureteral stricture treated with an antegrade approach, so the following description will be limited to the method used for patients with ileal conduits. The procedure begins with antegrade injection of con­ trast through the nephrostomy to demonstrate the stric­ ture (Figure 54.2) and the renal and ureteral anatomy, as well as to assess for any filling defects in the kidney and ureter. A 0.038 or 0.035 inch hydrophilic tip guidewire is passed through the nephrostomy tube into the collecting system and manipulated through the ureteropelvic junc­ tion and down the ureter. Various 4 or 5 Fr angle‐tipped

54  Endoscopic Management of Ureteroenteric Strictures

Figure 54.2  Antegrade nephrostogram showing left ureter tapering to a stricture, with no contrast seen beyond the stricture.

Figure 54.4  Digital flexible ureteroscope view of uretero‐ileal stricture with guidewire passing through the stricture. The area is too narrow to advance the ureteroscope close enough to perform laser endoureterotomy.

Balloon dilation

Figure 54.3  Radiographic view of flexible ureteroscope examining left uretero‐ileal anastomotic stricture. Guidewire is through the stricture into an ileal conduit.

catheters (Kumpe™, Cobra™) can assist in these manipu­ lations. After incising the fascia along the wire with a scalpel, an 8/10 Fr coaxial dilator/safety wire introducer is passed over the working wire. A safety wire can then be placed down the ureter. Next, a 13 or 14 Fr short ureteral access sheath is advanced over the working wire. Further dilation or placement of a larger sheath is typi­ cally unnecessary. The renal collecting system and ureter can then be examined with a flexible fiber‐optic or digital ureteroscope (Figures  54.3 and 54.4). Any suspicious lesions should be biopsied at this point. If the ipsilateral ureter happens to be very dilated, the tract can be upsized to a larger access sheath using an Amplatz dilat­ ing system, and an 18 Fr sheath can be placed in order to use a flexible cystoscope for subsequent manipulations. However, this is not typically necessary. After establishing working access, any of the various treatment modalities reviewed herein can be employed. At the conclusion of treatment a ureteral stent is posi­ tioned to maintain patency during healing.

The use of balloon dilation in urology was first described in the nineteenth century for the treatment of urethral strictures [25]. It was not until the 1980s that dilation was used in the treatment of ureteral strictures [26]. Since then, the use of ureteral balloon dilation has become commonplace in endourology. Balloon dilation may be used as primary endoscopic treatment, or in combination with other modalities. An advantage of balloon dilation when used as monotherapy is that it can be accomplished under local anesthesia and can be done by an interventional radiologist. The renal tract does not need to be dilated nor a working sheath placed. Once wire access is established, the dilation balloon is posi­ tioned under fluoroscopic guidance across the strictured area. The balloon is then slowly inflated with diluted radiographic contrast media until it assumes the typical hourglass shape caused by the stricture. Inflation contin­ ues until the hourglass shape gives way and the balloon is completely inflated (Figure 54.5). The dilation is then held for approximately 3–5 minutes before deflation. This cycle may be repeated as necessary until the entire stricture is treated. Figure  54.6 shows the endoscopic appearance of a UES immediately after balloon dilation. Endoureterotomy Endoureterotomy, or incision of the ureter, was intro­ duced due to the disappointing long‐term success of

631

632

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

peri‐ureteral fat. This is confirmed by visualization of peri‐ureteral fat or extravasation of contrast on fluoros­ copy [27]. For dense strictures, endoscopic injection of 3–5 ml of 40 mg/ml triamcinolone into the incised stricture has been advocated to improve outcome [24, 28]. Cold‐knife endoureterotomy

Figure 54.5  Radiographic view of an inflated balloon catheter dilating a stricture.

Cold‐knife treatment typically requires a semirigid ureteral resectoscope for retrograde incision of the stricture. Because of the larger diameter and lack of flex­ ibility, the extent of narrowing that can be treated under direct vision is limited. An alternative method has been described in which a flexible wire‐mounted cold knife is passed antegrade through a nephrostomy and then withdrawn to perform an endoureterotomy [29]. This may be performed under fluoroscopic guidance or visually in conjunction with a ureteroscope. Regardless, several incisions may be required. Cauterization of urothelial or mucosal bleeding is not necessary and should be avoided because of the risk of thermal damage [30]. Ureteral stents are typically utilized as the ureter heals. Electrocautery endoureterotomy

Figure 54.6  Endoscopic view of a stricture after balloon dilation. The passage to the ileal conduit can be seen in the upper left quadrant.

balloon dilation. Endoureterotomy may be performed using a variety of instruments, including cold knife, elec­ trocautery, or laser. Additionally, the Acucise™ cutting balloon catheter combines electrocautery with balloon dilation of the ureter. The primary goal of each modality is to create a full‐thickness incision that extends approxi­ mately 1 cm beyond each end of the stricture and into

Electrocautery is typically performed under direct visu­ alization through a semirigid or flexible ureteroscope. Safety wires should be insulated to avoid application of electrical current outside the target treatment area. A 2 or 3 Fr Greenwald electrode is advanced through the ure­ teroscope and incision is made on pure cutting current at a power of 75 W. Multiple controlled incisions into the fibrotic tissue may be made under direct visual control. It is challenging, but imperative, to maintain precise, linear, incision tracking with a flexible ureteroscope to avoid surrounding thermal damage. Lovaco and associ­ ates reported a method in which a guidewire is passed antegrade and a dilation balloon is passed retrograde, inflated at the stricture, and pulled down to intussuscept the stricture into the bowel segment. The stricture is thus well exposed and can be incised precisely from below [19]. This method seems to provide a theoretical advantage of decreased injury to retroperitoneal blood vessels and bowel, but no subsequent publications of this technique have been forthcoming. Acucise balloon catheter endoureterotomy

The Acucise™ cutting balloon catheter (Applied Medical, Rancho Santa Margarita, CA, USA), comprising a mono­ polar electrocautery cutting wire and a 24 Fr 3 cm bal­ loon can be used to treat strictures throughout the ureter [31]. After identification of the stricture, the device is deployed over a guidewire and positioned so the radio­ paque markers straddle the stricture. Special attention must be given to the location of the cutting wire after visual inspection to avoid any peri‐ureteral vessels.

54  Endoscopic Management of Ureteroenteric Strictures

Treatment begins with inflation of the balloon with 2 ml of dilute contrast media along with simultaneous activa­ tion of the cutting wire at 75  for a maximum of 5 seconds. Similar to pure balloon dilation, Acucise balloon inflation may be maintained for 3–5 minutes. The manufacturer suggests no more than two treatments be undertaken at one time. Presence of a safety wire during electrocautery activation is not recommended because of potential conduction injury. Laser endoureterotomy

Laser endoureterotomy for UES may be performed with a variety of lasers, but the holmium:YAG laser is preferred because of its favorable safety characteristics with a depth of tissue penetration of only 0.4 mm [27]. Incision is performed visually through a flexible uret­ eroscope with a 200 µm fiber set at 1 J and 10 Hz (10 W) (Figures 54.7 and 54.8). Direct visual inspection prior to incision is necessary to avoid any pulsations represent­ ing peri‐ureteral vessels and, afterwards can confirm the presence of fat. Again, care must be taken to make precise cuts to avoid thermal damage to a wide area of the ureteral circumference, which can be quite challeng­ ing with a flexible ureteroscope. After incision, contrast injection into the ureter should reveal extravasation (Figure 54.9).

Figure 54.8  View of incised stricture after first pass with the laser. Laser is positioned to start the second pass to deepen the incision.

Figure 54.9  Radiographic view of contrast media injection through ureteroscope resulting in extravasation, indicating full‐ thickness endoureterotomy.

­Post‐treatment ureteral stenting

Figure 54.7  A 200 µm holmium laser fiber poised to perform endoureterotomy. The laser is positioned just inside the conduit and drawn back through the stricture into the ureter (see Video 54.1).

Regardless of the primary method used to treat UES, ureteral stenting is commonly employed to allow heal­ ing, limit extravasation of urine, and maintain patency. Ideal duration of stenting in the postoperative period is undefined, and four to six weeks may be reasonable. There is some evidence to suggest that prolonged stenting may be detrimental and lead to tissue over­ growth and fibrosis [27]. There is also disagreement as to the optimal stent diameter. Some recommend larger stents or even double stents, while others that argue an excessively large stent may induce ischemia and scarring [24, 32, 33].

633

634

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Ureteral stents may be deployed either forward or retrograde in a through‐and‐thorough fashion over a guidewire with fluoroscopic assistance. Synthetic double‐J stents are most commonly used. For patients with ileal conduits, a nephroureterostomy tube can be positioned in reverse fashion, with the distal pigtail in the renal pelvis and the proximal port in the urostomy bag [34]. For patients with severe comorbidities or those who do not want to attempt a definitive procedure, chronic ureteral stenting may be acceptable, despite the risk of encrustation, infection, and the need for frequent exchanges (every 3–6 months). This method is often successful in relieving obstruction but does not treat the underlying stricture. To alleviate some of the problems with polymer stents, the use of metal stents has been investigated. Metal stents offer the benefits of resistance to compression and increased exchange interval [35]. Metal stents have been used previously in the setting of malignant obstruction with some success, but their use in benign stricture disease is controversial [36]. Their use in UES is even more limited. Many studies evaluate their use in the con­ text of general ureteral obstructions, both benign and malignant, and report on only a handful of UES as a subgroup. A variety of metal stents have been used: self expandable, balloon expandable, thermo‐expandable shape memory, covered, and double pigtail stents [37]. Each type has its own manufacturer‐provided deployment device and instructions. Many require dilation of the stricture before insertion. Details regarding the frequency of exchanges is device‐specific. The following metal stents have been used primarily in ureteral strictures of both benign and extrinsic malignant obstructions, but have also been reported in UES in small numbers. There are few direct comparisons of these products in treatment of ureteral obstruction, and fewer in the setting of UES. Resonance (Cook Medical, Bloomington, IN, USA) is made of a magnetic resonance imaging (MRI)‐compatible nickel‐cobalt‐chromium‐molybdenum alloy without a  lumen and is similar in shape to a double‐J stent. It  is  deployed through an 8 Fr sheath introducer. The Memokath 051 (Endotherapeutics, Epping, NSW, Australia) is a thermo‐expandable shape memory stent made of nitinol and has a lumen. The stent is deployed over a guidewire with the provided sheath. The stent is then expanded in situ with the injection of normal saline at 65 °C [38]. The Allium URS stent (Allium Medical, Caesarea Industrial Park South, Israel) is a nickel‐titanium alloy mesh invested with a biocompatible polymer to prevent tissue ingrowth and encrustation. It is availa­ ble in two sizes, 30 and 24 Fr, and can be retrieved ­endoscopically. It is deployed over a guidewire in con­ junction with the provided 10 Fr sheath [39]. The Uventa

(TaeWoong Medical, Gyeonggi‐do, South Korea) incor­ porates a triple‐layer design consisting of a layer of PTFE between two nitinol layers in an expandable mesh capable of treating the entire length of the ureter. It is placed over a guidewire with a preloaded delivery system. The stent comes in 7, 8, and 10 Fr diameters.

­Novel techniques Recently, there have been descriptions of novel endo­ scopic treatments of UES. These are typically technologies borrowed from other fields which have been adapted for experimental use in the ureter. Little or no comparative data exist, and publications have very limited follow‐up. In 2010, Boylu and associates reported use of a peripheral cutting balloon microsurgical dilator initially designed for use in coronary angioplasty. The balloon features four longitudinal microsurgical blades on a 2 cm‐long balloon that dilates to 8 mm. In their study of only three patients with 12 month follow‐up, improve­ ment in hydronephrosis and serum creatinine were observed [40]. In 2007 Orsi and colleagues treated four UES with the Polar‐Cath balloon dilator (Boston Scientific, Marlborough, MA, USA), requiring only one re‐intervention during 12 months of follow‐up [41].

­Surgical outcomes The definition of success varies in the literature, but typi­ cally involves radiographic improvement in – or resolu­ tion of – obstruction, as well as absence of pain, infection, or stent, with recovery of normal activity. Balloon dilation Balloon dilation is the oldest and most thoroughly evalu­ ated endourologic treatment modality. Ten contemporary studies were reviewed comprising a total of 232 primary procedures. Success rates varied from 0 to 67% with a mean of approximately 22% [6, 18, 42–50] (Table 54.1). Follow‐up ranged from 9 to 29 months. Larger contem­ porary series with mean follow‐up of greater than 24 months demonstrate similar levels of success and reduced patency rates at longer‐term follow‐up [42]. There was great variability pertaining to balloon size, inflation pressure, time of inflation, and number of cycles needed to perform successful dilation. There was no standardization in the size of stent used postoperatively nor in the duration of stenting. When reported, stricture length was the parameter most predictive of treatment success or failure, with longer strictures having worse outcomes [6, 42, 43, 47].

54  Endoscopic Management of Ureteroenteric Strictures

Table 54.1  Results following balloon dilation of ureteroenteric strictures.

Number of procedures

Mean follow‐up (months)

Success rate (%)

Stricture location

Stricture length

Stricture diameter

Balloon size

Duration/cycles/ pressure

Stent size (Fr)

Stent duration (weeks)

Schöndorf et al. 2013 [42]

84

29

25

NS

>1 cm predicted failure

ND

DS

DS

DS

4–6

Nassar and Alsafa 2011 [43]

16

47

50

NS

>1 cm predicted failure

ND

DS

DS

7

4–6

Milhoua et al. 2009 [18]

4

16

0

NS

NS

NS

DS

DS

6–16

1.5–9

Tal et al. 2007 [44]

6

26

0

ND

ND

ND

DS

DS

DS

DS

DiMarco et al. 2001 [6]

52

24

15

NS

>1 cm predicted failure

NS

8–10

DS

DS

3–6

Kwak et al. 1995 [45]

18

9

28

ND

ND

ND

8

45 s/3/15 atm

10

4

Aliabadi et al. 1990 [46]

3

12

67

ND

ND

ND

6–8

10 m/DS/DS

10

6

Beckman et al. 1989 [47]

5

22

60

ND

>2 cm less successful

ND

4–8

DS

7–10

4–8

Shapiro et al. 1988 [48]

37

12

16

NS

ND

NS

4–10

1–2 min/ DS/17 atm

8–24

1–6

O’Brien et al. 1988 [49]

7

12

14

ND

ND

ND

4–6

DS/DS/6–17 atm

DS

DS

Study

NS, predictor discussed but not significant; ND, predictor not discussed; DS, details not specified.

Endoureterotomy Due to the poor outcome and long‐term durability of balloon dilation, endoureterotomy has become the ini­ tial endoscopic treatment of choice [18]. Regardless of the energy source used, incision of the ureter, with or without concomitant balloon dilation, appears to be more effective than balloon dilation alone. In the 15 studies included in this review (Table 54.2), 215 indi­ vidual procedures were captured. Success rates were reported between 33 and 100% (mean of 60%) with a follow‐up ranging between 10 and 60 months [3, 7, 18, 19, 24, 28, 29, 42, 43, 50–58]. Studies of cold‐knife inci­ sion were the least common, and the lack of new publi­ cations over the past several years indicates this technique has largely been abandoned. Wire‐mounted cold‐knife incision achieved a patency rate of 60.5% with 3 year follow‐up in the largest and most recent study of this technique in 2003 [29]. Electrosurgical and holmium laser endoureterotomy are more commonly cited in the literature and have similar success rates (70 and 64%, respectively), although the former group had longer follow‐up [3, 7, 18, 19, 28, 42, 56–58]. These techniques are advantageous because

they allow direct visual inspection and incision of the ureter. Additionally, these modalities utilize instruments commonly used in other urologic procedures. Acucise incision has demonstrated superiority to balloon dilation with a mean success rate of 35%, which is lower than the methods which use direct visualization [18, 24, 42, 52–55]. Head‐to‐head comparison of each modality is difficult. Even in the study by Schondorf and associates [42], in which patients underwent balloon dilation, Acucise, or holmium laser endoureterotomy, patients were not randomized and the choice of modality used was not explained. Despite this, as well as different patient numbers in each group, Acucise and holmium laser incision had similar success rates of 33%. Electro­ incision and cold‐knife incision were not evaluated in this study. As with balloon dilation, all procedures were con­ cluded with stent placement, but no consensus on stent size (6–22 F) or duration (1.5–28 weeks) was noted. Six weeks was the most commonly cited duration of stenting [7, 19, 50, 52–54, 56]. When assessed, stricture length less than 1 cm and ipsilateral renal function greater than 25% were the strongest predictors of success. As would

635

Table 54.2 Results of endoureterotomy techniques for ureteroenteric strictures.

Study

Number of procedures

Mean follow‐up (months)

Success rate (%)

Stricture location

Stricture length

Stricture diameter

Balloon size

Duration/ cycles/pressure

Stent size (Fr)

Stent duration (weeks)

Cold knife Nassar and Alsafa 2011 [43]

21

47

52

NS

>1 cm less success

ND

DS

DS

7

4–6

Poulakis et al. 2003 [29]

43

38.8

60.5

NS

>1.5 cm predicted failure

ND

NA

NA

8–12

Bierkens et al. 1996 [50]

2

12

100

ND

ND

ND

NA

NA

12

6

Schneider et al. 1991 [51]

2

15

100

ND

ND

ND

NA

NA

14

3–6

Lovaco et al. 2005 [19]

25

51

80

NS

Greater length, likely failure

ND

DS

DS

6–7

Meretyk et al. 1991 [28]

14

28.6

57

ND

ND

ND

6–12

DS

8–27

3–28

7

13.5

71

ND

ND

ND

10–12

DS

7–18

>2

Schondorf et al. 2013 [42]

9

29

33

NS

>1 cm predicted failure

ND

DS

DS

DS

4–6

Milhoua et al. 2009 [18]

2

23.2

50

NS

NS

NS

DS

DS

6–16

1.5–9

Touitiet al. 2002 [52]

6

16

50

ND

ND

ND

NA

NA

8–12

6

10

24

30

NS

NS

NS

NA

NA

10

6 6

6–12

Electrocautery

Kramolowsky et al. 1988 [3]

6

Electro‐incision (Acucise)

Lin et al. 1999 [53] Kabalin et al. 1997 [54]

4

22

10

ND

ND

ND

NA

NA

10

Wolf et al. 1997 [24]

9

>36

39

left more likely to fail

NS

NS

NA

NA

7–16

Preminger et al. 1997 [55]

9

DS

33

ND

ND

ND

NA

NA

6–7

33

NS

>1 cm predicted failure

ND

DS

DS

DS

4–6 1.5–6

variable 3–11

Holmium laser Schondorf et al. 2013 [42] Milhoua et al. 2009 [18]

3

29

15

23.2

33

NS

NS

NS

DS

DS

6–16

3

60.5

100

NA

NA

NA

NA

NA

12

6

Watterson et al. 2002 [7]

24

22.5

71

Left tended to fail

>1 cm tended to fail

NS

6

DS

6–12

6

Laven et al. 2001 [57]

19

20.5

57

Left tended to fail

ND

ND

NA

NA

7–14

4–6

Singal et al. 1997 [58]

9

10.8

89

ND

ND

ND

6–8

DS

6–12

4–6

Hibi et al. 2007 [56]

NS, predictor discussed but not significant; ND, predictor not discussed; DS, details not specified.

54  Endoscopic Management of Ureteroenteric Strictures

Table 54.3  Results of stenting for ureteroenteric strictures.

Study

Number of strictures

Type of stent

Time to exchange

Mean follow‐up (months)

Success Secondary rate (%) procedure (%)

Worsening renal failure (%)

Stent migration (%)

UTI (%)

Synthetic Tal et al. 2007 [44]

20

17 10.2 Fr NU/ 3 double‐J

q3m

26

45

41

15

5

0

56

8 mm Wallstent

DS

39.2

41.1

22.4

DS

1.8

DS

Liatsikos et al. 2010 [62]

6

6 Fr Resonance

DS

6.8

50

50

0

0

0

Liatsikos et al. 2007 [63]

24

6–8 mm self‐expanding

NA

21

>50

62.5

0

0

0

Rapp et al. 2004 [64]

6

8 mm Wallstent

NA

10

100

0

0

0

0

Wakui et al. 2000 [65]

1

6 mm Palmaz stent

NA

11

100

0

0

0

0

10

8–10 mm Wallstent

NA

22.4

100

10

0

0

0

Daskalopoulos et al. 2001 [67]

3

6–10 mm Wallstent

NA

9

100

0

0

0

0

Barbalias et al. 1998 [68]

6

8 mm self‐expanding

NA

12

100

25

0

0

0

Pollak et al. 1995 [69]

6

10 mm Wallstent NA

6

0

0

0

25.6

Reinberg et al. 1994 [70]

2

8 mm Wallstent

NA

12.5

100

0

0

0

0

Sanders et al. 1993 [71]

2

Palmaz stent

NA

7

100

0

0

0

0

Metal Campschroer et al. 2014 [61]

Palascak et al. 2001 [66]

16.7

NS, predictor discussed but not significant; ND, predictor not discussed; DS, details not specified; NU, nephroureterostomy; UTI, urinary tract infection.

be expected, some investigators demonstrated lower success rates for left‐sided strictures. Chronic stenting as long‐term management Chronic stenting (Table  54.3) is most often utilized for patients who are too ill for definitive intervention, have a limited life expectancy, or wish to be less aggressive with treatment. Despite the use of chronic stenting in other ureteral obstructive processes, little data is available for its use in management of UES. Only one study reported long‐term data for chronic stenting [44]. Success was only 45% at 26 months and periodic exchanges were nec­ essary. Although stent exchange in patients with ileal conduits is not typically complicated, sometimes the altered anatomy can make exchanges difficult [59, 60]. Interest in metal stents is growing and several small studies have evaluated their use. Because of heterogene­ ity in metal stent designs, assessing them as a single group may not be appropriate. As described previously,

there are a variety of metal stents (self‐expandable, balloon expandable, thermo‐expandable shape memory, covered, and double pigtail stents) for UES. The most studied are the Wallstent self‐expandable stent (Boston Scientific), the Palmaz balloon‐expandable stent (Palmaz Scientific, San Antonio, TX, USA) and the Resonance stent (Cook Medical). The Wallstent and other self‐ expandable stents are the best reported with 108 proce­ dures. Overall success was 62% (range of 16.7–100%) [61–70]. However, most studies are small and have lim­ ited follow‐up (6–39 months). In the single largest and most contemporary study of 56 procedures, success was 41.1% with mean follow‐up of 39.2 months [61]. Balloon expandable stents such as the Palmaz stent have similarly reported success rates of 100%; however, this is in only three reported procedures with mean follow‐up of 10.3 months [63, 65, 68, 71]. Resonance double‐J metal stents were also reported; however, success was only 50% at a mean of 6.8 months [62]. Newer thermo‐expandable shape memory stents like the Memokath 105 are being

637

638

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

used, but both short‐ and long‐term data are lacking [72, 73]. Clearly, more research with larger cohorts and longer follow‐up is needed.

­Complications Complications of endourologic management of UES include pyelonephritis, sepsis, and bleeding. In the most contemporary series of 96 interventions, there were a total of nine infectious complications [42]. Overall, bal­ loon dilation had the fewest side effects and complica­ tions. Endoureterotomy is known to have increased risks compared to balloon dilation. The most serious compli­ cations involve vascular injury. In the series of 30 endoureterotomies of Wolf and colleagues, there was one reported laceration of the common iliac [24]. More recent series using direct visualization techniques do not report any serious bleeding complications [7, 19, 42]. Overall, it appears that as the techniques become more refined, the likelihood of complications decreases. Complications related to stenting are primarily infec­ tion, encrustation, and obstruction [44]. Even use of metal stents has risks. Because of the heterogeneity of devices, it is again hard to group them as a whole. The resonance stent, most notably, was found to have a migration rate of 90% in one study [74], however most investigators have not encountered such a high incidence [62]. As many of the studies involving metal stents included strictures other than UES, complications specifically pertaining to UES are hard to ascertain. Based on the literature, there does appear to be a risk of tissue ingrowth [75]. Tables 54.1– 54.3 summarize outcomes pertaining to complications of endoscopic management of UES.

­Postoperative follow‐up Due to the high failure rate of endourologic treatment methods, close monitoring is imperative. While there are no standard guidelines on surveillance schedules, follow‐ up should include serum chemistries to monitor electro­ lytes and renal function, and routine imaging to assess for hydronephrosis or stability of renal morphology [18, 19, 29, 57]. Because UES are rare and can present in a heterogeneous fashion, and because multiple endoscopic

treatment modalities exist, surveillance needs to be tai­ lored to individual patients. Many UES patients will have a history of urothelial carcinoma and will be monitored routinely for recurrence of malignancy with computed tomography, which can also serve to monitor for return of UES. A reasonable follow‐up protocol for UES may include serum chemistries as well as periodic imaging with ultrasound at intervals beginning at 3 months and increasing at the clinician’s discretion. Any suggestion of recurrent obstruction, such as flank or abdominal pain, pyelonephritis, rising serum creatinine, or worsening hydronephrosis on imaging, should prompt a renewed investigation into the cause, using the same methods as described for initial evaluation.

­Conclusion UES are a relatively uncommon but difficult to manage complication of urinary diversion. At this time, there are few if any definitive technical considerations at time of anastomosis to eliminate the risk of strictures. Initial management remains a dilemma, and advances in endo­ scopic technology have led to a variety of approaches. Despite inferior long‐term success compared to open repair, endoscopic treatment remains a reasonable first‐ line approach in appropriately selected patients, and does not seem to greatly complicate matters should later open surgical revision become necessary. Balloon dila­ tion is the safest and most easily accomplished proce­ dure, but has disappointing durability. Endoureterotomy, with or without concomitant dilation, seems to have become the minimally invasive treatment of choice regardless of incision method, but has a slightly increased risk of complications. Generally, success is more likely in patients with right‐sided strictures and satisfactory ipsi­ lateral renal function. Stricture length less than 1 cm also appears to be a significant factor predicting success. Long‐term stenting still remains a viable option for those willing to undergo periodic exchanges, and refinement of metal stent technology may lead to additional therapeu­ tic choices. Since UES are relatively rare and tend to be treated at tertiary referral centers, an international col­ laborative registry gathering data on large numbers of patients may be the only rigorous way to evaluate these methods and advance techniques and outcomes.

­References 1 Grurek BM, Lieber MM, and Blute ML. Comparison of

Studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. J Urol 1998;160:721–723.

2 Sullivan JW, Grabstald H, and Whitmore WF Jr.

Complications of ureteroileal conduit with radical cystectomy: review of 336 cases. J Urol 1980;124:797–801.

54  Endoscopic Management of Ureteroenteric Strictures

3 Kramolowsky EV, Clayman RV, and Weyman PJ.

4

5

6

7

8

9

10

11

12

13

14

15

16

Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair. J Urol 1988;139:1195–1198. Vandenbroucke F, Van Poppel H, Vandeursen H et al. Surgical versus endoscopic treatment of non‐malignant uretero‐ileal anastomotic strictures. Br J Urol 1993;71:408–412. Laven BA, O’Connor RC, Gerber GS et al. Long‐term results of endoureterotomy and open surgical revision for the management of ureteroenteric strictures after urinary diversion. J Urol 2003;170:1226–1230. DiMarco DS, LeRoy AJ, Thieling S et al. Long‐term results of treatment for ureteroenteric strictures. Urology 2001;58:909–913. Watterson JD, Sofer M, Wollin TA et al. Holmium:YAG laser endoureterotomy for ureterointestinal strictures. J Urol 2002;167:1692–1695. Shah SH, Movassaghi K, Skinner D et al. Ureteroenteric strictures after open radical cystectomy and urinary diversion: The University of Southern California Experience. Urology 2015;86:87–91. Kurzer E and Leveillee RJ. Endoscopic management of ureterointestinal strictures after radical cystectomy. J Endourol 2005;19:677–682. Kouba E, Sands M, Lentz A et al. A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer. J Urol 2007;178:945–949. Farnham SB and Cookson MS. Surgical complications of urinary diversion. World J Urol 2004;22:157–167. Large MC, Cohn JA, Kiriluk KJ et al. The impact of running versus interrupted anastomosis on ureterointestinal stricture rate after radical cystectomy. J Urol 2013;190:923–927. Pantuck AJ, Han KR, Perrotti M et al. Ureteroenteric anastomosis in continent urinary diversion: long‐term results and complications of direct versus nonrefluxing techniques. J Urol 2000;163:450–455. Davis NF, Burke JP, McDermott T et al. Bricker versus Wallace anastomosis: A meta‐analysis of ureteroenteric stricture rates after ileal conduit urinary diversion. Can Urol Assoc J 2015;9(5–6):E284–E290. Varkarakis IM, Delis A, Papatsoris A, and Deliveliotis C. Use of external ureteral catheters and internal double J stents in a modified ileal neobladder for continent diversion: a comparative analysis. Urol Int 2005;75:139–143. Mattei A, Birkhaeuser FD, Baermann C et al. To stent of not to stent perioperatively the ureteroileal anastomosis of ileal orthotopic bladder substitutes and ileal conduits? Results of a prospective randomized trial. J Urol 2008;179:582–586.

17 Mullins JK, Guzzo TJ, Ball MW et al. Ureteral stents

18

19

20

21

22

23

24

25

26

27

28

29

30

31

placed at the time of urinary diversion decreases postoperative morbidity. Urol Int 2012;88:66–70. Milhoua PM, Miller NL, Cookson MS et al. Primary endoscopic management versus open revision of ureteroenteric anastomotic strictures after urinary diversion – single institution contemporary series. J Endourol 2009;23:551–555. Lovaco F, Serrano A, Fernandez I et al. Endoureterotomy by intraluminal invagination for nonmalignant ureterointestinal anastomotic strictures: description of a new surgical technique and long‐term followup. J Urol 2005;174:1851–1856. McDougal WS. Use of intestinal segments and urinary diversion. In: Campbell’s Urology, vol 4, 8e (ed. PC Walsh, AB Retik, ED Vaughan Jr, and AJ Wein), 3745–3788. Philadelphia: W.B. Saunders, 2002. Schumacher MC, Scholz M, Weise ES et al. Is there an indication for frozen section examination of the ureteral margins during cystectomy for transitional cell carcinoma of the bladder? J Urol 2006;176:2409–2413. Schoenberg MP, Carter HB, and Epstein JI. Ureteral frozen section analysis during cystectomy: a reassessment. J Urol 1996;155:1218–1220. Raj GV, Tal R, Vickers A et al. Significance of intraoperative ureteral evaluation at radical cystectomy for urothelial cancer. Cancer 2006;107:2167–2172. Wolf JS Jr, Elashry OM, and Clayman RV. Long‐term results of endoureterotomy for benign ureteral and ureteroenteric strictures. J Urol 1997;158:759–764. Marino RA, Mooppan UM, and Kim H. History of urethral catheters and their balloons: drainage, anchorage, dilation, and hemostasis. J Endourol 1993;7:89–92. Martin EC, Fankuchen EI, and Casarella WJ. Percutaneous dilatation of ureteroenteric strictures or occlusions in ileal conduits. Urol Radiol 1982;4:19–21. Hafez KS and Wolf JS. Update on minimally invasive management of ureteral strictures. J Endourol 2003;17:453–464. Meretyk S, Clayman RV, Kavoussi LR et al. Endourological treatment of ureteroenteric anastomotic strictures: long‐term followup. J Urol 1991;145:723–727. Poulakis V, Witzsch U, De Vries R et al. Cold‐knife endoureterotomy for nonmalignant ureterointestinal anastomotic strictures. Urology 2003;61:512–517. Eshghi M and Lifson B. Cold knife endoureterotomy. In: Controversies in Endourology (ed. AD Smith), 302–309. Philadelphia: WB Saunders, 1995. Babayan RK. Use of the Acucise balloon catheter. In: Controversies in Endourology (ed. AD Smith), 309–313. Philadelphia: WB Saunders, 1995.

639

640

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

32 Ibrahim HM, Mohyelden K, Abdel‐Bary A, and

33

34

35

36

37

38

39

40

41

42

43

44

45

46

Al‐Kandari AM. Single versus double ureteral stent placement after laser endoureterotomy for the management of benign ureteral strictures: a randomized clinical trial. J Endourol 2015;29:1204–1209. Siegel JF and Smith AD. The ideal ureteral stent for antegrade and retrograde endopyelotomy: what would it be like? J Endourol 1993;7:151–154. Tal R, Bachar GN, Baniel J et al. External‐internal nephro‐uretero‐ileal stents in patients with an ileal conduit: long‐term results. Urology 2004;63:438–441. Pauer W and Lugmayr H. [Self‐expanding permanent endoluminal stents in the ureter. 5 years results and critical evaluation]. Urologe A 1996;35:485–489. Liatsikos EN, Kagadis GC, Barbalias GA et al. Ureteral metal stents: a tale or a tool? J Endourol 2005;19:934–939. Al Aown A, Iason K, Panagiotis K, and Liatsikos EN. Clinical experience with ureteral metal stents. Indian J Urol 2010;26:474–479. Kulkarni RP and Bellamy EA. A new thermo‐ expandable shape‐memory nickel‐titanium alloy stent for the management of ureteric strictures. BJU Int 1999;83:755–759. Moskovitz B, Halachmi S, and Nativ O. A new self‐ expanding, large‐caliber ureteral stent: results of a multicenter experience. J Endourol 2012;26: 1523–1527. Boylu U, Oommen M, Raynor M et al. Ureteroenteric anastomotic stricture: novel use of a cutting balloon dilator. J Endourol 2010;24:1175–1178. Orsi F, Penco S, Matei V et al. Treatment of ureterointestinal anastomotic strictures by diathermal or cryoplastic dilatation. Cardiovasc Intervent Radiol 2007;30:943–949. Schöndorf D, Meierhans‐Ruf S, Kiss B et al. Ureteroileal strictures after urinary diversion with an ileal segment‐ is there a place for endourological treatment at all? J Urol 2013;190:585–590. Nassar O and Alsafa M. Experience with ureteroenteric strictures after radical cystectomy and diversion: open surgical revision. Urology 2011;78:459–465. Tal R, Sivan B, Kedar D et al. Management of benign ureteral strictures following radical cystectomy and urinary diversion for bladder cancer. J Urol 2007;178:538–542. Kwak S, Leef JA, and Rosenblum JD. Percutaneous balloon catheter dilatation of benign ureteral strictures: effect of multiple dilatation procedures on long‐term patency. AJR Am J Roentgenol 1995;165:97–100. Aliabadi H, Reinberg Y, and Gonzalez R. Percutaneous balloon dilation of ureteral strictures after failed surgical repair in children. J Urol 1990;144:486–488.

47 Beckmann CF, Roth RA, and Bihrle W 3rd. Dilation of

benign ureteral strictures. Radiology 1989;172:437–441.

48 Shapiro MJ, Banner MP, Amendola MA et al. Balloon

49

50

51

52

53

54 55

56

57

58

59

60

61

catheter dilation of ureteroenteric strictures: long‐term results. Radiology 1988;168:385–387. O’Brien WM, Maxted WC, and Pahira JJ. Ureteral stricture: experience with 31 cases. J Urol 1988;140:737–740. Bierkens AF, Oosterhof GO, Meuleman EJ et al. Anterograde percutaneous treatment of ureterointestinal strictures following urinary diversion. Eur Urol 1996;30:363–368. Schneider AW, Conrad S, Busch R et al. The cold‐knife technique for endourological management of stenoses in the upper urinary tract. J Urol 1991;146:961–965. Touiti D, Gelet A, Deligne E et al. Treatment of uretero‐intestinal and ureterovesical strictures by Acucise balloon catheter. Eur Urol 2002;42:49–54. Lin DW, Bush WH, and Mayo ME. Endourological treatment of ureteroenteric strictures: efficacy of Acucise endoureterotomy. J Urol 1999;162:696–968. Kabalin JN. Acucise incision of ureteroenteric strictures after urinary diversion. J Endourol 1997;11:37–40. Preminger GM, Clayman RV, Nakada SY et al. A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol 1997;157:1625–1629. Hibi H, Ohori T, Taki T et al. Long‐term results of endoureterotomy using a holmium laser. Int J Urol 2007;14:872–874. Laven BA, O’Connor RC, Steinberg GD et al. Long‐ term results of antegrade endoureterotomy using the holmium laser in patients with ureterointestinal strictures. Urology 2001;58:924–929. Singal RK, Denstedt JD, Razvi HA et al. Holmium:YAG laser endoureterotomy for treatment of ureteral stricture. Urology 1997;50:875–880. Schulte‐Baukloh H, Sturzebecher B, Stolze T et al. A simple and comfortable technique for replacing ureteric stents in patients with strictured uretero‐ intestinal anastomosis or strictures at the vesico‐ ureteric junction. BJU Int 2005;95:1361–1363. Zhang Z, Zhang C, Wu C et al. Progressive ureteral dilations and retrograde placement of single‐J stent guided by flexible cystoscope for management of ureteroenteral anastomotic stricture in patients after radical cystectomy and Bricker urinary diversion. J Endourol 2015;29:90–94. Campschroer T, Lock MT, Lo RT, and Bosch JL. The Wallstent: long‐term follow‐up of metal stent placement for the treatment of benign ureteroileal anastomotic strictures after Bricker urinary diversion. BJU Int 2014;114:910–915.

54  Endoscopic Management of Ureteroenteric Strictures

62 Liatsikos E, Kallidonis P, Kyriazis I et al. Ureteral

63

64

65

66

67

68

obstruction: is the full metallic double‐pigtail stent the way to go? Eur Urol 2010;57:480–486. Liatsikos EN, Kagadis GC, Karnabatidis D et al. Application of self‐expandable metal stents for ureteroileal anastomotic strictures: long‐term results. J Urol 2007;178:169–173. Rapp DE, Laven BA, Steinberg GD et al. Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. J Endourol 2004;18:677–681. Wakui M, Takeuchi S, Isioka J et al. Metallic stents for malignant and benign ureteric obstruction. BJU Intl 2000;85:227–232. Palascak P, Bouchareb M, Zachoval R et al. Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long‐term follow‐up. J Endourol 2001;15:575–580. Daskalopoulos G, Hatzidakis A, Triantafyllou T et al. Intraureteral metallic endoprosthesis in the treatment of ureteral strictures. Eur J Radiol 2001;39:194–200. Barbalias GA, Liatsikos EN, Karnabatidis D et al. Ureteroileal anastomotic strictures: an innovative approach with metallic stents. J Urol 1998;160:1270–1273.

69 Pollak JS, Rosenblatt MM, Egglin TK et al. Treatment

70

71

72

73

74

75

of ureteral obstructions with the Wallstent endoprosthesis: preliminary results. J Vasc Inter Radiol 1995;6:417–425. Reinberg Y, Ferral H, Gonzalez R et al. Intraureteral metallic self‐expanding endoprosthesis (Wallstent) in the treatment of difficult ureteral strictures. J Urol 1994;151:1619–1622. Sanders R, Bissada NK, and Bielsky S. Ureteroenteric anastomotic strictures: treatment with Palmaz permanent indwelling stents. J Urol 1993;150:469–470. Kabir MN, Bach C, Kachrilas S et al. Use of a long‐term metal stent in complex uretero‐ileal anastomotic stricture. Arab J Urol 2011;9:251–3. Efthimiou IP, Porfyris OT, and Kalomoiris PI. Minimal invasive treatment of benign anastomotic uretero‐ileal stricture in Hautmann neobladder with thermoexpandable ureteral metal stent. Indian J Urol 2015;31:139–141. Garg T, Guralnick ML, Langenstroer P et al. Resonance metallic ureteral stents do not successfully treat ureteroenteric strictures. J Endourol 2009;23:1199–1202. Rapp DE, Orvieto MA, Lyon MB et al. Case report: urothelial hyperplasia causing recurrent obstruction after ureteral metal stent placement in treatment of ureteroenteric anastomotic stricture. J Endourol 2006;20:910–912.

641

642

55 Ureterorenoscopy: Ureteral Stents and Postoperative Care Ben H. Chew, Anthony Emmott, Dirk Lange, & Ryan F. Paterson Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada

Ureteroscopy is commonly used to treat urolithiasis and has become a standard endoscopic technique replacing open stone surgery of the past. This chapter will discuss analgesia and other medications utilized in the postoperative period. The use of ureteral stents and new and future technologies will also be discussed. Finally, the use of postoperative imaging following ureteroscopy will be examined.

­ reteroscopy: outpatient versus U inpatient management The overwhelming majority of patients undergoing flexible or semirigid ureteroscopy and intracorporeal lithotripsy are treated on an outpatient basis. Common indications for unplanned admission postprocedure include flank or bladder pain not manageable with oral analgesics, fever, urinary retention, or significant hematuria. In addition, management of the uncommon procedural complications of ureteral perforation or avulsion account for a small percentage of admissions. In common with other planned outpatient procedures, late procedure start times and social circumstances precluding early discharge may result in overnight admission [1]. Box 55.1 lists techniques to increase the likelihood of maintaining ureteroscopy as an outpatient procedure. Emergency admission for renal colic with subsequent emergent ureteroscopy can increase the likelihood of ongoing hospital stay postprocedure [1].

­Prescriptions Following any surgery, physicians typically prescribe medications for the postoperative period consisting of an antibiotic and/or analgesic. Following ureteroscopy, there

are many types of analgesics that can be prescribed and there is very little evidence for antibiotics in the postoperative period. In addition, there are two other types of medication that can be prescribed to patients with urolithiasis. In the case of uric acid stones, patients may be prescribed a urinary alkalinizing agent to dissolve any remaining fragments. The second are alpha‐antagonists which have been utilized to facilitate passage of fragments by relaxing ureteral smooth muscle [2, 3] and to help alleviate postoperative ureteral stent symptoms [4–7]. Antibiotics Patients are often prescribed antibiotics following s­urgical cases to prevent infection. The decision on whether to prescribe antibiotics should balance the risk of infection with the risk of adverse effects of antibiotics and the induction of antibiotic‐resistant bacterial strains. In cases where the risk of infection is high, the risk of complications such as Clostridium difficile colitis and inducing bacterial resistance is justified. In cases where there is a low risk of infection, then the utility of postoperative antibiotic prophylaxis becomes less clear. There is good evidence to give antibiotics at the time of surgery. A randomized trial of 113 patients were administered either levofloxacin 250  mg by mouth 60 minutes prior to ureteroscopy or no antibiotics [8]. The rate of bacteriuria in the control group was 12.5% compared to 1.8% in those receiving levofloxacin. They did not examine the use of antibiotics in the postoperative period. The current American Urological Association guidelines (2016) recommend preoperative antibiotic prophylaxis in all patients undergoing ureteroscopy administered within 60 minutes of the start of surgery. It can be a single oral or intravenous dose of antibiotic that covers

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

55  Ureteral Stents and Postoperative Care

Box 55.1  Technique to increase likelihood of outpatient ureteroscopy. 1)  Thorough discussion with patient and family preoperatively regarding postureteroscopy clinical course and expectations 2)  Operative start time during morning or early afternoon 3)  Prompt surgical intervention in patients presenting emergently with renal colic 4)  Dose of nonsteroidal anti‐inflammatory drug such as Ketorolac at completion of procedure 5)  Bladder drainage at completion of procedure 6)  Avoidance of routine ureteral stenting for uncomplicated ureteroscopy 7)  Appropriate stent length and diameter 8)  Consideration of anticholinergic medications for stent‐related bladder spasms 9)  Consideration of alpha‐blocker medication for stent discomfort

both Gram‐positive and Gram‐negative uropathogens. Local antibiograms should be consulted for selecting an appropriate antibiotic to prevent antimicrobial resistance and ensure the best patient outcomes. There is no good evidence in the literature for using antibiotic prophylaxis in the postoperative period. Analgesics Analgesics for renal colic and passage of fragments

The options for treating postoperative pain range from the commonly used analgesics which target pain at the central nervous system to medications that target specific receptors in the urothelium. The literature is lacking in suggestions for analgesics specifically after ureteroscopy, but the passage of fragments after intracorporeal lithotripsy can be accompanied with pain very similar to that found in renal colic. Alpha‐antagonists for stone expulsion

Alpha‐antagonists inhibit smooth muscle contraction and have been used extensively in the treatment of benign prostatic hyperplasia. In the endourological world, they have found two further purposes: as medical therapy to facilitate stone expulsion and to relieve ureteral stent symptoms. The theory underlying these observations is relaxation of ureteral smooth muscle to allow ureteral stones to pass and, in the case of stents, to prevent ureteral spasm. This is done by inhibiting selective alpha1‐adrenergic receptors and reducing ureteral contractility [9, 10]. Medical expulsive therapy has been found to increase the stone passage rate as well as hasten the time to stone

passage and reduce pain, narcotic requirement, and hospitalizations for renal colic [11, 12]. A Cochrane systematic review of 32 studies (5864 participants) found significantly higher stone‐free rates in the alpha‐blocker group compared to standard therapy (risk ratio 1.48, 95% confidence interval [CI] 1.33–1.64). Reductions were found in stone‐expulsion time, number of pain episodes, need for analgesic medication, and hospitalization with alpha‐blockers. However, patients experienced more adverse effects with alpha‐blocker therapy than standard therapy or placebo [13]. Another meta‐analysis evaluating 693 pooled patients found a greater likelihood of stone passage than those given placebo when given an alpha‐blocker or calcium channel blocker with steroids [3]. The number needed to treat in this analysis was only four, indicating that this is a worthwhile and effective treatment for ureteral stones. Some studies have produced an even higher rate of stone expulsion in patients administered tamsulosin [14]. A more recent large, multicenter clinical trial randomized 1167 patients with a single ureteral stone 10 mm or less to tamsulosin, a calcium channel blocker (nifedipine), or placebo [15]. The primary end point was need for intervention by 4 weeks after randomization. Participants, clinicians, and trial personnel were blinded to treatment assignment. There was no difference in stone passage rates between tamsulosin, nifedipine, or placebo groups, as 80–81% of patients did not need further intervention in all three groups. No differences were found between the trial groups for visual analogue pain scores at 4 weeks, number of days of analgesic use, or time to stone passage. Criticisms of this study include the fact that the need for surgery was used as a surrogate end point rather than radiologic testing. Additionally, since more than 75% of the stones were 5 mm or less, one could argue that these stones were likely going to spontaneously pass anyway and that the alpha‐blockers were unable to show a difference. Analgesics for stent‐related pain

Phenazopyridine and oxybutynin have been administered orally in an attempt to relieve stent‐related symptoms. A  randomized trial involving 60 patients randomized to phenazopyridine, oxybutynin, or placebo was performed and the following measures were recorded: narcotic use, flank pain, suprapubic pain, urinary frequency, urgency, dysuria, and hematuria [16]. There was a trend, although statistically insignificant due to the small group numbers, for a reduction in narcotic usage in the oxybutynin group. Phenazopyridine significantly reduced the amount of hematuria patients had on postoperative day 1 compared to placebo. Perhaps a larger study would discern if either of these medications would be helpful in relieving stent symptoms. A meta‐analysis of 1408 patients showed

643

644

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

reduction in stent‐related symptoms, as measured by  the International Prostate Symptom Score, visual ­analogue pain scale, and quality of life instruments, for alpha‐­blockers (alfuzosin or tamsulosin) alone and antimuscarinics (tolterodine or solifenacin) alone compared to control. The combination of alpha‐blockers and antimuscarinics provided even greater reduction in stent‐related symptoms [17]. Alpha‐blockers and stent‐related pain

Patients randomized to alfuzosin following ureteroscopy and stent insertion had significantly less narcotic use, less overall pain in the back and groin area, less flank pain during urination, and less urinary frequency compared to patients given placebo [18]. Tamsulosin also produced similar significant results in other placebo‐ controlled prospective trials of patients undergoing ­ureteral stent placement following ureteroscopy [4, 7, 19]. In a network meta‐analysis, tamsulosin and alfuzosin were shown to have significant reduction in the urinary symptom scores and body pain scores of the Ureteric Stent Symptoms Questionnaire when compared to placebo. However, no significant difference was found between tamsulosin and alfuzosin with respect to these measures [20]. It would appear that alpha‐blockers administered postureteral stent insertion is an excellent way to prevent and relieve symptoms.

­ o stent or not to stent? That is T the question The decision must be made at the end of each ureteroscopy on whether or not a ureteral stent should be placed. The absolute indications to leave a ureteral stent are listed in Box 55.2 [21]. The evidence on whether to stent Box 55.2  Indications for ureteral stenting postureteroscopy [21]. 1)  Ureteral perforation intraoperatively 2)  Ureteral dilation greater than 10 Fr (either coaxial or balloon dilator) 3)  Significant ureteral edema due to stone (e.g. impacted stone) 4)  Failure to advance the ureteroscope due to a narrow ureter or ureteral orifice and in preparation for a subsequent ureteroscopy after 7 days 5)  Infected urinary system with an obstructing system 6)  Large stone burden with many fragments remaining to pass 7)  Solitary kidney

a patient following ureteroscopy is controversial. There is good evidence from randomized clinical trials suggesting that patients without ureteral stents experience fewer symptoms than those who receive a ureteral stent [1, 22–25]. In unstented patients postureteroscopy, few patients require surgical intervention for ureteral obstruction with the majority managed by improved pain control. In addition, the vast majority of patients treated on a “stent‐less” basis have no obvious preprocedure predictor of subsequent flank pain or obstruction. Although the avoidance of a postprocedure ureteral stricture is commonly encountered in the literature as a justification for ureteral stenting, the meta‐analysis of randomized controlled trials by Nabi et al. indicates no difference in stricture rate between those stented and nonstented [26]. Supporting the role of postprocedure ureteral stenting is the study by Borboroglu et  al. in which the authors reported a risk for admission for flank pain post­ureteroscopy of 7.4% in the unstented group versus a 0% re‐admission rate in the stented group [27]. However, the overall cohort of unstented patients had substantially less flank pain. While some studies have shown fewer symptoms and less pain in those patients without a stent, a meta­analysis found a trend towards fewer urologic complications in patients who received a stent following ureteroscopy [28]. Some of the trials included in this analysis did not find a difference in complication rates between stented and unstented patients, but there was an overall 4.5% reduction in rate of complications in those patients who underwent placement of a stent following ureteroscopy (P = 0.001, 95% CI 1.8–7.3%). When a more stringent random effects model was applied, however, this difference was  not statistically significant (4.1% risk difference, 95% CI 1.8%–10.1%, P = 0.175). At present in the literature, there is no significant difference in outcomes between patients who receive a ureteral stent compared to those who do not receive a ureteral stent f­ollowing ureteroscopy. When a ureteral access sheath is used during ureteroscopy, there is good evidence to place a stent afterwards. A retrospective comparison of 51 patients stented and 51 patients not stented after flexible ureteroscopy with a ureteral access sheath found that stented patients had significantly lower postoperative pain scores and were less likely to seek medical attention for pain compared to unstented patients [29]. In another retrospective review, the rate of return to the  emergency department of nonstented patients after ureteroscopy was significantly higher in those who had a ureteral access sheath (37%) compared to those treated without a ureteral access sheath (14%) (P = 0.04) [30].

55  Ureteral Stents and Postoperative Care

­Which stent is most comfortable? Once a decision to place a stent is made, the question becomes which stent to use. There are no conclusive data as to which commercially available stent is the most comfortable for patients. There are a variety of factors that are taken into consideration including the softness (durometer) of the stent, its design, and its size both in length and diameter. Intuitively, one would think that softer stents would be more comfortable than harder stents; however, randomized trials have shown no difference between soft and hard stents in terms of urinary symptoms, pain, time away from work, or sexual dysfunction utilizing the Ureteral Stent Symptom Questionnaire (USSQ) [31], the only validated tool for evaluating ureteral stent symptoms [32, 33]. In one trial, patients randomized to a “stiffer” stent that was greater than 64A durometer in stiffness (Percuflex® stent; Boston Scientific, Natick, MA, USA) were compared to patients who received a softer stent of less than 64A (Contour™ stent, Boston Scientific) [32]. No differences between groups were seen at 1 and 4 weeks in terms of urinary symptoms, overall body pain, work performance, or general health index. Lennon et al. randomized patients to firm polyurethane stents or a softer Sof‐Flex™ stent [33]. Patients with firmer stents had a higher rate of dysuria, and renal and suprapubic pain; however, there was no significant difference in the degree of bladder inflammation, stent encrustation, urgency, frequency, nocturia, or hematuria. The only shortcoming of this study is that patients were not evaluated with a validated stent symptom questionnaire, the USSQ. More recently, Lingeman et al. and the Comfort Study Team utilized the USSQ to assess whether patient comfort was best in a short loop tail stent, a long loop tail stent, or a Percuflex Plus stent (Boston Scientific) or Polaris stent (Boston Scientific) [34]. All kidney curls were identically composed of a 6 Fr pigtail curl and the Percuflex Plus stent consists of the same material and coil in the bladder end. The distal ends differed in the other three stents: the short loop tail stent (5 cm long, 3 Fr diameter) and long loop tail stent (8 cm long, 3 Fr diameter) consisted of two loops and the Polaris stent was a dual durometer stent with a stiffer renal curl to prevent migration but a softer curl in the bladder in an attempt to decrease bladder irritation and symptoms. The 236 patients were randomized to receiving one of the stents following uncomplicated ureteroscopy and were administered the USSQ at baseline, 4 days after stent placement, and 5 days after stent removal. There were no statistically significant differences in pain scores between any of the stent groups. There was decreased use of narcotics in the first 1–3 days after stent placement in the short loop tail stents, but this was insignificant at

4 days. Most notably, the USSQ may not have been administered at the correct time as all patients had the most severe discomfort symptoms on postoperative day 1. By day 4, all symptoms had subsided when the USSQ was administered, thus there may have been a significant difference if it was measured at day 1. It also goes to support the theory that stent symptoms occur from irritation of the trigone of the bladder. Having softer material that also has less mass in the bladder may help alleviate ­ureteral stent‐related symptoms.

­Stent length relating to discomfort Even though there are no clear data to support the use of one type of stent over another, there are good data that longer stents that protrude into the bladder produce more symptoms. Choosing the correct length of stent will significantly reduce patient stent symptoms. Stents that cross the midline of the bladder result in significantly more dysuria, urgency, and irritative voiding symptoms and more impaired quality of life than stents that do not cross the midline [35, 36]. Giannarini et  al. found significant association between the distal stent loop crossing the midline of the bladder and the urinary symptoms, body pain, general health, work performance, and sexual matters domains of the USSQ [37]. Long stents are associated with excess material in the bladder – and, therefore, presumably with more bladder irritation – but do not result in excess stent length in the kidney [35]. Fluoroscopic studies of stented patients show that, with motion, the stent tends to bow in the mid and proximal ureter and the excess length slides in and out of the bladder at the ureterovesical junction, with relatively little motion seen in the kidney [38]. Flank pain was not affected by stent length, but there is good evidence that negative bladder symptoms are increased in patients with longer stents compared with those who are stented with the correct length stent. However, more recent studies have not been able to consistently support the association between excess stent length and urinary symptoms. In one study, patients completed the USSQ before stent removal and were categorized by X‐ray into three groups with contralateral, tangential, or ipsilateral stent position. While the ipsilateral stent group showed lower USSQ scores, these differences were not statistically significant between groups for the USSQ total score (P = 0.35) and subgroup scores [39]. A multicenter randomized trial between multilength 6 Fr × 22–30 cm Contour VL and 6 Fr × 24 cm Contour ureteric stents also found no significant difference in the same USSQ subgroup scores, adding ambiguity to the question of whether excess stent material in the bladder adds to stent‐related symptoms [40].

645

646

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

How is the correct stent length chosen? This question has baffled many a urologist and numerous methods have been described including measuring patient height, torso length, intravenous urography, and direct ureteral measurement. One study found that direct intraoperative measurement of ureteral length was better than patient height at correlating with the correct stent length [41]. Another study evaluated several anthropometric factors, including patient height, body mass index, and distances from the acromion process (shoulder) to the head of the ulna (wrist), olecranon process (elbow) to the head of the ulna, xiphoid process to pubis, umbilicus to pubis, and anterior iliac spine to anterior iliac spine [42]. They measured ureteral length intraoperatively with a 5 Fr ureteral catheter and found that height, xiphoid process to pubis distance, and the shoulder to wrist distance all correlated with ureteric length. Ho et al. recommend a 22 cm stent for patients 149.5–178.5 cm in height, but did not study patients outside this height range [36]. To date, there is no standard accepted method of determining the most appropriate length of ureteral stent.

­Stent coatings In an effort to reduce bacterial infection related to indwelling material, antimicrobial peptides have been proposed to reduce bacterial adhesion and biofilm formation, thus preventing infection. Antimicrobial peptides have been shown to substantially improve the infection resistance of biomaterial surfaces using polymer brushes to increase the density of the antimicrobial peptides [43]. Antimicrobial activity was observed for both Gram‐positive and Gram‐negative organisms. Antimicrobial peptides may be used in the future to reduce systemic antibiotic administration for ureteral stent‐related infections and thus prevent the induction of antibiotic resistance.

­Biodegradable ureteral stents Ureteral stents typically require a secondary procedure for removal if a suture tether is not used. This can add cost, inconvenience, and patient discomfort. In addition, if a patient is lost to follow‐up and if there is any miscommunication about the patient having a stent, a “forgotten” stent may result, potentially requiring several surgeries for removal or even loss of the renal unit [44– 46]. There have been case reports of mortality stemming from forgotten ureteral stents [47]. Attempts to reduce retained stents have included a stent registry [48, 49]. A stent without a suture tether that does not require

cystoscopic removal has also been developed using a high‐powered magnet catheter that is inserted into the bladder to bind a steel bead attached to the distal end of the stent for removal [50]. This low‐cost alternative to cystoscopy offers a safe “blind” removal of the ureteral stent in any type of setting under local anesthetic. Perhaps the holy grail of preventing a retained stent is one that would degrade over time. The ideal biodegradable stent must function to provide drainage like a plastic stent, be easy to deploy, be radiopaque, and maintain its integrity for at least a certain amount of time in order for ureteral edema etc. to subside, but not overstay its welcome and take too long to degrade. Furthermore, it should be comfortable, biocompatible to surrounding tissues, and degrade in a fashion that does not obstruct the distal ureter. Lingeman et  al. performed a phase I clinical trial to evaluate the Temporary Ureteral Drainage Stent (TUDS, Boston Scientific) in 18 patients [51]. All stent material weeks with only one stent was extruded within 4  prematurely migrating into the bladder at day 1. A phase II trial of the TUDS stent evaluated 88 patients following ureteroscopy and the stents were eliminated from the ureter at a median time of 8  days and eliminated completely from the body at a median of 15 days [52]. By 30  days, 84% (74/88) of the stents had completely degraded. Unfortunately, three patients retained stent fragments at 3 months and required surgical intervention for removal. For the majority of patients (78.2%), the stent was effective at providing upper tract drainage for at least 48 hours postoperatively: the targeted time to define success. Due to the manufacturer’s concerns about retained fragments, the TUDS stent is no longer commercially available. A more recent degradable stent composed of l‐lactide, glycolide, and copolyester components similar to those found in absorbable sutures has been developed and tested in a porcine model (Uriprene™, Poly‐Med, Greenville, SC, USA) [53]. It has been developed to degrade within 2–3 weeks with 90% of stents being completely eliminated from the body by week 4 in a porcine model [54], with one pig retaining three small fragments less than 1.5  cm in the bladder. The biodegradable stent was biocompatible on histology, with fewer abnormal histological findings, and resulted in significantly less hydronephrosis in comparison to the control biostable stents. Drainage was equivalent to control stents as seen by excretory urogram. The safety of this stent has been tested and proven in animal model of ureteral stenting. Human trials will determine its true degradation time and if there is any improvement in comfort. Hopefully, the development of biodegradable stents will aid in reducing stent symptoms and infection, and avoiding the forgotten stent syndrome.

55  Ureteral Stents and Postoperative Care

­ ostoperative imaging following P ureteroscopy Routine imaging postoperatively remains controversial despite over a decade of studies reported in the era of small‐diameter semirigid and flexible ureteroscopes. Multiple authors, in the setting of either a randomized controlled trial of stented versus unstented ureteroscopy, or as a retrospective case series, have demonstrated a low risk of postureteroscopy obstruction [22, 55–69] (Table 55.1). Given the high stone‐free rate for ureteroscopy of upper tract calculi, the major indication for postprocedure

imaging is the detection of a ureteral stricture, with a risk in uncomplicated cases of less than 5%. Predisposing factors for ureteral stricture postureteroscopy include preoperative factors such as chronic stone impaction, reduced renal function, coexistent ureteral stricture on the treated side, and complete ureteral obstruction [65, 70, 71]. In addition, intraoperative factors such as significant ureteral edema, ureteral trauma, or ureteral perforation are established risk factors for ureteral stricture and mandate close long‐term radiologic follow‐up [70, 71]. Indeed, the retrospective case series of Roberts et al. [71] reported a 24% incidence of ureteral stricture in patients with chronic ureteral stone impaction greater

Table 55.1  Ureteroscopy: follow‐up imaging.

Stone location

Study

N

Gokce et al. 2016 [66]

116, pediatric

Ureteroscopy Imaging type modality

Mean duration follow‐up

Postoperative Postoperative Postoperative surgical hydronephrosis stricture interventions

At least 3 weeks

27.6%

0%

–

Renal and R&F ureter

US or NCCT

Renal and R&F ureter

US or CT 6–7 weeks

15%

0.6%

–

0.6%

–

Barbour et al. 2015 [68]

324

El‐Abd et al. 2014 [67]

1980

Ureter

R&F

KUB, US, 42 months CT‐IVU

–

Schatloff et al. 2010 [56]

60

Ureter

R

US or CT 1 month

–

Manger et al. 2009 [64]

289

Renal and R&F ureter

US

1 month

9.3%

0.3%

2.8%

Renal

US

1 month

–

0%

–

NCCT

16 months

10.7%

5.3%

–

10 months

5.6%

0%

Breda et al. 2009 [69] Adiyat et al. 2009 [65]

51 Complicated ureteroscopy (n = 158)

F

Renal and R&F ureter

Uncomplicated ureteroscopy (n = 56)

1.7%

Elashry et al. 2008 [61]

4512

Distal ureter

R

US, IVP

7.6 months

–

0.2%

–

Ibrahim et al. 2008 [22]

220

Distal ureter

R

US, CT

25 months

–

1.4%

–

Karadag et al. 2008 [62]

268

Ureter

R

IVP, US

27.4 months 1.1%

0.7%

–

Renal and F ureter

NCCT

1 month

–

1.7%

–

Geavlete et al. 2436 2006 [60]

Ureter

–

56 months

–

0.1%

–

Weizer et al. 2002 [57]

241

Renal and R&F ureter

IVP, CT, or US

5.4 months

12.3%

1.2%

–

Sofer et al. 2002 [58]

330

Renal and R&F ureter

IVP, US

>1.5 months –

2.4%

–

Portis et al. 2006 [59]

58

R

Numbers of patients, where reported, consists of patients with upper tract urolithiasis undergoing ureteroscopic intervention. R, semirigid ureteroscope; F, flexible ureteroscope; US, ultrasound; CT, computed tomography; IVP, intravenous pyelography; IVU, intravenous urogram; KUB, kidney–ureter–bladder; NCCT, noncontrast computerized tomography.

647

648

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

than 2 months. However, previous iatrogenic ureteral perforation from previous stone manipulation was encountered in the majority of stricture cases. Regardless, the more contemporary series of Beiko et al. [70] reported that all four cases of ureteral stricture postureteroscopy occurred in patients with risk factors. Adiyat et  al. [65] retrospectively compared the incidence of ureteral stricture between a high‐risk group of complicated ureteroscopy cases (n = 56) compared to a cohort of uncomplicated ureteroscopy patients undergoing routine stone surveillance imaging (n = 158) (Table  55.1). In common with other authors, complicated ureteroscopy, consisting of cases with encountered impacted stone, need for ureteral balloon dilation, or ureteral perforation, demonstrated a substantial risk of ureteral stricture of 5.3%. In contrast, long‐term radiologic surveillance in the uncomplicated ureteroscopy group (mean follow‐up of 10.2 months) revealed no ureteral strictures. This evidence further supports selective imaging in patients with known risk factors for postoperative ureteral stricture development. The predisposition of a ureteral stricture from ureteral balloon dilation remains controversial with some authors suggesting this a risk factor [65, 70] while others do not [1, 68]. In one study, the rate of stricture in patients who underwent ureteral balloon dilation was 1 in 107 patients reviewed (0.9%) [72]. Multiple authors advocating limited radiologic evaluation in the early postureteroscopy period have based this recommendation on the presence or absence of pain as an indication for imaging [62]. The majority of studies assessing the etiology of pain after ureteroscopy demonstrate a substantially greater likelihood of a retained stone fragment rather than a stricture being responsible [65, 73]. Barbour and Raman [68] studied 324 patients following ureteroscopy and found a 48‐fold greater risk of abnormal imaging postureteroscopy for patients with symptomatic presentation. They also found that of those with symptomatic presentation and hydronephrosis on subsequent imaging, 43% were due to ureteral obstructing residual fragments and thus recommend directly proceeding to stone protocol CT for symptomatic patients. Other factors that were found to increase risk of abnormal imaging included larger stone size (5 mm increments, odds ratio 5.1, P = 0.008), longer operation duration (30 minute increments, odds ratio 1.01, P = 0.001), and prior ipsilateral ureteroscopy, and thus a CT or renal ultrasound was recommended for this population. Bugg et al. [73], as advocates of limited postureteroscopy imaging, reviewed the chance of postoperative obstruction when pre‐operative obstruction and postoperative pain are combined. The authors reported that patients with preoperative obstruction and postoperative pain had a 67% chance of having residual

fragments and a 50% chance of residual obstruction. In contrast, 96% of patients without preoperative obstruction and no postoperative pain had no persistent obstruction or residual fragments. However, the risk of missing silent obstruction remains as 25% of asymptomatic patients had residual stone fragments or obstruction. The correlation of pain with postureteroscopy ureteral obstruction has been questioned by Weizer et  al. [57], who caution urologists regarding the risk of silent hydronephrosis. In this retrospective case series, the absence of pain was noted in seven patients who presented postoperatively with silent hydronephrosis out of a total 241 patients. This translates into a 3% risk of renal functional impairment in patients undergoing ureteroscopy if relying on only symptoms to prompt imaging. Similarly, Manger et al. [64], in a retrospective case series of 289 patients with available postureteroscopy sonography, reported that 27 (9.3%) had sonographic evidence of hydronephrosis (14 asymptomatic). From this series, the risk of silent obstruction is significant (4.8%), with the number needed to diagnose of 18 asymptomatic patients postureteroscopy to diagnose one case of hydronephrosis. Further, the negative predictive value and positive predictive value of ipsilateral flank pain for hydronephrosis were 94 and 35%, respectively. In conflict with this large percentage of patients with postureteroscopy hydronephrosis (providing evidence for routine postureteroscopy imaging) is the small number of patients in this series with asymptomatic hydronephrosis who eventually required surgical intervention. Sutherland et al. [74] compared the economic costs of routine imaging after ureteroscopy with selective imaging in only symptomatic patients after ureteroscopy. They considered the costs of complications following ureteroscopy, including postoperative pain, stricture, and silent obstruction with subsequent renal loss due to silent obstruction causing chronic kidney disease, endstage renal disease, and cardiovascular disease. Taking these complications into account and assuming a rate of silent obstruction of 1.9%, the authors found the cost of ureteroscopy with routine postoperative imaging to be US$5326 per patient whereas with selective imaging it was $5196 per patient. Despite a modest $130 cost savings per patient under a selective imaging model, Sutherland et  al. recommended routine postureteroscopy imaging to offset the patient risk of loss of kidney function due to silent obstruction. The majority of studies assessing imaging postureteroscopy have relied on intravenous pyelography or CT scans to rule out obstruction. In contrast, Manger et al. [64] demonstrate the value of renal ultrasound postureteroscopy as a screening study. Given the increasing recommendations to limit medical radiation exposure in our urology patients [75, 76], combined with ready availability

55  Ureteral Stents and Postoperative Care

of sonography, the authors recommend renal ultrasound as the imaging study of choice postureteroscopy in asymptomatic patients to rule out obstruction.

require re‐intervention (P = 0.01). The authors suggest pre‐emptive treatment of residual fragments greater than 4 mm to prevent complications based on these findings.

­ esidual fragments after R ureteroscopy

­Summary

The management of residual stone fragments after urologic stone procedures is controversial. These stone fragments have the potential to grow, cause obstruction or infection, and contribute to recurring stone episodes. A retrospective study from six centers in North America of 232 patients with residual stone fragments found a 44% rate of stone‐related complications, with 15% not requiring intervention and 29% requiring intervention [77]. Stone fragments greater than 4 mm were more likely to grow (p 15 mm and proximal stones [4]; anatomic features also contributing to operative difficulty include patient body habitus, intrinsic or extrinsic ureteral narrowing, stone impaction, ureteral edema or lesions (iatrogenic or pathologic),

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

654

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Table 56.1  Clavien‐Dindo and Modified Sativa classification systems for surgical complications. Clavien‐Dindo

Satava, Modified

Grade I: any deviation from normal postoperative course

Grade 1: incidents without consequences for the patient

Grade II: requiring pharmacologic therapy with drugs other than those allowed in Grade I

Grade 2a: managed intraoperatively with endoscopic maneuvers

Grade III: requiring surgical, endoscopic, or radiological intervention: a)  without general anesthesia b)  requiring general anesthesia

Grade 3: managed with open surgery or laparoscopy

Grade 2b: managed with retreatment (additional surgery) endoscopically

Grade IV: life‐threatening complication requiring intensive/ critical care management: a)  single organ failure b)  multiple organ failure Grade V: death Suffix “d” may be added for disability, indicating follow‐up is needed after discharge to fully evaluate the complication

or genitourinary anatomy. Specific genitourinary anatomy that contributes to difficulty includes a cystocele, enlarged prostate, large intravesical median lobe, generalized edema, trabeculations, cellules, and abnormalities related to the ureteral orifice location, such as re‐implanted, ectopic, or duplicated ureters. Perhaps the safest option for the management of failed access is to abort the procedure with ureteral stenting if possible. Techniques for difficult ureteral access Tight ureteral orifice

Numerous difficulties can arise when attempting to access the ureteral orifice. Several techniques exist for orifice identification or cannulation. These include telescoping the wire through a ureteral catheter to improve direction and stability, converting to a straight or curved hydrophilic wire, emptying/filling the bladder, and manually reducing a cystocele or vaginal prolapse (e.g. vaginal packing). Ancillary instruments for complex access include a ureteroscope, flexible cystoscope, Albarran bridge with 70° lens, or specialty ureteral catheters (Figure  56.1). In the absence of complete ureteral obstruction, Methylene blue or Fluorescein can be administered intravenously to endoscopically visualize the effluxing ureteral orifice, and intravenous contrast can illuminate the distal ureter radiographically. Furosemide administration will expedite this process. If the ureteral orifice is narrow or stenotic, it may not accommodate the ureteroscope. Dilation may be accomplished with tapered dilators or dilating balloons. Such dilation can be associated with perforation, stone extrusion, and avulsion [5]. To prevent such injury from

Figure 56.1  Ureteral catheters. Source: Boston Scientific Corporation, Massachusetts, USA. Reproduced with permission of Boston Scientific.

unknown ureteral anatomy or ureteral stone, the ureter should be visualized using retrograde pyelography before dilating maneuvers. Prestenting the ureter (staged approach) is also an option.

56  Ureteroscopy Complications

Difficult ureter

If difficulty is encountered passing a wire, several techniques may be employed. Retrograde ureterography can opacify the challenging anatomy and guide maneuvers. Telescoping the wire through a ureteral catheter and/or converting wires (e.g. combination polytetrafluoroethylene (PTFE)/hydrophilic wire, straight or curved hydrophilic wire) may be beneficial. If an obstruction or impacted stone is present, lubricating lidocaine jelly can be injected through a ureteral catheter positioned 1–2 cm beneath the stone/obstruction in an attempt to relax the ureteral smooth muscle and create separation between the stone and ureteral wall. To fluoroscopically visualize this maneuver, contrast agent can be mixed into the jelly. However, excessive injection force/pressure may injure the ureter, producing extravasation. Lastly, URS can be performed to endoscopically visualize the difficult ureteral segment and advance the wire under direct vision. If wire access is achieved but URS remains difficult, entering a narrow ureteral orifice and negotiating a difficult ureter can be accomplished using two wires (safety and working wire) and by maintaining maximal distance between the wires opening the ureter to “shoehorn” the scope (railroad technique). The scope should be rotated, as needed, to maintain scope orientation between the wires. If a stricture is encountered distal to a stone, it may be tapered or balloon‐dilated followed by case resumption. If the stricture is incised, a stent should be placed with stone treatment later to prevent stone fragments migrating into the disrupted ureteral wall. When deciding between the two techniques, the surgeon should note that balloon dilation provides faster, less forceful access through a narrowed ureter [6]. Because ureteroscopes have decreased in size, incidence of balloon dilation has decreased; however, UAS utilization has been reported to increase balloon dilation use [7]. Failure to advance UAS after balloon dilation is rare but merits termination of case and stenting [7]. Repeat URS can be performed 1–2 weeks later. An antegrade approach remains an option should retrograde fail. Equipment failure Equipment failure can preclude ureteroscopic success, with procedure abortion reported at a suspected underestimated 0.8% [1], while scope failure necessitating repair can be expected every 9–50 cases [8–11]. Most ureteroscope damage is iatrogenic, such as improper handling during instrumentation [12]. Most commonly, damage occurs to the working channel, especially the distal tip. The primary mechanism is passing instruments with the scope deflected or firing the laser within the scope’s working channel. The use of lithotrite alone

predicts ureteroscope damage [12]. A major risk from laser use in a maximally deflected scope is damage to the channel at the point of maximum deflection due to energy released through microfractures in the quartz core material [13]. Stones should be repositioned to more favorable calyces prior to laser treatment. Backloading the ureteroscope over the stiff portion of a wire also risks internal channel punctures and flap creation. The most fragile portion of the scope is the active deflection unit. Excessive force/stress on the deflection mechanism expedites deterioration, typically occurring when the deflection circumference is greater than the renal pelvis size [9, 13]. Newer scopes with exaggerated active deflection may therefore shorten the interval between major repairs [14]. Duration of scope use inside the patient and patient’s body mass index were correlated with loss of downward deflection during use [15]. Lastly, applying excessive torque on the semirigid scope shaft leads to image distortion and scope failure [16]. To improve longevity, handling is critical: this includes maintaining the scope loosely coiled in transit, holding the handpiece with tip relaxed in a dependent position, straightening the scope into neutral position before advancing instruments through the channel, and using jelly or silicone lubricants to reduce frictional forces within the working channels. Ensuring both proximal and distal sections of the scope are synchronized mitigates torque‐twisting damage. Other recommendations include using UAS, nitinol devices, smaller holmium laser fibers, and laser tip visualization during use [17]. Stone migration Ascending/proximal migration

Proximal stone migration occurs in 3.5–12.2% of URS cases [1, 3, 4, 18, 19]. This increases operative/anesthesia time and may prevent case completion, subjecting a patient to additional anesthetic. Risks of proximal stone migration include initial proximal stone location, degree of ureteral dilation, pneumatic or electrohydraulic lithotrites, laser settings, and increased fluid irrigation. Antiretropulsion products are available to prevent proximal stone migration [1]. Ureteral stone extrusion

Stone migration into the ureteral wall occurs 4 hours, body mass index >20 kg/m2, and smoking. Other less common nerve injuries related to position include obturator, posterior tibial, and pudendal nerves, which warrant neurology and/or physical therapy consultations. Hemorrhage Hemorrhage from URS is typically minor and self‐limiting and rarely warrants monitoring or intervention. Mild bleeding has been reported as the most common intraoperative complication at a rate of 1.4%, and the most common reason for requiring repeat URS [3, 49]. Innate bleeding risks should be screened using patient history and labs seeking to identify underlying coagulopathy or anticoagulant use. These patients should be counseled prior to procedure, and measures should be implemented to reduce risk, such as holding medications prior to surgery. URS is the preferred surgical option in those with bleeding diathesis. These authors prestent patients whose risks of thromboembolic event precludes cessation of anticoagulants. Intraoperative bleeding is managed by aborting the procedure, stent placement, and fluid hydration. Profuse or pulsatile intraoperative bleeding could indicate iliac vessel injury. Significant postoperative bleed, especially with drop in hematocrit, warrants immediate workup with contrasted imaging studies or interventional arteriogram. Ureteral balloon placed in the distal ureter can temporize

56  Ureteroscopy Complications

bleeding until interventional or vascular repair is achieved. Perinephric (subcapsular) hematoma is suspected with flank pain out of proportion and subsequently diagnosed with imaging. This is a rare complication attributed to laser misfiring, wire perforation, high‐pressure irrigation, and forceful retrograde pyelogram and is managed with observation, reassurance, and analgesia. Occasionally, a ureteral stent is warranted and, rarely, a transfusion. Venous thromboembolism Deep vein thrombosis is a rarely encountered surgical complication. It carries the potentially fatal sequel of pulmonary thromboembolism, which is exceedingly rare (0.02%) [3]. Pulmonary thromboembolism is one of the most common causes of nonsurgical death in patients undergoing urologic surgery and is associated with significant long‐term morbidity [50]. The American Urological Association (AUA) Best Practice Statement does not specify URS procedures; however, all patients should be provided mechanical compression modalities and encouraged for early ambulation, and high‐risk patients should be considered for pharmacologic prophylaxis [50]. Urinary tract infection Complicated UTI and pyelonephritis have a post‐URS incidence of 1–3.7% [3, 51]. General risks of infectious complications include older age, obesity, female gender, nutrition or immune system impairment, diabetes mellitus, smoking, coexisting bodily infection, and increased bacterial load [52]. Increased bacterial load is associated with history of urogenital infections, preceding or recent hospitalization, urinary obstruction, large urinary stone, or long‐term urinary drainage tubes [52]. The AUA recommends antibiotic prophylaxis for all patients undergoing URS; however, the European Association of Urology (EAU) only recommends prophylaxis for select URS cases of proximal or impacted stones and patients with risk factors associated with infectious complications [52, 53]. Martov retrospectively reviewed the Clinical Research Office of the Endourological Society (CROES) database identifying that in patients having negative baseline urine culture, the rates of post‐URS UTI and fever were not reduced by preoperative antibiotic prophylaxis; moreover, female patients or those with impaired immunity (such as Crohn’s disease) and higher American Society of Anesthesiologists (ASA) grades were at greatest risk of post‐URS fever or infection. However, antibiotic use was not controlled, and conceivably higher risk patients were provided antimicrobial prophylaxis [51]. Although several randomized controled trials have reported that antibiotic prophylaxis significantly decreased bacteriuria

following URS [54, 55], Ramaswamy and Shah demonstrated that a course of prophylactic antibiotics following an uncomplicated ureteroscopic procedure provided no benefit in preventing infectious complications, and is therefore not recommended [56]. A study reviewing the CROES data showed a significantly reduced incidence of postoperative infectious complications with a UAS (fever 28 vs. 39%, UTI 18 vs. 24%, and sepsis 4 vs. 15%, for UAS vs. non‐UAS groups, respectively) [57]. A urine culture or urinalysis should be obtained prior to URS, and bacteriuria or positive culture should be treated prior to surgery. If frank pus or pyonephrosis is encountered intraoperatively, especially in the setting of obstruction, the case should be terminated with placement of stent or nephrostomy tube and antibiotics tailored towards cultures. Infection/sepsis Sepsis is an uncommon but life‐threatening complication of URS, reported at 0.3% [3]. Retrograde seeding of bacteruria or infected calculi are contributory factors. The surgeon should be cognizant of fluid pressure transmitted to the upper tracts, especially in patients with chronic indwelling urinary drainage tubes or urinary stasis. Additional antibiotics may be used postprocedure for higher‐risk patients. Renal urine aspirate and stone culture can be obtained intraoperatively to guide antibiotic administration if infection does manifest. A significantly reduced incidence of infectious complications (specifically >50% reduction in sepsis) has been reported in patients treated using a UAS [51].

­Late postoperative complications Ureteral stricture The miniaturization of technology and improved technique has led to dramatic decrease in stricture rates. Contemporary studies suggest stricture incidence of 0.5–4% [32, 58, 59] with some reporting a consistently infrequent rate of 2 months carries a greatly increased incidence of stricture [63]. Ureteral perforation increases

663

664

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

a retrograde fashion are typically transurethral. The incidence of urethral stenosis in women is extremely rare, but it is more commonly observed in males. This complication should be suspected in any patient with a history of transurethral instrumentation who has new onset voiding symptoms, split stream, or change in ­urinary flow pattern. This diagnosis can be worked up with uroflowmetry and followed with cystoscopy and surgical management, as needed. Persistent vesicoureteral reflux

Figure 56.9  Ureteral stricture recognized endoscopically.

stricture formation simply as an ischemic event; however, ureteral perforation at the site of stone impaction was identified as the greatest primary risk factor for stricture formation [33, 63, 64]. If perforation is identified, stenting for 2–3 weeks may decrease the risk of stenosis [33]. Some investigators suggest ureteral balloon as a precipitating event to stricture formation but a multi‐ institutional study showed only one stricture (0.9%) developed in 151 patients who underwent balloon dilation [7]. The use of UAS does not seem to significantly increase the risk of stricture formation [37]. In order to prevent missing the rare but potentially catastrophic silent obstruction the AUA Guideline Panel recommends routine postoperative ultrasound (±kidney, ureter, and bladder) imaging after URS. The relatively low cost and lack of ionizing radiation with ultrasonography justifies its use. Management of ureteral stricture is discussed in other chapters in this volume. Briefly, short (2 cm) typically require more invasive procedures for a durable outcome. Those intermediate length strictures (1–2 cm) require a balanced assessment of patient acuity and durability of technique; e.g. younger, healthier patients likely needing more durable procedure and older, less healthy patients perhaps benefiting from less invasive procedures.

Vesicoureteral reflux may be present after URS even if ureteral dilation was not performed. Its incidence has been reported as high as 10% within the first 24 hours post‐URS. Resolution of vesicoureteral reflux is typically observed within 2 weeks; however, 5–10% of these patients (mostly those having undergone ureteral dilation, incision of the ureteral orifice, or excised lesions at  the intramural ureter) demonstrate persistent vesicoureteral reflux 3–20 months after their procedure [33]. Theoretically, persistent vesicoureteral reflux can increase the risk of upper tract infections in the presence of lower tract bacteriuria, but indication for surgical correction is rare. Grades 1–3 sterile reflux typically have no consequences in adult populations, and therefore radiographic vesicoureteral reflux evaluation after URS is not routine [65]. If treatment is required because of recurrent upper tract infections or high‐pressure voiding, bulking agents are injected at 6 o’clock beneath the ureteral orifice and are usually sufficient to reduce the reflux. Formal antirefluxing reimplantation can be performed but is exceedingly rare.

­Conclusion ●●

●●

●●

Urethral stricture Any transurethral procedure has the potential to injure or scar the segments of the urinary tract undergoing instrumentation. As such, URS procedures performed in

●●

Adherence to general safety rules for endourology will help minimize perioperative complications: a safety wire is essential to maintaining access. Always visualize ureteroscope advancement, working instruments, and energy sources. When unsure or encountering difficulty during a procedure, the urologist should continue with extreme caution, using fluoroscopy for orientation. Patient selection, appropriate procedure selection, and surgical planning are critical to successful outcomes. Complications can typically be conservatively managed, with opportunities for staged and successful outcomes using either a repeat or alternative approach. Forced maneuvers must be avoided with low threshold for stenting and staging a procedure, if difficulty is encountered.

56  Ureteroscopy Complications

­References 1 Tepeler A, Resorlu B, Sahin T et al. Categorization of

15 Usawachintachit M, Chi T, Xu A et al. Loss of flexible

2

16

3

4

5

6

7

8

9

10

11

12

13

14

intraoperative ureteroscopy complications using modified Satava classification system. World J Urol 2014;32(1):131–136. Schuster TG, Hollenbeck BK, Faerber GJ, and Wolf JS Jr. Complications of ureteroscopy: analysis of predictive factors. J Urol 2001;166(2):538–540. de la Rosette J, Denstedt J, Geavlete P et al. The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients. J Endourol 2014;28(2):131–139. Mursi K, Elsheemy MS, Morsi HA et al. Semi‐rigid ureteroscopy for ureteric and renal pelvic calculi: predictive factors for complications and success. Arab J Urol 2013;11(2):136–141. Siddiq FM and Leveillee RJ. Complications of ureteroscopic approaches, including incisions. In: Advanced Endourology: The Complete Clinical Guide (ed. SY Nakada and MS Pearle), 299–320. Totowa, NJ: Humana Press, 2006. Harmon WJ, Sershon PD, Blute ML et al. Ureteroscopy: current practice and long‐term complications. J Urol 1997;157(1):28–32. Kuntz NJ, Neisius A, Tsivian M et al. Balloon dilation of the ureter: a contemporary review of outcomes and complications. J Urol 2015;194(2): 413–417. Landman J, Lee DI, Lee C, and Monga M. Evaluation of overall costs of currently available small flexible ureteroscopes. Urology 2003;62(2):218–222. Heckman JE, Healy KA, Hubosky SG, and Bagley DH. PD36–10 ureteroscope damage in clinical use. J Urol 2014;191(4):e904–e905. Gregory E, Simmons D, and Weinberg JJ. Care and sterilization of endourologic instruments. Urologic Clin Am 1988;15(3):541–546. Traxer O, Dubosq F, Jamali K et al. New‐generation flexible ureterorenoscopes are more durable than previous ones. Urology 2006;68(2):276–279; discussion 280–281. Carey RI, Gomez CS, Maurici G et al. Frequency of ureteroscope damage seen at a tertiary care center. J Urol 2006;176(2):607–610; discussion 610. Afane JS, Olweny EO, Bercowsky E et al. Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr. J Urol 2000;164(4):1164–1168. Knudsen B, Miyaoka R, Shah K et al. Durability of the next‐generation flexible fiberoptic ureteroscopes: a randomized prospective multi‐institutional clinical trial. Urology 2010;75(3):534–538.

17

18 19

20

21

22 23

24

25

26

27

28

29

ureteroscope flexion is associated with increased repair rates: a prospective multicenter study [Abstract MP36–2]. J Endourol 2015;29(S1):PA271. Smith AD, Badlani G, Preminger G, and Kavoussi LR (eds). Smith’s Textbook of Endourology, 3e. New York: John Wiley and Sons, 2012. Pietrow PK, Auge BK, Delvecchio FC et al. Techniques to maximize flexible ureteroscope longevity. Urology 2002;60(5):784–788. Johnson DB and Pearle MS. Complications of ureteroscopy. Urologic Clin Am 2004;31(1):157–171. Abdelrahim AF, Abdelmaguid A, Abuzeid H et al. Rigid ureteroscopy for ureteral stones: factors associated with intraoperative adverse events. J Endourol 2008;22(2):277–280. Grasso M, Liu JB, Goldberg B, and Bagley DH. Submucosal calculi: endoscopic and intraluminal sonographic diagnosis and treatment options. J Urol 1995;153(5):1384–1389. Geavlete P, Georgescu D, Nita G et al. Complications of 2735 retrograde semirigid ureteroscopy procedures: a single‐center experience. J Endourol 2006;20(3): 179–185. Dretler SP and Young RH. Stone granuloma: a cause of ureteral stricture. J Urol 1993;150(6):1800–1802. Moretti KL, Miller RA, Kellett MJ, and Wickham JE. Extrusion of calculi from upper urinary tract into perinephric and periureteric tissues during endourologic stone surgery. Urology 1991;38(5):447–449. Kriegmair M and Schmeller N. Paraureteral calculi caused by ureteroscopic perforation. Urology 1995;45(4):578–580. Armenakas NA. Ureteral trauma. In: Urological Emergencies: A Practical Guide (ed. H Wessells and JW McAninch), 25–37. Totowa, NJ: Humana Press, 2005. Moore EE, Cogbill TH, Jurkovich GJ et al. Organ injury scaling. III: Chest wall, abdominal vascular, ureter, bladder, and urethra. J Trauma 1992;33(3):337–339. Traxer O and Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013;189(2):580–584. Schoenthaler M, Buchholz N, Farin E et al. The Post‐Ureteroscopic Lesion Scale (PULS): a multicenter video‐based evaluation of inter‐rater reliability. World J Urol 2014;32(4):1033–1040. Baseskioglu B, Sofikerim M, Demirtas A et al. Is ureteral stenting really necessary after ureteroscopic lithotripsy with balloon dilatation of ureteral orifice? A multi‐institutional randomized controlled study. World J Urol 2011;29(6):731–736.

665

666

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

30 Butler MR, Power RE, Thornhill JA et al. An audit of

31

32

33

34

35

36

37

38

39

40

41

42 43

44

45

2273 ureteroscopies–a focus on intra‐operative complications to justify proactive management of ureteric calculi. The Surgeon 2004;2(1):42–46. Lingeman JE, Matlaga BR, and Evan AP. Surgical management of upper urinary tract calculi. In: Campbell‐Walsh Urology, 10e (ed. MF Campbell, PC Walsh, AJ Wein, and LR Kavoussi), 1357–1410. Philadelphia, PA: Saunders, 2012. Geavlete P. Ureteroscopy complications. In: Smith’s Textbook of Endourology (ed. AD Smith, G Badlani, G Preminger, and LR Kavoussi), 506–518. Oxford: Wiley‐Blackwell, 2012. Stoller ML, Wolf JS Jr, Hofmann R, and Marc B. Ureteroscopy without routine balloon dilation: an outcome assessment. J Urol 1992;147(5):1238–1242. Stern JM, Yiee J, and Park S. Safety and efficacy of ureteral access sheaths. J Endourol 2007;21(2): 119–123. Kourambas J, Byrne RR, and Preminger GM. Does a ureteral access sheath facilitate ureteroscopy? J Urol 2001;165(3):789–793. Rehman J, Monga M, Landman J et al. Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Urology 2003;61(4):713–718. Delvecchio FC, Auge BK, Brizuela RM et al. Assessment of stricture formation with the ureteral access sheath. Urology 2003;61(3):518–522; discussion 522. Gaizauskas A, Markevicius M, Gaizauskas S, and Zelvys A. Possible complications of ureteroscopy in modern endourological era: two‐point or “scabbard” avulsion. Case Reports Urol 2014;2014:308093. Ge C, Li Q, Wang L et al. Management of complete ureteral avulsion and literature review: a report on four cases. J Endourol 2011;25(2):323–326. Tanimoto R, Cleary RC, Bagley DH, and Hubosky SG. Ureteral Avulsion Associated with Ureteroscopy: Insights from the MAUDE Database. J Endourol 2016;30(3):257–261. Tang K, Sun F, Tian Y, and Zhao Y. Management of full‐length complete ureteral avulsion. Int Braz J Urol 2016;42(1):160–164. Blute ML, Segura JW, and Patterson DE. Ureteroscopy. J Urol 1988;139(3):510–512. Turna B, Stein RJ, Smaldone MC et al. Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol 2008;179(4):1415–1419. Jeon SS, Hyun JH, and Lee KS. A comparison of holmium:YAG laser with Lithoclast lithotripsy in ureteral calculi fragmentation. Int J Urol 2005;12(6):544–547. Tipu SA, Malik HA, Mohhayuddin N et al. Treatment of ureteric calculi–use of Holmium: YAG laser

46

47

48 49

50

51

52

53

54

55

56

57

58

59

lithotripsy versus pneumatic lithoclast. J Pakistan Med Assoc 2007;57(9):440–443. Sofer M, Watterson JD, Wollin TA et al. Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients. J Urol 2002;167(1):31–34. Abdel‐Razzak OM and Bagley DH. Clinical experience with flexible ureteropyeloscopy. J Urol 1992;148(6): 1788–1792. Grasso M. Ureteropyeloscopic treatment of ureteral and intrarenal calculi. Urologic Clin Am 2000;27(4):623–631. Brandt AS, von Rundstedt FC, Lazica DA, and Roth S. [Ureteral reconstruction after ureterorenoscopic injuries]. Der Urologe Ausg A 2010;49(7):812–821. Forrest JB, Clemens JQ, Finamore P et al. AUA Best Practice Statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. J Urol 2009;181(3):1170–1177. Martov A, Gravas S, Etemadian M et al. Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: a matched case‐control analysis on antibiotic prophylaxis from the CROES URS global study. J Endourol 2015;29(2):171–180. Grabe M, Bjerklund‐Johansen T, Botto H et al. Guidelines on Urological Infections 2013. European Association of Urology. http://uroweb.org/guidelines (accessed 19 April 2018). Wolf JS Jr, Bennett CJ, Dmochowski RR et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008;179(4): 1379–1390. Knopf HJ, Graff HJ, and Schulze H. Perioperative antibiotic prophylaxis in ureteroscopic stone removal. Eur Urol 2003;44(1):115–118. Fourcade RO. Antibiotic prophylaxis with cefotaxime in endoscopic extraction of upper urinary tract stones: a randomized study. The Cefotaxime Cooperative Group. J Antimicrob Chemother 1990;26 Suppl A:77–83. Ramaswamy K and Shah O. Antibiotic prophylaxis after uncomplicated ureteroscopic stone treatment: is there a difference? J Endourol 2012;26(2):122–125. Traxer O, Wendt‐Nordahl G, Sodha H et al. Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol 2015;33(12):2137–2144. Clayman RV, Basler JW, Kavoussi L, and Picus DD. Ureteronephroscopic endopyelotomy. J Urol 1990;144(2 Pt 1):246–251; discussion 251–252. Meretyk I, Meretyk S, and Clayman RV. Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques. J Urol 1992;148(3):775–782; discussion 782–783.

56  Ureteroscopy Complications

60 Kramolowsky EV. Ureteral perforation during

ureterorenoscopy: treatment and management. J Urol 1987;138(1):36–38. 61 Ono Y, Ohshima S, Kinukawa T et al. Long‐term results of transurethral lithotripsy with the rigid ureteroscope: injury of intramural ureter. J Urol 1989;142(4):958–960. 2 Francesca F, Scattoni V, Nava L et al. Failures and 6 complications of transurethral ureteroscopy in 297 cases: conventional rigid instruments vs. small caliber semirigid ureteroscopes. Eur Urol 1995;28(2):112–115.

63 Roberts WW, Cadeddu JA, Micali S et al. Ureteral

stricture formation after removal of impacted calculi. J Urol 1998;159(3):723–726. 64 Meng MV and Stoller ML. Hellstrom technique revisited: laparoscopic management of ureteropelvic junction obstruction. Urology 2003;62(3):404–408; discussion 408–409. 5 Stoller ML and Wolf JS. Endoscopic ureteral injuries. 6 In: Traumatic and Reconstructive Urology (ed. JW McAninch), 199–211. Philadelphia, PA: WB Saunders, 1996.

667

668

57 Retrograde Intrarenal Surgery in the Future: Robotics Anup Patel Consultant Urological Surgeon, London, UK

­Introduction As the world enters the fourth industrial revolution, there will be rapid evolution in the areas of artificial intelligence (AI), robotics, three‐dimensional (3D) printing, nanotechnology, genetics, and biotechnology. “Robots” have been part of human society since before Leonardo Da Vinci described gears, wheels, and pulleys to animate a robotic knight for a Milan pageant in the 1490s. Robot, a derivation of the Czech word “robota” from a 1920 play entitled R.U.R. (Rossumovi Univerzalini Roboti) by Czech author Karel Capek, meant forced labor or serf. Capek described fictional human‐like machines that continuously performed repetitive hard, dull, or dangerous complicated tasks for their human counterparts without feeling. The machines eventually became “resentful,” rebelled, and killed all the humans. Consequently, over time, the word “robot” has encompassed several meanings including that of a brutal human being who has become insensitive or machine‐ like because of overwork and mistreatment. In 1939, after meeting Ernest and Otto Binder at the Queens Science Fiction Society, who had published a story entitled I, Robot about a sympathetic misunderstood robot called Adam Link (who was motivated by love and honor), and following a conversation a year later with John W. Campbell, Isaac Asimov introduced his Three Laws of Robotics in a short story called “Runaround.” 1) A robot may not injure a human being or, through inaction, allow a human being to come to harm. 2) A robot must obey the orders given it by human beings except where such orders would conflict with the First Law.

3) A robot must protect its own existence as long as such protection does not conflict with the First or Second Laws. A fourth law was later added: 4) A robot may not harm humanity, or, by inaction, allow humanity to come to harm. Since then, robots have been remade in mankind’s image, and popularized by the televisual industry. Before Azimov, Edgar Allen Poe (1839) related the story of a wounded soldier whose body was rebuilt with synthetic parts. During the early part of the space race (1960) this was termed a cybernetic organism, for it was envisaged that blending technology with astronauts’ bodies could help endurance and survival in space. This led to a plethora of medical technologies such as pacemakers, insulin pumps, cochlear implants, prosthetics, and exo‐suits, all of which are already integrated into human society. In today’s world, the real issues regarding robots’ future roles center over debate as to whether they will primarily augment or replace current human functions. Autonomous robotic technology has increasingly replaced traditional tedious repetitive industrial human manufacturing roles, performing dull, dirty, and dangerous tasks, leaving their human counterparts in the shade for both accuracy and efficiency. Simultaneously, programmable and master/slave‐controlled drone technology, automated driverless vehicles (cars and airplanes), and crop spraying and seed dispersal farming drones have all begun to impact different aspects of daily human life, while also replacing humans in situations of inherent task‐associated danger. Where sustained precision, reliability, reduced costs, and greater productivity are desired, advanced sensor robotic technology can

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

57  Retrograde Intrarenal Surgery in the Future: Robotics

easily augment or supplant human performance without fatigue. More human functions are or will be threatened in the coming years, and some have even predicted that the ultimate supremacy of robotic over human development will be reached in only two more decades. It is a potential revolution akin to the Internet, where robots can fulfill diverse roles in society as human substitutes, companions, and partners (co‐bots). For medical applications, a key issue is whether robotic machines are better, or simply enhance human performance by lacking or reducing fatigability, allowing greater precision and efficiency over longer durations. This is particularly true for master/slave devices where expensive development costs can be offset by time saved, greater task performance precision, and increased productivity, and perhaps also consistency, particularly in repetitive or endurance‐based tasks. Ideally, a master/ slave human–robot partnership should enhance the capability of each individual component part provided the master can maintain concentration throughout the task. In interventional urology, robotics has already made great inroads through the use of devices that are master‐independent, such as the PUMA560 [1] (1988; arm with six degrees of freedom used for brain biopsy and later for transurethral resection of prostate) and, more recently, the Cyberknife for precision radiotherapy. Zeus and Aesop (US Food and Drug Administration [FDA] approved in 1990; Computer Motion, Santa Barbara, CA, USA), were bought and quashed by Intuitive Surgical (Sunnyvale, CA, USA) in favor of their Da Vinci™, a next‐generation master/slave console‐­ controlled robotic device with endo‐wrist technology (FDA approved in 2000) [2, 3]. It and the Sensei‐Hansen device (Hansen Medical, Mountain View, CA, USA) [4, 5] were their urological successors, incorporating console‐based 3D optical visualization with magnification, motion control and scaling, tremor reduction, and a greater range of movement and ergonomics compared to traditional instruments. Although it is beyond the scope of this chapter to examine cost‐benefits, this aspect of all new technologies will be amplified in an era of economic austerity coupled to higher healthcare demands from chronic illness, fueled by obesity and ageing pandemics, and falling birth rates in the world’s developed nations. Rupel and Brown’s endourological legacy of cystoscopic nephroscopy for renal stones at open surgery in 1941 [6] has been the evolution of a wide range of extracorporeal, ureteroscopic, percutaneous, and laparoscopic procedures, all embraced by urologists worldwide. The dominant large/branched renal stone treatment remains percutaneous nephrolithotomy (PCNL). Nevertheless, after two decades of evolution, classical retrograde intrarenal surgery (cRIRS) is now the most dominant endourological stone treatment modality overall.

Expertise and allied technological growth has projected cRIRS to the mainstream of complex endourological stone and soft tissue treatment in the upper urinary tract. For the first time, cRIRS rightly challenges the dominant alternative of PCNL treatment of larger intrarenal calculi [7–12]. However, cRIRS for large stones remains a technically challenging procedure requiring specific expert endo‐skill sets, real‐time problem solving capabilities [13–15], and both physical and mental endurance. Even when ureteral access sheaths (UAS) are used (almost mandatory in this setting), and the stone(s) can be accessed and completely laser‐fragmented, the single‐sitting stone‐free rate is limited by the operator’s stamina during long dusting and “pop‐corning” procedures, and the size and number of stone fragments that can safely be removed down the ureter in a safe, timely manner (in turn dependent on stone composition and hardness, and collecting system anatomy). Additional limiting factors are current flexible ureterorenoscope (FUR) design, a moving target (renal respiratory excursion) during fragmentation, and awkward calyceal anatomy, particularly if several such cases are scheduled per day. This has resulted in ≥50% secondary procedure rates to render patients stone‐free. Furthermore, the surgeon depends on assistants for key task performance, to activate lasers (standby‐ready and energy‐rate settings adjustments), deploy nitinol baskets and capture fragments, maintain and enhance irrigant flow, aspirate, and to draw/inject contrast, while manipulating and targeting the ureterorenoscope tip. All operating room staff are exposed to radiation over a longer period (range of 1.7–56 μSv [16–18]). Meanwhile, less invasive evolutionary PCNL techniques (mini, ultra‐mini, super‐mini, and micro‐PCNL [19–24]) have also evolved to challenge cRIRS, to gain parity or ascendancy in the current larger renal stone treatment paradigm, particularly in Asia, so further technological and technique evolution is mandated. During the last two decades, significant changes in both semirigid and FUR design, specifically tip and shaft size reduction along with configuration changes, have facilitated easier natural orifice access into the upper urinary tract for the majority of users (albeit at the cost of increased fragility and repair costs). Greater direction and range of tip deflection (both single and dual active flexion/extension motion range) has made navigation through the intrarenal collecting system easier, allowing more urologists to reach and inspect >95% of the entire collecting system (the most challenging part being the lower antero/medial calyx, especially in a dilated pelvicalyceal system which limits use of both active and secondary passive deflection). In 2012, ELMED (Ankara, Turkey) started developing a procedure‐specific robot‐assisted RIRS (RA‐RIRS)

669

670

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

device [25]. The IDEAL (idea, development, evaluation, assessment, long‐term study) framework for surgical innovation stages was embraced from prototype to the commercially available Avicenna Roboflex (IDEAL stage 1), and early clinical experience with treatments performed by different experienced endourologists (IDEAL stages 2–4) was reported as follows.

­Device development The basic Avicenna Roboflex design from prototype (Figure  57.1a) to successive versions (Figure  57.1b–d) consisted of a master control console (MCC) seating the surgeon and a manipulator arm (MA), which can now be coupled to any standard commercially available FUR using a custom‐made model‐specific adapter. During the early developmental phase, incremental improvements were made to the size and design of the MCC, the joysticks to control advancement, rotation, and tip deflection, and to develop a system to remotely advance‐ retract the laser fiber. Master control console design features The current Avicenna Roboflex (version 5) MCC (Figure 57.2a) is connected to the MA unit, and its monitor is connected as a slave to the operating room stack monitor. It has key‐control on‐switch, with separate red push‐button emergency stop (Figure  57.2b). The MCC reclining seat has adjustable height, head, and armrests. Six users can store individual seat positions and all preferred custom deflection‐scaling settings in the system memory (Figure 57.3). The comfortably seated surgeon activates wheel locks, selects endoscope type, brightness,

time, background screen color (one of six options), rotation precision and direction, deflection precision, and horizontal plane movement speed via the set‐up menu. Moreover, they can also select low‐ (0.5×) or high‐­ precision (1.5×) modes, timer stopwatch start or reset options, and define target kidney side (right or left) on the touch‐screen panel (also displayed on the center right of the monitor screen). The MCC touch screen also allows control of laser fiber actuator, irrigation flow rate, short bursts of flush, and abdominal compression belt inflation to reduce renal respiratory movement (Figure 57.4). Below this on the monitor screen is the endoscope deflection and rotation icon, and above it are laser fiber and irrigation flow rate indication bars (Figure 57.5). The rotation display circle containing the endoscopic view is in the center. The surgeon controls two joysticks (with adjustable padded wrist support) to manipulate the FUR, which is mounted on the MA component. The right‐hand vertical joystick bulb’s “magic wheel” controls fine tip deflection akin to the handpiece of any standard FUR (Figure  57.6a), but with additional tenfold motion scaling. The deflection direction (upwards, downwards) can be programmed for logical deflection (down = tip down and up = tip up) or counterintuitive deflection (down = tip up and vice versa). The new horizontal left joystick (Figure  57.6b) allows clockwise and counterclockwise MA rotation, as well as advancement and retraction of the endoscope shaft with millimeter per second adjustment, using +/– buttons. The rotation speed, scale (2, 1, 0.5×) and MA rotation direction (clockwise or counterclockwise), and advancement can be regulated by console touch‐screen control. Warning display box alerts inform the user about rotating the MA to the mounting position (90°  clockwise), continuing from a particular position, or returning to the neutral position.

Figure 57.1  (a) Avicenna Roboflex version 1 prototype for RA‐RIRS: simple circular holder for FURS control and laser fiber movement, controlled from console with two small four‐way joysticks (left for forward/backward and laser fiber in/out, right for rotation clockwise/ counterclock wise, and deflection up/down). The joysticks were later modified with bigger, thicker handles. (b) Similar manipulator arm with longer horizontal movement (forward/backward movement) for easier basket application, and smaller control console with height adjustable seat. Control of the left joystick movements were unchanged, but right joystick had a thick, rotatable handle to control FUR rotation and there was another individually rotatable disk incorporated into the top of the joystick handle to control up/down deflection. (c) Version 3: new manipulator arm design (with high‐precision robotic components) with open‐type endoscope holder and new master control console (MCC). Rotation movements over 440° were designed for smooth precision following hand movement. Special endoscope holder was designed for easy docking with deflection control unit. A force‐torque deflection mechanism sensing system was developed to protect the device against high‐deflection torsion. Horizontal movement (forward/backward) was set to a speed of 22 mm/second (adjustable from 0.5 to 22 mm/ second). The MCC was designed with two joysticks to control rotation and forward/backward movement (left joystick), and deflection movement on the right joystick. Laser fiber movement and vertical movement (according to patient tabletop position) were controlled from the touch screen. Later, a central precision control cylinder was added to the center of the MCC for fine tip deflection control as a modification of that version. (d) Version 4 incorporating a new interchangeable endoscope holder system to accommodate all FUR brands/models. The right joystick controlled rotation and two‐stage speed control for forward/backward movements and incorporated a thumb wheel (“magic wheel”) for tip deflection. Precision or scale of all rotation and tip deflection movements were selectable from the MCC touch screen. A new MCC foot‐ pedal unit was incorporated to control any laser or fluoroscopy foot pedals. Additional visual guidance was provided on the video monitor screen to indicate the spatial position of the FUR (such as horizontal distance, rotation angle, and deflection angle).

672

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Figure 57.1  (Continued)

57  Retrograde Intrarenal Surgery in the Future: Robotics

(a)

(b)

Figure 57.2  (a) Version 5 MCC unit with key control start, and improved adjustable seat design, headrest, and wrist support bar as an ergonomically sound comfortable surgical workstation. Horizontal left joystick for horizontal and rotational movement control, and right vertical joystick with magic wheel to control fine tip deflection (all with adjustable precision from MCC touch screen). (b) Red emergency stop button.

Figure 57.3  System memory for six users.

673

674

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Figure 57.4  The MCC touch screen with various functions in the set‐up menu: adaptation to FUR mode (i.e. American or non‐American), change of rotation, deflection precision, horizontal advancement/retraction speed, laser fiber advancement and retraction, irrigation flow rate adjustment, compression belt inflation‐deflation, and degree of rotation, deflection, and horizontal insertion display, along with timer and stop watch.

The assistant introduces the laser fiber at the start with the endoscope tip in a “0” straight position, with the tip cladding just visible endoscopically, and the touch‐screen “eye button” in the laser fiber box is pressed. The zero button is then activated to level the fiber tip with the work‐channel exit point. The endoscope can now be safely maneuvered to the stone before advancing the fiber tip 1.8 mm for safe firing. The MCC floor‐mounted red right foot pedal controls laser firing, while the white left pedal controls the fluoroscopy (Figure  57.7a), both aided by compressed air cabling to a foot‐pedal coupler unit (Figure  57.7b). The laser fiber foot pedal is automatically disabled when the fiber tip is within 1.6 mm of the endoscope tip (the red warning bar is a useful safety feature).

Manipulator arm design The MA consists of computer‐controlled motor systems, a robotic arm, which holds and moves the endoscope, and the lower stabilizing arm to which vertical supports are attached in two places. The arm height can be adjusted according to the patient’s anatomy. The endoscope hand piece with appropriately placed deflection lever is fixed into the arm’s customized coupler housing and secured by double clip holders after draping (Figure 57.8). The distal vertical stabilizer is fixed to the preplaced UAS hub, while the proximal one stabilizes the straight endoscope shaft approximately 5 cm further back (Figure  57.9a). A UAS is virtually mandatory for Avicenna Roboflex procedures, due to lack of haptic

Figure 57.4  (Continued)

Figure 57.5  MMCC with slave monitor screen for endoscopic image within central rotation indicator circle, progress bars for irrigation flow rate and laser fiber extrusion distance from tip (mm) on right upper, side of kidney right central, FUR tip deflection indicator right lower, and insertion rate progress bar left of center.

676

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Figure 57.6  (a) Magic wheel atop bulb of right‐hand MCC control joystick for fine scaled up‐and‐down endoscope tip deflection. (b) Left‐hand horizontal control joystick of MCC for clockwise and counterclockwise rotation, and in‐and‐out endoscope movement.

feedback, reducing risk of inadvertent ureteral injury. The custom‐made coupler accepts any FUR, although initial development was made using a digital instrument (Flex‐XC; Karl Storz, Tuttlingen, Germany). The MA can be rotated bidirectionally by 210° allowing overlap for a total 440° compared to 120° for humans. Miniaturized hand‐piece adaptor motors allow endoscope steering lever movement for deflection and enable motion scaling of the cable‐based endoscope tip movement mechanism. Due to FUR design and cabling inertia, a short lag period between robot control and endoscope tip reaction exists. This is vital for the user to understand and remember, for

there is a tendency to continue MCC deflection if no immediate visible screen reaction is seen, leading to delayed deflection overshoot. The same lag occurs for the same reason when switching deflection direction. Normally, a 10° manual lever deflection moves the tip 60°. With Avicenna Roboflex, FUR tip control precision is eightfold greater than manual operation. The thumb‐ wheel scaling precision, which can be low or high, or on a scale of 1–10 as set on the MCC, allows 10° of thumb movement to result in 3–30° of tip deflection. The applied forces were limited to 1 N/mm2 for safety to minimize the risk of collecting system and endoscope injury.

57  Retrograde Intrarenal Surgery in the Future: Robotics

Moreover, the coupling hand‐piece adapter accepts placement of a micromotor‐driven actuator system, which is connected to the instrument’s working‐channel for precise laser fiber advancement (Figure 57.9b). (a)

­Experimental evaluation For all MCC steering, and movement reliability functions, the Avicenna Roboflex was tested in a validated flexible ureterorenoscopy in vitro training model (Minnesota University Kidney Model [25]) containing artificial stones. This enabled safe prototype(s) simulations to evaluate key parameters and all device functions. It was also used for hands‐on training of all participating surgeons. In vitro studies Avicenna Roboflex showed safe, stable maneuverability, with easy translation of MCC functions when in both bench training models and pig ureters. Prototype ergonomics were already good, but incremental improvements to wrist movements, and fine‐tuning of deflection were made.

­Surgical technique (b)

Figure 57.7  (a) MCC floor‐mounted red right foot pedal (for laser firing control) and white left pedal (for fluoroscopy control). (b) Compressed air cable activated foot‐pedal coupler unit.

With the patient under general anesthesia, supine in lithotomy, intravenous diuretic (lasix) and antibiotic prophylaxis are given, and manual cystoscopy, retrograde pyelography, and placement of a safety guidewire can be performed. The ureteral orifice is accessed with a semirigid ureteroscope, inspecting the ureteral lumen up to/ beyond the ureteropelvic junction, thereby achieving maximal optical ureteral orifice and ureteral dilation, leaving behind a working wire as needed. A suitable size (10–12/12–14 Fr) and length (35–46 cm) UAS is then advanced into the upper ureter under fluoroscopic control as needed, confirming ureteral integrity postplacement with further pyelography via the access sheath obturator.

Figure 57.8  The MA custom endoscope coupler and motorized actuator housing, with FUR hand piece fixed in the manipulator coupler and stabilized by double clip holder after draping.

677

678

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

(a)

(b)

Figure 57.9  (a) The proximal stabilizer supports the straight endoscope shaft, while the distal stabilizer fixes the UAS shaft in the same plane. (b) The laser fiber (and irrigation tube) is attached to the endoscope by a motorized actuator for fine laser fiber movements.

Next, the FUR is inserted into the UAS lumen and its hand piece is fixed in the sterile plastic‐draped robotic‐arm coupling adaptor, where it is securely locked with securing clips. Thereafter, checks are made for a stable, secured, straight FUR shaft, before console steering can begin. Using the MCC touch screen and control levers, the target stone(s) is endoscopically visualized and recorded with fluoroscopic snapshot (master console floor left foot pedal). If the laser fiber was not inserted at the start, the endoscope is placed in a neutral straight retracted position with the console zero button to guarantee safe laser fiber insertion without risking work channel damage. The MCC provides a memory function to guide the scope back to its previous position near the stone surface after laser fiber insertion. The inserted laser fiber tip with cladding should be just visible near the endoscope tip and the eye button on the master control laser fiber box is activated for memory entry. Only then can the fiber be retracted to a position level with the scope tip (zero button) and advanced from there by the console touch screen controls using the actuator device fitted to the endoscope work channel. The fiber cannot be retracted inadvertently into the scopes working channel and energy activated, where it might damage the instrument. Once the fiber is advanced (as shown by bicolored bar in MCC laser fiber panel) with precision to the optimal distance from the stone surface, laser‐induced lithotripsy can be initiated, ideally “dusting” the stone surface with meandering rotation and small up‐ and‐down deflection movements of the laser fiber tip in the millimeter range using the left hand rotation control lever and/or the right hand pin‐wheel control, or by fragmentation (various techniques). Any commercially available holmium:YAG laser unit can be used, but one that allows higher‐frequency application at low energy is

recommended for optimal dusting. Smaller fiber sizes allow sufficient scope tip deflection with lowest risk of fiber fracture in the work channel at maximum energy and frequency. Once fragmentation has started, higher energy frequency gives a “popcorn effect” for fragment pulverization when dusting is not possible. Sometimes, with fiber tip in the calyx lumen center, this can even be done “hands‐free” if time‐consuming (see Video 57.1). Fiber tip erosion must be monitored, as it reduces energy transfer over time, and judicious appropriate cleaving with fiber re‐introduction is undertaken as required. To introduce nitinol baskets for fragment retrieval at the end, the laser actuator has to be driven back to its preset zero position with the endoscope tip straight, and the fiber exchanged for the basket, once the laser console is on standby (assistant). This might be time‐consuming especially if there are multiple fragments, and hence ablation by stone dusting is preferred until a suitably sized fragment is retrieved at the end for stone analysis. The need for JJ stent placement at the end of the procedure is not mandated, but left to the operator’s discretion.

­Published clinical experience Patients and outcomes In the first peer‐reviewed study, Ankara Medical School ethics commission approval was secured, and 81 patients were treated (IDEAL stage 2) (Table  57.1). Inclusion criteria were aged >6 year, single or multiple stones with a 30 mm total diameter ceiling, absent active urinary tract infection, and no previous ureteral surgery. All patients or minors’ parents were informed about Avicenna

57  Retrograde Intrarenal Surgery in the Future: Robotics

Table 57.1  Baseline RA‐RIRS demographic and outcomes data (n = 81). Criteria

Value

Range

SD

Comment

Age (years)

42a

6–68

25.4

According to inclusion criteria

Male/female

56/25 –

–

–

Left/right

35/46 –

–

–

Single/multiple calculi

29/52 –

–

–

Upper calyx

62

–

–

–

Middle calyx

23

–

–

–

Lower calyx

62

–

–

–

Renal pelvis

26

–

–

–

5–30

5.3

Multiple calculi: sum of lengths

a

Stone diameter (mm)

13

Stone volume (mm3)

1296a 432–3100 544.3 Calculated based on preoperative computed tomography

Treatment time (minutes)

74a

40–182

31.8

Inclusive of UAS and double‐J stent placement

Robot docking time (seconds)

59.6a

35–124

45

46 seconds after 42 cases

a

Stone visualization time (minutes)

3.7

2–8

1.4

Including complete inspection of collecting system

Fragmentation time (minutes)

46a

18–115

21.7

Depending on stone size/hardness

18–46

6.1

Increasing to 32.7 mm3/min after 42 cases

3

Fragmentation speed, (mm /minute)

a

29.1 a

Console time (minutes)

53

23–135

23.2

Depending on stone size and learning curve

Complications

1

–

–

Endoscope failure (case 42), cRIRS not possible; double‐J stent placement

cRIRS

31.3a

16–40

7.8

Based on last 10 cases performed by each surgeon at own institution

RA‐RIRS

5.6a

3–10

2.4

Based on immediate subjective evaluation

Re‐treatment

2

–

–

cRIRS

Robotic failure

None –

–

–

3‐month stone‐free rate

65 – (80%)

–

16 patients (20%) with clinically insignificant residual fragments ≤3 mm

Ergonomic scores

UAS in 72 patients; nine patients with tight ureters (six children and three females) had optical rigid ureteroscopic dilation, placement of safety guidewire, and FUR without UAS. Seven experienced surgeons (5–16 years’ individual cRIRS experience) with all MCC Avicenna Roboflex functions learned in the in vitro training model. SD, standard deviation. a  Mean value. Source: [26]. Reproduced with permission of Elsevier.

Roboflex use and provided informed consent. Primary end points included RA‐RIRS safety and reproducibility based on successful fragmentation data, second sessions, auxiliary measures, complications (Clavien‐Dindo classification), and any FUR‐related/robot malfunction. Secondary end points were robot docking time, stone location time, fragmentation time, and speed (cubic millimeters per minute) based on computed tomography (CT) stone volume evaluation [27–29], console, and treatment time. Numerical data were expressed as mean with standard deviation (SD) including range; categorical data were expressed as numbers. SPSS v.15 (IBM Corp, Armonk, NY, USA) was used for data analysis. Categorical variables were analyzed using the χ2 test

(or Fisher exact test). The Mann–Whitney U test was used for numeric variables. P values 1.5 cm, as reflected in updated international European and American guidelines. However, cRIRS is not without its challenges, particularly in these complex cases (e.g. larger stone burden or multiple intrarenal and/or ureteral calculi). Ergonomic problems [36–38] (hand elbow, shoulder, neck, back, hips, knees, ankles) are related to wearing protective lead gowns, thyroid shields, and hand and eye protection in some cases, when performing standing or seated cRIRS on stools for long time periods, leading to operator fatigue. Further challenges include respiratory renal excursion, hindered working space, and the need to simultaneously use various foot pedals to control lasers and/or fluoroscopy equipment, while relying on allied team members to activate laser panel settings and between standby and active settings, or for irrigation adjustments and fluid bag changes, and simultaneously dealing with rapidly changing intraoperative circumstances and fleeting stone treatment opportunities which may influence ultimate success or failure. Together, these lead to cumulative operator fatigue amd physical exhaustion, particularly when treating several such challenging cases of over an hour each throughout the day. This has obvious

681

682

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Table 57.3  Summary of cRIRS series in the last decade. Study

Year

No. of patients

Stone size (cm)

Mean no. of procedures

% Stone‐free rate

Mariani [39]

2007

16

≥4

2.4

88

Riley [40]

2009

22

3

1.8

90.9

Breda [9]

2009

27

>2

1.6

85

Bader [41]

2010

24

2.975

1.7

92

Hyams [42]

2010

120

2.4

?

98

Aboumarzouk [43] (meta‐analysis)

2012

445

2.5

1.6

93.7

Takazawa [44]

2012

20

3.1 (2–5)

1.4

90

Cohen [45]

2013

145

2.9

1.6

87

Miernik [46]

2013

38

2.71

1.1

82

detrimental knock‐on effects to fine motor skills, task performance, and precision, even in expert hands! This may result in premature termination of a planned procedure, double‐J stent placement, and the inevitable consequence of staged treatment to render the patient stone free. This was validated by cRIRS treatment outcomes in expert hands this past decade (Table 57.3). Consequently, an opportunity to implement mechanically controlled devices into cRIRS procedures was presented. Desai et al. first exploited this opportunity with the Sensei‐Hansen Robotic Catheter System, a cardiology/ vascular system, adapting it for RA‐RIRS, testing it in pigs (one renal pelvic perforation) and then in 18 patients [4, 5] (0.5–1.5 cm renal stones). Their four‐component device consisted of a master input device, a dual catheter system with an inner flexible steerable component, a remote inner catheter/manipulation system, and an electronic rack containing computer hardware, power supplies, and video distribution units. The robotic flexible catheter system had a 12/14 Fr outer catheter sheath and inner 10/12 Fr catheter guide. A passive optical fiberscope was inserted through the inner catheter guide lumen. Remote catheter system manipulation maneuvered the flexible fiberscope tip, glued in place within the inner guide. The larger outer sheath tip, positioned at the ureteropelvic junction to stabilize the inner navigation guide within the collecting system, allowed passenger fiberscope manipulation within the inner catheter guide. Of 18 patients only three minor complications (transient fever in two and limb paresis in one), three secondary PCNL for stone residual, and 89% 3 month CT excretory urogram stone‐free rate were reported. This device has since been discontinued in urology. The Avicenna Roboflex robotic system was developed to be specifically dedicated to RA‐RIRS. It has tackled many of the ergonomic challenges of cRIRS. After a proof‐ of‐concept phase [25] (IDEAL stage 1) and progression from prototype to working design (IDEAL stage 2a),

Saglam et  al. demonstrated safe, efficacious device deployment, with a short learning curve, and disseminated the technology among selected experienced endourologists with varying cRIRS expertise (IDEAL stage 2b), publishing data from the first seven’s early cases (Table 57.1). RA‐RIRS performed in a comfortable ergonomically sound seated position remote from the operating table eliminated the drawback of surgeon (±assistant) fatigue from prolonged standing between the patient’s legs at the operating table. Additionally, the surgeon doesn’t need to wear protective lead items, for the Avicenna Roboflex MCC surgeon seat can be parked at a suitable safe distance from the operating table as our preliminary studies have shown [31]. The cumulative benefits of these ergonomic stress relieving RA‐RIRS aspects was subjectively scored by initial users in Saglam et al’s European Urology publication [26], and reported significant superiority over cRIRS, a finding verified by this author’s current personal series of 17 cases. The robotic MA enhances and directly drives all mechanical FUR functions, providing a further level of external control beyond the inherent endoscope mechanics, but does not eliminate disadvantages inherent to the FUR deflection cable‐drum design mechanism, leading to slightly lagged responses in fine up‐and‐down tip deflection. Custom‐made endoscope hand‐piece couplers (different for each manufacturer’s scope model) can be made, (an advantage) and are attached directly to a specially designed master plate of the robotic MA. The hand‐piece deflection lever is moved by computer‐ controlled micromotors in the coupler, which communicate with the MCC unit via a cable connector. The RA manipulator also enables two‐point shaft stabilization, allowing safe bidirectional rotation, plus advancement and retraction of the fixed instrument hand piece. Thus, RA‐RIRS can be performed using standard 10–12 or 12–14 Fr variable length UAS, although shorter length/ wider lumen is preferred to allow maximum deflection

57  Retrograde Intrarenal Surgery in the Future: Robotics

and dust efflux at the lowest pressures. All endoscope movements can be fine‐tuned and scaled to adjustable degrees through the MCC. This level of control is not possible manually in a sustained manner in cRIRS. The laser fiber actuator allows fine motorized forwards and backwards movements beyond the endoscope tip without moving the endoscope itself, with automatic repositioning to a baseline neutral position where it cannot damage the endoscope tip. This lends further operator‐ controlled precision to stone dusting performance, fragmentation, and ablation, by allowing the operator to maintain the optimal distance between fiber tip and target to maximize the photo‐acoustic pulsed stone surface ablation without having to adjust the scope tip position every time. Tables 57.4 and 57.5 describe and compare the ergonomic demands of cRIRs to RA‐RIRS. A key goal for introducing surgical master/slave robotic devices is to reduce the cumulative surgical ergonomic stresses of long and arduous cRIRS procedures for complex and large renal stones. A comfortable environment potentially augments an individual surgeon’s capabilities, improves quality and throughput, and provides a comfortable learning environment for the less experienced urologist/trainee endourologist. Hand/wrist/other ergonomic problems reported in up to one‐third of endourologists were re‐iterated by Saglam et  al. [26]. Avicenna Roboflex provided a comfortable platform that

significantly improved ergonomics after a short learning curve (subjective score 5.6 vs. 31.3, P 100 cases [48] by using the semirigid instrument as the workhorse and having the FUR tip occupied by a laser fiber in full deflection mode for the shortest possible time. However, initial experience reported here by Saglam (personal communication), if verified by others, suggests much greater scope longevity in RA‐RIRS compared to cRIRS. The Avicenna Roboflex design, requiring laser fiber insertion only in a straight scope position using a console based memory function, stepwise motorized advancement of the laser fiber, and force‐controlled (maximal 1 N/mm2) deflection of the scope with similar controlled rotation of the supported torque‐free shaft outside the UAS, are just some of the features that should contribute to potential FUR longevity (partially offsetting robot costs cumulatively). Possible Avicenna Roboflex limitations are current lack of tactile feedback (as with all master/slave robotic devices),

Table 57.4  Ergonomic demands of cRIRS. Operative action

Extremity(ies) required

Performed by

FUR insertion

Fingers of both hands (at glans‐access sheath hub, and FUR handpiece)

Surgeon

FUR deflection

Hand holding handpiece and thumb deflection lever; fingers of other hand at meatus‐access sheath hub to maintain straight shaft for optimal deflection capability

Surgeon

FUR rotation

Hand‐holding hand piece; fingers of the other hand rotating shaft at meatus

Surgeon

Fluoroscopy activation

Hand/foot

Radiology technician or certified surgeon

Multifunctional operating table or C‐arm movement

Arms/hand, foot, and torso

Radiology technician or certified surgeon

Irrigation control

Thumb and hand

Nurse or assistant

Syringe (contrast‐flush‐aspiration)

Thumb and hand

Surgeon

Nitinol accessories insertion or activation

Thumb and index finger(s)

Surgeon

Laser fiber insertion, advancement, and retraction

Thumb and index finger

Surgeon

Laser settings

Index finger

Nurse or assistant

Laser ready, standby modes

Index finger

Nurse or assistant

Laser activation

Foot

Surgeon

Source: [26]. Reproduced with permission of Elsevier.

683

684

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

Table 57.5  Comparing control of cRIRS and RA‐RIRS. Feature

cRIRS

RA‐RIRS

Surgeon’s position

Standing between patient legs in lithotomy

Seated comfortably with arm rest at MCC

FUR insertion

Manually through UAS

Manually through UAS

FUR advancement, rotation

With both hands

MCC joysticks (2)

Fine regulation of deflection

Not available, manual attempt

MCC right joystick pin wheel

Laser fiber insertion

Manually through working channel

Manually through working channel

Laser fiber fine movements in and out

Manually through working channel

MCC touch screen control

Laser activation in ready mode

Foot pedal (standing), not fixed to floor by operating table

Red foot‐pedal control (sitting), fixed to MCC floor (right)

Laser energy/frequency, standby/ active mode adjustment

Manually at device

Manually at device

Fluoroscopy activation

Hand/foot pedal control, radiographer

White foot‐pedal control (sitting), fixed to MCC floor (left)

Table or C‐arm movement

Manually, anesthetist/radiographer

Manually, anesthetist/radiographer

Irrigation control

By irrigant bag height (nurse) and/or surgeon‐ controlled pump (syringe, hand or foot pump)

MCC touch screen control

Nitinol accessories, insertion/ activation

Manually at scope work channel

Manually at scope work channel

Source: [26]. Reproduced and adapted with permission of Elsevier.

underpinning the enduring need of a certain degree of surgeon expertise using compensatory visual clues and precisely controlled movements, and spatial awareness of the scope in all three dimensions. This will change in the future as haptic feedback technology evolves, but is not as critical in RA‐RIRS as compared for laparocopic surgery, as the FUR coupled to the MA is introduced and advanced up the ureter inside the lumen of a ureteral access sheath. Additionally, there is the issue of the two‐dimensional image monitor screen for scope tip navigation, and problems with the continued need to use baskets for stone fragment extraction where dusting or pop‐corning is not possible. Although some have debated whether cRIRS should aim at complete stone ablation by dusting, or whether larger fragments should be actively retrieved using a nitinol basket via the UAS, the need for the latter should be minimal except for harder large stones once fragments are sub‐5 mm or in high frequency recurrent large stone formers with uncorrected underlying metabolic risk factors, thus avoiding the need for time consuming partial undocking from the MA shaft support feature. Finally, the device cost may become a significant issue, particularly with respect to financial restrictions of healthcare systems in austerity. Following the IDEAL framework, a multicenter multinational prospective randomized controled trial should be planned to provide more specific details about the potential advantages of RA‐RIRS versus cRIRS and smaller access

PCNL techniques, for medium–large or branched renal stones, using CT‐based end points for stone‐free rates. Presently, of over 4000 companies, 150 have a market cap of > US$200 million, with $2 billion worth of mergers and acquisitions, and $1.3 billion equity funding in the robotics sector of the global economy, with Japan leading the way. Most of this investment is dominated by civilian drone technology, with a 122% compound annual growth rate for 3D printing, and 36% industrial robotics growth in China alone between 2008 and 2013. As surgeons, we need the surgical tools of tomorrow, not as replacements for ourselves, but as a means to enhance our individual abilities in order to be our best selves without fear of fatigue, so as to deliver superior patient outcomes. With this in mind, many have asked if they really need an expensive tool such as a robotic device? The lab data perhaps suggest not, but the answer must surely be … only if it can deliver patient outcomes that are worth the premium price or ultimately lead to other cost savings (shorter operating time, lower operating room support personnel requirement, lower complication rates [intra‐and postoperative], less operator fatigue leading to lower retreatment rates, less FUR breakage, shorter operating room times per stone volume unit disintegrated, for a given stone hardness, location, and collecting system configuration, and lower auxiliary procedure rates). Ideally, it should allow us to tackle bigger stones in difficult places in the urinary tract without

57  Retrograde Intrarenal Surgery in the Future: Robotics

making painful holes [49] or risk bleeding, improving on current stone‐free rates, and still be able to send patients home safely in minimal discomfort the same day without fear of re‐admission or retreatment. New technology is “new” but never born perfect out of engineering development! After birth, it must pass through an evolutionary and clinical refinement process driven by a cadre of key experts collaborating with the engineering brains, by using it over a realistic time period in real‐world settings, based on complexity and learning curve issues. During this time, views are often polarized, sometimes perjoratively depending on how it is presented and who the early adopters are. Nevertheless, it generally creates public awareness, which leads to excitement and debate, especially (as seen with the Da Vinci), when marketed directly to patients and providers by organizations with vested interests. Thus at a time of increasing healthcare consumption, bottlenecks, and fiscal constraints, any new technology must ultimately prove its worth rather than being just another example of fulfilling the prophecy of “the emperor’s new clothes” [50]. This means that for all technology, there are price points for affordability and cost‐benefit to be considered. To underpin these, there must be a high‐quality evidence base. Currently, Avicenna Roboflex RA‐RIRS is somewhat limited by two factors: current FUR design and ureteral lumen size for access and fragment removal. So with RA‐RIRS we must ask ourselves, will this tool extend what we as expert surgeons can do for our patients today or in the near future? Does it enhance their, our, or our team’s safety? Does it have future development potential and versatility inside of and beyond the urological specialty? And is it future‐ proofed for modifications that could lead to improved performance for a reasonable time period to make the high initial investment outlay viable? Will most people be able to afford it eventually? Will it allow acquisition of advanced skill sets across a wider spectrum of practitioners, trainees, and novices, and can these be honed to perfection outside the clinical working environment, or is it just another very expensive comfortable chair? The answers to these questions will vary from unit to unit, and will depend on many factors such as skill sets and referral patterns. For example, you don’t need Avicenna Roboflex if the majority of ureters you deal with will not readily accept a UAS, or the majority of stones you treat are large branched hard renal stones where PCNL may still be arguably superior! However, if one’s goal is to maximize the control a surgeon has over their endourological working environment and potentially increase it in the future, improve ergonomics to reduce fatigue and allow increased quality and throughput other factors notwithstanding, reduce the need for invasive painful percutaneous surgical procedures in an increasingly elderly and obese population dynamic, afflicted by comorbidities

and needing blood‐thinning medications, in whom stone disease is increasing and has a higher recurrence rate, then RA‐RIRS should certainly be a mouth‐watering prospect. This is especially true in a training center with a tertiary referral practice of sufficient volume, where young surgeons are increasingly challenged in skills acquisition and transfer by reduced working hours. Together, they may provide a strong argument for expensive technology to be limited to regional centers to begin with. Moreover, it certainly is a potential asset where endourological precision is key such as in the renal conservative management of upper urinary tract urothelial cancer, where this author has undertaken the first RA‐RIRS case to date (see Video 57.1), or complex stone disease with reduced renal function that needs to be preserved to avoid dialysis, or for those at significant risk of bleeding complications (multiple puncture PCNL in high risk patients on blood thinning or antiplatelet medications that cannot safely be discontinued). Moreover, if by simply changing a coupling adaptor, the device becomes a flexible multispecialty tool, it has the potential for real cost‐effectiveness and becomes a viable part of the future hospital landscape beyond urology. Our young successors may be much safer (with regards to the long‐term consequences of cumulative radiation exposure) and proficient much faster than this endourologist generation [32]. The heavy burden of wearing lead protection for the whole duration of our careers, with long‐term impact on our vertebrae and attached musculature will finally be shed. With surgical robotics, we are not yet at the stage where we have self‐learning programmable autonomous systems like the proverbial autopilot that can fully operate aircraft from take off to landing. Will we ever want this in the human body shop? Only time will tell, depending on where processor and biosensor functions along with machine learning, drive us as physicians and surgeons. What is clear is that we are at the beginning of a global social robotic revolution and the future may bring us hybrid machines possessing ambient intelligence, which can bring lasting value to surgical procedure outcomes. Human empathy and creativity may be the last bastion against the rule of artificial intelligence. Quintessentially, human roles in medical care can be enhanced, leaving individuals with more time to care, teach, create, and innovate, by embracing technology and innovatively shaping it to human needs. The future is exciting indeed!

­Acknowledgments In the preparation of this chapter I am deeply indebted to Dr Remzi Saglam and Mr Sinan Kabakci for assistance in providing some historical figures, key aspects of unpublished information, and video‐editing assistance.

685

686

Section 3  Ureteroscopy: Ureteroscopic Management of Ureteral Obstruction

­References 1 Shao HM, Chen JY, Truong TK et al. A new CT‐aided

17 Hellawell GO, Mutch SJ, Thevendran G et al. Radiation

2

18

3

4

5

6

7

8

9

10

11

12

13

14

15

16

robotic stereotaxis system. Proc Annu Symp Comput Appl Med Care 1985; 13: 668–672. Abbou CC, Hoznek A, Salomon L et al. Remote laparoscopic radical prostatectomy carried out with a robot. Report of a case. Prog Urol 2000;10:520–523. Wolfram M, Bräutigam R, Engl T et al. Robotic‐assisted laparoscopic radical prostatectomy: the Frankfurt technique. World J Urol 2003;21(3):128–132. Desai MM, Aron M, Gill IS et al. Flexible robotic retrograde renoscopy: description of novel robotic device and preliminary laboratory experience. Urology 2008;72:42–46. Desai MM, Grover R, Aron M et al. Robotic flexible ureteroscopy for renal calculi: initial clinical experience. J Urol 2011;186:563–568. Rupel E and Brown R. Nephroscopy with removal of stone following nephrostomy for obstructive calculus anuria. J Urol 1941;46:177–179. Preminger GM, Tiselius H‐G, Assimos DG et al. 2007 guideline for the management of ureteral calculi. Eur Urol 2007;52:1610–1631. Beiko DT and Denstedt JD. Advances in ureterorenoscopy. Urol Clin North Am 2007;34:397–408. Breda A, Ogunyemi O, Leppert JT, and Schulam PG. Flexible ureteroscopy and laser lithotripsy for multiple unilateral intrarenal stones. Eur Urol 2009;55(5): 1190–1197. Rassweiler JJ, Knoll T, Köhrmann K‐U et al. Shock wave technology and application: an update. Eur Urol 2011;59:784–796. Patel A and Fuchs GJ. Expanding the horizons of SWL through adjunctive use of retrograde intrarenal surgery: new techniques and indications. J Endourol 1997;11:33–36. Knoll T, Jessen JP, Honeck P, Wendt‐Nordahl G. Flexible ureterorenoscopy versus miniaturized PNL for solitary renal calculi of 10–30  mm size. World J Urol 2011;29:755–759. Holden T, Pedro RN, Hendlin K et al. Evidence‐based instrumentation for flexible ureteroscopy: a review. J Endourol 2008;22:1423–1426. Somani BK, Aboumarzouk O, Srivastava A, and Traxer O. Flexible ureteroscopy: tips and tricks. Urol Ann 2013;5:1–6. Monga M, Dretler SP, Landman J et al. Maximizing ureteroscope deflection: “play it straight”. Urology 2002;60:902–905. Bagley DH and Cubler‐Goodman A. Radiation exposure during ureteroscopy. J Urol 1990;144:1356–1358.

19

20

21

22

23

24

25

26

27

28

29

exposure and the urologist: what are the risks? J Urol 2005;174:948–952. Kim KP, Miller DL, Berrington de Gonzalez A et al. Occupational radiation doses to operators performing fluoroscopically‐guided procedures. Health Phys 2012;103:80–99. Sabnis RB, Jagtap J, Mishra S, and Desai M. Treating renal calculi 1–2 cm in diameter with minipercutaneous or retrograde intrarenal surgery: a prospective comparative study. BJU Int 2012;110(8b):E346–E349. Desai MR, Sharma R, Mishra S et al. Single‐step percutaneous nephrolithotomy (microperc): the initial clinical report. J Urol 2011;186(1):140–145. Desai J, Zeng G, Zhao Z et al. A novel technique of ultra‐mini‐percutaneous nephrolithotomy: introduction and an initial experience for treatment of upper urinary calculi less than 2 cm. Biomed Res Int 2013;490793: doi:10.1155/2013/490793. Schoenthaler M, Wilhelm K, Hein S et al. Ultra‐mini PCNL versus flexible ureteroscopy: a matched analysis of treatment costs (endoscopes and disposables) in patients with renal stones 10–20 mm. World J Urol 2015;33(10):1601–1605. Datta SN, Solanki R, and Desai J. Prospective outcomes of ultra mini percutaneous nephrolithotomy: a consecutive cohort study. J Urol 2016;195(3):741–746. Zeng G, Wan SP, Zhao Z et al. Super‐mini percutaneous nephrolithotomy (SMP): a new concept in technique and instrumentation. BJU Int 2016:117(4):655–661. Saglam R, Kabakci AS, Koruk E, and Tokatli Z. How did we designed and improved a new Turkish robot for flexible ureterorenoscopy. J Endourol 2012; 26(Suppl 1):A275, MP44‐12. Saglam R, Muslumanoglu AY, Tokatlı Z et al. New robot for flexible ureteroscopy: development and early clinical results (IDEAL Stage 1–2b). Eur Urol 2014;66(6):1092–1100. Finch W, Johnston R, Shaida N et al. Measuring stone volume ‐ three‐dimensional software reconstruction or ellipsoid algebra formula? BJU Int 2014;113: 610–614. Rampinelli C, Fiori E, Raimondi S et al. In vivo repeatability of automated volume calculations of small pulmonary nodules with CT. Am J Roentgenol 2009;192:1657–1661. Patel SR and Nakada SY. Quantification of preoperative stone burden for ureteroscopy and shock wave lithotripsy: current state and future recommendations. Urology 2011;78:282–285.

57  Retrograde Intrarenal Surgery in the Future: Robotics

30 Rassweiler JJ, Goezen AS, and Jalal AA. et al. A new

31

32

33

34

35

36

37

38

39

platform improving the ergonomics of laparoscopic surgery: initial clinical evaluation of the prototype. Eur Urol 2012;61:226–229. Patel A, Tokatlı Z, Parmaksız A, et al. Preliminary radiation dose evaluation of patient and medical professionals in robotic assisted retrograde intra‐renal surgery with Roboflex Avicenna. J Endourol 2016;30(Suppl. 2):MP42‐4:35. Binbay M, Gokce I, Tokatli Z et al. A short learning curve of robotic assisted flexible ureteroscopy may help the trainees. J Endourol. 2014;28(Suppl. 1): MP10‐02:24. Gao X, Zeng G, Chen H et al. A novel ureterorenoscope for the management of upper urinary tract stones: initial experience from a prospective multicenter study. J Endourol 2015;29(6):718–724. Patel A. Lower calyceal occlusion by autologous blood clot to prevent stone fragment reaccumulation after retrograde intra‐renal surgery for lower calyceal stones: first experience of a new technique. J Endourol 2008;22(11):2501–2506. Sanguedolce F, Liatsikos E, Verze P et al. Use of flexible ureteroscopy in the clinical practice for the treatment of renal stones: results from a large European survey conducted by the EAU Young Academic Urologists‐ Working Party on Endourology and Urolithiasis. Urolithiasis 2014;42(4):329–334. Elkoushy MA and Andonian S. Prevalence of orthopedic complaints among endourologists are common and their compliance with radiation safety measures very important. Endourology 2011;25:1609–1613. Healy KA, Pak RW, Cleary RC et al. Hand and wrist problems among endourologists are very common. J Endourol 2011;25(12):1905–1920. Tjiam IM, Goossens RH, Schout BM et al. Ergonomics in endourology and laparoscopy: an overview of musculoskeletal problems in urology. J Endourol 2014;28(5):605–611. Mariani AJ. Combined electrohydraulic and holmium:YAG laser ureteroscopic nephrolithotripsy of large (greater than 4 cm) renal calculi. J Urol 2007;177(1):168–173.

40 Riley JM, Stearman L, and Troxel S. Retrograde

41

42

43

44

45

46

47

48

49

50

ureteroscopy for renal stones larger than 2.5 cm. J Endourol 2009;23(9):1395–1398. Bader MJ, Gratzke C, Walther S et al. Efficacy of retrograde ureteropyeloscopic holmium laser lithotripsy for intrarenal calculi >2 cm. Urol Res 2010;38(5):397–402. Hyams ES, Munver R, Bird VG et al. Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi‐institutional experience. J Endourol 2010;24(10):1583–1588. Aboumarzouk OM, Monga M, Kata SG et al. Flexible ureteroscopy and laser lithotripsy for stones & gt >2 cm: a systematic review and meta‐analysis. J Endourol 2012;26(10):1257–1263. Takazawa R, Kitayama S, and Tsujii T. Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2 cm or greater. Int J Urol 2012;19(3):264–267. Cohen J, Cohen S, and Grasso M. Ureteropyeloscopic treatment of large, complex intrarenal and proximal ureteral calculi. BJU Int 2013;111(3 Pt B):E127–E131. Miernik A, Schoenthaler M, Wilhelm K et al. Combined semirigid and flexible ureterorenoscopy via a large ureteral access sheath for kidney stones >2 cm: a bicentric prospective assessment. World J Urol 2014;32(3):697–702. Carey RI, Gomez CS, Maurici G et al. Frequency of ureteroscope damage seen at a tertiary care center. J Urol 2006;176:607–610. Defidio L, De Dominicis M, Di Gianfrancesco L et al. Improving flexible ureterorenoscope durability up to 100 procedures. J Endourol 2012;26(10):1329–1334. Sabnis R, Ganesamoni R, Doshi A et al. Micropercutaneous nephrolithotomy (microperc) vs. retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial. BJU Int 2013;112(3):355–361. Yaxley JW, Coughlin GD, Chambers SK et al. Robot‐ assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. The Lancet 2016;388:1057–1066.

687

689

SECTION 4 Shock-Wave Lithotripsy

691

58 Physics of Shock‐wave Lithotripsy Andreas Neisius1 & Pei Zhong2 1

 Department of Urology, Brüderkrankenhaus Trier, Johannes Gutenberg University, Mainz, Germany  Department of Mechanical Engineering and Materials Science, Duke University, Durham, NC, USA

2

­Introduction Since its inception in the early 1980s shock‐wave lithotripsy (SWL) has become the treatment of choice for the majority of urinary stones because of its non‐invasiveness compared to traditional stone treatments [1–3]. In the early 1990s more than 85% of stone patients in Europe and the United States were treated with SWL [4]. Although this trend has been in decline since then because of the rapid advance in endourological technology and technique, still about 70% of kidney stone patients in 2002 and fewer than 50% in 2005 were managed by SWL [2, 4–6]. A primary factor that has contributed to this gradual decline in the clinical use of SWL is the reduced treatment efficiency, compounded by the increased retreatment rate and higher risk of tissue injury produced by the second‐ and third‐generation lithotripters, compared to the first‐generation HM3 lithotripter [7, 8]. Although SWL technology has evolved significantly over the past two decades, there is still debate regarding the physical basis and clinical benefits of technical modifications such as the tight focal width and high peak pressure fields often used in many contemporary lithotripters [9–11]. Better design as well as effective and safe use of shock‐wave lithotripters must rely on a clear and fundamental understanding about the physics of this innovative technology. The physics and acoustical principles of SWL have been reviewed previously [12–14]. This chapter will therefore focus on the most salient features of SWL physics that are relevant to understanding the mechanisms of stone comminution and tissue injury with emphasis on contemporary technologies. The materials

in this chapter are condensed in acoustics and physics content from a recent review of the topic by the senior author [15], but otherwise expanded based on the latest studies in order to provide a guideline for better lithotripter design, and effective and safe clinical use of this non‐invasive technology for stone management.

­ verview of the clinical goal O and physical process in SWL The overarching goal of SWL is to pulverize kidney stones into gravels for spontaneous discharge in urine without inflicting adverse effects to surrounding tissues. As illustrated in Figure  58.1, disintegration of kidney stones by focused shock waves is a progressive process in which fragments of different size, shape, and distribution in the renal collecting system will be produced that may all influence the clinical outcome. In particular, the rate of stone comminution is not uniform throughout SWL. Stone disintegration accelerates initially within a few hundred shocks, followed by a gradually decelerating process towards the end of treatment. This critical observation suggests that different mechanisms of stone fragmentation may exist during the course of SWL, a unique feature that was not taken into account in the design of the second‐ and third‐generation lithotripters. To succeed in SWL, it is important to gain a fundamental understanding about acoustic waves (Box  58.1), the characteristics of focused shock waves produced by lithotripters (Box  58.2), and the physical basis for the optimal selection of lithotripter parameters and treatment protocol (or strategy) to maximize stone comminution while minimizing tissue injury.

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

Section 4  Shock-wave Lithotripsy

Figure 58.1  (a) Progressive comminution of a 10 mm spherical artificial stone in a membrane holder. (b) Dose‐dependence in stone comminution (solid lines) and normalized rate of stone comminution (dashed lines) produced by a contemporary electromagnetic shock‐wave lithotripter. Source: from [15] with permission of Springer‐ Verlag, Berlin, Heidelberg.

(a) 0

100

250

500

1 000

2 000 (shocks)

(b) 100

1.0

90

0.9

80

0.8

70

0.7

60

0.6 Hard begostone Soft begostone

50

0.5

40

0.4

30

0.3

20

0.2

10

0.1

0

0

250

500

750

1000

1250

1500

1750

Normalized rate of stone comminution

Stone comminution (%)

692

0 2000

Number of shocks

Box 58.1  Basics of acoustic waves [12]. An acoustic (or sound) wave is a form of mechanical vibration that propagates within a fluid (either gas or liquid). The wave locally compresses the fluid particles, i.e., the molecules are forced closer, pushing against each other. Compression in one region is accompanied by rarefaction (or tension) of the fluid particles in the adjacent region due to conservation of mass. This alternating vibration of compression and tension leads to the formation of a “wave” that travels through the fluid. The speed of wave propagation (referred to as the sound speed) is a  material property of the medium, which is about 340 m/second in air, and about 1500 m/second in water and most soft tissues of the body. Notably, individual molecules of the medium do not travel with the acoustic  wave; rather they just jostle adjacent molecules. Therefore, the medium serves as a carrier for the acoustic wave to propagate. This is an important physical distinction between mechanical waves (e.g., acoustic waves, water waves, elastic waves in solids) and electromagnetic waves (e.g., light waves, radio waves, X‐rays). For electromagnetic waves energy is carried by photons, which may be thought of as particles that physically travel through space without the need of a carrier medium. For example, light can travel through a vacuum; in contrast, sound cannot.

­ eneral principles of shock‐wave G lithotripsy All clinical lithotripters are constructed using four primary components: (i) shock‐wave generator, (ii) focusing device, (iii) coupling medium, and (iv) stone localization system. The original Dornier HM3 lithotripter employed a water tub for coupling to ensure effective transmission of the lithotripter‐generated shock wave (LSW) without significant loss of energy at the patient’s surface (Figure 58.2a). In contrast, for operation convenience all contemporary lithotripters use dry coupling modalities with a water cushion system (such as the Siemens Lithoskop shown in Figure  58.2b). Three primary types of shock‐wave lithotripters have been developed – electrohydraulic (EH), electromagnetic (EM), and piezoelectric (PE) shock sources – with a variety of focusing systems (Figure 58.3). Stone localization in modern lithotripters is performed using isocentric C‐arm fluoroscopy with optional inline or offline ultrasound imaging [3]. The combination of the shock‐wave generator and the focusing device determines the main characteristics of the lithotripter field. Shock‐wave generation In EH lithotripters, a spherically divergent shock wave is generated by a high voltage (12–30 kV) discharge between

58  Physics of Shock‐wave Lithotripsy

Box 58.2  Basics of lithotripter‐generated shock waves. planar shock front followed by diffracted waves originated from the aperture of the shock‐wave source [14, 23]. LSW can be significantly attenuated when propagating through interposing skin and soft tissues to reach the kidney stone. Although the pulse profile of the LSW remains similar, there is about 30% reduction in p + with a concomin tant threefold increase in the rise time of the shock front p B 1 (1) and 44–67% broadening of the focal width from in vitro to 0 in vivo [24]. Thermal effects in SWL are negligible. In clinical where p and ρ are the pressure and density of water SWL, a pulse repetition frequency (PRF) of ≤ 2 Hz is typically immediately behind the shock front, ρ0 is the density of utilized. However, even at a PRF of 100 Hz, the accumulated water under ambient conditions, B (= 3000 bars) is a temperature increase produced by a clinically relevant characteristic constant, and n = 7.15 [22]. It can be shown shock‐wave exposure was estimated to be less than 2 °C [25]. based on conservation of mass and momentum analysis Therefore the interaction of LSWs with biological tissues that the Mach number at the shock front (Ms = c/c0; and renal calculi is primarily through nonthermal mechaniwhere c is the speed of the shock front and c0 is the cal effects. In comparison, electromagnetic (EM) and piezoelectric sound speed in water under ambient conditions) is (PE) lithotripters have a larger dynamic range in pressure determined by [14]: output, longer lifetime of the shock source, and more stable r rn 1 (2) output than electrohydraulic (EH) lithotripters. Clinically, EM Ms2 , with r and EH lithotripters are more commonly used because n r 1 0 of  their broader focal width in combination with the Considering that positive peak pressure p + in a lithotripter higher  effective acoustic pulse energy produced than PE field is usually below 100 MPa, equations (1) and (2) indi- lithotripters [9, 26]. Low energy output compounded with cate a density ratio below 1.05 and a Mach number less narrow focal width of the PE lithotripters result in longer than 1.09 across the shock front of typical lithotripter‐­ treatment time, making them less favorable in high‐volume generated shock waves (LSWs). As a LSW approaches the stone clinics [10, 27]. The primary field parameters of differlithotripter focus, a Mach stem will be formed, leading to a ent types of lithotripters are summarized in Table 58.1. Several different approaches have been used to model the shock‐wave propagation and focusing in a lithotripter [19–21]. Majority of the models use the Euler equations for ­compressible fluids, in combination with the Tai equation of state for water shown below:

the tips of an electrode, which vaporizes and expands supersonically the surrounding fluid. In EM lithotripters, a magnetic field is produced by applying a high voltage (8–20 kV) pulse to a coil in flat, cylindrical, or spherical configuration to inject a strong current into the coil that repels an adjacent thin metallic membrane (in which a counter current is induced) to launch a high‐amplitude acoustic wave into the surrounding fluid. In PE lithotripters, a high‐voltage (1–10 kV) pulse is applied simultaneously to a mosaic of hundreds to few thousands piezoceramic elements that are mounted on a spherical carrier to generate a strong converging acoustic wave towards a common focus. Shock waves in EM and PE lithotripters are formed by nonlinear wave propagation in the coupling medium or interposing soft tissues between the shock source and the lithotripter focus [13]. Shock‐wave focusing Different designs of acoustic reflector and lens have been utilized for shock‐wave focusing. In EH lithotripters, the  spark‐generated shock wave (at F1) is focused by a

truncated ellipsoidal reflector to the second focus (F2) of the ellipsoid where the kidney stones are aligned under imaging guidance. In majority of EM lithotripters, either an acoustic lens or parabolic reflectors are used (Figure  58.3). In PE lithotripters, self‐focusing ensured by the geometrical configuration of the shock‐wave source is typically utilized. Self‐focusing is also employed in a recently developed EM lithotripter by Eisenmenger et al. [16]. Lithotripter‐generated shock‐wave profile and distribution Representative shock waves measured at the focus of the three different types of lithotripters are shown in Figure  58.4. A fiber‐optic probe hydrophone (FOPH) [17] recommended for lithotripter output characterization by the IEC standard is often used for such measurements [18]. All shock waves at the lithotripter focus consist of a leading shock front with a positive peak pressure (p+) of 40–70 MPa (1 MPa is about 10 times the atmospheric pressure) and an associated compressive

693

694

Section 4  Shock-wave Lithotripsy

(a)

(b)

Figure 58.2  Shock‐wave lithotripters: (a) first‐generation Dornier HM3 and (b) third‐generation Siemens Lithoskop. Source: from [15] with permission of Springer‐Verlag, Berlin, Heidelberg.

wave of 1–2 microseconds in duration (1 microsecond = 1 millionth of a second). This fast rise of the compressive wave is referred to as “shock.” After falling to zero there is then a region of tensile wave lasting about 3–5 ­microseconds in duration with a peak negative pressure (p−) about −10 MPa. The entire shock‐wave pulse duration varies from 5 to 10 microseconds. Shock waves

are broadband acoustic waves with a fundamental frequency in the range of 150–800 kHz (Figure 58.4a inset) [13]. As depicted in Figure 58.4a there is a notable pressure oscillation after the tensile wave produced by EM and PE lithotripters but not in EH lithotripters. In contrary to EH lithotripters in which the rise time of the leading shock front is less than 30 ns the shock‐wave rise

58  Physics of Shock‐wave Lithotripsy

Figure 58.3  Different types of shock‐wave lithotripters. EH, electrohydraulic; EM, electromagnetic; PE, piezoelectric. Source: from [15] with permission of Springer‐ Verlag, Berlin, Heidelberg.

EH

EM

PE

(Parabolic reflector) (Self-focusing)

(Acoustic lens)

(a) –10 –15

–40 10

10

10

f (Hz)

20

10 0

–25 –35 –40 10

2

4

6

8

10

t (μs)

(b)

10

10

f (Hz)

PE

–5 –10 –15 –20 –25

40

–30

–30 –35

30

–40 10

10

20

10

f (Hz)

10 0

P–

–10 0

–20

0

PE

50

–20

20

0

60

–15

30

10

–10

EM

–10

dB

dB

–35

30

P+

40

–30

70

0 –5

50

–20 –25

40

EM

dB

60

p (MPa)

EH

–5

50

p (MPa)

70

0

EH

p (MPa)

70 60

0

–20

2

4

6

–10 8

10

0

–20

t (μs)

2

4

6

8

10

t (μs)

p+ (MPa)

20

Radial distance (mm)

40 10 MPa

10

30

20 MPa 30 MPa

35 MPa

0

20

–10

–20

10

140

160

180

200

220

240

0

Axial distance (mm)

Figure 58.4  (a) Pressure waveforms produced by different types of lithotripters and (b) model calculated peak pressure distribution in an EM lithotripter. EH, electrohydraulic; EM, electromagnetic; PE, piezoelectric. Source: from [15] with permission of Springer‐Verlag, Berlin, Heidelberg.

time is about 100 ns for EM and PE lithotripters [13]. In general, pressure amplitudes are machine‐ and output‐ setting‐specific, and the values of p + can vary from 20 to 120 MPa and p − from −4 to −15 MPa (see Table 58.1). Limited aperture size of the shock source causes the pressure field to be elongated along the central axis of the lithotripter to form a so‐called “cigar‐shaped” focus (Figure 58.4b). The size of the lithotripter focal region is measured by the −6 dB focal width (i.e., the dimension in which the positive pressure is equal or above half of p+) along the longitudinal and transverse axis of the lithotripter, respectively. It should be noted that the focal width is only a measure of the tightness of the pressure

concentration in a lithotripter field. In general, the focal width may not be equated to the dimension of the fragmentation zone in a lithotripter field.

­ omposition and physical properties C of kidney stones To understand the mechanisms of stone fragmentation some basic features of kidney stones need to be considered. Kidney stones vary substantially in their chemical composition and structure. Stones are about 95%

695

696

Section 4  Shock-wave Lithotripsy

Table 58.1  Characteristics of different type of shock‐wave lithotripters.

Lithotripter type

C (nF)

V (kV)

Focal length (cm)

Aperture angle (°)

p + (MPa), typical/max

p − (MPa)

tr (ns)

t + (µs)

EH

20–200

12–30

13–17

60–80

20/80

−8 to −10

 0°). Right: shock‐wave incidence on a stone with curved surfaces and sharp corners, (c) at an oblique incident angle (θi > 0°) on a curved surface and (d) wave diffraction at a sharp corner when the incident angle changes abruptly from θi = 0° to θi = 90°, leading to generation of strong shear wave (P−S) and head wave (H) near the lateral boundary of the stone. In water, Pi and Pr denote incident and reflected pressure wave, DW indicates diffracted wave. In stone, P indicates longitudinal (or P) wave, S denotes transverse (or S for shear) wave, and P−S, S−S, and S−P indicate different reflected waves (denoted by the second letter) produced by the incident wave (denoted by the first letter) at stone/water boundaries. Lines with arrowheads indicate rays along the wavefront propagation direction, and dashed lines are used to show the locations of different wavefronts in water and stone.

LSW–stone interaction and resultant cavitation bubble collapse (see Figure  58.6), the stresses produced inside the stone will be significantly intensified at the tips of the pre‐exsiting microcracks, which are the weak spots inside the material (Figure  58.9a). Consequently, if the stress concentration exceeds a threshold value, measured by the fracture toughness of the stone material [38], there will be a progressive opening and growth of the microcracks. They coalesce to form macrocracks (Figure 58.9b), which eventually leads to fracture under repeated LSW bombardments (Figure  58.9c). This dynamic fatigue process is the fundamental mechanism by which stone fragmentation is produced in SWL [14, 39]. Although the theoretical framework has been well described, significant challenges remain in applying the principle of dynamic fatigue to analyze stone comminution because of the lack of understanding about the ­specific mechanisms that drive fracture formation in kidney stones during SWL [40, 41].

Traditional theories of stone fragmentation Extensive research has been devoted to uncover the mechanisms of stone fragmentation in SWL since the invention of this remarkable technology in the early 1980s. Figure 58.10 shows chronologically the primary mechanisms described previously in the literature, including (i) stress gradient and tensile failure at stone/ fluid boundaries [42, 43], (ii) cavitation [44–46], (iii) spalling [34, 47, 48], (iv) dynamic fatigue [14, 39], (v) quasi‐static squeezing [49], and (vi) dynamic squeezing

[41]. Several of these mechanisms, however, are either descriptive or based on stone fracture observed in the early stage of SWL under special circumstances. For example, spalling damage is often produced in large stones with flat surfaces such as a slab (or in lithotripters with a narrow focal width) at the beginning of SWL when the reflected tensile wave from the leading compressive component is superimposed constructively with the trailing tensile component of an advancing refracted P wave (see Figure 58.7a). Spalling will gradually become less effective as the size of fragments decreases [34] or in stones with curved boundaries [40] or when wave attenuation in the stone material is high [50]. As illustrated in Figure 58.8, the intensity of the P wave will decrease when the incident LSW impinges on a flat stone surface from an oblique angle (Figure  58.7b) or a stone with curved boundaries (Figure  58.7c). Moreover, although the importance of shear waves in stone comminution has been recognized for years [34, 40, 41, 49], the mechanism of shear wave generation was not adequently clarifed. In particular, “dynamic squeezing” has often been described in the literature as the dominant mechanism to create strong shear in stones [3, 41] using an idealized stone geometry (i.e., a cylindrical stone placed on the axis of the lithotripter with its flat surface facing the incident LSW). In contrast, as shown in Figure 58.8, the strong shear waves in kidney stones with smooth or curved surfaces are generated by the mode conversion at the proximal surface of the stone produced by the oblique incidence of the LSW based on the acoustical principles described in Box 58.3.

699

Section 4  Shock-wave Lithotripsy

(a)

(b) Cystine

1.0 0.8 0.6 0.4 0.2 0

Pi P

θi SP

P

Pi

Pi

Pi

(c)

1.0 UA 0.8 0.6 0.4 0.2 0 CA

0

40 60 20 ϴi (degrees)

80

θi

P

6.8 μs

Z

2.1 μs

P

θi

P

COM

9.3 μs

6.8 μs

4.7 μs

4.7 μs

P 2.1 μs (MPa)

2.1 μs

0.4 0 –0.4

1.0 0.8 0.6 0.4 0.2 0 2.0 μs

–0.8

60

40 2.0 μs

2.0 μs

2.0 μs

1.4 μs

1.2 μs

20

1.0 0.8 0.6 0.4 0.2 0 1.4 μs 0

S 5.8 μs

0.8

1.0 0.8 0.6 0.4 0.2 0 2.1 μs

–0.4

Pi S

ε(max)

4.7 μs

Dstone

P

ε(max) UA × 10–2

COM

–20

0

P

Pi

Pi

1.0 0.8 0.6 0.4 0.2 0 4.7 μs

20

1.0 MAPH 0.8 0.6 0.4 0.2 0

θi

Pi

S 5.2 μs

σT(max)

σT(max) 1.0 UA (MPa) 0.8 0.6 60 0.4 0.2 0 9.3 μs 40

Brushite

1.0 0.8 0.6 0.4 0.2 0

1.0 0.8 0.6 0.4 0.2 0

PS

S

4.0 μs S

S

1.1 μs

S Pr

1.0 COM 0.8 0.6 0.4 0.2 0

Energy flux density ratios

700

0 1.2 μs 0.4

–0.4

–20 0

0.4

–0.4

0

0.4

–0.4

0

0.4

r Dstone

Figure 58.8  (a) Variations in wave reflection and refraction (transmission) coefficients with incident angle (θi) for kidney stones of different compositions; (b) ray tracing showing the generation of P and S waves, and propagation and focusing of S wave in a spherical stone; and (c) transient LSW–stone interaction, generation of different stress waves, and the production of maximum tensile stress (σT(max)) and maximum tensile strain (εT(max)) inside COM and UA stones of spherical geometry. Reproduced with permission of Ying Zhang.

Contemporary theories of stone fragmentation While the traditional theories of stone fragmentation often focus on mechanims responsible for creating the initial fracture, contemporary theories of stone fragmentation [15, 51] aim at identifying the key lithotripter field parameters and their interactions that govern the overall process of stone comminution to achieve the

ultimate goal of SWL. Based on dimensional analysis (a tool used by engineers to identify the key nondimensional [or unitless] parameter of a particular problem, such as the Mach number for describing the compressibility of a fluid), recent studies have demonstrated a clear correlation between stone comminution and the average peak positive pressure (P+(avg)), or the local peak positive pressure of the LSW, incident on the stone

58  Physics of Shock‐wave Lithotripsy

(a)

σ

(b) σlocal

I

Microcracks

σ

δcr

r

II

δ

Initial flaws

Macrocrack

III III

Damaged

l l Cohesive zone

Undamaged

II I

σ

(c) o Sh ck W e av

1

n atio orm def stic Ela

0

sy

rip

ot

th

Li

σ σfr

Cr

Crack coalescence

ac

k

G

ro

δ/δcr

wt

h

1

Figure 58.9  Fundamental fracture mechanics. (a) Stress concentration near a crack tip and three primary modes of brittle fracture: mode I, opening mode due to tensile stress applied normal to the plane of the crack; mode II, sliding mode due to shear stress acting parallel to the plane of the crack and perpendicular to the crack front; and mode III, tearing mode due to shear stress acting parallel to the plane of the crack and parallel to the crack front. (b) Cohesive zone model of dynamic fatigue failure of brittle materials. (c) Progressive microcrack opening, growth, and coalescence in kidney stones during SWL. Symbol σ indicates stress and δ denotes crack tip displacement with subscripts “fr” and “cr” correspond to “fracture” and “critical,” respectively. Source: from [15] with permission of Springer‐Verlag, Berlin, Heidelberg.

s­ urface [51]. As shown in Figure 58.11a, this correlation holds true for both hard and soft artificial BegoStone of different geometries and sizes, which cover the broad range of acoustic and mechanical properties measured from kidney stones. More importantly, the results show that there is a distinct threshold of P+(avg) (denoted by Pf) for each stone type to initiate fragmentation, independent of the fluid medium around the stone. Hard BegoStone has a higher Pf than soft BegoStone, indicating that material properties of the stone such as the shear modulus (G) or Young’s modulus (E) may also be important in determining the fragmentation outcome. P avg Pf In fact, a new nondimensional parameter, Z , G in which G can be replaced by E or K (bulk modulus), has been constructed that unifies all the fragmentation results from both the hard and soft BegoStone samples treated in water [15]. Physically, Z indicates that stone fragmentation in SWL is manifested by the competition

between P+(avg) that represents the impact load imposed by the LSW on the stone and G (or E) that represents the resistance of the stone materials against shear‐ (or ­tension‐) induced material deformation. During SWL, kidney stones are fragmented progressively to smaller and smaller pieces (see Figure 58.1a). It has been shown as the stone (or fragment) size decreases, the P+(avg) threshold will increase [36] (see also Figure 58.11b). This observation has been attributed to the destructive wave interference in stones of small sizes, which will reduce the maximum tensile stress or stress integral that can be built up inside the stone to produce fracture (Figure 58.12a). This finding is consistent with the monotonic decrease in the rate of stone comminution after the initial accelerating phase in stone comminution observed during SWL (see Figure 58.1b). Furthermore, shape and orientation can also profoundly influence the location and magnitude of the maximum tensile stress produced in stones of ellipsoidal geometry with equal

701

(a)

(b)

A

C

(c)

B

(e) HTR

HTR

PI

PTR

PI 0.6 0.4

STR

PT

(d)

STR PR

S

0.2 S

PT

HTS

PR

0.3

0

–0.2 HTS

σ

(f)

(g)

–0.4 –0.6 –0.2 0

8.8 0.2 0.6 0.6 0.8

(h)

Macrocrack Damaged

Pi

p δ

l l Cohesive zone

1.2 1.4

(i)

Microcracks δcr

1

Initial flaws

Cleavage by strain

Undamaged p

σ

Figure 58.10  A chronological list of different proposed mechanisms for stone fragmentation in SWL. (a) Stress gradient and tensile failure at stone/fluid interface, (b, c) cavitation damage, (d, e) spalling and corner fracture due to reflected tensile wave, and shear‐enhanced damage, (f ) dynamic fatigue, (g) compression‐induced tensile failure, (h) quasi‐static squeezing, and (i) dynamic squeezing. Source: from [15] with permission of Springer‐Verlag, Berlin, Heidelberg.

58  Physics of Shock‐wave Lithotripsy

(a)

(b)

100

Hard stone (in H2O) R2 = 0.91 Hard stone (in But.) R2 = 0.88 Soft stone (in H2O) R2 = 0.98 Soft stone (in But.) R2 = 0.98

90 Stone comminution [%]

80

Spherical begostone (r=5 mm)

70

z

4 mm steps in focal plane

60

Cylindrical stones (equal height and diameter) of different sizes with matched total mass

r Tube holder (r = 7 mm)

50

–20 mm

40 30

–10 mm

20

8.8

LSW

5.1

10 0

10 mm hard stone (in H2O) R2 = 0.92 7 mm hard stone (in H2O) R2 = 0.95 4mm hard stone (in H2O) R2 = 0.87

3

7.9

7.6

14.4

LSW 9

21

12

21

9 12 P+(avg) [MPa]

30 3

P+(avg) [MPa]

30

Figure 58.11  Correlation between stone communication and the average peak pressure P+(avg) incident on the stone. (a): 10 mm spherical hard and soft stones, adapted from [51]. (b): cylindrical hard stones of different sizes with matched total mass, adapted from [36]. The P+(avg) threshold for initiating stone fragmentation is indicated by arrows in different cases. Source: from [51] with permission of Elsevier.

(b)

8

180 Max (σT) distributed pressure

Max (σT) (MPa)

6

4

140

120

100

2

2

4

6 8 10 Stone diameter (mm)

12

0

(σT – σ0)2 dt (×109 Pa2 s)

(σT – σ0)2 dt

160

σT (max) in ellipse/σT (max) in sphere

(a)

P (MPa) 20 10

1.37

σT (max) (MPa) 120

1.4

80

0

1.2

40

1

–10

1.17

0

–20

0.8 d L 0.6

d s

0.97

L

0.4 0.2

0.77 –1

Pi

–0.8 –0.6 –0.4 –0.2 0 0.2 Eccentricity

0.4

0.6

0.8

0

Figure 58.12  (a) The effect of size on the maximum tensile stress (red) and tensile stress integral (blue) produced inside spherical stones. Source: from [36] with permission of Elsevier. (b) The effect of eccentricity on the magnitude and location of the maximum tensile stress produced in stones of ellipsoidal geometry (courtesy of Ying Zhang). In both cases, stones are subjected to the lithotripter field of a Siemens Modularis with a peak pressure of about 45 MPa.

v­olume but different eccentricities (Figure  58.12b). As eccentricity increases, the “hot” spot corresponding to the region of maximum tensile stress will shift from the anterior to posterior surface of the stone with decreased stress magnitude. In summary, it is worth noting that the size of the fragmentation zone of a lithotripter is determined by Pf (i.e., the dimensions around a lithotripter focus where the local peak positive pressure is equal or above Pf). At a given output setting, the fragmentation zone of a lithotripter will vary for different types of kidney stones (because of their varying elastic stiffness), and will be

affected by stone geometry and size (because of their influence on internal wave focusing and interference). In general, the size of the fragmentation zone of a lithotripter will decrease as the treatment progresses unless the ­output energy is ramped up at the risk of higher propensity for tissue injury. Role of cavitation in stone fragmentation In contrast to stress‐wave‐induced fracture, cavitation produces primarily surface erosion due to the localized strong secondary shock wave or microjet impact from

703

Section 4  Shock-wave Lithotripsy

inertial (symmetric or asymmetric) collapse of bubbles near the stone boundary [52] (see also Figure  58.6). Damage produced by cavitation is largely confined on the surface and does not penetrate deep into the bulk of the stone [53]. Although cavitation activities will intensify as fragmentation progresses [54], it has been shown that stone comminution produced by cavitation alone in SWL is very limited [53]. On the other hand, as shown in Figure 58.11 and other studies, stone comminution produced by stress waves without cavitation will also be significantly reduced [41, 53, 55, 56]. All in all, it has been suggested that both stress waves and cavitation are needed simultaneously in SWL, and they act synergistically to produce effective and successful stone comminution [53]. A heuristic model of stone comminution in SWL Recently, a heuristic model that describes the overall progression of stone comminution in SWL has been developed, accounting for the contribution of two important lithotripsy parameters: (i) P+(avg) (controlled by the output kV or energy setting of the lithotripter) and (ii) dose of the shock waves delivered [57]. The model is based on the Weibull theory for brittle fracture [58], incorporating threshold values of P+(avg) and dose that are required to initiate fragmentation. Validated by experimental data obtained both in water and 1,3‐butanediol (a viscous medium that suppresses cavitation, but with  similar acoustic impedance to water so that LSW ­transmission and generation of stress waves in the stone are not affected), the model provides physical insight that may directly benefit the design and implementation of safe and effective treatment protocols in SWL. For

example, the asymptotic lines in the contour plot of stone comminution in Figure  58.13 suggests that effective treatment can be achieved by using moderate P+(avg) in the range of 15–20 MPa within 2000 shocks. Increasing P+(avg) beyond 20 MPa would not necessarily accelerate stone fragmentation, but may increase the propensity for tissue injury. Similarly, the model also indicates that in the low P+(avg) range of 10–15 MPa prolonged treatment to high doses will only marginally improve stone comminution, at the cost of longer treatment time and, potentially, elevating the risk of tissue injury. The ­optimal treatment strategy appears to be a progressive ramping of the lithotripter output (and thus P+(avg)) that can achieve effective stone comminution with minimal risk of tissue injury, as illustrated by the dashed line in Figure 58.13. A unified theory of stone comminution in SWL Figure 58.14 summarizes the mechanisms and processes of stone comminution in SWL. At the beginning (within a few hundred shocks), multiple mechanisms can be effective in producing fracture because the initial large size and smooth geometry of the stone favor wave focusing and constructive interference of different stress waves produced inside the stone by LSW–stone interaction. Moreover, the pre‐existing (or intrinsic) flaws in the stone provide ample weak spots to intensify tensile stress and, as a result, stone fragmentation accelerates. Thereafter, fragments of irregular shapes and smaller sizes are produced, which disrupt the conditions required for internal wave focusing and constructive wave interference. Further, the intrinsic flaw population is gradually depleted, making

25 60

30 20

20

P+(avg) [MPa]

704

+

50

10

68.5 ± 5.0

+

15

60 30 20

10

77.2± 2.9 80 70

50 40

10 1

77.1 ± 2.2

70

40

90

80

10

20 1

30

40 10

50 20

60 30 1

5 R2 = 0.93 (n = 35) 0

0

250

500

1000 Dose

2000

Figure 58.13  A heuristic model of stone comminution in SWL, adapted from [57]. The contour lines (with numbers) denote the percent of stone comminution as a function of the average positive pressure incident on the stone (P+(avg)) and shock‐ wave number delivered (dose). The dashed line shows an example of the optimal treatment strategy with pressure ramping in SWL. Source: from [57] with permission of Acoustic Society of America.

58  Physics of Shock‐wave Lithotripsy P(z,r)

Initial phase: 1. Multiple mechanisms at play all together

pf

2. Large stone size and smooth geometry enhance wave focusing

250 ~ 2,000 shocks

rrff

r Microjet

3. Accelerating rate 4. Fracture occurs at intrinsic weak spots inside the stone

100 ~ 250 shocks

0 ~ 100 shocks 200 SWs

0 SWs

SW

SW

300 SWs

SW

350 SWs

SW

Later phase: LSW LSW A. Stress wave inside the stone

B. Cavitation in the fluid surrounding the stone

1. Driven by incident pressure wave 2. Small stone size and irregular geometry inhibit wave focusing 3. Decelerating rate 4. Fracture enhanced by extrinsic weak spots (pitting from cavitation) on the surface of residual fragments

Lithotripter shock wave (LSW)

Figure 58.14  Summary of the mechanisms and processes of stone comminution in SWL, adapted from [15]. The radius of effective fragmentation zone in the lithotripter field is denoted by rf. Micro‐CT images are adapted from [102] and from images taken by James Williams Jr. Source: from [102] with permission of Acoustic Society of America.

it more difficult to initiate fracture from inside the stone. In addition, after the initial fracture spreading of stone fragments away from the lithotripter focus will effectively reduce the P+(avg) incident on the residual fragment population. Altogether, these multiple factors dictate that stone comminution will decelerate as the treatment progresses. Consequently, in the late stage (if not majority) of SWL, the dominant mechanism of stone comminution is likely to be the P+(avg)‐driven opening of surface (or extrinsic) flaws produced by cavitation damage, through a synergistic interaction between stress waves (including surface acoustic waves) and cavitation‐generating surface pitting [15].

­Tissue injury There is no doubt that LSWs can cause trauma to renal tissues surrounding the stone, and, in a very few severe cases, even resulted in death of the patient [59–61]. A detailed description of the various clinical complications of SWL is given in Chapter 63 of this book. Here we will

focus on reviewing the potential physical mechanisms of shock‐wave–tissue interaction that may lead to injury. As mentioned earlier in this chapter, the cigar‐shaped focal region of a lithotripter exceeds the average stone size along the propagation direction of the incident shock waves. Therefore, a significant volume of the kidney, including the perirenal tissues, will be exposed to high‐energy and high‐pressure shock waves. Moreover, the patient’s motion (due to respiration or pain‐induced movements) will exacerbate the risk of tissue injury because a significant portion of the shock waves (30–40%) may completely miss the target stone and hit the renal tissue solely [62, 63]. As a result, a higher dosage of shock waves will be needed in a single treatment session, which further increases the risk of renal injury [63]. Tissue injury in SWL has been described mainly as vascular lesions in the form of endothelial cell damage and rupture of small blood vessels along the lithotripter beam path throughout the thickness of the kidney [64, 65]. Based on in vitro phantom and in vivo animal studies, shear stress [66, 67] and cavitation [68–71] have been hypothesized to be the two main physical mechanisms

705

706

Section 4  Shock-wave Lithotripsy

responsible for tissue injury. Shear stress can be generated by the propagation of LSW through inhomogeneous tissue spaces [14, 39, 67] that may cause injury by accumulated shear deformation, especially in the papilla and at high pulse repetition frequency (PRF) [66]. In addition, LSW‐generated rapid and large intraluminal bubble expansion and collapse with resultant significant hoop stress imposed on the vessel wall may cause r­ upture of capillary and small blood vessels [71, 72]. In contrast, damage in large blood vessels or in the interstitial hemorrhage site may be mediated by LSW–bubble interaction with jet formation [73], a scenario that may be responsible for the deep poration of renal parenchyma produced by narrow focal width and high peak‐pressure lithotripters [74]. Furthermore it has been demonstrated that injection of contrast agents for imaging prior to SWL can greatly increase the propensity of renal injury and should be avoided [68, 70]. Although the mechanisms of tissue injury have not been completely understood, several risk factors for tissue injury have been identified, including lithotripter output settings such as PRF, output energy and energy flux density, total number of shocks, and patient characteristics such as pre‐existing hypertension in older ­people, pre‐treated kidneys, and pediatric patients [59, 69, 75–77]. Tissue injury in SWL increases substantially at high PRF [69]. Compared to the early days of SWL, it has been advocated in recent years that shock waves should be administered at a slower rate [9]. The benefit has been demonstrated in HM3 that even at the highest output setting of 24 kV tissue injury can be significantly diminished when PRF is reduced from 2.0 to 0.5 Hz [78]. Moreover, current clinical treatment protocols often include an initial priming of the kidney with a low dose of shock waves (i.e., ≈500) at low energy levels followed by a few minutes pausing of the treatment, which has been demonstrated by animal experiments in HM3 to exhibit a protective effect probably due to vasoconstriction [79–81]. However, the mechanism of this tissue‐protective strategy is not completely clear and needs to be thoroughly investigated using contemporary lithotripters under clinically relevant output settings.

­New technologies in SWL Lithotripters with broad focal width and low peak pressure Motivated by the success of the self‐focusing EM lithotripter (XX‐ES) [16], there is a resurgence of new clinical lithotripters (e.g., LG‐380 and Lithospace) with broad focal width and low peak pressure, which are the acoustic

field characteristics exemplified by the original HM3. Comparison studies between broad focal width (18– mm)/low peak pressure (12–30  MPa) lithotripters 20  (LG‐380 and XX‐ES) and a narrow focal width (≈2.6 mm)/ high peak pressure (≈90 MPa) lithotripter (SLX) have shown that the former can disintegrate stones more ­effectively in a large area around the lithotripter focus [82]. The high peak pressure of the SLX, while beneficial for breaking up stones located precisely at the lithotripter focus, is also responsible for producing more tissue injury [83]. Moreover, the narrow focal width/high peak pressure lithotripter field with its inherently large pressure gradient will exert a strong radiation force on the target stone that may cause more fragment dispersion. In contrast, LG‐380 and XX‐ES with minimal tissue injury produced even at their maximum output settings are considered relatively safe lithotripters [82]. The advantages of a broad focal width/low peak pressure lithotripter in stone fragmentation have also been attributed to other factors, including (i) a more uniform cavitation field, (ii) progressive fragmentation of the stone, (iii) less dispersion of residual fragments, and (iv) higher P+(avg) or local positive pressure at off‐axis locations in the lithotripter field [51, 52, 57, 84]. Overall, a lithotripter with broad focal width and low peak pressure will be more effective for treating stones that are less accurately aligned with the lithotripter focus, or when residual fragments are dispersed or significantly translated away from the lithotripter focus due to respiratory motion of the patient [84]. New acoustic lens design for electromagnetic shock‐wave lithotripters Over the past two decades, EM shock‐wave lithotripters have become the technology of choice primarily due to the durability and reproducibility in output pressure and acoustic pulse energy [85]. However, compared to the gold standard HM3, several fundamental drawbacks exist in EM lithotripters: including (i) the relatively ­narrow focal width, (ii) the non‐idealized pressure waveform exemplified by the secondary compressive wave immediately following the tensile wave, and (iii) the significant shift in the locations of p + (i.e., acoustic ­ focus) and peak negative pressure (p−) towards the shock source, especially at high output settings [86, 87]. These fundamental drawbacks have been recently addressed through acoustic lens modification of the Modularis lithotripter. By introducing a groove in the outer region of the original lens (Figure 58.15), the second compressive wave can be eliminated while the focal width of the lithotripter is broadened simultaneously via in situ pulse superposition [86]. Under the same effective acoustic pulse energy, the new lens design leads to a lower p + on the lithotripter axis, but higher off‐axis local peak pressure

58  Physics of Shock‐wave Lithotripsy

(a)

­ ther emerging technologies O and techniques in SWL

(b) Original lens

Ellipsoidal surface

New lens

(Spherical surface facing up)

(c)

z

Geometric focal plane (new) Geometric focal plane(orig.)l Target acoustic focal plane (new)

r Ø10 mm spherical BegoStone

Ellipsoidal surface (ae, be) Δt

Spherical surface (Rs)

Orig. lens

Coil

New lens

Ri

h

Source Ru

Ro

(........ indicates orig. lens geometry)

Figure 58.15  Improvement of contemporary electromagnetic shock‐wave lithotripter through lens modification. Source: from [87] with permission of PNAS.

with stronger cavitation activity [87]. Moreover, by reshaping the lens geometry the location of the acoustical focus at high energy settings can be aligned closely with the geometric focus of the lithotripter where kidney stones are placed during treatment. Both in vitro and in vivo studies have demonstrated that the new lens can significantly improve stone comminution with ­minimal tissue injury under clinically relevant energy settings [87]. Because of the simplicity in the modification, this design upgrade of acoustic lens or reflector can be easily implemented in principle in all clinical EM shock‐wave lithotripters.

There are other emerging technologies under investigation that require substantial modifications of the lithotripter system. For example, tandem pulse technology has been extensively evaluated in a hybrid EH‐PE shock source with coaxial alignment [88, 89], dual shock‐ head source aligned either opposite to each other [90], or at an acute angle [91], and a single PE source driven by a dual high‐voltage pulse generator [92], all aimed at ­promoting the contribution of cavitation in stone comminution. Despite proof of principle, challenges exist in the cost‐effective integration of the tandem pulse technology in clinical lithotripters and evaluation of its impact on tissue injury. Treatment monitoring is another area with active research, including stone targeting via spectral Doppler ultrasound [93] and assessment of stone fragmentation via cavitation‐produced acoustic emission [94] or acoustic scattering from residual fragments  [95]. In most cases, further refinements are needed before clinical applications. It should be noted that there is no current imaging technology that can monitor tissue injury ­during SWL. More recently, transcutaneous pulsed focused ultrasound has been demonstrated to displace stones or fragments in the renal collecting system without thermal damage [96]. This technology may be used to facilitate stone clearance following successful SWL. Focused ultrasound has also been used in burst wave lithotripsy to effectively fragment artificial and natural stones fixed on a holder in vitro using focal pressure of 6.5 MPa at less than 200 Hz burst repetition rate [97]. Further studies under clinically relevant conditions and in vivo experiments to assess potential tissue effects are warranted [97]. Finally, several techniques of cavitation manipulation have been demonstrated in vitro for either removing residual bubbles in the coupling medium using a turbulent jetting flow [98] or along the lithotripter beam path [99, 100] and near the stone surface using low‐pressure ultrasound bursts [101] for improved treatment efficiency.

­Summary As a remarkable engineering innovation, SWL truly ­represents a milestone in the surgical management of urolithiasis. Because of its non‐invasiveness and easy of use, SWL still remains as the therapy of choice for a majority of patients with kidney and upper urinary stones. In parallel to the widespread clinical applications, our understanding about the general physical principles

707

708

Section 4  Shock-wave Lithotripsy

Box 58.4  Future outlook. ●●

●●

●●

Development and integration of novel SWL technologies into contemporary clinical shock‐wave lithotripters, including the design of new shock source and focusing device, miniature wet coupling technique, adaptable and steerable beam formation in lithotripter fields, cavitation control and monitoring. Development of real time (acoustic) tracking of the stone or large residual fragments to fire shock waves only if the stone is in the focal zone. Development of acoustic techniques to monitor stone comminution process so that the treament can be stopped once the stone is sufficiently fragmented. Development of new imaging techniques for real‐time monitoring of hemorrhage and hemotama formation in peri‐ and intra‐renal tissues, which will be crucial and necessary for establishing a pressure or energy flux

●●

●●

and process of SWL has improved significantly in the past two decades. The state‐of‐the‐art theories regarding stone fragmentation and tissue injury during SWL are reviewed in this chapter. In the following, we summarize several main points pertinent to current status of SWL together with future overlook outlined in Box 58.4: ●●

●●

●●

●●

EM and EH technologies for shock‐wave generation and associated focusing means are predominantly used in contemporary clinical lithotripters while PE technology is less favored because of limited acoustic energy output. There is a trend of resurgence in broad focal width and low peak pressure lithotripters, exemplified by the original HM3. Dry coupling has replaced wet coupling in almost all contemporary lithotripters in favor of user convenience, but at the cost of providing an imperfect coupling interface between the shock source and the patient. Problems may arise in shock‐wave transmission if care is not taken in ensuring the quality of the coupling interface. The acoustic field of a lithotripter is determined primarily by the design characteristics of the shock source and focusing device. Among clinical lithotripters, the maximum of peak positive pressure of LSWs varies in the range of 20–120 MPa, with the minimum of peak negative pressure in the range of –4 to –12 MPa. The focal width of clinical lithotripters varies from 2 to 20 mm, and is inversely correlated with the aperture angle of the shock source. Stone fragmentation in SWL is the consequence of dynamic fatigue produced by stress waves and cavitation generated by lithotripter shock‐wave–stone interaction. Stress waves (longitudinal, transverse, and

●●

●●

­ ensity based threshold for tissue injury in SWL. With this d knowledge, we’ll be able to better define the lithotripter output parameter space to ensure a safe and effective treatment using high‐energy shock waves. Development of pulsed focused ultrasound techniques for effective and safe fragmentation of kidney stones with reduced treatment time or clearance of residual fragments from the collecting system following successful SWL. Further improvement in the fundamental understanding about the physics of SWL and the mechanisms of stone comminution and tissue injury will help us in rational selection of lithotripter characteristics and output settings to optimize treatment strategy for maximal stone fragmentation with minimal tissue injury and adverse effects.

surface acoustic waves) and associated tensile and shear stresses are the primary driving forces to create fracture, initially from the pre‐existing (or intrinsic) flaws or weak spots in kidney stones. In contrast, cavitation produces pitting and therefore introducing new weak spots (or extrinsic flaws) on the stone surface, leading to weakened mechanical integrity of the stone. Caviation induced in SWL is not sufficiently strong enough to disintegrate stones. Stress waves and cavitation are both necessary and work synergistically to produce effective and successful stone comminution in SWL. Cavitation damage can be considered as catalysts to enhance the efficiency of stress‐wave‐driven stone fracture. Average peak positive pressure incident on a stone, P+(avg), has been identified as a key lithotripter field parameter that is directly correlated with stone comminution. The threshold of P+(avg) to initiate stone fracture depends on the composition, geometry, and size of the stone. Kidney stones with higher wave speeds, acoustic impedance, and fracture toughness, such as calcium oxalate, brushite, and cystine stones, are more difficult to disintegrate than those with lower corresponding values such as uric acid, carbonate apetite, and struvite stones. A new nondimensional parameter Z has been identified that can be used to gauge the effectiveness of lithotripter field in stone comminution. Tissue injury in SWL is related to shear stress and cavitation, yet the exact mechanism has not been completely determined. In SWL, it is crucial to ensure treatment safety before pursuing treatment efficiency. Lowering peak pressure, energy flux density, PRF, and

58  Physics of Shock‐wave Lithotripsy

●●

●●

dose of shock waves delivered in a single treatment have all been demonstrated to lessen the risk of tissue injury during SWL. A heuristic model accounting for the effects of both P+(avg) and dose has been developed to assess the overall process of stone comminution in SWL. The model suggests that a progressive ramping of the lithotripter output (and hence P+(avg)) will be effective for achieving successful stone comminution with minimal risk of tissue injury. New technologies in SWL, such as self‐focused EM shock‐wave lithotripter and the new acoustic lens for

Modularis or other EM shock‐wave lithotripters, have been either developed or demonstrated. Other promising technologies and techniques for improving treatment efficacy and safety will continue to emerge. The integration of new technologies into clinical lithotripters will depend critically on the demand by urologists for better and safer lithotripters as well as the desire of medical device manufactuers to bring them to the markert to alleviate millions of kidney stone patients worldwide from their painful conditions.

­Acknowledgments We would like to thank Dr Glenn Preminger and Dr Michael Lipkin for their long‐term collaborations and support of our research in SWL, and Ying Zhang for producing several figures used in this chapter. This work

was supported in part by Ferdinand Eisenberger Grant NeA1/FE‐11 from the Deutsche Gesellschaft für Urologie (A.N.) and by a NIH grant 4R37DK052985 (P.Z.).

References 1 Chaussy C, Schmiedt E, Jocham D et al. First clinical

2

3

4

5

6

7

8

9

experience with extracorporeally induced destruction of kidney stones by shock waves. J Urol 1982;127(3): 417–420. Chaussy CG and Fuchs GJ. Current state and future developments of noninvasive treatment of human urinary stones with extracorporeal shock wave lithotripsy. J Urol 1989;141(3 Pt 2):782–789. Rassweiler JJ, Knoll T, Kohrmann KU et al. Shock wave technology and application: an update. Eur Urol 2011;59(5):784–796. Finlayson B and Ackermann D. Overview of surgical treatment of urolithiasis with special reference to lithotripsy. J Urol 1989;141(3 Pt 2):778–779. Kerbl K, Rehman J, Landman J et al. Current management of urolithiasis: progress or regress? J Endourol 2002;16(5):281–288. Pearle MS, Calhoun EA, and Curhan GC, Urologic Diseases of America Project. Urologic Diseases in America Project: urolithiasis. J Urol 2005;173(3):848–857. Gerber R, Studer UE, and Danuser H. Is newer always better? A comparative study of 3 lithotriptor generations. J Urol 2005;173(6):2013–2016. Graber SF, Danuser H, Hochreiter WW, and Studer UE. A prospective randomized trial comparing 2 lithotriptors for stone disintegration and induced renal trauma. J Urol 2003;169(1):54–57. Lingeman JE, McAteer JA, Gnessin E, and Evan AP. Shock wave lithotripsy: advances in technology and technique. Nat Rev Urol 2009;6(12):660–670.

10 Lingeman JE, Kim SC, Kuo RL et al. Shockwave

11

12

13

14

15

16

17

lithotripsy: anecdotes and insights. J Endourol 2003;17(9):687–693. Wess O. Shock wave lithotripsy “SWL” and focal size. In: Therapeutic Energy Applications in Urology— Standards and Recent Developments (ed. Ch. HG Chaussy, KU Kohrmann, and D Wilbert), 26–35. Stuttgart: Georg Thieme Verlag KG, 2005. Cleveland RO and McAteer JA. The physics of shock wave lithotripsy. In: Smith’s Textbook on Endourology, 2e (ed. AD Smith, GH Badlani, DH Bagley et al.), 317–332. Hamilton: BC Decker, 2007. Coleman AJ and Saunders JE. A survey of the acoustic output of commercial extracorporeal shock wave lithotripters. Ultrasound Med Biol 1989;15(3):213–227. Sturtevant B. Shock wave physics of lithotriptors. In: Smith’s Textbook on Endourology (ed. AD Smith, GH Badlani, DH Bagley et al.), 529–552. St. Louis, MO: Quality Medical Publishing, 1996. Zhong P. Shock wave lithotripsy. In: Bubble Dynamics & Shock Waves, vol. 8 (ed. CF Delale), 291–338. Berlin: Springer‐Verlag, 2013. Eisenmenger W, Du XX, Tang C et al. The first clinical results of “wide‐focus and low‐pressure” ESWL. Ultrasound Med Biol 2002;28(6):769–774. Staudenraus J and Eisenmenger W. Fibre‐optic probe hydrophone for ultrasonic and shock‐wave measurements in water. Ultrasonics 1993;31:267–273.

709

710

Section 4  Shock-wave Lithotripsy

18 IEC61846 I. 61846 Ultrasonics‐Pressure Pulse

19

20

21

22

23 24

25

26 27

28 29 30

31

32

33

34

35

Lithotripters‐Characteristics of Fields. Geneva: International Electrotechnical Commission, 1998. Averkiou MA and Cleveland RO. Modeling of an electrohydraulic lithotripter with the KZK equation. J Acoust Soc Am 1999;106(1):102–112. Fovargue DE, Mitran S, Smith NB et al. Experimentally validated multiphysics computational model of focusing and shock wave formation in an electromagnetic lithotripter. J Acoust Soc Am 2013;134(2):1598–1609. Iloreta JI, Zhou Y, Sankin GN et al. Assessment of shock wave lithotripters via cavitation potential. Phys Fluids 2007;19(8):86103. Thompson PA. Compressible Fluid Dynamics. Advanced Engineering Series. New York: McGraw‐Hill, 1972. Sturtevant B and Kulkarny VA. Focusing of weak shock‐waves. J Fluid Mech 1976;74:651–671. Cleveland RO, Lifshitz DA, Connors BA et al. In vivo pressure measurements of lithotripsy shock waves in pigs. Ultrasound Med Biol 1998;24(2):293–306. Filipczynski L and Piechocki M. Estimation of the temperature increase in the focus of a lithotripter for the case of high rate administration. Ultrasound Med Biol 1990;16(2):149–156. Rassweiler JJ, Tailly, GG, and Chaussy C, eds. Progress in Lithotriptor Technology. EAU Update Series, 2005. Lingeman JE and Zafar FS. Lithotripsy systems. In: Smith’s Textbook on Endourology (ed. AD Smith, GH Badlani, DH Bagley et al.), 553–589. St. Louis, MO: Quality Medical Publishers, 1996. Coe FL, Evan A, and Worcester E. Kidney stone disease. J Clin Invest 2005;115(10):2598–2608. Pak CY. Pharmacotherapy of kidney stones. Expert Opin Pharmacother 2008;9(9):1509–1518. Williams JC Jr, McAteer JA, Evan AP, and Lingeman JE. Micro‐computed tomography for analysis of urinary calculi. Urol Res 2010;38(6):477–484. Williams JC Jr, Saw KC, Paterson RF et al. Variability of renal stone fragility in shock wave lithotripsy. Urology 2003;61(6):1092–1096; discussion 1097. Bhatta KM, Prien EL Jr, and Dretler SP. Cystine calculi–rough and smooth: a new clinical distinction. J Urol 1989;142(4):937–940. Khan SR, Hackett RL, and Finlayson B. Morphology of urinary stone particles resulting from ESWL treatment. J Urol 1986;136(6):1367–1372. Xi X and Zhong P. Dynamic photoelastic study of the transient stress field in solids during shock wave lithotripsy. J Acoust Soc Am 2001;109(3):1226–1239. Brekhovskikh LM and Godin OA. Acoustics of Layered Media I: Plane and Quasi‐Plane Waves. Berlin: Springer‐Verlag, 1990.

36 Zhang Y, Nault I, Mitran S et al. Effects of stone size

37 38

39

40

41

42

43

44

45

46

47

48

49

50

51

on the comminution process and efficiency in shock wave lithotripsy. Ultrasound Med Biol 2016;42(11): 2662–2675. Dretler SP. Stone fragility–a new therapeutic distinction. J Urol 1988;139(5):1124–1127. Zhong P, Chuong CJ, and Preminger GM. Characterization of fracture toughness of renal calculi using a microindentation technique. J Mater Sci Lett 1993;12(18):1460–1462. Lokhandwalla M and Sturtevant B. Fracture mechanics model of stone comminution in ESWL and implications for tissue damage. Physics Med Biol 2000;45(7):1923–1940. Cleveland RO and Sapozhnikov OA. Modeling elastic wave propagation in kidney stones with application to shock wave lithotripsy. J Acoust Soc Am 2005;118(4):2667–2676. Sapozhnikov OA, Maxwell AD, MacConaghy B, and Bailey MR. A mechanistic analysis of stone fracture in lithotripsy. J Acoust Soc Am 2007;121(2):1190–1202. Chaussy C, Brendel W, and Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet 1980;2(8207):1265–1268. Forssmann B, Hepp W, Chaussy C et al. Method for no‐contact destruction of kidney stones by means of shock‐waves. Biomedizinische Technik 1977;22(7–8):164–168. Coleman AJ, Saunders JE, Crum LA, and Dyson M. Acoustic cavitation generated by an extracorporeal shockwave lithotripter. Ultrasound Med Biol 1987;13(2):69–76. Crum LA. Cavitation microjets as a contributory mechanism for renal calculi disintegration in ESWL. J Urol 1988;140(6):1587–1590. Sass W, Braunlich M, Dreyer HP et al. The mechanisms of stone disintegration by shock waves. Ultrasound Med Biol 1991;17(3):239–243. Dahake G and Gracewski SM. Finite difference predictions of P‐SV wave propagation inside submerged solids. II. Effect of geometry. J Acoust Soc Am 1997;102(4):2138–2145. Gracewski SM, Dahake G, Ding Z et al. Internal stress wave measurements in solids subjected to lithotripter pulses. J Acoust Soc Am 1993;94(2 Pt 1):652–661. Eisenmenger W. The mechanisms of stone fragmentation in ESWL. Ultrasound Med Biol 2001;27(5):683–693. Delius M, Ueberle F, and Gambihler S. Destruction of gallstones and model stones by extracorporeal shock‐waves. Ultrasound Med Biol 1994;20(3):251–258. Smith N and Zhong P. Stone comminution correlates with the average peak pressure incident on a stone

58  Physics of Shock‐wave Lithotripsy

52

53

54

55

56

57

58 59

60

61

62

63

64

65

during shock wave lithotripsy. J Biomech 2012;45(15):2520–2525. Zhong P and Chuong CJ. Propagation of shock waves in elastic solids caused by cavitation microjet impact. I: Theoretical formulation. J Acoust Soc Am 1993;94(1):19–28. Zhu S, Cocks FH, Preminger GM, and Zhong P. The role of stress waves and cavitation in stone comminution in shock wave lithotripsy. Ultrasound Med Biol 2002;28(5):661–671. Pishchalnikov YA, McAteer JA, Williams JC Jr et al. Why stones break better at slow shockwave rates than at fast rates: in vitro study with a research electrohydraulic lithotripter. J Endourol 2006;20(8):537–541. Delius M and Gambihler S. Effect of shock waves on gallstones and materials. In: Lithotripsy and Related Techniques for Gallstone Treatment (ed. G Paumgartner, T Sanerbruch, M Sackmann, and H Burhenne), 27–33. St. Louis, MO: Mosby Year Book, 1991. Vakil N, Gracewski SM, and Everbach EC. Relationship of model stone properties to fragmentation mechanisms during lithotripsy. J Lithotripsy Stone Dis 1991;3(4):304–310. Smith NB and Zhong P. A heuristic model of stone comminution in shock wave lithotripsy. J Acoust Soc Am 2013;134(2):1548–1558. Weibull W. A statistical distribution function of wide applicability. J Appl Mech 1951;Sep:293–297. Evan AP, Willis LR, Lingeman JE, and McAteer JA. Renal trauma and the risk of long‐term complications in shock wave lithotripsy. Nephron 1998;78(1):1–8. McAteer JA and Evan AP. The acute and long‐term adverse effects of shock wave lithotripsy. Semin Nephrol 2008;28(2):200–213. Tuteja AK, Pulliam JP, Lehman TH, and Elzinga LW. Anuric renal failure from massive bilateral renal hematoma following extracorporeal shock wave lithotripsy. Urology 1997;50(4):606–608. Leighton TG, Fedele F, Coleman AJ et al. A passive acoustic device for real‐time monitoring of the efficacy of shockwave lithotripsy treatment. Ultrasound Med Biol 2008;34(10):1651–1665. Sorensen MD, Bailey MR, Shah AR et al. Quantitative assessment of shockwave lithotripsy accuracy and the effect of respiratory motion. J Endourol 2012;26(8):1070–1074. Delius M. Medical applications and bioeffects of extracorporeal shock waves. Shock Waves 1994; 4 (2):55–72. Evan AP and McAteer JA. Q‐Effects of shock wave lithotripsy. In: Kidney Stones: Medical and Surgical Management (ed. FL Coe, MJ

66

67

68

69

70

71

72

73

74

75

76

77

78

79

Favus, CYC Pak et al.), 549–570. Pennsylvania, PA: Lippincott‐Raven, 1996. Freund JB, Colonius T, and Evan AP. A cumulative shear mechanism for tissue damage initiation in shock‐wave lithotripsy. Ultrasound Med Biol 2007;33(9):1495–1503. Howard D and Sturtevant B. In vitro study of the mechanical effects of shock‐wave lithotripsy. Ultrasound Med Biol 1997;23(7):1107–1122. Dalecki D, Raeman CH, Child SZ et al. The influence of contrast agents on hemorrhage produced by lithotripter fields. Ultrasound Med Biol 1997;23(9):1435–1439. Delius M, Jordan M, Liebich HG, and Brendel W. Biological effects of shock waves: effect of shock waves on the liver and gallbladder wall of dogs– administration rate dependence. Ultrasound Med Biol 1990;16(5):459–466. Matlaga BR, McAteer JA, Connors BA et al. Potential for cavitation‐mediated tissue damage in shockwave lithotripsy. J Endourol 2008;22(1):121–126. Zhong P, Zhou Y, and Zhu S. Dynamics of bubble oscillation in constrained media and mechanisms of vessel rupture in SWL. Ultrasound Med Biol 2001;27(1):119–134. Chen H, Kreider W, Brayman AA et al. Blood vessel deformations on microsecond time scales by ultrasonic cavitation. Phys Rev Lett 2011;106(3):034301. Philipp A, Delius M, Scheffczyk C et al. Interaction of lithotripter‐generated shock‐waves with air bubbles. J Acoust Soc Am 1993;93(5):2496–2509. Connors BA, McAteer JA, Evan AP et al. Evaluation of shock wave lithotripsy injury in the pig using a narrow focal zone lithotriptor. BJU Int 2012;110(9):1376–1385. Delius M, Denk R, Berding C et al. Biological effects of shock waves: cavitation by shock waves in piglet liver. Ultrasound Med Biol 1990;16(5):467–472. Willis LR, Evan AP, Connors BA et al. Relationship between kidney size, renal injury, and renal impairment induced by shock wave lithotripsy. J Am Soc Nephrol 1999;10(8):1753–1762. Bergsdorf T, Thuroff S, and Chaussy C. The isolated perfused kidney: an in vitro test system for evaluation of renal tissue damage induced by high‐energy shockwaves sources. J Endourol 2005;19(7):883–888. Evan AP, McAteer JA, Connors BA et al. Independent assessment of a wide‐focus, low‐pressure electromagnetic lithotripter: absence of renal bioeffects in the pig. BJU Int 2008;101(3):382–388. Handa RK, Bailey MR, Paun M et al. Pretreatment with low‐energy shock waves induces renal vasoconstriction during standard shock wave lithotripsy (SWL): a treatment protocol known to reduce SWL‐induced renal injury. BJU Int 2009;103(9):1270–1274.

711

712

Section 4  Shock-wave Lithotripsy

80 Willis LR, Evan AP, Connors BA et al. Prevention of

81

82

83

84

85

86

87

88

89

90

lithotripsy‐induced renal injury by pretreating kidneys with low‐energy shock waves. J Am Soc Nephrol 2006;17(3):663–673. Willis LR, Evan AP, Connors BA et al. Shockwave lithotripsy: dose‐related effects on renal structure, hemodynamics, and tubular function. J Endourol 2005;19(1):90–101. Pishchalnikov YA, McAteer JA, Williams JC Jr et al. Evaluation of the LithoGold LG‐380 lithotripter: in vitro acoustic characterization and assessment of renal injury in the pig model. J Endourol 2013;27(5):631–639. Connors BA, McAteer JA, Evan AP et al. Evaluation of shock wave lithotripsy injury in the pig using a narrow focal zone lithotriptor. BJU Int 2012;110(9):1376–1385. Qin J, Simmons WN, Sankin G, and Zhong P. Effect of lithotripter focal width on stone comminution in shock wave lithotripsy. J Acoust Soc Am 2010;127(4): 2635–2645. Lingeman JE. Extracorporeal shock wave lithotripsy. Development, instrumentation, and current status. Urol Clin North Am 1997;24(1):185–211. Mancini JG, Neisius A, Smith N et al. Assessment of a modified acoustic lens for electromagnetic shock wave lithotripters in a swine model. J Urol 2013;190(3): 1096–1101. Neisius A, Smith NB, Sankin G et al. Improving the lens design and performance of a contemporary electromagnetic shock wave lithotripter. Proc Natl Acad Sci USA 2014;111(13):E1167–E1175. Xi X and Zhong P. Improvement of stone fragmentation during shock‐wave lithotripsy using a combined EH/ PEAA shock‐wave generator‐in vitro experiments. Ultrasound Med Biol 2000;26(3):457–467. Zhou Y, Cocks FH, Preminger GM, and Zhong P. Innovations in shock wave lithotripsy technology: updates in experimental studies. J Urol 2004;172(5 Pt 1): 1892–1898. Sokolov DL, Bailey MR, and Crum LA. Dual‐pulse lithotripter accelerates stone fragmentation and reduces cell lysis in vitro. Ultrasound Med Biol 2003;29(7):1045–1052.

91 Sheir KZ, El‐Diasty TA, and Ismail AM. Evaluation of

a synchronous twin‐pulse technique for shock wave lithotripsy: the first prospective clinical study. BJU Int 2005;95(3):389–393. 92 Loske AM, Fernandez F, Zendejas H et al. Dual pulse shock wave lithotripsy: in vitro and in vivo study. J Urol 2005;174(6):2388–2392. 93 Bohris C, Bayer T, and Lechner C. Hit/Miss monitoring of ESWL by spectral Doppler ultrasound. Ultrasound Med Biol 2003;29(5):705–712. 94 Leighton TG, Fedele F, Coleman AJ et al. A passive acoustic device for real‐time monitoring of the efficacy of shockwave lithotripsy treatment. Ultrasound Med Biol 2008;34(10):1651–1665. 95 Owen NR, Bailey MR, Crum LA et al. The use of resonant scattering to identify stone fracture in shock wave lithotripsy. J Acoust Soc Am 2007;121(1): EL41–EL47. 96 Shah A, Harper JD, Cunitz BW et al. Focused ultrasound to expel calculi from the kidney. J Urol 2012;187(2):739–743. 97 Maxwell AD, Cunitz BW, Kreider W et al. Fragmentation of urinary calculi in vitro by burst wave lithotripsy. J Urol 2015;193(1):338–344. 98 Lautz J, Sankin G, and Zhong P. Turbulent water coupling in shock wave lithotripsy. Phys Med Biol 2013;58(3):735–748. 99 Duryea AP, Roberts WW, and Cain CA. Acoustic bubble removal to enhance SWL efficacy at high shock rate: an in vitro study. J Endourol 2014;28(1):90–95. 100 Wang JC and Zhou Y. Suppressing bubble shielding effect in shock wave lithotripsy by low intensity pulsed ultrasound. Ultrasonics 2015;55:65–74. 101 Duryea AP, Roberts WW, Cain CA, and Hall TL. Removal of residual cavitation nuclei to enhance histotripsy erosion of model urinary stones. IEEE Trans Ultrason Ferroelectr Freq Control 2015;62(5):896–904. 102 Cleveland RO, McAteer JA, and Muller R. Time‐lapse nondestructive assessment of shock wave damage to kidney stones in vitro using micro‐computed tomography. J Acoust Soc Am 2001;110(4):1733–1736.

713

59 Lithotripsy Systems Geert G. Tailly Department of Urology and Pediatric Urology, AZ Klina, Kapellen, Belgium

­Historic perspective Prior to the introduction of extracorporeal shock‐wave lithotripsy (ESWL) and other minimally invasive techniques such as percutaneous nephrolithotomy and ­ureterorenoscopy, open surgery was the principal treatment modality for urolithiasis. The first extracorporeal shock‐wave lithotripsy (ESWL) that was performed on a ­stone‐bearing patient in 1980 therefore thoroughly revolutionized modern stone management. As early as 1963 physicists at Dornier, an aircraft manufacturer in Friedrichshafen, Germany, had investigated the impact of raindrops on flying objects, as these impacts caused shock waves which not only damaged the outer shell of airplanes but also structures within. During these experiments an engineer at Dornier accidentally discovered the effects of these shock waves on biological tissue. At the same time the German Ministry of Defense was also interested in the interaction between shock waves and biological tissue. In 1974 a partnership to conduct research on the application of shock waves in humans was formed between Dornier Development and Research (W. Hepp and G. Hoff ), the Department of Urology at the Ludwig‐Maximilians Universität in Munich (E. Schmiedt and F. Eisenberger), and the Institute of Surgical Research at the same university (W. Brendel and Ch. Chaussy). Funding was obtained through the German Research and Technology Ministry [1–3]. Early on it was found that shock waves caused no damage when traveling through muscle, fat, or connective tissue, except at transition zones with high acoustic impedance. In the course of this project someone then formed the idea to fragment kidney stones in the human body [1, 2]. After extensive experiments the first lithotriptor for human treatment, the Dornier Human Model 1 or HM1, was built, in 1979.

Patient selection for the first treatments was very strict: ●●

●● ●● ●●

a radiopaque stone not larger than a cherry pip in the renal pelvis unobstructed urological tract no urinary tract infection no comorbidities.

The first patient was successfully treated using a Dornier HM1 on 7 February 1980 by Christian Chaussy, B. Forssmann, and D. Jocham [4]. The results of the first clinical study on 221 treatments in 206 patients were published in 1982 [5]. In order to promote the new technique as reproducible and safe, the HM1 needed several improvements: ●● ●● ●●

●● ●●

an improved X‐ray system an improved patient support an improved installation to produce the 1200 liters of degassed water for the waterbath an improved shock‐wave generator an ellipsoid with a treatment depth of 13 cm.

The Dornier HM3 was born. In 1983 the second lithotripsy center was opened in the Department of Urology (F. Eisenberger) of the Katharinen Hospital in Stuttgart. In March 1984 the first Dornier HM3 in the United States was installed in the Methodist Hospital in Indianapolis (Daniel M. Newman and James E. Lingeman). A study for marketing approval by the US Food and Drug Administration was monitored by Georges Drach [6]. The rest is history. Originally lithotripters were devices only dedicated to shock‐wave lithotripsy (SWL). With modern stone management demanding a judicious combination of endourologic techniques and SWL, there was an evolution toward the construction of multifunctional urologic

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

714

Section 4  Shock-wave Lithotripsy

workstations. A modern stone center needs to tailor the most appropriate treatment to both the patient and their stone. A multifunctional workstation where both endourological techniques and ESWL can be performed in great comfort therefore seems an essential tool.

­Components of a lithotripter The Dornier HM3 lithotripter represented the archetype of the first‐generation lithotripter, characterized by a large water bath in which the patient was immersed for optimal shock‐wave coupling. Equipped with an electrohydraulic shock‐wave source and an ellipsoidal reflector with a small aperture to focus the shock wave, the treatment required general or spinal anesthesia. A bidirectional fluoroscopic imaging system allowed targeting to  move the stone into the therapeutic focus F2. Multifunctional or multidisciplinary use was impossible. The results achieved with this device are still considered the basis for comparison in evaluating all new devices. Second‐generation lithotripters utilize an electrohydraulic, electromagnetic, or piezoelectric shock‐wave source. Transmission of the shock wave is provided by means of a water cushion or partial water bath. Stone localization is performed with an ultrasonic or fluoroscopic imaging system [7–10]. The anesthesia requirements have been reduced so that SWL can be performed without any medication or only in analgosedation. Multifunctional or multidisciplinary use is limited. Third‐generation lithotripters are also equipped with an electrohydraulic, electromagnetic, or piezoelectric shock‐wave source. All systems allow anesthesia‐free treatments. Apart from that they use both fluoroscopy and ultrasound, alternately or simultaneously, to target the stones. Finally, all components are integrated into a multifunctional system with a treatment table allowing both SWL and endourologic procedures to be performed on the same device. Shock‐wave sources Shock waves are acoustic waves. Acoustic waves are mechanical waves consisting of pressure and density variations which can travel through media in any of its phases: gaseous, liquid, or solid. They are also referred to as pressure waves. Acoustic waves propagate through a medium by alternating decompression and compression of the medium. At the interfaces of the media they pass, absorption, reflection, or refraction of the shock waves can occur [11]. An acoustic wave of very short duration is called an acoustic pulse and a shock wave is a very short acoustic pulse. On the wave front the positive pressure rises in a very short time from the ambient pressure

to the maximum pressure. Afterwards a short phase of underpressure follows. While the wave propagates through the medium, it gets continuously steeper until it forms a shock wave. The generated shock wave is characterized by a sudden drop from overpressure to underpressure. The short phase of underpressure generates cavitation in the transmission medium. The bubbles induced by cavitation subsequently collapse violently and create microjets or secondary shock waves. For medical purposes shock waves are generated in water and transmitted into the patient’s body using a (partial) water bath or a water cushion for coupling. Water is used as transmission medium due to having comparable acoustical properties to human tissue, leading to impedance matching with low reflection at the contact surface between the water bath or water cushion and the patient. In the Dornier HM3, the first lithotripter commercially available, shock waves were generated using an electrohydraulic shock‐wave source. In second‐ and third‐generation lithotripters any of three principles of shock‐wave generation are used: electrohydraulic, ­electromagnetic, or piezoelectric. Electrohydraulic shock‐wave sources Electrohydraulic shock‐wave generation

Electrohydraulic shock‐wave generation is based on an underwater spark discharge. A spark plug with two opposing electrode tips is positioned in the focus F1 of an ellipsoidal reflector. A capacitor of about 100 nF connected to the spark gap is charged to a voltage of 15–30 kV and then abruptly discharged, producing a fast‐growing plasma channel between the electrode tips and resulting in rapid vaporization of the surrounding water like a micro‐explosion. This releases a spherical shock wave that is reflected by the wall of the ellipsoidal reflector towards the therapeutic focus F2 of the reflector. The intensity of the shock wave can be adjusted by changing the discharge voltage. The treatment depth and focusing are defined by the geometrical parameters of the ellipsoidal reflector. This type of shock wave is still used in lithotripters today, and the shock‐wave source of the HM3 is still considered to be the most effective of this type. Electrohydraulic shock waves have the disadvantage, in that the life span of the electrode tips is limited to several thousand shocks. Degradation of the electrode tips causes output variations and instabilities of the focus position, particularly near the end of the electrode’s lifetime. Electroconductive shock‐wave generation

To compensate for the degradation of the electrode tips which causes variations and instabilities of the focal position and energy and limits the life span of the electrode to several thousand shocks, Technomed ­

59  Lithotripsy Systems

­eveloped a modified electrohydraulic generator, the d Diatron IV, an electroconductive shock‐wave generator. The electroconductive generator is a 100 nF generator connected to an electrode immersed in a highly conductive solution instead of degassed water. Due to a better conduction of electricity this highly conductive solution allows an extremely accurate spark position. This combined with reduced interelectrode distance leads to a reproducible and consistent focal spot. This spark gap technology also allows the generation of a focal zone that varies in size with the power output. An automatic pressure regulator permanently adapts the voltage input to consistently deliver the requested pressure to compensate the variations due to electrode wear and also controls the total energy delivered to the patient. Electromagnetic shock‐wave sources “Flat coil” electromagnetic shock‐wave emitter

The electromagnetic shock‐wave emitter (EMSE; Dornier, Siemens) features a flat coil that generates a strong magnetic field when a high current pulse flows through it. This field causes an isolated metallic membrane to be repelled into the surrounding water. This causes the water in the vicinity of the membrane to be compressed and a plane acoustic pulse is released, which is focused into the therapeutic focal area by a lens. The pressure across the membrane surface is essentially constant. During propagation to the focal area the pressure pulse undergoes nonlinear effects, leading to the generation of a shock wave. Specifically, the pulse’s rising slope becomes steeper and the pulse duration becomes shorter. Since the electromagnetic shock‐wave generation principle does not rely on the dielectric breakdown of a liquid, all the associated threshold effects and arc‐­ ­ forming instabilities are avoided. An EMSE can therefore ­produce effective pressure pulses over a very wide intensity range with a high degree of reproducibility. This wide dynamic range allows for different shock‐wave treatment strategies to be used. The instrument’s life time is in the order of 1 million pulses. An EMSE does not show progressive degradation in its output power but it needs to be exchanged on a regular basis when the insulating materials and the metals have reached their endurance limits. The plane acoustical pulse generated by the EMSE is focused by an acoustic lens. The choice of the diameter of the EMSE and the focal length of the lens define the aperture angle of the system. The wide dynamic range that is available for EMSE systems, together with the wide choice of aperture angles, provides a unique toolbox for the designer, serving the different needs of shock‐ wave field shaping in lithrotripsy, in orthopaedic shock‐wave application, and in other emerging applications.

An EMSE is easily incorporated into a multifunctional device. Newer EMSE designs provide treatment results comparable to or even better than the results with the unmodified Dornier HM3. There is ongoing research to improve the performance of electromagnetic lithotripters through modification of the lens geometry [12]. Storz electromagnetic shock‐wave source: cylinder source with parabolic reflector

The electromagnetic cylinder source was also developed to overcome some drawbacks of the powerful but unstable spark gap technology with a short life span of the eroding electrodes. The cylinder generator is based on a hollow electromagnetic cylinder composed of a cylindrical coil covered by an insulating membrane, which again is covered by an electrically conducting membrane of high strength. An intense pulse current with short rise time generates repelling pulse forces due to electromagnetic induction. When immersed in water the radially expanding membrane generates, primarily, an acoustic cylinder wave which is focused by a special rotational parabolic reflector. The principle works on the same basis as a loudspeaker, but with very intense and short acoustic pulses. The cylindrical coil/membrane configuration is very stable and delivers more than 1 million pulses without degradation or significant fluctuations of acoustic energy. The parabolic reflector can be designed with large apertures and, accordingly, large aperture angles without technical limitations. Due to the large aperture angle, the acoustic energy can be concentrated to laterally narrow and axially short focal zones with high peak pressure and high energy flux density values. Thus, the fragmentational shock‐wave energy is restricted to a relatively small area, reducing tissue lesions in front or behind the target stone. Also, anesthesia requirements and shock‐wave load affecting the coupling area at skin level are minimized. Contrary to the electrohydraulic spark gap technology, the energy level of each single shock‐wave pulse can be precisely adjusted between very low (painless) and powerful settings, exactly matching the pain tolerance of the patient. The generator configuration featuring a hollow ­cylinder provides sufficient space for favourable inline localizations either for fluoroscopic or ultrasonic targeting [13–15]. Piezoelectric shock‐wave sources

Piezoelectric shock‐wave generation was developed simultaneously by EDAP and Wolf [16–20]. The conversion of electrical to acoustic energy takes place in ceramic platelets that expand or contract in the surrounding water because of the piezoelectric effect when

715

716

Section 4  Shock-wave Lithotripsy

a pulse of several thousand volts is applied. Several dozen to ­several thousand platelets are usually mounted on a spherical segment transmitting the shock wave into the center of the sphere through direct focusing. However, compared to other generation principles the intensity of a typical piezoelectric generator is lower and a large converter surface is required to mount the platelets. The diameter of such a shock‐wave source is therefore large, providing sharp focusing of the acoustic pulse. The large diameter of the piezoelectric dish makes its incorporation in a multifunctional device more problematic, however. The piezoelectric shock‐ wave source of the Wolf Piezolith 3000 features a double layer of piezo‐ceramic elements, known as Double Layer Piezo‐technology. Each type of shock‐wave source produces a shock wave, i.e. an acoustic pulse of which the energy is focused towards and concentrated in the therapeutic focus. In an electrohydraulic lithoptripter the focusing is achieved by a semi‐ellipsoid reflector, whereas in an electromagnetic lithotripter shock waves are focused using an acoustic lens (Dornier, Siemens) or a parabolic reflector (Storz). In a piezoelectric system there is no focusing as such. Each ceramic crystal is to be considered as a separate point source that produces its own miniature shock wave. The ceramic crystals are arranged on a dish that directs the point sources towards the therapeutic focus, where the accumulation of the energy of all these separate point sources produces sufficient energy for stone fragmentation: direct‐ focusing lithotripsy (DFL). Burst‐wave lithotripsy

In a recently published experimental in vitro study bursts of high‐intensity ultrasound are used to disintegrate artificial and real urinary calculi. The conclusion of the in vitro study was that in vitro burst‐wave lithotripsy is ­feasible. The clinical use of this novel and interesting technique will of course depend on in vivo clinical studies proving both efficiency and the exclusion of adverse ­tissue effects [21, 22].

­Introduction to shock‐wave physics A shock wave is an acoustic pulse characterized by a very fast rise time, a very high overpressure, a very short pulse duration, and a phase of underpressure. The physics of shock waves being very complex [11], a basic understanding of some of the parameters in shock‐wave physics is useful (see also Chapter  58 in this volume). Only the more clinically relevant parameters will be ­discussed here.

Maximum treatment depth or penetration depth The maximum treatment depth is the distance between the shock‐wave head and the point of highest pressure in front of the shock‐wave head. This is the geometrical focus. The shock‐wave focus, however, is cigar shaped, with the axial dimension longer than the lateral. This means that there is still energy that may be sufficient to break a stone beyond the geometrical focus. This is referred to as the “blast path.” In their published specifications some manufacturers may “extend’ their treatment depth by also incorporate the blast path, thus adding half of the focal length to the geometrical focus and “stealing” some distance. Clinical relevance of focus size There is an ongoing debate on the ideal focus size in a lithotripter [21, 22]. The ideal focus would be a spherical volume exactly matching the size of the targeted stone, thus limiting the administration of energy to the stone and avoiding hitting the surrounding tissue, which would lead to adverse tissue effects [21, 22]. This is technically not feasible, however. Today’s lithotripters have a cigar‐ shaped focus with energy delivered in front, behind (blast path), and adjacent to the target. A small focus is highly confined and sharp. The higher pressure in a small focus leads to high efficiency in fragmenting hard stones. In order to obtain optimal fragmentation and to avoid adverse tissue effects, precise targeting is essential. In a large focus pressure is lower. Precise targeting is less critical but there is an increased analgesia need and a higher risk of adverse tissue effects. Sometimes there is a demand for larger focal zones in order to treat larger target volumes even if surrounding tissue may be affected more than technically necessary. To respond to this demand Storz introduced dual‐focus technology. The design of the electromagnetic cylinder source offers the possibility to select different focal zones, precise and extended, according to clinical and anatomical conditions. By modification of the electrical excitation of the coil, longer pulses may be genereated which, in turn, stretch the focal zone, both laterally and axially. The Wolf Piezolith 3000 features a triple focus: F1, small focus with high energy density (ED); F2, intermediate focus with medium to high ED; F3, larger focus with medium ED. Prospective trials would be useful to document the clinical benefits of selectable foci. Shock‐wave interaction mechanisms It is generally assumed that a combination of four different mechanisms is involved in the interaction between

59  Lithotripsy Systems

shock waves and the targeted stone: the Hopkinson effect, cavitation, quasistatic squeezing, and dynamic fatigue [7]. It is also assumed that cavitation and shear forces (the Hopkinson effect) are the main culprits in the origin of adverse tissue effects. Although both shear forces and cavitation are important and necessary in the stone comminution process, avoidance of the negative effects of shear forces and cavitation is considered important in reducing adverse effects due to shock waves. The idea behind the dual‐pulse technique [23, 24] is to “fill” the negative part of the pressure pulse with a positive pressure pulse. In the Direx Duet dual shock‐ wave sources are used. Fired synchronized or asynchronized they allow an increase in the total pressure and the shock‐wave rate. Sheir et  al. [23] demonstrated improved stone comminution with a synchronous discharge of a twin pulse. In another study [24] the same group demonstrated higher performance and efficacy with this twin‐head, twin‐pulse technique. At the same time this technique produced far less parenchymal damage than with the use of a single treatment head. Theoretically this would reduce cavitation and improve disintegration. In ongoing efforts to engineer better lithotripters ­several studies have been and are being conducted to control cavitation and reduce its adverse tissue [25–28]. Eisenmenger and colleagues [29–31] advocate the use of a wide focus with lower pressure to enhance quasistatic squeezing, as this would presumably reduce tissue trauma and improve disintegration. This low‐ pressure, wide‐focus technology is incorporated in the electrohydraulic Lithospace from Jena Med Tech GmbH (Jena, Germany) and the electrohydraulic LithoGold LG‐380 from MTS (Konstanz, Germany). In a study by Bhojani et  al. [32] comparing the electromagnetic Modulith SLX to the LithoGold LG‐380 stone‐free rates proved modest with both devices using SWL alone. Outcomes with both systems also proved similar. In this study an advantage of the wide‐focus, low‐pressure principle could not be demonstrated. Further prospective clinical studies to corroborate (or disprove) this concept are eagerly awaited.

­Coupling Shock waves are acoustic waves that travel through a medium by alternating decompression and compression of the medium. Absorption, reflection, or refraction of the shock waves can occur at interfaces between media with different acoustic impedance. As water has comparable acoustical properties to human tissue, shock waves are generated and transmitted in water. In order to minimize

energy loss of the shock wave at the interface between the patient and the shock‐wave source, coupling between shock‐wave source and patient is extremely important [31]. Total immersion of the patient in a water bath with degassed water where the shock wave is generated (Dornier HM3) is still considered the ideal coupling ­system. Second‐ and third‐generation lithotripters, however, feature “dry” coupling which consists of a water‐filled cushion that is inflated and pressed against the patient. The water cushion is made of elastic PVC or silicone, and is capable of adapting to the body shape of the patient. In order to guarantee good acoustic transmission, the water cushion is coupled to the patient through the application of ultrasound gel as an interface. In this process, both air bubbles in the coupling gel and folds in the water cushion could impair the transmission of acoustic waves. Even tiny air bubbles in this interface can lead to uncontrolled shock‐wave attenuation. In an in vitro experiment, Pishchalnikov et  al. [33] found a reduction in fragmentation of 20–40% when air bubbles were included that covered an area equal to 2% of the cushion surface. Decoupling the cushion from the test basin and recoupling it led to a drastic increase in air inclusions. This has led to the recommendation that, if one decouples the patient during treatment, one must repeat the coupling procedure, including cleansing the coupling cushion and subsequently reapplying gel. Based on their own stone model, Jain and Shah [34] were able to identify a considerable influence of air inclusions on the erosion capacity of the shock wave. After experimenting with various techniques for gel application, as a method of choice Neucks et al. [35] recommend applying the gel as a bolus, specifically from a vessel with a large opening. A small vessel opening and manual distribution of the gel lead to increased air pockets and poor disintegration results. Bergsdorf et al. [36] also recommend the selection of a proper coupling gel disc or gel with low viscosity and the accurate removal of air bubbles to improve efficiency in SWL. In an experiment with an electromagnetic Dornier lithotripter equipped with an inline ultrasound scanner, Bohris [37] demonstrated that 43% more shock waves were needed to fragment model stones when only 8% of the coupling area, visualized with an inline ultrasound scanner, was covered with air bubbles. Li et  al. [38] observed that the coupling interface is invisible during treatment and that the real problem is to avoid the entrapment of air bubbles during the coupling process. To monitor the coupling area in real time during stone treatments Bohris et al. [39] installed a video camera in the therapy head of a Dornier Lithotripter SII. In only 10 of 30 treatments could good coupling with an air ratio of less than 5% be obtained and in eight treatments the air ratio was higher than 20%.

717

718

Section 4  Shock-wave Lithotripsy

In a prospective clinical study using opical coupling control (see Figure  59.6 below) in a Dornier Gemini Tailly and Tailly‐Cusse [40] achieved comparable effectiveness quotients (EQ) with a reduction in shock‐wave numbers of 25.4% for renal and 25.5% for ureteral stones leading to a corresponding 25% reduction in treatment time. Energy levels could be reduced with 23.1% for renal and 22.5% for ureteral stones. In this study a video camera incorporated in the therapy head of a Dornier Gemini lithotripter allowed visual monitoring of the coupling area. Air bubbles that inevitably were trapped in this coupling area could easily be removed by gently swiping a hand between the patient and the water cushion, thus consistently achieving perfectly bubble‐free coupling.

rib shadows. Usually the appraisal of fragmentation is superior to an inline scanner. Proximal ureteral stones may be more difficult to find and targeting and positioning of prevesical stones is more cumbersome. To enhance targeting precision several manufacturers offer autopositioning and/or tracking systems: Dornier, EDAP TMS, Jena Med Tech, Storz, and Wolf. Machines where both ultrasound and X‐ray are integrated offer the most versatile imaging and targeting possibilities. Ideally these machines offer simultaneous online use of both ultrasound and X‐ray. Targeting versatility is further improved by the possibility to couple the therapy head to the patient both under and above the treatment table. Improved imaging and improved targeting will have a positive effect on the EQ.

­Imaging systems Adequate imaging is vital to the success of ESWL: ●● ●● ●●

localization and targeting of the stone surveillance of treatment progress identification of fragmentation.

Imaging modalities available on a lithotripter will to a great extent also define treatment strategies. Early lithotriptors were equipped either with ultrasound or fluoroscopy. In order to meet all the challenges in modern integrated stone management present day lithotriptors ideally should be equipped with both imaging modalities, to be used either independently and alternately or simultaneously. Inline use of both modalities is essential. Fluoroscopy allows targeting of radiopaque stones at all levels of the urinary tract. Direct targeting of radiolucent stones is impossible, however. Also smaller renal stones may prove more difficult to locate than with ultrasound. Further drawbacks are the absence of real‐time imaging and the exposure to radiation. With ultrasound it is generally impossible to locate stones in most parts of the ureter. On the other hand ultrasound allows direct visualization of radiolucent stones and offers easier targeting of smaller renal stones. A major advantage, however, is the real‐time imaging which provides better monitoring of the fragmentation process in the absence of exposure to radiation. Inline scanners are positioned along the shock‐wave propagation path and offer easier targeting of very proximal and very distal ureteral stones and easier dissociation between multiple stones. Image quality usually is poorer than with a lateral outline or free‐hand scanner, however, and rib shadows may hide stones from view. Outline scanners (free‐hand or mounted on a lateral isocentric arms) offer far better image quality and allow the selection of the most appropriate window to avoid

­Lithotripter design Dedicated or multifunctional machine? In the years following its introduction ESWL was the privilege of high‐volume stone centers. This was mainly due to the high capital, running, and maintenance costs of the first lithotripters. Only “dedicated” to extracorporeal lithotripsy these machines could only be operated in large centers with a high volume of stone patients. The construction of less expensive second‐ and third‐generation lithotripters with lower capital cost and lower running and maintenance costs made extracorporeal lithotripsy available in more and more centers, leading to a reduction of the number of patients treated per stone center. Stone therapy guidelines from international expert boards consider SWL in most types of stones as the first choice of treatment. However, in some indications endourologic procedures give equivalent or better results than SWL. Modern lithotripters are supposed to support urologists in any of these modalities. Consequently, in the past two decades lithotripters have undergone a transition from pure shock‐wave‐generating devices to multifunctional urologic workstations. One of the key components of such urologic workstations is the patient table. An increasing number of obese patients demands high‐load‐capacity tables with maximum accessibility in order to be able to approach the patient from all sides. For fluoroscopic imaging both in SWL and endourologic procedures the tabletop needs to be radiotransparent. Modern tabletops are therefore made of carbon fiber. Imaging modalities in a multifunctional workstation need to support the wide range of therapeutic options in urology. Large image intensifiers up to 40 cm ideally offer a large field of view of nearly the entire urinary tract. Full  digitization of the X‐ray imaging chain provides

59  Lithotripsy Systems

excellent image quality at low radiation doses. In the newer devices flat‐panel detectors (FPDs) replace the traditional image intensifiers. Increasing awareness of radiation safety and dose reduction make ultrasound stone localization an ideal tool for stone targeting and accurate therapy monitoring. Last but not least, a high‐performance shock‐wave source, which ideally can be coupled to the patient in an over‐ and undertable ­position, ­completes the design of a multifunctional lithotripter. Integrated or modular? Multifunctional machines can have a modular design, where all components are independent and connected according to need, or an integrated design, where all components are integrated in the machine and ideally adapted to their function. A third design, the “hybrid,” offers integration of imaging and/or therapy head in a common console with an independent treatment table. Modular design

In a lithotripter with a modular design (Figure 59.1) the different components, shock‐wave source, imaging components, and treatment table are separate modules to be connected to perform ESWL or endourological procedures. As the imaging components, both a fluoroscopic C‐arm and an ultrasound machine are usually available on site; investment cost is thus lower and limited to the shock‐wave module. The imaging components can also Figure 59.1  Modular design: Jena Med Tech Lithospace. Reproduced with permission of Jena Med Tech GmbH.

be used for other purposes both in urology and other departments. Modular systems have no need for a dedicated lithotripsy room and are easily transported from one center to another. Due to the ad hoc combination of different modules the footprint is larger and the floor is cluttered with an array of machinery. In endourologic procedures this footprint is still enlarged by the addition of an electrosurgical unit, light sources, and monitors, etc. The uro‐table is less urologist‐friendly with limited accessibility. Overall ­handling is more complicated and less user‐friendly. Integrated design

In an integrated design the different components are fully integrated in one stand alone system (Figures 59.2–59.4). These systems have a small footprint compared to the modular and hybrid designs. They are usually high‐end devices ideal for centers with a sufficient volume of patients for SWL and endourology. Due to the optimal integration and synchronization of their high‐end components to a synergistic system these machines offer maximal versatility in targeting and positioning for SWL. Uro‐table function usually is excellent and offers great comfort in the performance of endourologic procedures. Ideally the patient table is entirely radiotransparent, accessible over 360°, and capable of bearing obese patients. The high investment cost and the fixed installation in a dedicated endourology/ESWL room may prohibit its acquisition in centers with limited patient loads.

719

720

Section 4  Shock-wave Lithotripsy

Figure 59.2  Integrated design: Dornier Gemini. Reproduced with permission of Dornier MedTech GmbH.

Figure 59.3  Integrated design: Storz Modulith SLX‐F2. Reproduced with permission of Storz Medical AG.

Hybrid design

In these machines imaging (fluoroscopy and/or ultrasound) and shock‐wave source are mounted on a combined console (Figure  59.5). The patient treatment table is a stand‐alone component to be added to the system for SWL or endourological procedures. Both investment cost and footprint are medium, i.e. between that of a machine with integrated design and a device with modular design. These systems are easily transportable and do not need a dedicated room. Some of the components (imaging, patient table) are

suited for multifunctional and multidisciplinary usage. Uro‐table function usually is adequate and overall handling is in between the modular and the integrated design.

­Performance of lithotripters To measure the performance of a lithotripter, formulae have been devised that take into account stone‐free rate, retreatment rate, and auxiliary procedure rate. The

59  Lithotripsy Systems

Figure 59.4  Integrated design: EDAP TMS Sonolith i‐Sys. Reproduced with permission of EDAP‐TMS France.

Figure 59.5  Hybrid design: Wolf Piezolith 3000 plus. Reproduced with permission of Richard Wolf GmbH.

original effectiveness quotient (EQA) was defined by ­ Denstedt, Clayman and Preminger [7, 41]:

EQ A

% Stone free patients 100% % retreatment % auxiliary procedures post ESWL

100

721

722

Section 4  Shock-wave Lithotripsy

The “extended EQ” or EQB [10] and the “modified EG” or EQmod [10] were defined in order to fine tune the ­performance estimations.

EQ B

% Stone free patients 100% % retreatment % auxiliary procedures pre and post ESWL

100

Modified EQ :

EQ mod

% Stone free patients % curative auxiliary procedures 10 00% % re ESWL % pre ESWL auxiliary procedures

Although these formulae represent a mathematic tool to quantify and compare the performance of lithotripters, they only quantify stone‐free rate, auxiliary procedure rate, and retreatment rate. A number of other factors are not readily quantifiable, but do play an important role in the final outcome of stone management by SWL: shock‐ wave source, stone burden, stone impaction, imaging modality and quality, targeting, analgesia regimen, shock‐ wave coupling, shock‐wave release frequency, treatment strategy, and last but not least experience of the operator. Treatment strategies and experience and skill of the operator have long been underestimated in the performance of SWL. Operator skill and experience unquestionably are key factors in success in SWL, however. Although newer electromagnetic machines perform at least equally good or even better than the HM3 the unmodified Dornier HM3 is still considered the gold standard in SWL. Results with newer lithotripters are, often erroneously, claimed to be poorer than with the original HM3 and many urologists therefore tend to shift to endourologic techniques in several indications. Factors in the poorer results with modern lithotripters without a doubt are: ●●

●● ●●

Complexity of shock‐wave administration is generally underestimated, especially by new users: lack of background and training in SWL is often the cause of poorer results with modern machines. HM3 users were extensively trained prior to certification. Newer machines are too often misjudged as “plug‐ and‐play” with little attention paid to proper training of new users.

In order to improve results and reduce complication rate all (new) users of shock‐wave machines should be certified on the basis of: ●●

a theoretical understanding of the basic physics of shock waves

●●

●●

% post ESWL auxxiliary procedures

100

an extensive training in imaging, positioning and targeting, coupling, and treatment strategies a comprehensive understanding of shock‐wave complications and the ways to avoid complications and improve results.

Although lithotripter manufacturers are directing extensive research towards improvements in focal geometry and energy to improve stone disintegration and at the same time reduce collateral damage to the surrounding tissue, together with urology training centers they should also invest in proper training of lithotripter users. These coordinated efforts could and should lead to a renaissance of SWL as a valuable treatment of choice for urolithiasis at all levels of the urinary tract.

­The ideal lithotripter An “ideal” lithotripter would have to have a high‐performance shock‐wave source producing a spherical focus exactly matching the size of the targeted stone and with the following energy requirements: ●● ●●

●●

moderate positive peak pressure, p+ sufficient disintegration power (effective energy, E12mm) to disintegrate hard stones and to compensate for shock‐wave attenuation (obesity) minimal cavitation effects and hence minimal risk of adverse tissue effects.

Apart from producing a shock wave with the ideal focus, this high‐performance shock‐wave source would also have to meet the following requirements: prolonged lifetime without degradation or significant fluctuations of acoustic energy, wide range of energy settings, and adequate treatment depth (minimum 150 mm) to accommodate the ever‐increasing proportion of obese patients, easily incorporated in a multifunctional device.

59  Lithotripsy Systems

These requirements would almost automatically exclude conventional electrohydraulic sources: the lifetime of the electrodes is limited and the degradation of the electrode tips leads to output variations and instabilities of focal point and energy. Coupling of the therapy head containing the shock‐ wave source is an important issue. The water cushion needs to be made of a material that easily adapts to the body curves and that causes minimal absorption, reflection, or refraction of the travelling shock wave. Ideally the therapy head should incorporate a video camara for optical coupling control (Figure  59.6). Optical coupling control results in a reduction of the total energy needed to fragment a stone. At the same time this theoretically could result in less shock‐wave‐induced adverse tissue effects. Apart from that, the possibility to couple the treatment head to the patient both in an above‐ and an undertable position (Figure 59.7) is a very important asset, specifically in the in situ treatment of ureteral stones and especially in obese patients. Accurate targeting is key to success in SWL and depends on excellent image quality, both fluoroscopic and ultrasonic. In endourologic procedures image quality is equally important. A large image intensifier (up to 40 cm) offers a large view of nearly the entire urinary tract without the need to move the patient table. Orbital isocentric movements of the X‐ray C‐arm may prove useful in targeting in SWL. Full digitization of the X‐ray imaging chain guarantees excellent image quality at low radiation dose. Digitization also allows easy and efficient storage of the images in the patient’s records (DICOM capability). In newer lithotripters FPDs replace the traditional image intensifiers.

Patient

Coupling area Coupling cushion

Video camera SW source

Figure 59.6  Optical coupling control. SW, shock wave. Reproduced with permission of Dornier MedTech GmbH.

Figure 59.7  Bilateral over‐ and undertable position of the therapy head (Dornier Gemini). Reproduced with permission of Dornier MedTech GmbH.

Increasing awareness of radiation safety and dose reduction and the excellent image quality of modern ultrasound machines make ultrasound an ideal tool for stone targeting and real‐time monitoring of the entire treatment. An ideal lithotripter thus should be equipped with excellent imaging, both fluoroscopic and ultrasonic, preferably to be used online and simultaneously. Another key component of a modern multifunctional lithotripter is the patient table. An ever‐increasing number of obese and even morbidly obese patients demand a table with a high load capacity. To allow good imaging the tabletop needs to be radio‐transparent. Finally, in endourologic procedures such as percutaneous nephrolithotomy and nephrostomy tube placement, maximum accessibility (ideally 360°) of the table from all sides is extremely important. Good imaging and a careful urologist may provide accurate targeting, but respiratory movements continuously swing the targeted stone in and out of focus. A hit‐ and‐miss system, that would keep track of the stone during respiratory movements and would only release a shock wave when the stone is exactly in the focus, would improve outcomes and at the same time reduce collateral damage to the surrounding tissue. It would of course also slow down treatment. According to newer insights, however,

723

724

Section 4  Shock-wave Lithotripsy

Figure 59.8  Elements of “good lithotripsy.” SW, shock wave.

Experienced urologist

Guidelines

Precise imaging & targeting

Optical coupling control

Judicious SW application

Proper device settings

Energy dose

Voltage stepping

Pulse repetition frequency

Treatment pause

slowing down treatments not only improves treatment efficiency [42, 43], but also reduces overall treatment cost [44]. Finally, this sophisticated piece of equipment should only be operated by an interested and experienced urologist, who has a basic understanding of the physics of shock waves [11, 31] and who is closely involved in all treatment modalities (SWL, percutaneous n ­ ephrolithotomy, ureterorenoscopy, robot‐assisted retrograde intrarenal surgery) of modern stone management. A department of urology looking for the ideal lithotripter should also invest in good clinical practice and “good lithotripsy” (Figure  59.8). The actual choice of the ideal lithotripter for any given stone center will depend on the specific requirements of a specific setting. A multifunctional workstation for SWL and endourologic procedures is the best choice for centers with an adequate patient load in both treatment modalities. An integrated or hybrid design makes economic sense in very active stone centers. In centers with a modest patient load a modular system may probably be the better choice. Our own stone center functions 5 days a week with a patient load of approximately 3000 ­treatments per year (500 ESWL and 2500 endourologic

procedures). We try to solve any acute stone problem within 24 hours of admission, preferably on an outpatient basis. The centerpiece of this “integrated endourology concept” is a high‐end multifunctional lithotripter with integrated design.

­Summary The number of manufacturers and machines currently on the market prohibits an attempt to provide a complete overview of all systems available at present. Also, companies and machines come and go. Therefore this overview (see Tables 59.1–59.5) was limited to those traditional companies that were and still are very much involved in the development of and continued research in SWL. An exception to this rule was made for lithotripters designed with a philosophy derived from the theories of Eisenmeyer [29, 30]: wide focus, low focal pressure (Tables 59.6 and 59.7). Through their product managers most of these companies were very forthcoming in providing information, technical details, and illustrations for this chapter. See accompanying Video 59.1.

59  Lithotripsy Systems

Table 59.1  Overview of Dornier Gemini, Compact Delta II, and Compact Sigma. Dornier Gemini

Dornier Compact Delta II

Dornier Compact Sigma

Source

Electromagnetic (EMSE) flat coil with acoustic lens

Electromagnetic (EMSE) flat coil with acoustic lens

Electromagnetic (EMSE) flat coil with acoustic lens

Aperture (mm)

220

140

140

Aperture (degrees)

66

50

50

Max. treatment depth (mm)

170

150

150

Focus size (−6 dB) (mm)

5.9 × 89

8 × 105

8 × 105

Peak pressure (MPa)

77

51

51

Energy density (mJ/mm2)

1.6

0.88

0.88

Coupling

Water cushion/OptiCouple

Water cushion/ OptiCouple

Water cushion

Fluoroscopy

Integrated C‐C and orbital movements

Integrated C‐arm

Add‐on C‐arm

Ultrasound

Integrated Lateral isocentric

Integrated Lateral isocentric

Integrated Lateral isocentric

Overall design

Integrated

Hybrid

Modular

Multifunctional use

+++

With Relax + table

With Relax + table

Patient table: Load capacity = 250 kg ●● 360° accessibility ●● Radio‐transparent carbon fibre top Dual imaging: simultaneous online use of X‐ray and ultrasound OptiCouple: Optical coupling Control Satellite arms for flat screens, light source, camera controller Bilateral shock‐wave coupling over‐ and undertable UIMS: Urology Information Management System 40 cm image intensifier or FPD/Dicom capability Autopositioning in X‐ray mode

Tri‐mode imaging capability (with FarSight) FarSight Imaging capability with purpose designed transducer Simultaneous on‐line use of X‐ray and ultrasound Optional patient data management: UIMS Optional Dicom capability Over‐ and under‐ table treatment Multidisciplinary use of Relax + table

Shock‐wave generation

Focus (max values)

Imaging

Special features

●●

725

726

Section 4  Shock-wave Lithotripsy

Table 59.2  Overview of Siemens Modularis Variostar. Siemens Modularis Variostar

Shock‐wave generation Source

Electromagnetic (EMSE) flat coil with acoustic lens 125 48 140

Aperture (mm) Aperture (degrees) Max. treatment depth (mm) Focus Focus size (−6 dB) (mm) Peak pressure (MPa) Energy density (mJ/mm2)

12.5 × 145 59 0.13–1.14

Coupling

Water cushion

Imaging Fluoroscopy Ultrasound

Add‐on Add‐on

Overall design

Modular

Multifunctional use

Yes

Special features Autopositioning

No

Table 59.3  Overview of Storz lithotripters. Storz Modulith SLX‐F2 >>connect >inline5 000 000 shocks Triple focus: three adjustable focus sizes

Yes Long‐lasting therapy source >5 000 000 shocks Triple focus: three adjustable focus sizes

Shock‐wave generation Source Aperture (mm) Aperture (degrees) Max. treatment depth (mm) Focus Focus size (−6 dB) (mm) Peak pressure (MPa) Energy density (mJ/mm2)

Special features Autopositioning Source Triple focus

727

728

Section 4  Shock-wave Lithotripsy

Table 59.6  Overview of Jena Med Tech Lithospace lithotripter. Jena MedTech Lithospace

Shock‐wave generation Source

Electrohydraulic

Aperture (mm)

178

Aperture (degrees)

45.6 (210 mm)

58.3 (160 mm)

96.1 (80 mm)

Max. treatment depth (mm)

180 (16 kV)

205 (22 kV)

220 (26 kV)

Focus Focus size (−6 dB) (mm) Peak pressure (MPa) Energy density (mJ/mm2)

16 kV 10 × 64 3.6–26.1 0.14

22 kV 12 × 125 4.1–35.2 0.27

26 kV 20 × 160 5.0–37.9 0.40

Coupling

Water cushion

Imaging Fluoroscopy Ultrasound

Add‐on C‐arm Add‐on ultrasound machine

Overall design

Modular

Multifunctional use

Add‐on urotable

Special features

Flexibility and maneuvrability of shock‐wave head: under‐ and overtable Autonomous contact‐free targeting system for all X‐ray and ultrasound localization devices Stone localization and treatment volume superimposed in real time on the display Multi‐use electrode: RevoTrode for 15 000 shock waves

Table 59.7  Overview of LithoGold LG‐380 lithotripter (MTS Medical UG). LithoGold LG‐380

Shock‐wave generation Source Aperture Max. treatment depth (mm) Focus Focus size (−6 dB) (mm) Peak pressure (MPa) Energy density (mJ/mm2)

Electrohydraulic N/A 165 20 × 101 24.6 – 36.9 0.1 – 0.37

Coupling

Water cushion

Imaging Fluoroscopy Ultrasound

Add‐on C‐arm Lateral isocentric

Overall design

Modular

Multifunctional use

Add‐on urotable

­References 1 Chaussy C, Eisenberger F, and Forssmann B. Epochs in

endourology. extracorporeal shockwave lithotripsy (ESWL®): a chronology. J Endourol 2007;21:1249–1253. 2 Chaussy C, Eisenberger F, and Forssmann B. 25 Jahre ESWL. Lecture presented at the 57th Congress of the

Deutsche Gesellschaft für Urologie (DGU), Dusseldorf, 21–24 September 2005. 3 Brendel F. History of shock‐wave treatment of renal concrements. In: Extracorporeal Shock‐Wave Lithotripsy for Renal Stone Disease. Technical and Clinical Aspects

59  Lithotripsy Systems

4

5

6

7

8

9

10

11 12

13 14

15

16

17

18

19

(ed. JS Gravenstein and K Peter), 5–10. London: Butterworths, 1986. Chaussy C, Brendel W, and Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. The Lancet 1980;2:1265–1268. Chaussy C, Schmiedt E, Jocham D et al. First clinical experience with extracorporeally induced destruction of kidney stones by shock wave. J Urol 1982;127:417–420. Drach GW, Dretler S, Fair W et al. Report of the United States cooperative study of extracorporeal shock wave lithotripsy. J Urol 1986;135:1127–1133. Rassweiler JJ, Tailly GG, and Chaussy C. Progress in lithotriptor technology. EAU Update Series 2005;3:17–36. Chaussy C and Fuchs GJ. Current state and future developments of non‐invasive treatment of urinary stones with extracorporeal shock wave lithotripsy. J Urol 1989;141:782–789. Eisenberger F, Miller K, and Rassweiler J. Comprison of second generation lithotripters. In: Stone Therapy in Urology (ed. F Eisenberger, K Miller, and J Rassweiler), 125–136. Stuttgart: Thieme Verlag, 1991. Tailly GG. Consecutive experience with four Dornier Lithotripters: HM4, MPL9000, Compact, and U/50. J Endourol 1999;13:329–338. Loske AM. Shock Wave Physics. CFATA Universidad Nacional Autónoma de México, 2007. Neisius A, Smith NB, Sankin G et al. Improving the lens design and performance of a contemporary electromagnetic shock wave lithotripter. Proc. Natl. Acad. Sci. 2014;17:1167–1175. Cathignol D, Tavakkoli J, and Mestas JL. Lithotritie extracorporelle. ITBM‐RBM 2000;21:4–10. Thibault P, Vallancien G, and Brisset JM. Lithotritie extracorporelle à impulsions ultra‐ courtes. Premières applications cliniques du lithotripteur. Press Med 1986;15:1283. Vallancien G, Aviles J, Munoz R et al. Piezoelectric extracorporeal lithotripsy by ultrashort waves with the EDAP LT01 device. J Urol 1988;139:689–694. Marberger M, Türk C, and Steinkogler I. Painless piezoelectric extracorporeal lithotripsy. J Urol 1988;139:695–699. Grunberger I. Use of piezoelectric shock wave lithotripsy without analgesia. In: Controversies in Endourology (ed. Smith AD), 89. Philadelphia, PA: W.B. Saunders Company, 1995. Maxwell AD, Cunitz BW, Kreider W et al. Fragmentation of urinary calculi in vitro by burst wave lithotripsy. J Urol 2015;193:338–344. Chaussy CG and Tiselius H‐G. Engineering better lithotripters. Curr Urol Res 2015;16:52.

20 Loske AM. The role of energy density and acoustic

21

22

23

24

25

26

27

28

29

30

31

32

33

cavitation in shock wave lithotripsy. Ultrasonics 2010;50:300–305. Wess O. Shock wave lithotripsy (SWL) and focal size. In: Therapeutic Energy Applications in Urology: Standards and Recent Developments (ed. C Chaussy, G Haupt, D Jocham et al), 21–35. Stuttgart: Thieme Verlag, 2005. Haecker A and Wess O. The role of focal size in extracorporeal shock wave lithotripsy. In: New Trends in Shock Wave Applications to Medicine and Biotechnology (ed. Loske A), ch. 4. Research Signpost, 2009. Sheir KZ, Zabini N, Lee D et al. Evolution of synchronous twin‐pulse technique for shockwave lithotripsy: determination of optimal parameters for in vitro stone fragmentation. J Urol 2003;170:2190–2194. Sheir KZ, Elhalwagy SM, Abo‐Elghar ME et al. Evaluation of a synchronous twin‐pulse technique for shock wave lithotripsy: a prospective randomised study of effectiveness and safety in comparison to standard single‐pulse technique. BJU Int 2007;101:1420 – 1425. Duryea AP, Roberts WW, Cain CA et al. Acoustic bubble removal to enhance SWL efficacy at high shock rate: an in vitro study. J Endourol 2014;28:90–95. Lautz J, Sankin G, and Zhong P. Turbulent water coupling in shock wave lithotripsy. Phys Med Biol 2013;58:735–748. Duryea AP, Roberts WW, Cain CA et al. Controlled cavitation to augment SWL stone comminution: mechanistic insights in vitro. IEEE Trans Ultrason Ferroelectr Freq Control 2013;60:301–309. Zhou Y. Reduction of bubble cavitation by modifying the diffraction wave from a lithotripter aperture. J Endourol 2012;26:1075–1084. Eisenmenger W. The mechanisms of stone fragmentation in ESWL. Ultrasound Med Biol 2001; 27:683–693. Eisenmenger W, Du XX, Tang C et al. The first clinical results of “wide focus and low pressure” ESWL. Ultrasound Med Biol 2002;28:769–774. Lingeman JE, McAteer JA, Gnessin E, and Evan AP. Shock wave lithotripsy: advances in technology and technique. Nat Rev Urol 2009;6:660–670. Bhojani N, Mandeville JA, Hameed TA et al. Lithotripter outcomes in a community practice setting: comparison of an electromagnetic and an electrohydraulic lithotripter. J Urol 2015;193(3): 875–879. Pishchalnikov YA, Neucks JS, VonDerHaar RJ et al. Air pockets trapped during routine coupling in dry head lithotripsy can significantly decrease the delivery of shock wave energy. J Urol 2006;176(6):2706–2710.

729

730

Section 4  Shock-wave Lithotripsy

34 Jain A and Shah TK. Effect of air bubbles in the

35

36

37

38

39

coupling medium on efficacy of extracorporeal shock wave lithotripsy. Eur Urol 2007;51(6):1680–sxx1687. Neucks JS, Pishchalnikov YA, Zancanaro AJ et al. Improved acoustic coupling for shock wave lithotripsy. Urol Res 2008;36(1):61–66. Bergsdorf T, Chaussy C, and Thüroff S. The relevance of coupling gel viscosity for efficient energy coupling in SWL. Poster (VP18‐12) presented at the 27th WCE in Munich, 6–10 October 2009. Bohris C. Quality of coupling in SWL significantly affects the disintegration capability – how to achieve good coupling with ultrasound gel. In: Therapeutic Energy Applications in Urology II (ed. C Chaussy, G Haupt, D Jocham et al), 61–64. Stuttgart: Thieme Verlag, 2010. Li G, Williams JC Jr, Pishchalnikov YA et al. Size and location defects at the coupling interface affect lithotripter performance. BJU Int 2012;110:E871–E877. Bohris C, Roosen A, Dickmann M et al. Monitoring the coupling of the lithotripter therapy head with skin

40

41

42

43

44

during routine shock wave lithotripsy with a surveillance camera. J Urol 2012;187:157–163. Tailly GG and Tailly‐Cusse MM. Optical coupling control: an important step toward better shockwave lithotripsy. J Endourol 2014;8(11):1368–1373. Denstedt JD, Clayman RV, and Preminger GM. Efficiency quotient as a means of comparing lithotripters. J Endourol (Suppl.) 1990;S100. Pishchalnikov YA, McAteer JA, and Williams JC Jr. Effect of firing rate on the performance of shock wave lithotriptors. BJU International 2008;102:1681–1686. Chacko J, Moore M, Sankey N, and Chandhoke PS. Does a slower treatment rate impact the efficacy of extracorporeal shock wave lithotripsy for solitary kidney or ureteral stones? J Urol 2006;175:1370–1374. Koo V, Beattie I, and Young M. Improved cost‐ effectiveness and efficiency with a slower shockwave delivery rate. BJU Int Journal Compilation 2009;1–5.

731

60 Shock‐wave Lithotripsy of Renal Calculi Brian H. Eisner & Naren Nimmagadda Department of Urology, Massachusetts General Hospital, Boston, MA, USA

­Introduction

­Absolute contraindications

Once Chaussy and colleagues introduced extracorporeal shock‐wave lithotripsy (SWL) in 1980, SWL spread to other institutions by 1984 and subsequent series confirmed success rates upwards of 90% using the Dornier HM3 lithotripter [1, 2]. Over the ensuing two decades, SWL became the most common procedure for urinary stone disease; by 2005, SWL accounted for 52% of all stone treatments in the United States [3]. Modern lithotripters have eliminated the water bath as a coupling agent, improving accessibility and patient comfort. SWL success rates now range from 48 to 65% but with greater need for auxiliary procedures than before [4, 5]. In this chapter, we present factors and techniques that allow safe and effective treatment of renal stones using SWL.

Box 60.1 lists types of patients in whom SWL is contraindicated. These conditions are described below.

­Preoperative evaluation A thorough history and physical examination is crucial for proper patient selection. Urine analysis is necessary for all patients and, if the concern arises for urinary tract infection, urine culture must be obtained [6, 7]. Optional laboratory studies include pregnancy testing when appropriate and coagulation studies for patients with history of coagulopathy. Regarding preoperative imaging, historically, renal ultrasound and plain abdominal radiography (i.e. kidney–ureter–bladder, KUB) were used to confirm stone presence, and intravenous pyelogram (IVP) was used to predict SWL success. However, with computerized tomography (CT) now universally available, noncontrast CT is the preferred imaging of choice [6–8]. Though not absolutely necessary, CT has the advantage of allowing the urologist to assess for f­actors predictive of SWL success, which will be discussed later in this chapter.

Pregnancy SWL is prohibited in pregnant women [8]. Though a small series reported on six females treated safely early during pregnancy [9], animal experiments in mice have shown deleterious effects of shock waves on the mouse fetus, affecting viability [10]. Anticoagulants or uncorrected bleeding diathesis Patients in whom anticoagulant/antiplatelet agents cannot be held or reversed, and in whom coagulopathy cannot be controlled, should not be treated with SWL. Expert opinion concludes that bleeding diathesis should be controlled for 24 hours before and 48 hours postprocedure [8]. Renal hematomas are reported to occur in 1% of patients without coagulopathy after SWL [11]. The literature on SWL in individuals with iatrogenic and/or pathological bleeding diathesis is sparse, retrospective, and nonstandardized, however [12]. Continuation of aspirin during SWL has been reported but with mixed results [12]. A fourfold increase in the risk of postoperative hematoma was reported in one study when antiplatelet agents ­(aspirin/nonsteroidal anti‐inflammatory drugs) were continued during SWL: these patients were managed conservatively [11]. SWL in patients taking clopidogrel has been associated with cases of nephrectomy and death [13, 14]. Other reports looking at all causes of bleeding diathesis including pathologic conditions

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

Section 4  Shock-wave Lithotripsy

Box 60.1  Absolute contraindications to SWL. Pregnancy Uncontrolled bleeding diathesis Uncontrolled hypertension Untreated infection Significant skeletal malformations or severe obesity Arterial aneurysms in close proximity to target stone

such as hemophilia, von Willibrand disease, etc., suggested hematology consultation and consideration of SWL only if the coagulopathy can be corrected [15]. Uncontrolled hypertension Uncontrolled hypertension has been associated with an increased risk of renal hematoma after SWL and should be controlled prior to treatment [8]. The incidence is as high as 4.3% in this group [16]. Intraoperative hypertension (defined as blood pressure >140/90 mmHg) is also a significant risk factor for hematoma formation with a threefold increase in risk [11]. Arterial aneurysms in close proximity to the targeted stone Aortic or renal artery aneurysms near the renal stone are listed as contraindications to SWL [8]. Aortic aneurysm rupture is described after SWL in five case reports [17]. Calcified plaque within the aneurysm may be fragmented by shock waves leading to rupture. These case reports are in contrast to in vitro studies showing SWL does not significantly damage human calcified aneurysm tissue [18]. Some authors concede that SWL can be performed in the setting of arterial aneurysms provided that the patient is monitored [17]. Severe skeletal malformations or obesity Certain skeletal malformations may prevent positioning of the patient on the lithotripter table  [8]. Severe obesity may pose a similar issue and can also make visualization of the stone difficult under fluoroscopy or ultrasound. Anatomical or functional obstruction of the urinary tract Any patient with anatomic or functional ureteropelvic junction or ureteral obstruction distal to the stone should not undergo SWL [6–8]. These abnormalities may delay or impede clearance of residual fragments and lead to significantly lower stone‐free rates [19].

Untreated cystitis, pyelonephritis, or bacteriuria Patients with untreated cystitis, pyelonephritis, or bacteriuria are at risk of worsening infection and/or urosepsis during SWL. These patients should undergo proper ­antibiotic treatment first [6, 7].

­Stone characteristics Early experience demonstrated that stone composition influences SWL success. Dretler first described “stone fragility”: stones of various compositions have differing susceptibility to shock waves [20]. Subsequently, Dretler described stone breakability or “stone durility” [21]. Cystine, brushite, and calcium oxalate monohydrate stones are the least fragile (i.e. most durile) while uric acid stones are the most fragile [22]. This can be seen in vitro (Figure 60.1); however, the standard deviation of shocks required for each stone type is large, indicating variability in fragility within stones of the same composition [23]. Because of this variability, stone composition is less important in predicting SWL success than other factors such as Hounsfield density, which will be discussed later in this chapter. Secondary mineral composition, spatial arrangement of various mineral components, and variations in layer structures of different mineral components also affect stone ­fragility [23]. 1200

Shock waves to comminution

732

(1700)

(>2000)

1000 800 600 400 200 0

CYS UA HA COM BRU STR (n = 39) (n = 21) (n = 75) (n = 23) (n = 13) (n = 24)

Figure 60.1  Shock waves to comminution for various types of human kidney stones in vitro. Bars show mean value, error bars show standard deviation, and short horizontal lines show range of values. UA, uric acid; HA, hydroxyapatite; COM, calcium oxalate monohydrate; BRU, brushite; STR, struvite; CYS, cystine; n, number of stones of each type. Source: [23]. Reproduced with permission of Elsevier.

60  Shock‐wave Lithotripsy of Renal Calculi

Multiple factors obtained from preoperative imaging are useful for patient selection. While stone size and location can be gathered from plain abdominal radiography or renal ultrasound, Hounsfield density, pelvicalyceal anatomy, and skin‐to‐stone distance are only available with CT imaging. Stone size and location Stone size and location are the most influential factors in determining the management of renal stones. SWL stone‐free rates at 3 months are quoted to be 86–89% for renal pelvis, 71–83% for upper calyx, 73–84% for middle calyx, and 37–68% lower calyx stones across ­several generations of lithotripters [24]. A critical review of SWL outcomes for lower pole stones first published in 1994 reported stone‐free rates of 60% after one treatment. When broken down by stone size, stone‐free rates for stones 2 cm were 74, 56, and 33%, respectively [25]. The general consensus is that individuals with stones >2 cm in the upper and middle calyces and >1 cm in the lower calyx should not be offered SWL as first‐line therapy [6, 7]. Subsequent studies of newer generation lithotripters have demonstrated lower success rates than initial studies; 3 month stone‐free rates for the second‐ generation Dornier MFL5000 for lower pole stones were 56% [26], and overall stone‐free rates for the third‐­ generation Siemens Lithostar Plus were decreased by 40% when compared to the earlier Dornier HM3 [4]. Finally, the fourth‐generation Storz Modulith (SLX‐F2) lithotripter was found to have equivalent stone‐free rates for solitary renal stones compared to the HM3 but required significantly more shocks to achieve this [27]. Incomplete fragmentation can lead to steinstrasse, which is a column of stone fragments that lodge within the ureter causing obstruction after SWL [28, 29]. The word steinstrasse is German for “stone street” which refers to the radiographic appearance of this condition. Steinstrasse occurs when the lithotripter fragments the stone into pieces that are not easily passed spontaneously [28]. Size and location are two independent risk factors for this to occur [28, 29]. SWL performed on renal stones is 2.7 times more likely to cause steinstrasse than ureteral stones [28]. Incidence rates for steinstrasse after SWL for renal stones 2 cm were 4.4, 15.7, and 24.3%, respectively. This study also found renal pelvis stones to be a significant predictor of steinstrasse compared with calyceal stones [29]. To date, five randomized controlled trials (RCTs) have evaluated SWL versus other endourological procedures [24]. The two highest quality, RCTs evaluated lower pole stones [30, 31]. The first multicenter study evaluated the

Efficiency quotient

­Imaging characteristics

PCNL SWL

100 90 80 70 60 50 40 30 20 10 0 1–10

11–20

21–30

Size (mm) % Stone free EQ = ×100 100 + % retreatment + % auxiliary procedures

Figure 60.2  Efficiency quotients for SWL and PCNL for lower pole calculi stratified by stone size. Source: [30]. Reproduced with permission of Elsevier.

efficacy of SWL versus percutaneous nephrolithotomy (PCNL). Of note, multiple generations of lithotripters were used across the institutions. Stone‐free rates were significantly higher with PCNL for every stone size (2 cm), and for stones >1 cm only 21% of patients became stone‐free with SWL. Retreatment and auxiliary procedure rates were significantly lower for PCNL. SWL had an acceptable 50% efficiency quotient for stones 1 cm (Figure  60.2). The authors concluded that as stone size increases beyond 1 cm, the likelihood of becoming stone‐free with SWL decreases significantly and that SWL is suitable only for lower pole stones 4 mm and observation for ≤2 mm. Tubeless PCNL Tubeless PCNL was first implemented to reduce postoperative pain and shorten convalescence in uncomplicated PCNL procedures. Bellman et  al. matched 50 patients by age, gender, and procedure (tubeless vs. standard PCNL), and compared complications, analgesia requirements, length of hospitalization, and cost of treatment between groups [41]. Patients undergoing tubeless PCNL had significantly shorter length of stay (0.6 vs. 4.6 days, P = 0.0001) and less morphine sulfate use (11.58

Table 72.4  Cost data of tubeless versus standard (tubed) PCNL.

Study

Type of PCNL

Number

Cost (mean ± SD) in US$

Bellman et al. [41]

Standard Tubeless with stent

50 50

3750 1638

Feng et al. [42]

Standard Mini‐PCNL Tubeless with stent

10 9 8

7555 ± 619 6565 ± 300 5562 ± 356

Choi et al. [43]

Standard Totally tubeless

49 44

2846 ± 824 2380 ± 549

vs. 36.06 mg, P = 0.001), both of which contributed to a $2112 cost saving per case (tubeless $1638 vs. standard $3750). Time to return to normal activities was also shorter by nearly 9 days. This result has been replicated in other studies as shown in Table 72.4. The main cost‐ savings component for tubeless PCNL is shorter hospital stay with associated lesser costs of inpatient care. Since the original description by Bellman et al. tubeless PCNL has been shown to be safe and effective for use in children, simultaneous bilateral procedures, staghorn ­ stones, supracostal access, in obese patients, and in renal units with anatomical anomalies [44]. When a secondary procedure is not needed, tubeless PCNL has a clear cost advantage compared to standard PCNL. There is a clear need for more prospective studies investigating the cost‐effectiveness of PCNL, URS, and SWL for the treatment of renal stones, especially given the expanded use of URS to treat large renal stone ­burdens and increasing use of tubeless and mini‐PCNL. Future research should account for both stone size and stone location for determining relative cost‐effectiveness among these treatment modalities.

­ edical evaluation and M management Dietary and medical management aimed at reducing stone recurrence seems desirable given the rising prevalence of stone disease. While dietary modification has been shown to be effective at reducing recurrence and comes at little to no added cost, it does so to a lesser extent than medical therapy, which has been shown to decrease stone recurrence compared to no treatment [45]. When making decisions regarding the need for stone prevention clinicians must weigh the costs of medical therapy along with potential side effects and the effects of lifestyle changes against the idea that not all recurrent stones are symptomatic or require treatment. Numerous

859

860

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

authors have investigated the economic consequences of these approaches to better understand these conflicting outcomes. An early study evaluating medical therapy was performed by Parks and Coe [46]. The authors calculated the cost savings of metabolic evaluation and medical treatment by comparing rates of stone occurrence before and after the initiation of medical therapy. All patients received initial extensive laboratory evaluation and counseling on dietary modifications aimed at minimizing lithogenic risk factors. Select patients were prescribed medications such as allopurinol, potassium citrate, and thiazides based on metabolic background. This approach produced a stone remission rate of 83%. By applying this  remission rate, along with estimates of rates of stone  ­passage events, cost of surgical procedures, and need for hospitalization, they estimated that their preventative regimen resulted in an average cost savings of $1162–3162/patient/year. This result is likely an overestimate due to absence of systematic incorporation of dietary measures in the control group, which have been shown to reduce recurrence rates [47–49], until after entry into the stone clinic. It is important to point out there was no true control group in this study, and pretreatment stone incident rates were based on patient recall, which is subject to bias. Disease aggressiveness certainly plays a role in the decision to initiate dietary and/or medical therapy. Lotan et al. performed a cost analysis (decision‐tree modeling) to compare the costs of six different treatment strategies: dietary measures only (conservative), empiric drug ­therapy (empiric), or directed drug treatment based on simple (SMEM) or comprehensive (CMEM) metabolic evaluation with either all patients undergoing drug treatment (SMEM or CMEM) or only selected patients with diagnosed metabolic abnormalities receiving drugs (modified SMEM and modified CMEM) [50]. The model accounted for accrual of cost for evaluation, drugs, ­emergency treatment, and surgical treatment for recurrent stones. Conservative therapy was the most cost‐effective strategy for first‐time stone formers, resulting in a recurrence rate of one stone episode every 14 years. Conservative therapy was also the least costly approach for recurrent stone formers, but it was associated with an excessively high recurrence rate of 0.3 stones/patient/year. As expected, each of the four drug treatment strategies were all more costly than dietary measures alone ($885–1187 vs. $258/year for the conservative approach), but the benefit was that drug treatment further reduced recurrence rates by 60–86% compared to conservative t­ herapy. Modified SMEM was slightly more costly and marginally more effective than empiric therapy. Modified CMEM had little or no improvement in efficacy over modified or

Table 72.5  Model outcomes by treatment strategy.

Strategy

Stone formation rate (stones/ patient/year)

Model cost ($/year)

First‐time stone formers Conservative

0.070

133

Empiric

0.013

966

Modified SMEM

0.011

1085

SMEM

0.028

835

Modified CMEM

0.009

1170

CMEM

0.015

1087

Conservative

0.300

258

Empiric

0.057

990

Modified SMEM

0.048

1104

SMEM

0.120

885

Modified CMEM

0.041

1187

CMEM

0.065

1114

Recurrent stone formers

CMEM, comprehensive metabolic evaluation; SMEM, simple metabolic evaluation. For details about the treatments, see text. Source: [50]. Reproduced with permission of Elsevier.

empiric SMEM with equivalent or greater cost. This data can be seen in Table 72.5 [50]. Significant improvements in recurrence rates (by up to 60%) were observed with treatment strategies in which all patients received medication, regardless of metabolic abnormalities, compared to strategies where only patients with a 24 hour urine abnormality were prescribed drugs. Moreover, since CMEM significantly increased the cost of treatment without added efficacy, the results recommend modified SMEM in which all patients received either drug treatment or empiric therapy. Interestingly, since the least costly approach (conservative therapy) was associated with an disappointingly high recurrence rate, this model demonstrated the benefit of treating every recurrent stone former with medication despite the relatively high drug costs, due to the associated significant reduction in rate of recurrence. Decision‐tree analysis has also been used to evaluate the cost‐effectiveness of medical evaluation and treatment strategies across healthcare systems. Lotan et al. created a model using data derived from a published international cost survey to determine the most cost‐effective strategy for countries for which data was available [6, 51]. Treatment arms were limited to conservative therapy, empiric treatment, and comprehensive metabolic evaluation with targeted medical therapy for patients with a metabolic abnormality. For first time stone formers, conservative (dietary) therapy alone was the most ­

72  Cost‐effective Strategies for Stone Management

c­ ost‐­effective strategy in all 10 countries. The most cost‐ effective strategy for recurrent stone formers in all countries except the UK was conservative therapy, followed by empiric therapy and then directed therapy. Empiric therapy was the least costly strategy in the UK that enjoyed a low cost of drug therapy (at the time estimated at only $29/patient/year). Similarly, in other countries with relatively low medication costs, like Switzerland and Turkey, there was a marginal cost difference between conservative and empiric therapy; however, empiric therapy produced a significant improvement in efficacy. Two‐way sensitivity analysis demonstrated that more than one stone episode per year would be necessary to render empiric therapy cost superior to conservative therapy in all analyzed countries except Switzerland and the United Kingdom. In countries with high drug costs, like the United States, conservative therapy naturally offered an even greater cost advantage. Use of metabolic evaluation to direct medical therapy was not cost‐effective in any of the countries studied since the model had little difference in efficacy between empiric and targeted medical therapy. International cost analyses make it clear that differences in medication costs and surgery across healthcare systems, predominantly based on subsidization, drive differences in the cost‐effectiveness of medical manage-

ment treatment schemes. Drug therapy is favored when medication costs are low. A conservative approach is favored when medication costs are higher, due to relatively less frequent need for surgical treatment of stone recurrences and fixed reimbursement for surgical procedures.

­Conclusion Delivering high‐quality, cost‐effective healthcare is more important now than ever before. For stone disease, cost can be scrutinized at every step of care, from diagnosis to decisions about observation versus treatment and subsequent need for medical prevention. While cost‐effectiveness is certainly important when considering care in the abstract sense, medical and surgical treatment decisions should always be made with best interests and safety of the patient in mind. This may result in a treatment selected to maximize stone clearance compared to another outcome and in the process result in higher cost. Going forward, new comprehensive cost analyses and cost‐effectiveness studies will help clinicians further refine and improve stone treatment.

­References 1 Scales CD, Smith AC, Hanley JM et al. Urologic Diseases

2

3

4

5

6

in America project. Prevalence of kidney stones in the United States. Eur Urol 2012;62:160–165. Stamatelou KK, Francis ME, Jones CA et al. Time trends in reported prevalence of kidney stones in the United States: 1976–1994. Kidney Int 2003;63:1817–1823. Pearle MS, Calhoun E, and Curhan G. Urolithiasis. In: Urologic Diseases in America (ed. MS Litwin and CS Saigal), 282–319. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington DC: US Government Printing Office, 2007. Antonelli JA, Maalouf NM, Pearle MS et al. Use of the National Health and Nutrition Examination Survey to calculate the impact of obesity and diabetes on cost and prevalence of urolithiasis in 2030. Eur Urol 2014;66:724–729. Saigal CS, Joyce G, and Timilsina AR. Direct and indirect costs of nephrolithiasis in an employed population: opportunity for disease management? Kidney Int 2005;68:1808–1814. Lotan Y, Cadeddu JA, and Pearle MS. International comparison of cost effectiveness of medical management strategies for nephrolithiasis. Urol Res 2005;33:223–230.

7 Eikefjord E, Askildsen JE, and Rørvik J. Cost‐

effectiveness analysis (CEA) of intravenous urography (IVU) and unenhanced multidetector computed tomography (MDCT) for initial investigation of suspected acute ureterolithiasis. Acta Radiologica 2009;49:222–229. 8 Grisi G, Stacul F, Cuttin R et al. Cost analysis of different protocols for imaging a patient with acute flank pain. Eur Radiol 2000;10:1620–1627. 9 Smith‐Bindman R, Aubin C, Bailitz J et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014;371:1100–1110. 10 Lotan Y, Gettman MT, Roehrborn CG et al. Management of ureteral calculi: a cost comparison and decision making analysis. J Urol 2002;167: 1621–1629. 11 Miller OF and Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol 1999;162:688–691. 12 Coll DM, Varanelli MJ, and Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol 2002;178: 101–103.

861

862

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

13 Hübner WA, Irby P, and Stoller ML. Natural history

14

15

16

17

18

19

20

21

22

23

24

25

26

and current concepts for the treatment of small ureteral calculi. Eur Urol 1993;24:172–176. Hollingsworth JM, Rogers MA, Kaufman SR et al. Medical therapy to facilitate urinary stone passage: a meta‐analysis. Lancet 2006;368:1171–1179. Pickard R, Starr K, MacLennan G et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo‐controlled trial. Lancet 2015;386:341–349. Pickard R, Starr K, MacLennan G et al. Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo‐ controlled, randomised controlled trial and cost‐ effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha‐blocker (tamsulosin) (the SUSPEND trial). Health Technol Assess 2015;19:1–172. Pearle MS, Pierce HL, Miller GL et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 1998;160:1260–1264. Mokhmalji H, Braun PM, Martinez Portillo FJ et al. Percutaneous nephrostomy versus ureteral stents for diverson of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 2001;165:1088–1092. Assimos D, Krambeck A, Miller NL et al. Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 2016;196(4):1153–1160. Barrionuveo Moreno P, Asi N, and Benkhadra K et al. Surgical management of kidney stones: a systematic review. Mayo Clinic 2015 (unpublished). Matlaga BR, Jansen JP, Meckley LM et al. Economic outcomes of treatment for ureteral and renal stones: a systematic literature review. J Urol 2012;188: 449–454. Tosoian JJ, Ludwig W, Sopko N et al. The effect of repair costs on the profitability of a ureteroscopy program. J Endourol 2015;29:406–409. Carey RI, Gomez CS, Maurici G et al. Frequency of ureteroscope damage seen at a tertiary care center. J Urol 2006;176:607–610. Carey RI, Martin CJ, and Knego JR. Prospective evaluation of refurbished flexible ureteroscope durability seen in a large public tertiary care center with multiple surgeons. Urology 2014;84:42–45. Pietrow PK, Auge BK, Delvecchio FC et al. Techniques to maximize flexible ureteroscope longevity. Urology 2002;60:784–788. Afane JS, Olweny EO, Bercowsky E et al. Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr. J Urol 2000;164:1164–1168.

27 Semins MJ, George S, Allaf ME et al. Ureteroscope

28

29

30

31

32

33

34

35

36

37

38

39

40

41

cleaning and sterilization by the urology operating room team: the effect on repair costs. J Endourol 2009;23:903–905. Proietti S, Dragos L, Molina W et al. Comparison of new single‐use digital flexible ureteroscope versus nondisposable fiber optic and digital ureteroscope in a cadaveric model. J Endourol 2016;30:655–659. Weizer AZ, Auge BK, Silverstein AD et al. Routine postoperative imaging is important after ureteroscopic stone manipulation. J Urol 2002;168:46–50. Bugg CE, El‐Galley R, Kenney PJ et al. Follow‐up functional radiographic studies are not mandatory for all patients after ureteroscopy. Urology 2002;59:662–667. Manger JP, Mendoza PJ, Babayan RK et al. Use of renal ultrasound to detect hydronephrosis after ureteroscopy. J Endourol 2009;23:1399–1402. Omar M, Chaparala H, Monga M et al. Contemporary imaging practice patterns following ureteroscopy for stone disease. J Endourol 2015;29:1122–1125. Sutherland TN, Pearle MS, and Lotan Y. How much is a kidney worth? cost‐effectiveness of routine imaging after ureteroscopy to prevent silent obstruction. J Urol 2013;189:2136–2141. Assimos D, Krambeck A, Miller NL et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 2016;196(4):1161–1169. Chandhoke PS. Cost‐effectiveness of different treatment options for staghorn calculi. J Urol 1996;156:1567–1571. Albala DM, Assimos DG, Clayman RV et al. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis‐ initial results. J Urol 2001;166:2072–2080. May DJ, Chandhoke PS. Efficacy and cost‐effectiveness of extracorporeal shock wave lithotripsy for solitary lower pole renal calculi. J Urol 1998;159:24–27. Bagrodia A, Gupta A, Raman JD et al. Predictors of cost and clinical outcomes of percutaneous nephrostolithotomy. J Urol 2009;182:586–590. Raman JD, Bagrodia A, Bensalah K et al. Residual fragments after percutaneous nephrolithotomy: cost comparison of immediate second look flexible nephroscopy versus expectant management. J Urol 2010;183:188–193. Raman JD, Bagrodia A, Gupta A et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol 2009;181:1163–1168. Bellman GC, Davidoff R, Candela J et al. Tubeless percutaneous renal surgery. J Urol 1997;157:1578–1582.

72  Cost‐effective Strategies for Stone Management

42 Feng MI, Tamaddon K, Mikhail A et al. Prospective

43

44

45

46 47

randomized study of various techniques of percutaneous nephrolithotomy. Urology 2001;58:345–350. Choi SW, Kim KS, Kim JH et al. Totally tubeless versus standard percutaneous nephrolithotomy for renal stones: analysis of clinical outcomes and cost. J Endourol 2014;28:1487–1494. Zilberman DE, Lipkin ME, de la Rosette JJ et al. Tubeless percutaneous nephrolithotomy–the new standard of care? J Urol 2010;184:1261–1266. Pearle MS, Roehrborn CG, and Pak CY. Meta‐analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. J Endourol 1999;13:679–685. Parks JH and Coe FL. The financial effects of kidney stone prevention. Kidney Int 1996;50:1706–1712. Borghi L, Meschi T, Amato F et al. Urinary volume, water and recurrences in idiopathic calcium

48

49

50

51

nephrolithiasis: a 5‐year randomized prospective study. J Urol 1996;155:839–843. Borghi L, Schianchi T, Meschi T et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 2002;346: 77–84. Hiatt RA, Ettinger B, Caan B et al. Randomized controlled trial of a low animal protein, high fiber diet in the prevention of recurrent calcium oxalate kidney stones. Am J Epidemiol 1996;144: 25–33. Lotan Y, Caddedu JA, Roehrborn CG et al. Cost‐ effectiveness of medical management strategies for nephrolithiasis. J Urol 2004;172:2275–2281. Chandhoke PS. When is medical prophylaxis cost‐ effective for recurrent calcium stones? J Urol 2002;168:937–940.

863

864

73 Long‐term Stenting of the Ureter Panagiotis Kallidonis,1 Wissam Kamal,1 Dimitrios Kotsiris,1 Dimitrios Karnabatidis,2 & Evangelos Liatsikos1 1 2

Department of Urology, Laparoscopy and Lithiasis Unit, University Hospital of Patras, Rion, Patras, Greece Department of Radiology, University Hospital of Patras, Rion, Patras, Greece

­Introduction Ureteral stents are widely used in urologic clinical practice. The efficacy of ureteral stents in the management of various urologic conditions causing upper urinary tract obstruction has been extensively proven and their contribution to urology remains enormous. Ureteral ­ stents are available in various shapes and made of various ­materials. Ureteral stents can be divided into polymeric stents (PSs) and metal mesh stents (MSs). PSs are usually composed of polyurethane and silicon‐based polymeric biomaterial. A unique category of PSs is the biodegradable stents which are composed of biomaterials such as poly‐l‐lactide‐co‐glycolide (PLGA) or l‐lactide‐glycolic acid copolymer. MSs are based on metal alloys such as  MP35N (a nonmagnetic nickel–cobalt–chromium– molybdenum alloy), nickel‐cobalt, or stainless steel. Stent designs depend on their use and composition. The most commonly used PS design is the double‐pigtail (double‐J) design, which is characterized by coil‐shaped stent ends. MSs are either MSs identical to those used in coronary vessels or double‐J stents composed of metal wire (Resonance, Cook Urological) [1]. Regardless of the stent design and composition, the use of ureteral stents is associated with several complications, which limit their use and necessitates the escalation of research towards the introduction of the “ideal” ureteral stent. The properties of the ideal stent include the ability to hold its position (memory) over time (durometry), easy manipulation of its shape (elasticity), and excellent tensile strength while having elongation capacity. Moreover, placement of the ideal ureteral stent should not be associated with degradation of its s­ tructure and function (biodurability) or influence the urothelium (biocompatibility). The ideal stent should be radiopaque

and therefore visualized by fluoroscopy [1, 2]. Patient comfort and resistance to bacterial colonization could also be considered important properties of the ideal stent. The ideal stent is currently not available and the problems related to ureteral stenting remain an issue, especially in cases requiring long‐term stenting to ­maintain ureteral patency.

­Indications for ureteral stents The insertion of stents in the ureter serves several ­purposes: relief of ureteral obstruction, promotion of ureteral healing, and prevention of possible complications. Postoperative nephrostomies are usually avoided by the use of ureteral stents. The stent acts as a scaffold for the growth of epithelium, promotes ureteral healing by aligning the ureteric wall, and reduces extravasation around the ureter (less inflammation) [3, 4]. The use of ureteral stents for the management of stone disease provides obstruction/hydronephrosis relief, and reduction of colic and infection incidents. Double‐pigtail PSs are inserted in lithiasis patients for temporary management of stone‐related obstruction [5]. An absolute indication for the management of stone cases by ureteral stenting is the concomitant presence of ureterolithiasis and active infection [6]. The routine use of double‐pigtail PSs after shock‐wave lithotripsy (SWL) and ureteroscopy (URS) remains questionable [7, 8]. Transplantation‐ related ureteral strictures are an indication for PS insertion [9–11]. Partial ureteral lacerations are successfully managed by double‐pigtail stent placement [12], as are ureteropelvic junction obstructions (UPJOs); this provides relief of flank pain and healing of the repaired site after pyeloplasty and endopyelotomy [4, 11]. PSs are

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

73  Long-term Stenting of the Ureter

also inserted intraoperatively in reconstruction of the ureter to, as mentioned above, provide alignment of the  area of the anastomosis and act as scaffold around the ureter, which may eventually facilitate the healing process. Moreover, the presence of a ureteral stent ­ ­minimizes urine extravasation and reduces ureteral wall edema [4]. Ureteral stents make a significant contribution to the treatment of ureteral fistulas: 85% of such cases are efficiently healed with the use of a PS [12]. Malignant ureteral obstruction remains a challenging field for PSs. Despite the use of PSs as an alternative to nephrostomy tubes in the above cases, extrinsic malignant ureteral obstruction managed by PSs is associated with high failure rates [13, 14]. Two ipsilateral pigtail ureteral stents were proposed as a method to address cases of single stent failure, with various success rates. A double‐lumen double‐pigtail stent has also been introduced and evaluated with promising results in a pig model [5, 15]. MSs have been used for the management of extrinsic malignant ureteral obstruction in cases where PSs have failed. The reported success rates were high and the method proved to be useful [2]. The use of MSs has expanded in benign cases of ureteroileal anastomotic strictures and UPJO, with promising success rates. In fact, long follow‐up of the former indicates that MSs are an alternative to challenging reintervention procedures performed for ureteroileal anastomotic strictures and UPJO [2, 15, 16].

­Complications of ureteral stents Long‐term urinary drainage by ureteral stent insertion is limited by several complications. These complications are related to the design and material of the stent. Major problems of stent use include infection, patient discomfort, encrustation, migration, and hyperplastic reaction. Stent syndrome The “stent syndrome” represents the most common ­double‐pigtail PS‐related complication and is characterized by irritative voiding symptoms, flank pain, suprapubic discomfort, and occasional hematuria [4, 5]. Urinary ­system symptoms may be present in up to 80% of patients with stented ureters. Bladder pain (80%) and incontinence (60%) are important problems for these patients [17]. Insertion technique and stent characteristics are unrelated to these symptoms, while selection of the appropriate stent length is related to reduced morbidity [4, 18, 19]. Voiding symptoms, such as urgency and dysuria, attributed to irritation of the bladder floor by the stent, were significantly more frequent in patients with

longer stents [20]. Nevertheless, flank pain was not reduced by the stent length as this symptom is related to vesicoureteric reflux [22]. Softer or tapered lumenless tails have been also proposed for symptoms reduction [21, 22]. Recently, the concept of replacing the distal coil of the double‐pigtail PS stent with a 0.3 Fr suture was evaluated. The suture is left in the bladder and facilitates removal. Moreover, the presence of less foreign material in the bladder was theorized to result in reduced lower urinary tract symptoms. A prospective study on 79 patients showed that this design significantly reduced urinary symptom score and pain score [23]. Stent migration Several factors affect stent migration including stent length, material, and diameter [24, 25]. Migration of the PSs is associated with stent design. Double‐pigtail stents are less prone to migration in comparison to single‐pigtail stents. PSs usually migrate towards the kidney rather than towards the bladder [26]. Proximal stent migration is less common with an incidence of 1–4.2%; the management of these cases could represent a greater challenge in comparison to the distal migration [27–29]. When the distal end is below the pelvic brim it could be managed with the use of URS, a stone basket, or a Fogarty catheter with success rates reaching 90% [30]. A percutaneous approach might be more successful than the retrograde retrieval in special circumstances including cases of proximal migration above the pelvic brim, migration above a stricture, or a recent ureteral repair [31]. Covered MSs have been ­associated with rates of migration up to 81.2% [32]. Encrustation Encrustation is a major problem encountered in long‐ term ureteral stenting with both PSs and MSs. The risk of encrustation is associated with both the stent biomaterial and the patient’s history. Stent encrustation in ­urolithiasis patients occurs in 9.2% of stents removed in under 6 weeks, 47.5% of stents removed between 6 and 12 weeks, and 76.3% of stents removed after more than 12 weeks [28]. Kawahar et al. observed that stents smaller than 6 Fr were significantly more likely to encrust than those 7 Fr or larger [33]. Other risk factors for stent encrustation include urinary tract infection or urosepsis, history of stone disease, pregnancy, urinary diversions, metabolic or congenital abnormalities, and chronic renal failure [34–36]. Encrustation is always related to biofilm formation despite the absence of evident urinary infection. Biofilm is formed by adhesion of microorganisms on the stent surface and gradual development of a thin film of extracellular matrix around them [37]. Biofilms and urease‐producing organisms on a stent surface

865

866

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

induce elevation of urinary pH and precipitation of salts such as calcium hydroxyapatite and magnesium ammonium phosphate. The latter process eventually ­ results in struvite and calcium phosphate accumulation [38]. The subsequent encrustation and infection of stents may be responsible for pain, hematuria, and sepsis [39]. The phenomenon of encrustation makes routine exchange of PSs necessary for the prevention of related complications. “Stone formers” are difficult to manage because the exchange intervals are unpredictable [4]. Many algorithms have been proposed for the classification and management of encrusted stents. The suggested management modalities include URS, percutaneous nephrolithotomy, extracorporeal SWL, and cystolitholapaxy [40–42]. Encrustation of MSs is associated with the aperistaltic segment of the stented ureter in conjunction with ­ureteral peristalsis and urinary stasis, resulting in encrustation of the areas of the MS uncovered by urothelium [43]. An encrustation‐resistant MS needs to be made of a ­biomaterial resistant to bacterial infection and subsequent biofilm formation. In addition, it should be easily ­covered by endothelial cells and become incorporated into the ureteral wall [44, 45]. Urothelial hyperplasia Urothelial hyperplasia is a significant complication of MS insertion in the ureter. Ureteral patency can be ­compromised by the development of hyperplastic tissue protruding through the stent struts. The hyperplastic ­tissue is responsible for restenosis of the stented ureter. An experimental study in a porcine model by Desgrandchamps et  al. revealed that only one of eight stents was patent 35 days after insertion [45]. It appears that hyperplasia can be prevented by avoiding overextension of the strictured area of the ureter, followed by careful stent implantation. It should be noted that urothelial hyperplasia regresses within 4–6 weeks of MS insertion, resulting in ureteral lumen narrowing [46–50]. Flueckiger et al. suggested that the initial effect (first 1–2 weeks) of the inserted MS in the ureter is reactive swelling of the ureter and not hyperplasia of the urothelium leading to constriction of the ureteral lumen [51]. A characteristic trumpet‐like morphologic configuration of the ureter located on the upper extremity of the stent has been described, but is not related to ­ureteral patency risk [27, 50].

­Polymeric stents PSs are the most commonly used ureteral stents. A variety of synthetic polymeric compounds has been used for  the manufacture of PSs. These materials are based

on  polyurethane or silicone, such as Silitek (Surgitek, Medical Engineering Corporation, Racine, WI, USA), C‐Flex (Cook Urological, Spencer, IN, USA), and Percuflex (Boston Scientific, Natick, MA, USA) [52, 53]. Silitek is a block copolymer based on silicon, while C‐Flex is a proprietary silicone with styrene/ethylene/butylene block copolymer. Percuflex is composed of an olephinic block copolymer. In contrast, Tecoflex (Thermedics, Woburn, MA, USA) is a proprietary aliphatic thermoplastic and is not based on silicone or polyurethane. Polyurethane is a relatively cheap material and has the advantage of high versatility, but its biocompatibility is considered poor and it is related to significantly more urothelial ulceration and erosion [54]. The gold standard of biocompatibility is silicone [55]. Although all the polymeric materials described above are susceptible to encrustation, Siliteck, C‐Flex, and Tecoflex are less frequently affected by this complication. Moreover, polyurethane, Silitek, and Percuflex provide high tensile strength [53]. Double‐pigtail polymeric stents The efficiency of retrograde ureteral stenting in obstruction of extrinsic and intrinsic etiology has been reported by Yossepowitch et al. [56]. Extrinsic obstruction was associated with a higher degree of hydronephrosis and the site of obstruction was located more distally. Ureteral stents achieved successful alleviation of the obstruction in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. Intrinsic obstruction cases were successfully managed at 3 month follow‐up, while extrinsic ureteral obstruction was successfully relieved in only 54.6% of the stents after the same time period. Other investigators reported a success rate for retrograde stenting of intrinsic ureteral obstruction of 88%. The mean follow‐up was 25.5 months [57]. The experience gained by the same investigators with the management of extrinsic ureteral obstruction by retrograde stenting revealed success rates of 81, 85, and 100% for malignant, retroperitoneal fibrotic, and benign‐etiology obstruction, respectively. Average ­follow‐up was 16 months (range 0.7–98 months) [58]. A large experience with 2431 patients (2685 ureters) who were treated by double‐pigtail stent insertion has been recently published [59]. The majority of the indications for ureteral stent insertion were URS or percutaneous lithotripsy, SWL, and open lithotomy. Iatrogenic ureteral injury, extrinsic ureteral obstruction, UPJO, and ureterocysteoneostomy were also managed by double‐ pigtail stent insertion. Several complications were observed: pain, gross hematuria, bladder irritation, high fever, encrustation, stent migration, and stenosis (or recurrence of stenosis). The mean follow‐up period was 31 ± 1.9 days (range 1–123 days). As a result, the insertion of double‐J stents for endoscopic and open procedures

73  Long-term Stenting of the Ureter

for upper urinary tract diseases can be considered as a safe and efficient method, at least for up to 4 months. The long‐term outcome of double‐pigtail ureteral stenting for the management of extrinsic ureteral obstruction was evaluated by Rosevear et al. in a study including experience accumulated over 9 years [58]. In total, 54 patients (87 ureters) with malignant, retroperitoneal fibrosis, or benign tumors were successfully treated in 81, 85, and 100% of cases, respectively. The mean follow‐up period was 16  months (range 0.7– 27 months) and mean interval between stent exchanges was 3.6 months. The average interval to stent failure was 4.8 months (range 0.7–27 months). Quality of life is an important issue for patients with ureteral stents as the stent‐related complications may have a significant impact. Joshi et al. investigated the effect of ureteral stents on quality of life and associated urinary symptoms. Storage symptoms, bladder pain, and hematuria were the most common symptoms observed, and at least one symptom was encountered in 80% of patients. In addition, the available questionnaires did not elucidate the entire range of symptomatology [60]. A coil‐reinforced polymeric double‐pigtail stent has been recently introduced for the treatment of malignant ureteral obstruction. The Silhouette stent (Applied Medical, Rancho Santa Margarita, CA, USA) has been introduced due to the high failure rate of common polymeric ureteral stents [5]. The stent proved to be more resistant to extrinsic compression than the also newly introduced double‐J all‐metal Resonance [60]. A unique double‐pigtail stent is the Zebra (Neo Medical, Bruckmühl, Germany). It is a Teflon‐coated lumenless double‐pigtail stent, which facilitates passage of residual stone fragments through the ureter. Comparison of Zebra to standard PSs in two stone‐ forming patients who underwent SWL revealed no ureteral damage, and after 4 and 5 weeks there was no encrustation on the Zebra stent, while the standard PSs were ­ covered by considerable encrustation [61]. Moreover, the material fatigue evaluation of the Zebra stent in an experimental model simulating the movement of the ureter estimated that the stent would not break even if it was left indwelling for 9 months [62].

r­etroperitoneal fibrosis, and middle‐ureter stricture. These patients were managed successfully by the insertion of two ipsilateral 7 Fr ureteral stents, which were exchanged at 3 month intervals until the patients were managed ­surgically [63]. In a subsequent report, malignant ureteral obstruction in seven patients was managed by the insertion of two ipsilateral stents [64]. Previous insertion of a single double‐pigtail stent had been unsuccessful in the management of the obstruction. Three patients died within 3 months of insertion of the two ipsilateral stents, while the remaining four had a mean follow‐up of 16 months (38 months maximum). Stents were exchanged every 4–6 months to avoid long‐term complications. Recently, Elsamra et  al. published the largest series in TUS. TUS insertion or exchange was performed in 187 cases. The latter cases included 39 renal units with malignant ureteral obstruction and 36 units with benign ureteral obstruction. Stent failure was noted in 12.8% of patients with malignant ureteral obstruction and none in the benign ureteral obstruction cases. The investigators proposed that TUS are highly successful in both benign and malignant causes of obstruction [65] A novel dual‐lumen double‐pigtail stent composed of two adhered ureteral stents has been evaluated in a ­porcine model. The stent provides better flow in comparison to a single ureteral stent. The main advantage of this stent is that its insertion requires only one guidewire, whereas insertion of two ipsilateral stents requires two guidewires, making the procedure more cumbersome, Clinical experience with this interesting stent has not been reported since its experimental evaluation [15].

Ipsilateral and dual‐lumen double‐pigtail polymeric stents

Biodegradable polymeric materials and stents have been present in urology for over a decade. Their main advantage is that they do not need to be removed. The additional procedure for the extraction of the inserted stent is not necessary, the complications of this procedure are avoided, and the period of discomfort for the patient is shortened [5, 53]. In a porcine model, a PLGA ureteral stent inserted after experimental Acucise™ balloon incision endopyelotomy

The use of two ipsilateral double‐pigtail PSs for the management of extrinsic ureteral obstruction resistant to a single stent insertion was proposed more than a decade ago [63]. This stent configuration has been referred to in the literature as “tandem ureteral stents” (TUS). The first report included five patients who were treated for ureteral obstruction due to ureteral orifice stricture, ­

Coil‐reinforced double‐pigtail polymeric ureteral stent, the Silhouette stent

The coil‐reinforced double‐pigtail PS Silhouette stent is a new metal stent that has been tested in vitro studies. These showed that the stent can resist higher compressional forces than the Resonance stent and is less prone to kinking than other stents, and hence has a lower rate of failure [66, 67]. Nevertheless, clinical data are not ­currently available to evaluate the efficacy of this PS. Biodegradable polymeric stents

867

868

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

was shown to provide similar drainage to a standard PS (Applied Medical) in pigs, but its biocompatibility was not favorable compared to a standard stent since the musculature of the incised ureteral segments revealed inferior healing [68]. A biosolvable ureteral stent (TUDS, Boston Scientific) was evaluated in terms of biodegradation and biocompatibility in a porcine model. The stent is designed to maintain ureteral patency for 48 hours, after which it softens and eventually degrades. Histologic results were similar for both a standard hydrogel‐coated stent and TUDS [69]. The clinical assessment of the TUDS stent showed safe and efficient drainage. Dissolution took place in 90% of the stents after an average of 8 days. Satisfaction was reported by 89% of the patients treated by TUDS [70]. Tajla et al. evaluated a horn‐shaped helical PGLA stent that was used for the postoperative management of antegrade endopyelotomy (cold‐knife technique) performed for UPJO [71]. In vitro studies estimated the degradation time for the stent to be 2–2.5 months. Percutaneous nephrostomy or stent removal procedures were not deemed necessary for the treated patient. The stent contributed to the reduction of vesicoureteral reflux and postoperative renal infection due to its function as a ­partial catheter. Uriprene is a biodegradable copolymer composed of l‐glycolic acid, polyethylene glycol, and barium sulfate which has been recently considered for use in PSs. In vivo studies in porcine models of uriprene stents showed promising preliminary results. These stents resulted in lower inflammatory response compared to conventional PSs and successfully degraded after 4 weeks [72–74]. Newer biodegradable substances are also under investigation. Novel substances include the tocopherol acetate and the magnesium yttrium biodegradable alloy which seem to possess antibacterial characteristics and have been tested in vitro [75–77]. Another biodegradable stent comprising polysaccharides of natural origin was recently described by Barros et al. [78]. These stents contained different blends of gellan gum, gelatin, and alginate and were tested in in artificial urine. The stent degraded between 2 weeks and 2 months with the ability to control degradation rate by altering the ratio of biodegradable materials. The ability to resist bacterial adherence was evaluated and compared to a plastic biostable stent as a control. The comparison showed that there was no difference in bacterial adherence between the described biodegradable stent and the control. In addition, no encrustation was observed within the tested time frame [78]. Considering the above, the field of ­biodegradable stents seems to be promising for stents that could be used for long‐term stenting of the ureter

without significant complications. In addition, the need for removal of the stent may be diminished. Drug‐eluting and drug‐coated polymeric stents Polymeric ureteral stents that are coated with pharmaceutical substances or release drugs from their surface to the surrounding tissue have been introduced and clinically tested. Triclosan is a broad‐spectrum antibacterial and antifungal agent that has been reported to inhibit the growth of common bacterial uropathogens in vitro, and is thus considered useful for the reduction of urinary tract infection and subsequent encrustation of an indwelling stent [79]. A significant decrease in Proteus mirabilis growth and survival was observed in a rabbit experimental model when a triclosan‐eluting ureteral stent was inserted in the urinary system (bladder) [80]. In eight patients significantly fewer antibiotics were administered, and there was a slightly higher number of positive urine cultures, but significantly fewer symptomatic infections with long‐term use of the triclosan‐­eluting stent. Bacterial resistance to triclosan was not noted during the 3 month follow‐up period [81]. Mendez‐Probst et  al. evaluted triclosan‐eluting stent in a randomized prospective study. They compared the ­ triclosan‐eluting stent with a non‐eluting stent (control). The triclosan‐eluting stent group didn’t receive any ­antibiotics and the control group received 3 days of ­prophylactic levofloxacin. The results showed no significant differences in the infection rate or encrustation. Nonetheless, triclosan‐eluting stents showed to significantly decrease ureteral‐stent‐related symptoms [82]. Ketorolac‐eluting stent was evaluated for its short‐ term efficacy in a double‐blind randomized multi‐­ institutional clinical trial [83]. The 276 patients included were divided into two groups (triclosan stent and conventional stent). There were no significant differences in primary and secondary intervention rates between the two groups. Fewer patients with the ketorolac‐eluting stents used pain medication in comparison to the control group. A heparin‐coated double‐pigtail ureteral stent was introduced in an attempt to minimize microbial adhesion, biofilm formation, and subsequent encrustation of long‐term indwelling stents in the urinary tract. In five patients, a heparin‐coated ureteral stent was inserted in one ureter and a conventional double‐pigtail stent in the other for a month [84]. The thickness of the encrustations observed by electron microscopy on the heparin‐ coated stents was significantly less compared to that on the conventional ureteral stents. Moreover, the encrustation on the heparin‐coated stents was less uniform and more compact. Two heparin‐coated stents were left

73  Long-term Stenting of the Ureter

indwelling in long term (10 and 12 months) and on removal showed no evidence of encrustation and an unchanged heparin layer.

­Metal mesh stents Self‐ and balloon‐expandable metal mesh stents MSs used in the ureter can be divided into four general groups: self‐expandable, balloon‐expandable, covered, and thermo‐expandable shape‐memory stents. Covered MSs were introduced in an attempt to minimize tissue ingrowth, which eventually compromises ureteral patency [27]. MSs implanted in the ureter for the management of various malignant and benign diseases are the Wallstent (Microvasive, Natick, MA, USA), Memokath 051 (PNN Medical, Kvistgaard, Denmark), self‐expanding polytetrafluoroethylene‐covered nitinol stent (Hemobahn Endoprosthesis, W.L. Gore and Associates, Flagstaff, AZ, USA), and the recently introduced all‐metal double‐pigtail Resonance stent. The Wallstent is composed of braided biomedical cobalt‐based alloy monofilaments and is the most extensively used self‐expandable endoprosthesis in the ureter [1]. Inserted in the ureter it appears to represent a safe and effective method for the palliative treatment of malignant ureteral strictures. Benign and malignant ureteral strictures in patients not suitable for surgical treatment were treated with the Wallstent by Pollak et al. [85] One of six stented ureters were patent after 11 months. In two patients, three stents were implanted for the palliative management of malignant disease and were patent up until death (3–5 months after implantation). Ingrowth of hyperplastic and granulation tissue was responsible for the occlusion of all stents inserted for benign strictures, while tumor ingrowth and granulation tissue were observed in malignant cases. Wallstent endoprosthesis proved to be ineffective for long‐term drainage in patients with benign ureteroenteric strictures. The mid‐term ­clinical outcome of the Wallstent self‐expandable stent implantation for the management of malignant ureteral obstruction was evaluated in 40 patients with 54 malignant ureteral obstructions [49]. Patency was confirmed in 51 of the stented ureters during the mean follow‐up period of 10.5 months (range 1–44 months). Almost half of the ureters (49%) required additional procedures to maintain patency. Adequate drainage preventing hydronephrosis was observed in the majority of the cases and major complications were not encountered. Malignant ureteral strictures due to gynecologic cancer were managed in 14 patients with self‐expandable MSs in a report by Barbalias et al., and ureteral obstruction was relieved in all cases [50]. The mean follow‐up

months (range 9–24  months). Tumor time was 15  ingrowth requiring additional coaxial stent placement and borderline tumor overgrowth was observed in one case each. Urothelial hyperplasia was noted in all stented ureters and additional retrograde insertion of a double‐ pigtail stent was deemed necessary for a 1 month period. On the proximal edge of the stent, a mild ureteral narrowing was noted (trumpet‐like configuration), which did not impact ureteral patency. The trumpet‐like configuration was a constant finding during the follow‐up period. The authors concluded that the implantation of self‐expandable MSs is a safe and effective method for by‐passing gynecologic malignant ureteral obstruction. The combination of self‐expandable MSs with coaxial double‐pigtail stents was proposed by Hekimoglu et al. [39]. Ten ureters (10 patients) with malignant obstruction were treated with this combination. The double‐ pigtail stents were removed in seven patients 2 and 3 months after the implantation. Six patients developed hydronephrosis and double‐pigtail stents were reinserted. PS exchange was performed at 3 month intervals. The MS lumen was compromised by hyperplastic tissue and encrustation. Nevertheless, this combination was adequate to achieved internal urinary drainage. Several authors have reported promising results with the management of ureteroileal anastomotic strictures by MS insertion [2, 5, 86–93]. In these reports between one and 18 patients were treated, while the number of treated ureteroileal strictures ranged between one and 24. The mean follow‐up period ranged from 6 to 22 months. Stricture recurrence was observed by the majority of the authors. Our group reported long‐term results in 18 patients with ureteroileal anastomotic strictures who were managed with MS placement [2]. Mean follow‐up was 21  months (range 7–50  months). The technical success rate of stricture crossing and stenting was 100%. Immediate poststenting patency rate was 70.8% (17 of 24 cases), while primary patency rates at 1 and 4 years were 37.8 and 22.7%, respectively. Fifteen stented ureters required secondary interventions. Secondary patency rates were 64.8 and 56.7% at 1 and years, respectively. Periodic exchange of external– 4  internal double‐pigtail catheters until the end of the follow‐up period was performed in six ureteroileal ­ ­conduits. Definitive treatment for the ureteroileal strictures was achieved by MSs in more than half of the cases. The remaining cases were managed by regular exchange of double‐J catheters in retrograde fashion. Surgical revisions of ureteroileal anastomotic strictures are ­ ­challenging, while MS implantation provides efficient drainage while preserving the quality of life. Barbalias et al. have proposed the use of self‐­expandable MSs for the management of UPJO [16]. MSs were placed  in four patients who had previously undergone

869

870

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

open pyeloplasty and in whom recurrence of UPJO was diagnosed. The mean follow‐up period was 16 months (range 9–24 months). The placement procedure was ­successful in all cases and patency was confirmed in all four patients. Ingrowth of fibrotic tissue through the stent led to additional coaxial overlapping MS insertion in one patient 2 months after initial stent placement. The results were promising and the authors suggested the performance of more extensive clinical trials in order to validate this application of MSs. Balloon‐expandable stents have not been extensively used in the ureter. Barbalias et al. treated six patients with malignant disease with self‐expanding stents and six with balloon‐expandable stents [46]. Additional interventions were deemed necessary in three cases due to urothelial hyperplasia, tumor ingrowth, and local recurrence of primary cancer invading the upper end of the ureter. Mean follow‐up was 9 months (range 8–16 months). The Memokath 051 represents a unique type of MS. It is a thermoexpandable shape‐memory stent composed of nickel and titanium alloy. It has a tight spiral structure, which prevents urothelial growth [94]. The Memokath 051 softens below 10 °C and regains its shape when reheated to 50 °C. The thermal shape memory feature makes the removal of the stent possible. Kulkarni and Bellamy have used the endoprosthesis for the management of ureteral obstruction of both benign and malignant etiology [95]. Long‐term results for the management of malignant and recurrent benign strictures are available: 18 malignant and 10 recurrent benign cases were treated with the Memokath 051 and followed up for a mean of 19.3 months (range 3–35 months). At the end of the follow‐up period, 15 stents (13 patients) provided adequate drainage, while eight patients carrying 13 functioning stents had died. Infection and migration ­ were not observed. In general, the Memokath 051 proved to be advantageous over conventional double‐J catheters. Moreover, the potential for removal of the stent due its thermal memory was a significant advantage over conventional MSs. This removal capability was not a feature of any other MS until the introduction of the Resonance double‐pigtail MS. Such favorable results with the Memokath 051 were not reported by Klarskov et al., who used it to treat 37 stenosed ureters (33 patients) attributed to both malignant and benign conditions [96]. The mean follow‐up period was 14 months (range 3–30 months). Migration towards the bladder was observed in 10 stents and 12 stents malfunctioned, giving a total of 22 nonfunctioning MSs. Encrustation resulted in occlusion of four stents at intervals after stent insertion ranging between 1 and 10 months. In other studies, a need for stent reinsertion or manipulation was reported in 20–25% of patients. Long‐term complications of the Memokath 051 were

noted to be encrustation in 3–5% and stent migration in 15–18% [97, 98]. Li et  al. evaluated a titanium–nickel alloy‐based self‐ expandable stent in benign ureteral strictures over a long mean follow‐up period of 92 months (range 12–131 months) [99]. Encountered complications included hyperplastic reaction, infection, and encrustation with stone formation. The investigators concluded that MSs could adequately manage selected cases of ureteral strictures. Recently, we reported our 10 year experience with metal mesh stenting for the management of malignant ureteral obstruction [100]. Ninety patients (119 ureters) with ureteral obstruction from various pelvic and metastatic tumors were treated with several different types and brands of MSs in an attempt to provide long‐term urinary drainage without requiring nephrostomy tubes, and followed up for a mean of 15 months (8–38 months). Hyperplastic reaction and/or tumor ingrowth resulting in tissue protruding through the stent struts and obstructing the stent lumen were the most common problems and were addressed by repeat balloon dilations. Those cases resistant to balloon dilation were managed by insertion of a double‐pigtail stent coaxially, which ensured ureteral patency. With primary and ­secondary patency rates of 51.2 and 62.1% it was concluded that metal mesh stenting of the ureter should be carefully considered for long‐term urinary drainage. Covered metal mesh stents Covered MSs were introduced as a solution to the urothelial hyperplasia compromising the patency of ­conventional MSs. The high migration rate (81.2%) of covered MSs, which could induce renal colic, represented a major problem in clinical application and ­minimized further use of these stents in the urinary tract. The inability of covered MSs to anchor into the ureteral wall was associated with the coating material and the enhanced ureteral peristalsis [27]. Migration was managed by cystoscopic removal of the migrated ­covered stents and the coaxial insertion of bare stents. Recently, an S‐shaped covered MS was introduced and underwent comparative evaluation to bare MSs in the canine ureter. The shape of the stent was responsible for the anchoring into the ureteral wall. The stent was covered with polytetrafluoroethylene (PTFE) for prevention of lumen occlusion due to hyperplastic reaction. Both migration and the hyperplastic ureteral obstruction were avoided [101]. In an attempt to reduce urothelial hyperplasia, a study group recently evaluated the additive effects of placing a PS together with a MS in the management of obstructive uropathy in animal model. The PS is inserted through the MS in order to maintain the patency of the latter stent. The one group underwent covered MS

73  Long-term Stenting of the Ureter

and PS placement. The other group received the same MS without a PS. Although there was no significant ­difference in the development of urothelial hyperplasia, the group with the combination of PS and MS showed a significantly lower degree of obstruction severity due to hyperplasia [102]. Allium (Allium Medical Solutions Ltd, Caesarea, Israel) and the UVENTA (Taewoong Medical Co. Ltd, Gyeonggi‐ do, South Korea) stents,which are specially designed for the urinary tract‐covered MSs, have been recently introduced [103, 104]. The Allium stent is composed of nitinol and is covered with PTFE to avoid tissue ingrowth inside its lumen and early encrustation. It has an intravesical anchor to prevent migration. Moskovitz et al. inserted the Allium stent in 49 cases with a history of malignant disease [103]. Perioperative complications were not ­ observed. Over a mean follow‐up time of 21 months (range 1–63 months) stent migration occurred in 14.2% and only one case of stent occlusion was noted. Other investigators evaluated the Allium stent in 12 benign cases of ureteral obstruction and achieved patency in all cases without intraoperative complications [105]. The UVENTA stent has a PTFE‐membrane‐covered metal mesh to avoid tissue ingrowth and hence prevent hyperplasia related obstruction. The design of the stent also aim to prevent any migration [43]. Kim et al. [104] published their experience with the use of UVENTA stent in 18 patients with malignant ureteral obstruction. During a mean follow up of 7.3 months no obstruction of the stents occurred. In addition, hyperplastic reactions, migration or encrustation were not observed. Chung et  al. evaluated UVENTA over a 10 month follow‐up period and reported a primary patency rate of 64.8% and a secondary patency rate of 81.7%. Stent failure was predominantly a result of tumor progression at an adjacent ureteral segment. Stent migration was not reported [106]. Another study evaluated the efficacy of the UVENTA in comparison to Memokath 051 [107]. It showed that UVENTA had a higher clinical success rate over the Memokath 051 in benign and malignant obstructions. A multicenter study compared the efficacy of UVENTA with PS insertion for the ­management of 42 malignant ureteral obstructions. The study showed that the UVENTA was superior to the PSs in terms of technical success and patency [108]. Double‐pigtail metal stents (Resonance) The Resonance stent was recently introduced as an all‐ metal double‐pigtail stent. It is composed of MP35N alloy in a tight spiral structure. Ureteral obstruction, due to either malignant or benign conditions, can be managed with Resonance [109–112]. Borin et  al. were the first to report a case of Resonance stent insertion and

successful management of ureteral obstruction due to retroperitoneal fibrosis from metastatic breast cancer [109]. The obstruction had not been controlled by the previous insertion of two 6 Fr double‐pigtail PSs. The ureter was patent over a 4 month follow‐up period. Resonance stent insertion was used to manage malignant ureteral obstruction without bulky pelvic disease in 15 patients (17 ureters) who were followed up for between 1 week and 8 months [110]. In three patients, the initial stent was exchanged after 6 months, and after 12 months in one patient. Long‐term drainage of the obstructed ureters was reported to be efficient and encrustation was minimal. Stents were patent and functioning in four patients who were still alive at the end of the follow‐up period. The Resonance stents were not removed in seven patients who died during the follow‐ up period. Nagele et al. treated 14 patients (18 ureters) with ureteral obstruction of either benign (n  =   5) or malignant etiology (n  =  13) [111]. Mean follow‐up was 8.6 months. Encrustation was evident on two stents. Seven stents were removed due to persistent hematuria, severe dysuria, pain, and inadequate drainage. In an attempt to ensure patient comfort, an appropriate stent length should be selected. In addition, satisfactory drainage under circumstances of extrinsic ureteral obstruction was confirmed by an experimental study. Nevertheless, less overall flow than with a standard PS was noted for the Resonance stent [113]. Our group assessed in a porcine model the effect of SWL or radiotherapy on ureters with an indwelling Resonance stent. The histologic deterioration of pig ureters stented with Resonance was not significant compared to control ureters (standard stents) after SWL or radiotherapy, and ureteral temperature was not detected to be significantly higher for the Resonance ureters [114, 115]. The clinical efficiency of Resonance was evaluated by our group in a clinical trial including 50 patients with malignant or benign ureteral obstructions [112]. All cases of extrinsic obstruction due to malignant factors were managed adequately (25 patients), while patency was observed in 44% of the benign intrinsic obstruction cases (25 patients). The benign case group included patients with lithiasis, ureteroileal obstruction, iatrogenic strictures, or an occluded ureteral MS and who were contraindicated for any surgical or endoscopic procedures due to  comorbidities. Further clinical trials are deemed ­necessary to clarify the indications for the insertion of the  Resonance stent. Average overall follow‐up was 8.5 months (range 4–14 months), and the mean f­ ollow‐up for malignant and benign cases was 11 months and 6.8 months, respectively. The removed Resonance stents underwent laboratory investigation to identify the presence of encrustation and the type of deposits. Encrustation was evident in 20% of the extracted stents. The most

871

872

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

common location of enscrustation was the edges of the stent. Even stents without evident encrustation were observed to have deposits on scanning ­electron microscopy (Figures  73.1 and 73.2). Calcium oxalate was the most frequent encrustation deposit. (a)

The clinical application of the Resonance stent in ureteroenteric strictures was reported to be unsuccessful by Garg et al., who inserted it for the management of 10 strictures in 10 patients with ileal conduits [116]. Distant migration was observed in nine cases in a mean of (b)

Figure 73.1  (a) Scanning electron microscopy image obtained from the lower extremity of a Resonance stent that was indwelling for 9 months. Note the encrustation layer, which was barely visible macroscopically. (b) Same Resonance stent at higher magnification. The crystals of the encrustation deposits are visible.

(a)

(b)

Figure 73.2  (a) A heavily encrusted Resonance stent with an indwelling time of 12 months. At the exchange of the stent, a large stone burden on the distal coil of the stent was noted. Removal of the stent was impossible and the patient was treated with laser lithotripsy of the stone. Some visible encrustation sites are also present on the stent. (b) The distal coil of the stent with a portion of the initial stone burden on it. Notice that the spiral coil of the stent has been damaged during the laser lithotripsy.

73  Long-term Stenting of the Ureter

21 days (range 3–60 days). Lopez‐Huertas et  al. managed 13 patients with benign upper urinary tract ureteral obstructions with the Resonance stent (15 stents) [117]. The majority of the stents provided adequate drainage and 12 patients were efficiently managed. The stents were removed in three patients who showed voiding symptoms such as hematuria. The remaining patients had their stents exchanged after a mean follow‐ up of 11.6 months. The investigators also conducted a cost‐effectiveness analysis and reported a significant cost reduction in favor of the Resonance stent. More recently, Kadlec et al. published their 5‐year experience with the Resonance stent [118]. A total of 139 metallic stents were placed in 47 patients, including 27 (57%) with malignant and 20 (43%) with a benign etiology ureteral obstruction. A failure rate of 28% was reported due to pain, stent migration, progressive renal insufficiency, encrustation, recurrent urinary tract infection, progressive hydronephrosis, hematuria, or lower urinary tract symptoms. The failure rates were similar for malignant and benign cases. Nonetheless, Resonance stents were successful in managing benign and malignant ureteral obstruction in the majority of the patients in their series, and a subset of patients in each group continued to do well for more than 3 years’ overall follow‐up [118]. See Video 73.1 .

­Outcome of long‐term ureteral stenting The long‐term use of ureteral stents currently represents a challenge for biomaterial science, pharmacology, and urologic research [1]. The frequent exchange of double‐pigtail PSs is accepted clinical practice, with complications addressed by pharmaceutical therapy or additional interventions, and these stents should not be expected to be in place for longer than a few months. Clinical experience with biodegradable PSs remains limited and further refinement is necessary for the wide acceptance of these stents [1]. The development of newer biodegradable materials could lead to the introduction of new biodegradable stents. Drug‐eluting and drug‐coated PSs are rapidly evolving and their first clinical application appears promising. Moreover, the potential of the latter stent type could be increased with the countless pharmaceutical substances that could be used on their surfaces. MSs are a completely different category of stent and are used significantly less frequently in urologic practice. Nevertheless, experience has accumulated over the years. Long‐term results have proved to be poor despite the initial promising outcome [1, 99]. Thus, patients

Drug‐eluting metal mesh stents Interventional cardiology has gained significant experience with drug‐eluting MSs (DESs). In fact, the DESs represent the most commonly used stents in this ­specialty. The concept of DESs is to minimize or even eliminate the reaction of the coronary tissue to the stent, which is responsible for platelet adhesion (activation of coagulation cascade) and neointimal hyperplasia [119]. The use of DESs in the ureter is currently limited to experimental animal studies, which have demonstrated reduction of ureteral tissue hyperplasia. Our group has investigated the effect of the paclitaxel‐eluting stent in porcine ureters (10 pigs in total). A DES was inserted in one ureter and a bare MS in the other ureter of each animal. Over a follow‐up period of 21 days, the majority of MSs were occluded and the remaining MSs were stenosed by hyperplastic reaction, while all the DESs were patent [119]. Later, we evaluated zotarolimus‐­ eluting MSs (Endeavor; Medtronics, Minneapolis, MN, USA) in porcine and rabbit models. Three weeks after placement we observed less hyperplastic reaction in the DESs in comparison to the bare MSs, which were used as the control in the contralateral ureter of the same ­animals [120] (Figure 73.3). The effectiveness of DESs in these animal models is promising for their clinical application.

Figure 73.3  Fluoroscopic image of a zotarolimus metal stent a week after its insertion in a rabbit ureter. Note the trumpet‐like configuration on the ureter segment located at the upper extremity of the stent. The configuration did not influence the patency of the stent. Note the lack of hyperplastic reaction in the lumen of the stent.

873

874

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

should be carefully selected for stenting with an MS. The first MS with a double‐pigtail design provides adequate drainage in cases of PS failure and has shown excellent results in long‐term management of malignant ureteral obstruction. In contrast, benign cases have been associated with unfavorable results. Further clinical investigations will elucidate the true efficacy and indications for

these stent [111]. DESs are the next step in the evolution of metal stenting in the ureter. These stents have a tremendous impact in interventional cardiology. Their use to overcome the difficulties encountered during metal stenting is expected. Available experimental reports are rare but still promising regarding the possible outcome in clinical trials.

­References 1 Liatsikos E, Kallidonis P, Stolzenburg JU, and

Karnabatidis D. Ureteral stents: past, present and future. Expert Rev Med Devices 2009;6(3):313–324. 2 Liatsikos EN, Kagadis GC, Karnabatidis D et al. Application of self‐expandable metal stents for ureteroileal anastomotic strictures: long‐term results. J Urol 2007;178(1):169–173. 3 Denstedt JD. The endosurgical alternative for upper‐ tract obstruction. Contemp Urol 1991;3(1):19–26; 31. 4 Lawrentschuk N and Russell JM. Ureteric stenting 25 years on: routine or risky? ANZ J Surg 2004;74(4):243–247. 5 Yachia D. Recent advances in ureteral stents. Curr Opin Urol 2008;18(2):241–246. 6 Nabi G, Cook J, N’Dow J, and McClinton S. Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta‐analysis. BMJ (Clin Res edn) 2007;334(7593):572. 7 El‐Assmy A, El‐Nahas AR, and Sheir KZ. Is pre‐shock wave lithotripsy stenting necessary for ureteral stones with moderate or severe hydronephrosis? J Urol 2006;176(5):2059–2062; discussion 2062. 8 Sigman DB, Del Pizzo JJ, and Sklar GN. Endoscopic retrograde stenting for allograft hydronephrosis. J Endourol 1999;13(1):21–25. 9 Gerrard ER Jr, Burns JR, Young CJ et al. Retrograde stenting for obstruction of the renal transplant ureter. Urology 2005;66(2):256–260; discussion 260. 10 Agarwal G, Palagiri AV, Bouillier JA, and Cummings JM. Endoscopic management of ureteral complications following renal transplantation. Transplant Proc 2006;38(9):2921–2922. 11 White MA, Kepros JP, and Zuckerman LJ. Bilateral partial ureteropelvic junction disruption after blunt trauma treated with indwelling ureteral stents. Urology 2007;69(2):384.e15–384.217. 12 Chang R, Marshall FF, and Mitchell S. Percutaneous management of benign ureteral strictures and fistulas. J Urol 1987;137(6):1126–1131. 13 Chung SY, Stein RJ, Landsittel D et al. 15‐year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents. J Urol 2004;172(2):592–595.

14 Ganatra AM and Loughlin KR. The management of

15

16

17

18

19

20

21

22

23

24

25

malignant ureteral obstruction treated with ureteral stents. J Urol 2005;174(6):2125–2128. Hafron J, Ost MC, Tan BJ et al. Novel dual‐lumen ureteral stents provide better ureteral flow than single ureteral stent in ex vivo porcine kidney model of extrinsic ureteral obstruction. Urology 2006;68(4):911–915. Barbalias GA, Liatsikos EN, Kagadis GC et al. Ureteropelvic junction obstruction: an innovative approach combining metallic stenting and virtual endoscopy. J Urol 2002;168(6):2383–2386; discussion 2386. Candela JV and Bellman GC. Ureteral stents: impact of diameter and composition on patient symptoms. J Endourol 1997;11(1):45–47. Rane A, Saleemi A, Cahill D et al. Have stent‐related symptoms anything to do with placement technique? J Endourol 2001;15(7):741–745. Thomas R. Indwelling ureteral stents: impact of material and shape on patient comfort. J Endourol 1993;7(2):137–140. Lennon GM, Thornhill JA, Sweeney PA et al. ‘Firm’ versus ‘soft’ double pigtail ureteric stents: a randomised blind comparative trial. Eur Urol 1995;28(1):1–5. Dunn MD, Portis AJ, Kahn SA et al. Clinical effectiveness of new stent design: randomized single‐ blind comparison of tail and double‐pigtail stents. J Endourol 2000;14(2):195–202. Puri R and Murray KH. Triradiate graspers for removal of retained ureteric stent. Br J Urology 1994;73(3):314–315. Vogt B, Desgrippes A, and Desfemmes FN. Changing the double‐pigtail stent by a new suture stent to improve patient’s quality of life: a prospective study. World J Urol 2015;33(8):1061–1068. Damiano R, Autorino R, De Sio M et al. Does the size of ureteral stent impact urinary symptoms and quality of life? A prospective randomized study. Eur Urol 2005;48(4):673–678. Erturk E, Sessions A, and Joseph JV. Impact of ureteral stent diameter on symptoms and tolerability. J Endourol 2003;17(2):59–62.

73  Long-term Stenting of the Ureter

26 Chin JL and Denstedt JD. Retrieval of proximally 27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

migrated ureteral stents. J Urol 1992;148(4):1205–1206. Barbalias GA, Liatsikos EN, Kalogeropoulou C et al. Externally coated ureteral metallic stents: an unfavorable clinical experience. Eur Urol 2002;42(3):276–280. el‐Faqih SR, Shamsuddin AB, Chakrabarti A et al. Polyurethane internal ureteral stents in treatment of stone patients: morbidity related to indwelling times. J Urol 1991;146(6):1487–1491. Nagele U, Praetorius M, Schilling D et al. Comparison of flexible grasping forceps and stone basket for removal of retracted ureteral stents. J Endourol 2006;20(6):418–422. Livadas KE, Varkarakis IM, Skolarikos A et al. Ureteroscopic removal of mildly migrated stents using local anesthesia only. J Urol 2007;178(5):1998–2001. LeRoy AJ, Williams HJ Jr, Segura JW et al. Indwelling ureteral stents: percutaneous management of complications. Radiology 1986;158(1):219–222. Costerton JW, Cheng KJ, Geesey GG et al. Bacterial biofilms in nature and disease. Annu Rev Microbiol 1987;41:435–464. Kawahara T, Ito H, Terao H et al. Ureteral stent encrustation, incrustation, and coloring: morbidity related to indwelling times. J Endourol 2012;26(2):178–182. Robert M, Boularan AM, El Sandid M, and Grasset D. Double‐J ureteric stent encrustations: clinical study on crystal formation on polyurethane stents. Urologia Int 1997;58(2):100–104. Vanderbrink BA, Rastinehad AR, Ost MC, and Smith AD. Encrusted urinary stents: evaluation and endourologic management. J Endourol 2008;22(5):905–912. Ahallal Y, Khallouk A, El Fassi MJ, and Farih MH. Risk factor analysis and management of ureteral double‐j stent complications. Rev Urol 2010;12(2–3):e147–e151. Tunney MM, Jones DS, and Gorman SP. Biofilm and biofilm‐related encrustation of urinary tract devices. Methods Enzymol 1999;310:558–566. Choong S, Wood S, Fry C, and Whitfield H. Catheter associated urinary tract infection and encrustation. Int J Antimicrobial Agents 2001;17(4):305–310. Hekimoglu B, Men S, and Pinar A. Urothelial hyperplasia complicating use of metal stents in malignant ureteral obstruction. Eur Radiol 1996;6:675–681. Acosta‐Miranda AM, Milner J, and Turk TM. The FECal Double‐J: a simplified approach in the management of encrusted and retained ureteral stents. J Endourol 2009;23(3):409–415. Aravantinos E, Gravas S, Karatzas AD et al. Forgotten, encrusted ureteral stents: a challenging problem with

42

43

44

45

46

47

48

49

50

51

52

53 54

55

56

57

an endourologic solution. J Endourol 2006;20(12):1045–1049. Weedin JW, Coburn M, and Link RE. The impact of proximal stone burden on the management of encrusted and retained ureteral stents. J Urol 2011;185(2):542–547. Tunney MM, Keane PF, Jones DS, and Gorman SP. Comparative assessment of ureteral stent biomaterial encrustation. Biomaterials 1996;17(15):1541–1546. Pauer W and Lugmayr H. Metallic Wallstents: a new therapy for extrinsic ureteral obstruction. J Urol 1992;148(2 Pt 1):281–284. Desgrandchamps F, Tuchschmid Y, Cochand‐Priollet B et al. Experimental study of Wallstent self‐expandable metal stent in ureteral implantation. J Endourol 1995;9(6):477–481. Barbalias GA, Siablis D, Liatsikos EN et al. Metal stents: a new treatment of malignant ureteral obstruction. J Urol 1997;158(1):54–58. Thijssen AM, Millward SF, and Mai KT. Ureteral response to the placement of metallic stents: an animal model. J Urol 1994;151(1):268–270. Lugmayr H and Pauer W. Self‐expanding metal stents for palliative treatment of malignant ureteral obstruction. AJR Am J Roentgenol 1992;159(5):1091–1094. Lugmayr HF and Pauer W. Wallstents for the treatment of extrinsic malignant ureteral obstruction: midterm results. Radiology 1996;198(1):105–108. Barbalias GA, Liatsikos EN, Kalogeropoulou C et al. Metallic stents in gynecologic cancer: an approach to treat extrinsic ureteral obstruction. Eur Urol 2000;38(1):35–40. Flueckiger F, Lammer J, Klein GE et al. Malignant ureteral obstruction: preliminary results of treatment with metallic self‐expandable stents. Radiology 1993;186(1):169–173. Roemer FD. There isn’t an ideal smooth‐surface material–yet: the history and future of urologic materials. J Endourol 2000;14(1):1–4. Beiko DT, Knudsen BE, Watterson JD et al. Urinary tract biomaterials. J Urol 2004;171(6 Pt 1):2438–2444. Marx M, Bettmann MA, Bridge S et al. The effects of various indwelling ureteral catheter materials on the normal canine ureter. J Urol 1988;139(1):180–185. Denstedt JD, Wollin TA, and Reid G. Biomaterials used in urology: current issues of biocompatibility, infection, and encrustation. J Endourol 1998;12(6):493–500. Yossepowitch O, Lifshitz DA, Dekel Y et al. Predicting the success of retrograde stenting for managing ureteral obstruction. J Urol 2001;166(5):1746–1749. Wenzler DL, Kim SP, Rosevear HM et al. Success of ureteral stents for intrinsic ureteral obstruction. J Endourol 2008;22(2):295–299.

875

876

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

58 Rosevear HM, Kim SP, Wenzler DL et al. Retrograde

59

60

61

62

63

64

65

66

67

68

69

70

71

72

ureteral stents for extrinsic ureteral obstruction: nine years’ experience at University of Michigan. Urology 2007;70(5):846–850. Hao P, Li W, Song C et al. Clinical evaluation of double‐pigtail stent in patients with upper urinary tract diseases: report of 2685 cases. J Endourol 2008;22(1):65–70. Joshi HB, Okeke A, Newns N et al. Characterization of urinary symptoms in patients with ureteral stents. Urology 2002;59(4):511–516. Buchholz NN, Cannaby C, Fong R et al. A new SWL titanium stent (Zebra Stent): resistance to shockwave exposure. J Endourol 2005;19(5):584–588. Staios D, Patel M, Papatsoris A et al. Material fatigue testing of a new intraureteral wire stent (Zebrastent). J Endourol 2008;22(6):1389–1393. Hamm M and Rathert P. [Therapy of extrinsic ureteral obstruction by 2 parallel double‐J ureteral stents]. Der Urologe Ausg A 1999;38(2):150–155. Rotariu P, Yohannes P, Alexianu M et al. Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents. J Endourol 2001;15(10):979–983. Elsamra SE, Motato H, Moreira DM et al. Tandem ureteral stents for the decompression of malignant and benign obstructive uropathy. J Endourol 2013;27(10):1297–1302. Pedro RN, Hendlin K, Kriedberg C, and Monga M. Wire‐based ureteral stents: impact on tensile strength and compression. Urology 2007;70(6):1057–1059. Miyaoka R, Hendlin K, and Monga M. Resistance to extrinsic compression and maintenance of intraluminal flow in coil‐reinforced stents (Silhouette Scaffold Device): an in vitro study. J Endourol 2010;24(4):595–598. Olweny EO, Landman J, Andreoni C et al. Evaluation of the use of a biodegradable ureteral stent after retrograde endopyelotomy in a porcine model. J Urol 2002;167(5):2198–2202. Auge BK, Ferraro RF, Madenjian AR, and Preminger GM. Evaluation of a dissolvable ureteral drainage stent in a Swine model. J Urol 2002;168(2):808–812. Lingeman JE, Preminger GM, Berger Y et al. Use of a temporary ureteral drainage stent after uncomplicated ureteroscopy: results from a phase II clinical trial. J Urol 2003;169(5):1682–1688. Tajla M, Multanen M, Valimaa T, and Törmälä P. Bioabsorbable SR‐PLGA horn stent after antegrade endopyelotomy: a case report. J Endourol 2002;16(5):299–302. Hadaschik BA, Paterson RF, Fazli L et al. Investigation of a novel degradable ureteral stent in a porcine model. J Urol 2008;180(3):1161–1166.

73 Chew BH, Lange D, Paterson RF et al. Next generation

74

75

76

77

78

79

80

81

82

83

84

85

biodegradable ureteral stent in a yucatan pig model. J Urol 2010;183(2):765–771. Chew BH, Paterson RF, Clinkscales KW et al. In vivo evaluation of the third generation biodegradable stent: a novel approach to avoiding the forgotten stent syndrome. J Urol 2013;189(2):719–725. Elayarajah, Rajendran R, Venkatrajah, Sreekumar S, Sudhakar A, Janiga, et al. Biodegradable tocopherol acetate as a drug carrier to prevent ureteral stent‐ associated infection. Pak J Biol Sci 2011;14(5): 336–343. Lock JY, Draganov M, Whall A et al. Antimicrobial properties of biodegradable magnesium for next generation ureteral stent applications. Conference proceedings. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. Conf Proc IEEE Eng Med Biol Soc 2012;2012:1378–1381. Lock JY, Wyatt E, Upadhyayula S et al. Degradation and antibacterial properties of magnesium alloys in artificial urine for potential resorbable ureteral stent applications. J Biomed Mater Res A 2014;102(3):781–792. Barros AA, Rita A, Duarte C et al. Bioresorbable ureteral stents from natural origin polymers. J Biomed Mater Res B Appl Biomater 2015;103(3):608–617. Chew BH, Cadieux PA, Reid G, and Denstedt JD. In‐vitro activity of triclosan‐eluting ureteral stents against common bacterial uropathogens. J Endourol 2006;20(11):949–958. Cadieux PA, Chew BH, Knudsen BE et al. Triclosan loaded ureteral stents decrease proteus mirabilis 296 infection in a rabbit urinary tract infection model. J Urol 2006;175(6):2331–2335. Cadieux PA, Chew BH, Nott L et al. Use of triclosan‐ eluting ureteral stents in patients with long‐term stents. J Endourol 2009;23(7):1187–1194. Mendez‐Probst CE, Goneau LW, MacDonald KW et al. The use of triclosan eluting stents effectively reduces ureteral stent symptoms: a prospective randomized trial. BJU Int 2012;110(5):749–754. Krambeck AE, Walsh RS, Denstedt JD et al. A novel drug eluting ureteral stent: a prospective, randomized, multicenter clinical trial to evaluate the safety and effectiveness of a ketorolac loaded ureteral stent. J Urol 2010;183(3):1037–1042. Cauda F, Cauda V, Fiori C et al. Heparin coating on ureteral Double J stents prevents encrustations: an in vivo case study. J Endourol 2008;22(3):465–472. Pollak JS, Rosenblatt MM, Egglin TK et al. Treatment of ureteral obstructions with the Wallstent endoprosthesis: preliminary results. J Vasc Interventional Radiol 1995;6(3):417–425.

73  Long-term Stenting of the Ureter

86 Rapp DE, Laven BA, Steinberg GD, and Gerber GS.

100 Liatsikos EN, Karnabatidis D, Katsanos K et al.

87

101

88

89

90

91

9 2

93

94

95

96

97

98

99

Percutaneous placement of permanent metal stents for treatment of ureteroenteric anastomotic strictures. J Endourol 2004;18(7):677–681. Kurzer E and Leveillee RJ. Endoscopic management of ureterointestinal strictures after radical cystectomy. J Endourol 2005;19(6):677–682. Barbalias GA, Liatsikos EN, Karnabatidis D et al. Ureteroileal anastomotic strictures: an innovative approach with metallic stents. J Urol 1998;160(4):1270–1273. Sanders R, Bissada NK, and Bielsky S. Ureteroenteric anastomotic strictures: treatment with Palmaz permanent indwelling stents. J Urol 1993;150(2 Pt 1): 469–470. Reinberg Y, Ferral H, Gonzalez R et al. Intraureteral metallic self‐expanding endoprosthesis (Wallstent) in the treatment of difficult ureteral strictures. J Urol 1994;151(6):1619–1622. Pallascak P, Bouchareb M, Zachoval RJ et al. Treatment of benign ureterointestinal anastomotic strictures with permanent ureteral Wallstent after Camey and Wallace urinary diversion: long‐term follow‐up. J Endourol 2001;15:575–580. Gort HB, Mali WP, van Waes PF, and Kloet AG. Metallic self‐expandible stenting of a ureteroileal stricture. AJR Am J Roentgenol 1990;155(2): 422–423. Wakui M, Takeuchi S, Isioka J et al. Metallic stents for malignant and benign ureteric obstruction. BJU Int 2000;85(3):227–232. Kulkarni RP and Bellamy EA. A new thermo‐ expandable shape‐memory nickel‐titanium alloy stent for the management of ureteric strictures. BJU Int 1999;83(7):755–759. Kulkarni R and Bellamy E. Nickel‐titanium shape memory alloy Memokath 051 ureteral stent for managing long‐term ureteral obstruction: 4‐year experience. J Urol 2001;166(5):1750–1754. Klarskov P, Nordling J, and Nielsen JB. Experience with Memokath 051 ureteral stent. Scand J Urol Nephrol 2005;39(2):169–172. Agrawal S, Brown CT, Bellamy EA, and Kulkarni R. The thermo‐expandable metallic ureteric stent: an 11‐year follow‐up. BJU Int 2009;103(3):372–376. Papatsoris AG and Buchholz N. A novel thermo‐ expandable ureteral metal stent for the minimally invasive management of ureteral strictures. J Endourol 2010;24(3):487–491. Li X, He Z, Yuan J et al. Long‐term results of permanent metallic stent implantation in the treatment of benign upper urinary tract occlusion. Int J Urol 2007;14(8):693–698.

102

103

104

105

106

107

108

109

110

111

Ureteral metal stents: 10‐year experience with malignant ureteral obstruction treatment. J Urol 2009;182(6):2613–2617. Chung HH, Lee SH, Cho SB et al. Comparison of a new polytetrafluoroethylene‐covered metallic stent to a noncovered stent in canine ureters. Cardiovasc Intervent Radiol 2008 May‐Jun;31(3):619–628. Morcillo E, Sanchez‐Margallo FM, Serrano A et al. Effects of preventive double‐J stent placement in ureteral obstruction treatment with metal stents on animal model. Archivos espanoles de urologia 2015;68(9):701–709. Moskovitz B, Halachmi S, and Nativ O. A new self‐expanding, large‐caliber ureteral stent: results of a multicenter experience. J Endourol 2012;26(11):1523–1527. Kim JH, Song K, Jo MK, and Park JW. Palliative care of malignant ureteral obstruction with polytetrafluoroethylene membrane‐covered self‐ expandable metallic stents: initial experience. Kor J Urol 2012;53(9):625–631. Leonardo C, Salvitti M, Franco G et al. Allium stent for treatment of ureteral stenosis. Minerva Urol Nefrol 2013;65(4):277–283. Chung KJ, Park BH, Park B et al. Efficacy and safety of a novel, double‐layered, coated, self‐ expandable metallic mesh stent (Uventa) in malignant ureteral obstructions. J Endourol 2013;27(7):930–935. Kim KS, Choi S, Choi YS et al. Comparison of efficacy and safety between a segmental thermo‐expandable metal alloy spiral stent (Memokath 051) and a self‐ expandable covered metallic stent (UVENTA) in the management of ureteral obstructions. J Laparoendoscopic Adv Surg Tech A 2014;24(8): 550–555. Chung HH, Kim MD, Won JY et al. Multicenter experience of the newly designed covered metallic ureteral stent for malignant ureteral occlusion: comparison with double J stent insertion. Cardiovasc Intervent Radiol 2014;37(2):463–470. Borin JF, Melamud O, and Clayman RV. Initial experience with full‐length metal stent to relieve malignant ureteral obstruction. J Endourol 2006;20(5):300–304. Wah TM, Irving HC, and Cartledge J. Initial experience with the resonance metallic stent for antegrade ureteric stenting. Cardiovasc Intervent Radiol 2007;30(4):705–710. Nagele U, Kuczyk MA, Horstmann M et al. Initial clinical experience with full‐length metal ureteral stents for obstructive ureteral stenosis. World J Urol 2008;26(3):257–262.

877

878

Section 5  Stone Management in Urology: Cost-effectiveness and Long-term Stenting

112 Liatsikos E, Kallidonis P, Kyriazis I et al. Ureteral

113

114

115

116

obstruction: is the full metallic double‐pigtail stent the way to go? Eur Urol 2010;57(3):480–486. Blaschko SD, Deane LA, Krebs A et al. In‐vivo evaluation of flow characteristics of novel metal ureteral stent. J Endourol 2007;21(7):780–783. Liatsikos EN, Kallidonis P, Kyriazis I et al. Metallic double pigtail ureteral stent usage during extracorporeal shock wave lithotripsy in the swine model: is there any effect on the ureter? J Endourol 2009;23(4):685–691. Liatsikos E, Kyriazis I, Kallidonis P et al. Ureteric response to abdominal radiotherapy and metallic double‐pigtail ureteric stents: a pig model. BJU Int 2009;104(6):862–866. Garg T, Guralnick ML, Langenstroer P et al. Resonance metallic ureteral stents do not successfully

117

118

119

120

treat ureteroenteric strictures. J Endourol 2009;23(7):1199–1201; discussion 1202. Lopez‐Huertas HL, Polcari AJ, Acosta‐Miranda A, and Turk TM. Metallic ureteral stents: a cost‐effective method of managing benign upper tract obstruction. J Endourol 2010;24(3):483–485. Kadlec AO, Ellimoottil CS, Greco KA, and Turk TM. Five‐year experience with metallic stents for chronic ureteral obstruction. J Urol 2013;190(3): 937–941. Liatsikos EN, Karnabatidis D, Kagadis GC et al. Application of paclitaxel‐eluting metal mesh stents within the pig ureter: an experimental study. Eur Urol 2007;51(1):217–223. Kallidonis P, Kitrou P, Karnabatidis D et al. Evaluation of zotarolimus‐eluting metal stent in animal ureters. J Endourol 2011;25(10):1661–1667.

i1

Index Note: page numbers in italics refer to figures; those in bold to tables or boxes. abdominal leak point pressure (ALPP) 1862 abdominal pain, acute pregnancy 787, 788 renal colic  798 abdominal pressure (Pabd) 1632 abdominal radiography, renal colic  800 abdominal sacrocolpopexy see sacrocolpopexy, abdominal abdominal surgery, prior iatrogenic ureteral strictures  594, 616 laparoscopic access  944, 987, 991 laparoscopic and robotic pyeloplasty 1330 laparoscopic and robotic surgery  901, 909–910 living kidney donors  1250 robotic radical cystectomy  1107 abdominal wall, anterior anatomy 973, 974 closure, laparoscopic surgery  952, 1013–1016 compliance, pediatric patients 1324–1325 elevators, laparoscopic surgery  922 hernias see hernias, abdominal wall Ablatherm™ high‐intensity focused ultrasound system  1569–1570, 1572, 1574 abobotulinumtoxiA (Dysport™) 1776 abscesses after midurethral sling surgery 1864–1865 mesh complications  1883 renal  803, 1401, 1405 seminal vesicle  1292, 1294 absorption, laser energy  1675–1676, 1694 absorption length, laser energy  1675, 1694 accommodation, visual  49 Accordion™ device PCNL 288–289, 290 ureteroscopy 508 acetazolamide, uric acid stones  358 acetohydroxamic acid  360, 840 acetylcysteine (N‐acetylcysteine), cystine stones  359, 360 acetylsalicylic acid see aspirin

ACMI DCN‐2010 digital flexible cystoscope  502, 1646 ACMI HTO‐5 ureteroscope  468 ACMI MR‐6 ureteroscope  469 ACMI Rigiflex ureteroscope  467, 468 acoustic waves  691, 692, 714 reflection and refraction at fluid/solid boundaries  696, 698, 699 shock‐wave lithotripsy  694–695 see also shock waves Acubot robotic system  271–272 Acucise® endopyelotomy distal ureteral strictures  613, 624, 625 mid‐ureteral strictures  599 UPJ obstruction  381, 585, 590 ureteroenteric strictures  632–633, 635, 636 acupuncture, bladder pain syndrome  1797 acute‐phase reactants  921 adaptive iterative dose reduction (IARD) 24–25 adaptive statistical iterative reconstruction (ASIR) 24–25 ADD Stat™ laser fiber  1679 adenosine diphosphate (ADP) receptor inhibitors 75–76 adhesiolysis, robotic vesicovaginal fistula repair 1246 adhesives, skin  1016 see also fibrin sealants; glue embolization adipose‐derived stem cells  1851 adipose tissue see fat adrenal arteries anatomy 1279, 1280, 1479, 1480 embolization  1480 adrenalectomy 1278–1289 laparoscopic (LA)  1278–1286 avoiding capsular injury  1281 complications 1281 hand‐assisted 1001 history of development  1278 indications 1278–1279 LESS‐A vs.  1288–1289 partial 1282 perioperative care  1279 port placement  978–979, 1282–1283, 1284–1285 postoperative drainage  1017

with radical nephrectomy  1080, 1083 retroperitoneal 1279–1281, 1284–1286 techniques 1282–1286 transperitoneal 1279–1281, 1282–1284 LESS (LESS‐A)  1286–1289, 1378–1379 indications 1288 laparoscopic surgery vs.  1288–1289 techniques 1286–1288 NOTES 1286 adrenal glands anatomy 87, 89 left vs. right  1282 living donor nephrectomy  1253 sparing, radical nephrectomy  1080, 1083 transperitoneal access  978–979 vascular anatomy  1279, 1280, 1479, 1480 adrenal tumors  1278–1279, 1288 aldosterone‐producing adenomas (APAs)  1281, 1282 incidental nonfunctioning  1279 LESS surgery  1378–1379 malignancy risk  1281 adrenal veins anatomy 1279, 1280 laparoscopic adrenalectomy  1283, 1284 living donor nephrectomy  1252, 1253 radical nephrectomy  1080 adrenocortical cancer (ACC)  1278, 1281 Advanced Image and Data Acquisition (AIDA)™ system (Karl Storz)  152 Advanced Modular Manikin program  161 AdVance™ transobturator sling  1893–1894, 1895–1897 AdVance™ XP transobturator sling  1894 Advantage midurethral sling  1856 adventitia, ureter  606 Aesculap reusable trocars  945, 946 AESOP robot  273 Agency for Health Care Policy and Research (AHCPR) 1736 air bubbles, shock wave coupling and  717–718, 749 air embolism see gas embolism air nephrogram endoscopically‐guided PCNL  231–232 staghorn calculi  318

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

i2

Index AirSeal® insufflation system  923, 945, 959 LESS surgery  1368–1369 potential complications  1033 robotic‐assisted radical cystectomy  1109 ureteral reconstruction  1198 air supply, operating room  144 Ajust™ single‐incision sling  1834, 1835, 1840–1841, 1856 ALARA (as low as reasonably achievable) 21–22 Albarran deflecting bridge  524 aldosterone‐producing (adrenal) adenomas (APAs)  1281, 1282 alfuzosin 644 ALF‐X robotic system  883, 884 Alken dilators  275–276, 278–279 combined endoscopic‐fluoroscopic approach 181 complications 281 tricky situations  280 Alken guide  276, 281 Allium™ bulbar urethral stent  1824 Allium ureteral stent  634, 871 allografts prolapse repair  1881 pubovaginal slings  1873 allopurinol  358, 845 alpha‐blockers renal colic  807–808 ureteral stent‐related pain  644 ureteral stone expulsion  543, 643, 778 see also tamsulosin alprazolam  1664 alprostadil, intracavernosal  1187 Altis® single‐incision sling  1834, 1842–1843 American Association for the Surgery of Trauma (AAST), ureteral injury grading  657 American Brachytherapy Society (ABS)  1535, 1536, 1540, 1541–1542 American College of Cardiology (ACC)  76, 77, 79 American College of Chest Physicians (ACCP)  75, 77–78 American College of Surgeons (ACS) Accredited Educational Institutes (ACS‐AEI) program  888, 889 laparoscopy training  891–892 American Joint Committee on Cancer (AJCC) kidney cancer  1411 prostate cancer  1551 American Psychological Association (APA) Standards for Educational and Psychological Tests  161 American Urological Association (AUA) antibiotic prophylaxis  57, 61, 62, 63, 642–643, 663 BPH therapy  1728, 1744 interstitial cystitis  1795, 1796 laparoscopic and robotic surgery training 892 preoperative imaging in prostate cancer 1049 prostate brachytherapy  1535 prostate cancer screening  1551 prostate cryoablation  1581 radiofrequency ablation of renal tumors 1443 stress urinary incontinence  1871, 1872 Volume 1 pages 1–878, Volume 2 pages 879–1913

American Urological Association (AUA)/ Endourological Society kidney stones  550, 558, 858 pediatric urolithiasis  332 staghorn calculi  310–311 ureteral stones  745, 747, 855 American Urological Association Symptom Index (AUA‐SI)  1728 hexa‐aminolaevulinic acid (5‐ALA)  42, 566 amitriptyline, bladder pain syndrome  1797 amniotic tissue wraps, radical prostatectomy 1186–1187 amphotericin B, upper tract instillation  361, 368–370 Amplatz dilators  275, 278–279 children 335 complications 281 Amplatzer vascular plugs, gonadal vein embolization 1470 Amplatz sheath see nephrostomy access sheath AMS 800 artificial urinary sphincter  1892 analgesics after laparoscopic/robotic surgery  932–933 minimally invasive prostate therapy  1664 postureteroscopy 643–644 renal colic  643, 806–807 AnchorPort  1374 Anchor Tissue Retrieval System™  1011 androgen‐deprivation therapy (ADT) cryoablation and  1594–1595 HIFU therapy with  1574 radiotherapy and  1535–1536, 1541, 1554 anesthesia ceiling pendant services  144 cryoablation of renal masses  1456, 1457 laparoscopic and robotic surgery 929–930 laparoscopic/robotic retroperitoneal lymphadenectomy 1067 patient positioning and  173–174, 202 pregnancy 791–792 TURP 1736 ureteroscopy  523, 544, 551 see also general anesthesia; local anesthesia anesthetic challenge, interstitial cystitis 1796 anesthetic management, laparoscopic and robotic surgery  928–938 cardiac patients  936 complications 934–936 enhanced recovery after surgery 931–932 fluid management  930 obesity 937–938 older patients  937 physiologic changes  930–931 postoperative nausea and vomiting 933–934 postoperative pain  932–933 pregnancy 937 preoperative assessment  928–929 angio‐embolization adrenal artery  1480 gonadal vein  1464–1477 renal artery see renal angio‐embolization selective arterial prostate  1489–1493

angiographic catheters ureteral access  524 ureteral stricture management  610, 611 angiography mesenteric, neobladder construction 1132 prostatic artery  1491 renal see renal angiography see also venography angiomyolipomas (AMLs), renal angiography and embolization 1483–1484, 1485 contrast‐enhanced ultrasound  1608 imaging 1395, 1402, 1403–1406 angiotensin II receptor blockers  1188 angle of view rigid ureteroscopes  468 semirigid ureteroscopes  472 Sun’s ureterorenoscope  487–488 antegrade endopyelotomy see endopyelotomy, antegrade antegrade nephrostogram/pyelography children  334, 337 difficult ureteroscopic access  297 ureteral obstruction  596 ureteroenteric strictures  630, 631 antegrade renal access see percutaneous renal access anterior abdominal wall see abdominal wall, anterior anterior pararenal space  87, 89 anterior superior iliac spine (ASIS)  1054, 1173 antibiotics postoperative sepsis  69 prophylactic 60–67 children  332, 338 guidelines  57, 58, 61 nephrolithiasis 62–66 open and laparoscopic surgery  66–67 PCNL 230 percutaneous antegrade ureteroscopy 295 radical prostatectomy  1181 SWL  61, 63, 736, 748 transurethral surgery  60–62 TURP 1736 ureteroscopy  61, 63–64, 65, 544, 642–643, 663 vesicoureteric reflux  1788 resistance  58, 60 ureteral stents eluting  613 anticholinergics overactive bladder  1775 percutaneous tibial nerve stimulation vs. 1910 prostate surgery  1664 anticoagulants 73–76 living donor nephrectomy  1254 see also heparin anticoagulated patients  73–81 laser prostatectomy  1696–1697, 1699, 1712–1713 PCNL  390, 399 perioperative management  78–81 risk stratification  76–78 SWL  80, 731–732, 748 ureteroscopy  80, 522, 544–545

Index antidiuretic hormone (ADH; vasopressin)  919, 920 antiemetics postoperative nausea and vomiting 933–934 renal colic  807 antifungal therapy  367–370 anti‐incontinence surgery see incontinence surgery antimicrobial agents see antibiotics antimicrobial peptide‐coated ureteral stents 646 antiplatelet agents  73, 75–76 PCNL in patients on  399 perioperative management  79, 80–81 safety and risk stratification  76–78 SWL  731–732, 748 antiproliferative factor (APF)  1794–1795 antisperm antibodies (ASA)  1314 antithrombin 74 antithrombotics kidney stone management and  550 PCNL in patients on  399 safety and risk stratification  76–78 see also anticoagulants; antiplatelet agents Antopol–Goldman lesions  1403 aortic aneurysms, abdominal differential diagnosis  803 SWL and  732, 758 aortic valve prostheses  77, 78 apixaban 75 apoptosis, tubular  135–136 apparent diffusion coefficient (ADC)  1497, 1618–1619 appendix, ureteral reconstruction  600 AQ Taper dilators  612 AquaBeam® system  1730 aquablation of prostate  1730 arcuate (renal) arteries  91, 265 arcuate (renal) veins  91, 92 area cribrosa  92, 93 l‐arginine 134 argon beam coagulator (ABC)  949–950 argon laser, urethral strictures  1823 Aris midurethral sling  1856 Arrhenius‐based damage estimation  1524, 1525 arrhythmias see cardiac arrhythmias Artemis biopsy system  1503, 1504–1505 arterial anastomosis, robotic kidney transplantation 1265, 1266 arterial aneurysms, SWL and  732, 758 arterial puncture, during PCNL  392, 393, 401 artificial urinary sphincter (AUS)  1892, 1895 Artis Zee® Ceiling System  223, 224 ASCENDE‐RT trial  1544, 1553, 1554 ascending colon, kidney relations  90, 91 asepsis, history  3 as low as reasonably achievable (ALARA) 21–22 aspirin (acetylsalicylic acid) perioperative management  79, 80–81 SWL and  731, 747 Association for the Advancement of Medical Instrumentation (AAMI), sterilization guidelines  9, 11 Volume 1 pages 1–878, Volume 2 pages 879–1913

Association of Operating Room Nurses (AORN), disinfection and sterilization guidelines  10, 11–12 Association of Program Directors in Surgery (APDS) 891–892 ASTRO definition, prostate cancer relapse 1596 atherosclerosis, selective arterial prostate embolization 1492 atorvastatin 1187–1188 atrial fibrillation  76–77, 78 atrial natriuretic peptide (ANP)  133–135 AUA see American Urological Association audio mixer  155 augmented reality (AR)  52–53, 161, 1160–1162 autoclaves  3, 7 Autocon® II 400 Electrosurgical System (Karl Storz)  1753, 1754 autologous grafts prolapse repair  1881 pubovaginal slings  1871, 1872–1873 see also tissue‐engineered bulking agents autologous nerve grafts, radical prostatectomy 1186–1187 autosomal dominant polycystic kidney disease (ADPKD)  1221 Avicenna Roboflex flexible ureteroscopy robot  483, 670–685, 882 advantages  682–683, 685 classical techniques vs.  681–685 development 670–677 experimental evaluation  677 limitations 683–684 manipulator arm (MA)  674–677, 678, 681 master control console (MCC)  670–674, 675–677 published clinical studies  678–681 surgical technique  677–678 AVRA Surgical Robotics System  884–885 bacille Calmette–Guérin (BCG) mechanism of action  364 upper tract instillation  364–366, 388, 578 back table preparation living donor nephrectomy  1254 lower tract surgery  1654–1655, 1656 bacteria, stone formation  360 bacteriuria preoperative 59 SWL and  732, 757 ballistic lithotripsy  325–326 mechanism of action  325, 533, 534 ureteroscopy 533–534, 539 ballistic–ultrasonic lithotripters, combined  327–328, 535 balloon dilation bladder neck contracture  1828 extraperitoneal pelvic access  991, 992 infundibular stenosis  347 nephrostomy tract  276 calyceal diverticula  345 children  334, 335 comparative studies  278–279 complications 281 non‐ideal situations  280 staghorn calculi  315, 318 retroperitoneal space  988, 989

ureteral 509 diagnostic ureteroscopy  563 distal ureteral strictures  619, 620, 623–624 flexible ureteroscopy  525, 526 mid‐ureteral strictures  598, 599 rigid ureteroscopy  517 tip‐flexible ureterorenoscopy  492, 493 ureteral access sheath placement  528 ureteroenteric strictures  631, 632, 634, 635 ureteropelvic junction percutaneous antegrade  378–379 retrograde ureteroscopic  380–381, 587 urethral strictures/stenoses  1821 balloon dilators nephrostomy tract  276 retroperitoneal access  944, 945 ureteral  509, 522, 525, 612–613 ureteroenteric strictures  634 balloon dissection extraperitoneal pelvic access  991, 992, 1145 retroperitoneoscopy 988, 989 balloon electrocautery, UPJ incision  381 balloon tamponade, PCNL‐related bleeding  392, 400–401 Bard Dimension® stone basket  317, 509 Bard PerFix® Plug  1307 Bard Sensor guidewire  507 bare metal stents (BMS), coronary  77, 79 bariatric surgery, stone disease after 844–845 Basic Laparoscopic Urological Skills (BLUS) 891 BCG see bacille Calmette–Guérin behavioral therapy, bladder pain syndrome 1797 benign prostatic hyperplasia (BPH)  1488–1493 ablative and emerging techniques 1727–1730 cystoscopy  1635, 1645 detrusor underactivity  1635–1636 diagnostic workup  1489–1490 local anesthesia  1661–1668 lower urinary tract symptoms see under lower urinary tract symptoms outcome measures  1728 prostatectomy 1269–1275 choice of technique  1763–1764 indications 1270 laparoscopic and robotic  1270–1275 laser see laser prostatectomy LESS 1762–1768 open  1269–1270, 1273, 1274 transurethral see transurethral resection of prostate prostatic urethral lift procedure 1719–1725 selective arterial prostate embolization 1489–1493 treatment options  1488–1489, 1763–1764 ureteroscopy 521 urinary incontinence  1638–1640 urodynamic evaluation  1627–1634, 1640 benzodiazepines  1664

i3

i4

Index Bertin, columns of  92, 93 Bierhoff leg holders  203 biofeedback therapy, postoperative  1188–1189 biofilms 865–866 bioinjectables stress urinary incontinence  1847–1851 vesicoureteral reflux  1784–1785 Biojet fusion biopsy system  1505 Biolitec laser  1674 biologic implants hernia/wound repair  1300, 1301 pubovaginal slings  1873 BiopSee fusion biopsy system  1505 biopsy bladder lesions  1645, 1798 prostate see prostate biopsy prostatic urethra  1117 renal see renal biopsy renal mass see renal mass biopsy upper tract neoplasms  384–385, 564–565, 570–572, 1431 biopsy forceps flexible ureteroscopes  478, 479, 482 rigid cystoscopes  1654 upper tract tumor resection  387, 573 upper tract tumor sampling  384–385, 564, 570 bipolar electrosurgery  1657–1658 en bloc resection of bladder tumors  1808 EndoWrist robotic instruments  956 laparoscopic instruments  950 robot‐assisted radical prostatectomy 1186 transurethral equipment  1655 see also electrosurgery bipolar transurethral resection of prostate (BiTURP) 1743–1750 complications 1748–1749 cost 1749 education issues  1749 efficacy 1746–1748 equipment 1744, 1745 monopolar TURP vs.  1658, 1741, 1743 patient selection  1743–1744 surgical technique  1745–1746 bipolar transurethral vaporization of prostate (TUVP)  1752–1760 button‐type bipolar plasma vaporization 1758–1760 clinical experience  1755–1756 comparative studies  1757–1758 electrode and generator design 1753–1755 mechanism of action  1752–1753 bipolar transurethral vaporization resection of prostate (TUVRP)  1757–1758 bipolar vaporesection of prostate see bipolar transurethral resection of prostate Bitrack robotic system  883 Bjork–Shiley valve  77 bladder backfill test, vesicovaginal fistulas  1243, 1244 biopsy  1645, 1798 compliance, measurement  1632–1633

Volume 1 pages 1–878, Volume 2 pages 879–1913

cuff excision, laparoscopic nephroureterectomy  981, 1101, 1103–1104 cystoscopic examination  1644, 1646 epithelial permeability  1794 exposure, ureteral reconstruction  1199 filling symptoms, evaluation  1631–1632, 1633 hydrodistention, bladder pain syndrome  1795–1796, 1798–1799, 1800 injuries, laparoscopic orchiopexy  1326 laparoscopic access  982, 983 mesh/tape erosion into  1866, 1886 mobilization partial cystectomy  1118, 1119 radical cystectomy  1109 radical prostatectomy  1174, 1386 ureteral reconstruction  1199, 1339, 1340 vesicovaginal fistula repair  1246–1247 overdistention, ureteroscopy  653 perforation, midurethral sling surgery  1863, 1866 volume, prostate radiotherapy  1560 bladder cancer bladder‐preservation therapy  1116–1117 laparoscopic and robotic radical cystectomy 1107–1112 multifocal disease  1116 muscle‐invasive (MIBC) partial cystectomy  1115–1116 preoperative evaluation  1051, 1117 narrow band imaging  1646–1647 non‐muscle‐invasive (NMIBC) en bloc resection  1806–1813 narrow‐band imaging  1647 TURBT 1806 pelvic lymphadenectomy  1051–1052, 1110 preoperative imaging  1051 robotic partial cystectomy  1115–1123 thulium laser resection  1715 transurethral resection (TURBT) see transurethral resection of bladder tumor trimodality therapy (TMT)  1116–1117 see also bladder tumors bladder carcinoma in situ (CIS) narrow band imaging  1646–1647 partial cystectomy  1116 bladder contractility index (BCI)  1633 bladder neck anatomy  1143, 1816 dilation 1828 plication, simple prostatectomy  1273 reconstruction for contracture  1829 at radical prostatectomy  1149–1150, 1184–1186 sparing, radical prostatectomy  1182, 1827 transection, radical prostatectomy  1145, 1146, 1147, 1175 bladder neck contracture (BNC) etiology 1818

post‐radical prostatectomy  1826–1829 etiology 1826–1827 evaluation 1827 management 1828–1829 post‐TURP 1740 thulium laser therapy  1714 bladder outlet obstruction (BOO) after midurethral sling surgery  1863–1864, 1865 after vaginal prolapse surgery  1886 causes in men  1627 cystoscopy 1645 detrusor underactivity and  1636 prostate debulking techniques  1489 prostatic urethral lift procedure 1719–1725 ureteral kinking  459 ureteroscopy 521 urodynamic evaluation  1633–1634, 1637 uroflowmetry 1630 bladder outlet obstruction index (BOOI) 1633 bladder pain syndrome see interstitial cystitis/bladder pain syndrome bladder‐preservation therapy  1116–1117 bladder tumors cystoscopy  1117, 1645 distal ureteral obstruction in children  1335 en bloc resection  1806–1813 narrow band imaging  1646–1647 new, treated upper tract neoplasms  576 see also bladder cancer Blandy resection technique, TURP  1737 bleeding diatheses kidney stone management  550 percutaneous renal surgery  294 SWL  731–732, 748 ureteroscopy  550, 662 see also anticoagulated patients bleeding/hemorrhage anticoagulated patients  77, 80–81 laparoscopic surgery  1024–1025 equipment kit  1025 inspection for  1013 intraoperative 1036–1040 management 1037–1039 postoperative  1028, 1040 laser prostatectomy  1702, 1711, 1712 lithotrite‐related 660–661 open renal stone surgery  397 PCNL‐related 397–405 blind access  267 catastrophic 401 children 338 delayed  398, 404–405 endoscopic guidance and  234 etiology  391–392, 397–398 hemostatic agents  401–402 intraoperative 400–402 intrathoracic see hemothorax management 400–405 miniaturized systems  306 patient positioning and  201, 205 postoperative 402–405 preoperative prevention  399 rates  391, 397 risk factors  398–399 staghorn calculi  319

Index tract dilation  277 upper pole access  260 pediatric renal tumors  1485, 1486 radiofrequency ablation of renal tumors 1446 renal angiomyolipomas  1404, 1406, 1483, 1484 renal injuries  1482–1483 retrograde endopyelotomy  589 robotic surgery  1039–1040 simple prostatectomy  1272, 1273, 1275 trocar site  977–978 TURP‐related  1739–1740, 1749 upper tract, flexible ureteroscopy  526 upper tract urothelial tumor resection 387 ureteroscopy‐related 662–663 urological procedures  80–81 see also blood loss; hemostasis blended waveform, electrosurgery  1735 blind percutaneous renal access see percutaneous renal access, without image guidance blood loss laparoscopic pyelolithotomy  1208, 1209 laparoscopic radical prostatectomy  1151 laparoscopic/robot‐assisted radical cystectomy 1111 monitoring, PCNL  400 preoperative prediction, PCNL  110, 119 robotic kidney transplantation  1267 robotic radical prostatectomy  1170 robotic simple prostatectomy  1273, 1274 see also bleeding/hemorrhage; transfusion rates blood transfusion consent 902 laparoscopic radical prostatectomy  1151, 1153 PCNL 400 see also transfusion rates BLUS (Basic Laparoscopic Urological Skills) 891 Boari flap  608 indications 1196 mid‐ureteral strictures  600 pediatric laparoscopic and robotic  1340–1342 ureterovaginal fistula repair  1247 BOA Vision digital ureteroscope (Richard Wolf ) 480 imaging technology  43, 45 nephroscopy 287 technical details  477, 500 body mass index (BMI)  843 radiation exposure and  15, 24 thoracic complications of PCNL and  412 see also obesity bone‐anchored male slings  1892–1893, 1895 bone metastases prostate cancer  1593 renal cell carcinoma  1413, 1415 bone scans prostate cancer  1552, 1593 radiation exposure  23

Volume 1 pages 1–878, Volume 2 pages 879–1913

boom‐arms, equipment  143–144, 1649 Bosniak classification  348, 1222, 1223, 1396–1399 Boston Scientific LithoVue™ see LithoVue™ flexible ureteroscope botulinum toxin A (BTX‐A)  1776 adverse effects  1778 intraprostatic injections  1730 intravesical injections bladder pain syndrome  1799–1800 overactive bladder  1775–1779, 1902 mechanism of action  1776 bowel continent cutaneous urinary diversion 1134–1135 infarction, post‐laparoscopy  934–935 intracorporeal ileal conduit  1127 mobilization live donor nephrectomy  1252 vesicovaginal fistula repair  1246 neobladder construction  1132–1134, 1137–1138 bowel graspers, laparoscopic  948 bowel injuries laparoscopic hernia repair  1305–1306 laparoscopic surgery  1025–1027, 1040–1041 access related  978, 1022, 1025, 1040 prevention 991 midurethral sling surgery  1863 PCNL  394–395, 422–424 see also colonic injuries bowel preparation laparoscopic pyeloplasty  1329 laparoscopic surgery  902 lower ureteral reconstruction in children 1337 prostate brachytherapy  1538 robotic radical cystectomy  1107–1108 robotic radical prostatectomy  1172 robotic surgery  902, 910–911 Bozzini, Phillip  465, 466 BPH see benign prostatic hyperplasia brachial plexus injury  1653 prone position  187, 203 steep Trendelenburg  914, 935–936 brachytherapy, prostate  1534–1545 access 1536–1537 cost‐effectiveness 1544 dose selection and organs at risk 1541–1542 external beam radiotherapy with  1541, 1543–1544, 1553, 1554 focal 1514 high dose rate (HDR)  1514, 1534 dose selection  1542 history 1535 outcomes 1543 salvage 1541 technique  1538, 1540 history 1534–1535 image‐guided 1534–1545 low dose rate (LDR)  1514, 1534 dose selection  1541–1542 history 1534–1535 implant quality assessment  1539–1540 outcomes 1542–1543

planning and treatment delivery 1538–1539 salvage 1540–1541 source selection  1537–1538 technique 1537–1540 patient selection  1535–1536, 1552–1553 radiation exposure  27–28 results 1542–1544 salvage 1540–1541 salvage therapy after  1574–1576, 1581–1582 techniques 1536–1542 toxicity and quality of life  1544 bradycardia, laparoscopy‐related  922, 1023, 1033 brain, effects of laparoscopy  920, 931 bremsstrahlung 15 Broedel’s bloodless line  256, 265–266 brushes, endoscope cleaning  5, 6 brushite stones, SWL  697, 700, 732 buccal mucosal ureteroplasty, robot‐ assisted  600, 1203–1205 Bugbee electrode  612, 1800 Bugbie dilators  612 Bulkamid™ (polyacrylamide hydrogel)  1849, 1850 bulking agents, injectable stress urinary incontinence  1847–1851 vesicoureteral reflux  1784–1785 bullseye technique, calyceal puncture  188–191, 214 children 335 Sharma & Sharma modification  215–216 staghorn calculi  315 bupivacaine 1662–1663 Burch colposuspension  1855 midurethral slings vs.  1858 prolapse repair with  1235 pubovaginal fascial slings vs.  1876 burst‐wave lithotripsy  707, 716 button‐type bipolar plasma vaporization (BTPV) 1758–1760 N‐butyl cyanoacrylate (nBCA) glue embolization  1470–1472, 1482 cadavers, as surgical simulators  895 Cadiere forceps  956 Caiman® bipolar device  950 calcifications dystrophic, bladder neck  1829 plain abdominal radiographs  800 renal cysts  1222, 1396, 1399, 1401 seminal vesicle  1292, 1293 solid renal masses  1406, 1409 calcium metabolism, in pregnancy  786–787 supplementation in pregnancy  787 calcium carbonate apatite stones acoustic and physical properties  697 medical dissolution therapy  360 staghorn calculi  310 urinary diversion patients  837 calcium channel blockers (CCB) distal ureteral stone expulsion  778 facilitating stone passage  543, 643 renal colic  807–808 see also nifedipine

i5

i6

Index calcium hydroxylapatite (Coaptite)  1784–1785, 1849–1850 calcium oxalate stones acoustic and physical properties  696, 697 calyceal diverticula  341 chemolysis  361–362, 448 diagnostic imaging  129 obesity  843, 845 SWL  732, 746 urinary diversion patients  837, 839–840 calcium stones acoustic and physical properties  697 chemolysis  361–362, 448 urinary diversion patients  837 calculi see stone(s) calyceal diverticula  341–346 classification 1229 diagnosis 341–342, 343, 1229–1230 etiology 1229 flexible ureteroscopy  556–558 fulguration  344, 345 laparoscopic treatment  1229–1232 complications 1232 indications  343, 1230 operating room setup  1230 patient and trocar positioning  1230–1231 postoperative care  1231 surgical technique  1231 percutaneous treatment  343–346 complications 346 flexible nephroscopy  286 technique 344–345 stones  341, 342, 1229 laparoscopic surgery  343, 1213, 1214 pelvic kidneys  822 percutaneous treatment  343, 345 posttreatment analysis  346 retrograde ureteroscopy  343 SWL 342–343, 739, 740 treatment options  342–343, 783 calyceal fornix anatomy  93 percutaneous access  103–104, 105–106 calyceal infundibula see infundibula, calyceal calyces anatomy  92–101, 266 Broedel configuration  266 groups A and B  94, 95 Hodson configuration  266 anterior anatomy 97, 99, 100 fluoroscopy 186, 187 supine position  204 crossed  94, 96–97, 98 inferior see lower (inferior) pole kidney midzone  99–101 lateral kidney margin and  97, 99, 100 major 92, 93 anatomical classification  94, 95 minor 92, 93 anatomical classification  94, 95 crossed 96–97, 98 perpendicular 95, 96, 97 obstructed, percutaneous nephroscopy  285, 286 Volume 1 pages 1–878, Volume 2 pages 879–1913

percutaneous puncture see renal collecting system puncture polar regions  98–99, 100 posterior anatomy 97, 99 bullseye puncture  188–191 fluoroscopy 186, 187, 213 nephroscopy  287, 288 selection of puncture site  391 S.T.O.N.E. nephrolithometry  110 superior see upper (superior) pole see also renal collecting system Calypso 4D Localization System  1562–1564 cameras CCD chip see charge‐coupled device chip cameras data archiving  155 LESS surgery  1368, 1369 video see video cameras Camper’s fascia  973 cancer risks see malignancy risks Candela Laser Corporation semirigid ureteroscope 469 candidiasis, urinary tract  367, 368, 369 capnothorax  1041, 1042 Captura® stone grasper  317 carbolic acid  3 carbonate apatite stones see calcium carbonate apatite stones carbon‐coated zirconium beads (Durasphere) 1850 carbon dioxide (CO2) absorption during laparoscopy  919, 931 embolism see gas embolism end‐tidal monitoring  919 insufflation advantages 918 technique 976 technology 944–945 pneumoperitoneum 918–923 cardiac and hemodynamic effects  919–920 cerebral effects  920 complications 921–922 modifications 922–923 obese patients  922 pulmonary effects  918–919 renal effects  920 stress response  920–921 warmed gases  922–923 cardiac arrhythmias pneumoperitoneum‐related 922 SWL and  738, 757–758 cardiac disease, laparoscopic surgery  936, 1325 cardiac index, prone positioning  202 cardiac output, laparoscopic surgery  919, 930, 936 cardiopulmonary resuscitation (CPR), prone position 202 cardiovascular changes patient positioning and  202, 204, 918 pneumoperitoneum  919–920, 930 post‐SWL 757–758 C‐arm units  145–146, 1649 lower tract procedures  1650–1651 PCNL 150 lateral(‐flexed) position  193–194, 196

prone position  186, 188–189, 214–215 staghorn calculi  314, 315, 318, 319 supine‐modified position  175, 176 upper pole access  257–258 ureteroscopy  147, 506, 516 Carter–Thomason closure devices  992, 1014, 1015 cavitation electrohydraulic lithotripsy  322, 323, 508 high‐intensity focused ultrasound  1568 SWL  696–697, 703–704, 717 ultrasonic cleaning  6 ureteral injury  533 urinary tract injury  323, 706 CCD see charge‐coupled device ceiling, operating room  144 Center for Research in Simulation and Education Technologies (CREST)  894 Centers for Disease Control (CDC), disinfection and sterilization guidelines  9, 10, 11 central venous line, prone position  202 central venous pressure, laparoscopic and robotic surgery  919, 930 cerebral blood flow, laparoscopic surgery  920, 931 cerebrovascular accident see stroke certification, surgeons  897–898 cesium‐131 (131Cs), prostate brachytherapy 1538 CHA2DS2‐VASc score  76, 78 Chamberland(–Pasteur) filter  3 charge‐coupled device (CCD) chip cameras  38, 39–40, 146 ureteroscopes  42–43, 476, 501–502 videoendoscope design  41 chemolysis of urinary calculi  357–363 calcium stones  361–362 cystine stones  358–360 irrigation systems  354–355, 356 residual fragments 448–449 struvite stones  360–361, 362 uric acid stones  357–358, 359 chemotherapy bladder cancer  1116 intravesical instillation  1808 upper tract instillation  363–367, 578 chest tube drainage  394, 416–417, 419 chest X‐rays, post‐PCNL  415 children asymptomatic stones  773 calyceal diverticula  341 distal ureteral obstruction  1335–1336 laparoscopic and robotic lower ureteral reconstruction 1335–1343 laparoscopic and robotic pyeloplasty  1328–1333 laparoscopic varicocelectomy  1353–1359 laparoscopy 1323–1326 anatomy and physiology  1324–1325 complications 1325–1326 indications 1323–1324 instrumentation 1325 safety and efficacy  1323 overactive bladder  1777–1778 PCNL 332–339 access and tract dilation  334–335

Index complications 338–339 indications 332 instrumentation 335–337 lithotripsy energy sources  337 miniaturized  276, 302, 336–337 patient positioning  333–334 postoperative drainage  337–338 residual fragments 448 risks 332–333 sandwich therapy  338 staged procedures  338 radiation safety  28–29 renal tumor embolization  1485, 1486 residual stone fragments 338, 448, 773 shock‐wave lithotripsy  338, 740 residual fragments 448 ureteral stones  746 undescended testes  1323–1324, 1344–1349 chip‐on‐the tip technology  41 laparoscopes 45, 47 ureteroscopes  42–43, 44, 46, 476, 501–502 choline magnetic resonance spectroscopy 1620 chondrocytes, autologous  1785 chopstick technique, robotic LESS  1381, 1385–1386 chromophores, body  1675 chronic kidney disease (CKD) kidney transplantation  1259, 1261 live kidney donor risks  1250 staghorn calculus‐related  768 chronic obstructive pulmonary disease (COPD) 945 chronic pelvic pain  1474–1475, 1796 chylous ascites, postoperative  1042, 1043 cimetidine, bladder pain syndrome  1797 ciprofloxacin prophylactic  230, 1560 resistance  58, 60 citrate magnetic resonance spectroscopy 1620 clamps laparoscopic 949 robotic bulldog  957–958 Clavien‐Dindo classification, surgical complications 653, 654 clean–contaminated surgery, antimicrobial prophylaxis  61, 67 cleaning, instrument  4–6 clean instrument processing facilities  10 clean intermittent catheterization (CIC), overactive bladder  1776, 1778 clean surgery, antimicrobial prophylaxis  61, 67 Clinical and Research Office of Endourology Society see CROES clinically insignificant residual fragments (CIRFs)  441, 771 clip appliers, endoscopic  966–968 laparoscopic surgery  951 multiple‐load disposable  966–968 robotic surgery  956–957 single‐load reusable  966, 967 clips 966–970 application principles  969 laparoscopic 951 metallic 968–970 Volume 1 pages 1–878, Volume 2 pages 879–1913

nonmetallic  967, 968 tissue reaction  970 clopidogrel perioperative management  75–76, 80, 81 SWL and  731 Cloquet’s node  1063–1064 CMOS see complementary metal oxide semiconductor CO2 see carbon dioxide coagulation cascade  74 coagulation necrosis  1523, 1528, 1568 coagulation waveform, electrosurgery  1735 coagulopathies see bleeding diatheses; hypercoagulable states Coaptite (calcium hydroxylapatite) 1784–1785, 1849–1850 Cobra fiber‐optic ureteroscope (Richard Wolf )  479, 480, 509 comparative studies  482, 499, 510 specifications  477 Cobra grasper  956 Cobra Vision digital ureteroscope (Richard Wolf )  287, 499, 500 cognitive fusion prostate biopsy  1497, 1511 cognitive task analysis (CTA)  893 Cohen cross trigonal reimplantation  518, 608 coil embolization gonadal vein  1470, 1471 horseshoe kidney  1482 cold cup biopsy forceps  387 cold‐knife endopyelotomy antegrade 378–379 retrograde  380, 381–382, 588 cold‐knife endoureterotomy distal ureteral strictures  619–620, 624, 625 instruments 613, 614 postoperative ureteral obstruction  609, 610 ureteroenteric strictures  632, 635, 636 cold‐knife incision infundibular stenosis  347 ureterocele 518 cold‐knife urethrotomy  1822 COLD registry see Cryo‐On‐Line Database registry collagen, glutaraldehyde crosslinked bovine (Contigen™)  1784, 1847, 1849 collecting system, renal see renal collecting system Collin’s knife‐electrode  611–612 colon anatomy 90, 91 ectopic and transplanted kidneys  240 mobilization adrenalectomy 1284 live donor nephrectomy  1252 lower ureteral reconstruction  1338 retrorenal 90 injury risk  422, 423 prone vs. supine position  200, 261 colonic injuries PCNL  394, 422–423 children 338–339 patient positioning and  174, 199–201, 204–205 upper pole access  261

radiofrequency ablation of renal tumors 1447–1448 Coloplast Virtue® quadratic male sling  1894, 1898 colorectal surgery, iatrogenic ureteral strictures  594, 616 colovesical fistulas  1244 Colpopexy and Urinary Reduction (CARE) trial 1235 colposuspension midurethral slings vs.  1858 see also Burch colposuspension colpotomy, vesicovaginal fistula repair 1247 combination endoscopic laser ablation of prostate (CELAP)  1681 combined antegrade‐retrograde approaches distal ureteral strictures  620–621 instillation of topical agents  356 radiation safety  27 rationale 177–181 residual stone fragments 178, 181 see also endoscopic combined intrarenal surgery common iliac artery pelvic lymph node dissection  1053, 1057 ureteral relations  592, 593, 605 common iliac vein, pelvic lymph node dissection 1057 Common Terminology Criteria for Adverse Events (CTCAE)  1555, 1556 compartment syndrome, lower extremity (well‐leg) 1035 patient positioning and  934, 1653 robotic surgery  907, 913 complementary and alternative medical therapies, bladder pain syndrome 1797 complementary metal oxide semiconductor (CMOS) sensors  41 ureteroscopes  42–43, 44, 476, 501–502 computed tomography (CT) 3D see three‐dimensional computed tomography angiography (CTA) prostatic arteries  1491, 1492 renal arteries, prior to PCNL  222 bladder cancer  1117 calyceal diverticula  342, 343, 1229–1230 chest, post‐PCNL  415 cone‐beam (CBCT) prostate radiotherapy  1561 selective arterial prostatic embolization  1491, 1492 contrast‐enhanced ultrasound vs.  1605, 1608, 1609 cost‐effectiveness 854 cryoablation of renal masses  1457, 1458, 1459, 1461 dual‐energy (DECT)  18–19, 1394, 1400 fluoroscopy  222, 223 image‐guided prostate radiotherapy  1558, 1561 image‐guided surgery  52–53 iterative reconstruction technology 24–25 living kidney donors  1250–1251 low‐dose (LDCT)  24–25 lymph node metastases  1049, 1051

i7

i8

Index computed tomography (CT) (cont’d) multi‐detector (MDCT)  24, 1393–1394 noncontrast (NCCT)  18, 25 allograft lithiasis  829 renal colic  801–802, 803 renal masses  1393–1394 S.T.O.N.E. nephrolithometry  109, 110 urinary tract obstruction  129–130 PCNL guidance  221–226 calyceal diverticula  344 horseshoe kidney  815 preoperative imaging  212–213, 222, 230, 311 standard CT  221–223 Uro Dyna‐CT  223–226, 246, 248–251 pelvic congestion syndrome  1474, 1475 pregnancy 790 pyelography 595 radiation exposure  18–19, 23, 222 radiation safety  23–25 pediatric patients  28–29 pregnancy 30 radiofrequency ablation of renal tumors 1444–1445 renal colic  800, 801–802 renal cysts  1221, 1222, 1396–1397 renal masses  1393–1394, 1427 renal stones  731, 733–735 renal tumors  1078, 1088 seminal vesicles  1293, 1294 standard‐dose (SDCT)  24 upper tract transitional cell carcinoma 1413–1416, 1417 ureteral stones  294, 295, 745, 746, 854 ureteral strictures  595 ureteroenteric strictures  630 Uro Dyna‐guided renal access see Uro Dyna‐CT‐guided renal access urography renal masses  1393 upper tract neoplasms  568 ureteral anatomy  458–459 ureteral strictures  595 computer‐assisted surgery (CAS)  52–53 confocal laser endomicroscopy (CLE)  42, 566 consent, informed blood transfusion  902 laparoscopic and robotic surgery 901–902 laser prostatectomy  1699–1700 living donor nephrectomy  1251 patient handouts  1659–1660 retrograde endopyelotomy  586 retroperitoneal lymph node dissection 1067 ureteral reconstruction  1195 ureteroscopy  522, 544 contaminated procedures, antimicrobial prophylaxis  61, 67 Contigen™ (glutaraldehyde crosslinked bovine collagen)  1784, 1847, 1849 continence see urinary continence continent urinary diversion, minimally invasive 1128–1138 keys to success  1137–1138 laparoscopic 1135 operating room setup  1129 Volume 1 pages 1–878, Volume 2 pages 879–1913

orthotopic neobladder see neobladder outcomes 1135–1137 patient positioning  1129 patient selection  1129 postoperative management  1135 preoperative evaluation  1129 procedures 1131–1135 robot‐assisted cutaneous  1134–1135 trocar placement  1129–1131 contrast agents, ultrasound  1605–1606 drug delivery  1611–1612 targeted 1610–1611 contrast‐enhanced ultrasound (CEUS) 1605–1612 drug delivery  1611–1612 fusion imaging  1612 prostate  1606–1608, 1610 quantification 1610, 1611 renal masses  1608–1609, 1610 targeted microbubbles  1610–1611 contrast nephropathy  595 control room, data relay  156–157, 158 Cook Flexor® ureteral access sheaths  507 Cook Injekt VUR injection needle  1789 Cook laser catheter sleeve  482 Cook Medical Flexor Vue digital ureteroscope  500 Cook Medical VueLite LED Light Source 46–47 Cook N‐Circle® stone basket  317, 509 Cook N‐Compass stone basket  509 Cook NGage stone grasper  509 Cook N‐Trap  508 Cope loop nephrostomy tube  428 core biopsy (CB) needles 1429–1430 renal masses  1428, 1429–1431 Core™ operating room (Richard Wolf ) 151 corneal abrasions  203, 935 coronary artery disease, perioperative anticoagulation 80 coronary stents  77, 79, 80 cost‐effectiveness cryoablation of renal masses  1457 laparoscopic radical prostatectomy 1158–1159 laser prostatectomy  1682, 1684–1685, 1690, 1713 neuromodulation 1910–1911 prostate brachytherapy  1544 stone management methods  853–861 urethral bulking agents  1848 costs, economic assessing and analyzing  853–854 Avicenna robot system  684 bipolar TURP  1749 BPH treatment  1728 end‐stage renal disease  827 laparoscopic varicocelectomy  1357 miniaturized PCNL  306, 307 postureteroscopy imaging  648 proximal ureteral stone therapy  779 robotic pyeloplasty in children  1328 stone management  853–861 stress urinary incontinence  1848 upper tract tumor management  578 ureteroscopic lithotripters  538 coumarin laser lithotripsy  324, 537

Councill tip nephrostomy tube (NT)  428 COX‐2 inhibitors, postoperative pain  933 creatinine, postoperative drain fluid  1122, 1123 cremasteric artery  1354 Fowler–Stephens technique  1348–1349 Crew Resource Management (CRM)  1032 critical items (Spaulding classification)  4 CROES nomogram  109, 110, 112–113 comparative assessment  113–120 review of literature  115–116 strengths and weaknesses  112–113 crossover technique, LESS adrenalectomy 1287, 1288 crowdsourcing, technical skills assessment 897 cryoablation (cryotherapy) history of development  1454–1455, 1589 mechanisms of action  1455, 1580–1581, 1590–1591 nephrostomy tract  402 prostate cancer see prostate cryoablation renal masses  1454–1461 biopsy during  1435–1436 complications 1456 contrast‐enhanced ultrasound  1609, 1610 extirpative therapy vs.  1455–1456 imaging 1419, 1420 indications 1454 laparoscopic 1461 LESS 1380 other ablative therapies vs.  1456–1457 outcomes 1461 percutaneous procedure  1457–1461 cryogenic injury  1455, 1580–1581, 1590–1591 cryoimmunology 1581 Cryo‐On‐Line Database (COLD) registry  1589, 1593, 1596, 1597–1598 cryoprobes, stick mode  1457, 1459 cryoshock 1455 cryptorchidism see undescended testes CT see computed tomography curriculum development  893–894 cutaneous urinary diversion, robot‐assisted continent 1134–1135 cutting devices EndoWrist robotic  956 laparoscopic 949 see also electrosurgery; scissors cutting waveform, electrosurgery  1734–1735 CyberWand lithotripter  328, 535 cyproterone acetate  1554 cystectomy hand‐assisted laparoscopic  1001 partial see partial cystectomy radical see radical cystectomy ureteral strictures complicating  617 cystine stones  358–360 dissolution 359–360 SWL  697, 732, 746 cystinuria 358–359 cystitis interstitial see interstitial cystitis/bladder pain syndrome SWL and  732

Index cystogram, positionally instilled  1788 cystography  23, 61 see also voiding cystourethrography cystolithotomy, urinary‐diversion calculi 837–839 other approaches  838–839 percutaneous 837–838 cystometry, filling  1631–1632 cystoprostatectomy, laparoscopic, with intracorporeal ileal conduit  1125–1127 cystorrhaphy, partial cystectomy  1120–1121 cystoscopes 1643 flexible see flexible cystoscopes high‐level disinfection  11 historical perspective  465 rigid 1643, 1644, 1653–1654 cystoscopy 1643–1647 advances in  42, 1646–1647 antimicrobial prophylaxis  61 benign prostatic hyperplasia  1635, 1645 bladder neck contracture  1827 bladder pain syndrome  1795–1796, 1798 bladder tumors  1117, 1646 equipment preparation  1653–1655 female genitourinary fistulas  1243 flexible 1644–1646 intravesical botulinum toxin injection  1778–1779 laparoscopic sacrocolpopexy  1237, 1239–1240 laser prostatectomy  1700 mesh complications  1886 operating room design  1649 operating tables 1650–1651 PCNL  213, 231 prostatic urethral lift procedure  1722–1723 rigid 1643–1644 robot‐assisted partial cystectomy  1118–1119, 1120 topical urethral anesthesia  1663–1664 trainers/simulators  162 TURP 1736–1737 upper tract neoplasms  569, 577 ureteral access  516–517, 523–524 ureteral reconstructive surgery  1198, 1199 urethral bulking therapy  1849 urethral strictures/stenosis  1820 cystotomy laparoscopic nephroureterectomy  1103 open prostatectomy  1269–1270 robotic partial cystectomy  1118–1119 robotic simple prostatectomy  1271 robotic vesicovaginal fistula repair  1246, 1247 cytokines renal fibrosis  136, 138 sepsis  58, 68 cytology bladder cancer  1117, 1122 intraoperative imprint, nephron‐sparing surgery 1098 renal masses  1428, 1429 upper tract neoplasms  568–569, 572 ureteroscopic samples  564, 570–571 Volume 1 pages 1–878, Volume 2 pages 879–1913

dabigatran 75 data‐acquisition systems, integrated surgical 151–153 data management  153–157, 1651 data archiving  154–155 data capture  153–154 data relay  155–157, 158 da Vinci Robotic System  954–957 dual console capability  958 EndoWrist instruments  955–957 failure  913, 958 operating room setup  911–912 optical system  954, 955 partial nephrectomy  1089, 1090–1091 patient cart  954–955 radical prostatectomy  1169 surgeon console  954, 955 TilePro video display mode  957 troubleshooting 958–959 da Vinci Single‐Site® surgical system  881 da Vinci SP (single‐port) system  881, 1369, 1370, 1381, 1389 LESS prostatectomy  1771, 1772, 1773 da Vinci S/Si Surgical System  954, 955 continent urinary diversion  1129–1130, 1131 EndoWrist instruments  956 operating room setup  905 patient positioning  907, 912, 1034, 1035 pelvic lymph node dissection  1054 retroperitoneal lymph node dissection  1069–1070, 1071, 1072 R‐LESS technique  1385 da Vinci Xi Surgical System  954, 955 continent urinary diversion  1130–1131 EndoWrist instruments  956, 957 integrated table motion  958 kidney transplantation  1262 operating room setup  905, 911–912 patient positioning  906, 907, 912, 1034 pelvic lymph node dissection  1054 retroperitoneal lymph node dissection  1070–1071, 1072 R‐LESS technique  1385 Davol drain  1017 deep venous thrombosis (DVT) perioperative anticoagulation  77 post‐radical prostatectomy  1172, 1181 deferential artery/vein  1313, 1354 deflazacort, renal colic  808 deflection, endoscope active vs. passive  502 digital flexible ureteroscopes  500, 502 flexible ureteroscopes  477, 478, 503, 509 deterioration over time  481 impact of inserted instruments  479, 482, 508 Sun’s ureterorenoscope  489, 490, 491 Deflux neurogenic bladder  1788 STING procedure for reflux  1785–1789 Denonvilliers’ fascia anatomy  1142, 1292 radical prostatectomy  1145, 1174 simple prostatectomy  1272 terminology  1141, 1142 Department of Defense (DoD)  161, 888, 889 depth perception  49

descending colon, kidney relations  90, 91 Deschamps needle  1014, 1015 desmopressin (DDAVP), renal colic  807 Desormeaux, Antoine Jean  465, 466, 466 detergent, instrument cleaning  4 detrusor acontractility  1636 holmium laser enucleation of prostate 1686 detrusor contraction duration (DCD)  1633–1634 detrusor overactivity filling cystometry  1631–1632 post‐prostatectomy 1891 urodynamic evaluation  1633, 1634, 1635 see also overactive bladder detrusor pressure (Pdet) 1632 detrusor pressure–uroflow flow study (PFS)  1633, 1640 detrusor underactivity (DU) benign prostatic hyperplasia  1635–1636, 1638 holmium laser enucleation of prostate 1686 male urethral slings and  1895 post‐prostatectomy bladder neck contracture 1826 uroflowmetry 1630, 1631 dexamethasone, postoperative pain  933 dextran copolymer, transurethral injection 1851 dextranomer/hyaluronic acid, crosslinked see Deflux Dextrus™ Access Port  995, 996, 997 diabetes mellitus post‐SWL onset  758 urolithiasis risk  843–844 diagnostic laparoscopy nonpalpable testes  1323–1324, 1345, 1346 pelvic congestion syndrome  1474 diagnostic reference levels (DRLs), radiation dose  21, 23 diagnostic ureteroscopy  562–566, 569–570 diaphragm kidney relations  88–89, 90, 409 laparoscopy‐related injuries  936, 1027, 1041–1042 diathermy see electrosurgery Diatron IV lithotripter  715 diazepam  1664 DICOM (Digital Imaging and Communication in Medicine)  1651 dietary therapy bladder pain syndrome  1797 stone disease cost effectiveness  859–861 obesity 845 urinary diversion  839–840 see also weight loss diethylene triaminepentacetic acid (DTPA) renography 127 Dietls crisis  126 diffusion‐weighted imaging (DWI) prostate cancer  1496, 1497, 1617, 1618–1619 renal masses  1394 digital flexible ureteroscopes see flexible ureteroscopes (FUR), digital

i9

i10

Index digital imaging data capture  153–154 radiation dose reduction  211 video cameras  39–40, 41 video signal formats  38–39 Digital Imaging and Communication in Medicine (DICOM)  1651 digitally reconstructed radiographs (DRRs) 1558 digital tomosynthesis (DT)  25 digital ureteroscopes see ureteroscopes, digital digital videoendoscopes  40–46, 1646 data capture  153 light sources  46–47, 153 dilators nephrostomy tract  275–276 see also balloon dilators; fascial dilators dimethyl sulfoxide (DMSO), intravesical 1798 diode lasers  1673, 1679 direct‐vision internal urethrotomy (DVIU) 1821–1823 Direx Duet lithotripter  717 dirty instrument processing facilities  10 dirty operations, antimicrobial prophylaxis 67 disinfection guidelines 11–12 high‐level (HLD)  3–4, 9–12 low‐level 4 disk kidney  462 disorders of sexual development (DSD)  1344 dissecting graspers, laparoscopic  948 dissolution, stone see chemolysis of urinary calculi distal ureter anatomy 455, 456, 604–608 laparoscopic nephroureterectomy  1102, 1103–1104 obstruction in children  1335–1336 rigid ureteroscopy  514 tumors, children  1335 vascular supply  605, 606 see also ureteral orifices distal ureteral reconstruction  1196 laparoscopic and robotic pediatric 1335–1343 basic procedure  1338–1339 bladder mobilization  1339, 1340 Boari flap  1340–1342 diagnostic evaluation  1335–1336 entry and port placement  1337–1338 patient positioning  1337 patient preparation  1337 principles 1336 psoas hitch  1339–1340 stent placement  1342 ureteroneocystotomy 1339 options  658, 1196 patient positioning  1197 trocar configuration  1198 see also ureteral reimplantation distal ureteral stones management 777–779 medical expulsive therapy  769 percutaneous antegrade ureteroscopy 297 rigid and semirigid ureteroscopy  514 Volume 1 pages 1–878, Volume 2 pages 879–1913

Sun’s ureterorenoscope  491–492 SWL  747, 748–749 distal ureteral strictures  604–625 anatomical variations  608–610 children 1335–1336 combined antegrade/retrograde approach 620–621 diagnosis 618 endoureterotomy 619–620 etiologies 615–617, 618 instruments 610–613 meatotomy 619 post‐TURP and TURBT  619 stents 613–615 treatment 618–625 follow‐up 621–622 outcomes 622–624, 625 stenting after  621 techniques 618–621 see also ureteral strictures diuresis forced Dietls crisis  126 living donor nephrectomy  1254 PCNL 66 post‐SWL  738–739, 749–750 postobstructive 134–135 diuretic renography radiation dose  23 ureteral obstruction  595–596, 1195 urinary tract obstruction  127–128 DNA fragmentation, varicocelectomy and 1358 X‐ray induced damage  17 DNA microarrays, renal cell carcinoma 1436–1437 documentation integrated data‐acquisition systems 151–153 operating room integration  1651 doors, operating room  145 Doppler ultrasonography contrast‐enhanced, targeted prostate biopsy 1607 endourologic uses  1605 robotic kidney transplantation  1266 robotic partial nephrectomy  1093, 1094 ureteral reconstruction  1200 ureteral strictures  594 urinary tract obstruction  128–129 Dornier Compact Delta II lithotripter  725 Dornier Compact Sigma lithotripter  725 Dornier Gemini lithotripter  718, 720, 725 Dornier HM1 lithotripter  713 Dornier HM3 lithotripter  694, 714 coupling  692, 717 development 713 performance 722 shock‐wave source  714 tissue injury  706 Dornier Lightguide 200 laser fiber  508 dorsal lithotomy position see lithotomy position dorsal vein complex (DVC) laparoscopic radical prostatectomy  1145, 1146, 1148 robotic radical cystectomy  1110

robotic radical prostatectomy  1174, 1182 terminology  1141 dose area product (DAP)  15 double‐dye tampon test  1243, 1244 double HIT method, periureteral Deflux injection 1785–1786 double‐pigtail stents see ureteral stents, double pigtail double ring stands  1657 doxazosin, renal colic  807 drainage, postoperative  1016–1018 inguinal lymphadenectomy  1064 partial cystectomy  1121–1122 procedures 1018 robotic kidney transplantation  1266 systems available  1017–1018 drapes, surgical  1652–1653 PCNL  176, 177, 187–188 drop test  975–976 drug‐coated ureteral stents  613, 646, 868–869 drug‐eluting stents (DES) coronary  77, 79 ureteral  613, 868–869, 873, 874 DTPA (99mTc‐diethylene triaminepentacetic acid) renography  127 dual‐energy computed tomography (DECT)  18–19, 1394, 1400 dual‐pulse shock‐wave lithotripsy  717 duodenal injury, PCNL  394–395, 423–424 DUR‐8 Elite ureteroscope  477, 477, 478, 479, 510 DUR‐8 Ultra ureteroscope  477, 479 Durant maneuver, air embolism  1023 Durasphere (carbon‐coated zirconium beads) 1850 DUR‐D Invisio ureteroscope  477, 477, 479, 502 comparative studies  481, 499, 503, 510 disadvantages  497, 503–504 dusting, stone see stone dusting DVD recordings  157 Dyna‐CT‐guided renal access see Uro Dyna‐CT‐guided renal access dynamic contrast‐enhanced (DCE) magnetic resonance imaging HIFU follow‐up  1576 prostate cancer  1496, 1497, 1617, 1620–1621 dynamic squeezing, stone comminution 699, 702 dyspareunia, after mesh prolapse repair  1882, 1886–1887 EAU see European Association of Urology E‐BLUS (European Basic Laparoscopic Urological Skills)  891, 898 E‐cadherin 137 echinococcal disease, seminal vesicles  1292 ECIRS see endoscopic combined intrarenal surgery economic costs see costs, economic ectopic kidneys (renal ectopia) crossed fused  461–462 stone management  818–822 laparoscopic pyelolithotomy  821–822 nephrolithotomy 822 open surgery  822

Index PCNL  240, 820–821 SWL  739, 740, 819 ureteroscopy 819–820 UPJ obstruction  822–823 see also pelvic kidneys; transplant kidneys ectopic ureters  460–461 edoxaban 75 EDTA (ethylene‐diamine‐tetraacetic acid), stone dissolution  361 effectiveness quotient (EQ)  721–722 ejaculatory ducts anatomy 1292 laparoscopic seminal vesicle surgery 1296 transurethral resection  1294 elastography contrast‐enhanced ultrasound with  1608 prostate cancer  1586, 1587 elderly patients laparoscopic surgery  937 midurethral slings  1860–1861 radiofrequency ablation of renal tumors 1449 SWL 748 electrical impedance needle sensor  271 electrocautery see electrosurgery electroconductive shock‐wave generation 714–715 electrohydraulic lithotripsy (EHL) percutaneous intracorporeal  322–323 children 337 complications 323 mechanism of action  322, 323 pregnancy 793 ureteroscopic intracorporeal  532–533 mechanism of action  508, 532, 533 pros and cons  532–533, 539 technical tips  533 see also shock‐wave lithotripsy electrohydraulic (EH) lithotripters  692, 696 clinical use  708 disadvantages 723 shock‐wave focusing  693, 695 shock‐wave generation  692–693, 714–715 shock‐wave profile and distribution 693–695 electromagnetic cylinder source with parabolic reflector (Storz)  715 electromagnetic (EM) lithotripters  692, 696 clinical use  708 new acoustic lens design  706–707 shock‐wave focusing  693, 695 shock‐wave generation  693, 715 shock‐wave profile and distribution 693–695 electromagnetic shock‐wave emitter (EMSE) 715 electromagnetic tracking systems fusion biopsy of prostate  1502 percutaneous renal access  246, 247–248, 249, 252–253 prostate radiotherapy  1562–1564 electromyographic (EMG) biofeedback 1188–1189 Electronic Data Generation for Evaluation (EDGE) simulator  895 electronic medical records (EMR)  1651 Volume 1 pages 1–878, Volume 2 pages 879–1913

electrosurgery (diathermy)  1657–1658 blended waveform  1735 calyceal diverticular cavity  345 coagulation waveform  1735 current waveforms  1734–1735 cutting waveform  1734–1735 en bloc resection of bladder tumors  1807, 1808 endoureterotomy  619–620, 632, 635, 636 EndoWrist robotic instruments  956 history 1733 Hunner’s lesions  1799, 1800 PCNL tract bleeding  402, 435, 437 percutaneous tumor resection  386–387 radical prostatectomy  1186 renal cysts  349 retrograde endopyelotomy  586, 588 robotic partial nephrectomy  1094 spray coagulation waveform  1735 TURP 1733–1734 upper tract tumors  573 see also bipolar electrosurgery; monopolar electrosurgery Embosphere microspheres  1489, 1492 embryo, radiation exposure  29 emergency department (ED) triage, renal colic 804–806 emphysema, subcutaneous  921, 1023 empyema  414, 415 management 418 en bloc resection of bladder tumors see transurethral resection of bladder tumor (TURBT), en bloc encirclement resection technique, TURP 1737 ENDOALPHA™ integrated surgical system (Olympus) 152–153 Endobag™  1011 endoburst technique, UPJ obstruction 380–381 EndoCAMeleon 1368, 1369 EndoCAMeleon telescope  45, 47 Endo Catch™  1011 Endo Close™ 1014–1015 Endocone device  1362–1363, 1365, 1374 Endoeye Flex digital laparoscope (Olympus) 947 imaging technology  45, 47 LESS surgery  1368, 1369, 1763 EndoEye semirigid ureteroscope (Olympus) 471, 472 Endo‐FMS Urology irrigation/suction system 511 Endo GIA™ stapler device  970, 971 endoluminal ultrasound upper tract tumor staging  571 ureteral obstruction  596 endometriosis, ureteral obstruction  617 Endo‐Paddle™ retractor  949 endopelvic fascia incision, radical prostatectomy  1145, 1146, 1147, 1174 pubovaginal slings  1874, 1876 radical cystectomy  1109 retropubic robotic simple prostatectomy 1273 sparing, radical prostatectomy  1183 terminology  1141, 1142 endoplasmic reticulum (ER) stress  136, 137

Endopouch™ retriever  1011 endopyeloplasty 379 see also pyeloplasty endopyelotomy antegrade  377–379, 590 indications 382 invagination technique  379 outcomes 381–382 pelvic kidneys  822 retrograde  379–381, 584–590 clinical use  589, 590 complications 589 electrocautery 588 history 584–585 holmium:YAG laser  587–588 operative technique  379–381, 586–587 patient preparation  586 patient selection  585–586 postoperative care  588–589 results 589 see also Acucise® endopyelotomy endopyelotomy‐endoureterotomy stents chemolysis of struvite stones  354–355, 356 distal ureteral strictures  614, 615 retrograde endopyelotomy  587–588 ureteropelvic junction obstruction  379 endorectal probes, HIFU  1569–1570, 1572 endoscope protection system (EPS)  498, 504 endoscopes cleaning 5–6 data capture  153 high‐level disinfection  9–12 history 465–467 leak tests  5 precleaning 6 sterilization see sterilization storage 10 see also cystoscopes; laparoscopes; nephroscopes; ureteroscopes endoscopic combined intrarenal surgery (ECIRS)  175, 177–181 endoscopic intussusception method, nephroureterectomy 1104 endoscopic pluck method, nephroureterectomy 1103–1104, 1105 endoscopic subcutaneous modified inguinal lymph node dissection (ESMIL) 1060–1065 endoscopy‐guided percutaneous renal access see percutaneous nephrolithotomy (PCNL), endoscopic guidance Endo Stitch™ device  965–966 endotoxins, renal stones  66 endotracheal intubation, laparoscopic surgery 929 endotracheal tubes laparoscopic surgery  929 prone position  202, 213–214 endoureterotomes 613, 614 endoureterotomy complications 638 distal ureteral strictures  619–620, 624, 625 mid‐ureteral strictures  598–599 ureteroenteric strictures  631–633, 635–637

i11

i12

Index endoureterotomy scissors  611, 612 endourethroplasty 1829 endourology origin of term  159 training see training, endourology EndoWrist robotic instruments  955–957 endstage renal disease (ESRD) costs of treatment  827 kidney transplantation  1259, 1261 live kidney donor risks  1250 stone‐promoting factors  828 energy intake, stone risk and  844 energy sources, endourology  1657–1659 enhanced recovery programs (ERPs) 931–932 laparoscopic/robotic continent urinary diversion 1135 robot‐assisted radical cystectomy  1111 Enseal® bipolar device  950 entrapment devices, laparoscopic  952, 1010–1011 epidermal growth factor (EGF)  1795 epididymis anatomy 1313–1314 post‐vasectomy dilation  1314 epidural anesthesia  929 epigastric vessels anatomy 973, 974 perioperative injury  1024 epinephrine, local anesthesia  1662 epithelial‐mesenchymal transition (EMT), renal tubules  136, 137 Epix inline angled dissector  1367 erbium:YAG (Er:YAG) laser lithotripsy 538–539 principles 1673 erectile function postoperative HIFU of prostate  1577 internal urethrotomy  1822 laser prostatectomy  1713 prostate cryoablation  1584, 1585–1586, 1598, 1599 TURP 1741 post‐radical prostatectomy  1158, 1171, 1182–1183 interventions  1187–1188, 1189 see also laparoscopic radical prostatectomy (LRP), nerve sparing preoperative evaluation  1180 prostatic urethral lift procedure and  1721, 1724 ergonomics classical retrograde intrarenal surgery 681–682, 683 laparoscopic radical prostatectomy  1159, 1160 operating room  48 patient positioning and  907 robot‐assisted retrograde intrarenal surgery  679, 680, 682 erythropoietin (EPO)  1188 Escape nitinol stone basket  509 Escherichia coli  58, 60 estrogen therapy  1245, 1872 ESWL (extracorporeal shock‐wave lithotripsy) see shock‐wave lithotripsy

Volume 1 pages 1–878, Volume 2 pages 879–1913

ethanol embolization, horseshoe kidney  1482 intraprostatic injections  1729–1730 Ethicon Prolene® hernia system  1307 ETHOS™ platform  1160 ethylene‐diamine‐tetraacetic acid (EDTA), stone dissolution  361 ethylene oxide (ETO)  3, 7 European Association for Research and Treatment of Cancer (EORTC)/ Radiation Therapy Oncology Group (RTOG) radiation morbidity criteria 1555, 1556 European Association of Urology (EAU) antibiotic prophylaxis  57, 61, 62, 63, 663 BPH therapy  1744 laparoscopic and robotic surgery training  888, 891 pelvic lymphadenectomy  1049, 1050 prevention of urological infections  58–59 radiofrequency ablation of renal tumors 1443 renal stone management  549–550, 551 single‐incision slings  1833, 1835 testicular germ cell tumors  1066 European Basic Laparoscopic Urological Skills (E‐BLUS)  891, 898 European Robotic Urology Section (ERUS) 893 European School of Urology (ESU), laparoscopic and robotic surgery training 892 excretory urography, urinary tract obstruction 126 exit strategies laparoscopic see laparoscopic exit PCNL 427–437 children 337–338 staghorn calculi  317–318 external beam radiotherapy (EBRT), prostate cancer  1534, 1550–1564 biochemical failure criteria  1553 brachytherapy with  1541, 1543–1544, 1553, 1554 dose escalation  1553–1554 electromagnetic field tracking  1562–1564 focal 1514 grading toxic events  1555–1557 image guidance methods  1560–1561 patient selection  1552–1553 post‐prostatectomy 1553 results 1553–1554 salvage therapy after  1540–1541, 1574–1576, 1581–1582 toxicity profile  1554–1555 treatment delivery  1560 treatment planning  1557–1560 whole‐pelvis, high‐risk disease  1554 external iliac artery pelvic lymph node dissection  1055, 1056 robotic kidney transplantation  1265, 1266 external iliac vein pelvic lymph node dissection  1053, 1056 robotic kidney transplantation  1264–1265 external oblique muscle  265 extinction length, laser beam  1675, 1694 extracorporeal assist devices, laparoscopic surgery 948

extracorporeal shock‐wave lithotripsy (ESWL) see shock‐wave lithotripsy extraperitoneal pelvic surgery  990–992 disadvantages 991 exit 992 inguinal hernia repair  1307, 1308–1310 laparoscopic radical prostatectomy 1143–1144, 1145 LESS surgery  1366 patient positioning  991 patient selection  990–991 pelvic lymphadenectomy  991, 1173 robotic radical prostatectomy  1172, 1173–1174 robotic simple prostatectomy  1271 trocar placement  991–992 ex vivo biopsy, renal masses  1431–1432 ex vivo ureteroscopy  830–831 eye injuries iatrogenic see ocular complications laser‐induced 1658–1659 eyepiece designs rigid ureteroscopes  468, 469 semirigid ureteroscopes  470, 472 Sun’s ureterorenoscope  487–488 eye protection, lasers  1658–1659 EZ Glider (Olympus)  506 factor Xa  74, 75 fascia, periprostatic  1141, 1142 fascia lata inguinal lymph node dissection  1064 pubovaginal slings  1872–1873 fascial closure, port site see port site, fascial closure fascial dilators PCNL  191, 275, 276 ureteral strictures  612, 619, 620 fascial incision needle  217 fat pararenal 87, 89 perirenal 87, 89 adrenalectomy 1285 periureteral endopyelotomy 587 endoureterotomy 632 perivesical, bladder neck incision  1828 renal tumors containing  1402, 1403, 1404, 1406 visceral, SWL outcome and  846 FDA see Food and Drug Administration fecal incontinence, sacral nerve stimulation 1904 females genitourinary fistulas  1242–1248 robot‐assisted radical cystectomy  1110–1111 SWL safety  748, 758 urinary continence mechanisms  1832, 1855, 1871 femoral nerve injury  1653 femoral vein approach, gonadal vein  1467, 1468 fertility evaluation, vasectomy reversal  1314 SWL and  748, 758 varicocele and  1353, 1357 fetus, radiation exposure  29, 788

Index fever after BCG immunotherapy  366 post‐PCNL, children  338 fiber‐optics 465–466 flexible ureteroscopes  475–476 semirigid ureteroscopes  468, 470, 471 Sun’s flexible‐tipped ureterorenoscope  487, 490 fibrinolytic therapy, empyema  418 fibrin sealants laparoscopic surgery  951 nephrostomy tract  435, 437 fibroblast‐specific protein‐1 (FSP‐1)  137 fibroepithelial polyps (FEPs) ureteroscopic diagnosis  564, 570 ureteroscopic therapy  579 fidelity, simulation devices  161 fiducial markers, prostate radiotherapy 1560 field of view rigid ureteroscopes  468 semirigid ureteroscopes  472 Sun’s ureterorenoscope  487–488 filling cystometry  1631–1632 fine needle aspiration (FNA), renal masses 1428–1431 Firefly Fluorescence Imaging system  957 fistulas, female genitourinary see genitourinary fistulas, female 532nm high‐power lasers see high‐power 532nm lasers flank pain diagnostic imaging  129, 800–802 differential diagnosis  802–803 postureteroscopy  644, 648 pregnancy 787 renal colic  798 stent syndrome  865 urinary tract obstruction  124, 126 flank position laparoscopic renal surgery  905 preventing complications  1023–1024, 1034–1035 retroperitoneal lymph node dissection 1067, 1068 retroperitoneal renal/adrenal access  988, 989 ureteral reconstruction  1196–1197 ureteroenteric strictures  630 see also lateral‐flexed position; lateral position flash sterilization  8–9 flat‐panel detectors (FPD), SWL  719, 723 flexible cystoscopes digital  41–42, 1646 fiber‐optic 1644–1645 nephroscopy  286, 287 reprocessing 11 urinary‐diversion calculi  837, 838 flexible cystoscopy  1644–1646 procedures 1645 robot‐assisted partial cystectomy 1118–1119, 1120 technique 1645–1646 ureteral access for ureteroscopy  524 flexible endoscopes digital 41–46

Volume 1 pages 1–878, Volume 2 pages 879–1913

high‐level disinfection  9 laparoscopy 947 leak tests  5 see also deflection, endoscope flexible laparoscopes  45, 47, 947 flexible nephroscopes  286–287 flexible nephroscopy children 335–336 indications 286, 287 retrograde flexible ureteroscopy with 178, 181 second look (SLFN)  446–448 staghorn calculi  317, 318–319 stone fragmentation and extraction 290–291 tips and tricks  291–292 flexible‐tipped ureterorenoscope, Sun’s see Sun’s flexible‐tipped ureterorenoscope flexible ureteroscopes (FUR)  475–484 Avicenna robot system  676–677, 678 comparative studies  482–483 components 475 currently available  477, 479–480, 509–510 diagnostic ureteroscopy  563, 564, 569 digital  476–478, 497–504, 510 care and maintenance  502–504 currently available  477, 479–481, 500 diagnostic ureteroscopy  563 disposable 499, 500, 501 durability  481, 497–499, 502–504, 510 fiber‐optic ureteroscopes vs.  482–483, 497, 498, 499 illumination 502 imaging technology  42–44, 45, 46, 501–502 renal stones  549 reusable 497–499, 500 setup 499–501 stone management  544 technical features  499–502 disposable  483, 499, 510 durability  481–482, 510 Avicenna robot system  681, 683 intraoperative failure  655 fiber‐optic  475–476, 501, 510 damaged optic fibers  476, 503 digital scopes vs.  482–483, 497, 498, 499 disposable 510 durability 510 renal stones  549 flexion and deflection  478 future directions  483 history of development  475, 549 irrigation systems  478–479, 510–511 limitations 481 maintenance 481–482 nephroscopy 286–287 optics and illumination  475–476 working channels  478–479 flexible ureteroscopy (fURS) diagnostic  564, 569 operating room setup  522 preoperative evaluation  521–522 renal stones  549–559 apnea during lithotripsy  558

calyceal diverticula  556–558 complications 559 contraindications 551 indications 549–550, 551 lithotripsy and extraction  552–555 lower pole stones  555–556 outcomes 558–559 techniques 551–558 upper tract access  551–552 ureteral stenting  558 rigid and semirigid ureteroscopy vs.  514 robotic see Avicenna Roboflex ureteral access  521–530 difficult 524–527 equipment 522 prior ureteral stenting  527 prior urinary diversion  527 standard procedure  522–524 ureteral access sheaths see ureteral access sheaths ureteral stones  543–544, 545 wireless 526 see also ureteroscopy Flex robot  882–883 Flexvision U‐500 flexible ureteroscope (Stryker) 510 Flex‐X2 flexible ureteroscope (Karl Storz) 480 comparative studies  482, 503 Flex‐Xc digital flexible ureteroscope (Karl Storz)  480, 497, 498 comparative studies  482, 499, 510 imaging technology  42, 43–44 nephroscopy 286–287 technical details  500 Flexxiva® laser fiber (Boston Scientific) 508 flight simulators  888, 889 Flo‐Assist irrigator  516 flooring, operating room  144 FLS (Fundamentals of Laparoscopic Surgery)  891, 892, 897–898 fluconazole 368 fluid management laparoscopic and robotic surgery  930 renal colic  806 FluidSmart® irrigation system  511 fluorescein, intravenous  654 fluorescence cystoscopy  42, 44 fluorescence imaging  957 see also near‐infrared fluorescence fluorescence in situ hybridization (FISH), upper tract urothelial carcinoma 569 fluorescent lamps  145 fluoroscopy CT  222, 223 data archiving  155 diagnostic ureteroscopy  569 occupational radiation exposure  20 PCNL see under percutaneous nephrolithotomy percutaneous antegrade ureteroscopy 296 percutaneous nephrostomy see under percutaneous renal access pregnant women  29–30 pulsed  27, 211

i13

i14

Index fluoroscopy (cont’d) radiation dose reduction  21, 25–27, 29 radiation exposure  19–20 robotic‐assisted retrograde intrarenal surgery  677–678, 680–681 SWL  718, 723 thoracic complications  415 ureteroscopy  516, 522 fluoroscopy time (FT) minimizing  21, 26, 27 predictors of prolonged  20 focal laser ablation (FLA) of prostate cancer  1512, 1523–1531 contrast‐enhanced ultrasound  1607 indications 1524 MRI changes after  1529–1531 MRI‐guided 1525–1526, 1527 MRI‐ultrasound fusion‐ guided 1526–1528 outcomes  1517, 1528–1531 post‐radical prostatectomy  1531 principle 1523 prostate tissue effects  1528, 1529 technology 1523–1524 temperature monitoring  1524–1525 Foley catheters Boari flap  1342 PCNL  213, 218, 231 percutaneous antegrade endopyelotomy 379 postoperative holmium laser enucleation of prostate 1686 partial cystectomy  1121–1122, 1123 retrograde endopyelotomy  588 robotic radical prostatectomy  1173, 1174, 1175, 1181 robotic simple prostatectomy  1273 robotic vesicovaginal fistula repair  1245 follicle‐stimulating hormone (FSH), serum 1314 Food and Drug Administration (FDA) instrument care and sterilization  8, 9 mesh complications  1856, 1880–1881 single‐incision slings (SIS)  1833–1835 forced diuresis see diuresis, forced foreign bodies, cystoscopic removal  1645 formalin 3 fossa navicularis  1815, 1816, 1817 fossa of Marseilles  1053 4K ultra‐high‐definition (UHD) digital imaging systems  45–46, 948, 1160 four‐field box technique, radiotherapy planning 1557–1558 Fowler–Stephens orchiopexy  1348–1349, 1350 fracture mechanics  698–699, 701 Fraley’s syndrome  346 frequency‐doubled double pulse neodymium:YAG (FREDDY) laser 537 frozen sections, intraoperative nephron‐sparing surgery  1098 partial cystectomy  1116, 1120, 1121 radical prostatectomy  1183 retroperitoneal lymph node dissection 1073 fructose intake, stone risk and  844 fume hoods  10, 11 Volume 1 pages 1–878, Volume 2 pages 879–1913

functional residual capacity (FRC)  202, 1324 Fundamental Inanimate Robotic Skills Tasks (FIRST) 892 Fundamentals of Laparoscopic Surgery (FLS)  891, 892, 897–898 fundamentals of robotic surgery (FRS) 892 fungal balls, upper tract  368, 369 fungal infections, urinary  361, 367–370 furosemide diuretic renography  127–128, 595–596 percutaneous renal surgery  66 gabapentin, postoperative pain  933 gadolinium‐based contrast agents pregnancy 790 renal function and  1394–1395 Galdakao‐modified supine Valdivia (GMSV) position 175–177 gallbladder injury, PCNL  199–201, 394, 424 gas embolism  921–922, 1033 management  934, 1023 gasless laparoscopy  922 gas plasma sterilization  8 gastrointestinal complications radiation therapy  1554–1556 SWL 758 gastrointestinal disorders, renal colic vs. 803 gauze jacket, graft kidney  1263, 1266 gelatin‐based sealants laparoscopic surgery  951 nephrostomy tract  402, 435–437 GelPOINT Mini port  1362–1363, 1364–1365 GelPOINT® port  1362, 1364–1365, 1374 living donor nephrectomy  1256 robotic kidney transplantation  1260, 1261–1262 Gelport®  952, 995–996 GelSeal® cap  1261–1262 gemcitabine, upper tract instillation  367 gene delivery, ultrasound microbubbles 1611 general anesthesia flexible ureteroscopy  551 laparoscopic and robotic surgery  929 prone position  202 supine position  174 GeniStrong  1011 genitofemoral nerve pelvic lymph node dissection  1053, 1056 ureteral relations  592, 593 genitourinary fistulas, female  1242–1248 clinical presentation  1242–1243 diagnosis and evaluation  1243, 1244 goals of surgery  1244 incidence and prevalence  1242 indications for transabdominal repair 1243 laparoscopic and robotic repair 1244–1248 nonsurgical management  1243–1244 optimization for surgery  1245 postoperative care  1248 preoperative preparation  1245

robot‐assisted laparoscopic repair 1245–1248 surgical approaches  1244–1245 timing of surgery  1244 see also vesicovaginal fistulas genitourinary toxicity, prostatic radiotherapy  1544, 1555–1556 gentamicin resistance  60 Gerota’s fascia (renal fascia) anatomy 87–88, 89 laparoscopic adrenalectomy  1284, 1285 ureteral reconstruction  1200 Gibson incision laparoscopic nephroureterectomy  1103 laparoscopic specimen extraction  1012 Gil‐Vernet trigonoplasty  608, 1247 glaucoma 931 Glenn‐Anderson(‐O’Donnell‐Puri) ureteral implantation technique  518, 608 Glidewire (Boston Scientific)  506 glomerular filtration rate (GFR) ureteral obstruction bilateral  131–133, 134 role of fibrosis  135 unilateral 130–131 see also renal function glomerulations, bladder mucosa  1795, 1798, 1799 glove technique, LESS surgery  1361–1364 glue embolization gonadal vein  1470–1472 renal artery  1482 glutaraldehyde 9 glycosaminoglycan (GAG) layer, bladder epithelium  1794, 1797 goblet sign  459 GOLIATH trial  1698–1699, 1703 gonadal vein catheterization 1467, 1468 collateral vessels  1466, 1467–1468, 1469 embolization 1464–1477 pelvic congestion syndrome 1473–1477 varicocele 1464–1473 living donor nephrectomy  1252, 1253 radical nephrectomy  1080 venography 1467–1470 gonorrhea, urethral strictures  1817 Goodwin, William  210, 229 Gore™ Suture Passer  1015 goserelin 1554 granulomas, upper tract, after BCG immunotherapy 366 graspers EndoWrist robotic  956 laparoscopic 948 see also stone forceps/graspers Graspit stone retrieval device  509 Grays (Gy)  14 GreenLight HPS 120W laser  1697, 1698, 1701 GreenLight XPS 180W laser  1698–1699, 1701 Greenwald needle  611 groin pain, after midurethral sling surgery 1864 gross intraoperative evaluation (GIE), nephron‐sparing surgery specimens 1098

Index guidewires flank to meatus through‐and‐through  217–218 children 335 endoscopically‐guided placement  178–181, 232 supine position  174 percutaneous intrarenal  216, 217, 266–267 antegrade endopyelotomy  378 calyceal diverticula  344–345, 346 children  334, 335 complications  281, 392–393 flexible nephroscopy  292 multiple tracts  316 staghorn calculi  314, 315, 318 ureteroenteric strictures  630–631 ureteral diagnostic ureteroscopy  563–564, 569 difficult passage  524–525, 655 distal ureteral strictures  610–611 flexible ureteroscopy  523–524, 551 PCNL  213, 231 rigid and semirigid ureteroscopy  515–516, 517 stone management  545 tip‐flexible ureterorenoscopy  492, 493 ureteral access sheaths  528 ureteroscopy 506–507 Guy’s stone score (GSS)  109, 110–112 comparative assessment  113–120 review of literature  114–115 strengths and weaknesses  111–112 gynecological disorders, renal colic vs. 803 gynecological malignancy distal ureteral obstruction  609–610 stenting of ureteral obstruction  597–598, 869 gynecological surgery distal ureteral strictures after  609, 610, 616 mid‐ureteral strictures after  593 hair removal, preoperative  1652 half knot  963 hammock theory, urinary continence  1855, 1871 hand‐assisted laparoscopic surgery (HALS) 994–1004 adjuncts 997 devices  952, 995–996, 997 placement 998, 999 history 994–995 living donor nephrectomy  1000, 1001, 1256 pros and cons  1003 radical nephrectomy see under radical nephrectomy results 1000–1003 techniques 997–998 tips and tricks  998–1000 usefulness 1003–1004 handouts, patient  1659–1660 HandPort 995 hands‐on training (HoT)  888 modular 891–893 Harmonic Synergy® scalpel  950 Volume 1 pages 1–878, Volume 2 pages 879–1913

HAS‐BLED score  77 Hasson (open entry) technique, laparoscopic access  944, 976 advantages 1022 radical nephrectomy  1078 Hasson trocars  945, 991 head, prone position  187 healthcare‐associated infections  9, 57 heart valves, mechanical  77, 78, 78 heat sink effects  1444 Heilbronn technique, laparoscopic radical prostatectomy 1145, 1147 Heineke–Mikylicz repair, pediatric laparoscopic pyeloplasty  1331 helium pneumoperitoneum  918, 945 hematologic tests, renal colic  799–800 hematoma post‐SWL  757, 758 see also perinephric hematoma; renal hematoma hematospermia, after HIFU of prostate 1577 hematuria bilateral upper tract  563 bladder cancer  1117 diagnostic ureteroscopy  562, 566 flexible cystoscopy  1645 post‐PCNL 402–403, 405 post‐SWL 756 renal colic  799 hemiacidrin (renacidin)  361, 362, 840 hemiresection, transurethral prostatic 1738–1739 hemodynamic effects patient positioning  202, 204, 918 pneumoperitoneum  919–920, 930 hemoglobin laser energy absorption  1694 post‐PCNL decrease  306, 338 Hem‐o‐Lok™ clips  967, 968 complications  968, 1827 contraindications  968, 1254 principles of application  969 robotic surgery  956–957, 968 tissue reaction  970 hemorrhage see bleeding/hemorrhage hemorrhagic shock, PCNL  400 hemostasis EndoWrist robotic instruments  956 intraoperative techniques  1037–1039 laparoscopic surgery  949–951 laser prostatectomy  1685, 1702 minimally invasive surgery  960, 961 robotic partial nephrectomy  1094, 1095 robotic simple prostatectomy  1272, 1273, 1275 single‐port transvesical enucleation of prostate 1767 TURP  1738, 1746 hemostatic agents laparoscopic surgery  950–951 nephrostomy tract  401–402, 435–437 hemothorax  261, 413–414 diagnosis 416 management 418 radiofrequency ablation of renal tumors 1447 risk factors  412 Hemovac 1017

heparin 73–74 ‐coated ureteral stents  868–869 living donor nephrectomy  1254 perioperative use  79–80 heparin‐binding epidermal growth factor‐ like growth factor (HB‐EGF)  1795 hepatic hematomas, post‐SWL  758 hereditary nonpolyposis colorectal cancer (HNPCC) 578–579 hereditary papillary renal cancer  1407, 1408 hernias, abdominal wall  1299–1311 incisional see incisional hernias inguinal 1306–1309 laparoscopic repair  1299, 1302–1311 parastomal 1309–1311 port site see port‐site hernias technical principles  1299–1302 ventral 1302–1306 hexa‐aminolaevulinic acid (5‐ALA)  42, 566 hidden incision endoscopic surgery (HIdES), pediatric robotic pyeloplasty  1331 HIFU see high‐intensity focused ultrasound high‐definition (HD) video systems  42, 44–45, 146, 1159–1160 high‐intensity focused ultrasound (HIFU) of prostate 1567–1577 complications  1575, 1576–1577 contrast‐enhanced ultrasound  1607 focal therapy  1512, 1516, 1574, 1575 indications 1570 mechanism of action  1568 postoperative follow‐up  1576 procedure 1570–1574 salvage therapy  1574–1576 treatment devices  1569–1570 high‐level disinfection (HLD)  3–4, 9–12 high‐power 532nm lasers  1693–1703 60W systems  1694–1695 80W systems  1695–1697 120W systems  1697 180W systems  1679, 1698–1699 history of evolution  1678–1679, 1694–1699 physics  1678, 1693 prostatectomy see laser prostatectomy, 532nm high‐power lasers tissue interactions  1678, 1694 see also GreenLight HPS 120W laser; GreenLight XPS 180W laser; KTP lasers; lithium triborate lasers; MoXy™ Fiber hilar kidney region see mid kidney region hilum of kidney see renal hilum HiQ LS handles and instruments  1366, 1367 histamine H1 and H2 antagonists, bladder pain syndrome  1797 HIT method, periureteral Deflux injection 1785 hockey‐stick‐type ablation of prostate 1512, 1514 holmium laser ablation of prostate (HoLAP)  1676–1677, 1682–1684 holmium laser enucleation of prostate (HoLEP) 1685–1690 bipolar vaporization of prostate vs.  1758 cost efficacy  1690 durability 1688, 1689, 1689 efficacy 1687, 1688

i15

i16

Index holmium laser enucleation of prostate (HoLEP) (cont’d) functional outcomes  1686–1687 lasers 1676–1677 learning curve  1688–1690 mechanism of action  1674 postoperative care  1686 safety 1686 technique 1685–1686 thulium laser vasoenucleation and  1710, 1711–1712 holmium laser resection of prostate (HoLRP)  1676–1677, 1684–1685 holmium laser transurethral incision of prostate (HoL‐TUIP)  1676–1677, 1682 holmium:YAG laser BPH therapy  1681–1690, 1727 equipment and instruments  1682, 1683 history and evolution  1681 techniques  1676–1677, 1682–1690 en bloc resection of bladder tumors  1808, 1809, 1812 endoureterotomy distal ureteral strictures  612, 624, 625 mid‐ureteral strictures  599 ureteroenteric strictures  633, 635, 636 hazards 1659 incision of bladder neck contracture 1828 infundibular stenosis  347 physics  1673, 1676, 1681–1682 prostate tissue interaction  1676 retrograde endopyelotomy  380, 586, 587–588 steam bubbles  1674, 1675 upper tract urothelial carcinoma  387, 566, 573–574 urethrotomy 1823 holmium:YAG laser lithotripsy  537–538 Avicenna robot system  678 PCNL 324–325 children 337 distal ureteral stones  297 flexible nephroscopy  290 pregnancy 792–793 ureteral injuries  617, 661 ureteroscopy  508, 537–539 laser parameters  552–554 renal stones  552–554 Sun’s ureterorenoscope  487, 492, 494 techniques 538–539 ureteral stones  545 ureteroscope design  471 homemade devices laparoscopic specimen retrieval  1011 LESS ports  1361–1364 Hopkins, Harold  466 Hopkinson effect  717 horseshoe kidney angiography and embolization 1481–1482, 1484 blood supply  812, 813, 1481 classification 811, 812 development  811, 1481 stone management  812–816 laparoscopic 815–816 PCNL  199, 813–815, 816

Volume 1 pages 1–878, Volume 2 pages 879–1913

SWL  739, 813 ureteroscopy 815 ureteral anatomy  461, 811 urolithiasis 812–813 hospital‐acquired infections  9, 57 hospital information management systems (HIMS)  151, 153–154 hospitalization, renal colic  805 hospital stay laparoscopic radical prostatectomy  1151 miniaturized PCNL  306, 307 robot‐assisted radical prostatectomy 1170 robotic simple prostatectomy  1274 Hot Shears™ 956 hot‐wire balloon endopyelotomy see Acucise® endopyelotomy Hounsfield density renal masses  1394 renal stones  734–735 choice of therapy and  780 S.T.O.N.E. score  110 stone composition and  129, 802 ureteral stones  745, 746 Huffman ureteroscope  467 Hunner’s lesions diagnosis 1792, 1793, 1798 management  1799, 1800, 1801 hyaluronic acid intravesical, bladder pain syndrome  1799 transperineal injection, prostate brachytherapy 1543 hydatid cysts, seminal vesicles  1292 hydration status living donor nephrectomy  1254 spontaneous stone passage and  770 hydration therapy, renal colic  806 hydrocalyx, infundibular stenosis  347 hydrocele, post‐varicocelectomy  1356, 1357, 1368 hydrochlorthiazide, stone fragment clearance 448 hydrocodone/acetaminophen  1664 hydrodissection cryoablation 1457 radiofrequency ablation  1444, 1447–1448 hydrodistention bladder pain syndrome  1795–1796, 1798–1799, 1800 grading system, vesicoureteral reflux 1786, 1787 STING procedure for reflux  1785 hydrogen peroxide gas plasma sterilization  8 high‐level disinfection  9, 11 hydronephrosis asymptomatic renal stones  768 cost‐effective management  855 diagnostic imaging  127 gestational 786 infectious complications  66 PCNL for staghorn calculi  314 pelvic kidneys  818 postpyeloplasty follow‐up  1331 postureteroscopy  648, 662 S.T.O.N.E. score  109 SWL  740, 746

UPJ obstruction  378 upper tract urothelial carcinoma  385 ureteral stones  769 hydrothorax  394, 412 diagnosis 415–416 etiology and risk factors  410–412 management  259, 417, 419 supracostal access  260, 261 hydroxyzine, bladder pain syndrome  1797 hyoscyamine  1664 hypercalciuria, urinary diversion patients 836 hypercarbia, laparoscopy‐associated children 1324 patient selection and  909, 918 physiology  919, 920, 931, 1033 hypercoagulable states  77 hyperinsulinemia, urolithiasis and  843–844 hyperoxaluria after bariatric surgery  845 kidney transplant recipients  828 urinary diversion patients  837, 839–840 hyperparathyroidism, tertiary  828 hypertension, and SWL  732, 758–759 hyperuricemia, renal transplant recipients 828 hypocitraturia kidney transplant recipients  828 obesity 844 urinary diversion patients  836, 839 hyponatremia, dilutional bipolar TURP  1747, 1748 monopolar TURP  1489, 1657, 1740, 1743 see also transurethral resection (TUR) syndrome hypospadias, cryptorchidism with  1344 hypothermia regional therapeutic radical prostatectomy  1186 robotic kidney transplantation  1260–1261, 1263, 1264 systemic during anesthesia  929 during PCNL  399 pediatric patients  333, 1324 hysterectomy midurethral slings with  1861–1862 ureteral strictures  593, 609, 610, 616 ibuprofen, stone passage and  543 idarucizumab 75 IDEAL EYES HD laparoscope  1368 IDEAL guidelines, robotic kidney transplantation 1260 ileal conduit urinary diversion laparoscopic and robotic intracorporeal  1125–1127, 1128 marionette technique  1126 technique 1126–1127 parastomal hernia  1309–1310 stone formation  836 trocar placement  982 ureteral access for ureteroscopy  518 ureteroenteric strictures  630, 631 see also urinary diversion surgery ileocolonic anastomosis  1134 ileoileal anastomosis  1127, 1132–1133 ileum, neobladder construction  1132–1134

Index illumination see light sources image adaptive radiation therapy (IART) 1550 image‐guided brachytherapy, prostate cancer 1534–1545 image‐guided radiation therapy (IGRT), prostate cancer  1550–1564 image‐guided surgery (IGS)  52–53 laparoscopic radical prostatectomy  1160–1162 imaging lithotripsy systems  718–719, 723 radiologic see radiology video see video imaging technology immediate‐use steam sterilization (IUSS) 8–9 immune responses, unilateral ureteral obstruction 138 immunohistochemistry (IHC), renal cell carcinoma  1435, 1437 immunosuppressive therapy, stone formation 828 immunotherapy, upper tract instillation 363–367 implantable cardiac defibrillators, SWL and  738, 758 implantable pulse generator (IPG), implantation  1903, 1907, 1908 implant surgery see prosthetic surgery impotence see erectile function incisional hernias  1302–1306 hand‐assist ports  1002 laparoscopic port site see port‐site hernias laparoscopic repair  1302–1306 complications 1305–1306 modifications 1303–1304, 1305 open repair vs.  1304–1305, 1306 results 1304 specimen extraction sites  1012 incontinence see urinary incontinence incontinence surgery male urethral slings  1892–1899 maxi/pubovaginal slings  1871–1877 midurethral slings  1832–1835, 1854–1867 prolapse repair with  1235, 1861–1862 single‐incision slings  1832–1843, 1862–1863 urethral bulking agents  1847–1851 Indiana pouch stone formation  836 stone management  837, 839, 840 indigo carmine, ureteral orifice visualization  524, 527 indocyanine green (ICG) robotic partial nephrectomy  1095 robotic surgery  957 robotic ureteral reconstruction  1201 ureteral obstruction  596 infants robot‐assisted laparoscopic pyeloplasty 1329 undescended testes  1344 infections interstitial cystitis etiology  1793–1794 mesh  1883, 1886 obstructing ureteral stones  855 postprocedure

Volume 1 pages 1–878, Volume 2 pages 879–1913

laparoscopic port site  978 laparoscopic surgery  1035–1036 laser prostatectomy  1702–1703 midurethral sling surgery  1864–1865 PCNL  260, 319, 338 radiofrequency ablation of renal tumors 1448 risk factors  59 SWL 757 TURP 1740 ureteroscopy 663 seminal vesicle  1292 ureteral strictures  617, 618 urethral strictures  1817 see also sepsis infection stones chemolysis 360–361 staghorn 310 urinary diversions  836, 837, 840 see also struvite stones inferior epigastric artery/vein  973, 974 inferior hypogastric (pelvic) plexus  1143, 1662 inferior pole see lower pole inferior vena cava (IVC) inadvertent ligation  1024 laparoscopic adrenalectomy  1283 obstruction, prone position  202 renal cell carcinoma involvement  1410, 1414 inflammasome 138 inflammation, neurogenic  1794 information sheets, patient  1659–1660 informed consent see consent, informed infracostal approach, upper pole access 255, 256 infundibula, calyceal  92, 93 anatomical variations  94, 96 draining polar regions  98–99, 100 percutaneous access  101–103 inadvertent 232 inferior pole  103, 104 middle kidney  103 risks 104, 105 superior pole  101–103 infundibular arteries see interlobar arteries infundibular stenosis  346–348 diagnosis 347 percutaneous treatment  285, 286, 347–348 infundibular veins see interlobar veins inguinal hernia after laparoscopic orchiopexy  1348 laparoscopic repair  1306–1309 complications 1308–1309 results 1308 total extraperitoneal (TEP)  1307, 1308–1310 transabdominal preperitoneal (TAP) 1307 vasectomy reversal after repair  1315 inguinal lymph node dissection, endoscopic subcutaneous modified (ESMIL) 1060–1065 complications 1065 indications 1060 operating room setup  1061, 1062 patient position  1061, 1063

postoperative care  1065 preoperative preparation  1061 procedure  1061, 1062–1064 trocar placement  1061–1062, 1063 inguinal lymph nodes deep 1063–1064 involvement, penile cancer  1060 superficial 1062–1063, 1064 Innova Quartz 400 laser fiber (Gyrus‐ACMI) 508 inside‐out tracking system  52 instillation of topical agents, upper urinary tract see topical therapy of upper urinary tract instructions for use (IFU)  5, 7, 9, 12 instruments cleaning 4–6 EndoWrist robotic  955–957 handling 6 laparoscopic surgery  902, 903, 944–952 LESS surgery  1366–1368 lower tract surgery  1653–1659 maintenance 6 pediatric patients  335–337, 1325 percutaneous renal access  230, 237–238 processing  3–6, 10 protection 6 Spaulding classification  4 sterilization  3–12, 146 storage  4, 10 ureteroscopy  506–511, 563 insufflation, abdominal complications  921, 934, 1023, 1033–1034, 1171 gases 918 high pressure  1033 pediatric patients  1324–1325 technique 976 technology 944–945 see also carbon dioxide; pneumoperitoneum insulin resistance, urolithiasis and  843–844 integral theory, female urinary continence  1832, 1855 integrins  136, 137–138 intensity‐modulated radiation therapy (IMRT) prostate cancer  1550, 1560 quality of life effects  1556–1557 toxicity 1555–1556 intercostal approach nephroscopy  288, 289 surgical anatomy  88–89 upper pole access  255, 256 intercostal nerve  393 intercostal vessels  255–256 bleeding  401, 412 interferon‐α, upper tract instillation  364, 365, 366 interleukin‐1 (IL‐1)  58 interleukin‐1β (IL‐1β) 138 interleukin‐18 (IL‐18)  138 interlobar (infundibular) arteries  91, 265 percutaneous access  101, 102, 103, 104 interlobar (infundibular) veins  91, 92 percutaneous access  101, 102 interlobular arteries  91, 265

i17

i18

Index interlobular veins  91 internal iliac artery, pelvic lymph node dissection  1053, 1056–1057 internal jugular vein catheterization  1467, 1468 International Commission on Radiological Protection (ICRP)  14–15, 20, 21 International Prostate Symptom Score (IPSS)  1488, 1535, 1552, 1728 International Urogynecological Association/ International Continence Society (IUGA/ICA) classification of mesh complications 1881, 1883 definitions of mesh complications  1881, 1882 interpelviocalyceal (IPC) region/space  94, 96–97, 98 interpolar kidney region see mid kidney region interstitial cystitis/bladder pain syndrome (IC/BPS) 1792–1801 definition 1792 endoscopic procedures  1798–1800 epidemiology 1792–1793 etiology 1793–1795 intravesical agents  1797–1798 management 1796–1797 minimally invasive procedures  1797–1801 sacral nerve stimulation  1904 signs/symptoms and diagnosis  1795–1796 subtypes 1792 interstitial laser coagulation (ILC) of prostate, local anesthesia  1666, 1667 interventional radiology benign prostatic hyperplasia  1489–1493 horseshoe kidney  1481–1482 pelvic congestion syndrome  1474–1477 percutaneous nephrostomy  241, 312 post‐PCNL bleeding  403–405 prostate cancer  1526 radiation dose reduction  25–27 radiation exposure  19–20, 23 renal injuries  1482–1483 renal tumors  1483–1485 varicocele 1467–1473 see also radiologists intra‐abdominal organ injuries laparoscopic surgery  1025–1027, 1040–1041 PCNL  394–395, 422–425 children 338–339 patient positioning and  174, 199–201, 204–205 staghorn calculi  319 supracostal access  261 see also bowel injuries; liver injury intra‐abdominal pressure (IAP) laparoscopy in children  1324–1325 physiologic effects of raised  918–919, 920, 930 intra‐abdominal stone loss, laparoscopic surgery  1211, 1217 intracorporeal lithotripsy endoscopic combined intrarenal surgery 178, 180 percutaneous antegrade  322–328 Volume 1 pages 1–878, Volume 2 pages 879–1913

children 337 distal ureteral stones  297 flexible nephroscopy  290 infectious complications  66 proximal ureteral stones  296 rigid nephroscopy  289–290 staghorn calculi  317 pregnancy 792–793 ureteroscopic  508, 532–539 comparative costs  538 methods compared  539 procedures 545–546 Sun’s ureterorenoscope  492, 494 ureteral injury  660–661 see also ballistic lithotripsy; electrohydraulic lithotripsy; holmium:YAG laser lithotripsy; laser lithotripsy; pneumatic lithotripsy; ultrasonic lithotripsy intracranial pressure (ICP), laparoscopic and robotic surgery  920, 931 intrafraction error, prostate radiotherapy 1560 intraocular pressure (IOP) laparoscopic and robotic surgery  907, 931, 935 prone positioning  203 intrarenal arteries  90–91 percutaneous access  101–104, 105–106 intrarenal pressure supine position  174 ureteroscopy  64, 507 intrarenal veins  91–92 percutaneous access  101–104, 105–106 intravaginal slingplasty (IVS)  1856–1857 intravenous pyelography/urography (IVP; IVU) digital tomosynthesis (DT)  25 pregnancy  29, 789–790 radiation exposure  18, 23 renal colic  800–801 upper tract neoplasms  568, 1413 ureteral strictures  594–595 urinary tract obstruction  126 intravesical therapy bladder cancer  1808 bladder pain syndrome  1797–1798 intrinsic sphincter deficiency (ISD) midurethral slings  1862 post‐prostatectomy  1891, 1895 pubourethral slings  1876 urethral injection therapy  1848 Intromit 995 invagination technique, percutaneous endopyelotomy 379 InVance™ bone‐anchored male sling  1892–1893, 1895 inversion therapy, post‐SWL  738–739 inverted papillomas  570, 579 Invisio DUR‐D ureteroscope see DUR‐D Invisio ureteroscope Inzii™ Retrieval System  1011 iodine‐125 (125I) prostate implants  1537–1538, 1540, 1541–1542 iPad‐assisted percutaneous renal access, marker‐based  52, 245–247, 252, 253 irreversible electroporation (IRE)

prostate cancer  1514, 1607 renal masses  1457 irrigation PCNL  174, 187–188 urinary diversion reservoirs  839 irrigation fluids bipolar TURP  1744 laser prostatectomy  1700 monopolar TURP  1736 irrigation systems flexible ureteroscopy  478–479, 510–511, 555 rigid and semirigid ureteroscopy  471, 516 stone chemolysis  354–355, 356 Sun’s ureterorenoscope  488–489, 492–493, 494 ischemic optic neuropathy laparoscopic and robotic surgery  907, 914, 935 prone position  203 ISDN networks  157 iterative reconstruction in image space (IRIS) 24 Jackson–Pratt wound drain  1017 jejunal injury, PCNL  423–424 Jena Med Tech Lithospace see Lithospace lithotripter JJ stents see ureteral stents, double pigtail Joint Commission  12, 1651 Joule–Thomson effect  1455, 1582, 1589, 1590 juxtaglomerular cell neoplasm  1407 Karl Storz bipolar resection system  1744, 1745 Karl Storz ureteroscopes flexible  477, 479, 480 semirigid  472 Kaufman procedure, post‐prostatectomy incontinence 1892 Kaye tamponade balloon  392, 401 ketamine, postoperative pain  933 ketorolac ‐eluting stents  868 living donor nephrectomy  1257 minimally invasive prostate therapy  1664 postoperative pain  933 renal colic  806–807, 808 keyhole technique, parastomal hernia 1310, 1311 kidney abnormal development  811, 818 anatomical variants see renal anomalies anatomy  87–104, 199 blind percutaneous access  264–266 coverings 87–88, 89 intrarenal vasculature  90–92, 265–266 pelvicalyceal system  92–101 relationships to other organs  88–90, 91 atrophy, diagnosis  563 exposure, ureteral reconstruction  1199 hilar region see mid (hilar) kidney region imaging 1393–1396 lower pole see lower pole mobility 264

Index Accordion™ device  289, 290 patient positioning and  174, 199, 200 see also respiratory motion morphometry 87 persistent fetal lobulation  1401 position 87, 88 pressure‐related injuries  661 superior pole see upper pole kidney cancer biopsy see renal mass biopsy LESS nephrectomy  1376, 1377 lymphadenectomy  1078, 1080–1081 radical nephrectomy  1077–1085 robotic partial nephrectomy  1088–1095 TNM staging system  1410, 1411 see also renal cell carcinoma; renal masses; renal tumors; upper tract urothelial carcinoma kidney stones see renal stones kidney transplantation  827 donor screening for nephrolithiasis 827–828 ex vivo ureteroscopy  829–830 indications 1261 laparoscopic 1259–1260 robotic (RKT)  1259–1268 complications 1267 contraindications 1261 gasless retroperitoneal  1267 history of development  1259–1261 learning curve  1266–1267 preoperative preparation  1261 regional hypothermia  1260–1261 renal function outcomes  1267 technique 1261–1266 vaginal graft insertion  1267 see also living donor nephrectomy; transplant kidneys kidney‐ureter‐bladder (KUB) radiographs pregnant women  29 radiation safety  18, 23, 25 renal colic  800, 802 Klebsiella 58 knots, suture  963–964 knot‐tying devices  964–965 Kocher maneuver  1080 Kock pouch, stones  836, 837 KTP lasers  1694–1697 60 W systems  1694–1695 80 W systems  1695–1697 photoselective vaporization of prostate  1678, 1694–1697 physical principles  1673, 1678–1679 urethral strictures  1823 KUB radiographs see kidney‐ureter‐bladder radiographs kyphoscoliosis, PCNL  198 labor, neglected obstructed  1242 lactate, uric acid stone dissolution  358, 359 laparoendoscopic single‐site (LESS) surgery 1361–1370 access 1366 adrenalectomy  1286–1289, 1378–1379 cameras/lenses 1368, 1369 extraperitoneal 1366 homemade ports  1361–1364 instrumentation 1366–1368 living donor nephrectomy  1256, 1378 Volume 1 pages 1–878, Volume 2 pages 879–1913

lower tract  1385–1389 ports  1361–1366, 1373–1374 prostate 1762–1773 radical prostatectomy  1162, 1386, 1769–1772 simple prostatectomy  1762–1768 pyeloplasty  1331, 1379–1380 renal cysts  1225–1226, 1227, 1228, 1380–1381 retroperitoneal  989, 1366 robotic see robotic laparoendoscopic single‐site (R‐LESS) surgery single‐incision multiport  1361, 1362, 1374 transperitoneal 1366 trocar placement  977, 1373–1376 upper tract  1373–1382 ablative procedures  1380–1381 extirpative procedures  1375–1379 future prospects  1381–1382 operative approach  1374–1375 reconstructive procedures  1379–1380 laparoscopes flexible 45, 47, 947 LESS surgery  1368, 1369 new technologies  44–46, 47 rigid 946 laparoscopic access children 1325 closed entry technique  974–976, 1021 complications  977–978, 1021–1022, 1036, 1037, 1040 extraperitoneal pelvic  990–992 guidelines for safe  1022, 1040 open technique see Hasson technique optical trocar  976, 1022 retroperitoneal 987–990 transperitoneal 973–984 Laparoscopic Assistant Robot System (LARS), modified  270 laparoscopic exit  1010–1018 drainage 1016–1018 extraperitoneal pelvic surgery  992 inspection 1012–1013 port site fascial closure  1013–1016 retroperitoneal approach  992 safe 1027–1028 skin closure  1016 specimen retrieval  1010–1012 devices  952, 1010–1011 extraction site  1012 morcellation 1011 step‐by‐step approach  1011 trocar removal  1013 laparoscopic radical prostatectomy (LRP) 1140–1162 antegrade technique  1145, 1146 antibiotic prophylaxis  1181 complications 1151–1153, 1154 ischemic optic neuropathy  907 predictive factors  1151–1153, 1154 urine leaks  1028 continence preservation amniotic wraps  1186–1187 anatomy 1142–1143 bladder neck reconstruction 1149–1150, 1184–1185 bladder neck sparing  1182

conventional technique  1145–1146, 1147, 1148 endopelvic fascia sparing  1182 Heilbronn technique  1145–1146, 1147, 1148 physical therapy  1180–1181, 1188–1189 puboprostatic ligament sparing  1143, 1146, 1181–1182 regional hypothermia  1186 results 1155–1158, 1159, 1171 surgical techniques  1145–1146, 1182–1183 urethral length sparing  1183 urethrovesical junction reconstruction 1149–1150, 1184–1186 ergonomics  1159, 1160 extraperitoneal access  1143–1144, 1145 extraperitoneal vs. transperitoneal  1144, 1145 historical background  1140, 1169 nerve‐sparing 1148 amniotic wraps  1186–1187 anatomy  1142, 1143, 1181–1182, 1185 antegrade technique  1148 antegrade vs. retrograde  1148, 1149 avoiding electrocautery  1186 graded approach  1183–1184 indications 1140, 1141 intraoperative frozen sections  1183 nerve grafts  1186–1187 post‐biopsy wait period  1179 postoperative therapy  1187–1188 retrograde technique  1148, 1149 robotic LESS  1386 robotic technique  1175, 1183–1184, 1185 non‐nerve sparing  1146, 1184 operative techniques  1143–1150 outcomes 1151–1159 cost‐effectiveness 1158–1159 functional 1155–1158 oncologic 1153–1155, 1156, 1157 optimizing 1179–1189 perioperative 1151, 1152–1153 patient positioning  1143, 1144 patient selection  1140–1141 postoperative drainage  1017 retrograde technique  1145, 1147 robot‐assisted see robot‐assisted laparoscopic radical prostatectomy specimen handling  1148, 1150 surgical anatomy  1141–1143 technical advances  1159–1162 transperitoneal access  1143, 1145 trocar placement  983–984, 1143, 1144 urethrovesical anastomosis  961, 1149, 1150 venous thromboembolism prophylaxis  1172, 1181 see also radical prostatectomy laparoscopic renal surgery equipment 903 hand‐assisted  994–995, 998–1004 operating room setup  149, 150, 902, 903 patient positioning  905–906, 1034–1035 retroperitoneal access  987–990 transperitoneal access  979–981

i19

i20

Index laparoscopic surgery  901–908 anesthesia 929–930 anesthetic management  928–938 antimicrobial prophylaxis  61, 66–67 bowel preparation  902 calyceal diverticula  343 cardiac patients  936 children 1323–1326 complications 1021–1030 access 1021–1022 anesthetic management  934–936 children 1325–1326 end‐organ 1024–1027 including robotics  1032–1043 intraoperative 1036–1042 miscellaneous 1028–1029 patient positioning  1023–1024, 1034–1035 physiologic 1022–1023 postoperative 1027–1028 prevention 1032–1033 contraindications  901, 928–929 enhanced recovery protocols  931–932 exit see laparoscopic exit extracorporeal assist devices  948 fluid management  930 gasless or low‐pressure  922 hand‐assisted 994–1004 hemostatic technology  949–951 high‐definition laparoscopes  44–45, 146, 1159–1160 imaging technology  946–948, 1159–1160 informed consent  901–902 instrumentation  902, 903, 944–952 insufflation see insufflation obesity 937–938 older patients  937 open conversion  1040 operating room design  48 operating room setup  149, 150, 902–905 patient positioning see positioning of patient, laparoscopic surgery patient preparation  901 physiologic changes  917–923, 930–931 pneumoperitoneum see pneumoperitoneum postoperative nausea and vomiting  933–934 postoperative pain management  932–933 pregnancy 937 preoperative assessment  928–929 pyeloplasty 381 reconstructive techniques  960–971 renal cysts  349 retroperitoneal approach see retroperitoneoscopic renal/adrenal surgery simulators  166, 894–895 specimen retrieval  1010–1012 stone management  783–784, 1208–1217 stress response  920–921 training 887–898 transperitoneal approach see transperitoneal laparoscopic/robotic surgery laparoscopic tower  946, 947 Volume 1 pages 1–878, Volume 2 pages 879–1913

laparoscopy, diagnostic see diagnostic laparoscopy laparoscopy‐assisted endourology, renal stones  1209, 1216–1217 laparoscopy‐assisted percutaneous nephrolithotomy (PCNL)  820–821, 1216–1217 laparotomy pad  998 Lapra‐Ty® clip  965 LapSac™  1011 LapX Hybrid simulator  895 laser(s)  1658–1659, 1672–1679 BPH therapy  1676–1679 continuous wave mode  1674 delivery of beam  1673–1674 development 536 physics  1672–1673, 1693 power density  1676, 1693 prostatic diseases  1655 pulsed mode  1674 safety  1658–1659, 1700 technical considerations  1658 tissue interactions  1674–1676, 1694 ureteroscope damage  479, 482, 498 wavelengths  1675 laser endoureterotomy distal ureteral strictures  612, 624, 625 mid‐ureteral strictures  599 thulium lasers  1714 ureteroenteric strictures  633, 635, 636 laser fibers  537 Avicenna robot system  674, 678, 683 BPH therapy  1676–1677, 1678–1679 design 1673–1674 end‐ or front‐firing  1674 flexible ureteroscopes  290, 508 handling 1658 lower pole renal stones  555–556 side‐firing 1674 sizes  508, 537, 554 twister 1674 ureteral strictures  612 ureteroscope damage  325, 482, 503, 504, 508 laser interstitial thermal therapy (LITT) see focal laser ablation Laserite™  479, 480 laser lithotripsy Avicenna robot system  678 laser types  537–538 mechanism of action  533, 536–537 PCNL 323–325 ureteroscopic  508, 536–539 lower pole stones  555–556 preventing ureteral injury  597 renal stones  552–554, 558 ureteral injury  661 ureteral stones  545 see also holmium:YAG laser lithotripsy laser prostatectomy 532nm high‐power lasers  1678–1679, 1693–1703 complications 1702–1703 contraindications 1703 patient preparation  1699–1700 postoperative care  1701–1702 preoperative preparation  1700 procedure 1700–1701 vaporesection/enucleation 1701

see also photoselective vaporization of prostate basic principles  1672–1679 equipment 1655 holmium laser  1676–1677, 1681–1690 equipment and instruments  1682, 1683 history and evolution  1681 techniques  1676–1677, 1682–1690 lasers used  1676–1679, 1727 light–tissue interactions  1524, 1674–1676 local anesthesia  1666, 1667–1668 open prostatectomy vs.  1270 thulium lasers  1677–1678, 1707–1713 clinical experience  1707–1712 economic issues  1713 patient subgroups  1712–1713 procedure nomenclature  1713, 1714 recent developments  1713 vapoenucleation 1710–1712 vaporesection 1707–1710 laser therapy BPH see laser prostatectomy en bloc resection of bladder tumors  1808, 1809, 1812, 1813 Hunner’s lesions  1800 prostate cancer see focal laser ablation (FLA) of prostate cancer upper tract urothelial carcinoma  387, 566, 573–574 laser urethrotomy  1823–1824 lateral‐flexed position PCNL 192–194 advantages  194 calyceal puncture  193–194, 195–198 morbid obesity  192–193, 198, 202 staghorn calculi  314 robotic partial nephrectomy  1089, 1092 lateral pelvic fascia (LPF)  1142, 1181–1182, 1183 lateral (decubitus) position laparoscopic adrenalectomy  1282 laparoscopic and robotic pyeloplasty 1329 laparoscopic renal surgery  905, 1034–1035 laparoscopic surgery  930 modified “Barts technique”  194 nerve injuries  203 PCNL 192–194 advantages  194 calyceal puncture  193–194, 217 morbid obesity  192–193, 198, 202 staghorn calculi  314 physiologic effects  917, 931 radical nephrectomy  1078, 1079 robotic renal surgery  912, 913, 930, 1034–1035 ureteral reconstruction  1197 ureteroenteric strictures  630 see also flank position; lateral‐flexed position lateral umbilical folds  1052–1053 latissimus dorsi muscle  265 lead aprons  22 leak tests, flexible endoscopes  5 learning curve holmium laser enucleation of prostate  1688–1690

Index miniaturized PCNL  307 robotic kidney transplantation 1266–1267 technical skills  159–160 leiomyomas, renal  1406–1407 LESS see laparoendoscopic single‐site levator fascia  1141, 1142 laparoscopic radical prostatectomy  1145–1146, 1147 LeVeen system  1444 Level 1 Normoflo irrigator  516 levofloxacin, prior to ureteroscopy  642 lichen sclerosus, urethral strictures  1817, 1821 Lich‐Gregoire ureteral reimplantation technique 608 Lichtenstein hernia repair  1306 Lichtleiter 465, 466 lidocaine 1662, 1663 intraureteral 546 intraurethral 1664 intravesical  1664, 1798 transrectal prostate blocks  1666 L.I.F.T. Study  1721, 1723, 1724–1725 Ligasure™ bipolar device  950 light‐emitting diodes (LEDs)  46–47, 145 digital flexible ureteroscopes  502 laparoscopes 947 lighting, operating room  145, 1650–1651 light sources digital flexible ureteroscopes  502 digital video endoscopes  46–47 fiber‐optic flexible ureteroscopes  475–476 laparoscopes 947 Sun’s ureterorenoscope  490 video 153 linear‐no‐threshold model (LNT), radiation hazards 20 Link Trainer  888, 889 lipomatosis, pelvic  617 liquid crystal display (LCD) shutter glasses 49–51 Lister, Joseph  3 lithium triborate (LBO) lasers  1678–1679, 1697 LithoBreaker lithotripter  534 LithoClast lithotripter  325, 326, 534, 545–546 LithoClast™ Master/Select with Vario Handpiece lithotripter  317 LithoClast Ultra lithotripter  327–328, 535 LithoGold LG‐380 lithotripter  706, 717, 728 Lithospace lithotripter (Jena Med Tech)  706, 717, 719, 728 lithotomy position  1652, 1653 complications  203, 934, 935 laparoscopic and robotic surgery  906, 914, 1035 surgical equipment  199 ureteral reconstruction  1197 ureteroscopy  506, 515, 523 lithotripsy see intracorporeal lithotripsy; shock‐wave lithotripsy lithotripsy systems (lithotripters)  713–724 components  692, 714–716 coupling  717–718, 723, 749 dedicated 718 Volume 1 pages 1–878, Volume 2 pages 879–1913

design 718–720 dual‐focus technology  716 effectiveness quotient (EQ)  721–722 examples of available  725–728 focus size  716 history of development  692, 694, 713–714 ideal 722–724 imaging systems  718 maximum treatment (penetration) depth 716 multifunctional 718–720 hybrid design  720, 721 integrated design  719, 720–721 modular design  719 new technologies  706–707, 708 optical coupling control  718, 723 performance 720–722 shock‐wave generation  692–693, 714–716 shock‐wave physics  692–695, 716–717 triple‐focus technology  716 types 692, 695, 696 wide focus/low pressure  706, 717, 728 LithoVac suction device  326 LithoVue™ flexible ureteroscope (Boston Scientific)  480–481, 499, 501, 510 cost effectiveness  857 imaging technology  44, 46 nephroscopy 287 technical details  477, 500 liver adrenal tumor adherence  1283, 1286 kidney relations  89, 90 retraction  1255, 1283 liver injury laparoscopic surgery  1027 PCNL  394, 424–425 patient positioning and  199–201 upper pole access  261 living donor nephrectomy, laparoscopic 1250–1257 complications 1257 hand‐assisted  1000, 1001, 1256 Hem‐o‐Lok™ clip risks  968, 1254 laparoendoscopic single‐site  1256 left‐sided 1251–1255 LESS  1256, 1378 postoperative care  1256–1257 preoperative evaluation  1250–1251 right‐sided 1255–1256 robot‐assisted 1256 surgical risks  1251 trocar placement  979–980, 981, 1251–1252, 1255 local anesthesia postsurgical pain  933 prostate procedures  1661–1668 neuroanatomy 1662 oral supplements  1663, 1664 patient preparation  1661–1662 prostate blocks  1665–1668 pudendal nerve block  1668 topical urethral anesthesia  1663–1664 local anesthetics intravesical, bladder pain syndrome  1798 pharmacology 1662–1663 toxicity 1663 lorazepam  1664 lower (inferior) pole

access for PCNL  191 horseshoe kidney  814 intra‐abdominal organ injury  200 nephroscopy 288 staghorn calculi  312 general anatomy  87, 88 nephroscopy  286, 287, 288 pelvicalyceal anatomy  94, 95 endocasts 98–101 SWL efficacy and  733–734 stones cost‐effective strategies  858–859 first‐line therapy  782 observation vs. treatment  768 SWL  733, 738–739 treatment options  550, 551 ureteroscopic removal  555–556, 558–559 vasculature 103, 104 lower quadrant incision, laparoscopic specimen extraction  1012 lower ureter see distal ureter lower urinary tract procedures documentation 1651 energy sources  1657–1659 equipment preparation  1653–1657 operating room  1649–1651 patient handouts  1659–1660 patient preparation  1652–1653 radiation safety  1659 robotic LESS  1385–1389 room preparation  1651–1652 universal protocol  1651 lower urinary tract symptoms (LUTS) 1627–1640 after midurethral sling surgery 1865–1866 after prostate cryoablation  1600 benign prostatic hyperplasia ablative and emerging techniques 1727–1730 assessment  1627–1640, 1728 goals of treatment  1728 management options  1488–1489 prostatic urethral lift procedure 1719–1725 selective arterial prostate embolization 1489–1493 TURP  1736, 1743–1744 defining and quantifying  1628 interstitial cystitis  1795 partial cystectomy and  1116 questionnaires 1628, 1629 stent syndrome  865 urodynamic evaluation  1630–1634 Lower Urinary Tract Symptom Score (LUTSS) 1628, 1629 low molecular weight heparin (LMWH)  74, 79–80 Lowsley retractor  1014, 1015 LRP see laparoscopic radical prostatectomy L‐shaped kidney  462 lumbar artery injury, PCNL  405 lumbar notch  265 lumbar vein, living donor nephrectomy 1253 Lumenis 272 laser fiber (Coherent)  508 Lumenis PolyScope®  477, 480, 499, 500 lump kidney  462

i21

i22

Index lung kidney relations  89, 90 PCNL‐related injuries  261, 394, 412–413, 424 supracostal access and  256–257 see also pulmonary physiology lung cancer, renal metastases  1418, 1419 lung metastases, renal cell carcinoma  1413, 1415 lung volumes, prone positioning  202 lymphadenectomy inguinal 1060–1065 kidney cancer  1078, 1080–1081 pelvic see pelvic lymphadenectomy postoperative drainage  1017 retroperitoneal 1066–1075 lymphatic vessels laparoscopic varicocelectomy  1356 leaks, laparoscopic surgery  1042 lymph node density, bladder cancer  1052 lymph node metastases bladder cancer  1051 penile carcinoma  1060 preoperative imaging  1049, 1051 prostate cancer  1048 renal cell carcinoma  1411–1413 lymphocele  1042, 1058, 1267 lymphoma, renal  1416–1417, 1418 Lynch syndrome  578–579 Lynx midurethral sling  1856 lysine, stone dissolution  361 Maciol suture needles  1014 macrophages, renal fibrosis  136, 138 Macroplastique periurethral injection  1849, 1850 STING procedure  1784 MAG3 (99mTc‐mercaptoacetyltriglycine) renography 127 magnesium ammonium phosphate hexahydrate (MAPH) stones see struvite stones magnetic resonance imaging (MRI) benign prostatic hyperplasia  1490, 1493 contrast‐enhanced ultrasound vs.  1605, 1609 cryoablation of renal masses  1461 image‐guided surgery  51 kidney cancer  1078 lymph node metastases  1049, 1051 multiparametric see multiparametric magnetic resonance imaging PCNL 212 pelvic congestion syndrome  1474, 1475 pregnancy 790 prostate cancer see under prostate cancer renal cysts  1222, 1395 renal masses  1394–1395 sacral nerve modulation and  1904 seminal vesicles  1294 upper tract neoplasms  568 urinary tract obstruction  129–130 magnetic resonance spectroscopic imaging (MRSI), prostate cancer  1620 magnetic resonance (MR) thermometry focal laser ablation  1524–1525 high‐intensity focused ultrasound  1512 magnetic resonance urography (MRU)  25, 595, 596 Volume 1 pages 1–878, Volume 2 pages 879–1913

Major Vessel Injury (MVI) repair simulator 894, 895 Malecot catheters large‐bore nephrostomy  428 topical upper tract therapy  354–355, 356 males causes of bladder outlet obstruction 1627 radical cystectomy  1109–1110 rigid cystoscopy  1644, 1663 SWL safety  748, 758 topical urethral anesthesia  1664 urethral anatomy  1815–1816, 1817 urinary continence  1142–1143, 1890, 1891 male urethral slings  1892–1899 bone‐anchored  1892–1893, 1895 patient selection and evaluation  1894–1895 quadratic  1894, 1898 surgical techniques  1895–1898 transobturator  1893–1894, 1895–1897 malignancy risks radiation exposure  17–18, 19 fluoroscopy‐guided PCNL  211–212 pediatric patients  28–29 pregnant women  29 prostate radiotherapy  1536, 1557 renal cysts  348, 1222, 1223, 1399, 1401 malignant ureteral obstruction/ strictures 617 balloon dilation  623, 624 stenting  622–623, 865 metal stents  622–623, 865, 869, 870, 871 polymeric stents  865, 867 retrograde and antegrade  597–598 ureteroscopic access  609–610 malrotated kidney, SWL  739, 740 mannitol, living donor nephrectomy  1254 marionette technique intracorporeal ileal conduit  1126 robotic LESS radical prostatectomy  1386 marker‐based iPad‐assisted percutaneous renal access  52, 245–247, 252, 253 markers fiducial, prostate radiotherapy  1560 intraoperative site Boari flap  1340–1341 urinary diversion  1132, 1134 skin see skin markers marsupialization, renal cysts  349 Maryland bipolar forceps  956 mast cells, interstitial cystitis  1794 MAUDE (Manufacturer and User Device Experience) database  1863, 1882 Maxiflex SemiFlex Scope™  477, 480, 499, 500 maximum urethral closing pressure (MUCP) 1862 maxi/pubovaginal slings  1871–1877 see also pubovaginal slings mayo stands  904, 1656–1657 May–Thurner syndrome  1473 McCarthy resectoscope  1733 mean arterial pressure (MAP) laparoscopic surgery  919 prone position for PCNL  202 meatotomy scissors  611, 619 mechanical heart valves  77, 78 medial umbilical ligament

partial cystectomy  1118, 1119 pelvic lymphadenectomy  1052, 1055 radical prostatectomy  1174 medical expulsive therapy (MET)  542–543, 643, 777 combination 808–809 cost‐effectiveness 854–855, 856 distal ureteral stones  777–779 post‐SWL residual fragments 750 pregnancy 791 proximal and mid‐ureteral stones  779 renal colic  807–809 steinstrasse 757 stone passage rates  543, 769 straining the urine  809 medical therapy of stone disease after SWL  448, 739 cost effectiveness  859–861 obesity 845 residual stone fragments 448–449 see also chemolysis of urinary calculi Medicated Urethral System for Erection (MUSE) 1187 medullary sponge kidney, SWL  739 megaureter congenital obstructive  615, 616 SWL  739, 740 Memokath stents BPH therapy  1729 ureteral obstruction  634, 637–638, 870 urethral strictures/stenoses  1824 meperidine, renal colic  806 mepivacaine 1663 mercaptoacetyltriglycine, 99mTc‐labelled (MAG3) 127 α‐mercaptopropionylglycine (MPG)  359, 360 mesenteric angiography, neobladder construction 1132 mesenteric ischemia  934–935 mesh, synthetic classification 1856, 1881 contraction 1882 exposure  1866, 1882, 1884 hernia repair  1299–1302 incisional 1303, 1304 inguinal  1306, 1307, 1309 parastomal 1310–1311 types available  1300 male urethral slings  1895, 1896–1897, 1898 midurethral slings  1855–1856 prolapse surgery  1234, 1881 popularity 1880 recommendations 1887 surgical techniques  1237, 1239, 1240 pubovaginal slings  1873 single‐incision slings  1833, 1834, 1835–1843, 1862–1863 see also biologic implants; prosthetic surgery mesh complications  1880–1887 abdominal sacrocolpopexy  1240, 1241, 1882 classification 1881, 1883 clinical presentation  1882, 1884 evaluation 1884, 1885 FDA warnings  1856, 1880–1881 incidence 1882

Index incontinence surgery  1856, 1866 management 1885–1887 outcomes 1887 prevention 1884–1885 risk factors  1882 terminology 1881, 1882 vaginal prolapse surgery  1880–1887 mesonephros 455 metabolic acidosis, pneumoperitoneum‐ related 1033 metabolic stones after bariatric surgery  845 calyceal diverticula  341 cost‐effective strategies  859–861 kidney transplant recipients  828 obesity 844 staghorn calculi  310, 768 urinary diversion patients  836, 837 metallic clips  968–970 metal ureteral stents (MS)  864, 869–873 balloon‐expandable  637, 870 complications of long‐term use  865–866 covered 870–871 double‐pigtail 871–873 drug‐eluting 873 malignant obstruction  622–623, 865, 869, 870, 871 outcomes 873–874 self‐expandable  637, 869–870 thermo‐expandable  637–638, 870 ureteral strictures  614–615 ureteroenteric strictures  634, 637–638, 869 metanephric adenomas  1406 metanephros 455 metastatic tumors adrenal glands  1278 kidneys 1418, 1419 seminal vesicles  1293 methylene blue aiding stone removal  291 female genitourinary fistulas  1243, 1244 ureteral orifice visualization  524, 527 metoclopramide, renal colic  807 Mick applicator  1539 microbubbles, ultrasound  1605–1606 drug delivery  1611–1612 targeted 1610–1611 Micro Hand S robotic system  884 micro percutaneous nephrolithotomy (micro‐perc)  302, 304–305 children 337 classification 303 comparative studies  307 tract dilation  276 microsphere embolization, prostatic arteries  1489, 1492 MicroSurge robotic system  884 Microvasive Zerotip  509 microvessel density (MVD), prostate cancer 1606 microwave ablation prostate see transurethral microwave therapy renal masses  1457 mid (hilar, interpolar) kidney region calyceal anatomy  94, 95, 99–101 nephroscopy 287 vascular relationships  103 Volume 1 pages 1–878, Volume 2 pages 879–1913

see also renal hilum mid ureter anatomy 455, 456, 592, 593 blood supply  605, 606 injuries, presentation  594 obstruction 592–600 mid‐ureteral reconstructive surgery options  658, 1196 patient positioning  1197 mid‐ureteral stones management 779 Sun’s ureterorenoscope  491–492 SWL 747 mid‐ureteral strictures  592–600 balloon dilation  598, 599 congenital 594 diagnosis 594–596 endoureterotomy 598–599 etiology 593–594 laparoscopic and robotic approaches  600 management 597–600 presentation 594 prevention 596–597 stenting 597–598 midurethral (synthetic) slings (MUS; MUSS)  1832–1835, 1854–1867 anatomic approaches  1855 complications 1863–1866 cost effectiveness  1848 elderly patients  1860–1861 history  1832, 1871 intrinsic sphincter deficiency  1862 mechanism of action  1855 mesh materials  1855–1856 mixed incontinence  1859–1860 obese patients  1860 patient selection  1854–1855 prolapse surgery/hysterectomy with  1235, 1861–1862 pubovaginal slings vs.  1877 repeat surgery  1861 results 1858–1862 surgical techniques  1856–1857 see also pubovaginal slings; single‐incision slings; tension‐free vaginal tape; transobturator tape slings milk of calcium appearance  341–342, 343 milliSieverts (mSv)  14 MiniArc™ single‐incision sling  1834, 1835, 1836–1838 mini‐laparoscopy 977 minimal effective concentration (MEC)  11 minimally invasive PCNL (MIP) instruments 276–277, 302 minimally invasive percutaneous (MIP) nephrolitholapaxy 301 minimally invasive surgery (MIS) benign prostatic disease  1269–1275, 1661–1668 clips 966–970 contraindications 901 enhanced recovery protocols  932 hemostatic methods  960, 961 reconstructive techniques  960–971 staplers 970–971 surgical video systems  153–154 sutures 960–966 UPJ obstruction  381

mini‐percutaneous nephrolithotomy (mini‐perc; mini‐PCNL)  301, 303 antegrade ureteroscopy  296, 297 children 336–337 classification 303 comparative studies  306, 307 laparoscopy‐assisted, pelvic kidneys  821 proximal ureteral stones  298, 299 tract dilation  276 transplant lithiasis  833 miniscopes see semirigid ureteroscopes mini‐ureteroscopes see semirigid ureteroscopes mirabegron 1775 MIRO robotic system  884 mitochondrial dysfunction, ureteral obstruction 137 mitomycin C (MMC) bladder neck contracture  1828–1829 upper tract instillation  365, 366–367, 578 urethral strictures/stenoses  1823 mitral valve prostheses  77, 78 mixed epithelial and stromal tumors, renal 1407 mixed reality (MR)  161 mixed urinary incontinence midurethral slings  1854, 1859–1860 pubourethral slings  1875 urethral injection therapy  1848, 1851 model‐based iterative reconstruction (MBIR) 24 modular hands‐on training, laparoscopic and robotic surgery  891–893 modular operating rooms (ORs)  151 modulators, data relay  155 Moiré effect  476 molecular diagnostics, renal cell carcinoma subtypes 1436–1437 monitors, videoendoscope see video monitors monopolar electrosurgery  1657 children 1325 circuit  1734 en bloc resection of bladder tumors  1808 EndoWrist robotic instruments  956 laparoscopic instruments  949 laparoscopic radical prostatectomy  1186 transurethral equipment  1655 TURP 1733–1741 see also electrosurgery Montreal mattress  191 morcellation holmium laser enucleation of prostate 1685–1686 laparoscopic specimens  1011, 1376 morphine, renal colic  806 Moses effect  537 mother‐in‐law sign  1483 Mount Everest sign  1666 MoXy™ Fiber  1674, 1679, 1698, 1701 MRI see magnetic resonance imaging MSH‐2 gene mutations  578–579 multilocular cystic nephromas  1399–1401, 1402 multiparametric magnetic resonance imaging (mpMRI), prostate  1495–1497, 1616–1623 diffusion‐weighted  1496, 1497, 1617, 1618–1619

i23

i24

Index multiparametric magnetic resonance imaging (mpMRI), prostate (cont’d) dynamic contrast‐enhanced  1496, 1497, 1617, 1620–1621 focal therapy  1511 HIFU  1570, 1576 interpretation 1497, 1498–1499, 1621–1622 MR spectroscopy  1620 T2‐weighted (T2W)  1616–1618 ultrasound fusion‐guided focal laser ablation  1526–1528, 1529 multiparametric magnetic resonance imaging/ultrasound fusion‐guided prostate biopsy (mpMRI‐TRUS FBx)  1497–1506, 1622–1623 active surveillance  1499 biochemically recurrent cancer 1499–1500 commercial systems  1503–1505 contrast‐enhanced ultrasound  1612 cryoablation therapy  1593 focal therapy follow‐up  1518 focal therapy planning  1511 indications 1497–1500 workflow 1500–1503 multiple endocrine neoplasia type 2 (MEN2) 1282 multiple sclerosis (MS), botulinum toxin injection  1776–1777, 1778 muscle layers, ureter  456–457, 605–606, 607 musculoskeletal deformities PCNL  176, 198 children 333 thoracic complications  412 SWL 732 N‐acetylcysteine (acetylcysteine), cystine stones  359, 360 nanosecond electropulse lithotripsy (NEPL) 535–536, 539 naproxen  1664 narcotic analgesics see opioid analgesics narrow band imaging (NBI)  42, 43 cystoscopy 1646–1647 laparoscopy 947 upper tract urothelial carcinoma  566, 570 National Comprehensive Cancer Network (NCCN) pelvic lymphadenectomy  1050 preoperative lymph node imaging  1049 prostate cancer  1534, 1535, 1536, 1541–1542, 1551 radiofrequency ablation of renal tumors 1445 testicular germ cell tumors  1066 National Television Systems Committee (NTSC) video signal format  38, 155 natriuresis, postobstructive  134–135 natural orifice transluminal endoscopic surgery (NOTES) adrenalectomy 1286 Flex robot  882–883 radical prostatectomy  1773 Navigator HD ureteral access sheath (Boston Scientific) 507 N‐butyl cyanoacrylate (nBCA) glue embolization  1470–1472, 1482 Volume 1 pages 1–878, Volume 2 pages 879–1913

near‐infrared fluorescence (NIRF)  947, 957–958 partial nephrectomy  1095, 1098 needle drivers laparoscopic  952, 962 revolving, robotic percutaneous nephrostomy 272 robotic  956, 962–963 needle‐holders, laparoscopic  948 Needleless® single‐incision sling  1834, 1839–1840 needlescopic trocars  1375–1376 neobladder laparoscopic/robotic construction  1128, 1131–1134 extracorporeal  1110, 1128, 1132 hybrid 1132 instrumentation 1129 keys to success  1137–1138 outcomes 1135–1137 patient positioning  1129 patient selection  1129 postoperative care  1135 pure intracorporeal  1132–1134 trocar placement  982, 983, 1129–1131 retrograde ureteral access  518, 527, 839 stone formation rates  836–837 ureteral stricture management  608–609 ureteroenteric strictures  630 ureters of  461 neodymium:YAG laser benign prostatic hyperplasia  1681, 1727 distal ureteral strictures  612 frequency‐doubled double pulse (FREDDY) 537 principles 1673 upper tract urothelial carcinoma  387, 566, 573–574 urethral strictures  1823 nephrectomy, laparoscopic (and robotic) children 1324 hand‐assisted  998–1000, 1001, 1003–1004 LESS 1376 postoperative drainage  1016, 1017 renal stone disease  1209, 1216 specimen extraction  1012 vascular injury  1036, 1038 see also living donor nephrectomy; partial nephrectomy; radical nephrectomy nephrolithiasis see renal stones nephrolithometry scoring systems (NLSS) 108–120 common variables  113–119 descriptions and assessments  108–113, 114–118 multiple procedures  120 predicting PCNL complications  119–120, 390, 391 predicting radiation time  120 quality of life  120 staghorn calculi  119, 311 nephrolithotomy laparoscopic anatrophic (LAN) 1211–1214 calyceal diverticular stones  343, 1213, 1214 indications  1209 outcomes 1211–1213

pelvic kidneys  822 procedure 1213–1214, 1215 open anatrophic (OAN)  1211 percutaneous see percutaneous nephrolithotomy nephromas, multilocular cystic  1399–1401, 1402 nephron‐sparing surgery (NSS) alternatives to  1442 contrast‐enhanced ultrasound  1609 intraoperative assessment of resection margins 1097–1099 kidney cancer  1077, 1088–1095 LESS cryoablation  1380 positive surgical margins (PSM)  1097, 1098, 1099 preoperative imaging  1418–1419 upper tract urothelial carcinoma 384–388 see also partial nephrectomy nephropexy, ureteral reconstruction  1200 nephropleural fistula  413, 415–416 management 418 nephroscopes flexible 286–287 rigid  285, 287 children 335, 336 nephroscopy 285–292 flexible see flexible nephroscopy importance of access site  287–289 indications 285–286 proximal ureteral stones  296–297 rigid see rigid nephroscopy Nephrostent (Boston Scientific)  615 nephrostomy, percutaneous see percutaneous renal access nephrostomy access sheath (Amplatz sheath) calyceal diverticula  345 hemorrhagic complications and  398 miniaturized techniques  301, 302, 303, 336 multiple tracts  218, 259 obesity 848, 849 placement 217 endoscopic guidance  180, 232–233 upper pole access  259 tamponade of bleeding  392, 400 thoracic complications and  411–412, 419 nephrostomy needles (trocars) blind insertion  266 children  334, 335 combined endoscopic‐fluoroscopic approach 232 CT‐guided insertion  221–222 Dyna‐CT‐guided insertion  224–225 fluoroscopy‐guided insertion  214–216, 217 incorporating an optical system  245, 246, 252 lateral(‐flexed) position  193–194, 195–197 prone position  189, 190 Smart Needle system  271 ultrasound‐guided insertion  238–240 nephrostomy tract bleeding, management  392, 400–403 classification by diameter  303 dilation 275–282

Index alternative techniques  281–282 antegrade ureteroscopy  296 calyceal diverticula  345 children  334, 335 complications  281, 301, 392 endoscopic guidance  232–233 equipment 275–276 fluoroscopic control  217–218 minimal  276, 302 one shot  276–277, 278–279 procedure 280–281 prone position  191 quality and safety of access  277–280 staghorn calculi  315, 316, 318 hemostatic agents  401–402, 435–437 length nephrolithometry scoring systems  119 S.T.O.N.E. score  108–109, 110 supine position  174 multiple  218, 315–316 bleeding risk  398 children 335 urothelial tumor seeding  387 nephrostomy tubes (NT)  427–430, 437 calyceal diverticula  345 children 337–338 collecting system perforations  319 devices for securing  428, 429 instillation of topical agents  354–355, 356 large‐bore 428–429 lower ureteral reconstruction in children 1337 mid‐ureteral obstruction  597–598 obesity 848 PCNL without see tubeless percutaneous nephrolithotomy postoperative bleeding  402–403 pregnancy 792 small‐bore  428–429, 431, 433, 433 staghorn calculi  317–318 transplant kidneys  831, 832 tubeless PCNL vs.  431, 432, 433 UPJ obstruction  377 ureteroenteric strictures  630 urine extravasation/urinoma  662 nephroureteral stents children  334, 337–338 placement 217–218 nephroureterectomy, laparoscopic (LNU)  1101–1105 distal ureterectomy techniques  1102–1104 endoscopic intussusception  1104 endoscopic pluck  1103–1104, 1105 open excision  1103, 1105 pure laparoscopy  1102–1103, 1105 results 1104–1105 hand‐assisted 1000 indications 1101 LESS 1377 open nephroureterectomy vs.  1101–1102, 1105 operative technique  1102–1104 outcomes 1101–1102 patient positioning  1102 postoperative drainage  1016, 1017 trocar placement  980, 981, 1102–1103 upper tract urothelial cancer  384, 385, 565, 568 Volume 1 pages 1–878, Volume 2 pages 879–1913

nephroureterostomy catheters (NUCs)  318, 429–430 nerve grafts, radical prostatectomy  1186–1187 nerve injuries laparoscopic and robotic surgery  935–936, 1028, 1035 prevention 929–930 PCNL  201, 203, 393 pelvic lymph node dissection  1057 poor patient positioning  1653 ureteroscopy 662 Nesbit resection technique, TURP  1737 NeuroArm robotic system  884 neurogenic bladder  1775 intravesical botulinum toxin  1776–1777, 1778, 1779 sacral nerve stimulation  1904 neuromodulation 1902–1911 history 1902–1903 mechanism of action  1903 percutaneous tibial nerve stimulation 1909–1910 sacral nerve stimulation  1903–1909 neuromuscular injuries robotic surgery  907, 913–914 surgeons  48, 907, 1002 neurovascular bundles (NVBs), periprostatic amniotic wraps  1186–1187 anatomy  1142, 1181–1182 avoiding traction  1186 clipping 1146 electrocautery safety  1186 preservation 1148, 1149, 1175 see also laparoscopic radical prostatectomy, nerve‐sparing neurovascular structure‐adjacent frozen‐section examination (NeuroSAFE)  1183 NGage™ basket  290 nifedipine cost‐effectiveness 855, 856 renal colic  808 ureteral stone expulsion  543, 643, 778 nitinol guidewires percutaneous nephrostomy  231, 258–259 retrograde ureteral access  506, 507, 515–516 nitinol stone baskets Avicenna robot system  678 percutaneous  290, 291, 317 ureteroscopic  478, 501, 509 entrapment 661 renal stones  554–555 tip deflection effects  479 nitinol ureteral stents  614–615, 634 nitric oxide (NO), bilateral ureteral obstruction 134 nitrofurantoin 65 nitrogen dioxide (N2O) pneumoperitoneum 918 nitroglycerin 1470 Nitze‐Leiter cystoscope  465, 466 noncritical items (Spaulding classification) 4 non‐seminomatous germ cell tumors (NSGCT), testis  1066–1075 nonsteroidal anti‐inflammatory drugs (NSAIDs) minimally invasive prostate therapy  1664

renal colic  806–807 see also ketorolac NOTES see natural orifice transluminal endoscopic surgery Nottingham dilator  612, 619 nuclear medicine, radiation safety  19 nutcracker syndrome  566, 1464, 1465 obesity kidney transplantation  1259, 1260 laparoscopic and robotic surgery  901, 922, 937–938 midurethral slings  1860 operating room equipment  1651 PCNL  194–198, 847–848, 849 complications of positioning  202, 205 lateral(‐flexed) position  192–193, 194, 198 prone position  198, 205, 847–848 supine position  174, 176, 847–848 thoracic complications  412 tips and tricks  850 radiation dose reduction  24 radiation exposure  15, 19, 211 robotic surgery  910 stone disease  843–850 diet and medical therapy  845 interventional therapies  845–848 prevalence 843 risk factors  843–845 SWL  732, 745–746, 846 obstructed labor, neglected  1242 obstructive nephropathy causes  125 pathophysiology  124, 130–138 see also urinary tract obstruction ObTryx midurethral sling  1856 obturator nerve injury  1028, 1057, 1653 pelvic lymphadenectomy  1053, 1056, 1057, 1175 stimulation during TURP  1740 obturators, visual  1654 occupational radiation exposure  20 brachytherapy placement  28 minimizing  21–22, 28, 1659 Occupational Safety and Health Administration 1659 OCTO Port V2  1362–1363, 1365 ocular complications laparoscopic and robotic surgery  907, 914, 935 prone position  202–203 office settings see outpatient/office settings OIH (131I‐ortho‐iodohippurate) renography 127, 128 older patients see elderly patients oliguria, pneumoperitoneum‐related  920 Olympus endoureterotome  613, 614 Olympus High Definition (HD) 10 mm laparoscope 44–45 Olympus High Definition Flexible Cysto‐Nephro Videoscope (HD CYF‐VH)  42 Olympus/Olympus Gyrus ACMI ureteroscopes flexible  477, 479–480 semirigid  472 Sun’s ureterorenoscope and  486–487

i25

i26

Index Olympus TURis bipolar system  1744, 1745, 1747–1748, 1749 omental wraps, ureteral anastomoses  1200 omentum interposition graft, vesicovaginal fistula repair 1247 mobilization, vesicovaginal fistula repair 1246 onabotulinumtoxinA (Botox™) overactive bladder  1776–1779 see also botulinum toxin A on‐board imaging, prostate radiotherapy 1560–1561 oncocytomas, renal biopsy  1428, 1429, 1435 imaging 1406, 1407 one‐shot dilation, PCNL  276–277, 278–279 complications 281 Onik maneuver, prostate cryotherapy  1589, 1595 open stone surgery PCNL after prior  398, 399 pelvic kidneys  822 renal stones  397, 783–784, 1208 transplant lithiasis  833 ureteral stones  783 urinary‐diversion stones  838 open urologic surgery prevention of infections  66–67 ureteral strictures complicating  617 operating room (OR)  143–158, 1649–1651 data management  153–157, 1651 design  144–146, 1650 designing and planning  143–144 energy sources  1657–1659 high‐definition camera systems  146 integrated data‐acquisition systems 151–153 lighting  145, 1650–1651 modular 151 size  144, 1649 sterilization facilities  146 Universal Protocol  1651 video system setup  48, 49, 50 workstations 154–155 zones and flow‐through  144 operating room (OR) setup  146–151 continent urinary diversion  1129 inguinal lymphadenectomy  1061, 1062 laparoscopic surgery  149, 150, 902–905 lower tract procedures  1651–1652 partial cystectomy  1118 partial nephrectomy  1089, 1090–1091 PCNL  147–150, 175, 176 radical cystectomy  1108 renal cyst decortication  1224 retroperitoneal lymph node dissection  1067–1071 robotic surgery  150, 151, 902–905, 911–912 ureteral reconstruction  1196 ureteroscopy 147, 148, 522 operating room (OR) table 145 lower tract procedures  1650–1651 PCNL 199 prone‐flexed position  187, 188, 189, 191 prone position  187, 188 supine‐modified position  175, 176 Volume 1 pages 1–878, Volume 2 pages 879–1913

robotic system integrated motion  958 Uro Dyna‐CT system  223 operative times laparoscopic pyelolithotomy  1208, 1209 laparoscopic radical prostatectomy  1151, 1152 laparoscopic ureterolithotomy  1215 LESS adrenalectomy  1289 miniaturized PCNL  306 PCNL‐related bleeding and  398 prone vs. supine PCNL  205 pyeloplasty in children  1332 robotic radical prostatectomy  1170 robotic simple prostatectomy  1273, 1274 Ophira™ mini sling system  1834, 1842 opioid analgesics (narcotics) after laparoscopic/robotic surgery  932–933 minimally invasive prostate therapy  1664 renal colic  806 optical coherence tomography (OCT)  42 partial nephrectomy margins  1098–1099 upper urinary tract tumors  566, 572 optical fiber composite overhead ground wire 155 optical puncture system, PCNL access  245, 246, 252 optics flexible ureteroscopes  475–476 rigid ureteroscopes  468 rod–lens systems  466–467, 468 semirigid ureteroscopes  470 Sun’s ureterorenoscope  487 see also fiber‐optics Optiflex stone basket (Boston Scientific) 509 OPUS (Outcomes Following Vaginal Prolapse Repair and Midurethral Sling) trial  1235, 1862 OR1™ modular operating room (Karl Storz) 151 Orchestra guidewire (Coloplast)  507 orchiectomy, laparoscopic testicular atrophy  1349 undescended testes  1345 orchiopexy, laparoscopic  1345–1349 bladder injury  1326 decision making  1345 Fowler–Stephens 1348–1349, 1350 outcomes 1349, 1350 surgical technique  1347–1348 trocar placement  1346 ortho‐iodohippurate (OIH) renography 127, 128 ortho‐phthalaldehyde (OPA)  9, 11 orthotopic neobladder see neobladder outpatient/office settings cystoscopy 1643–1647 disinfection and sterilization of instruments  9, 10, 12 focal laser ablation of prostate cancer 1528 local anesthesia for prostate procedures 1661–1668 robot‐assisted laparoscopic radical prostatectomy 1181 ureteroscopy  642, 643

ovarian veins embolization 1474–1477 pelvic congestion syndrome  1473, 1474 overactive bladder (OAB)  1775–1779 botulinum toxin injections  1775–1779 adverse outcomes  1778 mechanism of action  1776 repeat 1778 results 1776–1778 techniques 1778–1779 idiopathic  1775, 1777, 1779 neurogenic  1775, 1776–1777, 1778, 1779 neuromodulation 1902–1911 pediatric 1777–1778 percutaneous tibial nerve stimulation  1909–1910 sacral nerve stimulation  1903–1904, 1909 see also detrusor overactivity oxalate decarboxylase  361, 362 oxalate oxidase  362 oxidized cellulose, nephrostomy tract  435, 437 oxybutynin, ureteral stent‐related pain 643–644 oxycodone, stone passage and  543 oxycodone/acetaminophen  1664 pacemakers, and SWL  738, 758 paclitaxel‐eluting stent  873 padding lateral‐flexed position  192, 193 prone(‐flexed) position  187, 189, 202, 214 Page kidney  405, 1405 pain bladder pain syndrome  1795 postoperative see postoperative pain renal colic  643, 806–807 rigid cystoscopy  1663 ureteral 457 ureteral stent‐related  643–644, 645 PAKY‐RCM robot system  271 PAKY robot system  270–271, 273 palladium‐103 (103Pd) prostate implants  1537, 1538, 1541–1542 Palmaz balloon‐expandable stent  637 Palomo procedure  1357, 1466 pampiniform plexus female 1473 male  1354, 1464, 1465 pancreas laparoscopy‐related injuries  1041, 1284 metastases, renal cell carcinoma  1420 post‐SWL disorders  758 Panum’s region  49 papaverine, living donor nephrectomy 1254 papillary adenomas, renal  1406 papillary renal cell carcinoma  1408 hereditary 1407, 1408 Paquin ureteral reimplantation technique 608 paragangliomas 1278–1279 paramedian incision, laparoscopic specimen extraction 1012 parapelvic cysts  349, 1226–1228, 1405 pararenal space anterior 87, 89 posterior 87, 89

Index parastomal hernias  1309–1311 partial cystectomy  1115–1123 outcomes 1115 patient selection  1115–1116 robot‐assisted laparoscopic  1117–1123 complications 1123 operating room setup  1118 patient positioning  1117–1118 postoperative care  1122 preoperative preparation  1117 procedure 1118–1122 surveillance after  1122 trocar placement  1118 treatment strategies  1116–1117 tumor recurrence after  1116–1117, 1122 partial nephrectomy (PN), laparoscopic alternatives to  1442 augmented reality  52–53 children 1324 complications 1095 bleeding  1024–1025, 1040 urine leaks  1041 cryoablation vs.  1455–1456 equipment 903 hand‐assisted 1003 intraoperative assessment of resection margins 1097–1099 LESS 1376–1377 postoperative drainage  1016, 1017 renal stone disease  1209, 1216 renal tumors  1077, 1097, 1455 robot‐assisted 1088–1095 augmented reality  52–53 equipment 1089–1090 operating room setup  1089, 1090–1091 patient positioning  1089, 1092 postoperative care  1095 preoperative evaluation  1088–1089 simulators  167 technique 1091–1095 trocar placement  980–981, 1091–1092 simulators  166 thulium laser‐supported  1715 trocar placement  980–981, 1091–1092 warm ischemia time  1088 zero‐ischemia minimal‐margin  1094–1095 see also nephron‐sparing surgery Partin tables, prostate cancer staging  1049 Pasteur, Louis  3 Pathfinder irrigator  516 patient handouts  1659–1660 patient positioning see positioning of patient PCNL see percutaneous nephrolithotomy pediatric patients see children Peditrol irrigation system  511 pelvicalyceal system see renal collecting system pelvic congestion syndrome (PCS) 1473–1477 diagnostic evaluation  1474–1475, 1475 gonadal vein embolization  1475–1477 pathophysiology 1474 treatment options  1474 pelvic fascia see endopelvic fascia pelvic floor muscle training (PFMT) postoperative 1188–1189 preoperative 1180–1181 Volume 1 pages 1–878, Volume 2 pages 879–1913

pelvic floor physical therapy, bladder pain syndrome 1797 pelvic kidneys  818–824 blood supply  818, 819 embryology 818 nephrolithiasis 818 stone management  819–822 UPJ obstruction  822–823 see also ectopic kidneys; transplant kidneys pelvic lipomatosis  617 pelvic lymphadenectomy  1048–1058 anatomy 1051–1052 bladder cancer  1051–1052, 1110 complications 1057–1058 extended template (ET)  1048, 1053 bladder cancer  1051, 1052 procedure  1055, 1056–1057 prostate cancer  1050–1051 extraperitoneal approach  991, 1173 limited (standard) template (LT)  1048, 1050, 1053 prostate cancer  1048–1051 prior to cryoablation  1593, 1594 robotic 1054–1057 port placement  982, 983, 1054–1055 procedure  1055–1057, 1110 robot positioning  1055 robotic radical prostatectomy 1174–1175 super extended template (SET)  1048, 1053 bladder cancer  1051–1052 trocar placement  982, 983 pelvic neuroanatomy  1662 pelvic organ prolapse (POP)  1234–1241 abdominal vs. vaginal approaches  1234 incontinence surgery and  1235, 1861–1862 laparoscopic and robotic sacrocolpopexy  1234, 1235–1241 mesh complications  1856, 1880–1887 preoperative evaluation  1234–1235 stress urinary incontinence and  1872 vaginal approach see vaginal prolapse surgery pelvic pain after mesh prolapse repair  1882, 1886–1887 chronic  1473–1474, 1796 pelvic (inferior hypogastric) plexus  1143, 1662 pelvic surgery robotic see robotic pelvic surgery ureteral strictures after  609, 610 pelvis, bony, and SWL  779 pendant services, operating room  144 PENDUAL ENDOCAM Logic HD video camera  41 penetration depth, laser energy  1694 d‐penicillamine, cystine stones  359 penis anatomy 1815, 1816 carcinoma, lymphadenectomy  1060–1065 prostheses, equipment setup  1656–1657 Penrose drain  1017 pentosanpolysulfate, bladder pain syndrome  1797, 1798 peracetic acid  7–8, 9

Perc NCircle® stone basket  291, 317 Percuflex stents  645, 866 percussion, after SWL  738–739 percutaneous antegrade endopyelotomy see endopyelotomy, antegrade percutaneous cystolithotomy, urinary‐ diversion calculi  837–838 percutaneous instillation of topical agents see topical therapy of upper urinary tract percutaneous nephrolithotomy (PCNL) antegrade ureteroscopy  294–299 antibiotic prophylaxis  64–66, 338 bilateral, children  338 blind access  27, 264–267 anatomy 264–266 complications 267 indications 264 results 267 technique 266–267 calyceal diverticula  341–346 children 332–339 residual fragments 448 complications abdominal organ injuries see intra‐ abdominal organ injuries access‐related 390–395 blind access  267 children 338–339 endoscopic guidance  234 hemorrhagic see bleeding/hemorrhage, PCNL‐related horseshoe kidney  815, 816 miniaturized techniques  306 patient positioning and  199–203 prediction of risk  119–120, 390, 391 prevention 390 rates 390 risk factors  390, 391 staghorn calculi  319 thoracic see thoracic complications, PCNL upper pole access  259–262 contraindications 399 cost effectiveness  858–859 CT guidance  221–226 calyceal diverticula  344 horseshoe kidney  815 preoperative imaging  212–213, 222, 230, 311 standard CT  221–223 Uro Dyna‐CT  223–226, 246, 248–251 endoscopic guidance  229–234 advantages 233–234 complications 234 instrumentation list  230 limitations 234 patient positioning  231 preoperative preparation  230 radiation dose reduction  27, 233–234 renal puncture  231–232 retrograde preparation  231 supine‐modified position  177–181 surgical technique  230–233 through‐and‐through guidewire  232 tract dilation  232–233 exit strategies  427–437 children 337–338 staghorn calculi  317–318

i27

i28

Index percutaneous nephrolithotomy (PCNL) (cont’d ) failed, patient positioning and  204 fluoroscopic control  210–218, 244 disadvantages  221, 223 endoscopic guidance  231–232 flexible nephroscopy  292 horseshoe kidney  814–815 lateral(‐flexed) position  193–194, 195–197, 217 preoperative images 212–213 prone position  186, 187, 213–216 radiation exposure  19–20, 211–212 renal puncture  213–217 staghorn calculi  314, 315, 318–319 supine position  216 tract dilation  217–218 ultrasound control vs.  212, 241–242 upper pole access  257–258 history of development  210, 229, 301 horseshoe kidney  199, 813–815, 816 indications 549–550, 551 infundibular stenosis  346–348 laparoscopy‐assisted 820–821, 1216–1217 lithotripsy 322–328 micro (micro‐perc) see micro percutaneous nephrolithotomy mini (mini‐perc) see mini‐percutaneous nephrolithotomy miniaturized (small caliber) techniques 301–307 applications 306–307 classification 302–303 comparative studies  306, 307 tract dilation  276 multiple tract  218, 315–316 bleeding risk  398 children 335 nephrolithometric scoring systems 108–120 nephroscopy 285–292 obesity see obesity, PCNL operating room setup  147–150 patient positioning see positioning of patient, PCNL pelvic kidneys  820–821 pregnancy  30, 794 radiation exposure  19–20, 23 CT guidance  222 dose reduction strategies  27, 211 endoscopic guidance  233–234 fluoroscopic guidance  19–20, 211–212 new access technologies  252–253 occupational  20, 28 preoperative imaging  18 preoperative prediction  120 supine position  174 Uro Dyna‐CT guidance  224, 225, 253 renal cysts  348–349 residual stone fragments 444–448 children 448 management  319, 446–448 natural history  446, 772–773 robotic access  269–273 sandwich therapy  338 simulator training  28, 165 staged, children  338

Volume 1 pages 1–878, Volume 2 pages 879–1913

staghorn calculi see under staghorn calculi standard 303 stone size and  780, 781, 782 super‐mini (SMP)  276 tract see nephrostomy tract transplant kidneys  240, 823, 832–833 tubeless see tubeless percutaneous nephrolithotomy ultra‐mini see ultra‐mini percutaneous nephrolithotomy ultrasound‐endoscopic approach  244–245 ultrasound guidance  237–242, 244–245 ectopic kidneys  240 fluoroscopy vs.  212, 241–242 horseshoe kidney  814 indications 237 instrumentation 237–238 lateral(‐flexed) position  193 pelvic kidneys  821 preceptorship and mentoring  240–241 radiation dose reduction  27 transplant kidneys  240 ultrasound technique  238–240 upper pole access  255–262 anatomic aspects  255–257 complications 259–262 indications 255 outcomes 259 surgical technique  257–259 ureteral stones  296–297 urinary diversion patients  839 Uro Dyna‐CT guidance  223–226, 246, 248–251 percutaneous nephrostomy see percutaneous renal access percutaneous nerve evaluation (PNE)  1905–1906, 1909 percutaneous renal access anatomy  87–104, 199 general anatomy  87–92 intrarenal vasculature  101–104, 105–106 pelvicalyceal system  92–101 antegrade endopyelotomy  378 antegrade ureteroscopy  296 children 334–335 complications 390–395 cost‐effectiveness 855 CT guidance  221–223 electromagnetic tracking sensors  246, 247–248, 249 endoscopic guidance  229–234 advantages 233–234 complications 234 limitations 234 preoperative preparation  230 supine‐modified position  177–181 surgical technique  230–233 endoscopic‐ultrasound approach  244–245 failure rates  390 fluoroscopic control  213–217, 244 bullseye technique  188–191, 214 challenging situations  217 geometric model (Mues)  214–215 Sharma & Sharma technique  215–216 triangulation technique see triangulation technique

history  210, 229 instillation of topical agents see topical therapy of upper urinary tract iPad‐assisted marker‐based system  52, 245–247, 252, 253 multiple tracts  218, 315–316 needles see nephrostomy needles new technologies  244, 245–253 obesity 848, 849, 850 patient positioning  173–181, 185–205 planning  213, 222, 230 prone position  185–187 Uro Dyna‐CT  224, 225 retrograde technique  229 robotic 269–273 development 270–273 goals 269–270 mechanical gantry system  272–273 needle‐based therapies  271–272 Smart Needle system  271 telemedicine 273 sheath see nephrostomy access sheath staghorn calculi  312, 314–316 thoracic complications see thoracic complications, PCNL tracts see nephrostomy tract transplant kidneys  833 ultrasound guidance  237–242, 244–245 ectopic and transplanted kidneys  240 fluoroscopy vs.  212, 241–242 indications 237 instrumentation 237–238 lateral(‐flexed) position  193 needle guides  238, 239 optical puncture system  245, 246 preceptorship and mentoring  240–241 radiation dose reduction  27 SonixGPS navigation  246, 251–252 ultrasound technique  238–240 upper tract urothelial carcinoma  386 ureteroenteric strictures  630 Uro Dyna‐CT guidance  223–226, 246, 248–251 urologists vs. radiologists  241, 312, 399, 412 without image guidance (blind)  27, 264–267 anatomy 264–266 complications 267 indications 264 results 267 technique 266–267 see also nephrostomy tubes; renal collecting system puncture percutaneous renal surgery antibiotic prophylaxis  61, 64–66 calyceal diverticula  341–346 cryoablation of renal masses  1457–1461 infundibular stenosis  346–348 renal cysts  348–349 thoracic complications  409–420 UPJ obstruction  377–382, 590 upper tract urothelial carcinoma  384–388 percutaneous tibial nerve stimulation (PTNS)  1902, 1909–1911 Pérez‐Castro, Enriqué  467

Index perineal pain, after prostate cryoablation  1584, 1585, 1598–1600 perineal robot‐assisted laparoscopic prostatectomy 1387–1389 perineal skin care, urinary fistulas  1245 perinephric hematoma imaging 1401, 1405 post‐PCNL 405 post‐renal biopsy  1431 post‐SWL  80, 757 postureteroscopy 663 see also renal hematoma Peripheral Stent (Cook Medical)  614 perirenal coverings, anatomy  87–88, 89 perirenal space intermediate 87, 89 right and left  88 peritoneum inadvertent entry, retroperitoneal approach 992 interposition graft, vesicovaginal fistula repair 1247 laparoscopic adrenalectomy  1283 laparoscopic orchiopexy  1347 peritonitis, postoperative  394, 423, 1228 periumbilical incision, LESS surgery 1373–1374 periurethral route, urethral bulking therapy 1849 peroneal nerve injuries  203, 662, 1653 personal protective equipment (PPE)  4, 9 PET see positron emission tomography Pfannenstiel incision laparoscopic specimen extraction  1012 LESS surgery  1374–1375 live donor nephrectomy  980, 981, 1253–1254 radical nephrectomy  1081–1082 phenazopyridine female genitourinary fistulas  1243, 1244 ureteral stent‐related pain  643–644 pheochromocytoma laparoscopic adrenalectomy  1278–1279, 1281 LESS adrenalectomy  1288, 1289 partial adrenalectomy  1282 phleboliths  800, 802 Phoenix definition, prostate cancer relapse 1596 phosphodiesterase 5 (PDE‐5) inhibitors 1187–1188 photodynamic diagnosis (PDD) bladder cancer  42 upper tract urothelial cancer  43–44, 566 photofluorography, voiding cystourethrography 29 photoselective vaporization of prostate (PVP) 1694–1703 60W laser systems  1694–1695 80W laser systems  1695–1697 120W laser systems  1697 180W laser systems  1698–1699 complications 1702–1703 contraindications 1703 history of evolution  1678–1679, 1694–1699

Volume 1 pages 1–878, Volume 2 pages 879–1913

holmium laser therapy vs.  1682, 1684 laser physics  1678 patient preparation  1699–1700 postoperative care  1701–1702 preoperative preparation  1700 pudendal nerve block  1668 technique 1700–1701 Phyllanthus niruri 739 physical activity preoperative, radical prostatectomy  1180 stone risk and  844 physical therapy bladder pain syndrome  1797 postoperative 1188–1189 preoperative 1180–1181 picture archiving and communication systems (PACS)  1651 piezoelectric (PE) lithotripters  692, 696 clinical use  708 shock‐wave focusing  693, 695 shock‐wave generation  693, 715–716 shock‐wave profile and distribution 693–695 pigtail nephrostomy tube (NT)  428 piperacillin/tazobactam resistance  60 PI‐RADS v2 see Prostate Imaging Reporting and Data System version 2 PK™ dissecting forceps  956 PKS™ OMNI bipolar device  950 PK® SuperPulse® generator (Gyrus)  1655, 1754–1755 PK® tissue management system (Gyrus) 1744, 1745, 1756 bipolar TURP  1746–1747, 1748 bipolar vaporization of prostate  1753–1754, 1755–1756 transurethral vaporization resection of prostate 1757 plasma corona  1745–1746 plasmakinetic button vaporization of prostate 1758–1760 plasmakinetic vaporization of prostate see transurethral resection of prostate (TURP), bipolar Pleth Variability Index (PVI)  936 pleura, anatomy  88–89, 90, 257, 409–410 pleural effusions management  259, 418 percutaneous renal surgery  261, 413 pleural injury laparoscopic surgery  1041–1042 percutaneous renal surgery  201, 234, 394, 412–413 etiology and risk factors  410–412, 424 supracostal access  259, 260, 261 radiofrequency ablation of renal tumors 1447, 1448 see also hemothorax; hydrothorax; pneumothorax pneumatic lithotripsy mechanism of action  533, 534 staghorn calculi  317 ureteroscopy  508, 533–534, 539, 545–546 see also ballistic lithotripsy pneumodissection, cryoablation of renal masses 1457, 1460 pneumomediastinum 936

pneumopericardium 936 pneumoperitoneum 918–923 anesthetic management  929 cardiac and hemodynamic effects 919–920 cardiac patients  936, 1325 cerebral effects  920 complications  921–922, 1022–1023, 1033–1034 creation see insufflation high pressure  1033 inadvertent, extraperitoneal pelvic access 992 modifications 922–923 obese patients  922, 937–938 older patients  937 physiologic effects  918–923, 930–931, 1033–1034 children 1325–1326 pregnancy 937 pulmonary effects  918–919 renal effects  920 robotic partial nephrectomy  1091–1092 stress response  920–921 warmed gases  922–923 Pneumo Sleeve  995 pneumothorax laparoscopic surgery  921, 936, 1042 percutaneous renal biopsy  1431 percutaneous renal surgery  394, 412–413, 424 diagnosis 415 management 418–419 radiofrequency ablation of renal tumors 1447, 1448 Polar‐Cath balloon dilator, ureteroenteric strictures 634 Polaris stent  645 polarizing glasses  51 Politano‐Leadbetter ureteral reimplantation technique 608 polyacrylamide hydrogel (Bulkamid™)  1849, 1850 polycystic kidney disease, autosomal dominant (ADPKD)  1221 polydimethylsiloxane 1850 PolyScope® (Lumenis)  477, 480, 499, 500 polytetrafluoroethylene (PTFE; Teflon)  1784, 1847 polyvinyl alcohol (PVA) embolization, prostatic arteries  1492 popcorn effect  538, 553 Avicenna robot system  678 porcine dermal implant, transurethral injection 1851 port(s) hand‐assist  952, 995–996, 997 LESS surgery  1361–1366, 1373–1374 specimen retrieval  1012 see also trocar(s) port placement see trocar placement port site bleeding  977–978, 1013 fascial closure  1013–1016 children 1326 devices  952, 1013, 1014 extracorporeal instruments  1015 intracorporeal techniques  1013–1015

i29

i30

Index port site (cont’d) retroperitoneal and pelvic extraperitoneal cases  992 standard techniques  1015–1016 infections 978 skin closure  1016 port‐site hernias  978, 1025, 1026 children 1326 prevention  1013, 1302 see also incisional hernias port size  977 adrenalectomy 978 closure 1013 position‐encoded joint tracking, prostate biopsy 1502–1503 positioning of patient complications  1653 endoscopic inguinal lymphadenectomy 1061, 1063 laparoscopic surgery  905–908 adrenalectomy  1282, 1284 anesthetic aspects  929–930 calyceal diverticular surgery 1230–1231 complications  907, 935–936, 1023–1024 extraperitoneal pelvic access  991 living donor nephrectomy  1251 nephroureterectomy 1102 physiologic effects  917–918, 931 preventing complications  1034–1035 pyeloplasty 1329 radical nephrectomy  1078, 1079, 1081, 1083–1084 radical prostatectomy  1143, 1144 renal cyst decortication  1224–1225 renal surgery  905–906 retroperitoneal approach  988 retroperitoneal lymph node dissection 1067, 1068 lower tract procedures  1652, 1653 PCNL 185–205 anatomic aspects  199 children 333–334 comparative studies  203–205 complications and  199–203 complications specific to  202–203 CT‐guided access  221–222 endoscopic‐guided access  231 lateral and lateral‐flexed  192–194 morbid obesity  194–198 musculoskeletal abnormalities  198 prone and prone‐flexed  185–191 renal anomalies  198–199 renal mobility and  174, 199, 200 staghorn calculi  312–314 stone fragment drainage  291 supine and supine‐modified  173–181 surgical tables 199 percutaneous cryoablation of renal masses 1457 robotic surgery  906–908, 912, 913–914 anesthetic aspects  929–930 complications  907, 913–914, 935–936, 1043 continent cutaneous urinary diversion 1134

Volume 1 pages 1–878, Volume 2 pages 879–1913

continent urinary diversion  1129, 1137 kidney transplantation  1262 lower ureteral reconstruction in children 1337 partial cystectomy  1117–1118 partial nephrectomy  1089, 1092 pelvic surgery  906–907 physiologic effects  917–918, 931 pitfalls  907, 913–914 preventing complications  1034–1035 radical cystectomy  1108 radical prostatectomy  1171, 1173 retroperitoneal lymph node dissection 1067, 1068 ureteral reconstruction  1196–1197 vasectomy reversal  1315 SWL 748–749 transrectal biopsy of prostate  1501 ureteroenteric strictures  630 ureteroscopy  515, 551 complications 662 positive end expiratory pressure (PEEP) 929 positive surgical margins (PSM) en bloc resection of bladder tumors 1810–1811 nephron‐sparing surgery  1097, 1098, 1099 radical cystectomy  1111–1112 radical prostatectomy  1153–1155, 1170 see also frozen sections, intraoperative positron emission tomography–computed tomography (PET‐CT) lymph node metastases  1049, 1051 prostate cancer  1593 radiation exposure  19, 23 renal masses  1395–1396 positron emission tomography–magnetic resonance imaging (PET‐MRI)  1396 postembolization syndrome  404–405 posterior axillary line  175, 176 posterior detrusor apron, robotic simple prostatectomy 1272 posterior pararenal space  87, 89 posterior segmental (renal) artery  90–91, 265 intraoperative injury  101–103 postoperative nausea and vomiting (PONV) 933–934 postoperative pain gonadal vein embolization  1472 laparoscopic and robotic surgery  932–933, 1034 laparoscopic radical prostatectomy  1151 living donor nephrectomy  1257 mesh prolapse repair  1882, 1886–1887 midurethral sling surgery  1864 miniaturized PCNL  306 prostate cryoablation  1598–1600 radiofrequency ablation of renal tumors 1446 supracostal renal access  261–262 trocar‐related 978 tubeless PCNL  431 ureteroscopy  643–644, 648

post‐prostatectomy urinary incontinence 1890–1899 evaluation 1638–1640 laparoscopic and robotic surgery 1155–1158, 1159, 1171 management 1891–1892 pathophysiology 1890–1891 urethral sling surgery  1892–1899 see also laparoscopic radical prostatectomy (LRP), continence preservation Post‐Ureteroscopic Lesion Scale (PULS)  657 potassium citrate after SWL  448, 739 obese stone formers  845 stone dissolution therapy  358 potassium sensitivity test, interstitial cystitis 1796 potassium titanyl phosphate lasers see KTP lasers Potts scissors  957 POWER LED 300 system (Karl Storz)  46 prasugrel 76 precleaning, instrument  6 Prefyx PPS midurethral sling  1856 pregnancy anatomic changes  786, 787 diagnostic imaging  787–790 laparoscopic surgery  937 physiologic changes  786 radiation exposure  29–30, 787–788 robotic surgery  910 SWL  731, 758, 794 urolithiasis 786–794 diagnostic tests  30, 787–790 incidence 787 management 791–794 pathophysiology 786–787 presentation 787 preoperative assessment continent urinary diversion  1129 female genitourinary fistulas  1243 inguinal lymphadenectomy  1061 laparoscopic and robotic surgery 928–929 living donor nephrectomy  1250–1251 lower ureteral reconstruction in children 1335–1336 partial cystectomy  1117 partial nephrectomy  1088–1089 PCNL  311, 399 pelvic lymphadenectomy  1049, 1051 percutaneous antegrade ureteroscopy 294–295 radical nephrectomy  1078 radical prostatectomy  1179–1180 renal cysts  1222–1224 retroperitoneal lymphadenectomy  1067 risk factors for infection  59 robot‐assisted vasectomy reversal  1314 robotic abdominal sacrocolpopexy  1235 robotic ureteral reconstruction  1194–1195 selective arterial prostate embolization 1489–1490 SWL 731 TURP 1736

Index undescended testes  1344–1345 UPJ obstruction  377, 378 ureteroscopy  514–515, 521–522, 544 preoperative patient preparation  1652–1653 prep table 1655, 1657 preputial grafts, bladder neck contracture 1829 pressure‐related kidney injuries  661 pressure waves see acoustic waves presurgical checklists  1032 priapism, during TURP  1740 procalcitonin 68 ProGrasp forceps  956 prolapse, pelvic organ see pelvic organ prolapse prone‐flexed position, PCNL  185–191 adjuncts to assist  191 advantages  186, 191 choice of calyx  185–187 complications  199–200, 202–203 disadvantages  186, 191 renal puncture and tract dilation  187–191 staghorn calculi  313, 315 pronephros 455 prone position PCNL  173, 185–191 adjuncts to assist  191 advantages  186, 191 children 333 choice of calyx  185–187 comparative studies  203–205 complications  199–201, 202–203 CT‐guided access  221–222 disadvantages 173, 186, 191 fluoroscopy‐guided access  213–216 horseshoe kidney  814, 815 obesity  198, 205, 847–848 renal puncture and tract dilation 187–191 staghorn calculi  312–314 upper pole access  191, 257 SWL 748, 749 pelvic kidneys  819 prone split‐leg position, PCNL  186, 191, 314 propofol anesthesia  929 prostate ablative techniques for BPH  1727–1730 anatomy  1141–1143, 1181–1182 fascial  1141, 1142 terminology 1141–1142 contrast‐enhanced ultrasound  1606–1608, 1610 nerve supply  1142, 1181–1182, 1662 neurovascular bundles see neurovascular bundles (NVBs), periprostatic prostate artery embolization see selective arterial prostate embolization prostate biopsy antimicrobial prophylaxis  61 cognitive fusion  1497, 1511 contrast‐enhanced ultrasound‐ targeted 1607 cryoablation follow‐up  1596–1597 focal therapy of prostate cancer 1510–1511, 1513

Volume 1 pages 1–878, Volume 2 pages 879–1913

in‐gantry MRI  1497 local anesthesia  1665, 1666 MRI‐TRUS fusion see multiparametric magnetic resonance imaging/ ultrasound fusion‐guided prostate biopsy radical prostatectomy after  1179 transrectal ultrasound‐guided (TRUS Bx) anticoagulated patients  80 focal therapy of prostate cancer 1510–1511 limitations  1495, 1606 local anesthesia  1665, 1666 targeted biopsy after negative  1498 prostate blocks, local anesthetic 1665–1668 transperineal 1666–1667 transrectal 1665–1666 transurethral 1667–1668 prostate cancer (PCa)  1048–1051 active surveillance  1499, 1510 androgen‐deprivation therapy see androgen‐deprivation therapy benign prostatic hyperplasia  1275, 1746 biochemical relapse criteria  1553, 1595–1596 brachytherapy 1534–1545 contrast‐enhanced ultrasound 1606–1608 quantification 1610, 1611 targeted microbubbles  1611 cryotherapy see prostate cryoablation epidemiology 1550–1551 external beam radiotherapy  1514, 1534, 1550–1564 focal laser ablation  1523–1531 focal therapy  1509–1518 ablation patterns  1512, 1514 active surveillance and  1510 choice of modality  1514 concepts 1509 contrast‐enhanced ultrasound 1607–1608 follow‐up 1514–1518 historical perspective  1509 outcomes  1515–1517, 1518 patient selection  1510–1512, 1513 technologies 1512–1514 high‐intensity focused ultrasound  1512, 1567–1577 index lesion  1509, 1567–1568 lymph node imaging  1049 MRI 1616–1623 after focal laser ablation  1529–1531 focal laser ablation guidance 1525–1526, 1527 multiparametric 1495–1497, 1498–1499, 1616–1623 prior to cryoablation  1593, 1594 prior to laparoscopic surgery 1179–1180 T2‐weighted (T2W)  1616–1618 pelvic lymphadenectomy  1048–1051 patient selection  1049–1050 rationale for extended  1050–1051 post‐treatment urinary incontinence 1890

prior negative TRUS biopsy  1498 radical prostatectomy see radical prostatectomy risk stratification  1551–1552 screening 1551 selective arterial prostate embolization and 1490 staging multiparametric MRI  1511, 1617, 1618 prior to cryoablation  1593 prostate cryoablation  1580–1587, 1589–1601 complications  1584–1586, 1598–1601 equipment 1589–1590 focal (targeted)  1512, 1586–1587 hemigland 1591, 1592 history of development  1589–1590 mechanisms of action  1580–1581, 1590–1591 operative technique  1595 patient preparation  1594–1595 patient selection  1581–1582, 1592–1594 postoperative care  1595–1597 primary outcomes  1583, 1584–1586, 1597–1598 patient selection  1581, 1593–1594 results  1515–1516, 1583, 1584, 1597–1598 salvage complications 1585 indications  1581–1582, 1594 oncologic outcomes  1583, 1584, 1597, 1598 types 1591, 1592 whole‐gland 1582–1586 complications 1584–1585 functional outcomes  1585–1586 oncologic outcomes  1583 procedure 1582–1583 zonal 1591 prostatectomy (simple) indications 1270 laparoscopic 1270 rectal injury  1026–1027 ureteral injury  1029 laser see laser prostatectomy LESS 1762–1768 open (OSP)  1273, 1274, 1489 history 1269–1270 laser prostatectomy vs.  1687, 1690, 1711 retropubic approach  1272–1273 robot‐assisted see robot‐assisted laparoscopic prostatectomy see also radical prostatectomy; transurethral resection of prostate Prostate Imaging Reporting and Data System version 2 (PI‐RADS v2)  1497, 1498–1499, 1621–1622 prostate size see prostate volume prostate specific antigen (PSA) biochemical failure criteria  1553, 1595–1596 posttreatment

i31

i32

Index prostate specific antigen (PSA) (cont’d) cryotherapy 1595–1596 external beam radiotherapy  1553 focal laser ablation  1529, 1530 HIFU 1576 holmium laser enucleation of prostate 1687 laparoscopic radical prostatectomy 1155, 1156 laser prostatectomy  1702 MRI/TRUS fusion biopsy  1499–1500 salvage cryoablation  1582, 1594 pretreatment pelvic lymph node dissection  1049 selective arterial prostate embolization 1490 screening 1551 prostate stents  1729 prostate volume after holmium laser enucleation of prostate 1687, 1688 after selective arterial prostate embolization 1489, 1493 age‐related increase  1719 androgen‐deprivation therapy and  1535–1536, 1594–1595 bipolar TURP and  1748 cryoablation of prostate and  1581, 1594–1595 estimation 1490 laparoscopic radical prostatectomy and 1151–1153 photoselective vaporization of prostate and  1695, 1699 simple prostatectomy technique and 1764 prostatic capsule  1142 perforation, TURP  1740 prostatic fascia  1141, 1142 prostatic urethral lift (PUL) procedure 1719–1725 anatomy 1720 clinical outcomes  1723–1725 equipment  1654, 1720, 1721 indications 1720–1721 surgical technique  1721–1723 prosthetic surgery antimicrobial prophylaxis  61 equipment preparation  1655–1657 male urethral slings  1892–1899 midurethral slings  1832–1835, 1854–1867 operating room preparation  1651–1652 prostatic urethral lift procedure 1719–1725 pubovaginal slings  1873 single‐incision slings  1832–1843, 1862–1863 STING procedure for reflux  1784–1789 urethral bulking agents  1847–1851 see also mesh, synthetic protamine sulfate  74 Proteus, stone formation  360 proximal ureter anatomy 455, 456 percutaneous endopyelotomy  378, 379

Volume 1 pages 1–878, Volume 2 pages 879–1913

reconstructive surgery  1196 options  658, 1196 patient positioning  1196–1197 trocar configuration  1197–1198 tumors, percutaneous resection  386 vascular anatomy  605, 606 proximal ureteral stones management 779 migration into kidney  486, 491 Sun’s ureterorenoscope  492 ureter‐occluding devices  508–509 percutaneous antegrade ureteroscopy 296–297 outcomes  298, 299 percutaneous nephrostomy  255, 296 retrograde ureteroscopic access, failure 525 Sun’s ureterorenoscope  492 SWL 747 treatment options  294, 295 PSA see prostate specific antigen Pseudomonas 58 psoas hitch  608 mid‐ureteral strictures  600 pediatric laparoscopic and robotic 1339–1340 psoas muscle kidney relations  87, 89, 265 laparoscopic adrenalectomy  1283 living donor nephrectomy  1252 PCNL for pelvic kidneys  820 retroperitoneal renal/adrenal access  988, 989 puboprostatic collar preservation early continence after  1158 radical prostatectomy  1143, 1146, 1147 puboprostatic ligaments radical cystectomy  1110 radical prostatectomy  1143, 1146, 1182–1183 pubovaginal slings  1855, 1871–1877 autologous fascial tissue  1872–1873 clinical outcomes  1876–1877 complications 1874–1876 history 1871 indications 1872 operative techniques  1873–1874, 1875, 1876 postoperative care  1874 preoperative preparation  1872 synthetic mesh  1873 pudendal nerve anatomy  1142, 1662 block 1668 urinary continence  1143 pulmonary embolism perioperative management  77 postoperative  663, 1181 pulmonary injury, PCNL  261, 394, 412–413, 424 pulmonary physiology laparoscopy in children  1325 pneumoperitoneum and  918–919, 922, 930 prone positioning  202 Pulsatile Organ Perfusion, Optimist (POP) trainer  894, 895 pulsed‐dye laser lithotripsy  537

pulse repetition frequency (PRF), SWL  706 pyelography 3D collecting system anatomy and  94–101 intravenous see intravenous pyelography/ urography percutaneous antegrade see antegrade nephrostogram/pyelography retrograde see retrograde pyelography pyelolithotomy, laparoscopic (LPL) 1208–1211 horseshoe kidney  815–816 indications 1208, 1209 outcomes 1208–1209 pelvic kidneys  821–822 procedure  783, 1210–1211, 1212, 1213 pyeloplasty with  1209–1210 retroperitoneal approach  1211 robot‐assisted  1209, 1210, 1212 transperitoneal approach  1210–1211 pyelonephritis differential diagnosis  802, 1401–1403 postureteroscopy 663 SWL and  732 pyeloplasty hidden incision endoscopic surgery (HIdES) 1331 laparoscopic and robotic  381, 590 children  1323, 1328–1333 comparative outcomes  1332 complications 1331–1332 indications  1196, 1324, 1329 operative setup  1329–1330 patient preparation  1329 port placement  1330, 1331 postoperative care  1331 postoperative drainage  1017, 1330 procedures  1330, 1331 renal anomalies  823, 1330 reoperative 1333 stone extraction with  1209–1210 trainers/simulators  166 LESS  1331, 1379–1380 open surgical  584 ectopic pelvic kidneys  823 pediatric patients  1328, 1329, 1332 transumbilical multiport  1331 see also endopyeloplasty; endopyelotomy Pyeloplasty model simulator  894, 895 pyelovesicostomy, pelvic kidneys  823 pyonephrosis  369, 805 pyuria, preoperative  59 Qmax (maximum urinary flow)  1630, 1728 Q‐switching 1673 Quadport+  1362, 1364, 1374, 1763 quadratic male urethral sling (Coloplast)  1894, 1898 quadratus lumborum muscle  89, 265 quality of life (QOL) assessment, PCNL outcomes  120 benign prostatic hyperplasia  1728 external beam radiotherapy  1556–1557 intracorporeal urinary diversion  1137 overactive bladder  1775 prostate brachytherapy  1544 radical cystectomy technique and  1111 stented patients  867 QuikStitch® 966

Index radial artery access, prostate artery embolization 1490–1491 radial nephrotomy  1093 radiation 14–30 adverse fetal effects  788 deterministic effects  17, 211 hazards  17–18, 211–212 ionizing, sources in urology  18–20 shielding 22 stochastic effects  17–18, 211–212 radiation dose absorbed 14, 15 applying limits  22–23 cancer risks and  17 computed tomography  19, 23, 222 diagnostic reference levels (DRLs)  21, 23 dose area product (DAP)  15 effective 14–15 equivalent 14, 15 fetal, diagnostic imaging  788 occupational limits  20 recommended limits  20–21 strategies for reducing see radiation safety radiation exposure  145 brachytherapy 27–28 diagnostic imaging  18–19, 23 hazards of excessive  17–18, 211–212 interventional imaging  19–20 linear‐no‐threshold model (LNT)  20 malignancy risks see malignancy risks, radiation exposure maximizing distance  21–22 medical  14, 20 minimizing time  21 occupational see occupational radiation exposure PCNL see under percutaneous nephrolithotomy terminology 14–15 virtual reality simulator training  28 radiation safety  14, 20–30, 1659 brachytherapy 27–28 diagnostic imaging  23–25 interventional imaging  25–27 operating room design  145–146 pediatric urology  28–29 pregnant women  29–30, 787–788 principles 21–23 robot‐assisted retrograde intrarenal surgery 680–681 take‐home messages  22 virtual reality simulator training  28 radiation therapy 3D conformal  1559 image adaptive (IART)  1550 image‐guided (IGRT)  1550–1564 intensity‐modulated see intensity‐ modulated radiation therapy radical cystectomy after prior  1107 secondary cancers  1536, 1557 toxicity female genitourinary fistulas  1242 prostate cancer  1544, 1554–1557, 1827 scoring criteria  1555, 1556 ureteral strictures  617, 618 ureteroscopy after prior  521 see also brachytherapy; external beam radiotherapy

Volume 1 pages 1–878, Volume 2 pages 879–1913

Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring  1555 radical cystectomy laparoscopic (LRC)/robot‐assisted (RARC) 1107–1112 continent urinary diversion 1128–1138 female patients  1110–1111 indications 1107 with intracorporeal ileal conduit 1125–1127 operative setup  1108 patient positioning  1108 postoperative care  1017, 1111 procedure 1109–1110 results 1111–1112 trocar placement  982, 983, 1109 urethral–neobladder anastomosis 1110, 1111 open (ORC)  1107 partial cystectomy vs.  1123 patient preparation  1107–1108 pelvic lymphadenectomy  1051–1052, 1110 positive surgical margins  1111–1112 robotic LESS  1389 salvage  1117, 1122 urinary diversion procedures see urinary diversion surgery radical nephrectomy, laparoscopic (LRN) 1077–1085 contraindications 1077–1078 hand‐assisted 1082–1083 advantages  1003, 1082 procedure 1082–1083 results  1000, 1001–1002, 1085 trocar placement  1082 indications 1077 LESS 1376 patient preparation  1078 postoperative drainage  1016 preoperative evaluation  1078 results 1084, 1085 retroperitoneal 1081–1082 patient positioning  1081 procedure 1081–1082 robot‐assisted (RLRN)  1083–1084 aspirin‐treated patients  80 outcomes  1085 patient positioning  1083–1084 procedure 1084 trainers/simulators  167 trainers/simulators  166 transperitoneal 1078–1081 access 1078–1079 patient positioning  1078, 1079 procedure 1079–1081 trocar placement  980–981, 1078–1079 radical nephroureterectomy (RNU)  384, 568, 1101 laparoscopic see nephroureterectomy, laparoscopic radical prostatectomy adjuvant or salvage radiotherapy  1553 bladder neck contracture after 1826–1829

brachytherapy vs.  1544 focal laser ablation after  1531 laparoscopic see laparoscopic radical prostatectomy LESS (LESS‐RP)  1162, 1769–1773 robot‐assisted  1386, 1771–1772, 1773 transumbilical  1769–1770, 1771 transvesical  1770, 1772 NOTES 1773 retropubic (RRP), laparoscopic radical prostatectomy vs.  1151–1159 robot‐assisted see robot‐assisted laparoscopic radical prostatectomy urinary incontinence after see post‐ prostatectomy urinary incontinence radiofrequency ablation (RFA) BPH see transurethral needle ablation devices 1444 renal tumors  1442–1451 biopsy at  1435–1436, 1445, 1446 complications 1446–1448 contraindications 1443 contrast‐enhanced ultrasound  1609 cryoablation vs.  1456–1457 image guidance  1419, 1420, 1444–1445 indications 1443 laparoscopic  1445, 1449, 1451 mechanism of action  1442–1443 outcomes 1448–1451 percutaneous 1444–1445, 1449, 1451 postoperative surveillance  1445 technical aspects  1443–1444 treatment failure  1445–1446, 1447 tumor aspects  1444 radiofrequency (RF) amplifier  155 radiologists PCNL outcomes  390, 399, 412 percutaneous nephrostomy  241, 312 radiology image‐guided surgery  52–53 lymph node  1049 postureteroscopy  647–649, 857–858 pregnancy 787–790 radiation safety  14–30 renal colic  800–802 renal cysts  1221–1222, 1396–1401 renal masses  1393–1420 renal stones  733–736 stone disease  212–213 ureters 458–459 urinary tract obstruction  126–130 see also computed tomography; interventional radiology; magnetic resonance imaging; ultrasonography; X‐rays real‐time virtual sonography (RVS)  51, 1504 reconstructive urologic surgery, minimally invasive suture, staple and clip technology  960–971 ureteral 1194–1205 recto‐urethral fistulas after HIFU of prostate  1577 after prostate cryoablation  1584, 1600 rectovaginal fistulas  1244, 1886

i33

i34

Index rectum cooling system, HIFU  1569, 1570 irradiation  1559, 1560 laparoscopic prostatectomy‐related injury  1026–1027, 1171–1172 mesh erosion into  1886 rectus fascia, pubovaginal slings  1872, 1874 reflection, laser energy  1675, 1694 remote monitoring systems  156–157 renacidin (hemiacidrin)  361, 362, 840 R.E.N.A.L. nephrometry score  1447, 1448, 1449 renal abscess differential diagnosis  803 imaging 1401, 1405 renal agenesis  460 renal angio‐embolization  1479–1485 horseshoe kidney  1481–1482 post‐PCNL bleeding  403–405 renal injuries  1482–1483 renal tumors  1483–1485, 1486 renal angiography  1479–1485 horseshoe kidney  1481 post‐PCNL bleeding  403, 404 renal injuries  1482–1483 renal tumors  1483, 1484–1486 renal anomalies laparoscopic pyeloplasty  823, 1330 laparoscopic stone extraction  1216–1217 PCNL  119, 198–199 SWL 739–740 ureteral anatomy  460, 461–462 see also ectopic kidneys; horseshoe kidney renal arteriovenous fistulas angiography and embolization  1483, 1486 post‐partial nephrectomy  1040 post‐PCNL  398, 403–404 renal arteriovenous malformations (AVMs) 1403, 1405 renal artery(ies) anatomical variants  1479, 1480 anatomy 1479, 1480 catheterization 1481 intrarenal branches  90–91, 265–266, 1479, 1480 living donor nephrectomy  1253, 1254, 1255 radical nephrectomy  1080, 1083 robotic kidney transplantation  1265, 1266 robotic partial nephrectomy  1093, 1094–1095 upper pole access and  256 renal artery aneurysms renal angiomyolipoma  1406, 1485 SWL caveats  732 renal artery pseudoaneurysms angiography and embolization  1483, 1486 post‐partial nephrectomy  1040 post‐PCNL  398, 403–404 renal biopsy, percutaneous complications 1431 renal masses  1433–1434, 1437 techniques 1427–1431 see also biopsy; renal mass biopsy

Volume 1 pages 1–878, Volume 2 pages 879–1913

renal blood flow (RBF) bilateral ureteral obstruction  131–133 effects of pneumoperitoneum  930–931 unilateral ureteral obstruction  130–131, 132 renal calculi see renal stones renal capsule  87 renal cell carcinoma (RCC) ablative treatments  1455–1457 AJCC prognostic groups  1411 angiomyolipoma vs.  1403, 1406 biopsy  1425, 1433–1434 biopsy tract seeding  1431 chromophobe  1409, 1435 clear cell  1407–1408 contrast‐enhanced ultrasound 1608–1609 cryoablation  1454, 1455–1456 cystic 1399, 1401 distant metastases  1413, 1414–1415 extirpative therapy  1455–1456 fusion imaging  1612 hereditary papillary  1407, 1408 histologic grading  1434–1435 histologic subtypes  1407, 1408 additional pathologic methods 1436–1437 biopsy  1428, 1429, 1434–1435 imaging 1407–1409 imaging  1395–1396, 1407–1413 intraoperative assessment of resection margins 1097–1099 LESS radical nephrectomy  1376 lymphadenectomy  1078, 1080–1081 papillary 1408 radiofrequency ablation  1442, 1443, 1449–1451 recurrent, diagnosis  1420 renal arterial embolization  1484–1485 staging 1410–1413, 1414–1415 TNM staging system  1410, 1411 see also kidney cancer; renal tumors; small renal masses renal colic  798–809 antiemetics 807 combination medical therapy  808–809 diagnosis 799–802 differential diagnosis  802–803 hospitalization 805 hydration therapy  806 imaging studies  800–802 laboratory tests  799–800 management 803–809 mechanisms 799 medical expulsive therapy  807–808 pain relief  643, 806–807 post‐SWL  756, 757 radiation safety  24, 25 surgical intervention  805–806 symptoms and signs  798–799 triage 804–806 renal collecting system (pelvicalyceal system) anatomy 92–104 basic intrarenal  92, 93 classification 94, 95 endocasts 92, 93 pyelograms vs. endocasts  94–101 SWL and  95, 733–734

variability 94, 96, 311, 312 vascular relations  101–104, 105–106 cryoablation and  1456, 1457–1458 duplicated 460 post‐PCNL injuries  319, 338 topical therapy see topical therapy of upper urinary tract see also calyces; renal pelvis renal collecting system puncture calyceal diverticula  343 classic techniques  244–245 complications 391–393 CT guidance  222–223 directly onto stones  217, 318, 393 endoscopic guidance  231–232 fluoroscopic control  213–217 bullseye technique  188–191, 214 challenging situations  217 geometric model (Mues)  214–215 Sharma & Sharma technique  215–216 triangulation technique see triangulation technique horseshoe kidney  199, 814 lateral position  193–194, 217 minimizing bleeding  400 multiple  218, 315–316 new technologies  244, 245–253 planning  213, 222 prone position  185–187 Uro Dyna‐CT  224, 225 prone‐flexed position  187–191, 199, 200 prone position  187–191, 213–216 quality and safety of access  277–280 selection of calyx  391 staghorn calculi  312, 315 supine position  174, 204, 216 supracostal approach  257–259 through‐and‐through (two‐wall)  103, 104 ultrasound guidance  238–240 Uro Dyna‐CT guidance  224–225, 246, 248–251 vascular anatomy  103–104, 105–106 vascular injury risks  201 without image guidance  266–267 see also percutaneous renal access renal columns (columns of Bertin)  92, 93 renal cortex  92, 93 renal cysts  348–349, 1221–1228 Bosniak classification  348, 1222, 1223, 1396–1399 Bosniak type I  1396, 1397 Bosniak type II  1396–1397, 1398–1400 Bosniak type IIF  1397–1399 Bosniak type III  1399, 1401 Bosniak type IV  1399, 1401 contrast‐enhanced ultrasound  1608 diagnosis 348–349 hemorrhagic, imaging  1221, 1395, 1396, 1400 imaging  1221–1222, 1395, 1396–1401 laparoscopic treatment  349, 1221–1228 complications 1228 indications 1222 operating room setup  1224, 1225 patient positioning  1224–1225

Index patient preparation  1224 postoperative care  1228 preoperative evaluation  1222–1224 retroperitoneal  1225–1226, 1228 robotic assistance  1228 surgical technique  1226–1228 transperitoneal  1225, 1226–1228 trocar placement  1225–1226 LESS surgery  1225–1226, 1227, 1228, 1380–1381 multilocular cystic nephromas 1399–1401, 1402 parapelvic  349, 1226–1228, 1405 percutaneous treatment  349 retrograde ureteroscopic treatment  349 see also renal tumors renal ectopia see ectopic kidneys renal fascia see Gerota’s fascia renal fibrosis mechanisms 135–138 strategies to decrease  138 ureteral obstruction  124, 135–138 renal function distal ureteral obstruction in children 1335 gadolinium‐based contrast agents and 1394–1395 pneumoperitoneum effects  920, 930–931, 1033–1034 postoperative nephrostomy tract dilation  281 partial nephrectomy  1088 radiofrequency ablation of renal tumors 1449 robotic kidney transplantation  1260, 1267 SWL 756 ureteral deobstruction  799 pregnancy‐related changes  786 renal fusion anomalies  461, 811–812 see also horseshoe kidney renal hematoma imaging 1403, 1405 post‐PCNL 405 post‐SWL 757 see also perinephric hematoma renal hilum clamping, radiofrequency ablation of renal tumors 1444 hand‐assisted laparoscopic nephrectomy  1000, 1082–1083 laparoscopic anatrophic nephrolithotomy 1213–1214 laparoscopic radical nephrectomy  1081 living donor nephrectomy  1253, 1254–1255, 1256 proximal ureteral reconstruction  1200 retroperitoneal approach  987–988 see also mid kidney region renal infarction  1401, 1406 renal ischemia laparoscopic anatrophic nephrolithotomy 1211 partial nephrectomy  1088 see also warm ischemia time renal lymphoma  1416–1417, 1418 renal mass biopsy  1425–1437

Volume 1 pages 1–878, Volume 2 pages 879–1913

additional pathologic methods  1436–1437 complications 1431 core biopsy  1428, 1429–1431 diagnostic  1426, 1427 diagnostic yield  1427, 1433 ex vivo 1431–1432 failed  1426, 1433 fine needle aspiration  1428–1431 histology and grade accuracy  1434–1435 image guidance  1427 indeterminate  1426, 1433 nomenclature 1426–1427 nondiagnostic  1426, 1433 percutaneous 1433–1434 recommendations 1437 results 1431–1434 small renal masses  1434, 1435, 1437 techniques 1427–1431 during tumor ablation  1435–1436, 1445, 1446 renal masses benign solid  1401–1407 biopsy see renal mass biopsy contrast‐enhanced ultrasound  1608–1609, 1610 cryoablation see cryoablation, renal masses cystic see renal cysts imaging 1393–1420 lesions simulating tumors  1401–1403 malignant 1407–1420 small see small renal masses see also renal tumors renal medulla  92 renal medullary carcinoma  1409 renal metastases  1418, 1419 renal papilla  92, 93 renal papillary ducts  92, 93 renal parenchyma  92 bleeding during PCNL  392, 397–398 nephrostomy tract dilation  281 renal pelvic pressure (RPP) monitoring, instillation of topical agents 356 postoperative infections and  66 ureteral access sheaths and  507 renal pelvic tumors diagnostic ureteroscopy  565 percutaneous resection  386 see also upper tract urothelial carcinoma renal pelvis  93 puncture for intrarenal access  103 subepithelial hematomas  1403 topical therapy see topical therapy of upper urinary tract see also renal collecting system renal plasma flow, effective (eRPF), ureteral obstruction  130, 134 renal pyramids  92, 93 renal resistive index (RI)  128–129 renal scintigraphy radiation exposure  19, 23 see also diuretic renography renal stones asymptomatic incidence 765

natural history  765–768 observation vs. treatment  768 risk factors for growth  767–768 transplant kidneys  831 branching 768 burden, scoring  113–119 composition physical properties and  695–696, 697 staghorns 310 SWL and  698, 732 horseshoe kidney  811–816 Hounsfield density  110, 734–735 imaging characteristics  733–736 kidney donors  827–828 laparoscopic extraction (LSE)  783–784, 1208–1217 laparoscopic/robotic ureteral reconstruction 1201 location disease progression and  767–768 scoring 119 SWL and  733 management options  549–550, 551 cost effectiveness  858–859 initial choice  779–782, 783 migration down ureter, preventing  186–187, 288–289 natural history  765–769 open surgery  397, 783–784, 1208 pelvic kidneys  818–822 percutaneous management calyceal diverticula  345 flexible nephroscopy  286, 287, 290–292 intracorporeal lithotripsy  322–328 micro‐PCNL 304–305 mini‐PCNL 301 preoperative assessment  399 rigid nephroscopy  285, 286, 289–290, 291 staghorn calculi  317 ultra‐mini PCNL  301–302, 303–304 see also percutaneous nephrolithotomy; percutaneous renal access postoperative infections  62–66 prevention 63–66 risk factors  62–63 pregnancy, diagnostic imaging  788–789, 790 radiation exposure  18–19 residual fragments see residual stone fragments scoring systems  108–120 size disease progression and  767 efficacy of ureteroscopy and  558 S.T.O.N.E. score  108, 109, 110 SWL and  733 treatment options  550, 780–782, 783 staghorn see staghorn calculi Sun’s ureterorenoscope  494 SWL 731–741 see also shock‐wave lithotripsy transplant kidneys  827–833 UPJ obstruction with laparoscopic pyelolithotomy  1209–1210

i35

i36

Index renal stones (cont’d) percutaneous endopyelotomy  378, 382 SWL 732, 739, 740 ureteroscopic management  549–559 apnea during lithotripsy  558 Avicenna robot system  674, 678–679 calyceal diverticula  343, 556–558 complications 559 contraindications 551 follow‐up imaging  647 human limitations  669, 681–682 indications 549–550, 551 lithotripsy and extraction  552–555 lower pole stones  555–556, 782 obesity 846–847 outcomes 558–559 pelvic kidneys  819–820 stone size and  780, 781, 782 Sun’s ureterorenoscope  492 techniques 551–558 upper tract access  551–552 ureteral stenting  558 urinary diversion patients  839 renal trauma angiography and embolization 1482–1483 nephrostomy tract dilation  281 renal tubular acidosis, renal transplant recipients 828 renal tubules bilateral ureteral obstruction  134–135 unilateral ureteral obstruction  135–138 renal tumors angiography and embolization  1483–1485, 1486 benign solid  1401–1407 biopsy see renal mass biopsy cryoablation see cryoablation, renal masses incidental  1407, 1425, 1442 lesions simulating  1401–1403 malignant 1407–1420 metastatic 1418, 1419 multilocular cystic  1399–1401, 1402 partial nephrectomy  1077, 1097, 1455 radiofrequency ablation see radiofrequency ablation, renal tumors renal colic vs.  803 see also kidney cancer; renal cell carcinoma; renal cysts; renal masses; upper urinary tract neoplasms renal vascular resistance bilateral ureteral obstruction  131, 132 unilateral ureteral obstruction  132 renal vein(s) inadvertent puncture, PCNL  392–393 intrarenal branches  91–92 laparoscopic adrenalectomy  1284, 1285, 1286 living donor nephrectomy  1251, 1253, 1254, 1255, 1256 radical nephrectomy  1080 renal cell carcinoma involvement  1410, 1414 robotic kidney transplantation  1265 rendezvous procedures, ureteral transection 599–600 reninoma 1407

Volume 1 pages 1–878, Volume 2 pages 879–1913

renomedullary interstitial cell tumors  1406 renorrhaphy, partial nephrectomy bed  1094 reproductive system defects, renal ectopia  818 SWL safety  748, 758 see also fertility; sexual dysfunction resectoscopes  1643, 1654, 1656 bipolar TURP  1744 development 1733 equipment preparation  1655 monopolar TURP  1737 percutaneous tumor resection  386–387 residual stone fragments (RFs)  441–449 checking for  178, 181, 221, 292 clinically insignificant (CIRFs)  441, 771 economic costs  859 laparoscopic stone extraction  1217 medical therapy  448–449 pediatric patients  448 management 338 natural history  773 post‐PCNL 444–448 children 448 management  319, 446–448 natural history  446, 772–773 post‐SWL 441–442 adjunct techniques  738–739 children  448, 773 follow‐up 740 medical therapy  448, 739 natural history  441–442, 443, 770–772 postureteroscopy  442–444, 546 management  649, 661 natural history  442–444, 445, 772 postoperative imaging  648 resistive index (RI) ureteral strictures  594 urolithiasis in pregnancy  789 Resonance stent  634, 637, 638, 871–873 respiratory effects patient positioning  202, 204 pneumoperitoneum  918–919, 922, 930, 1325 respiratory motion flexible ureteroscopy  558 kidneys see kidney, mobility prostate radiotherapy  1550, 1560 SWL 749 reticulon proteins  137 Re‐Trace® ureteral access sheath (Coloplast) 507 retractors, laparoscopic  949 retrograde approach (to upper tract) instillation of topical agents  353–356, 363–364 during PCNL  177–181, 231 see also combined antegrade‐retrograde approaches retrograde ejaculation after HIFU of prostate  1577 after holmium laser enucleation of prostate 1687 after laser prostatectomy  1703 retrograde intrarenal surgery classical (cRIRS)  669, 681–685 robot‐assisted see robot‐assisted retrograde intrarenal surgery

upper tract urothelial carcinoma  386, 565–566, 572–577 see also flexible ureteroscopy; ureterorenoscopy; ureteroscopy retrograde (uretero)pyelography diagnostic ureteroscopy  564 flexible ureteroscopy  523, 526 laparoscopic pyeloplasty  1329 PCNL  185–187, 214, 231 calyceal diverticula  344 conditions preventing  264 staghorn calculi  314 percutaneous antegrade ureteroscopy 296 recurrent upper tract tumors  577 rigid ureteroscopy  517 Sun’s ureterorenoscope  492, 493–494 upper urinary tract neoplasms  569 ureteral obstruction  596 ureteroscopic stone management  545 retrograde urethrography  1819, 1820 retropelvic artery  90–91 intraoperative injury  101–103 retroperitoneal fibrosis ureteral deviation  459, 460 ureteral obstruction  617 ureteroscopy 521 retroperitoneal lymph node dissection (RPLND) 1066–1075 chylous ascites complicating  1043 laparoscopic (L‐RPLND)  1066–1075 access and port placement  1071 boundaries of dissection  1072–1073 operating room setup and instruments 1067–1069 patient positioning  1067, 1068 results 1073–1074 minimally invasive (MI‐RPLND)  1066–1075 anesthesia 1067 indications 1066–1067 operating room setup  1067–1071 patient preparation  1067 results 1073–1075 technique 1071–1073 open (O‐RPLND)  1066, 1075 robotic (R‐RPLND)  1066–1075 access and port placement  1071–1072 boundaries of dissection  1073 operating room setup and instruments 1069–1071 patient positioning  1067, 1068 results 1074–1075 retroperitoneal space compartments 87, 89 dissection, retroperitoneal access  988, 989 retroperitoneoscopic renal/adrenal surgery 987–990 adrenalectomy 1279–1281 surgical technique  1284–1286 balloon dilators  944, 945 balloon dissection  988, 989 chylous ascites complicating  1042, 1043 exit 992 finger dissection  988, 989 gasless robotic kidney transplantation 1267

Index Hasson technique  944 LESS surgery  1366 limitations 990 patient evaluation and selection 987–988 patient positioning  905, 912, 913, 988 physiologic effects  931 pregnancy 937 radical nephrectomy  1081–1082 renal cyst decortication  1225–1226, 1228 trocar placement  988–990 vascular complications  1024, 1036 retropubic midurethral slings  1832–1833, 1855 complications 1863–1866 intrinsic sphincter deficiency  1862 repeat surgery  1861 results  1858, 1859 surgical technique  1856–1857 transobturator slings vs.  1859 see also tension‐free vaginal tape retropubic radical prostatectomy (RRP) laparoscopic radical prostatectomy vs. 1151–1159 robotic LESS technique  1386 reverse Trendelenburg position (head up) gonadal vein embolization  1469–1470 physiologic effects  917, 918, 930–931 Rezūm water vapor therapy system  1730 RGB (Red‐Green‐Blue) video format 38–39 rhabdomyolysis  907, 1023, 1035 ribs 88–89, 90, 265, 409–410 Richard Wolf ureteroscopes see Wolf ureteroscopes rigid cystoscopes  1643, 1644, 1653–1654 rigid cystoscopy  1643–1644 procedures 1644 prostatic urethral lift procedure 1722–1723 technique 1644 topical urethral anesthesia  1663–1664 ureteral access for ureteroscopy  515, 523 rigid endoscopes history 465–467 laparoscopy 946 rigid nephroscopes  285, 287 children 335, 336 rigid nephroscopy  286 children 335, 336 staghorn calculi  317 stone fragmentation and retrieval  178, 180, 289–290 supine position  174–175 tips and tricks  291 rigid ureteroscopes  465–468, 515 angle of view  468 care, maintenance and failure  470–472 dimensions 468 eyepiece design  468, 469 field of view  468 with flexible tip see Sun’s flexible‐tipped ureterorenoscope history 465–467 irrigation 471 limitations 481 optics 468

Volume 1 pages 1–878, Volume 2 pages 879–1913

properties 467–468 tip designs  468, 470 working channel  468 rigid ureteroscopy equipment 515–516 patient positioning  515 preoperative preparation  514–515 ureteral access  514–518 anatomical variants  517–518 procedure 516–517 rim sign  802 RITA device  1444 rivaroxaban  73, 75 RoboSurgeon System® 1773 robot‐assisted laparoscopic prostatectomy (RALP) 1269–1275 comparative studies  1273, 1274 complications 1275 extraperitoneal approach  1271 historical context  1269–1270 retropubic approach  1272–1273 technique 1270–1273 transperitoneal approach  1271 robot‐assisted laparoscopic radical prostatectomy (RALRP; RARP) 1169–1176 anesthesia 929 apical dissection  1175, 1182 aspirin‐treated patients  81 bowel preparation  1172 complications 1171–1172 bladder neck contracture  1827 positioning‐related  913–914, 1171, 1181 urinary incontinence  1890 equipment 903 European perspective  1140 extraperitoneal access  1172, 1173–1174 fluid management  930 obesity 910 operative steps  1173–1176 outcomes 1169–1171 optimizing 1179–1189 as outpatient procedure  1181 patient positioning  1173 patient selection  1172 pelvic lymph node dissection  1174–1175 perineal approach  1387–1389 perioperative optimization  1181–1187 physiologic changes  930, 931 postoperative care  1176, 1187–1189 preoperative optimization  1179–1181 salvage 1172 trainers/simulators  167 transperitoneal access  1172–1173 trends in practice  1169 trocar placement  1173–1174 vesicourethral anastomosis  1175–1176 robot‐assisted retrograde intrarenal surgery (RA‐RIRS) 668–685 advantages  682–683, 685 classical techniques vs.  681–685 device development  670–677 ergonomics  679, 680, 682 experimental evaluation  677 historical background  668–670 limitations 683–684 published clinical studies  678–681

radiation safety  680–681 surgical technique  677–678 training study  681 robotic laparoendoscopic single‐site (R‐LESS) surgery  1361 lower tract  1385–1389 perineal prostatectomy  1387–1389 radical cystectomy  1389 radical retropubic prostatectomy 1385–1386 robotic docking  1385–1386 transvesical enucleation of prostate 1386–1387 ports  1364–1365, 1366 robots 881–883, 1369, 1370, 1381, 1389 semirigid instruments  1368 upper tract  1381 robotic pelvic surgery LESS 1385–1389 operating room setup  904–905 patient positioning  906–907, 912, 914–915, 1035 robotic renal surgery operating room setup  903–904 patient positioning  908, 912, 913–914, 1034–1035 robotic surgery  901–908, 909–915 anesthesia 929–930 anesthetic management  928–938 bowel preparation  902 bulldog clamps  957–958 complications 1032–1043 brisk bleeding  1039–1040 specific  913–914, 1043 contraindications  901, 910 dual console capability  958 enhanced recovery protocols  931–932 exit see laparoscopic exit flexible ureteroscopy  483 fluid management  930 history of development  668–669 imaging systems  957 indications 910 informed consent  901–902 instrumentation  912, 954–958 instrument malfunctions  913, 958, 1043 integrated table motion  958 multiple‐site robots  883–885 new systems  881–885 open conversion  1040 operating room setup  150, 151, 902–905, 911–912 patient positioning see positioning of patient, robotic surgery patient preparation  901, 910–911 patient selection  909–910 physiologic changes  917–923 postoperative pain management 932–933 preoperative assessment  928–929 pyeloplasty 381 reconstructive techniques  960–971 retroperitoneal approach see retroperitoneoscopic renal/adrenal surgery simulators  167

i37

i38

Index robotic surgery (cont’d) single‐site robots  881–883 training 887–898 transperitoneal approach see transperitoneal laparoscopic/robotic surgery troubleshooting 958–959 see also da Vinci Robotic System robotic targeting systems, prostate biopsy 1502–1503 Rocco stitch  1149, 1150, 1184–1185 rod–lens systems  466–467, 468 Roeder slipknot  964 Rotatip instruments  1367–1368 R‐port®, transvesical prostatectomy  1763, 1764 sacral nerve stimulation (SNS)  1902–1909, 1911 complications 1910 costs 1910 history 1902–1903 indications and efficacy  1903–1905 mechanism of action  1903 permanent vs. temporary lead test 1908–1909 sensory and motor neural responses 1908 staged lead placement  1906–1908 test procedure  1905–1906 Sacred Heart Halo  509 sacrocolpopexy abdominal (ASC)  1234 complications  1241, 1882 outcomes 1240–1241 prophylactic incontinence surgery with 1235 laparoscopic (LSC)  1234, 1235–1237 outcomes 1240–1241 patient preparation  1235 postoperative care  1237 procedure 1235–1237 preoperative evaluation  1234–1235 robotic laparoscopic  1234, 1237–1240 indications 1234–1235 outcomes 1240–1241 patient preparation  1237 procedure 1237–1240 sacrohysteropexy (sacrouteropexy) laparoscopic 1234 robotic laparoscopic  1240 sacrospinalis muscle  265 safe laser technique  504 sand‐wedge electrode, en bloc resection of bladder tumors  1807 sandwich therapy, children  338 Satava, Richard  888–889, 893, 895 Sateschi varicocele grading system  1466 Sativa classification, surgical complications 653, 654 scabbard injury  660 scattering, laser energy  1675, 1694 SCD Information Management System™, Stryker 153 Schafer nomogram  1633, 1635–1637 schistosomiasis, ureteral strictures  617 sciatic nerve injury, intraoperative  203

Volume 1 pages 1–878, Volume 2 pages 879–1913

scissors endoureterotomy 611, 612 EndoWrist robotic  956, 957 laparoscopic 949 meatotomy  611, 619 sclerotherapy pelvic congestion syndrome  1476–1477 renal cysts  349 varicocele 1470 ScopeSafe™ laser fibers  482 scrotal ultrasonography  1605 scrub nurse  1652 second harmonic generation (SHG)  1673 second look flexible nephroscopy (SLFN) 446–448 sedation, oral, minimally invasive prostate therapy 1663, 1664 segmental renal arteries  90–91, 265 safe intrarenal access and  101–103, 104 selective arterial prostate embolization (SAPE) 1489–1493 follow‐up 1492 history 1489 preoperative assessment  1489–1490 technique 1490–1492 transfemoral approach  1491 transradial approach  1490–1491 vascular anatomy  1492 semen analysis varicocele  1354, 1465 vasectomy reversal  1314, 1320 semicritical items (Spaulding classification) 4 SemiFlex Scope™, Maxiflex  477, 480, 499, 500 seminal vesicles  1292–1296 abscesses  1292, 1294 adenocarcinoma 1293 anatomy 1292 calcifications and stones  1292, 1293 cysts  1292–1293, 1294 diagnosis 1294 endoscopic interventions  1294 indications for surgery  1294 invasion, prostate cancer  1617 laparoscopic or robotic surgery 1294–1296 pathology 1292–1294 radical prostatectomy  1145, 1146, 1174, 1175 tumors 1293–1294 Semirigid LESS instruments  1367, 1368 semirigid ureteroscopes  468–471, 515 camera and video systems  471 development 468–470 diagnostic ureteroscopy  563, 564, 569 dimensions 470 durability  481–482, 655 endoureterotomy 619–620 irrigation 471 limitations 481 optics and eyepiece  470 tip designs  470, 472 working channel  471 semirigid ureteroscopy  514–518 anatomical variants  517–528 equipment 515–516

indications 514 lithotripters  535, 537 patient positioning  515 preoperative preparation  514–515 prior to flexible ureteroscopy  551 stone management  514, 543, 545 stone retropulsion  546–547 ureteral access  516–517 Sensei‐Hansen Robotic Catheter System 682 Seoul National University Renal Stone Complexity (S‐ReSC) score  109, 113 comparative assessment  119 review of literature  117–118 Seoul technique, laser prostatectomy  1701 sepsis 57–70 bacteriology 58 definitions 68 pathogenesis  57–58, 68 postoperative early management  68–69 PCNL  260, 319 TURP 1740 ureteroscopy 663 prevention  57, 58–68 catheterized patients  67–68 general measures  58–60 indwelling stents  68 open and laparoscopic surgery  66–67 postoperative urinary drainage  68 stone management  62–66 transurethral surgery  60–62 risk factors  59 severe  68, 69 see also urosepsis septic shock  68, 69 seromas, after laparoscopic hernia repair 1305, 1306, 1306 Sew‐Right SR5® 966 sexual dysfunction after holmium laser enucleation of prostate 1686–1687 after laparoscopic radical prostatectomy  1158, 1171 after laser prostatectomy  1703 after midurethral sling surgery  1866 after neobladder construction  1137 prostatic urethral lift procedure and 1724 sacral nerve modulation for female 1904–1905 see also erectile function; retrograde ejaculation shear forces iatrogenic ureteral injuries  606, 616–617 shock‐wave‐induced stone comminution  698, 699 shock‐wave‐induced tissue damage  705–706, 717 shielding, radiation  22 shock‐wave lithotripsy (SWL) anticoagulated patients  80, 731–732 antimicrobial prophylaxis  61, 63, 736, 748 average peak positive pressure  700–701, 703, 708 calyceal diverticula  342–343, 739, 740

Index clinical goal  691 complications  738, 756–758 dual‐pulse technique  717 good practice  724 history of development  713–714 imaging guidance  748 imaging systems  718 indications 549–550, 551 long‐term effects  758–759 machines see lithotripsy systems mechanisms of action  696–705, 708, 716–717 contemporary theories  700–703 fracture mechanics  698–699, 701 heuristic model  704, 709 role of cavitation  703–704 traditional theories  699, 702 unified theory  704–705 medical therapy after  448, 739 new technologies  706–707, 708, 709 obesity  732, 745–746, 846 percussion, diuresis and inversion therapy 738–739 physics  691–709, 716–717 pregnancy  731, 758, 794 pretreatment and pause  706, 737–738, 750 pulse repetition frequency (PRF)  706 radiation safety  18, 20, 23, 25–26 renal stones  731–741 adjunct therapy  738–739 anatomic anomalies or variations 739–740 contraindications 731–732 cost effectiveness  858–859 decision‐making 780–782 failure 740 follow‐up 740 horseshoe kidney  739, 813 imaging features  733–736 imaging guidance  723 pediatric patients  338, 740 pelvicalyceal anatomy and  95, 733–734 pelvic kidneys  819 prediction of outcome  735–736 preoperative evaluation  731 preoperative preparation  736 stone characteristics  732 technique 736–738 residual fragments after  441–442 adjunct techniques  738–739 children  448, 773 follow‐up 740 medical therapy  448, 739 natural history  441–442, 443, 770–772 shock‐wave number and rate  736–737, 750–751 side effects  756 stone comminution  691, 692 tissue injury mechanisms  705–706, 708–709 transplant kidneys  823, 832 ureteral stones  745–751 contraindications 746 cost effectiveness  855–856 distal ureter  778

Volume 1 pages 1–878, Volume 2 pages 879–1913

enhancing efficacy  748–750 indications 745–746 mid‐ and proximal ureter  779 outcomes  514, 747–748 predictors of success  745–746 treatment protocol  750–751 urinary diversion patients  740, 837, 839 voltage ramping  738, 750 shock waves  693, 716–717 coupling  717–718, 723 focusing 693, 695, 716 generation  692–693, 714–716 profile and distribution  693–695 reflection and refraction at fluid/solid boundaries  696, 698, 699 see also acoustic waves shoulder tip pain  933 Siemens Lithoskop lithotripter  692, 694 Siemens Modularis Variostar  726 Sieverts (Sv)  14, 15 sildenafil 1187–1188 Silhouette stent  867 silicone endoscopic treatment of reflux  1784 ureteral stents  614 urethral bulking  1850 Silitek ureteral stents  866 SILS hand instruments  1366, 1367 SILS port  1362, 1364, 1374 comparative studies  1365–1366 radical retropubic prostatectomy  1386 SimplyStrong™ bag  1011 simulation 160–161 laparoscopic and robotic surgery curriculum development  893–894 history of development  888–889 range of topics  889–893 validation 896–897 radiation safety  28 surgical training  887–888, 889 see also training simulators fidelity  161, 894 future technologies  161, 895 laparoscopic and robotic surgery  166–167, 894–895 hybrid 895 physical 894–895 virtual reality  895 urological skills training  162–167 validation  161, 889, 896–897 Single Action Pumping System  516 single‐incision multiport LESS surgery 1361, 1362, 1374 single‐incision slings (SIS)  1832–1843, 1862–1863 available devices  1833, 1834 EAU guidelines  1833, 1835 safety and efficacy  1833–1835 single‐incision triangulated umbilical surgery (SITUS)  1375 Single Port Orifice Robotic Technology (SPORT™) system  881, 882 single‐port surgery see laparoendoscopic single‐site surgery single‐port transvesical enucleation of prostate 1763–1768 advantages and disadvantages  1765

equipment and instruments  1764 outcomes 1767, 1769 prostate size  1764 robotic 1386–1387 surgical technique  1764–1767, 1768 Single‐Site™ port  1362–1363, 1365 sinks, dirty instruments  10 skeletal deformities see musculoskeletal deformities skin adhesives  1016 skin care, female genitourinary fistulas 1245 skin closure, port site  1016 skin markers external beam radiotherapy  1557, 1558 inguinal lymph node dissection  1061, 1063 percutaneous renal access  175–176, 223 retroperitoneoscopic access  988, 990 skin preparation, preoperative  187, 1652 skin‐to‐collecting system distance, children  333 skin‐to‐stone distance (SSD) PCNL see nephrostomy tract, length SWL efficacy and  735, 745–746, 846 treatment options  550 slipknot 963–964 small bowel injury, PCNL  394–395, 423–424 small‐caliber percutaneous instruments (SCPI) instillation of topical agents  356–357 PCNL 301–307 see also micro percutaneous nephrolithotomy; mini‐percutaneous nephrolithotomy; ultra‐mini percutaneous nephrolithotomy small renal masses (SRMs) biopsy  1425–1426, 1434, 1435, 1437 cryoablation  1380, 1454 incidental detection  1425, 1442 nephron‐sparing surgery  1088, 1097, 1442 radiofrequency ablation  1442, 1443, 1449 Smart Needle system  271 smoking cessation, preoperative  1180 α‐smooth muscle actin (α‐SMA) 137 snail protein  137 sodium bicarbonate cystine stones  359, 360 uric acid stones  358, 359 sodium (Na)‐tetradecyl‐sulfate (STS)  1470 Solyx™ SIS System  1834, 1838–1839, 1856 Sonablate™ high‐intensity focused ultrasound system  1569, 1570, 1571, 1574 SonixGPS navigation system  246, 251–252, 253 Sonochill™ rectal cooling system  1570 Sotelo prostatotomy device  1765, 1767 sound waves see acoustic waves space of Retzius laparoscopic radical prostatectomy  1143, 1145 robotic‐assisted partial cystectomy  1118, 1119 ureteral reconstruction  1199

i39

i40

Index spalling 699, 702 SPARC (Suprapubic Arc system)  1855 Spaulding classification  4 specimen retrieval  1010–1012 devices  952, 1010–1011 extraction site  1012 inguinal lymphadenectomy  1061–1062 morcellation 1011 radical nephrectomy  1081 sperm granuloma 1314 intraoperative visualization  1316 spermatic artery, ureteral blood supply 605, 606, 607 spermatic cord injury, inguinal hernia repair  1309 laparoscopic varicocelectomy 1355–1356 retroperitoneal lymph node dissection 1073 spermatic veins anatomical variations  1466 varicocele  1354, 1464 SPIDER surgical system, renal cyst decortication 1228 SPIES™ see Storz Professional Image Enhancement System spina bifida, PCNL  333 spinal anesthesia  929 spinal cord injury (SCI) intravesical botulinum toxin  1776–1777, 1778 PCNL safety  333 sacral nerve stimulation  1904 spinal cord ischemia, complicating PCNL 201 spinal needles, PCNL access in children  334, 335 spleen anatomy 89, 90 hematomas, post‐SWL  758 mobilization  1080, 1284 splenic injuries laparoscopic surgery  1027, 1041 PCNL  199–201, 261, 394, 424–425 splenorenal shunts, varicocele  1464, 1465 spongiofibrosis, urethral  1816, 1818, 1819 S‐Port™ device  1365 SPORT™ (Single Port Orifice Robotic Technology) system  881, 882 spray coagulation waveform, electrosurgery 1735 square knot  963, 964 S‐ReSC score see Seoul National University Renal Stone Complexity score SS‐31 peptide  137, 138 staghorn calculi complete 310 complications 310 composition 310 first‐line therapy  782 infectious complications  64–66 laparoscopic anatrophic nephrolithotomy (LAN) 1211 natural history  768–769 nephrolithometry scoring systems  119, 311

Volume 1 pages 1–878, Volume 2 pages 879–1913

partial  310, 768 PCNL 310–319 access problems  318, 393 access technique  314–315 complications  319, 399 cost effectiveness  858 endoscopic combined intrarenal surgery 181 exit strategies  317–318 fragmentation and removal  317 multiple tracts  218, 315–316 patient positioning  312–314 preoperative preparation  311 residual fragments 319 tips and tricks  318–319 upper pole access  255, 257 urologist vs. radiologist access  312 preoperative assessment  311 Staghorn Morphometry  119 Stamey needle male urethral sling  1892 pubovaginal sling  1874, 1875, 1876 staplers 970 complications 970 EndoWrist robotic  956, 957 laparoscopic 951 pediatric 1325 principles of use  970, 971 vascular control  1039 Starr–Edwards valve  77 steam autoclaves  3, 7 steam sterilization  7 immediate‐use (IUSS)  8–9 steinstrasse  733, 756–757, 813 stellate veins  91, 92 stem cells, autologous  1851 stents see endopyelotomy‐endoureterotomy stents; nephroureteral stents; ureteral stents; urethral stents stent syndrome  865 Step™ trocar system  946 stereotactic ablative radiosurgery (SABR) 1534 stereotactic body radiation therapy (SBRT) 1534 sterilization 3–12 alternatives 9–12 ethylene oxide (ETO)  7 flexible ureteroscopes  481–482, 502–504 gas plasma  8 guidelines 11–12 history 3 immediate‐use (flash)  8–9 methods 6–9 operating room design  146 peracetic acid  7–8 processing prior to  3–6, 10 steam 7 Sun’s ureterorenoscope  495 Steris System 1E Liquid Chemical Sterilant (SS1E) 8 steroid injections see triamcilonone injections STING procedure, vesicoureteral reflux 1784–1789 stirrups, footrest  1652, 1653 St Jude valve  77

stone(s) calyceal diverticula see calyceal diverticula, stones cultures  64, 66, 346 lost  656, 1211, 1217 natural history  765–773 residual see residual stone fragments scoring systems see nephrolithometry scoring systems straining urine for  809 submucosal  530, 655–656 see also renal stones; ureteral stones S.T.O.N.E. nephrolithometry  108–110 comparative assessment  113–120 review of literature  116–117 strengths and weaknesses  110 stone baskets Avicenna robot system  678 entrapment 661 percutaneous  290, 291, 317 ureteroscopic  478, 509 renal stones  554–555 tumor biopsy  564, 570 ureteral calculi  546 StoneBreaker lithotripter  317, 534 stone composition diagnostic imaging  129, 802 physical properties and  695–696, 697 staghorn calculi  310 SWL efficacy and  698, 732, 746 urinary diversion patients  837 Stone Cone (Boston Scientific)  508 stone disease asymptomatic, incidence  765 diagnostic imaging  18–19, 129 horseshoe kidney  812–813 management see stone management obesity 843–850 pelvic kidneys  818 pregnancy  30, 786–794 prevalence 14 prevention cost effectiveness  859–861 obesity 845 urinary diversion  839–840 transplant kidneys  823, 827–833 urinary diversions  836–841 see also renal stones; ureteral stones stone dissolution see chemolysis of urinary calculi stone dusting Avicenna robot system  678, 684 micro‐perc 304–305 ureteroscopic  444, 538 lower pole stones  556 renal stones  553 Sun’s ureterorenoscope  494 ureteral stones  546 see also stone fragmentation stone extraction laparoscopic 1211, 1212 PCNL 317 calyceal diverticula  345 flexible nephroscopy  290, 291 rigid nephroscopy  289–290 ultra‐mini PCNL  303–304 ureteroscopic  444, 509 Avicenna robot system  678, 684

Index renal stones  554–555 Sun’s ureterorenoscope  492 ureteral calculi  545–547 urinary‐diversion stones  838 stone forceps/graspers nephroscopy  289, 291, 317 ureteroscopy  509, 546 stone fragmentation Avicenna robot system  678 nephroscopy 289–291 PCNL  317, 322–328, 337 popcorn effect  538, 553 SWL 691, 692 high‐speed imaging  696, 697 mechanisms  696–705, 708, 716–717 ultra‐mini PCNL  303 ureteroscopic digital flexible ureteroscopes  498, 503–504 methods 532–539 renal stones  553–554 Sun’s rigid ureterorenoscope  494 ureteral calculi  545–547 see also stone dusting stone fragments, residual (persistent) see residual stone fragments stone‐free rates (SFR) laparoscopic anatrophic nephrolithotomy 1212 laparoscopic pyelolithotomy  1208, 1209 laparoscopic ureterolithotomy  1214 PCNL 444–446 children  332, 339 ectopic kidneys  820, 821 electrohydraulic lithotripsy  323 horseshoe kidney  815, 816 miniaturized techniques  306, 307 obesity 847–848 staghorn calculi  311 supine vs. prone position  204 supracostal access  259 preoperative prediction  112, 113–119, 311 SWL 441 obesity 846 pelvic kidneys  820 predictive models  735–736 renal stones  733, 735 ureteral stones  514, 747 ureteroscopy  442, 514 obesity 846–847 pelvic kidneys  820 proximal ureteral stones  492 renal stones  558–559 ureteral access sheaths  528, 529 see also residual stone fragments stone‐free status (SFS), preoperative prediction  108, 110, 111, 112, 113 stone granuloma  656 stone management  777–784 calyceal diverticula  342–343, 345, 783 cost‐effective strategies  853–861 horseshoe kidneys  812–816 integrated 724 laparoscopic  783–784, 1208–1217 medical expulsive therapy see medical expulsive therapy medical therapy see medical therapy of stone disease

Volume 1 pages 1–878, Volume 2 pages 879–1913

obesity 845–848 open surgery see open stone surgery pelvic kidneys  818–822 percutaneous nephrolithotomy see percutaneous nephrolithotomy postoperative infections  62–66 prevention 62–66 risk factors  59, 62–63 pregnancy 791–794 anesthetic risks  791–792 endourologic interventions  792–794 timing of intervention  791 prior, nephrolithometry scoring  119 radiation safety  18–20, 23–27 renal stones  779–782, 783 SWL see shock‐wave lithotripsy transplant kidneys  823, 830–833 ureteral stenting  770, 855, 864 ureteral stones  777–779, 780 ureteroscopic see ureteroscopy (URS), stone management urinary diversions  837–839 stone retrieval see stone extraction stone retrieval devices nephroscopy  289, 290, 291, 317 ureteroscopy  509, 546 Storz electromagnetic shock‐wave source 715 Storz endoureterotome  613, 614 Storz Modulith SLK lithotripter  726 Storz Modulith SLX‐F2 lithotripter  720, 726 Storz Professional Image Enhancement System (SPIES)™ 42 Flex‐Xc ureteroscope  43, 44 upper tract urothelial tumors  287, 566 Storz ureteroscopes see Karl Storz ureteroscopes St Petersburg maneuver, guidewire placement 232 streptokinase 369 stress response, laparoscopic surgery 920–921 stress urinary incontinence (SUI) bioinjectables 1847–1851 diagnosis 1871–1872 economics 1848 maxi/pubovaginal slings  1871–1877 midurethral slings  1832–1835, 1854–1867 post‐holmium laser enucleation of prostate 1686 post‐prostatectomy see post‐ prostatectomy urinary incontinence prevalence 1854 prolapse repair and  1234, 1235, 1861–1862, 1872 recurrent, repeat midurethral slings  1861 single‐incision slings  1832–1843, 1862–1863 stricture knife  611 stroke (cerebrovascular accident) during PCNL  201 perioperative anticoagulation  73, 78 struvite (MAPH) stones chemolysis 360–361, 362 irrigation system set‐up  354–355, 356 residual fragments 448

infectious complications  64, 66 staghorn 310 SWL  697, 732 urinary diversion patients  837, 840 Stryker ureteroscopes flexible  477, 480, 500 semirigid  472 Studer neobladder intracorporeal robot‐assisted construction 1132–1134 retrograde ureteral access  527, 528 Stuttgart definition, prostate cancer relapse 1596 subcutaneous emphysema  921, 1023 Suby’s solution G  361, 362 suction devices  1649 suction‐irrigation devices, laparoscopic 951 Sugarbaker repair, parastomal hernia  1310, 1311 sunset effect  503–504 Sun’s flexible‐tipped ureterorenoscope 481–495 care and maintenance  495 components 487, 488 development 486–487 dimensions 488 procedure for use  491–494 equipment 492–493 indications 491–492 lithotripsy 494 ureteral/renal access  493–494 properties 487–490 technical failure  494–495 tip design  488 superior epigastric artery/vein  973 superior pole see upper pole super‐mini percutaneous nephrolithotomy (SMP) 276 supine‐modified positions PCNL  173, 175–177, 216 advantages 173–174 comparative studies  204–205 staghorn calculi  314 robotic surgery  906 see also Galdakao‐modified supine Valdivia position supine position endoscopic inguinal lymph node dissection 1061, 1063 PCNL 173–177 advantages  173–174, 191 calyceal puncture  174, 204, 216 comparative studies  203–205 complications 200–201 CT‐guided access  221–222 disadvantages  174–175, 191 obesity  174, 176, 847–848 retrograde pyelogram  185–186 staghorn calculi  314 transplant kidneys  833 retroperitoneal lymph node dissection 1067, 1068 SWL 748–749 supracostal renal access  255, 256 anatomic aspects  255–257 complications  259–262, 393, 394, 411 indications 255, 256

i41

i42

Index supracostal renal access (cont’d) outcomes 259 surgical technique  257–259 suprapubic approach, LESS surgery 1374–1375 Suprapubic Arc system (SPARC)  1855 suprapubic catheters laser prostatectomy  1700, 1701 single‐port transvesical enucleation of prostate 1767, 1768 urethral strictures/stenosis  1819, 1820 suprarenal glands see adrenal glands Surgenius robotic system  883 surgeon experience flexible ureteroscopy  525 PCNL  119, 398, 412 see also training surgeons ceiling pendant services  144 ergonomics see ergonomics hand‐assisted laparoscopy  997–998 neuromuscular injuries  48, 907, 1002 SurgiBot 882, 883 surgical body‐GPS  53 surgical knot  963 surgical radar  53 surgical site, preparation  1652 surgical site infections (SSI) hand‐assisted laparoscopic surgery  1002 immediate‐use sterilization and  8 laparoscopic hernia repair  1305, 1306 preoperative prevention  1652–1653 robotic kidney transplantation  1267 surgical video systems (SVS)  153–154 see also video imaging technology Surgico 60 DHF™ C‐arm unit  145 Suture Assistant® 966 SutureCut™ needle driver  956, 963 suture needles  961–962 suturing 960–966 ancillary devices  965–966 blocking sequences  964 extracorporeal 964 instruments 962–963 laparoscopic  951–952, 962 robotic  956, 962–963 intracorporeal 964 knot‐tying devices  964–965 knot types  963–964 materials  961, 962 port site skin closure  1016 suture length  961 techniques 964 ureteral 1199 vascular repair  1039 S‐video (Y/C) format  38–39 SWL see shock‐wave lithotripsy sword fighting analogy  1287 systemic inflammatory response syndrome (SIRS)  68, 69 systemic vascular resistance (SVR), laparoscopic surgery  919, 930 table‐mounted instrument holders, laparoscopy 948 tamsulosin cost‐effectiveness 855, 856 pregnancy 791

Volume 1 pages 1–878, Volume 2 pages 879–1913

renal colic  807–808 ureteral access sheath deployment  230 ureteral stent‐related pain  644 ureteral stone expulsion  543, 643, 778 tandem ureteral stents (TUS)  867 teaching, audiovisual (AV) data relay 156–157 technical skills acquisition, taxonomies  159, 160 assessment 897–898 modular hands‐on training  891–893 Technomed Sonolith i‐Move lithotripter  727 Technomed Sonolith i‐Sys lithotripter  721, 727 Tecoflex stents  866 Teflon® (polytetrafluoroethylene; PTFE)  1784, 1847 teleconferencing 157 telementoring 273 telerobotics 273 temperature monitoring focal laser ablation of prostate 1524–1525, 1526, 1527 PCNL 399 prostate cryotherapy  1582, 1595 Temporary Ureteral Drainage Stent (TUDS)  646, 868 tension‐free vaginal tape (TVT)  1832–1833, 1854 complications  1863, 1864, 1865, 1866 elderly patients  1860–1861 intrinsic sphincter deficiency  1862 mesh type  1856 obese patients  1860 prolapse surgery/hysterectomy with 1861–1862 recurrent incontinence  1861 results  1858, 1859 surgical technique  1855 theoretical basis  1855 Tension‐Free Vaginal Tape (TVT)‐Secur™ system see TVT‐Secur™ system terazosin, renal colic  807 Terumo Glidewire  507 testes absent  1344, 1345, 1346 arterial blood supply  1348, 1349, 1354 atrophy 1344 after orchiopexy  1348, 1349, 1350 intra‐abdominal 1344 diagnostic laparoscopy  1323–1324, 1345, 1346 laparoscopic surgery  1345–1349 non‐seminomatous germ cell tumors (NSGCT) 1066–1075 size, varicocele  1353, 1354 undescended see undescended testes testicular artery Fowler–Stephens technique  1348–1349 varicocelectomy 1354 THAM (tromethamine)  358, 359 THAM‐E 358, 359 thermal injury laparoscopic bowel injuries  1041 laser lithotripsy  661 prostate cryoablation  1598 radical prostatectomy  1186

thermal probes focal laser ablation of prostate  1525, 1526, 1528 prostate cryoablation  1582, 1595 see also temperature monitoring thiotepa, upper tract instillation  365, 367 thoracic complications laparoscopic surgery  1027, 1041–1042 PCNL  319, 394, 409–420 anatomic considerations  409–410 blind access  267 descriptions 412–414 diagnosis 414–416 etiology and risk factors  410–412, 424 incidence 410, 411 management 416–419 patient positioning and  201 prevention 419 upper pole access  256–257, 260, 261 see also pleural injury; pneumothorax three‐dimensional (3D) computed tomography percutaneous renal access  212, 223–226, 248–251 renal colic  802, 803 see also Uro Dyna‐CT‐guided renal access three‐dimensional (3D) printing  161 three‐dimensional (3D) video imaging 49–51 laparoscopic surgery  947–948, 1160 ureteroscopy 473 thrombin  74, 75 thromboembolism after laparoscopic surgery  1036 after radical prostatectomy  1172, 1181 risk stratification  76, 77–78 see also venous thromboembolism thrombophilia 77, 78 thromboprophylaxis partial nephrectomy  1089 radical nephrectomy  1078 radical prostatectomy  1172, 1181 robotic kidney transplantation  1266 ureteroscopy  506, 523 thulium laser enucleation of prostate (ThuLEP)  1711, 1712, 1713, 1714 thulium laser resection of bladder tumors (ThuRBT) 1715 thulium lasers  1707–1715 animal studies  1707 BPH therapy  1707–1713 see also laser prostatectomy continuous wave (cw)‐mode  1674, 1675, 1707, 1708 en bloc resection of bladder tumors  1808, 1809, 1812 hazards 1659 physics  1677–1678, 1707, 1708 prostate tissue interactions  1677–1678 Tm‐fiber lasers (wavelength 1940nm) 1677 Tm:YAG (wavelength 2013nm)  1673, 1677 urinary stone fragmentation  1707 urinary tract conditions  1713–1715 thulium vapoenucleation of prostate (ThuVEP) 1710–1713, 1714 thulium vaporesection of prostate (ThuVARP) 1712–1713, 1714

Index thulium vaporization of prostate (ThuVAP)  1714 thyroid shields  22 tibial nerve stimulation, percutaneous  1902, 1909–1911 ticagrelor 76 ticlopidine 76 Ti‐Knot TK5® 965 TilePro video display mode  957 time‐intensity curves (TICs), contrast‐ enhanced ultrasound  1610 time‐out, presurgery  1651 tissue‐engineered bulking agents  1785, 1851 titanium clips  968–970 Tm lasers see thulium lasers topical therapy of upper urinary tract 353–370 antegrade approach  356 antifungal therapy  367–370 chemolysis of urinary calculi  357–363 chemotherapy and immunotherapy 363–367 combined approach  356 new concepts  356–357 retrograde approach  353–356 techniques 353–357 topical urethral anesthesia  1663–1664 torqueable catheters, ureteroscopy  507 total intravenous anesthesia (TIVA)  929 totally tubeless percutaneous nephrolithotomy (PCNL)  317, 434–435, 436 tract, nephrostomy see nephrostomy tract training disinfection and sterilization  9, 12 endourology 159–161 apprenticeship model  159 technical skills acquisition  159, 160 ultrasound‐guided PCNL  240–241 laparoscopic and robotic surgery  887–898 assessment and certification  897–898 curriculum development  893–894 history 888–889 procedural template  890 range of topics  889–893 simulation technologies  894–895 validation 896–897 LESS surgery  1381 see also simulation tramadol, renal colic  806 tranexamic acid, PCNL‐related bleeding 402 transcutaneous pulsed focused ultrasound  707, 708 transforming growth factor‐β (TGF‐β)  136, 137–138 transfusion rates, PCNL  391, 397 children 338 miniaturized techniques  303, 306 patient positioning and  201, 205 staghorn calculi  319 upper pole access  260 transient ischemic attack (TIA)  78 transitional cell (urothelial) carcinoma (TCC)

Volume 1 pages 1–878, Volume 2 pages 879–1913

bladder see bladder cancer thulium laser ablation  1714–1715 upper tract see upper tract urothelial carcinoma transitional cell epithelium  605 transobturator tape (TOT) slings  1833, 1855, 1856 complications 1863–1866 intrinsic sphincter deficiency  1862 male  1893–1894, 1895–1897 obese patients  1860 repeat surgery  1861 results 1858–1859 retropubic slings vs.  1859 surgical techniques  1857 transperineal approach focal laser ablation of prostate  1526, 1527, 1531 local anesthetic prostate block 1666–1667 MRI‐ultrasound fusion biopsy of prostate  1504, 1505 prostate brachytherapy  1534–1535, 1536–1537 prostate cryoablation  1582 robot‐assisted laparoscopic prostatectomy 1387–1389 thermal probe insertion  1528 transperineal mapping biopsy (TMB), prostate 1510 transperitoneal laparoscopic/robotic surgery access 973–984 anterior abdominal anatomy  973, 974 closed entry technique  974–976 complications 977–978 direct optical  976 instrumentation 944, 945 LESS surgery  1366 open (Hasson) technique  944, 976 specific procedures  978–984 adrenalectomy  1279–1281, 1282–1284 operating room setup  902, 903, 904 patient positioning  905, 905, 908, 912, 913, 914 physiologic effects  931 patient selection  987 pneumoperitoneum creation  973–976 pregnancy 937 radical nephrectomy  1078–1081 radical prostatectomy  1143, 1145, 1172–1173 simple prostatectomy  1271 trocar placement  976–977 complications 977–978 specific procedures  978–984 transplant kidneys stone disease  827–833 diagnostic workup  829 donor‐gifted 827 epidemiology 827–828 pathophysiology 828 presentation 828–829 stone management  823, 830–833 active surveillance  830 ex vivo ureteroscopy  829–830 open surgery  833 PCNL  240, 823, 832–833 surgical options  830

SWL 831 trial of passage  830 ureteroscopy 831 urgent decompression  830 ureteral obstruction  608, 617 clinical presentation  618, 828 combined retrograde/antegrade approach 621 urgent decompression  831 YAG laser endoureterotomy  624 ureteral strictures  624, 823–824 transplant (ureteral) stents  615 transradial approach, selective arterial prostate embolization  1490–1491 transrectal focal laser ablation, prostate 1526, 1527, 1528 transrectal prostate blocks  1665–1666 transrectal ultrasound (TRUS) contrast‐enhanced ultrasound with  1608 guided prostate biopsy see prostate biopsy, transrectal ultrasound‐guided guided prostate blocks  1666 guided prostate brachytherapy 1534–1535, 1536–1537, 1538 guided radical prostatectomy  1160–1162 prostate cryoablation  1582, 1589 seminal vesicles  1294 transurethral ethanol ablation of prostate (TEAP)  1666, 1729–1730 transurethral incision of bladder neck contracture (TUIBNC)  1828 transurethral laser enucleation of prostate (TLEP) 1701 transurethral laser prostatectomy see laser prostatectomy transurethral microwave therapy (TUMT)  1488, 1729 local anesthesia  1666 transurethral needle ablation (TUNA)  1488, 1729 local anesthesia  1666 transurethral procedures anticoagulated patients  80 antimicrobial prophylaxis  60–62 back table 1654–1655 benign prostatic hyperplasia  1488–1489 bladder neck contracture  1828 equipment preparation  1653–1655 internal urethrotomy  1821–1823 local anesthesia  1661–1668 operating room preparation  1651–1652 prep table 1655 thulium lasers  1707–1715 urethral bulking therapy  1849 transurethral prostate block  1667–1668 transurethral resection ejaculatory ducts  1294 Hunner’s lesions  1800 kits 1655 transurethral resection in one piece (TURBO) 1809 transurethral resection of bladder tumor (TURBT) 1117 antimicrobial prophylaxis  61, 62 en bloc 1806–1813

i43

i44

Index transurethral resection of bladder tumor (TURBT) (cont’d ) complications 1811 energy sources  1808 limitations 1810–1811 oncologic outcomes  1811–1812 pathological aspects  1809–1810, 1811 procedure 1807–1808 results 1808–1809 limitations  1806, 1810 second‐look 1810 thulium laser  1715 trainers/simulators  164 ureteral orifice resection or incision  619 transurethral resection of prostate (TURP) 1733–1741 anesthesia 1736 antibiotic prophylaxis  60–62, 1736 bipolar see bipolar transurethral resection of prostate bipolar TURP vs. monopolar  1658, 1741, 1743 bipolar vaporization of prostate vs.  1757 brachytherapy after  1552–1553 complications 1739–1741 current waveforms  1734–1735 detrusor underactivity  1636, 1638 hemiresection 1738–1739 history 1733 holmium laser therapy vs.  1684–1685, 1687 indications 1736 irrigation fluids  1736 limitations  1269, 1270, 1681, 1727 local anesthesia  1665, 1666, 1667 monopolar 1733–1741 outcomes 1739 photoselective vaporization of prostate vs.  1695–1696, 1697, 1698–1699 postoperative care  1739 preoperative evaluation  1736 principles 1733–1734 prostatic urethral lift procedure vs. 1723–1724 selective arterial prostate embolization vs. 1489 surgical technique  1736–1739 thulium laser vaporesection vs. 1709–1710 trainers/simulators  164 ureteral orifice resection or incision  619 transurethral resection (TUR) syndrome bipolar TURP  1748, 1749 laser prostatectomy  1702 monopolar TURP  1657, 1740, 1743 transurethral ultrasound ablation (TULSA) 1512 transurethral vaporization of prostate (TUVP)  1743, 1752 bipolar see bipolar transurethral vaporization of prostate transurethral vaporization resection of prostate (TUVRP)  1757–1758 transvaginal mesh (TVM) repair  1880–1887 mesh‐related complications see mesh complications recommended use  1887

Volume 1 pages 1–878, Volume 2 pages 879–1913

transversus abdominis muscle  265 transversus abdominis plane (TAP) block  932, 933 transvesical enucleation of prostate, single‐ port see single‐port transvesical enucleation of prostate transvesical robotic radical prostatectomy (TRRP), single‐site  1772 transvesical single‐site radical prostatectomy 1770 TrapBag™  1011 Trattner double balloon catheter test  1244 trauma renal  281, 1482–1483 ureteral strictures  617 urethral strictures  1817 Traxer and Thomas classification of ureteral injuries  657 treatment table, SWL  723 Trendelenburg position complications  907, 914, 935–936, 1043 continent urinary diversion  1129 extraperitoneal pelvic access  991 obese patients  922 patient safety  930 patient selection  991 pelvic lymphadenectomy  1054, 1055 physiologic effects  917–918, 930, 931, 1023 radical cystectomy  1108 robotic pelvic surgery  906–907, 912, 914, 1035 ureteral reconstruction  1197 see also reverse Trendelenburg position triage, renal colic  804–806 triamcilonone injections bladder neck contracture  1828 Hunner’s lesions  1800, 1801 ureteral strictures  611, 620 urethral strictures/stenoses  1823 triangulation technique lateral position  193–194, 196–197, 217 prone position  214 Sharma & Sharma modification  215–216 supracostal approach  257–259 triclosan‐coated ureteral stents  68, 613, 868 trimethoprim resistance  58 trimodality therapy (TMT), bladder cancer 1116–1117 Triple D score  736 TriPort+/TriPort15  1362, 1364, 1374 prostate specimen extraction  1767, 1768 suprapubic catheterization via  1767, 1768 transvesical enucleation of prostate  1763, 1764, 1767 transvesical insertion  1765, 1766 trocar(s) 945–946 blunt‐tipped 1061 complications  977–978, 1024 Hasson  945, 991 internal dilating  946 LESS surgery  1374, 1375–1376 nephrostomy see nephrostomy needles pediatric 1325 removal  992, 1013 reusable 945, 946 site see port site

size and type  977 visual entry (optical)  945, 946, 976, 1022 trocar placement adrenalectomy  978–979, 1282–1283, 1284–1285 bladder surgery  982, 983 continent cutaneous urinary diversion 1134 continent urinary diversion  1129–1131, 1137 extraperitoneal pelvic access  991–992 hand‐assisted laparoscopy  997–998, 999, 1082 incisional hernia repair  1302–1303 inguinal lymphadenectomy  1061–1062, 1063 kidney transplantation  1262 LESS surgery  1373–1376 living donor nephrectomy left side  979–980, 981, 1251–1252 right side  1255 lower ureteral reconstruction in children 1337 nephroureterectomy  980, 981, 1102–1103 orchiopexy 1346 partial cystectomy  1118 partial nephrectomy  980–981, 1091–1092 pelvic lymph node dissection  982, 983, 1054–1055 pyelolithotomy  1210, 1211 pyeloplasty in children  1330, 1331 radical cystectomy  1109 radical nephrectomy  980–981, 1078–1079, 1081, 1082, 1084 radical prostatectomy  983–984 laparoscopic 1143, 1144 robotic laparoscopic  1173–1174 renal cyst decortication  1225–1226 retroperitoneal access  988–990 retroperitoneal lymph node dissection 1071–1072 sacrocolpopexy 1235, 1236, 1238 seminal vesicle surgery  1295 simple prostatectomy  1270–1271 transperitoneal access  975, 976–977, 978–984 ureteral procedures  982, 1197–1198 varicocelectomy 1354, 1355 vesicovaginal fistula repair  1246 tromethamine (THAM)  358, 359 Trouvé, Gustave  465, 466 TRUS see transrectal ultrasound tubeless percutaneous nephrolithotomy (PCNL)  427, 430–437 children 337 cost effectiveness  859 early tube removal vs.  433–434 hemostatic methods  402, 403, 435–437 miniaturized techniques  306 modified JJ stent placement  434, 435 patient selection  431, 434 small‐bore nephrostomy vs.  431, 433 staghorn calculi  317 standard tubed PCNL vs.  431, 432, 433 totally  317, 434–435, 436 upper pole access  262

Index tuberculosis infundibular stenosis  346 ureteral strictures  617, 618 tuberous sclerosis renal angiomyolipomas  1403, 1406, 1484 renal cysts  1221 TUDS (Temporary Ureteral Drainage Stent)  646, 868 tumor necrosis factor‐α (TNF‐α) 58 tumor seeding renal masses  1431, 1456 upper tract urothelial carcinoma  387 TURBT see transurethral resection of bladder tumor TURP see transurethral resection of prostate TVT see tension‐free vaginal tape TVT‐Oburator (TVT‐O) sling  1840, 1855, 1856 results  1858, 1859 TVT‐Secur™ system  1834, 1835–1836 efficacy  1833, 1836, 1862–1863 UES‐40 SurgMaster generator (Olympus) 1753, 1754, 1758 ulnar nerve injuries  203, 1653 ultra‐high‐definition (UHD) digital videoendoscopes 45–46 ultra‐mini percutaneous nephrolithotomy (UMP) 303–304 applications 306–307 classification 303 comparative studies  304, 305, 306, 307 development 301–302 instruments 303, 304 tract dilation  276 ultrasonic–ballistic lithotripters, combined  327–328, 535 ultrasonic cleaners  6 ultrasonic cutting/coagulation devices  950 ultrasonic lithotripsy children 337 mechanism of action  326–327, 533, 535 PCNL 326–327 pregnancy 793 staghorn calculi  317 ureteroscope design  467 ureteroscopy 534–535, 539 ultrasonography calyceal diverticula  341–342 chest, post‐PCNL  415 contrast‐enhanced see contrast‐enhanced ultrasound cost‐effectiveness 854 data archiving  155 Doppler see Doppler ultrasonography endoluminal  571, 596 image‐guided prostate radiotherapy 1561 kidney allograft lithiasis  829 laparoscopic nephron‐sparing surgery 1098 mesh complications  1884, 1885 PCNL guidance  237–242, 244–245 combined with endoscopy  244–245 ectopic and transplanted kidneys  240 fluoroscopy vs.  212, 241–242 indications 237 instrumentation 237–238

Volume 1 pages 1–878, Volume 2 pages 879–1913

lateral(‐flexed) position  193 optical puncture system  245, 246 preceptorship and mentoring  240–241 radiation dose reduction  27 SonixGPS navigation  246, 251–252 technique 238–240 tract dilation  280 pelvic congestion syndrome  1474, 1475 postpyeloplasty follow‐up  1331 postureteroscopy follow‐up  648–649 pregnancy 788–789 renal colic  800 renal mass biopsy guidance  1427 renal masses  1395 SWL  26, 718, 723 transducers 237–238 transrectal see transrectal ultrasound upper urinary tract neoplasms  568 ureteral reconstruction  1200 ureteral stones  854 ureteral strictures  594, 595 ureteroscopy guidance  26 urethral strictures/stenosis  1819–1820 urinary tract obstruction  127 varicocele 1465, 1466 ultrasound high‐intensity focused see high‐intensity focused ultrasound transcutaneous pulsed focused  707, 708 ultrasound probes disinfection of rectal  11 laparoscopic 948 robotic 957 UltraTrack guidewire (Olympus)  507 umbilical incision laparoscopic specimen extraction  1012 LESS surgery  1366, 1373–1374, 1375 umbrella cells  605 underactive bladder  1636 undescended testes  1344–1349 inguinal canal  1345 laparoscopic management  1344, 1345–1349 diagnosis  1323–1324, 1345, 1346 Fowler–Stephens technique  1348–1349 orchiopexy technique  1347–1348 outcomes 1349 palpable 1345 physical examination  1344–1345 Universal Protocol  1651 UPJ see ureteropelvic junction upper (superior) pole access for PCNL  255–262 anatomical aspects  255–257 complications  200, 259–262, 394 horseshoe kidney  814 indications 255, 256, 257 nephroscopy via  287, 288 outcomes 259 prone‐flexed position  199, 200 prone position  191, 257 staghorn calculi  312 supine position  174, 200 surgical technique  257–259 thoracic complications and  410–411

anatomy 87, 88, 255–257 blood vessels  101–103 pelvicalyceal system  94, 95, 98–101 nephroscopy  287, 288 stones 255, 257 upper tract urothelial (transitional cell) carcinoma (UTUC; UTTCC)  568–579 clinical presentation  568 diagnosis endoscopic techniques  569–570 noninvasive 568–569 diagnostic ureteroscopy  564–565, 569–570 indications 562 new technologies  566, 570 patient preparation  563 grading  385, 571 high‐grade tumors  577 imaging 1413–1416, 1417 large tumors  576 LESS nephroureterectomy  1377 Lynch syndrome  578–579 multifocal 385 natural history and prognosis after surgery 572 percutaneous chemo/ immunotherapy 363–367 BCG  363–366, 388 mitomycin C  366–367 thiotepa 367 percutaneous resection/ablation  285, 384–388 long‐term follow‐up  387–388 patient selection  384–386 procedure 386–387 radical nephroureterectomy  384, 568, 1101 staging  385, 571–572 thulium laser ablation  1714 ureteroscopic treatment  565–566, 572–578 adjuvant therapy  578 bladder tumors after  576 complications  523, 577–578 costs 578 high‐grade tumors  577 large tumors  576 limitations 386 patient selection  573 recurrence after  575–576 results 575 surveillance after  577 upper ureter see proximal ureter upper urinary tract instillation of topical agents see topical therapy of upper urinary tract LESS surgery  1373–1382 ureteroscopic access  551–552 failure 653–654 techniques for difficult  654–655 upper urinary tract neoplasms benign  570, 579 biopsy percutaneous 1431 ureteroscopic  384–385, 564–565, 570–572 endoscopic diagnosis  569–570 familial 578–579

i45

i46

Index upper urinary tract neoplasms (cont’d ) noninvasive diagnosis  568–569 ureteroscopic therapy  572–578 ureteroscopy 568–579 see also renal tumors; upper tract urothelial carcinoma urease inhibitors  360 urease‐producing bacteria  360, 836 ureter agenesis 460 anatomy 455–462 distal ureteral strictures  604–608 endoscopic  459, 607 mid‐ureteral obstruction  592, 593 pelvic lymphadenectomy  1053 atraumatic traction  1200 bifid 460 blood supply  457, 592, 605, 606 congenital anomalies  460–462 contractions 457–458 curvature 604, 605 deviation  459, 460 distal see distal ureter duplicated 460 SWL  739, 740 ectopic 460–461 embryology 455 fused kidneys  461–462 histology  456–457, 592, 605–606 innervation  457–458, 605 living donor nephrectomy  1252, 1254, 1255 lymphatics  457, 592, 605 malpositioned kidney  461–462 middle see mid ureter neobladder 461 nerve supply  592 normal variations  460 pelvic lymphadenectomy  1056, 1057 proximal see proximal ureter radical cystectomy  1109, 1110 radical nephrectomy  1080, 1081 radiologic anatomy  458–459 retrocaval 460 surgery, trocar placement  982 surgical exposure  1199 suturing methods  1199 urinary conduits  461 ureteral access, ureteroscopic percutaneous antegrade  296–297 retrograde 506–507 diagnostic ureteroscopy  563–564 failure 653–654 flexible ureteroscopy  521–530, 551 rigid ureteroscopy  514–518 specific problems  608–610 Sun’s flexible‐tipped ureterorenoscope 493 techniques for difficult  524–527, 654–655 transplant kidneys  608, 823 urinary diversions  518, 527, 528, 839 ureteral access sheaths (UAS)  507, 527–530 Avicenna robot system  674–676, 677, 678 complications 528 digital vs. fiber‐optic ureteroscopes  544

Volume 1 pages 1–878, Volume 2 pages 879–1913

failure to advance  655 PCNL  231, 234 pelvic kidneys  820 placement 528–530 postprocedure stenting  530, 644 prevention of infection  64 staghorn calculi  318 stone disease  528, 529 ureteral wall trauma  459, 659 ureteroscope protection  482, 503 ureteroscopic kidney stone management 551–552 ureteral avulsion  659–660 etiology  547, 660 incomplete 660 management 526 prevention  596–597, 660 ureteral balloon dilators  509, 522, 525, 612–613 ureteral calculi see ureteral stones ureteral catheterization cytological sampling  569 laparoscopic pyelolithotomy  1210 PCNL  213, 231 children 333, 334 percutaneous antegrade ureteroscopy 296 percutaneous endopyelotomy  377 robotic vesicovaginal fistula repair  1245 ureteral catheters children 333, 334 instillation of topical agents  353–356, 363–364 post‐PCNL 317 tubeless PCNL  434 ureteral access  507 difficulties  525–527, 654 flexible ureteroscopy  523–524, 525 rigid ureteroscopy  517 ureteral dilation distal ureteral strictures  619, 620, 623–624 flexible ureteroscopy  525–526 rigid ureteroscopy  517 Sun’s ureterorenoscope  492 ureteral access sheath placement  528 ureteral stone management  545 ureteroscopy 509 ureteral dilators  612–613 see also ureteral balloon dilators ureteral injuries, iatrogenic causes  593–594, 615–617 electrohydraulic lithotripsy  533 laparoscopic partial cystectomy  1123 laparoscopic surgery  1029, 1041 management 656, 657 immediate  526, 597 rendezvous procedures  599–600 ureteral reconstruction  658 pelvic lymphadenectomy  1058 robotic laparoscopic radical prostatectomy 1172 ureteroscopy‐related 656–661 classification 656, 657 false passage/mucosal flap  657, 659 imaging 656, 658 lithotrite use  660–661

mucosal abrasion  657, 658 pressure‐related 661 prevention 596–597 stone basket entrapment  661 stone management  547 ureteral access sheaths  459, 659 see also ureteral avulsion; ureteral perforation ureteral meatal stenosis  615 ureteral meatotomy  619 ureteral mucosa abrasions 657, 658 flap creation/false passage  657, 659 histology  456, 605, 607 ureteral obstruction bilateral (BUO)  124 clinical presentation  124–126 pathophysiology 131–135 causes  125 cost‐effective management  855 distal 604–625 experimental 130–135 malignant see malignant ureteral obstruction/strictures mid ureter  592–600 pathophysiology  124, 130–138 postureteroscopy  648, 662, 857–858 preoperative imaging  1194–1195 renal colic  799 secondary signs  802 SWL and  732 transplant kidneys see transplant kidneys, ureteral obstruction unilateral (UUO)  124 clinical presentation  124–126 pathophysiology 130–131, 132, 134 renal fibrosis  135–138 renal resistive index (RI)  129 strategies to decrease fibrosis  138 tubular apoptosis  135–136 vs. bilateral obstruction  133, 134 ureteral stenting  866, 871–873 ureteral stones  769, 855 see also renal colic; ureteral strictures; urinary tract obstruction ureteral occlusion devices see ureter‐ occluding devices ureteral orifices (UOs) bulking agents, for reflux  1784–1785 cannulation for ureteroscopy  517, 523 diagnostic ureteroscopy  563–564 difficult access  654 failure to advance catheter/ ureteroscope 525–527 inability to advance guidewire 524–525 inability to visualize  524 transplanted kidneys  608, 823 dilation, for ureteroscopy  459, 654 ectopic 460–461 endoscopic appearance  459 meatotomy 619 neobladder 527, 528 post‐TURP and TURBT resection or incision 619 robotic simple prostatectomy  1271–1272 STING procedure  1784–1789 urinary diversion patients  839

Index ureteral–pelvic anastomosis  1199 ureteral perforation  659 electrohydraulic lithotripsy  533 nanosecond electropulse lithotripsy  536 prevention 596–597 ureteroscopic stone management  547 transplant kidneys  832 ureteroscopic therapy of upper tract tumors 578 ureteral pressure bilateral ureteral obstruction  131–133 unilateral ureteral obstruction  130–131, 132 ureteral reconstructive surgery options  658, 1195, 1196 robot‐assisted laparoscopic  1194–1205 abdominal exit  1200 avoiding complications  1201 bilateral disease  1199–1200 bladder exposure  1199 buccal mucosal grafts  1203–1205 complications 1201–1203 cystoscopy and stent placement  1198 instrumentation 1195 intraoperative ultrasound  1200 kidney exposure  1199 lower ureter in children  1335–1343 operating room setup  1196 patient positioning  1196–1197 postoperative care  1200 postoperative evaluation  1201 preoperative imaging  1194–1195 preoperative preparation  1195–1196 renal hilar control  1200 selected case indications  1196 tension‐free anastomosis  1200 tips and tricks  1200–1201, 1202 tissue bolstering  1200 trocar configuration  1197–1198 ureteral exposure  1199 ureteral suturing  1199 see also distal ureteral reconstruction ureteral reimplantation (ureteroneocystostomy) indications 1196 laparoscopic and robotic children 1339 complications  1201–1202, 1203 determining site  1199 simulator  166 ureterovaginal fistula repair  1247 techniques  608, 1788 ureteroscopic anatomy  461, 462, 518, 608 see also Boari flap; psoas hitch; ureterovesical anastomosis ureteral stents balloon‐expandable  637, 870 biodegradable  646, 864, 867–868 Boari flap  1341–1342 covered 870–871 double pigtail (double‐J)  614, 864 coil‐reinforced 867 dual‐lumen 867 long‐term use  866–867 metal 871–872 tubeless PCNL  430, 434, 435 two ipsilateral  867

Volume 1 pages 1–878, Volume 2 pages 879–1913

drug‐eluting/coated  613, 646, 868–869, 873, 874 encrustation  865–866, 871–872 ideal, properties  864 infundibular stenosis  347, 348 laparoscopic and robotic pyeloplasty  1329, 1330 laparoscopic pyelolithotomy  1211, 1212 long‐term 864–874 complications 865–866 indications 864–865 malignant obstruction  622–623, 865, 867 metal stents  869–873 outcome 873–874 polymeric stents  866–869 ureteral strictures  621, 870 ureteroenteric strictures  634, 637–638, 869, 872–873 lower ureteral reconstruction in children  1337, 1340, 1342 metallic see metal ureteral stents migration 865 occupational radiation exposure  20 pain management  643–644 pediatric 615 percutaneous antegrade endopyelotomy 378 polymeric (PS)  864, 866–869 biodegradable 867–868 complications 865–866 double‐pigtail 866–867 drug‐eluting and drug coated  868–869 malignant ureteral obstruction  865 post‐PCNL 317–318 pediatric patients  337 post‐percutaneous endopyelotomy  379 postureteroscopy 644–646 antegrade ureteroscopy  297 endopyelotomy  588, 590 flexible ureteroscopy  558 indications 644 length 645–646 patient comfort  645–646 rationale 644 selection of type  645, 646 ureteral access sheaths  530, 644 ureteroenteric strictures  633–634, 635–637 pregnancy 792 preoperative benefits 596 flexible ureteroscopy  525, 526, 527 retrograde endopyelotomy  586, 588 rigid ureteroscopy  515, 517 SWL  736, 750 prevention of infections  58–59, 63–64, 68 removal 1645 renal colic  805 retained forgotten  646 self‐expandable  637, 869–870 silicone  614, 866 stone management  770, 855, 864 tandem (TUS)  867 thermo‐expandable  637–638, 870 transplant kidneys  831 triclosan‐coated  68, 613, 868 types  613–615, 864

UPJ obstruction  869–870 ureteral reconstructive surgery  1198, 1200–1201 ureteral strictures  597–598, 621 duration 621 long‐term use  621, 870 outcomes 622–623 stent types  613–615 ureteroenteric strictures  633–634 chronic use  634, 637–638, 869, 872–873 complications  637, 638 post‐treatment  633–634, 635–637 ureterovaginal fistulas  1243–1244 urine extravasation/urinoma  662 Ureteral Stent Symptom Questionnaire (USSQ) 645 ureteral stones asymptomatic 769 conservative treatment  805 diagnosis 854 immediate decompression  855 impacted laparoscopic ureterolithotomy  1215–1216 stricture development  594, 617 ureterovesical junction  518 intracorporeal lithotripsy  322–328, 532–539 laparoscopic ureterolithotomy  1214–1216 management options  542–543 cost‐effectiveness 854–858 decision analysis models  856 initial choice  777–779, 780 renal colic  804–809 medical expulsive therapy see medical expulsive therapy migration into ureteral wall  655–656 extramural (lost stone)  656 intramural (submucosal stone)  530, 655–656 natural history  769–770 observation  542, 805, 854–855 pediatric patients  746 proximal see proximal ureteral stones radiation safety  24, 25 renal colic  798 residual fragments 442–444 retropulsion (proximal migration)  655 ballistic lithotripsy  534 electrohydraulic lithotripsy  533 laser lithotripsy  537–538 nanosecond electropulse lithotripsy 536 prevention  508–509, 546–547 semirigid ureteroscopy  486, 491 Sun’s ureterorenoscope  492 size spontaneous passage and  542, 769, 770, 801–802 SWL and  745 spontaneous passage  542–543, 769–770 observation  542, 805, 854–855 prediction  801–802, 805 stenting  770, 864 surgical intervention  855–856 SWL 745–751 see also under shock‐wave lithotripsy

i47

i48

Index ureteral stones (cont’d ) transplant kidneys  831 ureteral access sheath placement and 530 ureteroscopic management  508–509, 543–547 complications 547 cost effectiveness  855–858 distal ureter  778 dusting strategy  444, 538, 546 flexible ureteroscope  543–544, 545 follow‐up imaging  647–649, 857–858 lithotripsy  508, 532–539, 545–546 obesity 846–847 percutaneous antegrade  296–297 preoperative preparation  544 proximal and mid‐ureter  779 residual fragments 442–444, 445, 546 retrieval devices  509, 546 rigid ureteroscope  514 semirigid ureteroscope  514, 543, 545 stone extraction  545–547 Sun’s ureterorenoscope  491–492 surgical technique  544–545 ureter‐occluding devices  508–509 urinary diversion patients  839, 840 ureteral strictures acquired 615–617 benign 617 buccal mucosal ureteroplasty  600, 1203–1205 classification  593, 604 clinical presentation  594, 618 congenital  594, 615, 616 definition 604 diagnosis  594–596, 618 difficult ureteral access  525, 608–610, 655 distal 604–625 etiologies  593–594, 615–617 history taking  521 iatrogenic  593–594, 615–617 postureteroscopic imaging  647–648 postureteroscopy stenting and  644 prevention 596–597 upper tract tumors  578 ureteral access sheaths  528 ureteroscopic stone removal  547 infectious 617, 618 malignant see malignant ureteral obstruction/strictures mid ureter  592–600 post‐laparoscopic ureterolithotomy  1215 postureteroscopy 663–664 follow‐up imaging  647–648 pathogenesis  594, 616–617 prevention 596–597 reimplanted ureters  1203 stenting see under ureteral stents thulium laser therapy  1714 transplant kidneys  624, 823–824 treatment distal ureter  618–625 mid ureter  597–600 see also ureteral obstruction; ureteroenteric strictures ureteral transection inadvertent  594, 599–600 radical cystectomy  1109

Volume 1 pages 1–878, Volume 2 pages 879–1913

ureteral trauma, iatrogenic see ureteral injuries, iatrogenic ureteral–ureteral anastomosis see ureteroureterostomy ureterocalicostomy indications 1196 retrograde stent placement  1200–1201 suture technique  1199 ureter‐occluding devices PCNL  186–187, 288–289, 290, 314 ureteroscopy  508–509, 546 ureterocele 461 obstructed 615 Collin’s knife‐electrode  611–612 ureteroscopic access  518 ureterocolonic anastomosis, continent cutaneous urinary diversion  1134 ureteroenteric anastomoses, ureteroscopic access 518 ureteroenteric strictures (UES)  629–638 endourologic treatment  630–638 balloon dilation  631, 632, 634, 635 complications 638 endoureterotomy  631–633, 635–637 novel 634 outcomes  624, 634–638 postoperative follow‐up  638 stenting  633–634, 637–638, 869, 872–873 indications for therapy  630 pathogenesis 629 presentation and diagnosis  629–630 uretero‐ileal conduit anastomoses, intracorporeal  1126, 1127 ureterolithotomy, laparoscopic (LUL) 1214–1216 indications  1209 outcomes 1214–1216 procedure 1216 ureterolysis, robotic complications  1202, 1203 indications 1196 uretero‐neobladder anastomosis hybrid technique  1132 keys to success  1138 pure intracorporeal technique  1133 ureteroneocystostomy see ureteral reimplantation ureteropelvic junction (UPJ)  604 balloon dilation see under balloon dilation occlusion during PCNL Accordion™ device  288–289 ureteral occlusion balloon  186–187, 314 stenosis 460 ureteropelvic junction obstruction (UPJO) Acucise® endopyelotomy  381, 585, 590 congenital 615 definition 584, 585 diagnostic testing  585 differential diagnosis  803 ectopic kidneys  822–823 endopyeloplasty 379 laparoscopic and robotic pyeloplasty  381, 590 comparative outcomes  1332 complications 1331–1332 indications 1329

operative setup  1329–1330 patient preparation  1329 pediatric  1323, 1328–1333 postoperative care  1331 procedures  1330, 1331 renal anomalies  823, 1330 reoperative 1333 long‐term ureteral stenting  869–870 open pyeloplasty  584, 823, 1328 percutaneous endopyelotomy  377–382, 590 clinical applicability  382, 590 invagination technique  379 preoperative management  377, 378 results and prognosis  381–382 techniques 377–381 postpyeloplasty persistence  1331 renal stones with laparoscopic pyelolithotomy 1209–1210 percutaneous endopyelotomy  378, 382 SWL 732, 739, 740 retrograde endopyelotomy  379–381, 584–590 clinical usage  589 complications 589 electrocautery 588 history 584–585 instrumentation  586 operative techniques  586–588 patient preparation  586 patient selection  585–586 postoperative care  588–589 results 589 treatment options  381, 584–585 compared 590 ureterorenoscopy postoperative care  642–649 retrograde endopyelotomy  380 Sun’s flexible tipped see Sun’s flexible‐ tipped ureterorenoscope trainers/simulators  163 see also flexible ureteroscopy; ureteroscopy ureteroresectoscope, retrograde endopyelotomy  586, 588 ureteroscopes  465–473, 475–484 digital 497–504 flexible see flexible ureteroscopes, digital rigid 473 semirigid 471 flexible see flexible ureteroscopes future trends  472, 483 history  465–467, 475 intraoperative failure  655 maintenance and durability  471–473, 481–482, 856–857 rigid see rigid ureteroscopes semirigid see semirigid ureteroscopes ureteroscopy (URS) 3D imaging  473 antibiotic prophylaxis  61, 63–64, 65, 544, 642–643, 663 anticoagulated patients  80, 522, 544–545 biopsy 570–572 complications 572

Index patient selection  572 technique  564–565, 570–571 complications 653–664 classification 653, 654 early postoperative  661–663 intraoperative 653–661 late postoperative  663–664 diagnostic  562–566, 569–570 ex vivo 830–831 flexible see flexible ureteroscopy fluoroscopic guidance  516, 522 history 467 imaging follow‐up  647–649, 857–858 indications 562 infectious complications  64 prevention  61, 63–64, 65 risk factors  64 infundibular stenosis  347 instruments 563 irrigation systems  510–511 new technologies  511, 566, 570 operating room setup  147, 148, 522 patient preparation  506, 562–563 PCNL with retrograde flexible  27, 177–181, 231–232, 233 percutaneous antegrade  294–299 contraindications 294 distal ureteral stones  297 indications 294, 295 instrumentation  296 outcomes 298–299 postoperative care  297 preoperative assessment  294–295 proximal ureteral stones  296–297 techniques 296–297 urinary diversions  298, 839, 840 postoperative care  642–649 analgesics 643–644 antibiotics 642–643 imaging 647–649 outpatient vs. inpatient  642, 643 residual stone fragments 649 stenting 644–646 pregnant women  30, 792–794 radiation‐free (fluoroless)  26 radiation safety  20, 23, 26 renal cysts  349 residual stone fragments after see under residual stone fragments retrograde endopyelotomy  584–590 rigid 514–518 robotic/laparoscopic ureteral reconstruction 1201, 1202, 1204 semirigid see semirigid ureteroscopy stone management calyceal diverticula  343, 556–558 horseshoe kidney  815 obesity 846–847 pelvic kidneys  819–820 pregnancy 792–794 proximal ureteral stones  294, 296–297 transplant kidneys  823, 832 see also under renal stones; ureteral stones Sun’s flexible‐tipped ureterorenoscope 491–495 technique 563–564

Volume 1 pages 1–878, Volume 2 pages 879–1913

trainers/simulators  163 ultrasound guidance  26 upper tract access  551–552 failure 653–654 techniques for difficult  654–655 upper tract neoplasms diagnosis  564–565, 569–570 surveillance 577 therapy  386, 565–566, 572–578 ureteral access see ureteral access ureteral stenting after see ureteral stents, postureteroscopy virtual 473 working instruments  506–511 ureterosigmoidostomy, robot‐assisted 1135 ureteroureterostomy, laparoscopic and robotic complications 1203 indications 1196 mid‐ureteral obstruction  600 suturing technique  1199 ureterouterine fistulas  1244 ureterovaginal fistulas  1242 diagnosis and evaluation  1243, 1244 nonsurgical management  1243–1244 robot‐assisted laparoscopic repair  1247, 1248 ureterovesical anastomosis (UVA) robotic kidney transplantation  1266 technique 1199 trainers/simulators  166 see also ureteral reimplantation ureterovesical junction (UVJ) anatomy  456, 604 stone impaction  518 stones 777, 778 urethra anatomy 1815–1816, 1817 biopsy of prostatic  1117 bulbous 1815–1816, 1817 cystoscopic examination  1644, 1645 distraction defects, posterior  1818–1819 injuries, midurethral sling surgery  1863 length sparing, radical prostatectomy 1183 membranous 1816, 1817 mesh/tape erosion into  1866, 1886 neuroanatomy 1662 penile (pendulous)  1815, 1816, 1817 prostatic 1816, 1817 radical cystectomy  1110 topical anesthesia  1663–1664 urethral bulking agents (UBAs)  1847–1851 economics 1848 future 1851 history 1847 materials 1849–1851 mechanism of action  1847–1848 patient selection  1848–1849 post‐prostatectomy incontinence  1891 techniques 1849 urethral catheterization after internal urethrotomy  1822–1823 PCNL for staghorn calculi  314 times, laparoscopic radical prostatectomy 1151 urethral strictures/stenosis  1819

urethral catheters prevention of infections  58–59, 67–68 removal, antibiotic therapy  60 see also Foley catheters urethral dilation bladder neck contracture  1828 urethral strictures/stenoses  1819, 1821 urethral hypermobility bioinjectable therapy and  1848 midurethral slings and  1854, 1862 post‐prostatectomy incontinence  1893 urethral–internal pudendal artery fistula  1822 urethral–neobladder anastomosis, robot‐ assisted hybrid techniques  1110, 1111, 1132 keys to success  1138 pure intracorporeal techniques  1133, 1134 urethral reconstruction, open  1822 urethral sphincter anatomy in men  1142–1143, 1890, 1891 intrinsic deficiency see intrinsic sphincter deficiency nerve supply  1143, 1662 transperineal local anesthetic block  1667 TURP technique and  1737–1738 urethral stenosis  1815–1825 diagnosis and evaluation  1819–1821 etiology 1817–1819 terminology 1817 treatment 1821–1825 urethral stents  1824, 1829 urethral strictures anatomy 1816–1817, 1818 congenital 1818 diagnosis and evaluation  1819–1821 etiology 1817–1819 palliative management  1821, 1823 postprocedure HIFU of prostate  1575, 1577 laser prostatectomy  1702 prostate cryoablation  1584, 1585, 1599, 1600 TURP  1740, 1749 ureteroscopy 664 treatment 1821–1825 urethral warmers, prostate cryotherapy  1512, 1595 urethrocystoscopy see cystoscopy urethrography, contrast‐enhanced  1819, 1820 urethrorrhagia, idiopathic  1817 urethrotomy internal 1821–1823 laser 1823–1824 urethrovaginal fistulas  1242, 1244 urethrovesical anastomosis see vesicourethral anastomosis URF‐P3 flexible ureteroscope  486–487 URF‐P5 fiber‐optic ureteroscope (Olympus)  482–483, 510 URF‐V2 digital flexible ureteroscope (Olympus) 43, 500, 502 URF‐V digital flexible ureteroscope (Olympus)  480, 497 comparative studies  482–483, 499, 510 nephroscopy 286–287 technical details  500, 502

i49

i50

Index URF‐Vo ureteroscope (Olympus)  499, 510 urgency after midurethral sling surgery  1833, 1865–1866 after pubourethral sling surgery 1875–1876 interstitial cystitis  1795 Urgent® PC Neuromodulation System 1909 urge urinary incontinence (UUI) after holmium laser enucleation of prostate 1686 after midurethral sling surgery  1865 midurethral slings for  1859–1860 overactive bladder  1775, 1776–1777 uric acid stones acoustic and physical properties  697 diagnostic imaging  129 dissolution therapy  357–358, 359 obesity  843, 845 renal transplant recipients  828 SWL  732, 746 urinary calculi see stone(s) urinary conduits, ureters  461 urinary continence after laparoscopic radical prostatectomy  1155–1158, 1159, 1171 female  1832, 1855, 1871 male  1142–1143, 1890 neurologic aspects  1143 see also laparoscopic radical prostatectomy, continence preservation; urinary incontinence urinary diversion recipients retrograde ureteral access  518, 527, 528, 839 stones 836–841 antegrade ureteroscopy  298, 839, 840 etiology 836 incidence 836–837 management 837–839 prevention 839–840 SWL  740, 837, 839 types 837 ureteroenteric strictures  629–638 urinary diversion surgery bladder neck contracture  1829 continent 1128–1138 intracorporeal ileal conduit  1125–1127 options after radical cystectomy  1110, 1128 robot‐assisted continent cutaneous 1134–1135 robot‐assisted ureterosigmoidostomy 1135 see also ileal conduit urinary diversion; neobladder urinary incontinence benign prostatic hyperplasia  1638–1640 female  1854, 1871 female genitourinary fistulas  1242, 1243, 1245 neuromodulation 1902–1911 persistent, after female sling surgery  1861, 1876 physical therapy  1188–1189 post‐holmium laser enucleation of prostate 1686

Volume 1 pages 1–878, Volume 2 pages 879–1913

post‐prostate cryoablation  1584, 1585–1586, 1599, 1600–1601 post‐prostatectomy see post‐ prostatectomy urinary incontinence post‐prostate HIFU  1577 post‐TURP 1740 urodynamic evaluation  1635, 1639–1640 see also incontinence surgery; mixed urinary incontinence; stress urinary incontinence; urge urinary incontinence; urinary continence urinary retention holmium laser enucleation of prostate 1686 postprocedure HIFU of prostate  1575, 1576–1577 intravesical botulinum toxin  1778 midurethral slings  1863–1864, 1865 prostate cryoablation  1584–1585, 1598, 1599 pubovaginal slings  1874–1875 ureteroscopy 653 urethral bulking therapy  1849 sacral nerve stimulation  1904 urethral strictures/stenosis  1819 urinary tract injuries, laparoscopic surgery  1041 pregnancy‐related changes  786, 787 radiation toxicity  1544, 1554–1556 urinary tract infections (UTI) antibiotic resistance  58 bacteriology 58 hospital‐acquired 57 postoperative 57 children 338 intravesical botulinum toxin injections 1778 laparoscopic surgery  1035–1036 laser prostatectomy  1702–1703 midurethral sling surgery  1864 prevention  57, 58–68 risk factors  59 staghorn calculi  319 TURP 1740 ureteroscopy 663 sepsis vs.  57 SWL and  732 ureteroscopy and  522, 544 see also urosepsis urinary tract obstruction  124–138 causes  125 clinical presentation  124–126 diagnosis 126–130 differential diagnosis  803 infectious complications  66, 126 pathophysiology  124, 130–138 postureteroscopy 662 silent, asymptomatic renal stones  768 S.T.O.N.E. nephrolithometry  109 SWL caveats  732 see also bladder outlet obstruction; ureteral obstruction; ureteropelvic junction obstruction urine pH  799, 843 straining for stones  809 urine alkalization cystine stones  359

obese stone formers  845 uric acid stones  358, 359 urine cultures postoperative sepsis  69 preoperative  59, 62, 64, 65–66 children 332 percutaneous antegrade ureteroscopy 295 percutaneous instillation of topical agents 356 urine leaks, postoperative laparoscopic pyeloplasty  1331 laparoscopic surgery  1028, 1041 laparoscopic ureterolithotomy  1215 partial cystectomy  1123 radiofrequency ablation of renal tumors 1446 robotic radical prostatectomy  1172 robotic ureteral reconstruction  1203 tubeless PCNL  431 ureteroscopy 661–662 urine loss ratio (URL), after laparoscopic radical prostatectomy  1155–1157, 1158, 1159 urine output, during living donor nephrectomy 1254 urinoma after partial cystectomy  1123 postureteroscopy 661–662 see also urine leaks, postoperative urinothorax  413, 415 Uriprene™ stent  646, 868 URobotics program, Johns Hopkins  270–271, 272 Uro Dyna‐CT‐guided renal access  212, 223–226, 248–251 advantages  246, 251 disadvantages 226, 246, 251 equipment 223–224 outcome 225 procedure 224–225, 226 radiation exposure  224, 225, 253 vs. other new methods  252 urodynamics 1627–1634 antimicrobial prophylaxis  61 cystometry 1631–1632 female incontinence  1872 filling symptoms  1633, 1634 multichannel 1632 preparation for  1628–1630 technique 1632–1634 urethral strictures/stenosis  1820–1821 urinary incontinence  1635, 1639–1640 uroflowmetry 1630–1631 useful parameters  1628 voiding symptoms  1633–1634, 1635–1637 uroflowmetry  1630–1631, 1728 urography CT see computed tomography (CT), urography intravenous see intravenous pyelography/ urography magnetic resonance (MRU)  25, 595, 596 ureteral anatomy  458–459 UroLift® implants  1654, 1720, 1721 insertion technique  1722–1723 see also prostatic urethral lift procedure

Index urolithiasis see stone disease Urological Society of Australia and New Zealand (USANZ)  888 urologic surgery ureteral strictures complicating  594, 616–617 see also open urologic surgery urologists occupational radiation exposure  20 PCNL outcomes  390, 399, 412 percutaneous nephrostomy  241, 312 radiation safety  22 UroLume® stent  1729, 1824 bladder neck contracture  1829 UroNav biopsy system  1501, 1502, 1504 urosepsis 57 after stone dissolution therapy  361 bacteriology 58 flexible ureteroscopy  526–527 pathogenesis 57–58 post‐PCNL 319 prevention 58–68 renal colic with  805 see also sepsis Urostation biopsy system  1503, 1505 urothelial carcinoma see bladder cancer; upper tract urothelial carcinoma urothelial hyperplasia, ureteral stent‐ related  866, 870–871 urothelial injuries cryoablation of renal masses  1456 radiofrequency ablation of renal tumors 1446 see also urine leaks, postoperative UVENTA stent  871 Uventa ureteral stent  634 vacuum erection devices (VED)  1188 vagal stimulation, laparoscopic surgery  919 vagina dissection sacrocolpopexy  1236–1237, 1238–1239 vesicovaginal fistula repair  1246–1247 kidney graft insertion via  1267 laparoscopic specimen extraction  1012 mesh implant exposure  1866, 1882, 1884 vaginal manipulators, laparoscopic sacrocolpopexy 1236 vaginal prolapse surgery abdominal approach vs.  1234 ideal graft material  1881 mesh complications  1880–1887 popularity of mesh kits  1880 prophylactic midurethral sling with  1235, 1862 recommendations for mesh use  1887 vaginal surgery equipment setup  1657 operating room preparation  1651–1652 Valdivia position, Galdakao‐modified supine 175–177 Valdivia Urìa, J.G.  173 validation, training simulators  161, 889, 896–897 Valleylab system  1444 Valsalva maneuver pelvic congestion syndrome  1476 varicocele 1465, 1466, 1470

Volume 1 pages 1–878, Volume 2 pages 879–1913

van Velthoven single‐knot technique  1149, 1150 varicocele 1353–1354 anatomy and pathogenesis  1354, 1464 epidemiology 1464 gonadal vein embolization  1464–1473 complications 1472 outcomes  1357, 1472–1473 patient selection  1464–1466 procedure 1470–1472 sandwich technique  1470 sclerotherapy 1470 vascular access  1467 venography 1467–1470 grading systems  1465, 1466 preprocedure evaluation  1464–1466 recurrence  1357, 1472–1473 surgery see varicocelectomy treatment options  1353, 1466 varicocelectomy laparoscopic  1353–1359, 1466 complications 1357 follow‐up 1358 indications 1353–1354 outcomes 1357–1358 surgical procedure  1354–1356, 1357 microsurgical subinguinal  1357, 1466 open  1357–1358, 1466 varicose veins, pelvic congestion syndrome  1473, 1474, 1475 vasal artery, Fowler–Stephens technique 1348–1349 vascular access gonadal vein embolization  1467, 1468, 1474–1476 renal artery embolization  1481 selective arterial prostate embolization 1490–1491 vascular endothelial growth factor (VEGF)‐targeted microbubbles 1610–1611 vascular hitch procedure, pediatric laparoscopic pyeloplasty  1331 vascular injuries laparoscopic  1024–1025, 1036–1040 access‐related  978, 1022 equipment 1025 intraoperative 1036–1040 management 1037–1039 postoperative bleeding  1040 prevention 1036, 1038 midurethral sling surgery  1863 PCNL  101, 201, 392–393, 398 angio‐embolization 403–405 strategies to minimize  400 pelvic lymph node dissection  1057 robotic surgery  1039–1040 shock‐wave‐induced 705–706 see also bleeding/hemorrhage; blood loss vascular‐targeted photodynamic therapy (VTP), prostate cancer  1514, 1516 vas deferens anatomy 1313–1314 pelvic lymphadenectomy  1053, 1055 radical prostatectomy  969, 1145, 1146, 1174, 1175 seminal vesicle excision  1295, 1296

vasectomy reversal, robot‐assisted (RAVR) 1313–1320 anastomosis techniques  1317–1319, 1320 anatomy 1313–1314 anesthesia 1315 complications 1320 incision approaches  1315 patient positioning  1315 postoperative care  1320 preoperative evaluation  1314 vas deferens preparation  1315–1317 vasoconstriction bilateral ureteral obstruction  131 unilateral ureteral obstruction  130, 131 vasodilation bilateral ureteral obstruction  131 unilateral ureteral obstruction  130, 131 vasoepididymostomy, robot‐assisted (RAVE)  1314, 1316, 1319, 1320 vasopressin (antidiuretic hormone)  919, 920 vasovasostomy robot‐assisted (RAVV)  1314, 1316, 1317–1319 trans‐scrotal crossed  1318–1319 Vattikuti Urology Institute (VUI), robotic kidney transplantation  1260–1261 venography pelvic congestion syndrome  1476 varicocele  1467–1470, 1476 venous anastomosis, robotic kidney transplantation 1265 venous anastomotic arcades, intrarenal  91, 92 intraoperative injury risk  103, 104 venous puncture, PCNL access  392–393 venous return, laparoscopic surgery  919 venous thromboembolism (VTE) after radical prostatectomy  1172, 1181 perioperative anticoagulation  77, 78 postureteroscopy 663 Veress needle  944, 945, 1021 access technique  974–976 complications  921, 1023, 1024, 1040 robotic vesicovaginal fistula repair  1246 safe use  1022, 1036, 1037, 1040 vesical pressure (Pves) 1632 vesicoureteral reflux (VUR) diagnostic radiation exposure  29 dysfunctional elimination and  1789 hydrodistention grading system  1786, 1787 positionally instilled cystogram  1788 postureteroscopy  459, 664 STING procedure  1784–1789 bulking agents  1784–1785 clinical role  1787–1788 follow‐up 1786–1787 new technology  1789 technique 1785–1786 vesicourethral anastomosis ideal surgical technique  1826–1827 laparoscopic 1149 leaks  1028, 1172 LESS radical prostatectomy  1769 perineal robot‐assisted laparoscopic prostatectomy 1388

i51

i52

Index vesicourethral anastomosis (cont’d) robotic‐assisted laparoscopic  1175–1176 robotic LESS radical prostatectomy  1386 Rocco stitch  1149, 1150, 1184–1185 stricture see bladder neck contracture suture materials  961 van Velthoven single‐knot technique 1149, 1150 vesicourethral distraction stenosis  1818 vesicouterine fistulas  1242–1243 vesicovaginal fistulas  1242, 1244 clinical presentation  1243 diagnosis and evaluation  1243, 1244 goals of therapy  1244 nonsurgical management  1244 optimization for surgery  1245 preoperative preparation  1245 robot‐assisted laparoscopic repair 1245–1248 surgical approaches  1244–1245 timing of surgery  1244 vesiculodeferential artery  1292, 1295–1296 video‐assisted thoracic surgery (VATS)  418 video cameras  39–40, 41 data archiving  155 data capture  153 electronic exposure  46 high‐definition (HD)  42, 44–45, 146, 1159–1160 LESS surgery  1368, 1369 standard definition (SD)  146 ureteroscopes 471 video cart, endoscopic  47, 48, 1650 videocystoscopy 1646 videoendoscopes, digital see digital videoendoscopes video imaging technology  38–53 3D imaging  49–51 data archiving  154–155 data capture  153–154 data relay  155–157 digital imaging  38–39 future directions  48–53 laparoscopy  947–948, 1159–1160 operating room design  145, 146 robotic systems  954 setup 47–48, 49, 50 standard systems  39–47 ureteroscopy 471 video mixer  155 video monitors 3D systems  49–51 digital imaging formats  38–39 laparoscopic surgery  948 operating room setup  48, 49, 50, 145, 146 video recordings  39 video‐urodynamics  1632, 1640 Viper ureteroscope (Richard Wolf )  510

Volume 1 pages 1–878, Volume 2 pages 879–1913

Virtual Navigator biopsy system  1504 virtual reality (VR) simulators  895, 896 available  162–167 history of development  888–889 radiation safety  28 virtual ureteroscopy  473 Virtue® quadratic male sling  1894, 1898 Visera 4K UHD system  45–46 visual entry trocars  945, 946 visual estimation targeting (VET) see cognitive fusion prostate biopsy visual loss, postoperative (POVL) laparoscopic and robotic surgery  907, 914, 931, 935 prone positioning  203 vitamin K  75 vitamin K antagonists  74–75, 78–79 V‐Loc™ 180 suture  961, 963 voiding cystourethrography (VCUG) radiation safety  29 STING procedure follow‐up  1786 urethral strictures/stenosis  1819 voiding dysfunction after midurethral sling surgery  1863–1864, 1865 detrusor underactivity  1635–1636 endoscopic therapy of reflux and  1789 flexible cystoscopy  1645 neuromodulation 1902–1911 stent syndrome  865 urethral strictures  1819 urodynamic evaluation  1633–1634, 1635–1637 uroflowmetry 1630–1631 von Hippel–Lindau (VHL) syndrome pheochromocytoma 1282 renal cell carcinoma  1407, 1408 renal cysts  1221 Vurdex bulking agent  1785 Waldeyer’s separation  606 walls, operating room  145 Wallstent  637, 869 warfarin 74–75 perioperative management  78–79 safety of urological surgery  80, 81 warm ischemia time laparoscopic anatrophic nephrolithotomy  1211–1212, 1213 partial nephrectomy  1088 washers/decontaminators 6 washers/sterilizers 6 water bath, shock‐wave coupling  714, 717 water cushion, shock‐wave coupling  714, 717–718, 723 waterjet ablation (aquablation) of prostate 1730 waterjet en bloc resection of bladder tumors  1808, 1813

oncologic results  1812 surgical technique  1807 water vapor energy ablation of prostate  1730 Weigert‐Meyer rule  460 weight loss obese patients with stones  845 preoperative, radical prostatectomy  1180 urolithiasis risk  844 well‐leg compartment syndrome see compartment syndrome, lower extremity Whitaker test  128, 595, 596 white‐balancing  39, 146 Wilms’ tumor, hemorrhagic  1485, 1486 Wilson frame  191 wireless (WiFi) local area network  155 Wolf endoureterotome  613, 614, 619 wolffian duct  455 Wolf Piezolith 3000 lithotripter  716, 727 Wolf Piezolith 3000 plus lithotripter  721, 727 Wolf ureteroscopes  467 flexible  477, 480 semirigid  472 working channels flexible ureteroscopes  478–479 rigid ureteroscopes  467 semirigid ureteroscopes  471, 472 Sun’s flexible‐tipped ureterorenoscope 488–489 workstation, operating room  154–155 World Health Organization, presurgical checklist 1032 wound infections see surgical site infections xanthogranulomatous pyelonephritis (XPG) 1403 X‐Cone device  1362–1363, 1365 xenografts  1873, 1881 xenon lamps  46 Xpeeda™ D/S/L fiber  1684 X‐rays digital tomosynthesis (DT)  25 generation 15–17 hazards of excessive exposure  17–18 prostate radiotherapy  1557–1558, 1560–1561 tissue interactions  16–17 see also fluoroscopy XX‐ES lithotripter  706 Y/C (S‐video) format  38–39 Youssef ’s syndrome  1243 yttrium–aluminum–garnet (YAG)  1673 Zebra stent  867 Zinner syndrome  1293 zotarolimus‐eluting stent  873

Smith’s Textbook of Endourology

Smith’s Textbook of Endourology Fourth Edition VOLUME 2 Edited by Arthur D. Smith, MD

Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Glenn M. Preminger, MD

James F. Glenn Professor of Urology and Chief Division of Urology, Department of Surgery Duke University Medical Center Durham, NC, USA

Louis R. Kavoussi, MD

Waldbaum Gardner Professor and Chairman The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Gopal H. Badlani, MD, FACS, FRCS (Hon) Vice Chair Urology Professor of Urology and Gynecology Wake Forest University Winston‐Salem, NC, USA

Assistant Editor

Ardeshir R. Rastinehad, DO, FACOS

Associate Professor of Urology and Radiology Director of Focal Therapy and Interventional Urologic Oncology Department of Radiology and Urology Icahn School of Medicine at Mount Sinai New York, NY, USA

This edition first published 2019 © 2019 by John Wiley & Sons Ltd Edition History Wiley‐Blackwell (3e, 2012) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi and Gopal H. Badlani to be identified as the authors of the editorial material in this work has been asserted in accordance with law. Registered Offices John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. A catalogue record for this book is available from the Library of Congress and the British Library. ISBN 9781119241355 Cover images: © Tewan/iStock/Getty Images Plus; © ilbusca/Getty Images; © Gopal H. Badlani Cover design by Wiley Set in 10/12 pt Warnock Pro by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1

v

Contents List of Contributors  xvi Foreword  xl Preface  xli About the Companion Website  xliii

VOLUME 1 SECTION 1 

BASIC PRINCIPLES

  1

Care and Sterilization of Instruments  3 Carol Olsen

  2

Radiation Safety During Diagnosis and Treatment  14 Yasser A. Noureldin & Sero Andonian

  3

Enhanced Endoscopic Imaging  38 Ghalib A. Jibara & Michael E. Lipkin

  4

Preoperative Antibiotics and Prevention of Sepsis in Urologic Endoscopic Surgery  57 Manish N. Patel & Jorge Gutierrez-Aceves

  5

Management of the Anticoagulated Patient  73 Zeph Okeke SECTION 2  PERCUTANEOUS RENAL SURGERY Part 1  Perioperative Considerations

  6

Surgical Anatomy of the Kidney for Endourological Procedures  87 Francisco J.B. Sampaio

  7

Nephrolithometric Scoring Systems for Percutaneous Nephrolithotomy  108 Roshan Patel, Daniel J. Lama, & Zhamshid Okhunov

  8

Pathophysiology of Urinary Tract Obstruction  124 Frederick A. Gulmi & Diane Felsen

  9

Organizing the Endourological Operating Room  143 Ravindra B. Sabnis, Abhishek Singh, & Shashikant Mishra

10

Endoscopic Training/Simulation  159 Zichen Zhao & Robert M. Sweet

vi

Contents

Part 2 

Patient Positioning for Percutaneous Access

11

Patient Positioning, the Supine Position, and the Rationale of ECIRS  173 Cesare M. Scoffone & Cecilia M. Cracco

12

Prone, Lateral, and Flexed: Patient Positioning for Percutaneous Nephrolithotomy  185 Robert J. Sowerby, A. Andrew Ray, & R. John D’A. Honey Part 3 

Imaging for Access

13

Percutaneous Nephrolithotomy Access Under Fluoroscopic Control  210 Norberto O. Bernardo & Maximiliano Lopez Silva

14

Dyna-CT-Guided versus Standard CT-Guided Renal Access  221 Manuel Ritter & Maurice-Stephan Michel

15

Endoscopically Guided Percutaneous Renal Access  229 Zhamshid Okhunov, Kamaljot S. Kaler, Simone Vernez, Rahul Dutta, Jaime Landman, & Ralph V. Clayman

16

Percutaneous Nephrolithotomy Access Under Ultrasound  237 Mahesh R. Desai & Arvind P. Ganpule

17

New Concepts of Renal Access: iPad, GPS, and Others  244 Estevao Lima, Pedro L. Rodrigues, Marie-Claire Rassweiler-Seyfried, & João L. Vilaça Part 4 

Selection of Access and Dilation

18

Percutaneous Nephrolithotomy: Upper Pole Access  255 Davis P. Viprakasit & Nicole L. Miller

19

Percutaneous Nephrolithotomy Access Without Image Guidance  264 Arthur D. Smith

20

Percutaneous Nephrolithotomy Access: Robotic  269 Michelle Jo Semins, Dan Stoianovici, & Brian R. Matlaga

21

Dilation of the Nephrostomy Tract  275 Peter Alken Part 5 

Stone Removal

22

Rigid and Flexible Nephroscopy  285 Timothy Y. Tran & Mantu Gupta

23

Percutaneous Antegrade Ureteroscopy  294 Burak Turna, Umit Eskidemir, & Oktay Nazli

24

Small-caliber Percutaneous Nephrolithotomy: Mini, UMP, and Micro-Perc  301 Janak D. Desai & Arkadiusz Miernik

25

Percutaneous Nephrolithotomy: Special Problems with Staghorns  310 Monica A. Farcas & Kenneth T. Pace

Contents

26

Percutaneous Nephrolithotomy: Stone Extraction and Lithotripsy  322 Samir Derisavifard & Arthur D. Smith

27

Percutaneous Nephrolithotomy in Children  332 Adam S. Howe, Jordan S. Gitlin, & R. John D’A. Honey Part 6 

Other Uses of Nephrostomy Access

28

Percutaneous Nephrolithotomy of Calyceal Diverticula, Infundibular Stenosis, and Simple Cysts  341 Nadya E. York & James E. Lingeman

29

Percutaneous Instillation of Chemolytic, Chemotherapeutic, and Antifungal Agents  353 Mohamed A. Elkoushy, Philippe D. Violette, & Sero Andonian

30

Percutaneous Treatment of Ureteropelvic Junction Obstruction  377 Michael W. Sourial, Bodo E. Knudsen, & Paul J. Van Cangh

31

Percutaneous Management of Upper Tract Urothelial Carcinoma  384 Shu Pan & Piruz Motamedinia Part 7 

Exit Strategy and Complications

32

The Access-related Complications of Percutaneous Nephrolithotomy  390 Vinaya Vasudevan, Zeph Okeke, & Arthur D. Smith

33

Hemorrhagic Complications Associated with Percutaneous Nephrolithotomy  397 Sriram V. Eleswarapu & David A. Leavitt

34

Diagnosis and Management of Thoracic Complications of Percutaneous Renal Surgery  409 John R. Bell & Stephen Y. Nakada

35

Bowel and Other Organ Injuries with Percutaneous Nephrolithotomy  422 John J. Knoedler, Matthew T. Gettman, & Chad J. Fleming

36

Exit Strategies After Percutaneous Nephrolithotomy  427 Damien M. Bolton & Derek B. Hennessey

37

Problems with Residual Stones  441 Noah E. Canvasser & Margaret S. Pearle SECTION 3  URETEROSCOPY Part 1  General Principles

38

Ureteral Anatomy   455 Gary Faerber, Amir H. Lebastchi, & Rita P. Jen

39

Rigid Ureteroscopes  465 Omar M. Aboumarzouk & Francis X. Keeley, Jr.

40

Flexible Ureteroscopes  475 Vincent G. Bird & John M. Shields

vii

viii

Contents

41

Rigid Ureteroscope with Flexible Tip and Special Instrumentation  486 Yinghao Sun & Xiaofeng Gao

42

Digital Ureteroscopes  497 Murat Binbay & Burak Ucpinar

43

Ureteroscopy Working Instruments  506 Renato N. Pedro & Manoj Monga

44

Access to the Ureter: Rigid Ureteroscopy  514 Jose De La Cerda, III & Timothy Y. Tseng

45

Access to the Ureter: Flexible Ureteroscopy  521 Ojas Shah & Mark V. Silva

46

Ureteroscopy Energy Sources  532 Daniel A. Wollin & Glenn M. Preminger

47

Ureteroscopic Management of Ureteral Calculi  542 Charles U. Nottingham, Melanie A. Adamsky, Richard J. Fantus, & Glenn S. Gerber

48

Ureteroscopic Management of Renal Calculi  549 Steeve Doizi & Olivier Traxer

49

Diagnostic Ureteroscopy  562 Hendrik Heers & Benjamin W. Turney

50

Ureteroscopic Diagnosis and Treatment of Upper Urinary Tract Neoplasms  568 Scott G. Hubosky & Demetrius H. Bagley

Part 2 

Ureteroscopic Management of Ureteral Obstruction

51

Retrograde Endopyelotomy  584 Weil R. Lai & Raju Thomas

52

Endoscopic Management of Mid-ureteral Obstruction  592 Samuel Abourbih & D. Duane Baldwin

53

Endoscopic Management of Distal Ureteral Strictures  604 Michael Zhang, Ali Fathollahi, Joel Hillesohn, & Majid Eshghi

54

Endoscopic Management of Ureteroenteric Strictures  629 Thomas Masterson & Robert Marcovich

55

Ureterorenoscopy: Ureteral Stents and Postoperative Care  642 Ben H. Chew, Anthony Emmott, Dirk Lange, & Ryan F. Paterson

56

Ureteroscopy Complications  653 Joel E. Abbott & Roger L. Sur

57

Retrograde Intrarenal Surgery in the Future: Robotics  668 Anup Patel

Contents

SECTION 4 

SHOCK-WAVE LITHOTRIPSY

58

Physics of Shock-wave Lithotripsy  691 Andreas Neisius & Pei Zhong

59

Lithotripsy Systems  713 Geert G. Tailly

60

Shock-wave Lithotripsy of Renal Calculi  731 Brian H. Eisner & Naren Nimmagadda

61

Shock-wave Lithotripsy of Ureteral Calculi  745 Thomas Tailly & Hassan Razvi

62

Complications of Shock-wave Lithotripsy  756 Christian Türk & Aleš Petřík SECTION 5  STONE MANAGEMENT IN UROLOGY Part 1  General Principles

63

Natural History of Stones  765 Johann P. Ingimarsson & Amy E. Krambeck

64

Initial Choice of Therapy in the Stone Patient  777 Peter L. Steinberg & David M. Hoenig

65

Management of Urolithiasis in Pregnancy  786 Husain Alenezi & John D. Denstedt

66

Management of Renal Colic and Triage in the Emergency Department  798 Marius C. Conradie Part 2 

Management of Stones in Abnormal Situations

67

Management of Stones in Horseshoe Kidneys  811 Chandra Shekhar Biyani & Adrian D. Joyce

68

Pelvic Kidneys  818 Win Shun Lai, Vidhush K. Yarlagadda, & Dean G. Assimos

69

Management of Stone Disease in Renal Transplant Kidneys  827 Brian Duty & Michael Lam

70

Stones in Urinary Diversions  836 Bodo E. Knudsen & Michael W. Sourial

71

Management of Stones in Obesity  843 Omer L. Tuncay & Cenk Acar Part 3 

72

Cost-effectiveness and Long-term Stenting

Cost-effective Strategies for Stone Management  853 Justin I. Friedlander & Eric M. Ghiraldi

ix

x

Contents

73

Long-term Stenting of the Ureter  864 Panagiotis Kallidonis, Wissam Kamal, Dimitrios Kotsiris, Dimitrios Karnabatidis, & Evangelos Liatsikos Index  i1

VOLUME 2 SECTION 6  LAPAROSCOPY AND ROBOTIC SURGERY Part 1  General Principles 74

New Surgical Robotics  881 Alabdulaali Ibrahim & Koon Ho Rha 

75

Training and Credentialing Laparoscopic and Robotic Surgery  887 Domenico Veneziano & David M. Hananel

76

Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery  901 Weil R. Lai & Benjamin R. Lee

77

Patient Preparation and Operating Room Setup for Robotic Surgery  909 Dima Raskolnikov, Mahir Maruf, & Arvin K. George

78

Physiologic Considerations in Laparoscopic and Robotic Surgery  917 Adam G. Kaplan & Michael N. Ferrandino

79

Anesthetic Management During Laparoscopic/Robotic Surgery  928 Judith Aronsohn, Oonagh Dowling, & Greg Palleschi Part 2 

Instrumentation, Access, and Exit

80

Laparoscopic Surgery: Basic Instrumentation  944 Ornob Roy

81

Robotic Surgery: Basic Instrumentation and Troubleshooting  954 Wooju Jeong, Mouafak Tourojman, & Craig G. Rogers

82

Minimally Invasive Reconstructive Techniques: Suture, Staple, and Clip Technology  960 Ali Abdel Raheem & Koon Ho Rha

83

Transperitoneal Access and Trocar Placement  973 Angelo Territo & Alberto Breda

84

Retroperitoneal Access and Trocar Placement  987 Lambros Stamatakis & Soroush Rais-Bahrami

85

Basic Hand-assisted Laparoscopic Techniques  994 Sapan N. Ambani & J. Stuart Wolf, Jr.

86

Laparoscopic Exit: Specimen Removal, Closure, and Drainage  1010 Fernando J. Kim, Riccardo Autorino, & Rodrigo Donalisio da Silva Part 3 

87

Complications

Complications in Urologic Laparoscopy  1021 David Canes, Camilo Giedelman, & Rene J. Sotelo

Contents

88

Complications of Laparoscopy Including Robotics  1032 Friedrich-Carl von Rundstedt, Marcelo Chen, & Richard E. Link Part 4 

Laparoscopy/Robotics for Malignant Disease

89

Pelvic Lymphadenectomy  1048 Marc D. Manganiello & Andrew A. Wagner

90

Endoscopic Subcutaneous Modified Inguinal Lymph Node Dissection for Squamous Cell Carcinoma of the Penis  1060 Jay T. Bishoff & Kefu Du

91

Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection  1066 James R. Porter

92

Laparoscopic Radical Nephrectomy  1077 Simpa S. Salami

93

Robotic Partial Nephrectomy: Advancements and Innovations  1088 Sameer Chopra, Mehar Bains, & Inderbir S. Gill

94

Intraoperative Assessment of Tumor Resection Margins  1097 Ilan Z. Kafka & Timothy D. Averch

95

Laparoscopic Radical Nephroureterectomy  1101 Wayland J. Wu & Jessica E. Kreshover

96

Laparoscopic and Robotic Radical Cystectomy in Males and Females  1107 Douglas S. Scherr, David M. Golombos, & Abimbola Ayangbesan

97

Robot-assisted Laparoscopic Partial Cystectomy  1115 Manish A. Vira & Paras H. Shah

98

Laparoscopic Cystoprostatectomy with Intracorporeal Ileal Conduit  1125 Alvin C. Goh, Brian J. Miles, & Arun Rai

99

Laparoscopic/Robotic Continent Diversion  1128 Christopher R. Reynolds & Ashok K. Hemal

100

Laparoscopic Radical Prostatectomy  1140 Jens Rassweiler, Giovannalberto Pini, Marcel Fiedler, Ali Serdar Goezen, & Dogu Teber

101

Robot-assisted Laparoscopic Radical Prostatectomy  1169 Zeyad Schwen & Misop Han

102

Optimizing Outcomes During Laparoscopic and Robot-assisted Radical Prostatectomy  1179 Matthew Goland-Van Ryn, Daniel Rosen, Thomas Bessede, & Ashutosh Tewari Part 5 

103

Laparoscopy/Robotics for Benign Disease

Laparoscopic and Robotic Reconstructive Ureteral Surgery: Basic Principles  1194 Aaron C. Weinberg, Yuka Yamaguchi, Lee C. Zhao, & Michael D. Stifelman

xi

xii

Contents

104

Laparoscopic Applications to Renal Calculus Disease  1208 Christopher S. Han & Sammy E. Elsamra

105

Laparoscopic Treatment of Renal Cysts and Diverticula  1221 Salvatore Micali, Eugenio Martorana, Giacomo Maria Pirola, & Giampaolo Bianchi

106

Laparoscopic and Robotic Techniques for Management of Pelvic Organ Prolapse  1234 Sandeep Gurram & Farzeen Firoozi

107

Laparoscopic and Robotic Techniques for Repair of Female Genitourinary Fistulas  1242 Chad Baxter & Vishnukamal Golla

108

Laparoscopic, Laparoendoscopic Single-site, and Robot-assisted Living Donor Nephrectomy  1250 Ganesh Sivarajan & Ravi Munver

109

Robotic Kidney Transplantation  1259 Rajesh Ahlawat, Sohrab Arora, & Mani Menon

110

Minimally Invasive Surgery for Benign Prostate Disease: Laparoscopic and Robotic Techniques  1269 Mark Ferretti, Amul Bhalodi, & John Phillips

111

Laparoscopic Adrenalectomy  1278 Tadashi Matsuda, Hidefumi Kinoshita, Yoshihide Kawasaki, & Akira Miyajima

112

Laparoscopic and Robotic Surgery of the Seminal Vesicles  1292 Eric H. Kim, R. Sherburne Figenshau, & Gerald L. Andriole

113

Modern Techniques in Abdominal Wall Hernia Repair: a Guide for the Practicing Endourologist  1299 Douglas K. Held

114

Robot-assisted Vasectomy Reversal  1313 Parviz K. Kavoussi Part 6 

Laparoscopy/Robotics in Children

115

Laparoscopic Considerations in Children  1323 Rajeev Chaudhry, Michelle Yu, & Michael C. Ost

116

Laparoscopic and Robotic Pyeloplasty in Children  1328 Kai-wen Chuang

117

Lower Ureteral Reconstruction: Robotic Surgery  1335 S. Duke Herrell

118

Laparoscopic Management of the Undescended Testicle  1344 Brian A. VanderBrink

119

Laparoscopic Varicocelectomy  1353 Bradley A. Morganstern & Lane S. Palmer Part 7 

120

Laparoscopy and Robotics: LESS and NOTES

Laparoendoscopic Single-site Surgery: Ports, Access, and Instrumentation  1361 Noah E. Canvasser & Jeffrey A. Cadeddu

Contents

121

Laparoendoscopic Single-site Upper Tract Surgery  1373 Christian Tabib, Geoffrey Gaunay, & Lee Richstone

122

Robotic Laparoendoscopic Single-site Lower Tract Surgery  1385 Daniel Ramirez, Matthew J. Maurice, & Jihad H. Kaouk SECTION 7  IMAGE-GUIDED DIAGNOSTICS AND THERAPEUTICS Part 1  Upper Tract

123

Diagnosis of Renal Masses: Radiological  1393 Gail S. Smith, Carolyn K. Donaldson, & Richard M. Gore

124

Renal Mass Biopsy  1425 M. Pilar Laguna & Jean de la Rosette

125

Radiofrequency Ablation of Renal Tumors  1442 Ryan L. Steinberg & Chad R. Tracy

126

Percutaneous Cryoablation of Renal Masses  1454 David N. Siegel & Alok A. Anand Part 2 

Angio-embolization in Urology

127

Gonadal Vein Embolization  1464 Pratik A. Shukla, Gajan Sivananthan, & Ardeshir R. Rastinehad

128

Renal Angiography and Embolization  1479 Igor Lobko & Anthony D. Mohabir

129

Selective Arterial Prostate Embolization  1488 Robert C. Blue, Aaron M. Fischman, & Ardeshir R. Rastinehad Part 3 

Focal Therapy Lower Tract

130

The Role and Methodology of Multiparametric MRI and Fusion-guided Biopsy in the Management of Prostate Cancer Patients  1495 Raju R. Chelluri, Arvin K. George, Joseph A. Baiocco, Baris Turkbey, & Peter A. Pinto

131

Focal Therapy of Prostate Cancer  1509 Kae Jack Tay & Thomas J. Polascik

132

Focal Laser Ablation for Carcinoma of Prostate  1523 Tonye A. Jones, Shyam Natarajan, & Leonard S. Marks

133

Image-guided Prostate Brachytherapy  1534 Michael R. Folkert, Neil B. Desai, & Yoshiya Yamada

134

Image-guided External Beam Radiotherapy  1550 Brett Cox, Lucille Lee, & Louis Potters

135

High-intensity Focused Ultrasound of the Prostate  1567 Edward J. Bass, Mark Emberton, & Hashim U. Ahmed

xiii

xiv

Contents

136

Cryotherapy of the Prostate  1580 Daniel B. Rukstalis

137

Cryosurgical Ablation of the Prostate  1589 Rajan Ramanathan, Yaw A. Nyame, & J. Stephen Jones

138

Contrast-enhanced Ultrasound in Urology  1605 Rogier R. Wildeboer, Jean de la Rosette, Massimo Mischi, & Hessel Wijkstra

139

Principles of Prostate Magnetic Resonance Imaging  1616 Sonia Gaur, Baris Turkbey, & Peter L. Choyke

140

Male Lower Urinary Tract Symptoms and Assessment  1627 Henry Tran, Matthew P. Rutman, Doreen E. Chung, & Jerry G. Blaivas

141

Office-based Cystoscopy: Continued Advances  1643 Judson D. Davies & Sam S. Chang

142

Equipment Setup and Patient Handouts  1649 John R. Schwabe, Amanda P. Hughes, Crystal R. Combs, & Gopal H. Badlani

143

Local Anesthesia for Minimally Invasive Treatment of the Prostate in the Office Setting  1661 Arun Rai & Ricardo R. Gonzalez

144

Laser in Benign Prostatic Hyperplasia Treatment: Basic Principles  1672 Christopher Netsch, Bilal Chughtai, Alexis E. Te, Ahmed M. Elshal, Mostafa M. Elhilali, & Andreas J. Gross

145

Holmium Laser Therapy of the Prostate  1681 Ahmed M. Elshal & Mostafa M. Elhilali

146

532 nm High-power Transurethral Laser Prostatectomy  1693 Bilal Chughtai, Dominique Thomas, & Alexis E. Te

147

Thulium Lasers  1707 Andreas J. Gross & Christopher Netsch

148

The Prostatic Urethral Lift Procedure Using UroLift Implants: Novel, Minimally Invasive Therapy for Benign Prostatic Hyperplasia  1719 Daniel B. Rukstalis

149

Goals and Expectations of Ablation Techniques and Emerging Therapies for Benign Prostatic Hyperplasia: An Editorial  1727 Catriona I. MacRae & Peter J. Gilling

150

Monopolar Transurethral Resection of Prostate  1733 Madhu S. Agrawal & Dilip K. Mishra

151

Ablation of Prostate: Bipolar Resection  1743 Jaspreet S. Sandhu

152

Bipolar Vaporization of the Prostate  1752 Ahmet Karakeci, Kyle Richards, & Gopal H. Badlani

153

Single Port for Prostate Surgery  1762 Rene J. Sotelo, Oscar D. Martín Garzón, Camilo Giedelman, Fatima Z. Husain, & Mihir Desai

Contents

154

Bladder Injections for Refractory Overactive Bladder: Intra- and Transvesical Procedures  1775 Adam Althaus & Anurag K. Das

155

STING Procedure for Reflux  1784 Steve J. Hodges

156

Minimally Invasive Therapy for Bladder Pain Syndrome (Interstitial Cystitis)  1792 Ricardo Palmerola, Sandeep Gurram, & Robert Moldwin

157

New Techniques for Resecting Bladder Tumors  1806 Alexey G. Martov, Dmitry V. Ergakov, Nikolay A. Baykov, & Zhamshid Okhunov

158

Incision: Endoscopic Management of Urethral Stenoses  1815 Gerald H. Jordan & Kurt A. McCammon

159

Endoscopic Management of Bladder Neck Contracture Following Radical Prostatectomy  1826 Susan MacDonald, R. Caleb Kovell, Joseph Tortora, & Ryan P. Terlecki

160

Single-incision Slings  1832 Michael J. Kennelly & Dina A. Bastawros

161

Bioinjectables for Stress Urinary Incontinence  1847 Ryan Dobbs, Simone Crivellaro, & John J. Smith III

162

Midurethral Slings for the Treatment of Female Stress Urinary Incontinence  1854 Alice Drain & Victor W. Nitti

163

Maxi/Pubovaginal Sling  1871 Gopal H. Badlani & Joao P. Zambon

164

Mesh Complications Associated with Vaginal Prolapse Surgery  1880 Jeffrey S. Schachar & G. Willy Davila

165

Male Slings for Treatment of Post-prostatectomy Incontinence  1890 Ajay K. Singla & Nirmish Singla

166 Neuromodulation  1902 Dayron Rodríguez & Anurag K. Das Index  i1

xv

xvi

List of Contributors Joel E. Abbott, DO

Hashim U. Ahmed, FRCS(Urol), PhD, BM, BCh, MA

Associate Director Advanced Kidney Stone Center of the Americas Chesapeake Urology University of Maryland School of Medicine Hanover, MD, USA

Chair of Urology & Consultant Urological Surgeon Division of Surgery Department of Surgery and Cancer Faculty of Medicine Imperial College London; Imperial Urology Imperial College Healthcare NHS Trust London, UK

Omar M. Aboumarzouk, MBChB, MSc, PhD, MRCS(Glasg), FRCS(Urol)

Consultant Urological Surgeon Department of Urology Glasgow Urological Research Unit Queen Elizabeth University Hospital Glasgow, UK Samuel Abourbih, MDCM

Assistant Professor of Urology Loma Linda University Medical Center Loma Linda, CA, USA Cenk Acar, MD

Associate Professor Eryaman Hospital Department of Urology Ankara, Turkey Melanie A. Adamsky, MD

Husain Alenezi, MD

Consultant Urologist Urology Unit Department of Surgery Sabah Al‐Ahmad Urology Center and Al‐Adan Hospital Kuwait Peter Alken, MD, PhD

Professor of Urology Consultant Urologist Department of Urology University Clinic Mannheim Mannheim, Germany

Urology Resident Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA

Adam Althaus, MD

Madhu S. Agrawal, MBBS, MS, MCh, MNAMS

Assistant Professor Department of Urology University of Michigan Health Systems Ann Arbor, MI, USA

Head Department of Urology & Center for Minimally Invasive Endourology Global Rainbow Healthcare Agra, India Rajesh Ahlawat, MS, MCh

Chairman Medanta Kidney and Urology Institute Gurgaon, India

Resident in Urology Harvard Longwood Program in Urology Boston, MA, USA Sapan N. Ambani, MD

Alok A. Anand, MD, DABR, CIIP

Interventional Radiologist Chairman and Chief Quality Officer Department of Radiology – Eastern Connecticut Health Network Manchester, CT, USA

List of Contributors

Sero Andonian, MD, MSc, FRCSC, FACS

Demetrius H. Bagley, MD

Associate Professor Division of Urology McGill University Health Centre McGill University Montreal, QC, Canada

The Nathan Lewis Hatfield Professor of Urology Professor of Radiology Department of Urology Sidney Kimmel Medical College at Thomas Jefferson University Hospital Philadelphia, PA, USA

Gerald L. Andriole, MD

Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Judith Aronsohn, MD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA Sohrab Arora, MS, MCh

Senior Fellow – Robotic Surgery Vattikuti Urology Institute Detroit, MI, USA Dean G. Assimos, MD

Anton Bueschen Chairman Professor of Urology Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Riccardo Autorino, MD

Attending Urologist and Associate Professor of Urology Division of Urology McGuire VAMC and Virginia Commonwealth University Richmond, VA, USA Abimbola Ayangbesan, BA

Urology Resident Vanderbilt University Medical Center Nashville, TN, USA Timothy D. Averch, MD, FACS

Professor Vice Chair for Quality Director of Endourology Division Chief of Urology – UPMC Presbyterian Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Gopal H. Badlani, MD, FACS, FRCS (Hon)

Vice Chair Urology Professor of Urology and Gynecology Wake Forest University Winston‐Salem, NC, USA

Mehar Bains

Research Intern USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA Joseph A. Baiocco, BS

Medical Research Scholar Urologic Oncology Branch National Cancer Institute National Institutes of Health Bethesda; Medical Student Sidney Kimme Medical College Thomas Jefferson University Philadelphia, PA, USA D. Duane Baldwin, MD

Professor of Urology Director of Urologic Research Loma Linda University Medical Center Loma Linda, CA, USA Edward J. Bass, MBChB (Hons)

Urology Specialist Registrar The Division of Surgery and Interventional Science University College London London; Department of Urology University College London Hospitals London, UK Dina A. Bastawros, MD

Fellow Department of Obstetrics and Gynecology Female Pelvic Medicine and Reconstructive Surgery Atrium Health Charlotte, NC, USA Chad Baxter, MD

Assistant Professor of Urology David Geffen School of Medicine at UCLA Los Angeles, CA, USA

xvii

xviii

List of Contributors

Nikolay A. Baykov, MD

Chandra Shekhar Biyani, MS, D Urol, FRCS (Urol), FEBU, MSc

Doctor of Urology Department of Urology Municipal Hospital No. 57 Moscow, Russia

Consultant in Urology Department of Urology St James’ University Hospital Leeds, UK

John R. Bell, MD

Jerry G. Blaivas, MD

Assistant Professor Department of Urology University of Kentucky Lexington, KY, USA

Professor of Urology Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA

Norberto O. Bernardo, MD

Robert C. Blue, MD

Professor of Urology Chief, Endourology Hospital de Clínicas José de San Martín Universidad de Buenos Aires Buenos Aires, Argentina

Assistant Professor of Radiology Department of Radiology Icahn School of Medicine at Mount Sinai New York, NY, USA

Thomas Bessede, MD

Professor Department of Urology Austin Hospital Heidelberg; Olivia Newton‐John Cancer Wellness and Research Institute Heidelberg, VIC, Australia

Assistant Professor Department of Urology University of Paris‐Sud Orsay, France Amul Bhalodi, MD

Chief Resident New York Medical College Department of Urology Valhalla, NY, USA Giampaolo Bianchi, MD

Full Professor of Urology Department of Urology University of Modena and Reggio Emilia Modena, Italy Murat Binbay, MD

Associate Professor of Urology Chairman of Urology Department Department of Urology Haseki Training and Research Hospital Istanbul, Turkey Vincent G. Bird, MD

Professor of Urology Department of Urology University of Florida Gainesville, FL, USA Jay T. Bishoff, MD

Director Intermountain Urological Institute Intermountain Health Care Salt Lake City, UT, USA

Damien M. Bolton, MD, MBBS, BA, FRACS, FRCS

Alberto Breda, MD

Chief Uro‐Oncology Division and Kidney Transplant Units Fundació Puigvert Autonoma University of Barcelona Barcelona, Spain Jeffrey A. Cadeddu, MD

Professor Ralph C. Smith, MD, Distinguished Chair in Minimally Invasive Urologic Surgery Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA David Canes, MD

Associate Professor of Urology Tufts University Medical Center; Institute of Urology Lahey Hospital & Medical Center Burlington, MA, USA Noah E. Canvasser, MD

Assistant Instructor Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA

List of Contributors

Sam S. Chang, MD, MBA

Kai‐wen Chuang, MD

Patricia and Rodes Hart Endowed Chair of Urologic Surgery Professor of Urologic Surgery and Oncology Department of Urological Surgery Vanderbilt University Medical Center Nashville, TN, USA

CHOC Children’s Urology Pediatric Urologist HS Assistant Clinical Professor Department of Urology University of California Irvine, CA, USA

Rajeev Chaudhry, MD

Bilal Chughtai, MD

Pediatric Urology Fellow Children’s Hospital of Pittsburgh of UPMC Pittsburgh, PA, USA Raju R. Chelluri, MD, MS

Urology Resident Division of Urology Department of Surgery University of Pennsylvania Perelman School of Medicine; Research Fellow Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD, USA Marcelo Chen, MD, PhD

Senior Attending Urologist Department of Urology MacKay Memorial Hospital; Associate Professor Department of Medicine MacKay Medical College Taipei, Taiwan Ben H. Chew, MD, MSc, FRCSC

Associate Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Sameer Chopra, MD, MS

Resident Physician USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA Peter L. Choyke, MD

Program Director Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA

Assistant Professor of Urology Department of Urology Weill Cornell Medical College New York Presbyterian Hospital New York, NY, USA Doreen E. Chung, MD, FRCSC

Assistant Professor Department of Urology Female Pelvic Medicine & Reconstructive Surgery Columbia University New York, NY, USA Ralph V. Clayman, MD

Professor of Urology Department of Urology University of California Irvine, CA; Dean Emeritus University of California Irvine School of Medicine Orange, CA, USA Crystal R. Combs, RN, CNOR

Clinical Education Resource Nurse ‐ Robotics Wake Forest Baptist Health Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Marius C. Conradie, MD

Urologist in Private Practice President Southern African Endourology Society Netcare Waterfall City Hospital Johannesburg, South Africa Brett Cox, MD

Interim Chair Department of Radiation Medicine Lenox Hill Hospital; Chief of Brachytherapy Northwell Health; Co‐Director GU Center of Excellence Northwell Cancer Institute; Associate Professor of Radiation Medicine

xix

xx

List of Contributors

Zucker School of Medicine at Hofstra/Northwell Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Cecilia M. Cracco, MD, PhD

Urologist Department of Urology Cottolengo Hospital Torino, Italy Simone Crivellaro, MD

Assistant Professor of Urology Department of Urology University of Illinois at Chicago Chicago, IL, USA Anurag K. Das, MD, FACS

Director Center for Neuro‐urology and Continence Division of Urology Department of Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA Judson D. Davies, MD

Clinical Assistant Professor of Surgery Department of Urological Surgery Vanderbilt University Medical Center Nashville, TN, USA G. Willy Davila, MD

Chairman Department of Gynecology Section of Urogynecology and Reconstructive Pelvic Surgery Cleveland Clinic Florida Weston, FL, USA Jose De La Cerda III, MD, MPH

Urology Resident Department of Urology University of Texas Health Science Center at San Antonio San Antonio, TX, USA Jean de la Rosette, MD, PhD

Chairman Professor of Urology Department of Urology Istanbul Medipol University Istanbul, Turkey

John D. Denstedt, MD, FRCSC, FACS, FCAHS

Professor of Urology Division of Urology Department of Surgery Schulich School of Medicine & Dentistry The University of Western Ontario London, ON, Canada Samir Derisavifard, MD

Resident in Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Janak D. Desai, MS, MCh

Chief of Urology Services Samved Hospital and Sterling Hospitals Ahmedabad, India Mahesh R. Desai, MS, FRCS, FRCS, FACS

Medical Director Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Mihir Desai, MD

USC Institute of Urology Keck School of Medicine University of Southern California Los Angeles, CA, USA Neil B. Desai, MD, MHS

Assistant Professor Department of Radiation Oncology University of Texas Southwestern Medical Center Dallas, TX, USA Ryan Dobbs, MD

Urology Resident Department of Urology University of Illinois at Chicago Chicago, IL, USA Steeve Doizi, MD, MSc

Assistant Professor Sorbonne Université Department of Urology GRC n°20 Groupe de Recherche Clinique sur la Lithiase Urinaire Hôpital Tenon Paris, France Carolyn K. Donaldson, MD

Associate Professor Department of Radiology NorthShore University Health System

List of Contributors

University of Chicago Pritzker School of Medicine Evanston, IL, USA Rodrigo Donalisio da Silva, MD

Assistant Professor of Surgery/Urology University of Colorado Denver Denver Health Medical Center Denver, CO, USA Oonagh Dowling, PhD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA Alice Drain, MD

Department of Urology New York University Langone Medical Center New York, NY, USA

Mostafa M. Elhilali, MD (Deceased)

Division of Urology McGill University Montreal, QC, Canada Mohamed A. Elkoushy, MD, MSc(Urol), PhD(Urol)

Professor of Urology Department of Urology Suez Canal University Ismailia, Egypt Sammy E. Elsamra, MD

Assistant Professor Division of Urology Rutgers Robert Wood Johnson Medical School New Brunswick, NJ, USA Ahmed M. Elshal, MD

Urology and Nephrology Center Mansoura University Egypt Mark Emberton

Kefu Du, MD

Endourology Fellow Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Rahul Dutta, MD

Resident Physician Department of Urology University of California Irvine, CA, USA Brian Duty, MD

Associate Professor Department of Urology Oregon Health and Science University Portland, OR, USA Brian H. Eisner, MD

Assistant Professor Department of Urology Massachusetts General Hospital Boston, MA, USA

The Division of Surgery and Interventional Science University College London; Department of Urology University College London Hospitals London, UK Anthony Emmott, BSc, MD

Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Dmitry V. Ergakov, MD, PhD

Associate Professor Department of Urology Municipal Hospital No. 57 FMBA State Institute of Continuous Medical Education Moscow, Russia Majid Eshghi, MD, FACS, MBA

Professor of Urology Department of Urology Westchester Medical Center Health System New York Medical College Valhalla, NY, USA Umit Eskidemir, MD, FEBU

Sriram V. Eleswarapu, MD, PhD

Chief Urology Resident Vattikuti Urology Institute Henry Ford Health System Detroit, MI, USA

Urologist Department of Urology School of Medicine Ege University İzmir, Turkey

xxi

xxii

List of Contributors

Gary Faerber, MD

Professor Division of Urology University of Utah School of Medicine Salt Lake City, UT, USA Richard J. Fantus, MD

Resident Physician Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA Monica A. Farcas, MEng, MD, FRCSC

Assistant Professor Department of Surgery Division of Urology St. Michael’s Hospital Toronto, ON, Canada Ali Fathollahi, MD

Fellow Department of Urology New York Medical College New York, NY, USA Diane Felsen, PhD

Associate Professor of Pharmacology Research in Urology (Retired) Weill Cornell Medicine New York, NY, USA Michael N. Ferrandino, MD

Associate Professor of Urology Director, Minimally Invasive Urologic Surgery Division of Urologic Surgery Duke University Medical Center Durham, NC, USA Mark Ferretti, MD

Resident New York Medical College Department of Urology Valhalla, NY, USA Marcel Fiedler, MD

Consultant and Senior Registrar Department of Urology SLK Kliniken Heilbronn University of Heidelberg Heidelberg, Germany R. Sherburne Figenshau, MD

Chair, Minimally Invasive Urology Division of Urologic Surgery

Washington University School of Medicine St. Louis, MO, USA Farzeen Firoozi, MD, FACS

Director FPMRS Associate Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Aaron M. Fischman, MD, FSIR, FCIRSE

Associate Professor of Radiology and Surgery Department of Radiology Icahn School of Medicine at Mount Sinai Department of Radiology New York, NY, USA Chad J. Fleming, MD

Assistant Professor of Radiology Mayo Clinic Department of Radiology Rochester, MN, USA Michael R. Folkert, MD, PhD

Assistant Professor Residency Program Director Department of Radiation Oncology University of Texas Southwestern Medical Center Dallas, TX, USA Justin I. Friedlander, MD

Assistant Professor of Urology Director of Endourology Department of Urology Einstein Healthcare Network; Fox Chase Cancer Center Philadelphia, PA, USA Arvind P. Ganpule, MS(General Surgery), DNB(Urology), MNAMS(New Delhi)

Vice Chairman Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Xiaofeng Gao, MD

Secretary, Urolithiasis Group Deputy Director of the Department of Urology Chinese Urological Association Shanghai, China Oscar D. Martín Garzón

Clínica Cooperativa de Colombia Universidad Cooperativa de Colombia – Facultad de Medicina Villavicencio, Colombia

List of Contributors

Geoffrey S. Gaunay, MD

Peter J. Gilling, MD, FRACS

The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

Urologist Professor of Surgery University of Auckland Bay of Plenty Clinical School Tauranga, New Zealand

Sonia Gaur, BS

Research Fellow Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA Arvin K. George, MD

Assistant Professor Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD; Department of Urology Division of Urologic Oncology University of Michigan Ann Arbor, MI, USA Glenn S. Gerber, MD

Professor Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA Matthew T. Gettman, MD

Erivan Haub Family Endowed Professor of Urology Mayo Clinic Department of Urology Rochester, MN, USA Eric M. Ghiraldi, DO

Urology Resident Department of Urology Einstein Healthcare Network Philadelphia, PA, USA Camilo Giedelman, MD

Urologic Minimally Invasive Surgeon Clínica Marly and Fundación Universitaria Ciencia de la Salud Hospital de San Jose Bogotá, Colombia Inderbir S. Gill, MD

USC Institute of Urology Keck School of Medicine University of South California Los Angeles, CA, USA

Jordan S. Gitlin, MD

Assistant Clinical Professor Department of Pediatric Urology Cohen Children’s Medical Center Zucker School of Medicine at Hofstra/Northwell Long Island, NY, USA Ali Serdar Goezen, MD

Vice‐chairman Department of Urology SLK Kliniken Heilbronn, University of Heidelberg Heidelberg, Germany Alvin C. Goh, MD

Director of Advanced Laparoscopic and Robotic Urology Surgery Programs Methodist Institute for Technology, Innovation, and Education; Assistant Professor of Urology Weill Cornell Medical College Department of Urology Houston Methodist Hospital Houston, TX, USA Matthew Goland‐Van Ryn, MD

Chief Resident, Urology Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Vishnukamal Golla, MD, MPH

Urology Resident Department of Urology University of California Los Angeles, CA, USA David M. Golombos, MD

Assistant Clinical Professor Department of Urology Stony Brook School of Medicine Stony Brook, NY, USA Ricardo R. Gonzalez, MD

Director, Center for Voiding Dysfunction Houston Methodist Hospital Houston, TX, USA

xxiii

xxiv

List of Contributors

Richard M. Gore, MD

Misop Han, MD, MS

Professor of Radiology Department of Radiology NorthShore University Health System University of Chicago Pritzker School of Medicine Evanston, IL, USA

David Hall McConnell Professor in Urology and Oncology James Buchanan Brady Urological Institute Johns Hopkins School of Medicine Baltimore, MD, USA

Andreas J. Gross, MD

Director Center for Research in Education & Simulation Technologies University of Washington School of Medicine Seattle, WA, USA

Head of Department Department of Urology Asklepios Klinik Barmbek Hamburg, Germany Frederick A. Gulmi, MD

Vice Chairman Department of Urology Clinical Associate Professor of Urology NYU School of Medicine New York; Chief of Urology NYU Langone Hospital-Brooklyn Brooklyn, NY, USA Mantu Gupta, MD

Chair of Urology Mount Sinai West New York; Professor Icahn School of Medicine at Mount Sinai New York; Director of Endourology Mount Sinai Health Care System New York; Director Mount Sinai Kidney Stone Center New York, NY, USA Sandeep Gurram, MD

Resident Physician The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Jorge Gutierrez‐Aceves, MD

Professor of Urology Director of Endourology Wake Forest University School of Medicine Department of Urology Winston-Salem, NC, USA Christopher S. Han, MD

Urology Resident Division of Urology Rutgers Robert Wood Johnson Medical School New Brunswick, NJ, USA

David M. Hananel, BSc, BA

Hendrik Heers, Dr. med

Senior Endourology Fellow (EBU) Department of Urology Nuffield Department of Surgical Sciences University of Oxford Oxford, UK Douglas K. Held, MD, FACS

Northwell Health Long Island Jewish Medical Centre New Hyde Park, NY, USA Ashok K. Hemal, MD, MCh, FACS, FRCS

Professor Wake Forest Institute for Regenerative Medicine; Chair, Robotics Committee Baptist Medical Center; Fellowship Director Robotics and Minimally Invasive Surgery; Fellowship Co-Director Endourology Wake Forest Baptist Medical Center and Wake Forest School of Medicine Winston‐Salem, NC, USA Derek B. Hennessey, MD, MBBChBAO, BMedSci, DHSM, PDipHS, FRCSI, FEBU

Fellow Department of Urology Austin Hospital Heidelberg Olivia Newton‐John Cancer Wellness and Research Institute Heidelberg, VIC, Australia S. Duke Herrell, MD, FACS

Professor of Urologic Surgery, Biomedical and Mechanical Engineering Vanderbilt University Medical Center Nashville, TN, USA

List of Contributors

Joel Hillesohn, MD

Chief Resident Department of Urology New York Medical College New York, NY, USA Steve J. Hodges, MD

Assistant Professor of Pediatric Urology Pediatric Urology Institute for Regenerative Medicine Wake Forest University School of Medicine Winston‐Salem, NC, USA David M. Hoenig, MD

Chief of Urology Professor The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA R. John D’A. Honey, MA, MB, BChir, FRCS(Eng), FRCSC

University of Southern California Los Angeles, CA, USA Alabdulaali Ibrahim, MD

Consultant of Urology Department of Surgery Prince Mohammed Bin Abdulaziz Hospital Riyadh, Saudi Arabia Johann P. Ingimarsson, MD

Clinical Assistant Professor Maine Medical Center and Tufts School of Medicine Division of Urology Portland, ME, USA Rita P. Jen, MD, MPH

Resident Physician Department of Urology University of Michigan Health System Ann Arbor, MI, USA

Professor of Surgery Division of Urology St. Michael’s Hospital Toronto; Department of Surgery University of Toronto Toronto, ON, Canada

Wooju Jeong, MD

Adam S. Howe, MD

Resident Physician in Urology Department of Surgery Division of Urology Duke University Hospital Durham, NC, USA

Pediatric Urology Fellow Department of Pediatric Urology Cohen Children’s Medical Center Zucker School of Medicine at Hofstra/Northwell Long Island, NY, USA Scott G. Hubosky, MD

The Demetrius H. Bagley, Jr. M.D. Associate Professor of Urology Director of Endourology Vice Chair of Quality and Safety Department of Urology Sidney Kimmel Medical College at Thomas Jefferson University Hospital Philadelphia, PA, USA Amanda P. Hughes, BSN, RN, CNOR

Clinical Coordinator for Urology Inpatient Surgical Services Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Fatima Z. Husain, MD

USC Institute of Urology Keck School of Medicine

Senior Urologist Vattikuti Urology Institute Department of Urology Henry Ford Health System Detroit, MI, USA Ghalib A. Jibara MD, MPH

J. Stephen Jones, MD, MBA

President Cleveland Clinic Regional Hospitals and Family Health Centers Professor and Horvitz/Miller Distinguished Chair in Urological Oncology Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Tonye A. Jones, MD

Urology Resident UCLA Department of Urology Los Angeles, CA, USA Gerald H. Jordan, MD

Professor Emeritus Department of Urology Eastern Virginia Medical School Norfolk, VA, USA

xxv

xxvi

List of Contributors

Adrian D. Joyce, MS, FRCS(Urol)

Parviz K. Kavoussi, MD, FACS

Honorary Consultant in Urology Department of Urology St James’ University Hospital Leeds, UK

Reproductive Urologist Department of Reproductive Urology Austin Fertility & Reproductive Medicine/Westlake IVF; Adjunct Assistant Professor Department of Urology University of Texas Health Sciences Center at San Antonio Austin, TX, USA

Ilan Z. Kafka, MD

Endourology/Minimally Invasive Surgery Fellow Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Kamaljot S. Kaler, MD

Fellow Department of Urology University of California Irvine, CA, USA Panagiotis Kallidonis, MD, PhD, FEBU

Assistant Professor Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece Wissam Kamal, MD

Consultant Urological Surgeon Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece Jihad H. Kaouk

Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH, USA Adam G. Kaplan, MD

Fellow in Endourology, Laparoscopy and Robotic Surgery Division of Urologic Surgery Duke University Medical Center Durham, NC, USA Ahmet Karakeci, MD

Assistant Professor (International Observer) Department of Urology Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Dimitrios Karnabatidis, MD, PhD

Professor Department of Radiology University Hospital of Patras Rion, Patras, Greece

Yoshihide Kawasaki, MD

Assistant Professor Department of Urology Tohuku University Graduate School of Medicine Sendai, Miyagi, Japan Francis X. Keeley, Jr., MD, FRCS(Urol)

Consultant Urologist Bristol Urological Institute Bristol, UK Michael J. Kennelly, MD, FPMRS, FACS

Professor Department of Urology and Gynecology Women’s Center for Pelvic Health Atrium Health Charlotte, NC, USA Eric H. Kim, MD

Division of Urologic Surgery Washington University School of Medicine St. Louis, MO, USA Fernando J. Kim, MD, MBA, FACS

Professor of Surgery Division of Urology Urology‐Denver; Chief of Urology Denver Health Medical Center Denver, CO, USA Hidefumi Kinoshita, MD, PhD

Professor Department of Urology and Andrology Kansai Medical University Hospital Hirakata, Osaka, Japan John J. Knoedler, MD

Assistant Professor of Surgery Division of Urology Penn State Milton S. Hershey Medical Center Hershey, PA, USA

List of Contributors

Bodo E. Knudsen, MD, FRCSC

Daniel J. Lama, MD

Associate Professor Department of Urology The Ohio State University Wexner Medical Center Columbus, OH, USA

Resident Division of Urology University of Cincinnati School of Medicine Cincinnati, OH, USA

Dimitrios Kotsiris, MD

Urology Specialist Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece R. Caleb Kovell, MD

Assistant Professor of Clinical Urology in Surgery Department of Urology University of Pennsylvania Philadelphia, PA, USA Amy E. Krambeck, MD

Michael O. Koch Professor of Urology Department of Urology Indiana University Indianapolis, IN, USA Jessica E. Kreshover, MD, MS

Assistant Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA M. Pilar Laguna, MD, PhD

Professor of Uro‐oncology Department of Urology AMC University of Amsterdam Amsterdam, The Netherlands Weil R. Lai, MD

Clinical Instructor Fellow Department of Urology Tulane University School of Medicine New Orleans, LA, USA Win Shun Lai, MD

Resident Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Michael Lam, MD

Resident in Urology Department of Urology Oregon Health and Science University Portland, OR, USA

Jaime Landman, MD

Professor Chair Department of Urology University of California Irvine, CA, USA Dirk Lange, PhD

Associate Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada David A. Leavitt, MD

Associate Director of Endourology Director of Laser Surgery Vattikuti Urology Institute Henry Ford Health System Detroit, MI, USA Amir H. Lebastchi, MD

Chief Resident Department of Urology University of Michigan Health System Ann Arbor, MI, USA Benjamin R. Lee, MD, FACS

Professor Chief Division of Urology University of Arizona College of Medicine Tucson, AZ, USA Lucille Lee, MD

Assistant Professor of Radiation Medicine Zucker School of Medicine at Hofstra/Northwell Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Evangelos Liatsikos, MD, PhD

Professor Department of Urology Laparoscopy and Lithiasis Unit University Hospital of Patras Rion, Patras, Greece

xxvii

xxviii

List of Contributors

Estevao Lima, MD, FEBU, PhD

Marc D. Manganiello, MD

Director of CUF Urology Department Portugal and Department of Urology of Braga Hospital; Professor of Physiology and Urology Life and Health Sciences Research Institute Braga; ICVS/3B’s – Associate Lab. Guimarães Braga; School of Medicine University of Minho Braga, Portugal

Assistant Professor of Urology Tufts School of Medicine Lahey Hospital and Medical Center Boston, MA, USA

James E. Lingeman, MD, FACS

Leonard S. Marks, MD

Professor of Urology Department of Urology Indiana University School of Medicine Indianapolis, IN, USA Richard E. Link, MD, PhD

Carlton‐Smith Endowed Chair in Urologic Education Associate Professor of Urology Director Division of Endourology and Minimally Invasive Surgery Scott Department of Urology Baylor College of Medicine Medical Center Houston, TX, USA Michael E. Lipkin, MD

Associate Professor in Urology Department of Surgery Division of Urology Duke University Medical Center Durham, NC, USA Igor Lobko, MD

Chief Division of Vascular and Interventional Radiology Director Vascular and Interventional Radiology Fellowship Department of Radiology Long Island Jewish Medical Center New Hyde Park, NY, USA Susan MacDonald, MD

Assistant Professor of Surgery Division of Urology Penn State Milton S. Hershey Medical Center Hershey, PA, USA Catriona I. MacRae, MBBS, BSc

Registrar Department of Urology Tauranga Hospital Tauranga, New Zealand

Robert Marcovich, MD

Associate Professor and Director of Endourology Department of Urology University of Miami Miller School of Medicine Miami, FL, USA Professor of Urology UCLA Department of Urology Los Angeles, CA, USA Eugenio Martorana, MD

Urology Resident Department of Urology University of Modena and Reggio Emilia Modena, Italy Alexey G. Martov, MD, PhD, Honored Doctor of Russia

Professor Chairman Department of Urology Federal Medico‐biology Agency; Professor of Urology Russian Medical Academy of Postgraduate Education; Head of Urology Department Moscow City Hospital No. 57 Moscow, Russia Mahir Maruf, MD

Research Volunteer Urologic Oncology Branch National Cancer Institute National Institutes of Health Bethesda, MD, USA Thomas Masterson, MD

Resident Department of Urology University of Miami Miller School of Medicine/Jackson Memorial Hospital Miami, FL, USA Brian R. Matlaga, MD, MPH

The Stephens Professor James Buchanan Brady Urological Institute Johns Hopkins University School of Medicine Baltimore, MD, USA

List of Contributors

Tadashi Matsuda, MD, PhD

Professor Chairman Department of Urology and Andrology Kansai Medical University Hirakata, Osaka, Japan Matthew J. Maurice, MD

Clinical Fellow Cleveland Clinic Glickman Urological and Kidney Institute Cleveland, OH, USA Kurt A. McCammon, MD

Vanderbilt University Medical Center Nashville, TN, USA Massimo Mischi, PhD, MSc

Professor of Biomedical Signal Analysis Director of Biomedical Diagnostics Labs Department of Electrical Engineering Eindhoven University of Technology Eindhoven Noord‐Brabant The Netherlands Dilip K. Mishra, MBBS, MS, MRCS, MCh

Professor Chairman Department of Urology Eastern Virginia Medical School Norfolk, VA, USA

Consultant Urologist Department of Urology & Center for Minimally Invasive Endourology Global Rainbow Healthcare Agra, India

Mani Menon, MD

Shashikant Mishra, MS, DNB(Urol)

Chairman Vattikuti Urological Institute Detroit, MI, USA Salvatore Micali, MD

Associate Professor of Urology Department of Urology University of Modena and Reggio Emilia Modena, Italy Maurice‐Stephan Michel, MD

Full Professor of Urology Head of Department of Urology University Medical Centre Mannheim Heidelberg University Heidelberg, Germany Arkadiusz Miernik MD, PhD, FEBU

Associate Professor of Urology Head of Division of Urotechnology University of Freiburg – Medical Centre Department of Urology Freiburg, Germany Brian J. Miles, MD

Professor of Urology Weill Cornell Medical College Medical Director of Robotic Surgery Houston Methodist Hospital Houston, TX, USA Nicole L. Miller, MD

Associate Professor Department of Urology

Consultant Urologist Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Akira Miyajima, MD

Professor and Chairman Department of Urology Tokai University School of Medicine Isehara, Kanagawa, Japan Anthony D. Mohabir, MD

Consultant Urology Division of Vascular and Interventional Radiology Department of Radiology Long Island Jewish Medical Center New Hyde Park, NY, USA Robert Moldwin, MD

Director of Pelvic Pain Treatment Center The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Manoj Monga, MD

Professor of Surgery/Urology Director of the Stevan Streem Center of Endourology & Stone Disease Center of Endourology and Stone Disease The Cleveland Clinic Cleveland, OH, USA

xxix

xxx

List of Contributors

Bradley A. Morganstern, MD

Christopher Netsch, MD, FEBU

Assistant Professor of Pediatric Urology Chief, Pediatric Urology at Children’s Hospital of Georgia Medical College of Georgia Augusta University Augusta, GA, USA

Assistant Professor of Urology Fellow in Endourology Consultant Department of Urology Asklepios Klinik Barmbek Hamburg, Germany

Piruz Motamedinia, MD

Naren Nimmagadda, MD

Assistant Professor Department of Urology Yale University New Haven, CT, USA

Resident Physician Department of Urology Massachusetts General Hospital Boston, MA, USA

Ravi Munver, MD, FACS

Victor W. Nitti, MD

Professor Vice Chairman Department of Urology Hackensack University Medical Center Hackensack, NJ, USA Stephen Y. Nakada, MD, FACS

Professor Chairman The David T. Uehling Chair of Urology Departments of Urology, Radiology and Medicine University of Wisconsin School of Medicine and Public Health; Chief of Service Department of Urology UW Health Madison, WI, USA

Professor of Urology and Obstetrics and Gynecology Vice Chairman Department of Urology; Director Female Pelvic Medicine and Reconstructive Surgery Department of Urology New York University Langone Medical Center New York, NY, USA Charles U. Nottingham, MD

Resident Physician Section of Urology Department of Surgery University of Chicago Medicine Chicago, IL, USA

Shyam Natarajan, PhD

Yasser A. Noureldin, MD, MSc, PhD

Adjunct Assistant Professor Department of Urology and Bioengineering University of California Los Angeles, CA, USA

Lecturer Department of Urology Benha Faculty of Medicine Benha University Benha, Egypt

Oktay Nazli, MD

Professor Department of Urology School of Medicine Ege University İzmir, Turkey Andreas Neisius, MD

Associate Professor of Urology Department of Urology Brüderkrankenhaus Trier Johannes Gutenberg University Mainz, Germany

Yaw A. Nyame, MD, MBA

Resident Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Zeph Okeke, MD

Associate Professor The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

List of Contributors

Zhamshid Okhunov, MD

Shu Pan, MD

Endourology Fellow Department of Urology University of California Irvine, CA, USA

Resident Department of Urology Yale University New Haven, CT, USA

Carol Olsen, MSN, RN, CURN

Anup Patel, BSc, MBBS, FRCS, MS, FRCS(Urol)

Director System, Urology Clinical Services The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Michael C. Ost, MD

Chief Division of Pediatric Urology Children’s Hospital of Pittsburgh of UPMC; Associate Professor University of Pittsburgh School of Medicine; Vice Chairman Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Kenneth T. Pace, MD, MSc, FRCSC

Vice Chief of Surgery Head, Division of Urology Researcher, Keenan Research Centre Li Ka Shing Knowledge Institute St. Michael’s Hospital; Associate Professor Department of Surgery University of Toronto Toronto, ON, Canada Greg Palleschi, MD

Consultant Urological Surgeon London, UK Manish N. Patel, MD

Fellow in Endourology Wake Forest University School of Medicine Department of Urology Winston-Salem, NC, USA Roshan Patel, MD

Endourology Fellow Department of Urology University of California Irvine, CA, USA Ryan F. Paterson, MD, FRCSC

Assistant Professor Department of Urologic Sciences University of British Columbia Vancouver, BC, Canada Margaret S. Pearle, MD, PhD

Professor Vice‐Chair Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA Renato N. Pedro, MD, PhD

Assistant Professor Department of Anesthesiology Zucker School of Medicine at Hofstra/Northwell New York, NY, USA

Lithotripsy Center Coordinator – AME/SBO UNICAMP; Professor of Urology Faculdade de Medicina São Leopoldo Mandic Campinas, Brazil

Lane S. Palmer, MD

Aleš Petřík, MD, PhD

Professor of Urology and Pediatrics Chief, Division of Pediatric Urology Cohen Children’s Medical Center of New York Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Ricardo Palmerola, MD

Fellow, Female Pelvic Medicine and Reconstructive Surgery New York University Langone Medical Center New York, NY, USA

Assistant Professor Department of Urology Hospital Ceske Budejovice Ceske Budejovice; Charles University, 1st Faculty of Medicine Prague, Czech Republic John Phillips, MD, FACS

Residency Program Director New York Medical College

xxxi

xxxii

List of Contributors

Department of Urology Valhalla, NY, USA

Tanta University Hospital Tanta, Arab Republic of Egypt

Giovannalberto Pini, MD

Arun Rai, MD

Urologist Laparoscopy & Robotic Section Department of Urology San Raffaele Turro Hospital Milan, Italy

Resident Scott Department of Urology Baylor College of Medicine Houston, TX, USA

Peter A. Pinto, MD

Assistant Professor of Urology and Radiology Director, UAB Program for Personalized Prostate Cancer Care Departments of Urology and Radiology University of Alabama at Birmingham Birmingham, AL, USA

Urologic Oncology Branch National Cancer Institute National Institute of Health Bethesda, MD, USA Giacomo Maria Pirola, MD

Urology Resident Department of Urology University of Modena and Reggio Emilia Modena, Italy Thomas J. Polascik, MD, FACS

Professor of Surgery Director, Urologic Oncology Fellowship Director, GU program on Focal Therapy Duke Comprehensive Cancer Center Duke Cancer Institute Duke University Durham, NC, USA James R. Porter, MD

Director, Robotic Surgery Providence Health and Services Swedish Urology Group Seattle, WA, USA Louis Potters, MD, FACR, FASTRO

Professor Chairperson Department of Radiation Medicine Northwell Health New Hyde Park, NY, USA Glenn M. Preminger, MD

James F. Glenn Professor of Urology and Chief Division of Urology Department of Surgery Duke University Medical Center Durham, NC, USA Ali Abdel Raheem, MD, PhD

Consultant of Uro-oncology Minimally Invasive Urological Surgery Unit

Soroush Rais‐Bahrami, MD

Rajan Ramanathan, MD

Professor of Surgery Department of Urology Glickman Urological and Kidney Institute Cleveland Clinic Cleveland, OH, USA Daniel Ramirez, MD

Urology Associates of Nashville Nashville, TN, USA Dima Raskolnikov, MD

Resident Department of Urology University of Washington Seattle, WA, USA Jens Rassweiler, MD, FRCS(Glasg)

Professor of Urology Head of Department of Urology SLK Kliniken Heilbronn University of Heidelberg Heidelberg, Germany Marie‐Claire Rassweiler-Seyfried, MD, FEBU

Consultant of Urology Department of Urology University Medical Centre Mannheim Mannheim, Germany Ardeshir R. Rastinehad, DO, FACOS

Associate Professor of Urology and Radiology Director of Focal Therapy and Interventional Urologic Oncology Department of Radiology and Urology

List of Contributors

Icahn School of Medicine at Mount Sinai New York, NY, USA

2Ai – Polytechnic Institute of Cávado and Ave Barcelos, Portugal

A. Andrew Ray, MD, MSc, FRCSC

Dayron Rodríguez, MD, MPH

Adjunct Lecturer University of Toronto Royal Victoria Regional Hospital Barrie, ON, Canada Hassan Razvi, MD, FRCSC

Professor Chair Division of Urology Schulich School of Medicine and Dentistry Western University London, ON, Canada Christopher R. Reynolds

Fellow Robotics and Minimally Invasive Surgery Wake Forest Baptist Medical Center and Wake Forest School of Medicine Winston‐Salem, NC, USA Koon Ho Rha, MD, FACS, PhD

Professor of Urology Department of Urology Severance Hospital Yonsei University College of Medicine Seoul, South Korea Kyle A. Richards, MD, FACS

Assistant Professor Department of Urology University of Wisconsin-Madison Madison, WI, USA Lee Richstone, MD

Chief of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Manuel Ritter, MD

Associate Professor Department of Urology University Medical Centre Mannheim Heidelberg University Heidelberg, Germany

Resident in Urology Harvard Massachusetts General Hospital Program in Urology Boston, MA, USA Craig G. Rogers, MD

Director of Renal Surgery Vattikuti Urology Institute Henry Ford Hospital Detroit, MI, USA Daniel Rosen, MD

Resident Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Ornob Roy, MD

Assistant Professor of Urology Carolinas Medical Center Charlotte, NC, USA Daniel B. Rukstalis, MD

Professor Department of Urology Wake Forest University School of Medicine Winston-Salem, NC, USA Matthew P. Rutman, MD

Associate Professor of Urology at CUMC Director of Voiding Dysfunction and Female Urology Columbia University New York, NY, USA Ravindra B. Sabnis, MS, MCH

Chairman Department of Urology Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Simpa S. Salami, MD, MPH

Assistant Professor Department of Urology University of Michigan Ann Arbor, MI, USA

Pedro L. Rodrigues

Life and Health Sciences Research Institute ICVS/3B’s - Associate Lab. Guimarães Braga;

Francisco J.B. Sampaio, MD, PhD

Full Professor and Chairman Urogenital Research Unit

xxxiii

xxxiv

List of Contributors

State University of Rio de Janeiro; National Council for Scientific and Technological Development – CNPq Rio de Janeiro, Brazil

Columbia University Irving Medical Center Columbia University College of Physicians and Surgeons New York, NY, USA

Jaspreet S. Sandhu, MD

Paras H. Shah, MD

Associate Attending Urologist Department of Surgery Urology Service Memorial Sloan Kettering Cancer Center New York, NY, USA Jeffrey S. Schachar, MD

Fellow Female Pelvic Medicine and Reconstructive Surgery Cleveland Clinic Florida Weston, FL, USA Douglas S. Scherr, MD

Ronald Stanton Clinical Scholar in Urology Professor of Urology Clinical Director, Urologic Oncology Weill Cornell Medicine New York Presbyterian Hospital New York, NY, USA John R. Schwabe, MD

Resident Physician Wayne State University Department of Urology Detroit, MI, USA Zeyad Schwen, MD

Resident James Buchanan Brady Urological Institute Johns Hopkins School of Medicine Baltimore, MD, USA Cesare M. Scoffone, MD

Head of the Department of Urology Cottolengo Hospital Torino, Italy Michelle Jo Semins, MD

Assistant Professor Department of Urology University of Pittsburgh School of Medicine Pittsburgh, PA, USA Ojas Shah, MD

George F. Cahill Professor of Urology Director Division of Endourology and Stone Disease Department of Urology

Urologist Department of Urology Mayo Clinic Rochester, MN, USA John M. Shields, MD

Adjunct Clinical Post Doctorate Minimally Invasive Surgery and Endourology Fellow Department of Urology University of Florida Gainesville, FL, USA Pratik A. Shukla, MD

Radiology Resident Division of Vascular and Interventional Radiology Department of Radiology Mount Sinai Beth Israel New York, NY, USA David N. Siegel, MD, FSIR

Interventional Radiologist Vice Chairman, Clinical Affairs‐LIJMC Department of Radiology‐ Northwell Health Associate Professor of Radiology Zucker School of Medicine at Hofstra/Northwell New Hyde Park, NY, USA Mark V. Silva, MD

Resident Department of Urology Columbia University Irving Medical Center/ NewYork‐Presbyterian Hospital Columbia University College of Physicians and Surgeons New York, NY, USA Maximiliano Lopez Silva, MD

Staff, Urology Clínica San Camilo; Hospital Piñero Buenos Aires, Argentina Abhishek Singh, MS, MCH

MCH Urology Consultant Department of Urology

List of Contributors

Muljibhai Patel Urological Hospital Nadiad, Gujarat, India Ajay K. Singla, MD

Program Director, Urology Residency Program Department of Urology Massachusetts General Hospital Faculty Harvard Medical School Boston, MA, USA Nirmish Singla, MD

Assistant Instructor Fellow, Urologic Oncology Department of Urology University of Texas Southwestern Medical Center Dallas, TX, USA Gajan Sivananthan, MD

Keck School of Medicine University of Southern California Los Angeles, CA, USA Michael W. Sourial, MD, FRCSC

Endourology and Minimally Invasive Surgery Fellow Department of Urology The Ohio State University Wexner Medical Center Columbus, OH, USA Robert J. Sowerby, MD, MHM, FRCSC

Urologist Endourology and Minimally Invasive Urologic Surgery Division of Urology Mackenzie Health Hospital Vaughan, ON, Canada

Assistant Professor of Radiology and Surgery Vascular and Interventional Radiology Mount Sinai Medical Center Department of Radiology Icahn School of Medicine at Mount Sinai New York, NY, USA

Lambros Stamatakis, MD

Ganesh Sivarajan, MD

Peter L. Steinberg, MD

Endourology, Laparoscopic and Robotic Surgery Fellow Department of Urology Hackensack University Medical Center Hackensack, NJ, USA Arthur D. Smith, MD

Professor of Urology The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Gail S. Smith, MD

Assistant Professor of Radiology Department of Radiology NorthShore University Health System University of Chicago Pritzker School of Medicine Evanston, IL, USA John J. Smith III, MD

Senior Partner Novant Health Carolinas Pelvic Health Center Winston-Salem, NC, USA Rene J. Sotelo, MD

Professor of Clinical Urology USC Institute of Urology

Assistant Professor of Urology Department of Urology MedStar Washington Hospital Center Georgetown University Washington, DC, USA Director of Endourology Beth Israel Deaconess Medical Center Boston, MA, USA Ryan L. Steinberg, MD

Resident in Urology University of Iowa Department of Urology Iowa City, IA, USA Michael D. Stifelman, MD

Chairman Department of Urology; Chief of Urologic Oncology Hackensack University Medical Center Hackensack, NJ, USA Dan Stoianovici, PhD

Professor Director, Urology Robotics Program James Buchanan Brady Urological Institute Johns Hopkins University School of Medicine Baltimore, MD, USA Yinghao Sun, MD

Academician Chinese Academy of Engineering;

xxxv

xxxvi

List of Contributors

President Chinese Urological Association; President of Second Military Medical University Shanghai, China Roger L. Sur, MD

Director UCSD Comprehensive Kidney Stone Center Department of Urology University of California San Diego Health San Diego, CA, USA Robert M. Sweet, MD, FACS

Professor of Urology Executive Director WWAMI Institute for Simulation in Healthcare Medical Director Kidney Stone Program WWAMI Institute for Simulation in Healthcare (WISH) University of Washington Seattle, WA, USA Christian Tabib, MD, MBA

Senior Resident The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Geert G. Tailly, MD

Head of Department Department of Urology and Pediatric Urology AZ Klina Kapellen Belgium Thomas Tailly, MD, MSc, FEBU

Consultant Urologist Division of Urology University Hospital Ghent Ghent, Belgium Kae Jack Tay, MBBS, MRCS(Ed), MMed(Surg), MCI, FAMS(Urol)

Consultant Department of Urology Singapore General Hospital Singapore; Adjunct Assistant Professor Duke‐NUS Medical School SingHealth Duke‐NUS Academic Medical Center; Duke Comprehensive Cancer Center Duke Cancer Institute Duke University Durham, NC, USA

Alexis E. Te, MD

Professor of Urology Director, Brady Prostate Center; Director, Urology Program Iris Cantor Men’s Heath Center; Weill Medical College of Cornell University New York, NY, USA Dogu Teber, MD

Chairman of Department of Urology Klinikum Karlsruhe University of Heidelberg Heidelberg, Germany Ryan P. Terlecki, MD

Director, Men’s Health Clinic Director, Fellowship in Urologic Reconstruction, Prosthetic Urology, and Infertility Director, Medical Student Education Associate Professor of Urology and Obstetrics/Gynecology Department of Urology Wake Forest Baptist Health Winston-Salem, NC, USA Angelo Territo, MD

Medical Doctor Specialist in Urology Consultant in Uro-Oncology and Kidney Transplant Units Fundació Puigvert Autonoma University of Barcelona Barcelona, Spain Ashutosh Tewari, MBBs, MCh, FRCS

Chair Milton and Carroll Petrie Department of Urology Icahn School of Medicine at Mount Sinai New York, NY, USA Dominique Thomas, BS

Research Coordinator Department of Urology Weill Cornell Medical College New York Presbyterian Hospital New York, NY, USA Raju Thomas, MD, FACS, MHA

Professor Chairman Department of Urology Tulane University School of Medicine New Orleans, LA, USA

List of Contributors

Joseph Tortora, BSc, MS

Christian Türk, MD

Student Researcher Department of Urology Wake Forest Baptist Health Winston-Salem, NC, USA

Urologist Department of Urology Hospital of the Sisters of Charity; Urologische Praxis mit Steinzentrum Vienna, Austria

Mouafak Tourojman, MD

Senior Uro‐Oncology Robotic Fellow Vattikuti Urology Institute Department of Urology Henry Ford Health System Detroit, MI, USA Chad R. Tracy, MD

Associate Professor of Urology Director of Robotic and Minimally Invasive Surgery University of Iowa Department of Urology Iowa City, IA, USA Henry Tran, FRCSC, MD, BASc

Urologic Surgeon Department of Urology Columbia University Medical Center New York, NY, USA Timothy Y. Tran, MD

Assistant Professor of Urology Residency Site Director Providence VA Medical Center Brown University Providence, RI, USA Olivier Traxer, MD, PhD

Sorbonne Université Department of Urology GRC n°20 Groupe de Recherche Clinique sur la Lithiase Urinaire Hôpital Tenon Paris, France Timothy Y. Tseng, MD

Assistant Professor Department of Urology University of Texas Health Science Center at San Antonio San Antonio, TX, USA Omer L. Tuncay, MD

Chair Pamukkale University School of Medicine Department of Urology Denizli, Turkey

Baris Turkbey, MD

Staff Clinician Molecular Imaging Program National Cancer Institute National Institutes of Health Bethesda, MD, USA Burak Turna, MD, FEBU

Professor Department of Urology School of Medicine Ege University İzmir, Turkey Benjamin W. Turney, MA(Cantab), MSc(Oxon), DPhil(Oxon), FRCS(Urol)

Senior Clinical Researcher and Consultant Urological Surgeon University of Oxford and Oxford University Hospitals NHS Foundation Trust Oxford, UK Burak Ucpinar, MD

Resident in Urology Department of Urology Haseki Training and Research Hospital Istanbul, Turkey Paul J. Van Cangh, MD

Professor Chair University of Louvain Medical School Department of Urology Saint Luc University Hospital Brussels, Belgium Brian A. VanderBrink, MD

Associate Professor University of Cincinnati School of Medicine Cincinnati Children’s Hospital Medical Center Division of Urology Cincinnati, OH, USA Vinaya Vasudevan, MD

Resident Physician, PGY‐4 The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA

xxxvii

xxxviii

List of Contributors

Domenico Veneziano, MD, FEBU

Hessel Wijkstra, MSc, PhD

Urologist Department of Urology and Kidney Transplant Grande Ospedale Metropolitano “Bianchi, Melacrino, Morelli” Reggio Calabria, Italy

Research Director Department of Urology AMC University Hospital Amsterdam, The Netherlands

Simone Vernez, BA

Researcher PhD Student Biomedical Diagnostics Labs Department of Electrical Engineering Eindhoven University of Technology Eindhoven, The Netherlands

Medical Student Department of Urology University of California Irvine, CA, USA João L. Vilaça, PhD

Life and Health Sciences Research Institute ICVS/3B’s – Associate Lab. Guimarães Braga; 2Ai – Polytechnic Institute of Cávado and Ave Barcelos, Portugal Philippe D. Violette

Assistant Professor Departments of Surgery and Health Research Methods Evidence and Impact (HEI) McMaster University Hamilton, ON, Canada Davis P. Viprakasit, MD, FACS

Clinical Associate Professor Department of Urology University of North Carolina Chapel Hill, NC, USA Manish A. Vira, MD

Associate Professor of Urology Vice Chair for Urologic Research The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Friedrich‐Carl von Rundstedt, MD

Senior Staff Physician Department of Urology University Hospital Jena Germany Andrew A. Wagner, MD

Director of Minimally Invasive Urologic Surgery Beth Israel Deaconess Medical Center; Associate Professor of Surgery Harvard Medical School Boston, MA, USA Aaron C. Weinberg, MD

Clinical Instructor Department of Urology New York University School of Medicine New York, NY, USA

Rogier R. Wildeboer, MSc

J. Stuart Wolf Jr., MD, FACS

Professor Department of Surgery and Perioperative Care Dell Medical School at the University of Texas Austin, TX, USA Daniel A. Wollin, MD

Endourology Fellow Division of Urology Department of Surgery Duke University Medical Center Durham, NC, USA Wayland J. Wu, MD

Resident Physician The Arthur Smith Institute for Urology Zucker School of Medicine at Hofstra/Northwell Lake Success, NY, USA Yoshiya Yamada, MD, FRCPC

Senior Attending Radiation Oncologist Member Memorial Hospital Department of Radiation Oncology Memorial Sloan Kettering Cancer Center New York, NY, USA Yuka Yamaguchi, MD

Attending Physician Division of Urology Department of Surgery Alameda Health System Oakland, CA, USA Vidhush K. Yarlagadda, MD

Resident Department of Urology University of Alabama at Birmingham Birmingham, AL, USA Nadya E. York, MD, FRACS

Endourology Fellow Department of Urology

List of Contributors

Indiana University School of Medicine Indianapolis, IN, USA Michelle Yu, MD

Resident Department of Urology University of Pittsburgh Medical Center Pittsburgh, PA, USA Joao P. Zambon, MD, PhD

Associate Professor Department of Urology Wake Forest University Baptist Medical Center Winston‐Salem, NC, USA Michael Zhang, MD

Senior Resident Department of Urology New York Medical College New York, NY, USA

Lee C. Zhao, MD

Assistant Professor Department of Urology New York University School of Medicine New York, NY, USA Zichen Zhao, MD

ACS Simulation Fellow WWAMI Institute for Simulation in Healthcare (WISH) University of Washington Seattle, WA, USA Pei Zhong, PhD

Professor Department of Mechanical Engineering and Materials Science Duke University Durham, NC, USA

xxxix

xl

­Foreword “Endourology” was the 1978 branding brainchild of Elwin Fraley, Arthur Smith, and Paul Lange.1 Most felt that the Minnesota cold had finally gone beyond their woolen headgear to create a “brain freeze” of monumental proportions. Fast forward nearly 40 years and, today, endourology has become urology. Diagnostically, from the urethral meatus to the uppermost renal calyx, the entire urogenital tract can be revealed in great detail using both endoscopic and sophisticated imaging technologies. Therapeutically, urologists of talent, innovation, and persistence have supplanted standard incisional access with an endoscopic, image‐guided, or combined approach. If you are reading this Foreword then you are reading a book that contains every aspect of urology and how it is benefited by a minimally invasive (i.e. percutaneous, ureteroscopic, laparoscopic, robotic) or noninvasive ­ image‐guided (i.e. shock‐wave lithotripsy, focal therapy) approach. The authors are an international Who’s Who of experts in endourology. The content ranges from basic to futuristic endourology. In 166 chapters, the latest advances in antegrade and retrograde endoscopic nephrostomy, laparoendoscopic single‐site surgery, and robotic procedures as well the newest image‐guided therapies are clearly detailed and illustrated both in photographs and often by instructional video demonstrations. A wise mentor2 once advised me: “You are only as good as tomorrow.” That single sentence should haunt each of us as we arise every morning to provide relief to those

who suffer. To that end, we must seek methods to relieve suffering rather than cause it, to heal without harming, to cure without substituting one malady for another. Endourology empowers each of us to provide all individuals seeking our care with a kinder, gentler solution to their urological problems. In the first part of the twentieth century, Sir William Osler opined: “Diseases that harm require treatments that harm less.”3 A century later, his dictum has been largely realized in the practice of endourology. My heartfelt congratulations go out to Drs Smith, Badlani, Kavoussi, Preminger, and Rastinehad, who have provided a comprehensive guide of immense value to me, to you, and to all of our patients. Read Smith’s Textbook of Endourology well, apply its principles earnestly, and, if opportunity presents, seek to further innovate and build on its contents. The text is not an end in and of itself; rather, it is another paver in the surgical journey in which each of us plays a role — using techniques borne of today’s technology to proceed to further reduce the burden of the “surgical” cure we are obligated to apply.

Ralph V. Clayman, MD Professor of Urology/Dean (Emeritus) School of Medicine University of California, Irvine

Notes 1 Smith AD, Lange PH, and Fraley EE. Letter to the Editor:

applications of percutaneous nephrostomy. New challenges and opportunities in endo‐urology. J Urol 1979;121:382.

2 Arthur D. Smith. 3 Attributed to Sir William Osler (1849–1919).

xli

Preface The cover of this textbook synthesizes the concepts of endourology. In order to perform endoscopic surgery one needs access to the organ and various forms of energy to facilitate access, control bleeding, and obliterate tissues. These goals can only be accomplished with appropriate devices. Fortunately, evolving technology allows the manufacture of improved devices. It is essential for endourologists to keep abreast of these advances. The fourth edition of this book accomplishes this with an update of the existing chapters by the original authors or complete revision by new authors. In 1978 the concept of endourology was launched. It was defined as closed, controlled manipulation within the urinary tract. The word “closed” was used to indicate either a minimal incision or no incision at all and the control was achieved either endoscopically or by noninvasive imaging. Until then, residents had been taught that the only way to have good exposure was through a large incision. Now the ultimate goal is good exposure with no incision at all. This is achieved by utilizing a combination of endoscopy and the new modalities of imaging. There are now relatively few accepted open urological procedures and this has had the gratifying result of a dramatic decrease in the morbidity of our patients undergoing treatment. In this era of fewer working hours for residents, the amount of time that the residents spend in the operating room has decreased dramatically and the necessary skills have to be taught using a combination of additional educational modalities. In addition to books and journals, there are an abundance of videos on surgical techniques, animal laboratories, teaching models, and virtual reality simulators. Fortunately, endourologic techniques are uniquely suited to these modalities and the student can become quite adept by using them before being instructed in the operating room. As the technology has evolved, courses have been organized by the Endourology Society to train not only the residents and fellows, but also the practicing urologist so that their “learning curve” can be accelerated, and

they can then use these techniques with the required expertise. In addition, the Endourology Society has developed the Journal of Endourology and the Journal of Endourology Case Reports to update urologists on the latest technology. The Journal of Endourology allows the members access the Journal of Videourology which features videos of new and established techniques on the computer or tablet. This textbook consists of two volumes. Volume 1 is on stones of the upper tract. Volume 2 is on robotic and laparoscopic surgery and image‐guided diagnostic and therapeutic techniques together with minimally invasive therapy of the lower urinary tract. Volume 1 consists of five sections. Section 1 discusses the basic principles. Section 2 is devoted to percutaneous renal surgery. Section 3 discusses the intricacies of ureteroscopy. Section 4 is on shock‐wave lithotripsy. We are cognizant of the fact that there is no single modality for the treatment of stones and hence Section  5 describes the management of the patient with various stone‐related problems in a composite format. Volume 2 covers robotic and laparoscopic surgery. At present, there is very little difference between the techniques and that which there is is primarily related to technical experience, availability of the robot, and financial considerations. Sections 6 and 7 discuss image‐guided diagnostics and therapeutics. This is an important addition to our Textbook of Endourology, as it is an essential component of the armamentarium of the practicing urologist, particularly as we move into the era of “no incision.” If the procedures described in this section are not performed by urologists, then they will be taken over by radiologists. This in turn will result in the loss of ­continuity of care of our patients. I would like to thank each of the contributors for the many hours they have devoted to writing, illustrating, and creating videos for their chapters. Hopefully, they will be as delighted with the results as the editors and publishers of this textbook. I am also deeply indebted to my co‐editors, who have reviewed, edited, and re‐reviewed chapters countless times. Thanks to their families as well, as the

xlii

Preface

time spent on the book could have been devoted to them. The staff at Wiley Blackwell and the project manager Mirjana Misina have been highly professional and encouraging. When one deals with a large organization, it is reassuring to know that as a book bounces from one stage to the next there has been a “continuity of care throughout the operation.” They are a great team and we appreciate all the help we received from them.

Finally, I would like to thank my wife, Kay, who inspired me to edit this fourth edition and has repeatedly helped me with this and countless other projects throughout my academic career. If I am regarded as the “father” of endourology, she is unquestionably the “mother” who has helped to nurture this field of urology. June 2018

Arthur D. Smith

xliii

About the Companion Website This book is accompanied by a companion website:

www.wiley.com/go/smith/textbookofendourology The website includes: ●● ●●

Over 100 videos showing procedures as described in the book PowerPoints of all figures from the book for downloading

All videos are referenced in the text where you see this icon:

879

SECTION 6 Laparoscopy and Robotic Surgery

881

Part 1  General Principles

74 New Surgical Robotics Alabdulaali Ibrahim1 & Koon Ho Rha 2 1 2

Department of Surgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea

­Single‐site robots Robotic technology was first reported to have been incorporated with single‐site surgery in 2011 using the da Vinci Single‐Site© surgical platform (Intuitive Surgical, Sunnyvale, CA, USA), which aimed to improve the technical limitations of laparoscopic single‐site surgery including external clashes, poor visualization of critical structures, and surgeon fatigue [1]. In 2015 a systematic review showed that the da Vinci surgical platform had proven to be a valuable asset in single‐site surgery, owing to the combination of robot use and dedicated single incision; the main reported limitation was the lack of an EndoWrist [2]. The da Vinci single port (SP) is Intuitive Surgical’s new surgical platform for single‐incision surgery, and gained US Food and Drug Administration approval in early 2014. It is composed of a three‐dimensional (3D) high‐ definition (HD) camera and three fully articulated instruments, all in a 25 mm port. The fully wristed EndoWrist SP instruments have two more degrees of freedom than the da Vinci Single‐Site instruments. The surgeon controls the instruments and the endoscope while seated at the da Vinci Surgical System console. Intuitive Surgical plans not to release it onto the market until it has been made fully compatible with the latest da Vinci Xi robot. This will require product refinements, supply chain optimization, and additional regulatory clearances [3]. The system is designed for urologic minimally invasive procedures that are already performed via a single incision. Major urologic procedures have been successfully completed using the da Vinci SP without conversions [4]. A second single‐port system is called Single Port Orifice Robotic Technology (SPORT™; Titan Medical,

Toronto, ON, Canada; see Figures  74.1 and 74.2). The system utilizes a 25 mm single‐access port which c­ ontains a 3D HD vision system and interactive multi‐articulating instruments, and a highly ergonomic surgeon workstation that provides the surgeon with an interface to the  robotic platform, as well as a 3D endoscopic view inside the patient’s body cavity during minimal invasive surgical procedures. It is expected to be commercially available in late 2019. The first targets of the SPORT ­system are gynecologic, gastrointestinal, and urologic procedures [5]. In December 2015 the building of the first SPORT Surgical Systems to include both the work station and the patient cart was announced. These will undergo extensive testing as a part of engineering verification (EV). These two EV systems will be tested to measure performance in relation to design specifications and to measure compliance with regulatory guidelines. These EV systems were precursors of the systems that were made ready in early 2016 for the first in‐human trials. The multi‐articulating, interactive, snake‐like instruments are designed to couple with removable and sterile single‐patient‐use robotic tools that provide first‐use quality in every case and eliminate the need for instrument reprocessing. The use of reposable (re‐usable for a specific number of uses) robotic instruments and single‐patient‐use tools allows more use cases for each robotic instrument, thus reducing the per‐case cost. The robotic platform is also designed to include a mast, a boom, and wheels for optimal configurability for a variety of surgical indications and the ability to be maneuvered around the operating room and surgical centers where applicable [5].

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

882

Section 6  Laparoscopy and Robotic Surgery: General Principles

Figure 74.1  The patient cart of the SPORT system. Source: Titan Medical, Inc., Canada. Reproduced with permission of Titan Medical, Inc.

Another single‐port robot is the SurgiBot (TransEnterix, Morrisville, NC, USA; Figures  74.3 and 74.4). It enhances laparoscopic surgery through robotic assistance, while allowing the surgeon to remain in the sterile field, at the patient’s side. It is composed of an integrated 3D HD camera for HD images with depth perception and delivers up to three articulating instruments through a single incision. One of its main advantages is that it has minimal reliance on surgical assistants and staff [6]. The Avicenna roboflex flexible uretroscopy robot (Elmed, Turkey) consists of a console and a manipulator. The hand piece of the scope is locked to the robotic arm. The surgeon at the console can control two joysticks to manipulate the rotation, deflection, and in‐and‐out movements of the endoscope. A central wheel enables fine tuning of deflection inside the collection system. The surgeon can rotate robotically 440°. This minimizes the torsion risk of the endoscope. Laser fiber can be remotely moved in and out which is very helpful for providing a suitable distance between the stone and the tip of the laser fiber. Software prevents firing of the laser shot when the laser tip is very close to the endoscope to  prevent damage. The integrated water pump can also  be  adjusted remotely. In this way it is possible to treat a stone with a minimal flow rate and to provide

Figure 74.2  The surgeon console of the SPORT system. Source: Titan Medical, Inc., Canada. Reproduced with permission of Titan Medical, Inc.

low‐pressure lithotripsy [7]. A human trail on 81 patients showed efficacy, safety, and a significant improvement in ergonomics [8]. The last robot reaching the market soon and utilizing a single port (natural orifice transluminal endoscopic surgery, or NOTES) is the Flex (Medrobotics Corp., Raynham, MA, USA). It utilizes a highly articulated multilinked scope that can be steered along nonlinear, circuitous paths in a way that is not possible with traditional, straight scopes. The maneuverability of the scope is derived from its numerous mechanical linkages with concentric mechanisms. This enables surgeons to perform minimally invasive procedures in places that were previously difficult or impossible to reach [9]. Surgeons can operate through a single access site and direct the scope to the surgical target. Once positioned, the scope can become rigid, forming a stable surgical platform from which the surgeon can pass two flexible surgical instruments. The system includes on‐board HD visualization to give surgeons a clear view of the navigation path and surgical site [9].

74  New Surgical Robotics

Figure 74.3  The SurgiBot hand piece. Source: TransEnterix, USA. Reproduced with permission of TransEnterix, USA.

Approval was achieved in Europe in 2014, and aim for a first limited commercial launch on selected European markets [10].

­Multiple‐site robots Figure 74.5 shows the ALF‐X system, developed by Sofar S.p.A. (Trezzano Rosa, Milan, Italy) and currently owned by TransEnterix. It is a multiport remotely operated robotic system that utilizes a remote control station and robotic arms. Three system features include haptic feedback, an eye‐tracking system, and reusable endoscopic instruments. Haptic feedback allows the surgeon to “feel” the force employed through the instruments and the natural resistance of the tissues. The eye‐tracking system allows accurate movement of the 3D endoscope. The first targets of the system were gynecology, urology, and thoracic surgery procedures. The ALF‐X gained CE market approval in 2011 [11]. ALF‐X has a comprehensive set of multipurpose tools that can be sterilized, which allows a significant cost reduction in the field of robotic surgery and makes it more accessible. Another feature is that there is no need to dock the robotic arm to a trocar, which decreases the operative time and facilitates easy patient repositioning intraoperatively. The console handpiece is similar to that for laparoscopic instruments which facilitates easy familiarization and a shorter learning curve.

Figure 74.4  The SurgiBot patient‐side single port. Source: TransEnterix, USA. Reproduced with permission of TransEnterix, USA.

The system can handle up to four arms and each manipulating arm is carried by its own patient side cart. The tools are introduced through standard 5 mm laparoscopy ports, making it possible to maneuver both laparoscopic and robotic instruments simultaneously. Since the beginning of clinical trials in 2013, a few studies have shown safety and feasibility in the treatment of various gynecological conditions [12–14]. The second multiport system is Surgenius (Surgica Robotica S.p.A., Trieste, Italy). The system consists of six degrees of freedom (DOF) arms, equipped with six DOF tip‐force sensors, providing haptic feedback to the operator. The robotic arms can be positioned freely around the surgical bed, as they are independent of each other. They can be equipped with Surgica Robotica’s high‐dexterity instruments, which allow great precision and wide maneuverability. The surgical system can be configured with the number of robotic arms that is necessary for the intervention, from one single arm to as many arms as can fit around the surgical bed. Surgenius gained CE market approval in 2012 [15]. The Bitrack system by Rob Surgical Systems S.L. (Catalonia, Spain) was designed to cover current limitations in laparoscopic surgery, like for example a system’s lack of flexibility and modularity, and the set‐up time. The prototype for the robot was finished in early 2015 and moved into the clinical validation phase to gain approval for the European and US markets. Rob Surgical Systems expects to obtain European approval in 2018 [16, 17].

883

884

Section 6  Laparoscopy and Robotic Surgery: General Principles

Figure 74.5  The ALF‐X. Source: TransEnterix, USA. Reproduced with permission of TransEnterix, USA.

The Chinese surgical robotic system Micro Hand S was invented at Tianjin University. It has three main technical advantages. The first is multi‐DOF wire transmission, making instruments for minimally invasive surgery with the benefits of no coupled motion, fixation, skid resistance, and anti‐looseness more conducive to maintaining accuracy. Second is a reconfigurable layout and implementation of a “slave hand,” making the robot “arms” lighter and more adaptable to the needs of the operation. The third is homogeneous control model building technology for hand–eye– instrument motion consistency in the 3D visual environment. The first clinical trials were done in March 2014 and showed the safety and effectiveness of the Micro Hand S in performing robot‐assisted minimally invasive surgery [18]. The NeuroArm is a magnetic resonance imaging (MRI)‐compatible image‐guided computer‐assisted device specifically designed for neurosurgery. In 2008 it made history when the robotic system was used to operate on a human patient at the Faculty of Medicine, University of Calgary, Canada. This landmark operation was the first time a robot was used to perform image‐ guided neurosurgery [19]. End‐effectors are equipped with 3D force sensors, providing a sense of touch. The surgeon, seated at the workstation, controls the robot using force feedback hand controllers. The workstation recreates the sight and sensation of microsurgery by displaying the surgical site and 3D MRI displays, with superimposed tools. NeuroArm enables remote manipulation of surgical tools from a control room adjacent to the surgical suite. It was designed to function within the environment of 1.5 and 3.0 tesla intraoperative MRI systems. As NeuroArm is MR‐compatible, and stereotaxy can be performed inside

the bore of the magnet with near‐real‐time image guidance. NeuroArm possesses the dexterity to perform microsurgery outside of the MRI system [19]. The DLR Institute of Robotics and Mechatronics in Germany has developed MIRO, a second generation of robot arms for surgical applications. With a low weight of 10 kg and dimensions similar to those of the human arm, the MIRO robot can assist the surgeon directly at the operating table where space is tight. The scope of applications of this robot arm ranges from guiding a laser unit for the precise separation of bone tissue in orthopedics to setting holes for bone screws, robot‐ assisted endoscope guidance, and minimally invasive surgery. Arms can be mounted directly to the operating table [20]. The DLR also developed a system called MicroSurge, which includes a master console with a 3D display and two haptic devices as well as a teleoperator consisting of three MIRO robot arms. Usually two MIRO arms carry surgical instruments equipped with miniaturized force/ torque sensors to capture reaction forces with manipulated tissue. The third MIRO arm can (automatically) guide a stereo video laparoscope. The stereo video stream as well as the measured forces are displayed to the surgeon at the master console. Therefore the surgeon is not limited to seeing but can also experience force feedback from the input devices [21]. The system is designed to be able to perform complex procedures, e.g. beating‐heart operations, where the tools and camera are moved synchronously with the heart, to give the surgeon the impression that the heart stands still. The virtual stopping of the heart and lung reduces the trauma to the patient [10]. AVRA Surgical Robotics is developing a surgical robotic system of modular construction which offers a

74  New Surgical Robotics

portable lightweight and maneuverable robotic solution not available in any current available systems. The basic AVRA Surgical Robotics System (ASRS) employs four robotic arms with a weight/payload ratio that is unavailable in the current surgical robotics market [22]. This ratio allows robotic applications for a vast range of minimally invasive operations as well as robotic application for potential use in traditional open surgical procedures. ASRS’s intelligence is incorporated within the arms and joints. The system can be configured with four or fewer arms and as such can be used, for example, in a single‐ arm construct with applications such as in‐joint orthopedics. The ASRS arms can be mounted on a patient‐side cart, placed next to the operating table, or directly mounted to the operating table as well as attached to an overhead structure. The ASRS surgeon console merges the high‐ resolution view of the surgical field, the data, information management, and action of the robotic system with the biomedical and IT environment in the operating theater. This console will provide a newly developed

human–machine interface (HMI) for the maneuvering of both instruments and the camera head.

­Conclusion Robot‐assisted surgery is a rapidly growing field, helped by continually evolving technology and its use in a wide variety of surgical settings. The near future is packed with a promising number of surgical robotic systems which can give better outcomes. Product costs are expected to go down as more competitors offering distinct technologies enter the market. The first challenge for the near future will be to adapt the conventional forms of treatment to integrated, computer‐assisted alternatives. This requires new training plans for medical staff, and changes in the layout of hospitals to accommodate the new requirements. Without a team that can exploit these opportunities to the fullest, gains from the use of this technology will remain small.

­References 1 Kroh M, El‐Hayek K, Rosenblatt S et al. First human

10 Hoeckelmann M, Rudas IJ, Fiorini P et al. Current

2

11

3

4

5 6

7 8

9

surgery with a novel single‐port robotic system: cholecystectomy using the da Vinci Single‐Site platform. Surg Endosc 2011;25(11):3566–3573. Morelli L, Guadagni S, Di Franco G et al. Da Vinci single site© surgical platform in clinical practice: a systematic review. Int J Med Robot 2016;12(4):724–734. Intuitive Surgical. Press release. http://investor. intuitivesurgical.com/phoenix.zhtml?c=122359&p=irol‐ newsArticle&ID=1920546 (accessed 11 May 2018). Kaouk JH, Haber GP, Autorino R et al. A novel robotic system for single‐port urologic surgery: first clinical investigation. Eur Urol 2014;66(6):1033–1043. Titan Medical. Homepage. http://www.titanmedicalinc. com/(accessed 11 May 2018). TransEnterix. TransEnterix enters next phase of development of SurgiBot system. https://www. transenterix.com/news‐item/transenterix‐enters‐next‐ phase‐development‐surgibot‐system/(accessed 16 May 2018). Elmed. Homepage. http://www.elmed‐as.com (accessed 16 May 2018). Saglam R, Muslumanoglu AY, Tokatlı Z et al. A new robot for flexible ureteroscopy: development and early clinical results (IDEAL stage 1‐2b). Eur Urol 2014;66(6):1092–1100. Medrobotics. Homepage. http://medrobotics.com/ (accessed 11 May 2018).

12

13

14

15

16

capabilities and development potential in surgical robotics. Int J Adv Robotic Syst 2015; doi: 10.5772/60133. TransEnterix. TransEnterix, Inc. announces first sale of ALF‐XⓇ surgical robotic system. https://www. transenterix.com/news‐item/transenterix‐inc‐ announces‐first‐sale‐of‐alf‐x‐surgical‐robotic‐ system/(accessed 16 May 2018). Fanfani F, Monterossi G, Fagotti A et al. The new robotic TELELAP ALF‐X in gynecological surgery: single‐center experience. Surg Endosc 2016;30(1):215–221. Fanfani F, Restaino S, Gueli Alletti S et al. TELELAP ALF‐X robotic‐assisted laparoscopic hysterectomy: feasibility and perioperative outcomes. J Minim Invasive Gynecol 2015;22(6):1011–1017. Gueli Alletti S, Rossitto C, Cianci S et al. TELELAP ALF‐X versus standard laparoscopy for the treatment of early‐stage endometrial cancer: a single‐institution retrospective cohort study. J Minim Invasive Gynecol 2016;23(3):378–383. Surgica Robotica. Products page. http://www. surgicarobotica.com/products.html (accessed 11 May 2018). Rob Surgical Systems. Bitrack system. http:// robsurgical.com/bitrack.html (accessed 11 May 2018).

885

886

Section 6  Laparoscopy and Robotic Surgery: General Principles

17 Surgrob. The Bitrack system. http://surgrob.blogspot.

kr/2015/02/the‐bitrack‐system.html (accessed 11 May 2018). 18 Yi B, Wang G, Li J et al. The first clinical use of domestically produced Chinese minimally invasive surgical robot system “Micro Hand S”. Surg Endosc 2016;30(6):2649–2655. 9 NeuroArm. Homepage. http://www.neuroarm.org/ 1 (accessed 11 May 2018). 20 Institute of Robotics and Mechatronics. MIRO ‐ Versatile Robot Arm for Surgical Application.

http://www.dlr.de/rmc/rm/en/desktopdefault.aspx/ tabid‐3795/16616_read‐40535/(accessed 11 May 2018). 21 Institute of Robotics and Mechatronics. MiroSurge ‐ telemanipulation in minimally invasive surgery. http:// www.dlr.de/rmc/rm/en/desktopdefault.aspx/ tabid‐3795/16616_read‐40529/(accessed 11 May 2018). 2 AVRA Medical Robotics. Homepage. https: 2 //www.avramedicalrobotics.com (accessed 16 May 2018).

887

75 Training and Credentialing Laparoscopic and Robotic Surgery Domenico Veneziano1 & David M. Hananel 2 1 2

Department of Urology and Kidney Transplant, Grande Ospedale Metropolitano “Bianchi, Melacrino, Morelli”, Reggio Calabria, Italy Center for Research in Education & Simulation Technologies, University of Washington, School of Medicine, Seattle, WA, USA

­ urgical training today: a complex S scenario “See one, do one, teach one” has been the mantra of surgical training for decades. Unfortunately, when we ask where are we going to see, do, and teach, the answer is often still “the patient.” In its early days, laparoscopy was considered too challenging and surgeons asked “why work through a keyhole when you can just walk through the door?” [1]. Indeed, operating through a keyhole adds even more complexity to surgery: fulcrum effect, decreased haptic feedback, and loss of depth perception, to name a few [2]. Despite these challenges, the early 1990s saw rapid acceptance of laparoscopy driven by patient demands: reading and hearing about faster recovery, less pain, and less scarring. The field was caught by surprise and device companies started to provide training courses led by the early adopters. A weekend course was often considered enough by many surgeons to try this new technology at their home institutions. There was no standardized curriculum established and training was performed mainly on porcine models. The desire to overcome some of the challenges in laparoscopy and an interest in remote surgery to perform operations in underserved or dangerous venues led to research in robotically assisted surgery. These efforts were funded by Defense Advanced Research Projects Agency (DARPA; Arlington, VA, USA) and the National Aeronautics and Space Administration (NASA; Washington DC, USA) [3–5]. This new technology provided the surgeon with stereoscopic vision to reinstate depth perception, hardware compensation of the fulcrum effect via console design, and tremor control and scaled motion to improve the accuracy of instrument movement

well beyond what a normal set of hands was capable of. Yet robot‐assisted surgery came with its own learning curve in addition to the basics, such as console management, robotic instrument knowledge, docking of the machine, and emergency undocking in case of life‐threatening ­complications. At the same time, complete knowledge of surgical anatomy, procedural skills, and basic surgical principles still had to be properly mastered before dealing with the new technology. Moreover, modern surgery with  its complex scenarios has raised the importance of so‐called “nontechnical skills” [6] (situational awareness, communication, teamwork, leadership, stress management) in order to safely perform a surgical procedure, in spite of technological advancements. Whenever we approach mastering something new, scaffolding [7, 8] facilitates acquisition of the required skills. This principle is equally valid whenever we are learning to ride a bicycle or to perform a new surgical intervention. Despite the famous phrase “to err is human,” limiting errors and facilitating the correct technique becomes critical in the surgical field, as patients cannot continue to be the training platform. Simulation has the goal of approaching the same situation multiple times, in order to understand it, apply different strategies to solve it, assess the pros and cons, select a preferred approach, and improve on it in a safe environment. It is widely used in several nonmedical fields to test new products and procedures, improve performance, predict future outcomes, and certify the acquisition of skills. In surgery, shortened hospital stays, shortened residency hours, and the rate at which new procedures and new technologies are introduced translate into a reduced number of operative cases for learners to participate in for any given procedure [9–11].

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

888

Section 6  Laparoscopy and Robotic Surgery: General Principles

Moreover, in situ skills assessment is challenging and the results of residency training are barely measured or considered in view of becoming a full surgeon. Although the use of simulation could potentially fill these gaps, its application is not yet as standardized or widespread as one would imagine. Indeed, it is used to varying degrees from country to country and even from institution to institution, leading to significant differences in technical and nontechnical skills between young practitioners in the same field. The American College of Surgeons’ Accredited Educational Institutes (ACS‐AEI) program was started in 2005 with the aim of providing guidelines and standards for simulation centers inside and outside the United States. The results turned out to be outstanding, and there are currently 94 accredited centers worldwide [12]. Despite the significant inroads, many sim‐centers still prefer not to adopt a standardized training model, continuing to create their own model instead. In Europe simulation is not typically considered a critical part of the urology residency curriculum. In the last decade some countries have adopted standardized training protocols to provide learners with a unified model to follow, preparing them for medical practice. This happened in the Netherlands with the 40 hours program and in the United Kingdom with the “Guidelines for training” [13] written under the auspices of the British Association of Urological Surgeons (BAUS). In Europe, simulation centers are still not common and few universities offer residents a chance to use pelvic trainers or simulators in general. Recognition of the need for deliberate, repeated simulation training and the lack of proper tools has led hands‐on training (HoT) sessions to become more and more popular all over Europe. HoTs provide tutoring on dedicated models during congresses and educational events. These sessions use standardized training kits with predefined exercises and learning objectives. The European Urology Residents Education Program (EUREP) [14], flagship training event of the European Association of Urology (EAU), introduced the HoT format into its schedule in 2006 and today attracts hundreds of final‐year residents from all over Europe, exposing learners from many countries to a unified training protocol [15]. The Urological Society of Australia and New Zealand (USANZ) streamlined the training regimen with the nSET Program, which includes training activities through the six residency years up to independent clinical practice, including the achievement of primary operator skills for laparoscopic surgery. Technical skills training is still not common practice in Africa, South America, and Asia, where structured technical skills teaching is limited to few training centers and dedicated courses.

Robotic surgery training is not yet formally considered as a part of urological education worldwide and few residents have a chance to perform robot‐assisted surgery as first operators before the end of their learning path.

­ istory of surgical training: H a growing field Although ancient texts, such as the Sushruta Samhita from India, laid down in Sanskrit around 500 ce (original date unknown, but thought to go back to 1000 bce), mention the use of various models to practice surgical skills for speed and accuracy, we will focus on recent history to follow our current model for medical education. Surgical residency as we know it today in the United States began in the early 1900s at Johns Hopkins University in Baltimore, MD, under the guidance of William Halstead. During those formative years, we have evidence that dog labs were used to teach both procedural as well as team‐based skills. We also tend to point at flight simulators to make a case for the use of simulation in medicine. Surprisingly, that path began later, in 1929, with the Link Trainer (Figure 75.1) [16], which was instrumental in training young pilots how to land on aircraft carriers. These early trainers can be compared to the basic skills trainers we see today, such as FLS, BLUS, and E‐ BLUS (see below) [17–19]. The growth of the Link Trainer into today’s full flight simulators and regimented training programs could not have happened without a  significant investment by the US Department of Defense  (DoD) to develop the science and technology that underlies them. We can recognize multiple phases in the progression of simulation in healthcare. The initial driver was the promise of objective assessment. In theory, by using virtual reality (VR) for training and assessment, we could measure everything that was represented in the mathematical models. Thus we could look at variables such as time and distance, but also collisions, penetrations, and path lengths, and even the use of energy, radiation, and blood loss. The believers were so excited about the possibilities that the mantra was “build it and they will come.” For the first VR simulators to be developed a number of technologies had to evolve. Many of them were supported by the DoD, such as graphics processors, head mounted displays, and haptic interfaces. As these technologies came into existence, by many accounts Dr Richard Satava, a laparoscopic surgeon who at the time was at DARPA, began funding projects in the late 1990s to see if “flight simulators for surgery” were within reach

75  Training and Credentialing Laparoscopic and Robotic Surgery

Figure 75.1  The Link Trainer.

[20]. Some of these early efforts resulted in a sinus surgery platform [21, 22] and a vascular anastomosis trainer, among others [23, 24]. The second wave came only a few years after that, with the tagline “validate it and they will come.” Early validation studies provided much‐needed proof of the scientific and educational merits of surgical simulation. The key study which set the standard that many followed was that by Seymour et  al. [25]. By that time a number of companies in the United States and abroad had launched commercial products into the market. That opened up the door for the next phase in development: an integrated curriculum, where simulation was one component of the whole. Validation studies gave the new technology legitimacy, while the integrated curriculum concept paved the way for today’s comprehensive view: backwards design, predefined learning objectives, assessment tools, part task trainers, human patient simulators, and full procedural VR simulators. In the last few years the DoD has refocused on medical simulation with significant investment in infrastructure: funding the development of open‐standards‐based building blocks to support the big picture and exponentially accelerate development. To formalize even more the birth of this new field of medical education and to push its development and widespread, ACS‐AEI accredited in 2014 a research fellowship program in education and simulation technologies, to be delivered by selected centers.

­ rom FLS to the concept of modular F hands‐on training When a new surgical intervention has to be learned, there are many topics that need to be addressed. Given a learner’s previous experience, some of those may be skipped, some may just need refreshing, and others may require in‐depth study and practice. Figure  75.2 provides a picture of the many elements that go into learning a surgical procedure. The concept is based on two principles: first and foremost a focus on patient management; second, bringing all contributors to safely performing a new procedure under one umbrella. This allows the learners to assess what they already are comfortable with, review where they have gaps, and finally layer in the new and difficult components specific to the procedure. The complexity of the procedural training template in Figure 75.2 demonstrates how difficult it is to move from basic clinical knowledge in medicine combined with basic technical skills to complete procedures and finally take on the responsibility of independent patient management. The true value of having a standardized template is to allow academic surgeons from all over the world to collaborate and contribute to this vast endeavor in developing training materials for all procedures [9, 26, 27]. To acquire the technical skills portion of a new procedure, we can often use some of the existing simulators. One of the first simulators to be validated with sufficient

889

Pre-op orders including medications and bowel prep Or set-up

Normal Normal variations

Pre-op

Surgical anatomy

Abnormal variations

Patient positioning Team and positions

Pathology Immediate Short term Long term

Emergency vs elective

Tray (s)

Natural disease progression and physiology

Reflection on learners current ksa Brief to prepare learner for case

Basic science & general background

Basic steps of procedure Key technical skills required

Plan & visualize ahead

Special devices required

External patient view

Orientation

Hx

Procedural training

Px

Intra-op

Internal patient view

Key landmarks

Exposure

Danger zones Mis-step

The dissection

Labs

Unexpected findings

Imaging studies

Step

Adjunctive tests for equivocal situations

Mis-step

Plan B Plan B

DDx Cardiopulmonary assessment/ anesthetic risk assessment Family issues

Patient specific information Orders

Cultural insights Risk benefit assessment Alternate treatments Consent special issues Initial operative plan

Special recovery issues

Post-op

Complications: Work-up and management Criteria for hospital discharge Assessment for discharge

Expected hospital course

Follow-up and categorization

Figure 75.2  Procedural training template. Source: CREST, University of Washington, USA. Reproduced with permission of CREST.

Plan B

75  Training and Credentialing Laparoscopic and Robotic Surgery

rigor in order to be used for a high‐stakes exam was Fundamentals of Laparoscopic Surgery (FLS). It was first proposed at McGill University by Dr Gerry Fried [17], then developed under the auspices of SAGES, and validated in collaboration with the ACS [28]. FLS tasks were thought to reproduce the basic movements used in laparoscopy and were so well planned to be easily adapted to basic skills teaching in other laparoscopic specialties, such as gynecology and urology. FLS was developed to target basic maneuvers and not full procedures. In the United States FLS has been used as a starting point for the creation of the Basic Laparoscopic Urological Skills (BLUS) curriculum. Despite a study [18] showing validity, the BLUS exam is not mandated and is used only by choice at select residency programs. The EAU started to build upon the FLS experience in 2011, when the European Basic Laparoscopic Urological Skills (E‐BLUS) [19] exam was given for the first time. E‐BLUS is today the only technical skills certification to be mandated by an international urological society. It is made up of four tasks: peg transfer, circle cut, needle guidance, and intracorporeal knot tying (Figure  75.3). Depending on faculty’s preference, basic training protocols often include the use of a camera navigation trainer [29] for a 30° laparoscope, although this exercise is not included in the examination. Initially intended as a stand‐alone certification program, E‐BLUS is rapidly evolving into the first step of a comprehensive pathway, guiding the novice from basic skills to full procedures and mastery. Modular hands‐on training, as depicted in Figure 75.4, suggests approaching technical skills training in three distinct steps: basic (simple skills), intermediate (complex tasks), and advanced (full procedures) [30, 31]. Figure 75.3  The E‐BLUS tasks.

This general concept, in this case applied to laparoscopy, prescribes a logical progression for novices, a learning path to prepare them for mentored cases with patients. Basic skills target fundamental building blocks: simple maneuvers like camera handling, grasping, traction/ countertraction, cutting, and single‐knot tying, which form the basis of any surgical technique. These are common to different laparoscopic specialties and that’s why FLS, originally designed for general surgeons, was so easily adopted by urologists. Given the proven validity of trainers like FLS and E‐BLUS, a novice should never learn basic skills on a patient. Intermediate training is much more specialty‐specific and focuses on the “complex tasks:” the most challenging steps of full procedures. Indeed, mastering basic skills, as well as practicing complex tasks on bench models, prepares the trainee to approach full procedural, or advanced training. At this stage the trainee has to link all the concepts learned along the way in order to perform the whole procedure (making errors, and learning how to recover) in a safe, simulated environment, before working on a real patient. While progressing from basic skills to full procedures, focus shifts to different aspects of surgical education, from technical skills to decision making and patient management, necessitating very different types of simulators. While laparoscopic basic skills are already well documented and standardized, complex tasks for intermediate training are not yet fully defined and incorporated into validated curricula. Moreover, these are much more challenging to simulate. A first comprehensive curricular implementation exists as a joint effort between the ACS and the Association of Program Directors in Surgery (APDS) as the ACS/APDS Surgery Resident Skills

891

892

Section 6  Laparoscopy and Robotic Surgery: General Principles

Figure 75.4  Modular hands‐on training. Source: infographics by D. Veneziano MD.

Curriculum Phases I, II, and III, going from basic steps and tasks to procedures and team‐based training [32– 35]. Laparoscopic complex tasks according to the American Urological Association (AUA) and the EAU are summarized in Table  75.1. In either case, both American and European Urological societies agree that mastering complex tasks is critical before continuing on to perform complete procedures. If laparoscopy made control of the instruments more difficult, putting a surgical robot in between surgeon and the instruments created new challenges, still being studied. Regarding basic skills, robotic consoles are explicitly Table 75.1  Complex tasks according to AUA and EAU. AUA Laparoscopic, Robotic and New Surgical Technology (LRNST)

ESU/European School of Urology and section of Uro‐Technology (ESUT) training research group

Pyeloplasty

Horizontal anastomosis (as per pyeloplasty)

Y‐V plasty

Vertical anastomosis (as per vesicourethral)

Vesicourethral anastomosis

Hilar dissection

Control of aortic and inferior vena cava injury

Major vessel injury repair Tumor enucleation and suture of renal parenchyma

developed to make instrument control much easier, eliminating fulcrum effect and lack of depth perception. On the other hand, becoming proficient on the console itself requires practice. Just like the cockpit of a car, it has few but important controls that need to be internalized so that the operator can focus on the procedure itself. Moreover, robot‐assisted surgery requires continuous collaboration between console operator and bedside assistant, necessitating nontechnical skills training. Following on the footsteps of basic laparoscopy curricula, several training models [36] have been suggested for robotic surgery in urology. The first paper about the fundamentals of robotic surgery (FRS) was dated 2014 [37] and describes the process followed to design a basic training curriculum which could address the needs of multiple specialties and their societies. FRS includes cognitive content with pre‐, intra‐ and postoperative activities, psychomotor skills, and team training exercises. To support the FRS curriculum, a physical training dome has been designed in order to place FLS tasks into a tridimensional environment. To maximize repeatability and standardization, the FRS dome with its predefined tasks was also reproduced on virtual platforms. In 2015, Fundamental Inanimate Robotic Skills Tasks (FIRST), a second training model for basic robotic skills, was validated [38]. The study enrolled 96 participants and scored performance in relation to completion time and errors performed on four FLS‐inspired inanimate tasks. The most relevant experience in Europe regarding

75  Training and Credentialing Laparoscopic and Robotic Surgery

robotic training was documented in 2015 [39] under the auspices of European Robotic Urology Section (ERUS). The article describes a fellowship curriculum to be carried out at an ERUS‐accredited center, which is able to guide attendants in 6 months from VR training platforms up to the successful completion of a robot‐assisted radical prostatectomy. After the completion of a full training curriculum, mentored procedures on the patient can be supervised in robotic surgery thanks to the use of the dual console, which allows the tutor to eventually step into the procedure and help the operator, if needed. Both in laparoscopy and in robot‐assisted surgery, following a step‐by‐step path will shorten the learning curve, lead to faster mastery of a new surgical procedure, and increase patient safety.

­The science of curriculum development The creation of a comprehensive curriculum requires a rigorous process, beginning with deep insight into the intervention. The process links training outcomes to learning objectives and the validation process to the educational intent [25, 40]. The focus has to be on the curriculum, which in many cases will require a simulator to practice on. There are three distinct roles in developing curricula: the clinician, the educator, and the developer; it is key that those roles are kept separate. The clinician is the source of all insight into the intervention, the disease, management of the patient, and the underlying basic science. The educator helps with the educational design and creation of valid assessment instruments. Finally the developer addresses content development, which may include simulators. Although the participants may want to play multiple roles in the process, we should resist that and keep these efforts distinct to ensure the best outcome.

What

Implement Outcomes Curriculum Simulator & development development metrics

How

Figure 75.5  Full life‐cycle curriculum development template. Source: Richard Satava. Reproduced with permission of Richard Satava.

One effective template to follow in order to avoid missing any important step is the one described by Richard Satava, named full life‐cycle curriculum development [41] (Figure 75.5). The template describes a well‐defined process, which begins and ends at the same point (full life cycle): the outcomes. The primer ACS Principles and Practice for Simulation and Surgical Education Research [42] provides many tips on how to approach the process. Desired training outcomes and metrics need to be defined at the beginning, in order to guide the design process. These should be defined by the training program coordinator, in the case of an institution‐specific course, or by an expert committee if proposed by a professional society. The initial framing opens the way to collect all the data required to develop the curriculum. It starts with a thorough literature review and development of an Anatomic Bill of Material, indicating all structures involved in the procedure. The analysis of best practices will separate choreography from safety considerations. A well‐executed cognitive task analysis (CTA) [42, 43] allows us to document the series of decisions behind every single maneuver for a surgical procedure and the set of cues that need to be recognized to make those decisions [44–47]. It is usually completed by interviewing one or more experts while viewing a video of the procedure. Once completed, the CTA documents all steps of the procedure and, if appropriate, all phases of patient management in detail. It is the primary document used for all curriculum development work, didactic content, physical trainers, and assessment instruments. The CTA frames the educational requirements, which can be translated into simulation requirements. Based on these, simulators on the market are reviewed. If none meet the requirements, a development team is tasked to address those needs and create one or more dedicated simulators. Afterwards, the simulators are verified and validated along with the associated curriculum. In case validity is shown and no major modification is required, the curriculum can be implemented into training courses.

Consensus conference

Standard curriculum template

Engineering physical simulator

Validation studies

Standard validation template

Survey training certification

Current procedures

Issue certification

Issue mandates and certificates

893

894

Section 6  Laparoscopy and Robotic Surgery: General Principles

Multiple rigorous validation studies organized by professional societies can lead to the simulation being considered for credentialing. This could lead to certification that the learning objectives defined at the beginning of the development process have been reached [48, 49].

­ vailable and future simulation A technologies Learning objectives and desired training methods determine what kind of training is required and which simulators can be used. As identified in the full life‐cycle curriculum development template (Figure 75.5), simulator selection/development always comes after “outcomes and metrics” and “curriculum development.” Before considering the development of a new simulator, which can require considerable investment, one should review existing ones. Over the last decade the range of commercially available simulators for training healthcare professionals has grown exponentially. Training tools available for laparoscopic and robotic surgery range from physical and virtual to hybrid. In the context of simulation, a concept that needs to be carefully examined and understood is that of fidelity. Although “simulation” is considered a reproduction of reality, it is an approximation of the tasks with some degree of fidelity. A high‐fidelity surgical simulator aims to replicate the actual surgical setting, mimicking every detail from anatomy and physiology to tissue behavior. On the other hand, a low‐fidelity trainer has the goal of focusing just on some specific detail, putting the rest aside. Thus, a cadaver could be considered an “organic simulator” that is closest to the surgical concept of high fidelity, while FLS/E‐BLUS tasks, with their pegs and gauzes, are synthetic low‐fidelity trainers. High‐fidelity simulators, due to their complexity, are usually more expensive and require more time to be prepared for a training session, whereas low‐fidelity ones are often more transportable, cheaper, and easier to arrange. Some

exercises may be reproduced on both types of simulator; some others may not. Fidelity also needs to be seen in the context of the targeted learning objectives, which may change the definition of fidelity itself. Despite the level of fidelity, assessment capabilities also need to be considered, ranging from expert observation to embedded sensors or software‐based assessment. Physical simulators For laparoscopic training, the most common simulators today are physical. The first laparoscopic box-trainers were built in the 1990s and they are still produced in many different shapes (Figure  75.6). The concept is always the same, with a trocar‐retaining upper wall and a base to host different exercises. A great variety of tasks have been developed, with FLS‐related ones being the most common. Apart from the FRS dome, still not commercially available, and the FIRST tasks, validated basic skills physical simulators are not available in the robotic training field. These low‐fidelity trainers lack embedded assessment instruments, but rely on time to completion and counting of errors to assess performance. Some more sophisticated trainers have been recently made available by the Center for Research in Simulation and Education Technologies (CREST; University of Washington, Seattle, WA, USA). These simulators target the intermediate training level as they reproduce parts of full procedures. These include the Major Vessel Injury (MVI) repair model [50] and the Pyeloplasty model [51, 52] (Figure  75.7), which can be used for both laparoscopic and robotic training. These models, in contrast to to many other physical models, have embedded assessment markers to objectively measure surgical skill. The MVI model, connected to a synthetic‐blood bag, allows for objective measurement of blood loss, focusing on a clinically relevant measure. The Pyeloplasty model uses Black Light Assessment of Surgical Technique (BLAST) technology to objectively assess the alignment of the ureteropelvic junction. Similar tasks can also be performed, even without embedded assessment, on actual perfused

Figure 75.6  Three laparoscopic box trainers: (from left to right) Szabo Berci, Pulsatile Organ Perfusion, Optimist (POP), and Pro Lab.

75  Training and Credentialing Laparoscopic and Robotic Surgery

(a)

(b)

Figure 75.7  Two Intermediate training tasks: (a) MVI repair model and (b) Pyeloplasty model by CREST. Source: CREST, University of Washington, USA. Reproduced with permission of CREST.

animal organs inside dedicated boxes like the Pulsatile Organ Perfusion, Optimist (POP) trainer (Innsbruck, Austria), and the Pro Lab (INTECH, Reggio Calabria, Italy), shown in Figure 75.6. When it comes to advanced, full procedural training, cadavers are often considered the gold standard of surgical simulators, although they present significant pitfalls. Indeed, they are not able to provide objective feedback about performance, as relevant damage could be caused without ever knowing it. This shortcoming of cadavers used as simulators has already been addressed in the automotive safety field and lead to the creation in 1976 of Hybrid III [53], the first modern crash‐test dummy. Dummies have the ability to record an incredible amount of data, allowing a deeper understanding of what is happening to the driver during an automobile collison. Laboratory animals are often used for advanced training, although their anatomy is not a good analogue for the corresponding human one. Meanwhile, next‐generation physical simulators are being instrumented to support real‐time, objective assessment. Some attempts have already been made to create accurate synthetic anatomic structures representing the surgical space inside simple training boxes, to support repeatable advanced training without the use of organic or animal models. An example is the Radical Nephrectomy model by INTECH (www.intechsimulation.com), silicon-based and assembled over a 3D-printed structure. Mostly made of reusable parts, it was designed to fit inside a laparoscopic box-trainer. Finally, the US DoD has funded a major initiative for the development of an Advanced Modular Manikin(TM) open source, open standards platform that allows both technical and non-technical skills to be trained on a hybrid, full patient simulator being developed by CREST(Award# W81XWH-14-C-0101) (www.advancedmodularmanikin.com). Virtual reality simulators VR simulators were considered the future of healthcare education in the early 1990s. After more than 20 years

developers are still working to improve VR systems, to meet surgical education requirements. Realistic graphics and physics, as seen in videogames, although impressive are unfortunately not sufficient for surgery and very expensive to develop with current methods. Robot‐assisted surgery simulators use VR today for basic tasks, like moving objects or suturing drills. Some intermediate training exercises for procedural task training are under development, as well as systems that allow for an interaction between the first operator from the console and a second operator maneuvering laparoscopic instruments. Robotic VR trainers (Figure 75.8) are on the market as stand‐alone products or as upgrades for the actual robotic console. Hybrid simulators and future technologies Hybrid simulators have been designed in the attempt to match the physical feedback of inanimate models to data collection and assessment capabilities of VR technologies. These systems, like the Electronic Data Generation for Evaluation (EDGE; Simulab, Seattle, WA, USA) or the LapX Hybrid (Epona, Rotterdam, The Netherlands), and the ForceSense (Medishield B.V., Delft, The Netherlands), are still just based on FLS tasks and take advantage of video tracking and several sensors to record performance and eventually assess in real time. This concept could be enhanced by applying augmented reality to synthetic models. The advent of three‐dimensional printing is facilitating fast and cheap reproduction of physical models and instruments, which could accelerate adoption of technical skills training. This technology, coupled with biologic printing materials [54], could lead to the creation of standardized printed organs, designed to address training requirements and producible on site. Given the variety of simulators available, many learning objectives can be met today. These range from simple inanimate trainers like E‐BLUS, up to Human Patient Simulators that allow training of team skills [55–58]. In any case, citing Richard Satava, “the simulator is just

895

896

Section 6  Laparoscopy and Robotic Surgery: General Principles

(a)

(c)

(b)

(d)

Figure 75.8  Robotic VR trainers: (a) dV trainer by Mimic, (b) RobotiX Mentor by Simbionix, (c) RoSS by Simulated Surgical Systems, (d) backpack by Intuitive Surgical on a da Vinci console.

another tool, and it is the curriculum that will determine the training of the surgeon” [59]. For further information on available and future simulation technologies, please refer to Video 75.1.

­Validation: facts and controversies The desire to validate simulators has been an important and necessary effort from the very beginning. After all, we need to know if time spent on a simulator provides value. Today we have a tendency to use the term validation in a generic sense of “does it do what it is supposed to do?” We need to consider this term from different

points of view. While the surgical community considers simulators to prepare for patient care and increase safety, the education community talks about formative feedback and summative evaluation. Many important questions have been combined under this rubric, each with their own challenges: ●● ●●

●●

If I keep practicing on a simulator, do I get better? If I keep practicing on a simulator, do I get better in the operative room? How many times should I repeat an exercise or how long should I practice until I am done?

Let’s consider these questions individually. If you keep practicing on a simulator you will always get better at

75  Training and Credentialing Laparoscopic and Robotic Surgery

●●

●●

●●

Did the trainee properly study the didactic content preparing them for the exercise? Has a mentor observed and provided the trainee with formative feedback so that they get better at what they are doing? Was the trainee instructed properly on how to practice on the simulator?

If trainees do not understand the instructions, the simulator might not help them and, at the same time, even a mediocre simulator could allow them to learn if they were working with an excellent mentor. None of these questions directly relate to validation as defined by the educational community, which will clearly state that one can only validate an assessment instrument, to basically state that it correctly measures what was intended to be measured. That process is rigorous and complex, reflected in the fact that there are very few simulators that are formally validated. The standards for validation are published in Standards for Educational and Psychological Testing, 2014 edition [60]. Validation is not a process that can be undertaken as an afterthought, as it relates to intent: what were the learning objectives we had in mind? How are we assessing that these learning objectives are reached? What is the prescribed training protocol? As the Holy Grail is to assess whether time spent on a simulator translates to better patient care, we also should create assessment instruments that can be used both with the simulators and in the clinical environment. Then we could compare data directly and determine whether or not training transfer took place.

­The role of assessment and certification When discussing training, we also need to consider assessment. Without assessment we cannot tell if training is leading to improvement. Without assessment we can-

not tell the trainees how to improve their performance, or decide if the trainee is ready to move on to the next level. Creating a reliable assessment instrument is a difficult task. For example, time to completion has been widely used for assessment of technical skills, while studies have shown that time is not a valid measure for surgical performance; in fact, speed increases errors. In 1990 Miller created a template for the assessment of cognition and behavior in a clinical setting (Figure 75.9) [61]. He underlined the importance of separating the assessment of cognition from behavior: the examinee shows the they know the basic science and demonstrates that they know how to relate it to the procedure. After demonstrating cognitive skills, the trainee demonstrates how they apply their cognitive knowledge to the procedure and, finally, that they are able to actually do it. This whole process reminds us once again of the procedural training template depicted in Figure 75.2 and of the relevance of modular hands‐on training as a pattern of step‐by‐step skills assessment, during the “show how” phase. Assessment may include evaluation of both technical and nontechnical skill markers, such as the Global Evaluation and Assessment of Robotic Skills (GEARS) [62] and the Non‐Technical Skills for Surgeons (NOTSS) [63]. Crowdsourcing is now also being studied as an alternative to conventional tools, mostly based on expert evaluation. Indeed recent studies [64, 65] demonstrate how “crowd scores can provide similar or nearly identical concordance with faculty panel ratings and pass‐fail decisions” in approximately 48 hours, which is 60 times faster than the expert counterpart. Moving ahead, electronic sensors or video analysis could improve the measurement of technical skills, just as VR‐ based simulators claim to do. Indeed, relying on a solid assessment tool is critical when we talk about certification and licensing. In 2009, the American Board of Surgery (ABS) mandated that, in order to be eligible to sit for the board exam in General Surgery [66], a certificate documenting the successful completion of the FLS exam had to be

Does Professional Authenticity

doing that specific task on a simulator, which does not necessarily relate to the surgical task that we are preparing for. The second question moves us closer in that direction as it considers training transfer. Indeed, if the simulator was not designed properly you might actually get better on the simulator but worse in the operative room, which is known as negative training transfer. The third question, although not directly related to validation, is also a critical one. Unfortunately it is neither time nor repetition that can establish an end point. The correct answer has to be “until you reach proficiency,” as each individual learns at a different rate. The only thing that really matters is that, whenever a trainee stops practicing on the simulator they must be deemed safe to take care of patients. To further complicate the notion of validating a simulator, we need to consider some other items:

Behaviour

Shows how

Knows how Cognition Knows

Figure 75.9  The assessment of clinical skills/competence/ performance.

897

898

Section 6  Laparoscopy and Robotic Surgery: General Principles

submitted along with the application. Similarly, the E‐BLUS exam includes an online cognitive part to be completed before moving on to the technical skills part, to be ­certified. Creating a high‐stakes exam requires tremendous scrutiny and rigor. When a surgical society endorses an exam as “high stakes” it certifies that, by passing the exam, the applicant is considered by the society competent to perform the procedure with full autonomy. Urology board certifications in America, Europe, and Australia include today only cognitive assessment and rely on logbooks to certify practical

skills. The addition of technical skills assessment as an integral part of board exams would definitely improve the validity of these high‐stakes exams, leading to improved patient safety. As documented in the literature, assessment and certification in surgery are evolving with much room for improvement. Considering the role of simulators in civil aviation training, licensing, and re‐certification today, it would not be a surprise to see similar requirements in the laparoscopic and robotic surgery fields in the years to come.

­References 1 Moran ME. Minimally invasive urologic reconstructive

techniques: suture, staple, and clip technology. In: Smith’s Textbook of Endourology (ed. AD Smith), 431. Hamilton, ON: BC Decker, 2007. 2 Shepherd JM, Harilingam MR, and Hamade A. Ergonomics in laparoscopic surgery‐a survey of symptoms and contributing factors. Surg Laparoscopy Endoscopy Percutaneous Tech 2016;26(1):72–77. 3 Bowersox JC, Cordts PR, and LaPorta AJ. Use of an intuitive telemanipulator system for remote trauma surgery: an experimental study. J Am Coll Surg 1998;186(6):615–621. 4 Satava RM. Surgical robotics: the early chronicles ‐ a personal historical perspective. Surg Laparoscopy Endoscopy Percutaneous Tech 2002;12(1):6–16. 5 Doarn CR, Anvari M, Low T, and Broderick TJ. Evaluation of teleoperated surgical robots in an enclosed undersea environment. Telemed J E‐Health 2009;15(4):325–335. 6 Yule S and Smink D. Competency‐based surgical care: nontechnical skills in surgery. In: ACS Surgery: Principles and Practice (ed. S Ashley). 2013. Hamilton, ON: Dekker Publishing. 7 Carnine D, Jones ED, and Dixon R. Mathematics educational tools for diverse learners. School Psychol Rev 1994;23(3):406–427. 8 Dixon RC, Carnine D, and Kameenui E. Using scaffolding to teach writing. Educ Leadership 1993;51(3):100–101. 9 Bell RH Jr, Biester TW, Tabuenca A et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg 2009;249(5):719–724. 10 Peyton CC and Badlani GH. Dedicated research time in urology residency: current status. Urology 2014;83:719–724. 11 Cocci A, Patruno G, Gandaglia G et al. Urology residency training in italy: results of the first national survey. Eur Urol Focus 2016;pii: S2405‐4569(16)30066‐9.

12 American College of Surgeons. AEI consortium.

13

14

15

16

17

18

19

20 21

22

https://www.facs.org/education/accreditation/aei/ consortium (accessed 30 July 2016). The British Association of Urological Surgeons. Robotic surgery guidelines for training. http://www. baus.org.uk/_userfiles/pages/files/Publications/ Robotic%20Surgery%20Curriculum.pdf (accessed 30 July 2016). European Association of Urology. European Urology Residents Education Programme. http://www.eurep16. uroweb.org (accessed 30 July 2016). Somani BK, Van Cleynenbreugel B, Gozen A et al. The European Urology Residents Education Programme Hands-on Training Format: 4 years of Hands-on Training Improvements from the European School of Urology. Eur Urol Focus. 2018 March 14 doi: 10.1016/j.euf.2018.03.002. Western Museum of Flight. The 1942 Model C‐3 Link Trainer. http://www.wmof.com/c3link.html (accessed 16 May 2018). Fried GM. FLS assessment of competency using simulated laparoscopic tasks. J Gastrointest Surg 2008;12(2):210–212. Sweet RM, Beach R, Sainfort F et al. Introduction and validation of the American Urological Association Basic Laparoscopic Urologic Surgery skills curriculum. J Endourol 2012;26(2):190–196. Brinkman WM, Tjiam IM, Schout BMA et al. Results of the European Basic Laparoscopic Urological Skills Examination. Eur Urol 2014;65(2):490–496. Satava RM. Virtual reality surgical simulator. The first steps. Surg Endosc 1993;7(3):203–205. Fried MP, Sadoughi B, Weghorst SJ et al. Construct validity of the endoscopic sinus surgery simulator ‐ II. Assessment of discriminant validity and expert benchmarking. Arch Otolaryngol‐Head Neck Surg 2007;133(4):350–357. Fried MP, Satava R, Weghorst S et al. Identifying and reducing errors with surgical simulation. Qual Saf Health Care 2004;13 Suppl 1:i19–i26.

75  Training and Credentialing Laparoscopic and Robotic Surgery

23 O’Toole R, Playter R, Krummel T et al. Assessing skill

24

25

26

27

28

29

30

31

32

33

34

35

and learning in surgeons and medical students using a force feedback surgical simulator. Med Image Comput Comput Assist Interv 1998;1496:899–909. O’Toole RV, Playter RR, Krummel TM et al. Measuring and developing suturing technique with a virtual reality surgical simulator. J Am Coll Surg 1999;189(1):114–127. Seymour NE, Gallagher AG, Roman SA et al. Virtual reality training improves operating room performance: results of a randomized, double‐blinded study. Ann Surg 2002;236(4):458–463; discussion 463–464. Stolzenburg JU, Schwaibold H, Bhanot SM et al. Modular surgical training for endoscopic extraperitoneal radical prostatectomy. BJU Int 2005;96(7):1022–1027. Waxman SW, Winfield HN, Sweet RM et al. Developing a performance assessment device for the hilar dissection of the laparoscopic transperitoneal nephrectomy procedure. J Urol 2009;181(4 Suppl):790. Derossis AM, Fried GM, Abrahamowicz M et al. Development of a model for training and evaluation of laparoscopic skills. Am J Surg 1998;175(6):482–487. Veneziano D, Minervini A, Beatty J et al. Construct, content and face validity of the camera handling trainer (CHT): a new E‐BLUS training task for 30A degrees laparoscope navigation skills. World J Urol 2016;34(4):479–484. Aggarwal R, Moorthy K, and Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91(12):1549–1558. Aggarwal R, Grantcharov TP, Eriksen JR et al. An evidence‐based virtual reality training program for novice laparoscopic surgeons. Ann Surg 2006;244(2):310–314. Korndorffer JR Jr, Arora S, Sevdalis N et al. The American College of Surgeons/Association of Program Directors in Surgery National Skills Curriculum: adoption rate, challenges and strategies for effective implementation into surgical residency programs. Surgery 2013;154(1):13–20. Pentiak PA, Schuch‐Miller D, Streetman RT et al. Barriers to adoption of the surgical resident skills curriculum of the American College of Surgeons/ Association of Program Directors in Surgery. Surgery 2013;154(1):23–28. Sanfey HA and Dunnington GL. Basic surgical skills testing for junior residents: current views of general surgery program directors. J Am Coll Surg 2011;212(3):406–412. Scott DJ and Dunnington GL. The new ACS/APDS skills curriculum: moving the learning curve out of the operating room. J Gastrointest Surg 2008;12(2): 213–221.

36 Fisher RA, Dasgupta P, Mottrie A et al. An over‐view of

37

38

39

40

41

42

43

44

45

46

47

48

robot assisted surgery curricula and the status of their validation. Int J Surg 2015;13:115–123. Smith R, Patel V, and Satava R. Fundamentals of robotic surgery: a course of basic robotic surgery skills based upon a 14‐society consensus template of outcomes measures and curriculum development. Int J Med Robot Comput Assist Surg 2014;10(3):379–384. Goh AC, Aghazadeh MA, Mercado MA et al. Multi‐ institutional validation of fundamental inanimate robotic skills tasks. J Urol 2015;194(6):1751–1756. Volpe A, Ahmed K, Dasgupta P et al. Pilot validation study of the European Association of Urology Robotic Training Curriculum. Eur Urol 2015;68(2):292–299. Sweet RM, Hananel D, and Lawrenz F. A unified approach to validation, reliability, and education study design for surgical technical skills training. Arch Surg 2010;145(2):197–201. Khamis NN, Satava RM, Alnassar SA, and Kern DE. A stepwise model for simulation‐based curriculum development for clinical skills, a modification of the six‐step approach. Surg Endoscopy Other Interv Tech 2016;30(1):279–287. Hananel D, Stubbs J, and Sweet RM. Simulator development – from idea to prototype to product. In: ACS Principles and Practice for Simulation and Surgical Education Research (ed. R Aggarwal, J Korndorfer, and J Cannon‐Bowers), 138–152. Chicago, IL: American College of Surgeons, 2015. Brinkman W, Tjiam IM, Schout BMA et al. Designing simulator‐based training for nephrostomy procedure: an integrated approach of cognitive task analysis (CTA) and 4‐component instructional design (4C/ID). J Endourol 2011;25:A29. MacKenzie CL, Ibbotson JA, Cao CGL, and Lomax AJ. Hierarchical decomposition of laparoscopic surgery: a human factors approach to investigating the operating room environment. Minimally Invasive Ther Allied Tech 2001;10(3):121–127. Campbell J, Tirapelle L, Yates K et al. The effectiveness of a cognitive task analysis informed curriculum to increase self‐efficacy and improve performance for an open cricothyrotomy. J Surg Educ 2011;68(5):403–407. Munro A and Clark RE. Cognitive task analysis‐based design and authoring software for simulation training. Military Med 2013;178(10):7–14. Pugh CM, Santacaterina S, DaRosa DA, and Clark RE. Intra‐operative decision making: More than meets the eye. J Biomed Informat 2011;44(3):486–496. Veneziano D., Ahmed K., Van Cleynenbreugel B et al. Development methodology of the novel Endoscopic stone treatment step 1 (EST s1) training/assessment curriculum. J Endourol. 2017 Jul 10. doc: 10.1089/end 2017.0248.

899

900

Section 6  Laparoscopy and Robotic Surgery: General Principles

49 Veneziano D, Ploumidis A, Proietti S et al. Evolution

50

51

52

53

54

55

56

and Uptake of the Endoscopic Stone Treatment Step 1 (EST-s1) protocol: establishment, validation and assessment in a collaboration by the European School of Urology and the Uro-Technology and Urolithiasis Sections. On behalf of the European School of Urology training group. Eur Urol. 2018, doi: 10.1016/j. eururo.2018.05.012. Veneziano D, Poniatowski LH, Reihsen TE, and Sweet RM. Preliminary evaluation of the SimPORTAL major vessel injury (MVI) repair model. Surg Endoscopy Other Interv Tech 2016;30(4):1405–1412. Poniatowski L, Sweet R, Reihsen T, Sainfort F, Nakada SY, Averch TD, et al. Validity and acceptability of a high‐fidelity physical simulation model for training of laparoscopic pyeloplasty. J Endourol 2014;28(4): 393–398. Poniatowski LH, Wolf JS Jr, Nakada SY et al. Validity and acceptability of a high‐fidelity physical simulation model for training of laparoscopic pyeloplasty. J Endourol 2014;28(4):393–398. Hu J, Klinich KD, Reed MP et al. Development and validation of a modified Hybrid‐III six‐year‐old dummy model for simulating submarining in motor‐vehicle crashes. Med Eng Phys 2012;34(5):541–551. Katari R, Peloso A, Zambon JP et al. Renal bioengineering with scaffolds generated from human kidneys. Nephron Exp Nephrol 2014; 126(2):119. Wong AH‐W, Gang M, Szyld D, and Mahoney H. Making an “attitude adjustment” using a simulation‐ enhanced interprofessional education strategy to improve attitudes toward teamwork and communication. Simulat Healthcare J Soc Simulat Healthcare 2016;11(2):117–125. Arriaga AF, Gawande AA, Raemer DB et al. Pilot testing of a model for insurer‐driven, large‐scale

57

58

59 60

61 62

63

64

65

66

multicenter simulation training for operating room teams. Ann Surg 2014;259(3):403–410. Blum RH, Raemer DB, Carroll JS et al. A method for measuring the effectiveness of simulation‐based team training for improving communication skills. Anesth Analg 2005;100(5):1375–1380. Stevens L‐M, Cooper JB, Raemer DB et al. Educational program in crisis management for cardiac surgery teams including high realism simulation. J Thorac Cardiovasc Surg 2012;144(1):17–24. Satava R. The future of surgical simulation and surgical robotics. Bull Am Coll Surg 2007;92:13–19. American Educational Research Association. Standards for Educational and Psychological Testing. Washington DC: American Educational Research Association, 2014. Miller GE. The assessment of clinical skills/competence/ performance. Acad Med 1990;65 (9 Suppl):S63–S67. Goh AC, Goldfarb DW, Sander JC et al. Global evaluative assessment of robotic skills: validation of a clinical assessment tool to measure robotic surgical skills. J Urol 2012;187:247–252. Yule S, Flin R, Paterson‐Brown S et al. Development of a rating system for surgeons’ non‐technical skills. Med Educ 2006;40:1098–1104. Kowalewski TM, Comstock B, Sweet R et al. Crowd‐ sourcing assessment of technical skills for validation of basic laparoscopic skills tasks. J Urol 2016;195(6): 1859–1865. Plin MR, Siddiqui NY, Comstock BA et al. Crowdsourcing: a valid alternative to expert evaluation of robotic surgery skills. Am J Obstet Gynecol 2016;pii. S0002‐9378(16)30378‐7. ABS. News release. ABS to require ACLS, ATLS and FLS for general surgery Certification. http://www.absurgery.org/default.jsp?news_ newreqs (accessed 30 July 2016).

901

76 Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery Weil R. Lai1 & Benjamin R. Lee2 1 2

Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA Division of Urology, University of Arizona College of Medicine, Tucson, AZ, USA

­Introduction Laparoscopic and robot‐assisted procedures have become the cornerstone of a urologist’s surgical armamentarium over the past two decades. These minimally invasive procedures require additional equipment and operating room setup. Patient and operating room preparation are key features to successful and efficient surgery. It is imperative that the operating room personnel and surgeon are familiar with all equipment systems and proper preparation of equipment. Urology surgical team members also need to be able to troubleshoot unexpected occurrences during a case. Without proper preparation and positioning, patient safety and surgical outcomes may be compromised. In this chapter we describe key features of patient preparation and operating room configuration for common laparoscopic and robotic surgeries.

­Patient preparation Careful patient selection for minimally invasive urologic procedures is critical for successful outcomes. Patient selection begins with a thorough history and physical examination, including attention to cardiopulmonary status and previous abdominal surgeries. Medical and/or cardiovascular clearance may be warranted. Patients with chronic obstructive pulmonary disease require pulmonary clearance, including pulmonary function tests, because of the risk of hypercarbia. Appropriate laboratory data, such as complete blood count, basic metabolic panel, prothrombin time, partial thromboplastin times, and urinalysis with culture should be considered. Radiologic

imaging is helpful for surgical planning. For example, computed tomography (CT) with intravenous contrast is valuable for delineating the renal vascular supply for laparoscopic nephrectomy or partial nephrectomy, or for identifying crossing vessels prior to pyeloplasty. The indications for laparoscopic and robotic urologic procedures are almost identical to those of open surgery. Absolute contraindications to minimally invasive surgery include uncorrectable coagulopathy, abdominal wall infection, massive hemoperitoneum, and generalized peritonitis [1]. Intestinal obstruction was formerly considered an absolute contraindication; however, many general surgeons will perform diagnostic laparoscopy for small bowel obstruction if the bowel is not too dilated. Historically, relative contraindications to minimally invasive surgery included morbid obesity, extensive prior abdominal/pelvic surgery, pelvic fibrosis, organomegaly, ascites, pregnancy, hernias, and iliac or aortic aneurysms. However, in this current day and age laparoscopic and robotic surgery can be safely performed in patients with morbid obesity and previous abdominal surgery with minor technical adaptations. For example, Trocar placement for laparoscopic renal surgery can be shifted laterally for obese patients and the Veress needle can be introduced off site from abdominal scars in patients with previous abdominal incisions during initial insufflation. Pregnancy is no longer considered a contraindication for laparoscopy.

­Informed consent All patients should understand the risks, benefits, and alternatives of the proposed procedure. Complications associated with minimally invasive procedures are

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

902

Section 6  Laparoscopy and Robotic Surgery: General Principles

similar to their open counterparts with the exception of a few unique complications, including CO2 embolism, hypercarbia, postoperative crepitus, and shoulder pain from pneumoperitoneum. Every patient who undergoes a laparoscopic or robotic procedure should understand the potential for conversion to an open procedure and this should be documented in the written consent. Consent for blood products For surgeons who have experience with laparoscopy, blood type and screen can be sufficient for most minimally invasive urologic procedures. Type and cross for 2 units of packed red blood cells is appropriate for more extensive procedures, such as partial nephrectomy and radical cystectomy. We do not recommend preoperative donation of autologous blood prior to robot‐assisted radical prostatectomy because of lower estimated blood loss due to pneumoperitoneal compression of venous blood supply with the laparoscopic approach [2].

­Bowel preparation Preference for bowel preparation varies from surgeon to surgeon. It is our recommendation that patients take a half bottle of magnesium citrate the day before surgery for transperitoneal laparoscopic or robotic renal procedures. Many minimally invasive urologic surgeons do not routinely administer a bowel preparation prior to laparoscopic or robotic renal or prostate surgery. Our preference for bowel preparation prior to robot‐ assisted radical cystectomy is mechanical bowel preparation only with an oral electrolyte solution. We no longer routinely administer antibiotic bowel preparation (i.e. oral neomycin and metronidazole); however, broad‐ spectrum antibiotics are administered intravenously within 60 minutes of incision.

­Operating room setup Operating room setup, experienced nursing staff, and a team approach are keys to a smooth procedure. All operating room personnel should be familiar with the operating room setup and basic equipment function. Minimally invasive procedures require more equipment than standard open procedures; thus, the operating room should be large enough to accommodate the laparoscopic tower and the robotic system. All equipment should be tested prior to each procedure to make sure it is functional, including the aspiration–­ irrigation system, electrocautery, CO2 insufflation, camera,

and light source. If anticipated to be used, the argon beam electrocautery or saline‐enhanced radiofrequency cautery should also be tested prior to partial nephrectomy. Lists of equipment necessary for laparoscopic and robotic renal surgery, as well as robotic pelvic surgery, are given in Boxes 76.1–76.3. An open tray should be either set up or  immediately available in the room in the event rapid ­conversion to open surgery is needed. The room configuration for renal surgery varies from left to right side and from laparoscopic to robotic cases. Aerial diagrams of room setup for laparoscopic transperitoneal renal surgery and robotic pelvic surgery are shown in Figures 76.1–76.3. Most laparoscopic renal surgeries are performed with the surgeon and assistant on the same side of the table. Thus, two video monitors are ideal with the main laparoscopic tower (containing video monitor, light source, camera, and insufflators) placed on the side opposite the surgeons. The CO2 insufflator is placed in the surgeon’s view to allow for continuous monitoring of the intraperitoneal pressure. The second video tower is placed in view of the second assistant and the scrub nurse who are stationed on the side opposite the surgeons along with the instrument table. Incoming lines from the camera, light cord, CO2 insufflation tubing, aspiration–irrigation tubing, and electrosurgical devices enter from the contralateral side of the table or from the head or foot of the table. Additional lines from equipment, such as a Harmonic scalpel, LigaSure (Covidien, Boulder, CO, USA), or argon beam coagulator, should be arranged in an orderly fashion to prevent them from getting tangled during surgery. Pre‐existing or improvised pockets in the  laparoscopic drape can be helpful for organizing equipment.

Box 76.1  Basic equipment for laparoscopic surgical procedures. Mobile video cart with monitor Secondary video cart CO2 insufflator with CO2 tank or wall supply CO2 insufflation tubing Camera, high resolution, and control box 0 and 30° 5‐ or 10 mm laparoscopes Scope warmer High‐intensity light source Fiberoptic light cable Electrosurgical cords Electrosurgical unit with foot pedal (monopolar, LigaSure, HARMONIC, ENSEAL, and/or Thunderbeat) Aspiration–irrigation system with double canister suction apparatus High‐definition video recorder (optional)

76  Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery

During robotic procedures the surgeon console can be positioned in a corner of the operating room, depending on room configuration. In the newer‐generation robotic surgical systems, the optical viewer, arm rest, and foot pedals can be easily adjusted for surgeon comfort. For robotic renal surgery, the assistant is positioned on the

Box 76.2  Equipment for laparoscopic renal surgery. One Veress needle One 5 mm Trocar Two 12 mm Trocars One aspiration–irrigation tubing and probe Two 5 mm laparoscopic atraumatic grasping forceps (blunt) One 45 mm endovascular stapler Two endovascular stapler reloads One 5 mm laparoscopic monopolar scissors

Box 76.3  Equipment for robot‐assisted laparoscopic radical prostatectomy.

Additional equipment for laparoscopic partial nephrectomy Four bulldog clamps with remover Two 5 mm laparoscopic needle drivers One Satinsky clamp Additional 12 or 15 mm Trocar for assistant Laparoscopic ultrasound 0 polyglactin CT‐1 suture FloSeal Hemostatic Matrix (Baxter, Deerfield, IL, USA) Mini‐laparotomy pads Hem‐o‐lok ligation system (Teleflex Medical, Research Triangle Park, NC, USA) Lapra‐Ty absorbable suture clips (Ethicon, Somerville, NJ, USA) 2‐0 polyglactin SH suture Closed suction drain

One Veress needle Four 8 mm robotic Trocars (for da Vinci S, Si, Xi, X) One 12 mm Trocar One 5 mm Trocar One aspiration–irrigation tubing and probe Robotic monopolar scissors Robotic fenestrated bipolar grasper Robotic Prograsp grasper One 5 mm laparoscopic needle driver One 5 mm atraumatic grasping forceps Hem‐o‐lok ligation system (Teleflex Medical, Research Triangle Park, NC, USA) One 2‐0 polyglactin CT‐1 suture cut to 10 inches for dorsal vein stitch One 3‐0 barbed poliglecaprone RB‐1 suture for posterior reconstruction stitch (optional) Two 3‐0 barbed poliglecaprone RB‐1 suture as a “double‐ armed” stitch One 10 mm Endocatch bag One 18 Fr Foley catheter (intraoperative catheter) One 20 Fr Foley catheter (final catheter) Closed suction drain

Additional equipment for robot‐assisted procedures 0 and 30° robot camera lens One robot fenestrated bipolar grasper Two robot large needle drivers (Mega cut, Large needle driver) 8 mm robot Trocars One robot Prograsp grasper One robot monopolar scissors (a)

(b) Anesthesia Anesthesia

Aspiration-irrigation system OR table Camera assistant Surgeon Secondary video monitor

Electrosurgical unit

Aspiration-irrigation system Laparoscopic tower

Scrub nurse

OR table Laparoscopic tower

Surgeon

Scrub nurse

Camera assistant Secondary video monitor

Instrument table

Instrument table

Electrosurgical unit

Figure 76.1  Operating room (OR) setup. (a) Left‐sided laparoscopic transperitoneal renal surgery. (b) Right‐sided laparoscopic transperitoneal renal surgery.

903

Section 6  Laparoscopy and Robotic Surgery: General Principles

(a)

(b) Anesthesia

Instrument table

Anesthesia Nurse

Bedside assistant

Aspiration-irrigation system

OR

ta ble

Laparoscopic tower

ta ble

Robot Aspiration-irrigation system

OR

904

Bedside assistant Electrosurgical unit

Ultrasound Nurse

Instrument table

Electrosurgical unit

Robot

Ultrasound Laparoscopic tower

Robotic console

Robotic console

Figure 76.2  Operating room (OR) setup. (a) Left‐sided robotic transperitoneal renal surgery. (b) Right‐sided robotic transperitoneal renal surgery.

Figure 76.3  Operating room (OR) setup for robotic pelvic surgery.

Anesthesia Aspiration-irrigation system

Instrument table OR table Scrub nurse

Bedside assistant

Laparoscopic tower Robot

Secondary video monitor

Electrosurgical unit

Robotic console

side opposite the surgical site. For robotic pelvic surgery, the authors’ preference is for the bedside assistant to sit or stand on the patient’s right side with the scrub nurse on the patient’s left side. One advantage of having the scrub nurse and assistant on opposite sides of the table is that the scrub nurse can be positioned close enough to the table to actively participate in the surgery, such as during Foley catheter manipulation and for applying perineal pressure. A disposable plastic instrument holder can be secured to the laparoscopic‐assisted vaginal hysterectomy (LAVH) drape next to the bedside assistant for convenient intraoperative storage of fre-

quently used instruments. This helps minimize instrument passage across the patient’s body. Alternatively, a sterile Mayo stand can be positioned next to the bedside assistant as a “mini table” to hold the frequently used instruments. It should be noted that some surgeons prefer the bedside assistant to be located on the patient’s left side, allowing the fourth arm to be placed on the patient’s right side and the two grasping instruments to  be used simultaneously. A second video monitor is helpful for the remainder of the operating room staff. If  laparoscopic ultrasound is used, the screen should be placed within the assistant’s direct line of vision.

76  Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery

Once the robotic and assistant ports are placed, the robot is docked. It is important to align the base of the slave unit with the camera port. This allows for proper docking of the robotic instruments in order to have adequate range of motion and to avoid arm collisions. With the da Vinci Si Surgical System, it is important that the blue arrow on the camera arm be aligned within the “sweet spot” to ensure the slave unit is docked within the correct distance from the operating table to accommodate appropriate range of motion of all instruments. To reduce instrument and robotic arm collisions, the robotic ports are placed at least four fingerbreaths apart from each other, and the elbows of the robotic arms are rotated outwards. With the da Vinci Xi Surgical System, the patient cart is brought over the patient by aligning the laser crosshairs on the boom over the camera port. With the robot arm docked to the camera port and the camera focused on the target anatomy, the autotargeting button on the camera is pressed to rotate the boom to optimize the position of the remaining robot arms. The robot ports are placed at least 6–8 cm apart from each other. To minimize external robot arm collision, we adjust the space between the elbows of each robot arm to accommodate the size of a hand’s fist.

­Patient positioning Laparoscopic renal surgery In traditional open renal surgery, the patient is positioned in flank position in the lateral decubitus position with the kidney rest elevated and the table flexed. In contrast, laparoscopic transperitoneal renal surgery can be effectively performed with the patient in the modified flank position [3] (Figure 76.4). The patient is placed in the supine position with a 4 kg sandbag or gel roll under

Figure 76.4  Patient positioned in modified flank position for laparoscopic and robotic transperitoneal renal surgery.

the ipsilateral side, creating a 30–45° rotation. The bottom leg is slightly flexed at the hip and knee, and the top leg is left straight. Pillows are placed between the legs as a cushion and to slightly elevate the upper leg in line with the torso. The chest and hips are secured to the table with 8 cm silk tape. The ipsilateral arm is then padded and secured in a modified “sling” position, similar to the position used by orthopedics for clavicular fractures. The contralateral arm should be secured to an arm board. All pressure points are padded with egg‐crate foam or gel pads. Neither the kidney rest nor an axillary roll is necessary in this modified flank position. The table is then maximally rotated laterally, thus creating a true 90° angle relative to the horizontal. The lateral rotation of the bed should be tested prior to draping the patient and the anesthesia team should ensure patency of arterial and venous access. This positioning is ergonomic for the patient and surgeon. Positioning for retroperitoneal laparoscopic renal surgery is similar to that for open nephrectomy. The patient is placed in the full lateral position in the center of the table with the table flexed. An axillary roll is placed to prevent brachial plexus injury. Bilateral lower extremity antiembolic stockings and pneumatic compression devices should be in place prior to induction of anesthesia. An upper body and/or lower intraoperative warming device should be placed before the patient is prepped and draped. There is debate about  optimal surgical site preparation and preoperative antibiotics for prevention of incisional infections. A prospective randomized clinical trial comparing chlorhexidine–alcohol to povidone–iodine for surgical site preparation demonstrated a statistically significant reduction in both superficial and deep surgical incisional infections with the use of chlorhexidine–alcohol [4]. The entire abdominal wall should be prepped from the nipples to the pubis. The genitalia should be prepped in the

905

906

Section 6  Laparoscopy and Robotic Surgery: General Principles

field for minimally invasive nephroureterectomy and ureteral reimplant to allow for sterile Foley catheter placement on the field. Antibiotic prophylaxis should be administered within 60 minutes of the surgical incision. The American Urological Association’s best practice policy statement on urologic surgery antibiotic prophylaxis is an excellent resource for selecting specific preoperative antibiotics [5]. Prior to insufflation, an orogastric tube and Foley catheter should be in place in order to decompress the stomach and bladder to avoid inadvertent injury to these hollow viscera. Robotic pelvic surgery

tion with the buttocks at the end of the table break. Prior to induction of anesthesia, compression stockings and sequential compression devices are placed on the patient’s lower extremities. The legs are placed in Allen Yellofin stirrups (Allen Medical Systems, Acton, MA, USA) with the knees flexed. The foot of the table is then lowered until it is perpendicular to the floor. Care should be taken to align the toe, knee, and opposing shoulder, to ensure the heels are touching the heel of the boot, and to check that the calves have adequate space to avoid popliteal artery occlusion, peroneal nerve injury [6], or the devastating complication of lower extremity compartment syndrome [7]. The anesthesiologist should evaluate

For robotic pelvic surgery the patient is ultimately placed in a steep Trendelenburg position with the legs in a low lithotomy position (Figure 76.5). For the da Vinci Xi, we use the split‐leg position (without hyperextension of the hip) as the robot docks from the patient’s side rather than between the legs (Figure 76.6). This position allows gravity to pull the abdominal viscera away from the operative field and the assistant to access the perineum and genitalia intraoperatively. The operating table is prepared with egg‐crate foam taped to the table and a folded sheet placed under the egg‐crate foam to facilitate securing the arms. The friction between the egg‐crate foam and the patient’s skin will help prevent cephalad slippage or movement when the table is in the full Trendelenburg position. Some centers advocate the use of a gel pad instead of egg‐crate foam between the operating table and the patient’s skin because of reports of chafing and skin breakdown. The patient is placed in the supine posi-

Figure 76.5  Patient positioning in low lithotomy with the full Trendelenburg position for robotic pelvic surgery.

Figure 76.6  Patient positioning in split‐leg position for robotic pelvic surgery.

76  Patient Preparation and Operating Room Setup for Laparoscopic and Robotic Surgery

the position of the patient’s head before and after applying the Trendelenburg position in order to monitor for slippage. The arms are tucked at the patient’s side with the preplaced sheet under the gel pad. Alternatively, arm sleds can be utilized to secure the arms without tension; however, excess arm compression can result in temporary neuropraxia. The fingertips are positioned at the anterolateral thigh. The elbows and wrists are protected with gel padding, and small foam rolls are placed in the patient’s hands. Care should be taken to ensure that vascular lines and the pulse oximeter are properly functioning. The arms should be secured low enough for the prepped field to include the area lateral to the anterior superior iliac crest. Obese patients may require an arm board on the side of the table to support the arms. We do not recommend routine use of shoulder straps or taping the shoulders in a harness fashion because of the risk of brachial plexus injury [8, 9]. We recommend using foam‐ wrapped 8 cm cloth tape across the chest to prevent cephalad slippage in obese patients only. Care should be taken to ensure the chest tape does not impede mechanical ventilation. The patient is then prepped and draped from the costal margin to the mid thighs, including the genitalia and perineum. Surgical site preparation and preoperative antibiotic prophylaxis recommendations are the same as for laparoscopic renal surgery. An LAVH drape is useful for robotic pelvic surgery as it is a combination leg and laparoscopic drape. The field is established such that the bedside assistant can have access to the perineum and genitalia for intraoperative application of perineal pressure during initial anastomotic suture placement and for Foley manipulation. An 18 Fr Foley catheter is placed, sterile, on the field and the anesthesia team should place an orogastric tube. After initial insufflation and port placement, the patient should be placed in a steep Trendelenburg position. For the da Vinci Si and earlier‐generation robots, the robot is brought in for docking between the legs. The Allen Yellowfin stirrups should be low enough to accommodate the robot. For the da Vinci Xi robot, our preference is to use the split‐leg position and dock the patient cart to the patient’s side. Once the robot is docked, there should be no additional manipulation of the table position. Positioning pitfalls Suboptimal positioning can not only lengthen operative times and lead to surgeon frustration, but can lead to devastating complications. Despite proper patient positioning and preparation, patient injuries have been reported as a consequence of positioning during laparoscopic and robotic surgeries [6, 10]. Wolf et al. reported

on 1651 procedures that resulted in 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia, extremity sensory deficit, extremity motor deficit, clinical rhabdomyolysis, shoulder contusion, and back spasm. Patients with rhabdomyolysis were more often male, were heavier, and underwent longer procedures. Patients with motor deficits were older. Pre‐­ existing nerve dysfunction predisposes patients to motor nerve injury. It is important for the surgeon to remain comfortable throughout the procedure to avoid pain or fatigue. Interestingly, 28% of surgeons in the 18 academic institutions included in Wolf et  al.’s study reported frequent neck pain and 17% reported frequent shoulder pain [6]. Measures taken by surgeons to alleviate neuromuscular strain included lowering the table maximally, using lifts on the floor, altering the manner in which they held instruments (without fingers through the handles), and altering the position of the monitors. A devastating complication of robotic pelvic surgery is lower extremity compartment syndrome, which can occur when the patient is placed in Allen Yellofin stirrups in the extreme Trendelenburg position. This complication may require lower extremity fasciotomy [7, 11]. Proper positioning is key to prevention, specifically ensuring the patient’s ankle, knee, and contralateral shoulder are aligned in the stirrup, and that gel pads are used directly in contact with the patient’s skin to avoid cephalad slippage while in the Trendelenburg position. A high index of clinical suspicion will facilitate early recognition and prompt treatment. There have been reports of patients developing ischemic optic neuropathy after laparoscopic radical prostatectomy, thought to be a result of a combination of long operative time and the Trendelenburg position [12]. Intraocular pressure measurements in surgical patients confirmed a higher intraocular pressure in patients in the Trendelenburg compared to the supine position [13]. However, the direct clinical consequences of sustained elevated intraoperative intraocular pressures are not known. Positioning for other robotic procedures Other robot‐assisted laparoscopic pelvic surgery

Positioning for a robot‐assisted laparoscopic radical cystectomy and for robot‐assisted ureterovesical reimplant is similar to that for robot‐assisted laparoscopic radical prostatectomy. The only difference is shifting port placement slightly cephalad to allow for proximal ureteral dissection and for extended bilateral pelvic lymphadenectomy. The camera port is placed 2 cm above the umbilicus and the two robotic ports are placed approximately at the level of the inferior border of the umbilicus.

907

908

Section 6  Laparoscopy and Robotic Surgery: General Principles

Transperitoneal robot‐assisted laparoscopic renal surgery

Positioning for robot‐assisted laparoscopic kidney surgery is similar to that for the pure laparoscopic approach. Depending on operating room configuration, the operating table may need to be rotated 90° to accommodate docking the robot. For the da Vinci Si and earlier‐generation robots, the robot is docked at an angle from the ipsilateral side of the table in a direct line between the camera port and the renal hilum. For the da Vinci Xi, the robot is docked perpendicular to the patient’s back, followed by ­adjustments

with the boom to target its position over the camera port as previously described.

­Conclusions Time spent properly setting up the operating room and positioning the patient is invaluable. The entire urologic team should be involved in the process with the goal of optimizing outcomes.

­References 1 Collins S, Lehman DS, McDougall EM et al. AUA

2

3

4

5

6

7

Handbook of Laparoscopic and Robotic Fundamentals. http://www.auanet.org/content/residency/resident‐ education/basiclapguide.pdf. Miller J, Smith A, Kouba E et al. Prospective evaluation of short‐term impact and recovery of health related quality of life in men undergoing robotic assisted laparoscopic radical prostatectomy versus open radical prostatectomy. J Urol 2007;178:854–858. Martin GL, Nunez RN, Martin AD et al. A novel and ergonomic patient position for laparoscopic kidney surgery. Can J Urol 2009;16:4580–4583. Darouiche RO, Wall MJ Jr, Itani KM et al. Chlorhexidine‐ alcohol versus povidone‐iodine for surgical‐site antisepsis. N Engl J Med 2010;362:18–26. Wolf JS Jr, Bennett CJ, Dmochowski RR et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008;179:1379–1390. Wolf JS.Jr, Marcovich R, Gill IS et al. Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery. Urology 2000;55:831–836. Raza A, Byrne D, and Townell N. Lower limb (well leg) compartment syndrome after urological pelvic surgery. J Urol 2004;171:5–11.

8 Romanowski L, Reich H, McGlynn F et al. Brachial

9

10

11

12

13

plexus neuropathies after advanced laparoscopic surgery. Fertil Steril 1993;60:729–732. Phong SV and Koh LK. Anaesthesia for robotic‐assisted radical prostatectomy: considerations for laparoscopy in the Trendelenburg position. Anaesth Intensive Care 2007;35:281–285. Ngamprasertwong P, Phupong V, and Uerpairojkit K. Brachial plexus injury related to improper positioning during general anesthesia. J Anesth 2004;18:132–134. Raman SR and Jamil, Z. Well leg compartment syndrome after robotic prostatectomy: a word of caution. J Robotic Surg 2009;3:105–107. Weber ED, Colyer MH, and Lesser RL, Subramanian, P.S. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Clin Neuroophthalmol 2007;27:285–287. Awad H, Santilli S, Ohr M et al. The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg 2009;109:473–478.

909

77 Patient Preparation and Operating Room Setup for Robotic Surgery Dima Raskolnikov,1 Mahir Maruf , 2 & Arvin K. George 2,3 1

Department of Urology, University of Washington, Seattle, WA, USA Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA 3 Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA 2

­Introduction Since the advent of robotic surgery less than two decades ago, urologists have been on the leading edge of research into this technology’s role in the care of surgical patients. Robotic approaches have now supplanted laparoscopic and even open surgery for many common urological diseases. As the indications and complexity of robotic urological surgery has grown, so too has the body of research describing its relative risks and benefits. Though few randomized trials exist, the common thread among this work is encouraging. Robotic urological surgery is at least as efficacious as the conventional techniques that it complements, often with decreased postoperative pain, less blood loss, faster recovery, shorter hospital stays, and improved cosmesis. Critics of robotic surgery point to higher costs, while other analyses actually suggest potential for substantial cost savings [1]. Additionally, there exists the intangible benefit of improving patient access to minimally invasive surgery not always available with conventional laparoscopy. Much of this work is ongoing, but one thing has become clear: patients who are candidates for robotic surgery pose a unique set of clinical and technical challenges. Knowledge of these factors preoperatively is critical to ensuring the highest likelihood of successful surgical outcomes. The purpose of this chapter is to provide a comprehensive review of patient preparation and operating room setup for robotic urological surgery.

­Patient selection History and physical Many considerations in patient selection for robotic surgery are the same as those for conventional laparoscopic surgery. As with all preoperative consultations, this begins with a thorough history and physical examination. Urologists should pay particular attention to cardiac and pulmonary comorbidities. In all patients, abdominal insufflation with carbon dioxide raises the risk of clinically significant hypercarbia. Patients with chronic obstructive pulmonary disease (COPD) are at particularly high risk. When pneumoperitoneum is combined with steep Trendelenburg positioning for certain pelvic organ access, anesthetic considerations including higher driving pressures for adequate ventilation may arise. Urologists should be similarly cautious in patients with structural cardiac disease. Hypercarbia may be arrhythmogenic in such patients when superimposed on preexisting dysfunction. In patients with these or other concerning comorbidities, preoperative medical consultation for further testing, risk stratification, and medical optimization is reasonable before proceeding with elective surgery. Physical examination in anticipation of robotic surgery is the same as that before any urological surgery. However, one should pay special attention to the presence of surgical scars which may suggest a surgical history that patients have forgotten to disclose. Although some retrospective studies have demonstrated equivalent outcomes in such patients with

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

910

Section 6  Laparoscopy and Robotic Surgery: General Principles

a  history of intra‐abdominal surgery who go on to have open or laparoscopic urological surgery, this may be the  result of appropriate patient selection rather than true  equipoise [2]. Patients with a history of multiple abdominal surgeries may be better served with an open or retroperitoneal approach as indicated. Indications and contraindications The indications for robotic urological surgery are essentially the same as those for the corresponding open or laparoscopic techniques. As the body of comparative research grows, we may soon be able to delineate which patients stand to benefit the most from robotic surgery. In the meantime, the decision is largely a matter of surgeon preference, comfort, technical expertise, and robot availability. There are relatively few absolute contraindications to robotic surgery. These include uncorrectable coagulopathy, significant abdominal wall infections, massive hemoperitoneum, generalized peritonitis, intestinal obstruction unless accompanied by an intention to treat, and suspected malignant ascites. Given that the majority of urological robotic surgeries are performed on an elective basis, these absolute contraindications to robotic surgery would likely be impediments to the corresponding open or laparoscopic alternatives as well. In contrast, robotic surgeons disagree more readily regarding the relative contraindications to robotic surgery. The most well studied of these is obesity. Urologists have traditionally hesitated to offer robotic surgery to morbidly obese patients out of a concern for the physical constraints imposed by a thick body wall. This includes the possibility of inadequate robotic instrument length, a decreased ability to pivot Trocars, and higher pressures required for equivalent pneumoperitoneum. Recent work has validated some of these concerns, with a study of over 1600 robot‐assisted radical prostatectomies demonstrating increased operative time and estimated blood loss in patients with a body mass index (BMI) over 40 kg/ m2 [3]. Garcia‐Roca et al. reviewed their experience with renal transplantation in patients with an even higher BMI cutoff of 45 kg/m2; their group found no difference in patient and graft survival rates [4]. Surprisingly, it remains less clear whether the risk of complications with robotic surgery in obese patients is related to the degree of obesity. Two recent studies of patients undergoing robot‐assisted radical prostatectomy (RARP) demonstrated conflicting results. Khaira et al. found that BMI >30 kg/m2 was associated with longer anastomotic times, but that there was no significant difference in the total duration of surgery or the frequency of postoperative complications [5]. In contrast, Ahlering et al. found that obese men with BMI >30 kg/m2 had more surgical complications and a slower recovery of urinary function, and

required more time to return to baseline activities after RARP [6]. Although obese patients in this study had high levels of preoperative urinary and sexual dysfunction that may have confounded these findings, this serves as an important reminder for urologists to counsel obese patients about their increased surgical risk, even when the surgery is performed robotically. Other relative contraindications to a robotic approach include pelvic fibrosis, organomegaly, large‐volume ascites, hernias, vascular aneurysms, and pregnancy. The last of these is controversial, with some arguing that robotic surgery may still be performed safely in pregnant women. O’Connor et  al. reported performing laparoscopic nephrectomy in a pregnant woman, which has now been replicated robotically by Ramirez et al. [7, 8]. When urologists have access to a multidisciplinary team including specialists in obstetrics, anesthesia, and high‐ risk maternal fetal medicine, gravid women may be reasonably counseled about the risks and benefits of undergoing robotic urological surgery. Further research is necessary to precisely delineate the risks and benefits of robotic urological surgery in this high‐risk group. Irrespective of the presence of relative contraindications to a robotic approach, all patients should be counseled preoperatively about the risk of conversion to an open procedure. Contemporary analyses suggest that this risk is somewhere between 1 and 3% in case series of robotic nephrectomy and prostatectomy, as an example [9, 10]. The conversion rate may be elevated for high‐risk patients and those surgeries done at low‐volume centers, although retrospective studies are likely affected by patient selection, with high‐risk patients encouraged to undergo forego robotic surgery, thus lowering the resulting conversion rate [9].

­Patient preparation Urological and general surgery have both seen recent paradigm shifts in the management of anticipated postoperative ileus. Whereas extensive bowel preparations preoperatively and prolonged bowel rest postoperatively have long been the norm, both conventions are now being questioned. In one large study of over 700 men undergoing radical prostatectomy with or without preoperative mechanical bowel preparation, Sugihara et al. found no difference between the two groups with respect to overall complications, operative time, length of stay, and total costs [11, 12]. Perhaps even more convincingly, Ramirez et al. performed a systematic review to describe the incidence of postoperative ileus in patients after radical cystectomy with all types of urinary diversion [13]. Not only did mechanical bowel preparation fail to prevent postoperative ileus, but in many studies was in fact

77  Patient Preparation and Operating Room Setup for Robotic Surgery

associated with a prolonged time to first bowel movement [13]. Although practice patterns continue to vary, such data have been used to guide the continued refinement of early recovery care pathways for patients undergoing urological surgery [14]. Other components of preoperative preparation are either less standardized or have not yet been studied rigorously. Most urologists elect to type and screen patients preoperatively, rather than to crossmatch for blood. Studies of robot‐assisted partial nephrectomy versus open nephrectomy have demonstrated lower transfusion rates for the robotic cohort [15]. Similar data exist for large studies of patients undergoing robot‐assisted radical prostatectomy, who require fewer transfusions than do those who undergo open surgery [16]. Additional preoperative preparation is largely driven by individual patient needs. The American Urological Association (AUA) has issued a comprehensive best practice policy statement on perioperative antimicrobial prophylaxis, and should be used to guide decision making for robotic surgery as well [17].

­Operating room Robotic surgical system components and physical setup The physical layout of operating rooms used for robotic urological surgery varies. However, adherence to certain key principles is necessary to ensure optimal patient (a)

(b)

outcomes and to minimize costly operative time. First, the room size itself may become rate‐limiting; operating rooms used for robotic surgery must not only accommodate a large amount of additional equipment, but be large enough to facilitate variable patient positioning and the movement of robotic components. The robotic surgery platform that is currently in widespread use is the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA, USA). This system is composed of three main components: the patient‐side cart (robotic tower), the surgeon console, and the vision system (Figure 77.1). The patient‐ side cart is the operative component or “slave” unit of the system which contains robotic arms that hold the Endowrist instruments that are used to perform surgery. The surgeon console consists of the stereo viewer that integrates the imaging of the surgical field acquired by the endoscopy, the master controller by which the surgeon can manipulate the surgical instruments, and foot pedals which control camera movement, robotic arm selection, and energy delivery. Additionally, a central touchscreen control panel allows for management of various functions. The vision system houses the image processing equipment, light source, insufflator, and electrosurgical unit, along with a monitor and various minor components. The specific positioning of these components depends on the constraints of individual operating rooms, as well as patient positioning for the procedure in question. The introduction of the da Vinci Xi system allows for flexibility in operating room setup as the new device enables improved anatomic access regardless of

(c)

Figure 77.1  (a) da Vinci Xi vision cart, (b) surgeon console, and (c) patient‐side cart. Source: Intuitive Surgical, Inc., Calfiornia, USA. Reproduced with permission of Intuitive Surgical, Inc.

911

912

Section 6  Laparoscopy and Robotic Surgery: General Principles

patient‐side cart position and allows the endoscope to be placed via any surgical port. Longitudinal studies suggest that the presence of ancillary staff who are familiar with and can efficiently troubleshoot the robotic surgery equipment is critical to success [18]. Lastly, but importantly, all operating rooms equipped for robotic surgery should have a complement of open instruments either open or immediately available, should the need for them arise. A complete list of suggested basic equipment for robotic surgery is provided in Box 77.1.

Box 77.1  Basic equipment for robotic surgical procedures. Surgeon console Patient‐side cart Mobile video cart with monitora Camera, high‐resolution, and control boxa High‐intensity light sourcea Electrosurgical unita CO2 insufflatora with CO2 tank or wall supply Secondary video cart/monitor CO2 insufflation tubing 0 and 30° camera lens Scope warmer Fiber‐optic light cable Electrosurgical cords Aspiration–irrigation system with double canister suction apparatus High‐capacity media recorder (optional) Veress needle 12 mm Trocarb Three 8 mm robotic Trocarsc (for da Vinci S, Si, Xi, or fourth arm) 5 mm Trocar (optional assistant) Aspiration–irrigation tubing and probe Robotic monopolar scissors Robotic bipolar Maryland grasper Robotic prograsp Robotic fenestrated bipolar electrocautery (optional) Robotic Harmonic scalpel (optional) 5 mm atraumatic grasping forceps Laparoscopic needle driver Laparoscopic scissors Hem‐o‐lok ligation system (Teleflex Medical, Research Triangle Park, NC, USA) 10 mm titanium clip applier (optional) a

 Components housed in the vision system.  For Xi system, 12 mm Trocar is used as assistant port. For earlier systems, an additional Trocar is used as camera port. c  For Xi system an additional robotic Trocar is used as a camera port. b

Patient positioning: general concepts As with all types of surgery, patient positioning for robotic urological surgery is largely predicated on the anatomical site in question; preparation and positioning for flank surgery is inherently different from pelvic surgery. However, certain principles are universal. Patients should be positioned in ways that maximize access for robotic instruments, are ergonomic for the assistant, and minimize the likelihood of positioning‐related complications. Primary considerations in positioning include individual surgeon preference, surgical approach (transperitoneal vs. retroperitoneoscopic), laterality, and organ of interest. Patient positioning: retroperitoneal kidney For retroperitoneal surgery in the upper abdomen, the patient is placed in the lateral decubitus position, with the site of interest easily accessible. The patient’s bottom leg is flexed, the upper leg straight, and all pressure points are padded with pillows, foam, and typically an axillary roll. The table is flexed to increase the distance between the 12th rib and the iliac crest, maximizing access to the flank. Following port placement, the assistant remains facing the front of the patient. The robot patient‐side cart is then docked on the contralateral side (i.e. the patient’s back), or from the side of the patient’s head (Figure 77.2). Patient positioning: transperitoneal kidney For transperitoneal surgery in the upper abdomen, a modified lateral decubitus position is used (Figure 77.3). The robot is docked from the table’s contralateral side (Figure  77.4). This maximizes the assistant’s mobility while minimizing interference from the robotic arms. Patient positioning: pelvic Lastly, for pelvic surgery, the patient is placed in the Trendelenburg position, either supine (da Vinci Xi) or with the legs either on split‐leg positioners or in stirrups (da Vinci Si) (Figure 77.5). The additional mobility and rotational capability of the Xi patient‐side cart allows for positioning at the patient’s side. However with the Si, the patient‐side cart is docked between the patient’s legs, allowing the assistant to stand on either side (Figure  77.6). The addition of auxiliary video monitors provides flexibility in the location of the bedside assistant, can limit the necessity of moving the vision tower for different procedures, and provide a view of the procedure for the scrub assistant throughout the case.

77  Patient Preparation and Operating Room Setup for Robotic Surgery

Figure 77.2  Patient positioning for left retroperitoneoscopic upper tract surgery. Surgeon console (1), robotic tower (2), patient‐side cart (3), bedside assistant (4), scrub assistant (5), anesthesia (6). Source: Intuitive Surgical, Inc., Calfiornia, USA. Reproduced with permission of Intuitive Surgical, Inc.

6

3 1

4

2

5

Figure 77.3  Modified lateral decubitus position used for robotic transperitoneal renal surgery.

Complications Failure of the da Vinci system itself is quite rare, and likely becoming even more so as surgeon and engineering experience grows. In a single institution study of 1797 procedures performed with the early da Vinci S system from 2005 to 2008, there were 43 cases of mechanical failure (2.4%). However, these required that only three cases (0.17%) be converted to open or laparoscopic approaches [19]. In a larger study of 11 high‐volume

institutions performing over 8000 robotic cases, the rate of critical failure causing either conversion or case cancellation was 0.4% [20]. While such events are clearly problematic and reinforce the need for appropriate preoperative patient counseling, they are exceedingly rare and often outside of the surgeon’s purview. In contrast, urologists must remain constantly vigilant of the pitfalls of positioning when preparing patients for robotic surgery. These dangers are similar to those seen with other types of surgery. However, because robotic surgery often prolongs operative time, patients are exposed to these dangers to a greater degree. For example, the use of stirrups is associated with popliteal artery occlusion, peroneal nerve injury, and even lower‐ extremity compartment syndrome. In one study of 17 high‐volume centers performing RARPs in the United Kingdom between 2004 and 2011, lower‐extremity compartment syndrome was diagnosed following nine of 3110 procedures, for an incidence of 0.29% [21]. Although this rate is low, seven of nine patients went on to require lower extremity fasciotomy. The authors identified console time over 4 hours, early surgeon learning curve with fewer than 20 robotic cases, BMI >30 kg/m2, and peripheral vascular disease as risk factors [21]. Although some of these risk factors are not easily modifiable, this study serves as an important reminder for the surgeon to check all aspects of positioning before beginning a case.

913

914

Section 6  Laparoscopy and Robotic Surgery: General Principles

(a)

(b) 6

6

1

2 1

4

2 4 3 3

5

5

Figure 77.4  Patient positioning for left (a) and right (b) transperitoneal renal surgery. Surgeon console (1), robotic tower (2), patient‐side cart (3), bedside assistant (4), scrub assistant (5), anesthesia (6). Source: Intuitive Surgical, Inc., Calfiornia, USA. Reproduced with permission of Intuitive Surgical, Inc.

Figure 77.5  Patient positioning in low lithotomy with legs in stirrups for pelvic surgery.

Similar risks exist to a patient’s upper extremities. Older laparoscopic literature suggests that patients may be at risk of abdominal wall neuralgias, injuries to peripheral nerves, and musculoskeletal injury [22]. These same risks would be expected for robotic approaches to urological surgery, given the similarities in positioning. Case reports have now emerged of neurological injury following robotic surgery. In one study, Devarajan et al. identified three patients with upper and middle brachial plexus trunk injury following RARP [23].

The authors theorized that positioning in steep Trendelenburg caused abnormal distraction forces on the abducted arm, which over several hours led to brachial plexus neuropathy [23]. Echoing similar research described above, the authors argued for particular caution in patients who undergo cases with a prolonged operative time. An additional complication that is thought to be related to positioning in steep Trendelenburg is the development of ischemic optic neuropathy (ION). This phenomenon was described by Weber et  al. after two patients developed postoperative ION following laparoscopic radical prostatectomy. The authors theorized that this complication was due to venous stasis and facial edema caused by a prolonged surgical time with the head of the bed down [24]. Alarmingly, similar findings and even complete postoperative visual loss have now been reported after robotic pelvic surgery [25]. To clarify this relationship, Wen et al. used a national database to identify positioning‐related complications in patients following robotic or conventional laparoscopic radical prostatectomy [26]. Although ocular complications contributed the most to the overall cohort’s complication rate of 0.4%, the authors found that robotic surgery was associated with a decreased risk as compared to conventional laparoscopy [26]. Further research is clearly necessary to delineate risk factors such that urologists may take pre‐emptive steps to minimize the likelihood of positioning‐related complications.

77  Patient Preparation and Operating Room Setup for Robotic Surgery

Figure 77.6  Patient positioning for pelvic surgery. Surgeon console (1), robotic tower (2), patient‐side cart (3), bedside assistant (4), scrub assistant (5), anesthesia (6). Source: Intuitive Surgical, Inc., Calfiornia, USA. Reproduced with permission of Intuitive Surgical, Inc.

6

1

4

2

5

3

­Conclusion Robotic surgery is becoming an increasingly important part of the urologist’s armamentarium, with robotic techniques emerging as the standard of care throughout the scope of urological practice. However, this development requires caution. Success in robotic surgery requires extensive preparation on the part of

the patient, urologist, and operating room team. Although existing work has begun to clarify some of these issues, further research is necessary to continually improve perioperative care. Such work will ensure that robotic surgery performed by urologists in the future will be done even more safely and effectively than today. Review accompanying Video 77.1.

­References 1 Bijlani A, Hebert AE, Davitian M et al. A

2

3

4

5

multidimensional analysis of prostate surgery costs in the United States: robotic‐assisted versus retropubic radical prostatectomy. Value Health 2016;19(4):391–403. Parsons JK, Jarrett TJ, Chow GK, and Kavoussi LR. The effect of previous abdominal surgery on urological laparoscopy. J Urol 2002;168(6):2387–2390. Agrawal V, Feng C, and Joseph J. Outcomes of extraperitoneal robot‐assisted radical prostatectomy in the morbidly obese: a propensity score‐matched study. J Endourol 2015;29(6):677–682. Garcia‐Roca R, Garcia‐Aroz S, Tzvetanov I et al. Single center experience with robotic kidney transplantation for recipients with BMI of 40 kg/m2 or greater: a comparison with the UNOS Registry. Transplantation 2017;101(1):191–196. Khaira HS, Bruyere F, O’Malley PJ et al. Does obesity influence the operative course or complications of

6

7

8

9

10

robot‐assisted laparoscopic prostatectomy. BJU Int 2006;98(6):1275–1278. Ahlering TE, Eichel L, Edwards R, and Skarecky DW. Impact of obesity on clinical outcomes in robotic prostatectomy. Urology 2005;65(4):740–744. O’Connor J, Biyani C, Taylor J et al. Laparoscopic nephrectomy for renal‐cell carcinoma during pregnancy. J Endourol 2004;18(9):871–874. Ramirez D, Maurice MJ, Seager C, and Haber G‐P. Robotic partial nephrectomy during pregnancy: case report and special considerations. Urology 2016;92(4):1–5. Weiner AB, Murthy P, Richards KA et al. Population based analysis of incidence and predictors of open conversion during minimally invasive radical prostatectomy. J Urol 2015;193(3):826–831. Autorino R, Zargar H, Mariano MB et al. Perioperative outcomes of robotic and laparoscopic simple

915

916

Section 6  Laparoscopy and Robotic Surgery: General Principles

11

12

13

14

15

16

17

18

prostatectomy: a European‐American multi‐ institutional analysis. Eur Urol 2015;68(1):86–94. Sugihara T, Yasunaga H, Horiguchi H et al. Does mechanical bowel preparation improve quality of laparoscopic nephrectomy? Propensity score‐matched analysis in Japanese Series. Urology 2013;81(1):74–79. Sugihara T, Yasunaga H, Horiguchi H et al. Is mechanical bowel preparation in laparoscopic radical prostatectomy beneficial? An analysis of a Japanese national database. BJU Int 2013;112(2):76–81. Ramirez JA, McIntosh AG, Strehlow R et al. Definition, incidence, risk factors, and prevention of paralytic ileus following radical cystectomy: a systematic review. Eur Urol 2013;64(4):588–597. Cerantola Y, Valerio M, Persson B et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced recovery after surgery (ERAS??) society recommendations. Clin Nutr 2013;32(6):879–887. Xia L, Wang X, Xu T, and Guzzo TJ. Systematic review and meta‐analysis of comparative studies reporting perioperative outcomes of robot‐assisted partial nephrectomy versus open partial nephrectomy. J Endourol 2017;31(9):893–909. Stolzenburg JU, Kyriazis I, Fahlenbrach C et al. National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany. World J Urol 2016;32(3):1357. American Urological Association. Best Practice Policy. Statement on urologic surgery antimicrobial prophylaxis. Linthicum, MD: American Urological Association, 2008. Ou Y‐C, Yang C‐K, Chang K‐S et al. Prevention and management of complications during robotic‐assisted

19

20

21

22

23

24

25 26

laparoscopic radical prostatectomy following comprehensive planning: a large series involving a single surgeon. Anticancer Res 2016;36(4):1991–1998. Kim WT, Ham WS, Jeong W et al. Failure and malfunction of da Vinci Surgical Systems during various robotic surgeries: experience from six departments at a single institute. Urology 2009;74(6):1234–1237. Lavery HJ, Thaly R, Albala D et al. Robotic equipment malfunction during robotic prostatectomy: a multi‐institutional study. J Endourol 2008;22(9):2165–2168. Pridgeon S, Bishop CV, and Adshead J. Lower limb compartment syndrome as a complication of robot‐ assisted radical prostatectomy: the UK experience. BJU Int 2013;112(4):485–8. Wolf JS, Marcovich R, Gill IS et al. Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery. Urology 2000;55(6):831–836. Devarajan J, Byrd JB, Gong MC et al. Upper and middle trunk brachial plexopathy after robotic prostatectomy. Anesthesia Analgesia 2012;115(4):867–870. Weber ED, Colyer MH, Lesser RL, and Subramanian PS. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Neuro‐Ophthalmol 2007;27(4):285–287. Olympio MA. Postoperative visual loss after robotic pelvic surgery. BJU Int 2013;112(8):1060–1061. Wen T, Deibert CM, Siringo FS, and Spencer BA. Positioning‐related complications of minimally invasive radical prostatectomies. J Endourol 2014;28(6):660–667.

917

78 Physiologic Considerations in Laparoscopic and Robotic Surgery Adam G. Kaplan & Michael N. Ferrandino Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA

­Introduction Laparoscopic and robotic surgery challenge the patient with unique physiologic stresses. These stresses are ­primarily due to abdominal insufflation, but may be due to positioning requirements. Pneumoperitoneum, the result of abdominal insufflation, is considered necessary for visualization of the target organs, and may be maintained for prolonged periods of time. This can result in physiologic disturbances both during and after surgery as a result of increased abdominal pressure and absorption of the insufflated gas. The introduction of laparoscopic cholecystectomy in 1990 and laparoscopic nephrectomy in 1991 proved ­pivotal for the future of laparoscopy, as for the first time solid organs could be removed with laparoscopic instrumentation [1, 2]. Following these advances, two major changes occurred in the field of laparoscopic surgery: first, the complexity and – consequently – the duration of minimally invasive surgical cases increased dramatically. Second, the patients selected for laparoscopic and  robotic surgery covered an increasingly broader ­spectrum of disease states, with many patients having underlying cardiac and pulmonary comorbidities. As a result, the minimally invasive surgeon today must give significant consideration to the physiologic impact of prolonged pneumoperitoneum. While most patients tolerate the physiologic changes associated with l­ aparoscopy well, there are occasional life‐threatening complications as a result of the physiologic reaction to the laparoscopic environment. Pneumoperitoneum and patient positioning required for laparoscopy have several well‐understood physiologic effects which will be reviewed extensively in this

chapter, along with the complications of pneumoperitoneum and consideration of methods of altering pneumoperitoneum that mitigate certain unwanted side effects.

­Impact of patient positioning A number of patient positions are used during laparoscopy to more easily target the organ of interest. In urology, the lateral position is commonly used for upper urinary tract and retroperitoneal procedures; this position has little effect on hemodynamics unless there is extreme flexion or improper use of the kidney rest such that the vena cava is compressed, wherein venous return to the heart can be reduced [3]. The lateral position can lead to ventilation–perfusion mismatch and changes to pulmonary compliance for the dependent lung, as well as over‐inflation and potential barotrauma to the nondependent lung. During upper abdominal surgery, which is uncommon for urologic procedures, the patient can be placed head up (reverse Trendelenburg) to drop the bowel away. In most cases, this position demonstrates improved pulmonary mechanics [4–6]. However, this position also decreases cardiac output [7, 8] and can lead to profound hypotension and cerebral hypoperfusion, particularly in patients with pre‐existing dysfunction of cerebral autoregulatory mechanisms, such as those with chronic hypertension, history of cerebrovascular accident, or carotid occlusive disease. A position more commonly used by the urologist is Trendelenburg (head down), which can facilitate pelvic, lower urinary tract surgery such as radical

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

918

Section 6  Laparoscopy and Robotic Surgery: General Principles

prostatectomy. This position increases cardiac output modestly [9–12]. Additionally, it restricts diaphragmatic movement and increases ventilation–perfusion mismatch [5, 13, 14]. As one might expect, the effects  on cardiovascular and respiratory physiology are stronger with steeper head‐down angles [15]. Table 78.1 compares the cardiovascular effects of the head‐up and head‐down positions.

­ he gaseous medium: carbon dioxide T and other insufflation agents Today, the vast majority of laparoscopic and robotic cases are performed with carbon dioxide (CO2) pneumoperitoneum. During the development of laparoscopy, the early cases were performed using oxygen and room air for insufflation [16]. These proved to be dangerous and quickly abandoned due to the significant potential for venous air embolism, intra‐abdominal explosion, and combustion. Carbon dioxide was selected as it met a number of important criteria for the ideal gas for insufflation: it is readily available, inexpensive, non‐ combustible, rapidly soluble in plasma, and removed via respiration [17]. Due to the favorable properties of CO2, it was adopted quickly. The rapid absorption of CO2 decreased the chance of postoperative abdominal distention, and lowered the probability of developing a gas embolism. These same properties have dangers as well: they can lead to hypercapnia, hypercarbia, and cardiac dysrhythmia. While these sequelae are typically self‐limiting, they can be problematic for patients with poor cardiopulmonary function and those with chronic obstructive pulmonary disease, as the minute ventilation may not be able to be increased sufficiently to compensate for the increased CO2 absorption. Other insufflation agents such as nitrogen dioxide (N2O) and helium are possible alternatives in the select patient. While N2O came into favor in the 1970s and 1980s due to low cost, decreased peritoneal irritation, and fewer Table 78.1  Effects of patient position on hemodynamic parameters compared to the supine position.

cardiovascular adverse effects compared to CO2, case reports of intraoperative explosions due to its combustibility severely limited its use in the therapeutic setting [18–21]. In fact, it should be limited to cases where electrosurgical equipment is not needed. Helium, in contrast, is both inert and noncombustible. Rademaker et al. demonstrated favorable effects of helium on atrial partial pressure without hypercarbia or acidosis in a porcine model [22]. Helium insufflation may be useful in select patients with pulmonary disease who would not tolerate the hypercarbia associated with CO2 insufflation [23]. The main drawback of helium is its low blood solubility, which may portend to a higher risk of gas embolism [24]. Considering the widespread, nearly exclusive use of CO2 insufflation for laparoscopic procedures, the remainder of the chapter will focus on pneumoperitoneum with CO2.

­ hysiologic organ changes caused P by insufflation with carbon dioxide Effect on the lungs Pulmonary physiology is affected by a number of aspects during laparoscopic surgery. Patient size and the existence of underlying pulmonary pathophysiology certainly affect how the patient will respond to insufflation. The mechanical effects of pneumoperitoneum and the absorption of CO2, however, are the main drivers of the physiologic changes seen during laparoscopy (Table 78.2). As pneumoperitoneum increases the intra‐abdominal pressure (IAP), it exerts a mechanical limitation to excursion of the diaphragm. This limitation results in decreased lung capacity and compliance, with eventual ventilation–perfusion mismatch and shunting [25, 26]. Consequently, there is an overall decrease in vital capacity, functional residual capacity, total lung volume, and Table 78.2  Respiratory effects of laparoscopy with intra‐ abdominal pressure of 10–20 mmHg. Respiratory parameter

Change

Chest wall mechanical resistance

↑

Hemodynamic parameter

Head up

Head down

Peak inspiratory pressure

↑

Pulmonary compliance

↓

Heart rate

↑

↓

Alveolar dead space

↔ or ↑

Mean arterial pressure

↓

↑

Functional reserve capacity

↓

Systemic vascular resistance

↑

↓

Forced vital capacity

↓

Cardiac output

↓

↑

FEV1

↓

Intracranial pressure

↓

↑

Peak expiratory flow

↓

78  Physiologic Considerations in Laparoscopic and Robotic Surgery

pulmonary compliance, alongside increases in peak inspiratory pressure [4, 5, 27]. These changes are exacerbated by obesity or other causes of pre‐existing atelectasis and decreased lung volumes [4, 28]. Carbon dioxide has many properties, including its rapid solubility and quick absorption into the circulation, making it the ideal gas for insufflation. As such, it  must be eliminated efficiently by the lungs. While ­normal CO2 production in the average adult ranges from 150 to 200 ml/min [29, 30], the rate of CO2 absorption during laparoscopy is 14–48  ml/min [31–33]. Adjustments must be made in minute ventilation by either increasing tidal volume or respiratory rate to mitigate the effects of increased blood levels of CO2. If not corrected for, hypercarbia can lead to respiratory acidosis, which can depress cardiac function and cause arrhythmia. Subcutaneous emphysema, increased IAP, extraperitoneal insufflation, and prolonged surgery can also increase the rate of CO2 absorption [34]. The minimally invasive surgeon must be aware of the compounding effects of CO2 absorption over time, and how they can linger in the postoperative period. In a prospective study of changes in end‐tidal CO2 for healthy patients undergoing laparoscopic cholecystectomy, Meftahuzzaman et  al. showed that significant alteration occurs 40 minutes after insufflation during cholecystectomy [35]. Many urologic cases can extend well past this period of time, and close monitoring of end‐tidal CO2 is imperative. Additionally, some degree of CO2 is also sequestered in the skeletal system, which is the largest reservoir in the body, and it is eliminated slowly in the postoperative period. This can be particularly problematic for patients with pre‐existing cardiopulmonary dysfunction, and these patients must be monitored closely [36]. Effect on the heart and hemodynamics Several hemodynamic effects are seen as a result of increased IAP, including decreased cardiac output, increased mean arterial pressures (MAP), increased systemic vascular resistance (SVR), and increased pulmonary vascular resistance (Table 78.3). At low insufflation Table 78.3  Hemodynamic effects of laparoscopy with intra‐ abdominal pressure of 10–20 mmHg. Hemodynamic parameter

Change

Central venous pressure

↑

Systemic vascular resistance

↑

Heart rate

↑

Mean arterial pressure

↑

Cardiac output

↓

pressures (30 kg/m2, continues to increase in prevalence in the United States, now affecting over 30% of patients. Laparoscopy and robotic surgery may be more suitable than open surgery for many of these patients, but they carry unique risks and physiologic challenges from pneumoperitoneum. These patients tend to have a host of other comorbidities including diabetes mellitus, hypertension, hypercholesterolemia, arthritis, and asthma [92]. Obesity impacts respiratory mechanics, such that morbidly obese patients have reduced functional residual capacity, lower chest wall compliance, and ­ increased carbon dioxide production at baseline [27, 28]. Pneumoperitoneum will reduce compliance to a greater degree in obese patients compared with normal‐weight control subjects. Obese patients required 15% higher minute ventilation to maintain normocarbia in the supine position. Interestingly, changing to a Trendelenburg position had little impact on overall outcome, suggesting that obese patients who tolerate the induction of anesthesia and pneumoperitoneum in the supine position will likely tolerate the Trendelenburg position [27, 28]. This paradoxical finding was thought to be due the mechanical effects of pneumoperitoneum, which opposed the gravitational shift of abdominal contents. A “tilt test” has been found to be helpful in many cases. Once the patient is intubated and positioned, the patient can be placed in a steep Trendelenburg for 2–5 minutes and the cardiac and respiratory status can be monitored. If tolerated, meaning the patient remains normotensive with inspiratory pressures at  30–40 mmHg, the abdo-

men can then be insufflated and monitored. If the patient continues to tolerate insufflation, they are likely to tolerate the remainder of the laparoscopic procedure [93].

­Modifying pneumoperitoneum A number of modifications to standard CO2 pneumoperitoneum have been investigated, in the hope of mitigating the adverse effects of increased IAP and the absorption of insufflant. Low‐pressure or gasless laparoscopy has been extensively investigated, and there are now commercially available abdominal wall elevators that are secured to the operating table (Laparolift, Origin Medsystems, Menlo Park, CA, USA). A number of different devices were created and employed to do a similar task: elevate the anterior abdominal wall away from the intra‐abdominal organs, thereby creating a working space and eliminating the need for insufflation. This has allowed for completion of numerous laparoscopic procedures at pneumoperitoneum pressures down to 4 mmHg, which may be preferable for patients who would otherwise be unable to tolerate increased IAPs or hypercapnia [94–96]. These wall‐lifting methods have been shown to reduce stress response compared to standard pneumoperitoneum [97]. They have proven to be safe, to preserve pulmonary function, and in some cases decrease hospital stay [98]. While the low‐pressure environment certainly limits surgeon comfort, it has been shown to decrease postoperative pain [99]. Others have looked at altering the temperature of the gaseous medium but reports on the physiologic benefits are mixed. A study compared insufflation with warm CO2 to insufflation with CO2 at room temperature, finding that warm CO2 lead to higher core temperatures, increased urine output, and increased cardiac index [100]. This is thought to be due to regional vasodilatation of the renal vasculature which restores both renal blood flow and urine output. These improvements can be of particular benefit to those patients with renal dysfunction. Fluid management becomes more predictable with more reliable urine output Other perceived benefits of warmed and humidified insufflant have not panned out. While one multicenter double‐blind study randomized controlled trial showed no attenuation of the early inflammatory cytokine response [101], another study of patients undergoing laparoscopic cholecystectomy with warmed versus room temperature insufflation showed improvement in core temperature by 0.32 °C, but no major clinically relevant differences were seen [102]. In fact, a Cochrane review of the subject concluded that heated gas insufflation, with or without humidification, has minimal benefit on patient outcomes [103].

78  Physiologic Considerations in Laparoscopic and Robotic Surgery

AirSeal® (Surgiquest, CT, USA) is a novel valve‐free and membrane‐free insufflation and Trocar system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. It responds immediately to slight changes in IAP, and may be associated with reduced CO2 use and absorption. Horstmann et  al. prospectively compared the AirSeal Trocar system to a standard Versaport Plus V2 Trocar for assisting robotic radical prostatectomy. While there was no significant decrease in operative time, blood loss, camera cleaning, or overall CO2 consumption, the AirSeal Trocar provided a more stable pneumoperitoneum with only one episode of pressure loss during 19 cases, as compared to 38 pressure‐loss episodes in 17 cases performed with the standard port [104]. Further clinical studies are underway to characterize the potential benefits of the system [105].

­Conclusion The physiologic effects of laparoscopy and robotic surgery are the result of patient positioning and the effects of insufflation of the abdomen. Pneumoperitoneum is most frequently created with carbon dioxide gas, as it is  inexpensive, colorless, odorless, non‐flammable, and rapidly eliminated from systemic circulation. It creates a number of physiologic challenges due to increased IAP  and the absorption of CO2, for the cardiovascular, ­pulmonary, renal, brain, and endocrine systems. Complications such as subcutaneous emphysema, cardiac arrhythmia, and gas embolism may arise. In addition, special considerations for the obese patient and those with cardiopulmonary compromise must be made. While studies to improve laparoscopy and the effects of pneumoperitoneum continue, the effects of pneumoperitoneum are generally well tolerated.

­References 1 Dubois F, Icard P, Berthelot G, and Levard H.

2

3

4

5

6

7

8

Coelioscopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 1990;211(1):60. Clayman RV, Kavoussi LR, McDougall EM et al. Laparoscopic nephrectomy: a review of 16 cases. Surg Laparosc Endosc 1992;2(1):29–34. Lawson N. The lateral decubitus position. In: Positioning in Anesthesia and Surgery, 2e (ed. J Martin), 155. Philadelphia: WB Saunders, 1987. Casati A, Comotti L, Tommasino C et al. Effects of pneumoperitoneum and reverse Trendelenburg position on cardiopulmonary function in morbidly obese patients receiving laparoscopic gastric banding. J Anaesthesiol 2000;17(5):300–305. Rauh R, Hemmerling TM, Rist M, and Jacobi KE. Influence of pneumoperitoneum and patient positioning on respiratory system compliance. J Clin Anesth 2001;13(5):361–365. Salihoglu Z, Demiroluk S, and Dikmen Y. Respiratory mechanics in morbid obese patients with chronic obstructive pulmonary disease and hypertension during pneumoperitoneum. Eur J Anaesthesiol 2003;20(8):658–661. Cunningham AJ, Turner J, Rosenbaum S, and Rafferty T. Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br J Anaesth 1993;70(6):621–625. Hirvonen EA, Poikolainen EO, Pääkkönen ME, and Nuutinen LS. The adverse hemodynamic effects of anesthesia, head‐up tilt, and carbon dioxide

pneumoperitoneum during laparoscopic cholecystectomy. Surg Endosc 2000;14(3):272–277. 9 Sibbald WJ, Paterson NA, Holliday RL, and Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med 1979;7(5):218–224. 10 Reich DL, Konstadt SN, Raissi S et al. Trendelenburg position and passive leg raising do not significantly improve cardiopulmonary performance in the anesthetized patient with coronary artery disease. Crit Care Med 1989;17(4):313–317. 11 Torrielli R, Cesarini M, Winnock S et al. [Hemodynamic changes during celioscopy: a study carried out using thoracic electric bioimpedance]. Can J Anaesth 1990;37(1):46–51. 12 Johannsen G, Andersen M, and Juhl B. The effect of general anaesthesia on the haemodynamic events during laparoscopy with CO2–insufflation. Acta Anaesthesiol Scand 1989;33(2):132–136. 13 Fahy BG, Barnas GM, Flowers JL et al. The effects of increased abdominal pressure on lung and chest wall mechanics during laparoscopic surgery. Anesth Analg 1995;81(4):744–750. 14 Mäkinen MT and Yli‐Hankala A. Respiratory compliance during laparoscopic hiatal and inguinal hernia repair. Can J Anaesth 1998;45(9):865–870. 15 Kadono Y, Yaegashi H, Machioka K et al. Cardiovascular and respiratory effects of the degree of head‐down angle during robot‐assisted laparoscopic radical prostatectomy. Int J Med Robot 2013;9(1):17–22.

923

924

Section 6  Laparoscopy and Robotic Surgery: General Principles

16 Uhlich GA. Laparoscopy: the question of the proper 17

18

19

20

21

22

23

24

25

26

27

28

29

30 31

gas. Gastrointest Endosc 1982;28(3):212–213. Menes T and Spivak H. Laparoscopy: searching for the proper insufflation gas. Surg Endosc 2000;14(11):1050–1056. Sharp JR, Pierson WP, and Brady CE. Comparison of CO2‐ and N2O‐induced discomfort during peritoneoscopy under local anesthesia. Gastroenterology 1982;82(3):453–456. Minoli G, Terruzzi V, Spinzi GC et al. The influence of carbon dioxide and nitrous oxide on pain during laparoscopy: a double‐blind, controlled trial. Gastrointest Endosc 1982;28(3):173–175. Gunatilake DE. Case report: fatal intraperitoneal explosion during electrocoagulation via laparoscopy. Int J Gynaecol Obstet 1978;15(4):353–357. Hunter JG, Staheli J, Oddsdottir M, and Trus T. Nitrous oxide pneumoperitoneum revisited. Is there a risk of combustion? Surg Endosc 1995;9(5):501–504. Rademaker BM, Bannenberg JJ, Kalkman CJ, and Meyer DW. Effects of pneumoperitoneum with helium on hemodynamics and oxygen transport: a comparison with carbon dioxide. J Laparoendosc Surg 1995;5(1):15–20. Makarov DV, Kainth D, Link RE, and Kavoussi LR. Physiologic changes during helium insufflation in high‐risk patients during laparoscopic renal procedures. Urology 2007;70(1):35–37. Wolf JS, Carrier S, and Stoller ML. Gas embolism: helium is more lethal than carbon dioxide. J Laparoendosc Surg 1994;4(3):173–177. Hodgson C, McClelland RM, and Newton JR. Some effects of the peritoneal insufflation of carbon dioxide at laparoscopy. Anaesthesia 1970;25(3):382–390. Puri GD and Singh H. Ventilatory effects of laparoscopy under general anaesthesia. Br J Anaesth 1992;68(2):211–213. Sprung J, Whalley DG, Falcone T et al. The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanics during laparoscopy in morbidly obese patients. Anesth Analg 2003;268–274. Tomescu DR, Popescu M, Dima SO et al. Obesity is associated with decreased lung compliance and hypercapnia during robotic assisted surgery. J Clin Monit Comput 2017;31:85–92. Wolf J and Monk T. Anesthetic considrations. In: Smith’s Textbook of Endourology (ed. A Smith, G Badlani, and D Bagley), 731–753. St. Louis, MO: Quality Medical Publishing, 1996. Nunn J. Carbon dioxide. In: Applied Respiratory Physiology, 207–234. London: Butterworths, 1987. Seed RF, Shakespeare TF, and Muldoon MJ. Carbon dioxide homeostasis during anaesthesia for laparoscopy. Anaesthesia 1970;25(2):223–231.

32 Lewis DG, Ryder W, Burn N et al. Laparoscopy–an

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

investigation during spontaneous ventilation with halothane. Br J Anaesth 1972;44(7):685–691. Tan PL, Lee TL, and Tweed WA. Carbon dioxide absorption and gas exchange during pelvic laparoscopy. Can J Anaesth 1992;39(7):677–681. Mullet CEM, Viale JP, Sagnard PE et al. Pulmonary CO2 elimination during surgical procedures using intra‐ or extraperitoneal CO2 insufflation. Anesth Analg 1993;76(3):622–626. Meftahuzzaman SM, Islam MM, Chowdhury KK et al. Haemodynamic and end tidal CO2 changes during laparoscopic cholecystectomy under general anaesthesia. Mymensingh Med J 2013;22(3):473–477. Koivusalo A‐M and Lindgren L. Effects of carbon dioxide pneumoperitoneum for laparoscopic cholecystectomy. Acta Anaesthesiol Scand 2000;44(7):834–841. Wolf JS and Stoller ML. The physiology of laparoscopy: basic principles, complications and other considerations. J Urol 1994;152(2 Pt 1):294–302. Ho HS, Saunders CJ, Corso FA, and Wolfe BM. The effects of CO2 pneumoperitoneum on hemodynamics in hemorrhaged animals. Surgery 1993;114(2):381–388. Cunningham AJ and Brull SJ. Laparoscopic cholecystectomy: anesthetic implications. Anesth Analg 1993;76(5):1120–1133. Takata M, Wise RA, and Robotham JL. Effects of abdominal pressure on venous return: abdominal vascular zone conditions. J Appl Physiol 1990;69(6):1961–1972. Kashtan J, Green JF, Parsons EQ, and Holcroft JW. Hemodynamic effect of increased abdominal pressure. J Surg Res 1981;30(3):249–255. Giebler RM, Kabatnik M, Stegen BH et al. Retroperitoneal and intraperitoneal co2insufflation have markedly different cardiovascular effects. J Surg Res 1997;68(2):153–160. Wahba RW, Béïque F, and Kleiman SJ. Cardiopulmonary function and laparoscopic cholecystectomy. Can J Anaesth 1995;42(1):51–63. Solis‐Herruzo JA, Moreno D, Gonzalez A et al. Effect of intrathoracic pressure on plasma arginine vasopressin levels. Gastroenterology 1991;101(3):607–617. Walder AD and Aitkenhead AR. Role of vasopressin in the haemodynamic response to laparoscopic cholecystectomy. Br J Anaesth 1997;78(3):264–266. Joris JL, Chiche JD, Canivet JL et al. Hemodynamic changes induced by laparoscopy and their endocrine correlates: effects of clonidine. J Am Coll Cardiol 1998;32(5):1389–1396. Hirvonen EA, Nuutinen LS, and Vuolteenaho O. Hormonal responses and cardiac filling pressures in

78  Physiologic Considerations in Laparoscopic and Robotic Surgery

48

49

50

51

52

53

54

55

56

57

58

59

head‐up or head‐down position and pneumoperitoneum in patients undergoing operative laparoscopy. Br J Anaesth 1997;78(2):128–133. Mann C, Boccara G, Pouzeratte Y et al. The relationship among carbon dioxide pneumoperitoneum, vasopressin release, and hemodynamic changes. Anesth Analg 1999;89(2):278–283. O’Leary E, Hubbard K, Tormey W, and Cunningham AJ. Laparoscopic cholecystectomy: haemodynamic and neuroendocrine responses after pneumoperitoneum and changes in position. Br J Anaesth 1996;76(5):640–644. Koivusalo A‐M, Kellokumpu I, Scheinin M et al. Randomized comparison of the neuroendocrine response to laparoscopic cholecystectomy using either conventional or abdominal wall lift techniques. Br J Surg 1996;83(11):1532–1536. Koivusalo A‐M, Scheinin M, Tikkanen I et al. Effects of esmolol on haemodynamic response to CO2 pneumoperitoneum for laparoscopic surgery. Acta Anaesthesiol Scand 1998;42(5):510–517. Rosendal C, Markin S, Hien MD et al. Cardiac and hemodynamic consequences during capnoperitoneum and steep Trendelenburg positioning: lessons learned from robot‐assisted laparoscopic prostatectomy. J Clin Anesth 2014;26(5):383–389. Dunn M and McDougall E. Renal physiology: laparoscopic considerations. Urol Clin North Am 2000;(27):609–613. Wiesenthal JD, Fazio LM, Perks AE et al. Effect of pneumoperitoneum on renal tissue oxygenation and blood flow in a rat model. Urology 2011;77(6):1508. e9–1508.e15. Razvi HA, Fields D, Vargas JC et al. Oliguria during laparoscopic surgery: evidence for direct renal parenchymal compression as an etiologic factor. J Endourol 1996;10(1):1–4. Chiu AW, Chang LS, Birkett DH, and Babayan RK. Changes in urinary output and electrolytes during gaseous and gasless laparoscopy. Urol Res 1996;24(6):361–366. Mikami O, Fujise K, Matsumoto S et al. High intra‐ abdominal pressure increases plasma catecholamine concentrations during pneumoperitoneum for laparoscopic procedures. Arch Surg 1998;133(1):39–43. Hamilton BD, Chow GK, Inman SR et al. Increased intra‐abdominal pressure during pneumoperitoneum stimulates endothelin release in a canine model. J Endourol 1998;12(2):193–197. Dolgor B, Kitano S, Yoshida T et al. Vasopressin antagonist improves renal function in a rat model of pneumoperitoneum. J Surg Res 1998;79(2):109–114.

60 Harman PK, Kron IL, McLachlan HD et al. Elevated

61

62

63

64

65

66

67

68

69

70

71

72

73

intra‐abdominal pressure and renal function. Ann Surg 1982;196(5):594–597. Kirsch AJ, Hensle TW, Chang DT et al. Renal effects of CO2 insufflation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model. Urology 1994;43(4):453–459. McDougall EM, Monk TG, Wolf JS et al. The effect of prolonged pneumoperitoneum on renal function in an animal model. J Am Coll Surg 1996;182(4):317–328. de Barros RF, Miranda ML, de Mattos AC et al. Kidney safety during surgical pneumoperitoneum: an experimental study in rats. Surg Endosc 2012;26(11):3195–3200. Cisek LJ, Gobet RM, and Peters CA. Pneumoperitoneum produces reversible renal dysfunction in animals with normal and chronically reduced renal function. J Endourol 1998;12(2):95–100. Li W, Cao Z, Xia Z et al. Acute kidney injury induced by various pneumoperitoneum pressures in a rabbit model of mild and severe hydronephrosis. Urol Int 2015;94(2):225–233. Dolkart O, Khoury W, Amar E, and Weinbroum AA. Pneumoperitoneum in the presence of acute and chronic kidney injury: an experimental model in rats. J Urol 2014;192(4):1266–1271. Bishara B, Abu‐Saleh N, Awad H et al. Pneumoperitoneum aggravates renal function in cases of decompensated but not compensated experimental congestive heart failure: role of nitric oxide. J Urol 2011;186(1):310–317. Rosenthal RJ, Hiatt JR, Phillips EH et al. Intracranial pressure. Effects of pneumoperitoneum in a large‐ animal model. Surg Endosc 1997;11(4):376–380. Huettemann E, Terborg C, Sakka SG et al. Preserved CO(2) reactivity and increase in middle cerebral arterial blood flow velocity during laparoscopic surgery in children. Anesth Analg 2002;94(2):255–258. Kamine TH, Papavassiliou E, and Schneider BE. Effect of abdominal insufflation for laparoscopy on intracranial pressure. JAMA Surg 2014;149(4):380–382. Kim M‐S, Bai S‐J, Lee J‐R et al. Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep trendelenburg positioning proven by ultrasonographic measurement of optic nerve sheath diameter. J Endourol 2014;28(7):801–806. Mealy K, Gallagher H, Barry M et al. Physiological and metabolic responses to open and laparoscopic cholecystectomy. Br J Surg 1992;79(10):1061–1064. Targarona EM, Pons MJ, Balagué C et al. Acute phase is the only significantly reduced component of the injury response after laparoscopic cholecystectomy. World J Surg 1996;20(5):528–534.

925

926

Section 6  Laparoscopy and Robotic Surgery: General Principles

74 Schietroma M, Carlei F, Cecilia EM et al. A prospective

75

76

77

78

79

80

81 82

83

84

85

86

87

88

randomized study of systemic inflammation and immune response after laparoscopic nissen fundoplication performed with standard and low‐ pressure pneumoperitoneum. Surg Laparosc Endosc Percutan Tech 2013;23(2):189–196. Landman J, Olweny E, Sundaram CP et al. Prospective comparison of the immunological and stress response following laparoscopic and open surgery for localized renal cell carcinoma. J Urol 2004;171(4):1456–1460. Dalgic T, Oymaci E, Bostanci EB et al. Effects of carbon dioxide pneumoperitoneum on postoperative adhesion formation and oxidative stress in a rat cecal abrasion model. Int J Surg 2015;21:57–62. Tsiminikakis N, Chouillard E, Tsigris C et al. Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial. Surg Endosc 2009;23(12):2762–2769. Wolf JS, Clayman RV, Monk TG et al. Carbon dioxide absorption during laparoscopic pelvic operation. J Am Coll Surg 1995;180(5):555–560. Kent RB. Subcutaneous emphysema and hypercarbia following laparoscopic cholecystectomy. Arch Surg 1991;126(9):1154–1156. Hall D, Goldstein A, Tynan E, and Braunstein L. Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry. Anesthesiology 1993;79(1):173–174. Sivak BJ. Surgical emphysema: report of a case and review. Anesth Analg 1964;43:415–417. Herrerías JM, Ariza A, and Garrido M. An unusual complication of laparoscopy: pneumopericardium. Endoscopy 1980;12(5):254–255. Knos GB, Sung YF, and Toledo A. Pneumopericardium associated with laparoscopy. J Clin Anesth 1991;3(1):56–59. Pascual JB, Baranda MM, Tarrero MT et al. Subcutaneous emphysema, pneumomediastinum, bilateral pneumothorax and pneumopericardium after laparoscopy. Endoscopy 1990;22(1):59. Murray DP, Rankin RA, and Lackey C. Bilateral pneumothoraces complicating peritoneoscopy. Gastrointest Endosc 1984;30(1):45–46. O’Sullivan DC, Micali S, Averch TD et al. Factors involved in gas embolism after laparoscopic injury to inferior vena cava. J Endourol 1998;12(2):149–154. Schmandra TC, Mierdl S, Bauer H et al. Transoesophageal echocardiography shows high risk of gas embolism during laparoscopic hepatic resection under carbon dioxide pneumoperitoneum. Br J Surg 2002;89(7):870–876. Shulman D and Aronson HB. Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy. Can Anaesth Soc J 1984;31(4):455–459.

89 Derouin M, Couture P, Boudreault D et al. Detection

90 91

92

93

94

95

96

97

98

99

100

101

102

of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy. Anesth Analg 1996;82(1):119–124. Carmichael DE. Laparoscopy‐cardiac considerations. Fertil Steril 1971;22(1):69–70. Scott DB and Julian DG. Observations on cardiac arrythmias during laparoscopy. Br Med J 1972;1(5797):411–413. Mokdad AH, Bowman BA, Ford ES et al. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286(10):1195–1200. Lamvu G, Zolnoun D, Boggess J, and Steege JF. Obesity: physiologic changes and challenges during laparoscopy. Am J Obstet Gynecol 2004;191(2):669–674. Banting S, Shimi S, Vander Velpen G, and Cuschieri A. Abdominal wall lift. Low‐pressure pneumoperitoneum laparoscopic surgery. Surg Endosc 1993;7(1):57–59. Araki K, Namikawa K, Yamamoto H et al. Abdominal wall retraction during laparoscopic cholecystectomy. World J Surg 1993;17(1):105–108. Kitano S, Iso Y, Tomikawa M et al. A prospective randomized trial comparing pneumoperitoneum and U‐shaped retractor elevation for laparoscopic cholecystectomy. Surg Endosc 1993;7(4):311–314. Han C, Ding Z, Fan J et al. Comparison of the stress response in patients undergoing gynecological laparoscopic surgery using carbon dioxide pneumoperitoneum or abdominal wall‐lifting methods. J Laparoendosc Adv Surg Tech A 2012;22(4):330–335. Joshipura VP, Haribhakti SP, Patel NR et al. A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009;19(3):234–240. Vijayaraghavan N, Sistla SC, Kundra P et al. Comparison of standard‐pressure and low‐pressure pneumoperitoneum in laparoscopic cholecystectomy: a double blinded randomized controlled study. Surg Laparosc Endosc Percutan Tech 2014;24(2):127–133. Bäcklund M, Kellokumpu I, Scheinin T et al. Effect of temperature of insufflated CO2 during and after prolonged laparoscopic surgery. Surg Endosc 1998;12(9):1126–1130. Sammour T, Kahokehr A, Hayes J et al. Warming and humidification of insufflation carbon dioxide in laparoscopic colonic surgery: a double‐blinded randomized controlled trial. Ann Surg 2010;251(6):1024–1033. Farley DR, Greenlee SM, Larson DR, and Harrington JR. Double‐blind, prospective, randomized study of

78  Physiologic Considerations in Laparoscopic and Robotic Surgery

warmed, humidified carbon dioxide insufflation vs standard carbon dioxide for patients undergoing laparoscopic cholecystectomy. Arch Surg 2004;139(7):739–744. 03 Birch DW, Dang JT, Switzer NJ, Manouchehri N, Shi 1 X, Hadi G, Karmali S. Heated insufflation with or without humidification for laparoscopic abdominal surgery. Cochrane Database Syst Rev 2016;10:CD007821.

104 Horstmann M, Horton K, Kurz M et al. Prospective

comparison between the AirSeal® system valve‐less trocar and a standard Versaport TM Plus V2 Trocar in robotic‐assisted radical prostatectomy. J Endourol 2013;27(5):579–582. 05 Luketina RR, Knauer M, Köhler G et al. Comparison 1 of a standard CO2 pressure pneumoperitoneum insufflator versus AirSeal: study protocol of a randomized controlled trial. Trials 2014;15:239.

927

928

79 Anesthetic Management During Laparoscopic/Robotic Surgery Judith Aronsohn, Oonagh Dowling, & Greg Palleschi Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA

­Introduction Minimally invasive surgical techniques are rapidly becoming the accepted standard of care worldwide for many procedures performed by urologists. Laparoscopy is being increasingly utilized in nephrectomies (radical, partial, and living donor), nephroureterectomy, pyeloplasty, radical prostatectomy, pelvic lymph node dissection, varicocelectomy, and total cystectomy with ileal conduit formation. Significant advantages include decreased hospital length of stay, reduced blood loss, and fewer complications including in‐hospital deaths when compared to open surgery for many procedures [1, 2]. Additional benefits include less postoperative pain, lower narcotic requirements, improved cosmetic results, and earlier return to normal activity. Robotic technology offers a three‐dimensional view of anatomic structures, superior precision, and dexterity, and may be associated with a significantly faster learning curve than conventional laparoscopy [3, 4]. The anesthesiologist should be aware of the surgeon’s expertise in this area as it has a profound influence on the postoperative management of the patient.

­Anesthetic considerations The anesthesiologist is presented with a number of perioperative challenges during minimally invasive urologic surgery, and anesthetic management is guided by surgical complexity, patient positioning, duration of procedure, potential for blood loss, and the patient’s baseline status. Patient access may be severely limited during robotic surgeries, and the physiologic consequences of extreme positioning and pneumoperitoneum may not be well tolerated. Rapid port removal and robot disengagement

may become necessary during the case and requires clear communication with operating room personnel familiar with the equipment and operating room environment. Teamwork and effective communication are essential to assure optimal patient outcomes.

­Preoperative assessment Patients scheduled for elective procedures should be evaluated in a preoperative clinic to ascertain patient specific and procedural risk factors, facilitate a perioperative management plan, and manage comorbid conditions. Previous studies show that visiting an anesthesiologist‐ led preadmission testing clinic before surgery can reduce preoperative consultations, decrease surgical cancellations, reduce costs associated with unnecessary testing, and reduce in‐hospital mortality [5–7]. A complete ­history and physical exam should be performed with a focus on cardiopulmonary function and potential airway problems. Any pre‐existing neuropathies should be investigated and documented to avoid being misdiagnosed as a complication of surgical positioning. More extensive preoperative testing should be guided by the patient’s functional capacity, comorbidities, type of procedure, and surgical expertise. Current American College of Cardiology/American Heart Association guidelines should be followed for patients with known or suspected cardiac disease [8]. There are few, if any, agreed‐upon absolute contraindications to laparoscopic surgery, and its safety in high‐risk patients has been documented extensively [9–12]. Contraindications include patient conditions that preclude major surgery by any approach, such as severe decompensated cardiopulmonary disease or uncontrolled bleeding diatheses [13]. Patient‐specific factors

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

79  Anesthetic Management During Laparoscopic/Robotic Surgery

that may lead to procedural difficulties and prolonged surgery include morbid obesity, adhesions, and prior radiation therapy [14]. Patients considered high risk should be counseled in the rare event that a planned ­laparoscopic procedure must be converted to an open procedure.

­Anesthetic management The goal of anesthetic management is to provide optimal and safe surgical conditions while managing the physiologic and hemodynamic responses associated with laparoscopic surgery. General anesthesia with a secured airway and controlled ventilation is the most common technique used during laparoscopy. Although supraglottic airway devices have been used in laparoscopic ­cholecystectomies and short laparoscopic gynecologic procedures, their use in longer procedures requiring steep Trendelenburg position has not been sufficiently studied to recommend [15, 16]. Induction of general anesthesia and endotracheal intubation are usually accomplished with intravenous administration of ­propofol and an intermediate‐acting muscle relaxant. Etomidate and ketamine may be used in patients who cannot tolerate the hemodynamic effects of propofol. The endotracheal tube should be secured immediately after the cuff passes the vocal cords to prevent possible right endobronchial migration after abdominal insufflation [15, 17, 18]. Carbon dioxide pneumoperitoneum with Trendelenburg position increases endotracheal tube cuff pressure, leading to significant postoperative patient discomfort [19]. This can be avoided by periodically measuring the cuff pressure during the case. Anesthesia can be maintained with a volatile anesthetic combined with an opioid or total intravenous anesthesia (TIVA) with propofol. TIVA with propofol has been shown to decrease the incidence of early postoperative nausea and vomiting (PONV) in patients undergoing robot‐assisted radical prostatectomy (RALP) [20]. Complete muscle relaxation with controlled ventilation is recommended to provide optimal surgical conditions and prevent hypercapnia. Patient movement must be avoided at all costs when incorporating robot assistance. Minute ventilation may need to be increased as much as 30% to maintain normal PaCO2 levels [21]. Oxygenation and respiratory mechanics are similar whether ventilation is volume‐ or pressure‐controlled during laparoscopy, even in morbidly obese patients [22, 23]. Constant application of 5 cmH2O of positive end‐expiratory pressure (PEEP) effectively maintains PaO2 levels during ­prolonged pneumoperitoneum [24] and, combined with low tidal volumes (6 ml/kg), may decrease postoperative pulmonary complications [25]. In addition, application

of PEEP is associated with decreased blood loss during RALP [26]. The use of nitrous oxide, although not ­contraindicated, is frequently avoided due to its ability to  cause bowel distention and contribute to PONV. Additionally, it can worsen the effects of air embolism and pneumothorax [27, 28]. Standard patient monitoring should include electrocardiogram, noninvasive arterial blood pressure, pulse oximetry, capnography, peripheral nerve stimulator, airway pressure, and temperature probe. Invasive blood pressure monitoring may be indicated in patients with significant cardiopulmonary disease, particularly when access to the upper extremities is restricted. Frequent blood gas analysis may be necessary in patients with increased dead space ventilation (i.e. chronic obstructive pulmonary disease, asthma, acute respiratory distress syndrome), as end‐tidal CO2 is an unreliable estimate of PaCO2 in these conditions. Two large‐bore intravenous lines should be placed when significant intraoperative blood loss is anticipated or patient position precludes later placement should additional access become necessary. All lines and monitors should be rechecked after the patient is positioned to confirm they are functioning properly. A central line is rarely indicated. A fluid warmer and warming blanket is used to mitigate the effect of cold insufflated gasses on core body temperature. Even mild hypothermia is associated with adverse cardiac events, bleeding, and impaired wound healing [29]. Neuraxial techniques have been utilized successfully in a number of laparoscopic procedures, including transperitoneal nephrectomy, ureterolithotomy, and nephrolithotomy [30–32]. Drawbacks associated with the use of spinal and epidural anesthetics include inadequate abdominal relaxation, shoulder tip pain, urinary retention, and respiratory insufficiency secondary to carbon dioxide pneumoperitoneum. Benefits include less PONV and decreased need for postoperative analgesics. Laparoscopic cholecystectomy under epidural anesthesia has been successfully performed in high‐risk chronic obstructive pulmonary disease patients classified as “too sick” for general anesthesia and endotracheal intubation [33]. Meticulous attention to patient positioning is imperative to prevent nerve injury and other complications. Positioning is even more critical when the robot is employed because the camera system and working arms must be accommodated. All pressure points and dependent areas must be padded and avoidance of extreme flexion, extension, and abduction should be followed to help minimize neuromuscular injuries. The back of the head should be padded and the face protected with foam pads or a mayo stand to prevent contact with the robot camera. If foam pads are used over the face, they should be easily removable in case of an airway emergency. When

929

930

Section 6  Laparoscopy and Robotic Surgery: General Principles

steep Trendelenburg position is required, egg‐crate foam or surgical gel pads placed directly under the patient are commonly used to prevent cephalad migration on the operating room table. Shoulder straps, shoulder braces, and head rests are associated with neuromuscular injuries, particularly brachial plexus injury [34]. Chest straps are often utilized, but may decrease chest wall compliance. Some authors recommend placement of a throat pack to prevent gastric reflux through the lacrimal ducts with resulting chemical burns to the cornea [35]. For patients in the lateral decubitus position, a chest roll placed under the dependent hemithorax relieves tension on the brachial plexus by preventing compression of the axilla and shoulder. If an upper or double arm board is used, it must be properly set to prevent compression of the radial nerve at the posterior aspect of the humerus [36]. Excessive pressure on the dependent ear and eye should be avoided. Adhesive eye shields or Tegaderms can be used for eye protection.

­Fluid management Although evaporative losses and fluid shifts are significantly reduced during laparoscopic surgery compared to open procedures, the ideal strategy for fluid replacement remains elusive. Patient condition, type of procedure, and patient position during the case help inform intraoperative fluid replacement therapy. Heart rate, blood pressure, urine output, and central venous pressure are not reliable measures of volume status. Pneumoperitoneum and Trendelenburg position make goal‐directed fluid therapy indices difficult to interpret, and no single hemodynamic goal or monitoring method has been accepted across the literature [37, 38]. Restrictive fluid regimes have been associated with longer hospital length of stay and delayed postoperative wound healing in patients undergoing laparoscopic surgery, while fluid loading has successfully decreased rates of PONV [39, 40]. Conservative intravenous fluid administration during RALP decreases the amount of urine obscuring the operative field and may also reduce postoperative laryngeal edema resulting from prolonged Trendelenburg position [34].

­Physiologic changes The physiologic changes that accompany laparoscopic surgery are well tolerated in healthy (American Society of Anesthesiologists [ASA] grade I or II) patients. They are produced by the interaction of several factors, including pneumoperitoneum, carbon dioxide absorption, patient position,surgical procedure, and the patient’s baseline cardiopulmonary status.

Pneumoperitoneum Pneumoperitoneum has profound effects on the cardiovascular, cerebrovascular, and respiratory systems. Displacement of the diaphragm cephalad decreases tidal volume, pulmonary compliance, and functional residual capacity. Peak inspiratory pressure and plateau pressures increase secondary to atelectasis and narrowing of the large airways. Moderate Trendelenburg position does not seem to affect these changes, even in the morbidly obese [41, 42]. Steeper levels of Trendelenburg may worsen lung compliance [43]. Atelectasis may be more prominent in older people due to increased closing capacity with age. Strategies to mitigate the effects of these changes are discussed under Anesthetic management. Cardiovascular changes associated with pneumoperitoneum are related to the degree of increased intra‐abdominal pressure and position of the patient. Intra‐abdominal pressures up to 12 mmHg can cause an initial rise in cardiac output by increasing preload as blood volume is forced from the splanchnic vessels into the inferior vena cava. When intra‐abdominal pressure rises above 15 mmHg, reductions in preload and cardiac output can be seen secondary to caval compression. A rise in systemic vascular resistance (SVR) is due to many factors, including compression of the arterial vasculature, the release of catecholamines and vasopressin, and activation of the renin‐angiotension system. Odeberg et al. reported a 58% increase in central venous pressure and a 32% increase in pulmonary capillary wedge pressure in healthy patients after abdominal insufflation in the horizontal position when intra‐abdominal pressure was maintained between 11 and 13 mmHg. Cardiac filling pressures were further increased by 40% when patients were placed in the Trendelenburg position [44]. Lestar and colleagues found a threefold increase in central venous pressure in ASA grade I–II patients undergoing RALP in 45° Trendelenburg position with an intra‐abdominal pressure of 11–12 mmHg. Mean pulmonary artery pressure and pulmonary capillary wedge pressure increased twofold, but cardiac performance was unaffected [45]. It should be noted that the effects of intra‐abdominal hypertension may be exaggerated in hypovolemic patients or those with cardiovascular disease, particularly if the reverse Trendelenburg position is used. Severe reflex bradycardia resulting from stretching of the peritoneum during insufflation has also been reported [46]. Pneumoperitoneum decreases renal blood flow, although the clinical significance of this is unknown [47]. This decrease in blood flow is pressure dependent and intensified by the reverse Trendelenburg position. Mechanical compression of the renal vein and increased secretion of antidiuetic hormone decrease glomerular filtration and urine output. The renin‐angiotensin‐aldosterone system is

79  Anesthetic Management During Laparoscopic/Robotic Surgery

activated, leading to further reductions in renal blood flow. Pneumoperitoneum‐associated hemodynamic changes in kidney donors can negatively affect transplanted kidney function [48]. Suggested measures to protect renal function, particularly during laparoscopic live donor nephrectomy, include maintaining a positive intravascular fluid balance and limiting intra‐abdominal pressure to a ­maximum of 12 mmHg [49]. Ureteral obstruction due to mechanical pressure has not been shown to play a significant role in renal d ­ ­ysfunction associated with pneumoperitoneum [50]. Carbon dioxide absorption Carbon dioxide (CO2) is the gas most commonly used for abdominal insufflation during laparoscopy because it is highly soluble, inexpensive, nontoxic, nonflammable, and easily eliminated through the lungs. Its high solubility makes it less likely than air to cause clinically significant gas embolus. CO2 is systemically absorbed during laparoscopy, potentially causing respiratory acidosis. During carbon dioxide pneumoperitoneum, end‐tidal CO2 progressively increases, reaching a plateau after 40 minutes if minute ventilation is kept constant [51]. Thereafter, CO2 accumulates in the body and CO2 output may be increased for up to 30 minutes after abdominal decompression [52]. Factors contributing to a higher degree of CO2 absorption include higher insufflation pressure, longer insufflation time, and subcutaneous emphysema [53–56]. Hypercarbia can cause arrhythmias and contribute to increased SVR during laparoscopy. Excess CO2 is easily eliminated in healthy patients by increasing minute ventilation. However, hypercarbia can induce pulmonary vasoconstriction that may be poorly tolerated in patients with pulmonary hypertension. Alternatively, permissive hypercarbia causes vasodilatation and shifts the oxyhemoglobin dissociation curve to the right, improving tissue perfusion and oxygen delivery [57]. Elevated PaCO2 has also been shown to reduce shunting by increasing blood flow to noncollapsed lung regions [58]. Patient position The most common positions for laparoscopic and robotic urological procedures are the low dorsal ­lithotomy with steep (35°) Trendelenburg position, followed by the lateral jackknife decubitus position. Neurological complications after prolonged periods of steep Trendelenburg have been reported [59]. Schramm and colleagues used transcranial Doppler to investigate the time course of cerebral autoregulation during RALP. Their findings suggest a slow deterioration of cerebral autoregulation during extreme Trendelenburg position

combined with pneumoperitoneum [60]. Kim et  al. used optic nerve sheath diameter to assess intracranial pressure in 20 patients undergoing RALP. In 15% of patients optic nerve sheath diameter increased to levels equivalent to an intracranial pressure >20 mmHg. No postoperative neurological complications were noted in their study [61]. Although not strictly contraindicated, laparoscopic surgery in Trendelenburg position has been safely performed in patients with ventriculoperitoneal shunt [62]. Intraocular pressure (IOP) has been shown to increase significantly over time in patients undergoing RALP with steep Trendelenburg. However, no perioperative visual loss has been attributed to steep Trendelenburg positioning alone in patients without pre‐existing ocular disease [63, 64]. There is at least one case report of a patient with primary open‐angle glaucoma undergoing RALP. The IOP was measured after induction of general anesthesia and every 15 minutes thereafter. Increased IOP was treated with intravenous acetazolamide and mannitol. The patient’s visual acuity postoperatively remained unchanged [65]. Preoperative consultation with the treating ophthalmologist is recommended for patients with glaucoma as intraoperative treatment for increased IOP may be warranted. Some degree of lateral positioning is commonly used for kidney surgery depending on the surgical approach, i.e. transperitoneal or retroperitoneal. Advantages to the retroperitoneal approach include less need for visceral retraction and lack of peritoneal irritation from insufflated carbon dioxide. Transperitoneal is associated with a larger increase in peak inspiratory pressure and p ­ lateau pressure when compared to retroperitoneal [66]. This may be attributed to greater interference to diaphragmatic excursion when the transperitoneal is used. Which approach results in less CO2 accumulation is the subject of debate. Bannenberg et  al. found arterial CO2 levels increased significantly more during intraperitoneal insufflation compared to extraperitoneal insufflation in piglets [67]. This is presumably due to the increased diaphragmatic surface area exposed to CO2. Streich et  al. and Mullet et  al. found retroperitoneal carbon dioxide insufflation causes more carbon dioxide absorption than intraperitoneal insufflation [68, 69], and Ng et  al. found no difference in carbon dioxide absorption when comparing the retroperitoneal to the transperitoneal approach [70].

­Enhanced recovery after surgery Enhanced recovery programs (ERPs) have been utilized in urology for both open and minimally invasive procedures, but adoption has been slow. ERPs are increasingly

931

932

Section 6  Laparoscopy and Robotic Surgery: General Principles

being implemented to improve patient outcomes and reduce healthcare costs through standardized, evidence‐ based perioperative care. Minimally invasive surgery alone represents a major opportunity to enhance recovery and reduce morbidity, especially when combined with other aspects of an ERP. Although most of the literature on this topic is derived from colorectal surgery, many elements have been effectively applied to ERPs in other specialties. It should be noted that the number and type of ERP elements varies widely across the literature and the impact of any individual element on outcomes is not clear. Successful ERPs require a multidisciplinary, team‐based approach and coordination of evidence‐ based care throughout the perioperative continuum. Anesthesiologists are responsible for delivering many elements in an ERP, highlighting the importance of their commitment to this process. Collaboration between the surgeon and anesthesiologist is essential for an ERP to be effective and sustainable. An ERP begins when surgery is scheduled and ends when the patient returns to their preoperative functional status. ERP interventions can be classified as preoperative, intraoperative, and postoperative. The anesthesiologist plays an important role in the shared decision‐making for many of these interventions, including:

and/or elimination of elements in a protocol should be evidence‐based and procedure‐specific. Magheli et al. studied 50 patients undergoing laparoscopic radical prostatectomy randomized to conventional or enhanced recovery fast‐track care. Patients in the fast‐track group mobilized earlier, had lower pain scores and a decreased overall complication rate, and were discharged home earlier than patients in the conventional group. Postoperative pain in the fast‐track group was managed with a COX‐2 inhibitor [71]. Dudderidge and colleagues reduced intraoperative and postoperative opioid use by incorporating a pre‐emptive transversus abdominis plane (TAP) block as part of a standardized anesthetic technique into their care pathway for laparoscopic radical prostatectomy. Some 78% of patients who received a TAP block were discharged home on postoperative day 1, and 7% went home on the evening of surgery [72]. Enhanced recovery protocols have been utilized in robot‐assisted laparoscopic cystectomy and laparoscopic nephrectomy with promising results [73, 74]. More studies are needed in minimally invasive surgery as part of the enhanced recovery paradigm to assess and clarify its influence on patient outcomes and cost effectiveness.

1) identification and optimization of patient’s comorbid conditions before surgery, 2) utilizing opioid‐sparing anesthetic techniques, including regional blocks, that minimize postoperative pain and allow for rapid recovery, 3) aggressive prophylaxis and treatment of PONV, 4) utilizing effective pre‐emptive analgesics and an opioid‐sparing multimodal strategy for postoperative pain management, 5) providing goal‐directed or zero‐balance fluid therapy perioperatively (when evidence‐based).

­Postoperative pain management

Common elements found in many enhanced‐recovery or “fast‐track” protocols for gastrointestinal and urologic surgery are listed in Table 79.1. Inclusion, modification,

Minimally invasive laparoscopic procedures are known to cause less pain than open procedures. However, characteristics of the laparoscopic approach such as insufflation of the abdomen with CO2 can create unique postoperative pain management challenges. Postoperative pain associated with robotic/laparoscopic surgery is caused by tissue trauma at port incision, peritoneal distention, and diaphragmatic irritation that leads to referred shoulder pain. Although there are no procedure‐specific guidelines for pain management in urologic surgery the goal is to provide adequate analgesia while curtailing the administration of systemic opioids. Opioids are associated with a

Table 79.1  Common elements of enhanced recovery protocols. Preoperative

Intraoperative

Postoperative

Patient education and counseling Preoperative risk assessment and optimization (hypertension, diabetes, anemia) Carbohydrate drink (clear) night before and 2 hours before surgery Preoperative administration of non‐narcotic analgesics Avoidance of mechanical bowel preparation Alcohol and tobacco abstinence Thromboembolic prophylaxis

Fluid optimization to maintain euvolemia Fluid warmer and warming blanket to maintain normothermia Minimally invasive surgery Pre‐incision regional block/local anesthetic infiltration Opioid‐sparing techniques Prophylactic antiemetics, antimicrobial prophylaxis

Multimodal, opioid‐sparing analgesia Antiemetics Early routine mobilization Early enteral nutrition Avoidance of nasogastric tubes Avoidance of peritoneal drains Early removal of catheters Rehabilitation plan

79  Anesthetic Management During Laparoscopic/Robotic Surgery

number of undesirable side effects, including nausea, vomiting, pruritus, urinary retention, respiratory depression, and delayed return of bowel function. For this reason, opioid‐sparing multimodal analgesic techniques are increasingly being utilized to control postoperative pain and promote early recovery [75]. Multimodal protocols use combinations of analgesic medications with different mechanisms of action and sites of administration to provide optimal pain relief. Strategies for the management of postoperative pain frequently include the perioperative administration of nonsteroidal anti‐inflammatory agents, NMDA inhibitors, steroids, and acetaminophen combined with regional block or wound infiltration with a local anesthetic. Supplemental opioid may be added for breakthrough pain. There is evidence that the preoperative administration of COX‐2 inhibitors and gabapentin may be more effective than opioids and other nonsteroidal anti‐inflammatory drugs in reducing postoperative pain [76]. Preoperative systemic dexamethasone and perioperative ketorolac and ketamine have also been found to be effective adjuncts to reduce postoperative pain and opioid consumption in a variety of clinical ­settings [77–79]. Local anesthetics used for peripheral nerve blocks and local infiltration have been shown to reduce postoperative opioid requirements in laparoscopic surgery. Infiltration of a local anesthetic into laparoscopic port sites and other incisions is a common practice shown in the short term to decrease pain scores and the need for supplementary analgesia [80]. A meta‐analysis of laparoscopic surgery clinical trials demonstrated that pre‐ emptive administration of local anesthetic at the port incision site reduced postoperative pain compared with placebo but was found to have an analgesic effect similar to that of postincisional anesthetic infiltration [81]. Pre‐emptive timing of administration was only significant for intraperitoneal infiltration. The analgesic duration of most local anesthetics when administered as a single injection is less than 4–6 hours and may not ­provide significant long‐term postoperative analgesia. Liposomal bupivacaine is a delayed‐release local anesthetic approved for injection into the surgical site to produce postsurgical analgesia. Knight et al. found there was no significant difference with respect to opioid ­consumption and pain control between liposomal bupivacaine and free bupivacaine following injection of incision sites in laparoscopic and robot‐assisted urologic surgery cases [82]. The TAP block is a peripheral nerve block that anesthetizes the abdominal wall and is used as part of a ­multimodal strategy to optimize postoperative pain outcomes. While advocates of the TAP block propose that the analgesia provided reduces postoperative pain, opioid consumption, and related side effects, evidence for

TAP block use has been inconsistent. De Oliveira et al. detected a beneficial effect of TAP block on analgesia outcomes after laparoscopic surgery with the preoperative period as the optimal time for administration of the block [83]. A variety of methods have been tested to reduce the incidence and severity of shoulder tip pain. Guido et al. found no difference in shoulder pain after laparoscopic tubal ligation by gasless laparoscopy versus CO2 pneumoperitoneum while Goldberg and Maurer found the compromised surgical exposure and lack of benefits in terms of postoperative discomfort rendered this method unsuitable [84, 85]. Sarli et  al. performed laparoscopic cholecystectomy comparing 9 mmHg carbon dioxide pneumoperitoneum with 13 mmHg pneumoperitoneum and noted a decreased incidence and frequency of shoulder tip pain [86]. Sajid  et  al. concluded that the use of heated humidified CO2 for pneumoperitoneum in laparoscopic procedures is associated with lower postoperative pain and analgesic requirements when compared to dry CO2 [87]. Intraperitoneal local anesthetic nebulization has been found to reduce postoperative pain and referred shoulder pain after laparoscopic cholecystectomy and laparoscopic gynecologic surgery [88–90].

­Postoperative nausea and vomiting PONV is a common but distressing complication of surgery with a reported incidence of 25–36% [91]. The incidence of PONV has been found to be as high as 79% in certain high‐risk populations [92]. It can result in delayed postanesthesia care unit discharge, unplanned hospital admission, and increased healthcare costs. Patient anesthetic‐ and procedure‐related characteristics that confer increased risk for PONV include female gender, history of PONV, nonsmoking status, history of motion sickness, younger age (4 hours), patient position (lithotomy and lithotomy‐ Trendelenburg), obesity, systemic hypotension, m ­ uscular lower limbs, type of leg holder, epidural anesthesia, and peripheral vascular disease [109]. Clinical signs and symptoms of WLCS include paresthesia, disproportionate pain in the affected compartment, pain on passive stretch, and tight calves. Supplementary compartmental pressure measurement is recommended when the ­clinical signs are unclear [113]. Once a diagnosis is made, ­fasciotomy should be performed urgently to minimize the likelihood of adverse sequelae. Untreated compartment syndrome or delayed fasciotomy can result in limb loss, renal failure, and death [114]. Clinicians must ­maintain a high level of vigilance in patients with risk factors and explore ways to reduce this risk. Proposed risk‐reduction strategies include use of the modified lithotomy position, periodic mobilization of the lower extremities, avoidance of the Trendelenburg position, and ankle dorsiflexion and heel support [115]. Of ­interest, intermittent compression stockings have been reported to be a risk factor as well as a preventive ­measure to reduce the risk of WLCS [109, 116]. Mesenteric ischemia and bowel infarction There have been several reports of mesenteric ischemia and bowel infarction after routine laparoscopic procedures. Many of these complications occurred in patients with evidence of preoperative cardiovascular, hepatic, or renal compromise. Bandyopadhyay et al. describe a case of large bowel ischemia involving a 78‐year‐old man who

79  Anesthetic Management During Laparoscopic/Robotic Surgery

died within 30 hours after an elective laparoscopic transperitoneal inguinal hernioplasty. An autopsy revealed thrombosis of the inferior mesenteric artery and an infrarenal aortic aneurysm with thrombotic plaque on its wall [117]. At least nine cases of small bowel ischemia  following laparoscopic cholecystectomy have been reported, many of them fatal [118]. CO2 pneumoperitineum may play a role in this devastating event by reducing mesenteric perfusion in at‐risk patients [119]. Techniques that utilize the lowest possible insufflation pressure and intermittent decompression of gas during pneumoperitoneum have been suggested as preventive measures [120]. Intestinal ischemia should be considered whenever nonspecific abdominal symptoms are present after transperitoneal laparoscopic surgery. Ocular injuries Ocular complications of robot‐assisted urologic surgery can range from more frequent corneal abrasions to the rare but devastating postoperative visual loss. Corneal abrasions can cause considerable patient pain and discomfort. Possible etiologies include lagophthalmos during general anesthesia resulting in corneal drying, direct mechanical trauma, and chemical injury. Advanced age, general anesthesia, length of surgery, and Trendelenburg positon have been confirmed as perioperative risk factors for corneal abrasions [121]. A retrospective review of 1500 consecutive patients undergoing robotic prostatectomy found corneal abrasions to be the most common anesthesia‐related complication, occurring in 3% of cases with the use of eye tape [122]. This incidence was reduced to 1% following the introduction eye patches. In a United States nationwide sample of patients undergoing radical prostatectomy the overall incidence of corneal abrasion was reported as 0.18% [123]. Proposed measures to protect against corneal abrasions include the use of eye patches, and transparent occlusive dressings [122, 124]. Postoperative visual loss (POVL) is a rare complication following robot‐assisted laparoscopic surgery. Prolonged operative times in steep Trendelenburg have raised concerns about increased venous congestion in the head, facial edema, and elevated IOP interfering with optic nerve perfusion. Lee et al. reported three cases of POVL from the ASA POVL registry from 2006 to 2011 secondary to posterior ischemic optic neuropathy following RALP [125]. A small randomized trial by Raz et al. found that modifying the Trendelenburg position by placing the head and shoulders horizontally during RALP lowered IOP and accelerated its recovery to the normal range without affecting the procedure [126]. An ophthalmology consult ­ istory of severe should be considered in patients with h

ocular disease and older adults who may have elevated baseline intraocular pressure. Peripheral nerve injuries Nerve injuries related to patient positioning are injuries that occur when a peripheral nerve is subjected to stretching or compression during surgery. Mills et al. reviewed 334 adult urological robot‐assisted cases at their institution over a 2 year period and found 22 documented positioning injuries (6.6%). Twenty eight percent of these injuries persisted beyond 6  months. Retroperitoneal lymph node dissection was associated with the highest percentage of patients with injuries (40%), followed by adrenalectomy (17%). Patients at greatest risk for injury were those with a higher ASA classification [127]. Factors associated with positioning nerve injuries can be classified as patient‐ or procedure‐related. Patient‐related factors include ASA physical status, body mass index (BMI), variant anatomy, and comorbidities such as diabetes mellitus and vascular disease. Procedural risk factors include patient position and operative duration [127–129]. Lower extremity neuropathies involving the common peroneal, obturator, lateral femoral cutaneous nerve and sciatic nerve from prolonged standard and low lithotomy positioning have been documented with a frequency of 1 in 3608 [130]. Manny et al. reported a lower extremity neuropathy rate of 1.7% in RALP and prostatectomy cases with patients in the low lithotomy position [131]. Koc et al. reported that patients who developed lower extremity neuropathies had a significantly longer operative time than average and that use of a split‐leg table was found to put the femoral nerve at risk for injury [132]. Elements of correct lithotomy positioning include the use of boot stirrups, hip flexion of 60–120°, knee flexion of 90–120°, hip adduction of 90° or less, minimal external hip rotation, and the use of specific padding to prevent pressure against the peroneal nerve at the fibular head [133]. Larger BMI is a risk factor for upper extremity injury [128]. Mills et al. reported that 59% of all nerve injuries involved an upper extremity, with the highest proportion of injuries occurring when one upper extremity was adducted while the other was tucked beside the patient. The majority of these injuries occurred in the tucked extremity [127]. Brachial plexus injuries are the most commonly reported peripheral nerve injuries and have been linked to the use of shoulder braces and prolonged steep Trendelenburg positioning [134]. Most guidelines discourage the use of shoulder braces in favor of nonsliding mattresses [133]. Devarajan et  al. described three patients who developed brachial plexus injuries with the use of beanbag body supports in steep Trendelenburg position. The authors recommended adduction or tucking of the upper extremities and the use of nonslipping

935

936

Section 6  Laparoscopy and Robotic Surgery: General Principles

operating table mattresses to prevent cephalad migration of the patient in steep Trendelenburg position [135]. The use of padded arm boards, chest rolls, and elbow padding are also recommended [133]. Documentation of perioperative positioning actions with intermittent assessment of patient positioning is essential. Pneumothorax, pneumomediastinum, and pneumopericardium Pneumothorax (PTX), pneumomediastinum, and pneumopericardium are well‐known complications of laparoscopic surgery and can cause significant morbidity. Laparoscopic procedures performed near the diaphragm, inadvertent pleural or diaphragmatic injury, and congenital diaphragmatic defects have been identified as routes for CO2 entry into the mediastinal and pleural spaces [136–138]. PTX has a reported incidence of less than 1% during renal surgery and 3% during adrenalectomy [139, 140]. Risk factors associated with PTX during laparoscopic surgery include prolonged operative times, older age, intraoperative end‐tidal CO2 above 50 mmHg, and operator inexperience [140]. Signs of PTX during surgery include hypercapnia, increased airway pressure, hypoxemia, billowing of the diaphragm, and absent breath sounds. Concomitant hemodynamic instability indicates the PTX is likely under tension. While most cases are diagnosed intraoperatively, a valveless Trocar may obscure typical signs of PTX, impeding diagnosis [139]. The authors recommend a chest X‐ray in the immediate postoperative period when using a valveless Trocar for procedures close to the diaphragm. Treatment of PTX consists of immediate release of pneumoperitoneum, hyperventilation with 100% oxygen, PEEP, and hemodynamic support. Severe PTX or cases secondary to underlying lung disease may require immediate simple aspiration or ­ chest tube drainage. Given the favorable absorptive properties of CO2, asymptomatic or hemodynamically stable patients with PTX can be treated conservatively and allowed to resolve spontaneously [141]. Cardiac patients Patients with cardiac dysfunction undergoing laparoscopic surgery present a variety of challenges to the anesthesiologist. The physiological effects of CO2 pneumoperitoneum and extreme positioning may be poorly tolerated in these patients. Pneumoperitoneum ­activates the release of catecholoamines leading to tachycardia, increased afterload, and hypertension. Furthermore, mechanical compression of the aorta by insufflated CO2 may further increase SVR [142]. The tachycardia and increased afterload increase myocardial oxygen demand

and the likelihood of ischemia. Further increases in intra‐abdominal pressure as insufflation continues decreases venous return, preload, and end‐diastolic volume, with the magnitude of decrease in cardiac index directly related to the insufflation pressure [143]. By  occupying a less‐advantageous position on the Frank–Starling curve, cardiac output can subsequently decrease. Preload augmentation prior to pneumoperitoneum may be necessary. Limiting insufflation pressures should also be considered, as patients with limited cardiac reserve or compensated failure may not tolerate associated hemodynamic changes. Decreased cardiac output leads to decreased oxygen delivery to the periphery with a concomitant decrease in mixed venous oxygen saturation. Patients with severe congestive heart failure and valvular lesions are more likely to develop complications than those suffering from ischemic cardiac disease [144]. The possibility of rising arterial carbon dioxide tension may lead to, or exacerbate, pulmonary hypertension, resulting in right heart strain and ischemia. Standard monitoring may need to be supplemented with invasive monitoring in this patient population. TEE can be used to assess regional wall motion abnormalities, hydration status, and the degree of preload and end‐diastolic volume. Invasive arterial monitoring may be useful and pulmonary arterial catheterization may help maximize cardiac output and measure mixed‐venous oxygen saturation. Alternatively, noninvasive measures of hemodynamic parameters are commercially available. Noninvasive hemodynamic monitoring provides ease of use while eliminating the risks associated with the placement of invasive monitors. Algorithmic analysis of the Pleth Variability Index (PVI) has been advocated as a method for measuring intraoperative fluid balance, hemodynamic parameters, and hemoglobin. This method utilizes algorithmic analysis of the waveform generated from a standard or modified pulse‐oximeter probe. Hemodynamic parameters are derived from respiratory variations in the pulse oximeter waveform amplitudes [145]. While PVI has been shown to reliably predict fluid responsiveness in the mechanically ventilated there are few data to support the use of these monitors in those undergoing laparoscopic procedures [146]. In addition, the impact of abdominal insufflation on the validity of these noninvasive monitors is still unclear. Some data suggest that PVI is falsely elevated with abdominal insufflation. This could assign a false state of hypovolemia and result in the unnecessary, and potentially deleterious, administration of volume expanders [145]. The hemodynamic effects of steep Trendelenburg position commonly used in many robot‐assisted urologic procedures appears to be mitigated by the increased intra‐abdominal pressures associated with insufflation [142].

79  Anesthetic Management During Laparoscopic/Robotic Surgery

Older patients Older patients are more susceptible to adverse surgical outcomes because of decreased functional reserve and an increased number of coexisting diseases [147]. Most significantly, changes due to the physiologic stresses of pneumoperitoneum need to be anticipated in this surgical population as the customary insufflation pressures of 10–15 mmHg may cause significant physiologic disturbances. Increased intra‐abdominal pressure in octogenarians may decrease the cardiac output by 30% [148]. Heart rate typically increases in an effort to maintain oxygen delivery to the tissues. This compensatory increase may be diminished by medications typically taken by older people, particularly beta‐blockers. Elevations in heart rate, SVR, and mean arterial pressure that typically accompany pneumoperitoneum can increase myocardial workload and the risk of ischemia. The presence of atrial fibrillation further decreases cardiac reserve due to loss of the atrial contribution to ventricular filling. The pharmacokinetics and pharmacodynamics of drugs are significantly altered in older people. Elderly patients tend to have increased adipose tissue, decreased muscle mass, and decreased total body water accounting for many of the pharmacokinetic changes [149]. The subsequent decreased volume of distribution can lead to  exaggerated hemodynamic responses to induction agents and other drugs. Older people, particularly the malnourished, have a lower serum albumin concentration resulting in considerably higher plasma concentrations of unbound drug. Drug doses should be lowered and titrated to effect in these patients to avoid relative overdose. While is important to recognize age‐related physiologic changes, age alone has not been associated with an increased risk of intraoperative or postoperative complications [150]. Laparoscopic renal and adrenal surgery, radical prostatectomy, and robot‐assisted radical cystectomy in older adults have all been shown to be well tolerated with low perioperative morbidity. Pregnancy Pregnancy‐induced anatomical and physiological changes must be understood to provide optimal care to these surgical patients. Approximately 1–2% of pregnant patients require a non‐obstetric surgical intervention during their pregnancy, representing approximately 80 000 cases per year [151]. Laparoscopic partial nephrectomy for renal cell carcinoma in the pregnant patient has been described in the literature [152]. While there are numerous case reports that support the use of laparoscopy during pregnancy, by the end of the second trimester the size of the uterus often interferes with the laparoscopic approach and open surgery may be indicated [153]. Additionally,

many laparoscopic‐specific maternal and fetal complications bear consideration, including uterine and/or fetal trauma, fetal acidosis from carbon dioxide absorption, decreased maternal cardiac output, and decreased uteroplacental blood flow secondary to increased intraperitoneal pressure [151]. Pneumoperitoneum can initiate premature labor. Preservation of maternal hemodynamics, uteroplacental blood flow and avoidance of maternal and fetal hypoxia is paramount. While the retroperitoneal approach to the kidney for laparoscopic nephrectomy has been described, the best approach remains controversial. The transperitoneal approach affords the surgeon a larger working space while the retroperitoneal approach provides for early control of the renal vasculature and minimizes bowel and uterine manipulation, thereby potentially decreasing the risk of premature labor [154]. The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) has issued guidelines for laparoscopic surgery during pregnancy that include deferring surgery until the second trimester and maintaining low pneumoperitoneum pressures (2%

Yes

High

All patients

lymph node dissection given the technical difficulties and the potential for further and possibly unnecessary complications. Early reports of extended lymphadenectomy published complication rates of 12–24% and included lymphocele, lymphedema, and thromboembolic events. This led to development of the limited dissection template or the obturator fossa packet [20]. Clark et  al. prospectively randomized 123 patients undergoing radical retropubic prostatectomy to an extended lymph node dissection on one side and a limited lymph node dissection on the opposite side. The majority of these patients were T1c (72%) and Gleason 6 (68%). Positive lymph node metastases were similarly found between the extended (3.3%) and the limited (2.4%) groups (P = 0.15). In patients with complications attributed to the lymph node dissection (i.e. lymphocele, lower extremity edema, deep venous thrombosis, pelvic abscess, ureteral injury) the complication occurred 75% of the time on the side of the extended node dissection. Although this finding was not clinically significant (P = 0.08), the authors concluded that an extended lymph node dissection does not yield a higher rate of positive lymph nodes and that there may be a trend toward higher complications with an extended pelvic lymph node dissection [21]. On the other hand, Eden et al. describe a series of 374 men who had a pelvic lymph node dissection during laparoscopic radical prostatectomy. Of these, 253 men had a standard lymph node dissection, while 121 men underwent an extended template. The operative time for an extended template was significantly longer by a median of 26.5 minutes (180 vs. 206.5 minutes, P 40), prior episodes of peritonitis, and coagulopathy. Patients with prior abdominal surgeries can usually undergo success‑ ful MI‐RPLND after takedown of adhesions.

­Patient preparation Patients being considered for MI‐RPLND should undergo complete staging of the disease with radiographic imag‑ ing of the chest and abdomen, and tumor marker assess‑ ment including alpha‐fetoprotein, beta‐human chorionic gonadotropin, and lactate dehydrogenase. If there is a delay of more than six weeks from the initial CT scan of the abdomen to the time of surgery, it is prudent to repeat the CT to look for evidence of nodal enlargement as this may affect the clinical stage of the disease and the operative plan. Patients should be counseled that there is a possibility of conversion to open surgery due to vascu‑ lar or bowel injury and this should be clearly stated in the  informed consent. This is especially important in patients undergoing a postchemotherapy MI‐RPLND, where there can be significant fibrosis and scarring between the tumor and great vessels. The patient should also be informed of the possibility of nephrectomy as this is sometimes necessary due to tumor involvement of the renal hilum. They should be aware of the risk of blood transfusion. We routinely counsel patients that they will

be on a low‐fat diet (20 g of fat per day) for two weeks after the procedure to decrease the risk of developing chylous ascites that may require bowel rest with total parenteral nutrition and reoperation if it does not resolve. Finally, we encourage patients to bank sperm prior to surgery in the event of retrograde ejaculation. To decrease the size of the intestines and provide more working space for MI‐RPLND, patients are asked to undergo a modified bowel preparation the day prior to surgery with a clear liquid diet and magnesium citrate orally. We request that patients avoid platelet inhibitors such as aspirin and nonsteroidal anti‐inflammatory medications for seven days prior to the procedure. Patients are typed and crossed for blood in the event of acute hemorrhage during the procedure.

­Preoperative preparation Anesthesia and patient position Patients undergoing both L‐RPLND and R‐RPLND require general endotracheal anesthesia with continuous attention by the anesthesiologist to deep paralysis to maintain adequate pneumoperitoneum. A Foley catheter and orogastric tube are placed prior to positioning the patient to decompress the bladder and stomach and decrease the risk of injury during port placement as well as to provide more room in the peritoneal space for the procedure. Sequential compression stockings are placed on the lower extremities and a cephalosporin antibiotic is administered just prior to making the incision. For L‐RPLND and R‐RPLND using the lateral approach patients are placed in a 60° modified flank position with the side of prior orchiectomy up (Figure 91.1). The patients are well padded on a gel pad and the legs are supported with pillows. The arms are placed on an arm board with pillows placed between the arms, although we sometime place the arms in a “prayer” position for patients undergo‑ ing R‐RPLND. For R‐RPLND using the supine approach, patients are placed supine with the arms padded and tucked by the sides and the legs are straight with sequen‑ tial compression stockings (Figure  91.2). Because the patient is placed in a slight Trendelenburg position, a full body gel pad is placed between the patient and operating table to prevent patient movement. As with the lateral position, Foley catheter, orogastric tube, and pre‐incision antibiotics are employed. Operating room setup and equipment: L‐RPLND L‐RPLND is routinely accomplished with two assis‑ tants and a scrub nurse helping the primary surgeon (Figure  91.3). The room configuration for L‐RPLND

1067

1068

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

Figure 91.1  Lateral modified flank position for minimally invasive retroperitoneal lymph node dissection with arms on arm board.

requires the primary surgeon and the first assistant to be standing on the side contralateral to the side of prior orchiectomy. The second assistant and scrub nurse stand on the side opposite the primary surgeon and first assis‑ tant. The anesthesia team is at the patient’s head with full access to the airway and face. Video monitors are located on both sides of the patient to allow all involved personal to have an optimum view of the operative field. The first assistant’s primary role is to hold the endoscope and maintain a steady operative view. The second assistant usually controls a grasping device or retractor to provide tissue exposure. Laparoscopic instruments routinely used during L‐RPLND include endoscopic scissors, graspers, clip appliers, and blunt dissectors. A 30° endoscope is usually used. In the event of vascular injury, laparoscopic needle drivers should be available along with a “rescue stitch” to allow rapid control of bleeding if this is encountered. A rescue stitch in our experience is a 4‐0 polypropelene suture cut to 12 cm with a polymer clip on the end of the suture opposite the needle. This allows multiple throws of the needle without the need to tie the suture, although the clip can be removed and the sutured tied once bleed‑ ing is controlled if this is the surgeon’s preference. Lymph nodes are removed with the aid of an endoscopic retrieval bag that decreases the risk of potential tumor cells com‑ ing into contract with the abdominal wall or an extrac‑ tion port. Hemostatic agents are used at the end of the procedure to aid in the sealing of lymphatic changes that

Figure 91.2  Supine position with arms padded and tucked at sides.

91  Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

Figure 91.3  Room configuration for left laparoscopic retroperitoneal lymph node dissection.

r1

3

ito

n Mo

5

4

ito

on M r2

1

Figure 91.4  Room configuration for left robotic retroperitoneal lymph node dissection with da Vinci Si and the lateral approach. Robot is docked over the patient’s back.

daVinci Si

2

1. Primary surgeon 2. 1st assistant 3. 2nd assistant 4. Scrub nurse 5. Anesthesiologist

Vision ca monit rt or

4

2 1. Primary surgeon 2. Bedside assistant 3. Scrub nurse 4. Anesthesiologist

may remain open after lymph node removal. As with any laparoscopic procedure an open laparotomy set is in the room, opened and prepared in the event of rapid conver‑ sion to open surgery. Operating room setup and equipment: R‐RPLND The robotic setup will depend on whether the lateral or supine approach is used or whether the da Vinci® Si or Xi (Intuitive Surgical, Inc., Sunnyvale, CA, USA) is employed. For the lateral approach with the da Vinci Si

3

1

Surgeon’s console

the robot is docked over the patient’s back on the side of the bed ipsilateral to the orchiectomy (Figure 91.4). The bedside assist and scrub nurse are on the side opposite the robot and the primary surgeon resides at the sur‑ geon’s console. The anesthesia team is again located at the patient’s head. A second assistant is not routinely used during R‐RPLND. For the supine approach using the da Vinci Si, the robot is docked over the patient’s left shoulder after the patient is placed in a 15–20° Trendelenburg position (Figure 91.5). The bedside assis‑ tant stands on the patient’s right directed toward the head of the patient and the scrub nurse is usually on the

1069

1070

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

Figure 91.5  Room configuration for robotic retroperitoneal lymph node dissection with da Vinci Si in the supine approach. Robot is docked over left shoulder of patient.

i inc daV i S

Vis io mo n cart nito r

4

2

3

1. Primary surgeon 2. Bedside assistant 3. Scrub nurse 4. Anesthesiologist

Surgeon’s console

1

Figure 91.6  Room configuration for da Vinci Xi retroperitoneal lymph node dissection using supine approach. Robot is docked over the patient’s foot.

t ar n c or o i it s Vi on m

3

daVinci Xi

4

2

1. Primary surgeon 2. Bedside assistant 3. Scrub nurse 4. Anesthesiologist

1

Surgeon’s console

same side. The anesthesiologist will be on the right side of the patient’s head opposite the robot. The patient side vision cart holds the insufflator, electrosurgical unit, light source, and accessory energy components and can be placed in the optimum position depending on room size and configuration specific to the room. The da Vinci Xi is designed to allow docking from any position due to the presence of a rotating boom. This per‑ mits the robot to be brought in from any direction depend‑ ing on the side of the dissection and thereby simplifies

patient position and room configuration. It is also designed to allow extended reach of the robotic arms and allows multi‐quadrant access in the abdomen and is ideal for RPLND. Given these advantages, the da Vinci Xi is our preferred platform for R‐RPLND and we have abandoned the lateral position and da Vinci Si for R‐RPLND. For a left‐sided R‐RPLND using the da Vinci Xi the patient is placed in the Trendelenburg position and the robot can be brought in on the patient’s left side, right side or over the foot of the patient as shown in Figure 91.6.

91  Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

The bedside assistant stands on the right side directed up toward the head and the scrub nurse is on the patient’s left. The mirror image configuration is used for a right‐ sided R‐RPLND. The instrumentation used for R‐RPLND is much the same irrespective of the approach or which model robot used. The monopolar scissors are used in the right robotic arm, fenestrated bipolar in the left arm, and atraumatic grasper in the fourth robotic arm. For the lateral approach with the da Vinci Si, a 0° lens is used in the lateral camera position. For the supine approach with da Vinci Si or Xi, a 0° lens is used initially during exposure of the retroperitoneum and then switched to a 30° down lens during dissection of the lymph nodes. Other robotic instruments routinely used during R‐RPLND include the robotic needle drivers and the robotic clip applier. The robotic clip applier is an impor‑ tant aid for R‐RPLND as it allows clips to be applied in tight spaces and with angles that cannot be accom‑ plished by the bedside assistant. The bedside assistant uses a suction‐irrigation device throughout most of the procedure, but may be called upon to apply clips with a laparoscopic clip applier. Similar to the laparoscopic procedure we have a “rescue stitch” prepared and ready for vascular control. Lymph nodes are extracted with an endoscopic retrieval sac and hemostatic agents are applied to the dissection bed to decrease the risk of lymphatic leakage.

12 mm 5 mm

30° scope

Liver retractor

Figure 91.7  Right laparoscopic retroperitoneal lymph node dissection port configuration. 12 mm 5 mm 4th arm 0° scope

Liver retractor Assist

­Technique Access and port placement: L‐RPLND Once the patient has been sterilely prepped and draped, pneumoperitoneum is established by either an open technique using a Hasson port or a closed technique using a Veress needle. If a Veress needle is used this is usually placed in the midclavicular line below the ipsilat‑ eral costal margin to avoid the midline great vessels. For a right‐sided L‐RPLND a five‐port configuration is used as shown in Figure 91.7. A 12 mm camera port is placed in the midline midway between the xiphoid and umbili‑ cus. A second 12 mm port is used for the right hand to allow clip appliers and possibly a stapling device if nec‑ essary. The remaining ports are 5 mm located in the mid rectus muscle for the left‐hand instruments, laterally for assistance with retraction, and just below the xiphoid for liver retraction. The key for L‐RPLND is to move the ports medial relative to laparoscopic renal procedures to allow access to the midline structures such as the vena cava and aorta. A four‐port configuration is used for a left‐sided L‐RPLND as there is no need for a liver retractor.

Figure 91.8  Right robotic retroperitoneal lymph node dissection lateral approach port configuration with da Vinci Si.

Access and port placement: R‐RPLND Access for R‐RPLND is the same as for L‐RPLND and port placement varies depending on approach or which model da Vinci robot is being used. For a right lateral R‐RPLND using the da Vinci Si a six‐port configuration is used with the 12 mm camera port placed midway between the umbil‑ icus and xiphoid in the mid rectus muscle (Figure 91.8). In contrast to the lateral approach for L‐RPLND, the camera for R‐RPLND is placed lateral to the other ports to decrease external arm collision and allow more room for the bedside assistant. The left and right robotic arms are placed near the midline and the assistant is placed just medial to the line created by these two ports. The fourth robotic arm is placed laterally near the ipsilateral anterior superior iliac spine and is essential for R‐RPLND to allow retraction and to facilitate dissection behind the great vessels. A 5 mm

1071

1072

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

Vinci Xi port configuration is shown in Figure  91.10a. The ports are placed linear at a slight angle to allow room for the assistant in the left lower quadrant. The camera port and the right robotic arm port are placed on either side of the medial umbilical ligaments. The ports are placed approximately 6–7 cm apart to allow freedom of movement and avoid conflict. The robot is docked from the right side and the 30° lens is used after exposure is created. The left‐sided da Vinci Xi approach is shown in Figure  91.10b. For a full bilateral approach with the da Vinci Xi, as in the setting of postchemotherapy RPLND, the linear port configuration is not angled but placed at a right angle to the midline to allow access to both the right and left distal ureters. Figure 91.9  Supine robotic retroperitoneal lymph node dissection port configuration with da Vinci Si.

Boundaries of dissection: L‐RPLND The right‐sided template dissection performed during L‐RPLND begins with complete mobilization of the right colon and duodenum, exposing the retroperito‑ neum and great vessels. The gonadal vessels are clipped and dissected down to the internal inguinal ring where the entire cord is removed along with cord stump as indi‑ cated by retained suture. The renal pedicle establishes the upper limit of dissection while the inferior mesen‑ teric artery is the lower limit of resection medially. The lower limit of dissection laterally is the crossing of the ureter over the right common iliac artery. The modified unilateral template dissection on the right side includes removal of the precaval, paracaval, retrocaval, interaorta‑ caval, and preaortic node packages with extension to the left paraaortic nodes. The postganglionic sympathetic nerve fibers are identified coming off the sympathetic chain and are traced under the inferior vena cava on their way to the hypogastric plexus. These fibers are preserved within the template. The split and roll technique is used

subxiphoid port is placed to allow retraction of the liver. The mirror image port configuration for left‐sided R‐ RPLND is performed with the exception of the liver retrac‑ tor, which is not necessary on the left side. For supine R‐RPLND the port configuration depends on which model da Vinci is being employed. A five‐port fan configuration is utilized for da Vinci Si with the 12 mm camera port in the midline approximately 4 cm below the umbilicus (Figure  91.9). The 8 mm right robotic arm and fourth arm are placed on the patient’s left and the 12 mm assistant port is placed between the camera and the 8 mm left robotic port. This port con‑ figuration is used for both left‐ and right‐sided supine R‐RPLND using the da Vinci Si. The robotic arms on the da Vinci Xi are designed to avoid external arm conflict by placing the ports in a linear configuration without the need for port offset as com‑ monly employed with the da Vinci Si. The right‐sided da (a)

Figure 91.10  Right (a) and left (b) supine robotic retroperitoneal lymph node dissection port configuration with da Vinci Xi. For bilateral dissection the linear port array is placed horizontally below umbilicus.

(b)

30° camera 7 cm

L

4th arm R

7cm

12 mm assist

30° camera L7 cm 12 mm assist

R

7 cm

4th arm

91  Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

to remove retrocaval nodal tissue, which includes nodal tissue posterior to lumbar vessels. Care is taken to clip all lymphatic channels to prevent lymph leakage, especially the lymphatic channels crossing over the left renal vein. For the left‐sided L‐RPLND the descending colon is mobilized from the splenic flexure to the iliac vessels and medially to expose the great vessels. The gonadal vessels are once again mobilized and clipped at their proximal origin and dissected down into pelvis to remove the entire cord stump. Dissection of the paraaortic lymph nodes begins at the renal hilum and extends to the where the left ureter crosses over the common iliac artery. The postganglionic fibers on the left side are not as large as the right and can be difficult to identify and maintain. The preaortic and interaortocaval nodes are dissected from the renal hilum to the inferior mesenteric artery, which is spared. Excised tissues are removed in organ entrapment bags and sent for immediate frozen section analysis. Patients with positive lymph nodes and stage IIA or stage IIB dis‑ ease are repositioned for contralateral L‐RPLND with nerve sparing. In patients found at surgery to have stage IIC disease, the procedure is terminated after unilateral dissection and the patient is scheduled for post‐RPLND chemotherapy. Boundaries of dissection: R‐RPLND The dissection performed for the lateral robotic approach is the same as described for L‐RPLND, with the need to reposition and redrape the patient if positive nodes are found on frozen section. For supine R‐RPLND the dissection is the same with the da Vinci Si or Xi but is modified depending on the stage of the patient. To begin the dissection the retroperitoneum is exposed by incis‑ ing the posterior peritoneum medial to the cecum and extending this incision toward the ligament of Trietz. The cut edge of the posterior peritoneum is sutured to the right side of the anterior abdominal wall to provide exposure of the great vessels and retroperitoneum. The left side of the cut edge of the posterior peritoneum is likewise sutured to the left side of the anterior abdominal wall, creating a hammock‐like barrier preventing the small bowel from falling into the retroperitoneum. The combination of the suspension sutures and the Trendelenburg position provides excellent exposure. Although the suspension sutures provide the distal expo‑ sure of the retroperitoneum, the fourth robotic arm, using an atraumatic grasper, is used to retract the duode‑ num proximally and create proximal exposure. Patients with clinical stage I NSGCT undergo a unilateral template dissection with nerve sparing as described for L‐RPLND. Lymph nodes are sent for frozen section analy‑ sis and, if positive, a full bilateral dissection is performed.

For patients with postchemotherapy residual masses, a full bilateral dissection with nerve sparing is performed, including complete removal of the ipsilateral spermatic cord. With the da Vinci Si, this is accomplished by repo‑ sitioning the robot parallel to the ipsilateral leg, provid‑ ing access to the spermatic cord and internal inguinal ring. Dissection is then carried out caudally, excising the spermatic cord out of the internal inguinal ring until the remnant suture from radical orchiectomy is removed. With the da Vinci Xi, the spermatic cord is fully accessi‑ ble without the need to reposition the robot.

­Results The experience with MI‐RPLND began with L‐RPLND as case reports and then larger single and multi‐institutional series. The most extensive analysis of L‐RPLND was a review article authored by Rassweiler et al. that e­ valuated over 800 patients in 34 publications [13]. The majority of the patients underwent a modified template dissection and the mean number of lymph nodes removed across all studies was 16. Operative times were longer for L‐RPLND as compared to O‐RPLND, 208 versus 186 minutes, and complications for L‐RPLND were 15.6% with a 1.7% re‐intervention rate, both of which are comparable to O‐RPLND. Oncologic outcomes for L‐ RPLND were determined from five studies with 557 patients and a mean follow‐up of 63 months. The vast majority of patients (126 out of 140) with positive nodes after L‐RPLND received chemotherapy, and of the 14 patients who were followed, 2 patients had recurrences and were successfully salvaged with chemotherapy. Despite the large number of patients, there were no infield retroperitoneal recurrences in the area of the template dissection, although 1.4% of patients had recurrences out of the area of dissection and 3.3% of patients developed distant recurrences. There was one port site recurrence noted. Compared with O‐RPLND, there was no difference in relapse rates, percentage of patients receiving chemotherapy (29% vs. 31%), rate of salvage surgery (1.2% vs. 1.5%), and patients with no evidence of disease (NED; 100% vs. 99.7%). The authors concluded that L‐RPLND offers accurate staging and long‐term outcomes similar to O‐RPLND and that further studies should be performed to determine ­ the  therapeutic benefit of L‐RPLND in patients with low‐volume retroperitoneal disease. A multi‐institutional retrospective review of L‐RPLND from four centers of excellence was reported by Nielsen et  al. [14]. The study group included 120 patients with clinical stage I NSGCT who underwent primary RPLND employing a template dissection. Pathologically, 74 patients had stage I disease and 46 had positive lymph

1073

1074

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

nodes with stage II disease. Median lymph node count was 20 with a median count of 22 for patients with nega‑ tive lymph nodes and 15.5 for patients with positive lymph nodes. Thirty‐six of 46 (78%) with stage II disease received chemotherapy while 10 patients were observed. Of the 10 stage II patients observed, 2 had recurrence of disease, both at eight months after surgery. Both were successfully treated with chemotherapy. Of the 74 patho‑ logical stage I patients, 7 (9%) developed recurrence at a  mean follow‐up of 36.4 months, with 4 pulmonary, 2  pelvic, and 1 marker recurrence. All patients were salvaged with chemotherapy and surgery was performed for the patients with pelvic recurrence. With a median follow‐up of 29 months, there was no evidence of retro‑ peritoneal recurrence in the region of dissection. The authors concluded that in experienced hands, L‐RPLND can be performed safely and with outcomes comparable to O‐RPLND based on intermediate‐term follow‐up. The most recent experience with primary L‐RPLND for clinical stage I NSGCT was published by Hyams et al. from Johns Hopkins who reported on 91 patients over a 15‐year period [15]. The majority of patients had high‐ risk features, with 66% having lymphovascular invasion and 60% with greater than 40% embryonal carcinoma in the orchiectomy specimen. The median blood loss was 200 ml and two patients received transfusions. Operative times were not reported. There were 4 (4.3%) open con‑ versions and 4 (4.3%) intraoperative complications, including a renal vein injury and an aortic injury that were converted to open surgery. The remaining two intraoperative complications were a renal artery injury and a serosal injury both of which were repaired laparo‑ scopically. The mean length of stay was 2.1 days and there were 9 postoperative complications, 3 of which were related to lymphatic fluid leakage. Four patients experienced retrograde ejaculation. The mean lymph node count was 26.1 and 28 out of 91 patients had posi‑ tive lymph nodes. Seven of these patients were pN2 status and received chemotherapy, while the remaining 21 were pN1. Fourteen of the pN1 patients elected to receive postoperative chemotherapy and 7 were followed with no evidence of recurrence. At a median follow‐up of 38 months, no patient demonstrated a retroperitoneal recurrence and 5 of the pN0 patients developed systemic recurrence and were treated with chemotherapy. Although there a few select centers still performing L‐RPLND, the majority of MI‐RPLND has evolved to the robotic approach due to improved visibility, better access to the retroperitoneum, and more comfort in controlling bleeding encountered during dissection around the great vessels. The first report of R‐RPLND was presented by Davol et al. and demonstrated that it was technically feasible [16]. A case series of three patients with NSGCT undergoing primary R‐RPLND

was reported by Williams et  al. in 2011 [17]. Patients were placed in the lateral position and the technique described was an extension of the laparoscopic approach using the robot. All three patients underwent unilateral template dissections without complications and no positive lymph nodes. A series demonstrating the supine approach for R‑RPLND was recently published by Cheney et al. from the Mayo Clinic [18]. They reported on 18 patients, 9 with primary testicular cancer, 8 with residual masses after chemotherapy, and 1 with paratesticular rhabdo‑ myosarcoma. The supine approach was successful in 15 of the 18 patients with open conversion performed for hemorrhage, poor exposure, and robotic malfunction in three cases. Mean operative time was 311 minutes for primary R‐RPLND and 369 minutes for postchemo‑ therapy R‐RPLND (P = 0.03). Mean estimated blood loss was 100 ml for primary R‐RPLND and 313 ml for the postchemotherapy group (P = 0.13). Mean length of stay was 2.4 days and there were three minor (Clavien II) complications (17%). Mean lymph node count was 20 and lymph nodes were positive in 8 of 18 patients (44%), including 5 of 8 patients with postchemotherapy tumors and 3 of 10 patients undergoing primary R‐RPLND. No patient received adjuvant chemotherapy, and at a mean follow‐up of 22 months, there were no retroperito‑ neal recurrences, although two patients required salvage chemotherapy for pulmonary recurrence. This study highlighted the utility of the supine approach for R‐RPLND and demonstrated that a full bilateral dissection could be performed without the need for reprepping and redraping the patient. Our group recently reviewed our experience with R‐RPLND using both the lateral and supine approaches [19]. Our initial experience was an extension of our laparoscopic procedure and we quickly recognized that the robotic platform offered several advantages over the laparoscopic approach. The advantages include 3D vision with improved visibility, enhanced instrument dexterity, and most importantly, better control of major vascular bleeding. A major limitation of the lateral approach was the inability to perform a full bilateral dissection in the event of positive nodes or in patients with postchemotherapy residual masses. The supine approach using the da Vinci robot addresses this issue and allows a full bilateral dissection without redocking or repositioning the patient. It also permits a superior view of the postganglionic sympathetic fibers in those patients undergoing nerve‐sparing R‐RPLND. Our expe‑ rience includes 19 patients who underwent 20 proce‑ dures with 11 clinical stage I, 6 clinical stage II, and 3 clinical stage III patients. There were 16 primary and 4  postchemotherapy procedures with 11 lateral and 9 supine approaches. Median operative time for the group

91  Laparoscopic and Robotic Retroperitoneal Lymph Node Dissection

was 293 minutes, but was 259.7 minutes for unilateral dissections and 313 minutes for bilateral procedures. Median estimated blood loss was 50 ml and no patient required transfusion or conversion for bleeding. The median length of stay was 1 day with 14/20 (70%) of patients being discharged in less than 24 hours. Median lymph node count was 19.5. Eleven patients had patho‑ logic stage I disease and 8 patients had pathologic stage II. One of the 8 with retroperitoneal disease had clinical stage I, 6 had clinical stage II, and 1 had clinical stage III disease preoperatively. Teratoma was found in 3 patients: 2 with clinical stage II disease and 1 with clinical stage III disease. There has been no evidence of recurrence in these patients. Embryonal carcinoma was found in 5 patients, 4 of whom had pathologic stage IIA, and 1 pathologic stage IIC disease. Two of these 5 patients received chemotherapy: 1 with pathologic stage IIC dis‑ ease, and 1 with pathologic stage IIA disease who was followed and found to have a lung recurrence at four months after surgery. Three patients with pathologic stage IIA disease did not receive chemotherapy and have been followed expectantly; they have not required sys‑ temic therapy at follow‐up of 46, 47, and 91 months. There has been no evidence of retroperitoneal disease recurrence in any patient in the series at a median fol‑ low‐up of 49 months. There was one complication in the series. A ureteral transection occurred due to tumor involvement during a left‐sided R‐RPLND in clinical stage II patient. The ureter was repaired over a stent and remains patent after stent removal. Two patients who underwent bilateral R‐RPLND suffered ejaculatory dysfunction. A recent comparative analysis between L‐RPLND and R‐RPLND was reported by Harris et  al. in BJU International in 2015 [20]. They compared 21 L‐RPLND with 16 R‐RPLND performed by a single surgeon. The series represented a mature experience with L‐RPLND as compared to the early learning curve with R‐RPLND. Despite this difference in experience, the outcomes for the two MI‐RPLND techniques were essentially the same. The R‐RPLND operative time was 270 minutes versus 294 minutes for L‐RPLND, representing a differ‑ ence of 24 minutes that was not statistically significant.

Median estimated blood loss was 125 ml for L‐RPLND and 75 ml for R‐RPLND (P = 0.16). Median lymph node yield was 22 for L‐RPLND and 30 for R‐RPLND (P = 0.13). There were 2 (9.5%) postoperative complications in the L‐RPLND group and 1 (6.3%) complication in the R‐RPLND cohort. Follow‐up for both groups was too short to make any meaningful statements about onco‑ logic outcomes. The authors concluded that R‐RPLND appears comparable to L‐RPLND but at this stage it is unclear whether R‐RPLND offers any tangible benefits over standard laparoscopy.

­Conclusions MI‐RPLND has undergone an evolution with regard to both technique and intent of the procedure. Initially, L‐RPLND was performed as a staging procedure to direct adjuvant treatment in those patients with positive nodes, but with growing experience the procedure was carried out with therapeutic intent. To date, there have been many young men with pathologic stage II disease who have been cured with L‐RPLND and have avoided the sequelae of chemotherapy including neuropathy, cardiovascular disease, infertility, and secondary cancers. There have been no recurrences reported in the retrop‑ eritoneum when L‐RPLND was performed with care to remove the retrocaval and retroaortic tissues. Multiple studies have demonstrated that L‐RPLND is feasible, safe, and reproducible, with reduced surgical morbidity compared to O‐RPLND. The application of robotics to RPLND has addressed the major hurdle of L‐RPLND – the control of major ­vascular bleeding. In addition, the robotic platform has facilitated the development of the bilateral approach in patients with positive lymph nodes and opened the door for the safe application of minimally invasive surgery to postchemotherapy masses. R‐RPLND is the future of MI‐RPLND. There will be and should be continued scrutiny of MI‐RPLND, as the current standards set by O‐RPLND need to be adhered to and not compromised in the effort to reduce patient morbidity. See accompanying Video 91.1.

­References 1 Daugaard G, Petersen PM, and Rorth M. Surveillance in

stage I testicular cancer. APMIS 2003;111:76–85. 2 Amato RJ, Ro JY, Ayala AG, and Swanson DA. Risk‐ adapted treatment for patients with clinical stage I nonseminomatous germ cell tumor of the testis. Urology 2003;63(1):144–149.

3 Hermans BP, Sweeney CP, Foster RS et al. Risk of

systemic metastases in clinical stage I nonseminoma germ cell testis tumor managed by retroperitoneal lymph node dissection. J Urol 2000;163:1721–1724. 4 Donohue JP and Foster RS. Retroperitoneal lymphadenectomy in staging and treatment.

1075

1076

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

5

6

7

8 9

10

11

12

13

The development of nerve‐sparing technique. Urol Clin North Am 1998;25(3):461–468. Babaian R, Bracken RB, and Johnson DE. Complications of transabdominal retroperitoneal lymphadenectomy. Urology 1981;17:126–128. Baniel J, Foster RS, Rowland RG et al. Complications of retroperitoneal lymph node dissection. J Urol 1994;152:424–427. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Testicular cancer – nonseminoma, Version 2.2016. https://www. tri‐kobe.org/nccn/guideline/urological/english/ testicular.pdf (accessed March 2018). European Association of Urology. Guidelines on testicular cancer. Eur Urol 2011;60:304–319. Bhayani S, Ong A, Oh W et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer: a long term update. Urology 2003;62:324–327. Gerber G, Bissada N, Hulbert J et al. Laparoscopic retroperitoneal lymphadenectomy: multi‐institutional analysis. J Urol 1994;152:1188–1192. Steiner H, Peschel R, Janetschek G et al. Long term results of laparoscopic retroperitoneal lymph node dissection: a single center 10 year experience. Urology 2004;63:550–555. Rassweiler J, Frede T, Lenz E et al. Long term experience with laparoscopic retroperitoneal lymph node dissection in the management of low stage testis cancer. Eur Urol 2000;37:251–260. Rassweiler J, Scheitlin W, Heidenreich A et al. Laparoscopic retroperitoneal lymph node dissection:

14

15

16

17

18

19

20

does it still have a role in the management of clinical stage I nonseminomatuous testis cancer? A European perspective. Eur Urol 2008;54:1004–1019. Nielsen M, Guilherme L, Porter J et al. Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer. Urology 2007;70:1168–1172. Hyams E, Pierorazio P, Allaf M et al. Laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumor: a large single institution experience. J Urol 2012;187:487–492. Davol P, Sumfest J, and Rukstalis D. Robot‐assisted laparoscopic retroperitoneal lymph node dissection. Urology 2006;67:199.e7–199.e8. Williams S, Lau C, and Josephson D. Initial series of robot‐assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular cancer. Eur Urol 2011;60:1299–1302. Cheney S, Andrews P, Castle E et al. Robot‐assisted retroperitoneal lymph noded dissection: technique and initial case series of 18 patients. BJU Int 2015;115:114–120. Stepanian S, Patel M, and Porter J. Robot‐assisted laparoscopic retroperitoneal lymph node dissection for testicular cancer: evolution of the technique. Eur Urol 2016;70:661–667. Harris K, Gorin M, Allaf M et al. A comparative analysis of robotic and laparoscopic retroperitoneal lymph node dissection for testicular cancer. BJU Int 2015;116:920–923.

1077

92 Laparoscopic Radical Nephrectomy Simpa S. Salami Department of Urology, University of Michigan, Ann Arbor, MI, USA

­Introduction Laparoscopic surgery is a standard technique for the management of benign and malignant renal conditions. The first (pure) laparoscopic radical nephrectomy (LRN) was performed in 1991 by Clayman et  al. [1]. Since its inception, modifications have been made to the technique to improve perioperative, short‐ and long‐term functional and oncological outcomes. These modifications include retroperitoneal approach, hand‐assisted and robotic‐assisted techniques [2, 3]. The introduction of robot‐assisted laparoscopic surgery was rapidly adopted by urologists largely because of the improved learning curve. Although laparoscopic techniques have evolved, allowing urologic surgeons to perform minimally invasive partial nephrectomies for smaller yet complex renal masses (see Chapter 93), LRN remains the gold standard for clinically localized renal masses. This chapter will review the indications, techniques, and results for laparoscopic radical nephrectomy, including hand‐ and robotic‐assisted approaches.

­Indications for and contraindications to laparoscopic radical nephrectomy The most common indication for radical nephrectomy is kidney cancer, which accounts for 3–5% of all adult malignancies [4]. Most clinical practice guidelines, including the American Urological Association and European Association of Urology guidelines, recommend radical nephrectomy (RN; surgical removal of the entire kidney, including Gerota’s fascia, ± the ipsilateral adrenal gland) in patients with clinical stage T2, T3, or T4 renal cancer or in patients with multifocal ipsilateral renal masses without genetic predisposition [5, 6]. Although nephron‐sparing

surgery is recommended for T1 renal masses, RN may be performed in certain situations such as patient’s preference or surgeon’s inexperience (see Chapter  93). Whenever possible, however, partial nephrectomy should be performed for T1a renal masses [7]. The increased risk of cardiovascular mortality associated with decreased glomerular filtration rate (GFR) has been well documented [8]. This reduction in GFR has also been demonstrated in those who undergo radical nephrectomy for T1b lesions when compared to those who underwent partial nephrectomy [9]. Decreasing the risks associated with a compromised GFR, coupled with the sound oncologic data for nephron‐sparing surgery, has led to the recommendation for partial nephrectomy for complex or T1b renal masses [10–14]. If not amenable to minimally invasive techniques, an open partial nephrectomy should be considered [15]. LRN with or without hand or robotic assistance can be utilized for clinically localized T2 disease. Recently, these techniques have been successfully modified and popularized for advanced T3 or T4 disease [16–19]. Finally, LRN or RLRN may also be used in the setting of cytoreductive nephrectomy to reduce the overall tumor burden when the metastatic disease burden is smaller in size than tumor burden within the kidney [20]. Contraindications are the same as for open radical nephrectomy and those specific to laparoscopy in general. Patients with significant coagulopathy or comorbidities that preclude them from undergoing general anesthesia or major surgery should not be subjected to LRN. LRN is also contraindicated in patients with inability to tolerate pneumoperitoneum, such as in chronic obstructive pulmonary disease (COPD) or morbid obesity. Although previous surgery at the same site has demonstrated increased operative time and hospital stay, it is not an absolute contraindication to performing laparoscopy [21]. Previous abdominal surgery may increase risk of either

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

1078

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

complications or need for conversion to open surgery. Recent reports have been published regarding the minimally invasive management of a renal vein, inferior vena cava (IVC), or atrial thrombus, but this is limited and should only be performed in highly experienced centers [22]. Finally, advanced age is not an absolute contraindication to LRN [23].

devices are placed around the calves of the patient and initiated prior to the induction of general anesthesia. A  prophylactic dose of subcutaneous heparin may be administered.

­ reoperative evaluation and patient P preparation

Patient positioning

In general terms, the preoperative work‐up for a patient with a renal mass is no different for an LRN than that for an open radical nephrectomy (see Chapter  77 for details on patient preparation). Briefly, this includes a detailed history and physical examination, a complete blood count, serum electrolytes, coagulation profile, calcium, and alkaline phosphatase. A chest X‐ray or chest computed tomography (CT) scan is required to screen for pulmonary metastases. A bone scan is unnecessary in the absence of bone pain or an elevated alkaline phosphatase. A head CT scan is indicated in the presence of neurological symptoms. If the serum creatinine is elevated, a 24‐hour urine creatinine level and possibly a MAG3 or DMSA renal scan may be needed to assess differential renal function. Usually the patient presents with abdominal imaging demonstrating a renal mass. If abdominal imaging is inadequate, a three‐phase CT or magnetic resonance imaging (MRI) is required to document enhancement of the renal mass. Abdominal imaging may also inform operative planning and approach if multiple renal arteries are identified, for example. If there is concern for a renal vein or caval thrombus, an MR venogram should be obtained. Finally, although the evidence for lymphadenectomy in renal cell carcinoma remains inconclusive, careful attention should be paid on imaging to regional and retroperitoneal lymphadenopathy. Despite the European Organization for Research and Treatment of Cancer (EORTC) trial demonstrating no improvement in survival in those who underwent lymphadenectomy for localized renal cell carcinoma [24], others have demonstrated improved staging capability [25–27] and, in certain situations, improved survival with lymph node dissection for clinically detected lymphadenopathy [28]. The patient is kept nil per os after midnight the evening before surgery. The use of a mechanical bowel preparation is optional. Some prefer to use a bowel preparation in order to decompress the colon and small bowel for improved visualization and working space within the abdomen. A single dose of an antibiotic agent is given 30–60 minutes prior to the first incision to cover skin flora. Venous sequential compression

­Laparoscopic transperitoneal nephrectomy The patient is placed in the supine position upon arrival in the operating room. After induction of general endotracheal anesthesia, an orogastric tube and bladder catheter are inserted to decompress the stomach and bladder respectively. The location of the extraction site, usually a Pfannenstiel or an infra‐umbilical midline incision, is marked on the patient’s skin to ensure a straight incision after the patient is positioned. The patient is then carefully placed in a modified lateral decubitus position, angled at approximately 30° from the ground. The patient’s flank overlays the kidney rest, an axillary role is placed, and an additional roll is placed longitudinally along the patient’s back to support the thoracolumbar spine. The two legs are kept straight with a pillow or other padding placed behind the knees for support. Thick (silk or cloth) tape is used to secure the patient to the table (with paddings) at several points in order to prevent the patient from sliding off the table during the procedure should the table require rotating (Figure 92.1). Finally, the abdomen is prepped and draped in a sterile fashion, along with the corresponding flank in case the need arises to convert to an open procedure. Access This can be achieved in a variety of ways, including but not limited to the Veress needle or Hasson cut‐down technique, depending on the experience or comfort of the surgeon. The Hasson cut‐down technique is preferred by some surgeons, especially in cases of previous abdominal surgeries, although the utilization of Veress needle access is documented to be safe in this patient group as well [15]. The abdomen is insufflated to a pressure of 15–20 mmHg. Once sufficiently insufflated, a 10 mm reusable screw or a 12 mm disposable trocar is placed into the abdomen at the level of the umbilicus for the camera. The position of this trocar may be shifted proximal or lateral depending on the abdominal girth after sufficient pneumoperitoneum is achieved. A 0° or 30° lens is utilized depending on surgeon’s preference. The abdominal contents are inspected for any injury during access or from introduction of the first trocar. A second 12 mm trocar is placed at the level of the

92  Laparoscopic Radical Nephrectomy

Figure 92.1  Patient position for a transperitoneal laparoscopic or robot‐ assisted radical nephrectomy.

(a)

(b)

Figure 92.2  Port placement for a laparoscopic (a) right and (b) left radical nephrectomy. The extra (dotted line) 5 mm port may be utilized for liver retraction. Source: Visible Health, Inc., USA. Reproduced with permission of Visible Health, Inc.

umbilicus in the anterior clavicular line. A valveless (AirSeal®, ConMed, Utica, NY, USA) trocar system is preferred by some surgeons at this site, because of the documented stability of insufflation pressure during aggressive suctioning and reduction in CO2 consumption [29, 30]. A third, 5 mm trocar is placed approximately 8 cm cephalad to the umbilical trocar in the midline. For a right nephrectomy, an additional 5 mm port may be placed inferior to the subxiphoid process to assist with liver retraction (Figure  92.2). Again, if the patient is obese, all respective port positions may need to be placed laterally and superiorly in order to account for abdominal wall distortion. Further, for large renal masses, a 12 mm port should be considered in place of the 5 mm port to allow for maximum versatility in passing a greater

variety of instruments through any port location. Finally, if an additional port is needed for retraction, an ideal placement is in the previously marked Pfannenstiel or infra‐umbilical midline incision line. At the completion of the case, the extra port incision is extended and used to extract the specimen. Procedure The white line of Toldt is incised sharply. If electrocautery is utilized for this incision, care must be taken to avoid the risk of bowel injury from thermal spread. A plane is developed between the posterior mesenteric and anterior perirenal fat using a combination of blunt and sharp dissection. The respective colon is mobilized

1079

1080

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

medially from the iliac vessels to the respective hepatic or splenic flexure. For a right nephrectomy, the hepatic flexure is released by dividing the renocolic ligament. This allows for further medial mobilization of the colon. The duodenum is mobilized using sharp dissection. Minimal use of blunt dissection is encouraged around the duodenum to avoid inadvertent serosal injuries. Duodenal mobilization is completed after gaining adequate exposure to the IVC (also referred to as a Kocher maneuver). In the case of a left nephrectomy, the left colon is mobilized similarly with a combination of blunt and sharp dissection. The splenorenal ligament and splenophrenic attachments are divided in order to mobilize the spleen medially, en bloc with the splenic flexure, which provides medial reflection of the tail of the pancreas. This maneuver is important to minimize the risk of injury to the tail of the pancreas during left hilar dissection. Complete splenic mobilization often requires visualizing the stomach above the spleen. Finally, mobilization of the left colon is complete once the aorta is exposed. Once Gerota’s fascia is exposed, the psoas is identified, anterior to which is the ureter. Alternatively, the mid ureter can be found posterior and medial to the gonadal vein. This relationship is particularly important when tracing the ureter to the renal hilum in the case of a right nephrectomy. Care is taken to sweep the gonadal vein medially, separating it from the ureter and avoiding the risk for avulsing it from the vena cava. The ureter is kept intact, which allows it to be used as a handle for anterior and cephalad retraction of the kidney later in the case. At this point the lower pole of the kidney is mobilized within Gerota’s fascia. This has the potential for causing significant bleeding in the case of large, lower pole masses or if multiple parasitic vessels are encountered. To help facilitate lower pole mobilization with adequate hemostasis, electrocautery, any of a number of ultrasound‐based coagulation devices, or the LigaSure® (Valleylab, Boulder, CO, USA), which uses an electrical current to fuse blood vessels, may be utilized. Prior to the start of dissection, some surgeons recommend placing a small lap pad into the patient. In the event of unexpected bleeding, this can be used to improve visualization, or in the worst case scenario, tamponade bleeding to allow time for open conversion. With the lower pole of the kidney mobilized, the ureter can be traced cephalad to the renal hilum. Care needs to be taken when dissecting toward the renal hilum in the event of a lower pole accessory vessel that was not visible on preoperative imaging. Retracting anteriorly and cephalad on the kidney allows for better exposure to the renal vein and artery. Judicious use of energy‐based dissection may be required to divide the fibrous lymphatic tissue often surrounding the renal artery.

For a left nephrectomy, ensuring the left renal artery is positioned posterior to the exposed renal vein ensures that the superior mesenteric artery is not mistaken for the left renal artery. Next, when the left renal vein is isolated, the gonadal vein can be clipped and divided if necessary. Caution should be exercised at this point to prevent avulsing a potential lumbar vein draining into the posterior surface of the left renal vein. If the adrenal gland is to be taken, the left adrenal vein can be clipped and divided at this point. Once the renal artery and vein are isolated, an endovascular stapler or clips are used to secure the artery and vein. Once the artery has been divided, if the renal vein does not decompress as expected, thus raising the concern for a renal vein thrombus, or if there is a known renal vein thrombus preoperatively, laparoscopic ultrasound is employed to ensure the thrombus has retracted completely before dividing the vein. After the artery, followed by the vein, has been divided, the decision is made whether to preserve the adrenal gland or to take it with the specimen. For large, central tumors or those located in the upper pole of the kidney, removing the adrenal gland with the kidney should be considered to ensure there are negative margins or if there is any evidence of metastatic or contiguous involvement of the adrenal gland. In the case of a right nephrectomy, moving superiorly along the IVC will expose the short, right adrenal vein. Care should be taken to avoid avulsing the right adrenal vein, as this can lead to significant hemorrhage. Once divided, the use of energy‐based dissection can facilitate expeditious mobilization of the kidney and adrenal gland from the surrounding attachments and renal fossa, while securing potential parasitic vessels feeding the tumor. Care is taken superiorly to avoid inadvertent injury to the diaphragm. At this point, the ureter is clipped and divided, completely freeing the specimen. When taking the left adrenal gland, either the left renal vein can be stapled proximal to the insertion of the adrenal vein, or the adrenal vein can be clipped and divided separately. In the case of an adrenal‐sparing nephrectomy, energy‐ based dissection can be used to effectively dissect and coagulate any small feeding vessels between the kidney and the adrenal gland. Current evidence does not suggest a benefit to performing a lymph node dissection for T1 or T2 disease in the absence of clinically positive nodes [24, h 31]. However, retrospective data suggest some benefit to improved staging in those with clinically detected nodal disease [25]. Adding to the argument in favor of extended lymphadenectomy, Pantuck et  al. demonstrated improved survival in patients with metastatic disease who underwent cytoreductive nephrectomy and lymphadenectomy prior to immunotherapy compared to those who did not receive an extended lymphadenectomy [28].

92  Laparoscopic Radical Nephrectomy

Depending on the clinical situation and surgeon preference, the lymph node dissection can be performed either laparoscopically or robotically, and is not precluded based on a minimally invasive approach. Finally, the specimen is entrapped in any commercially available laparoscopic organ retrieval device. The specimen, depending on the size of the tumor, can be removed through a small extension of either the lateral or umbilical trocar incisions, or through a separate Pfannenstiel or midline infra‐umbilical incision. A few surgeons have advocated morcellation to minimize the size of the incision necessary for specimen extraction, but the potential for tumor spillage is theoretically higher [32].

L­ aparoscopic retroperitoneal radical nephrectomy Advantages/disadvantages The retroperitoneal approach to LRN may be useful in cases of prior abdominal surgeries. However, if the patient is particularly obese or has a large amount of retroperitoneal fat, proper orientation can be difficult. Improper orientation and loss of appropriate landmarks can lead to significant operative challenges and even inadvertent caval transection when mistaken for the renal vein [33]. Furthermore, previous renal surgeries or renal infections can lead to significant perirenal adhesions or scarring, making the retroperitoneal approach even more challenging. Finally, large renal masses with multiple parasitic vessels or those that may involve other organs should not be removed retroperitoneoscopically. Positioning The patient is placed in the full flank position. After the axillary roll and appropriate anterior/posterior bolsters are placed, the table is flexed to extend the space between the 12th rib and the iliac crest. The patient is secured with thick silk or cloth tape to the operative table. Procedure After the patient is prepped and draped sterilely, an incision is made off the tip of the 12th rib large enough to accommodate the surgeon’s index finger. With the oblique muscles divided, the lumbodorsal fascia is incised and the retroperitoneum is entered. The surgeon’s index finger is inserted into the retroperitoneum, and the psoas muscle and lower pole of the kidney are palpated. A commercially available balloon dilator that accommodates a 10 mm laparoscopic lens is inserted into the incision under direct vision. The potential

retroperitoneal space is dissected with the dilating balloon to a volume of approximately 800 ml. After deflating and removing the balloon, a blunt‐tipped trocar with a soft collar is placed into the incision. The soft collar on the inside of the incision helps maintain insufflation as well as prevent subcutaneous emphysema. Furthermore, this port does not project far into the working space, therefore not impairing the view of the kidney. The laparoscope is placed through this trocar. Two additional trocars are placed. A 12 mm trocar is placed lateral to the camera port and approximately 2 cm cephalad to the iliac crest. A second 5 mm trocar is placed off the tip of the 11th rib. Finally, an optional additional 5 mm port can be placed off the tip of the 10th rib. When placing the ports medial to the initial camera port, the peritoneal lining must be swept medially or inadvertent peritoneal entry and bowel injury may occur. After the 10 mm 30° lens is placed through the 12 mm inferior port, surgical orientation is achieved based upon the position of the psoas muscle and overlying ureter. At this point, the psoas muscle and tendon are dissected free of all retroperitoneal fat. Anterior and medial to the tendon will be the ureter. As with the transperitoneal approach, the ureter is traced back to the renal hilum and is used for placing traction on the kidney and hilum. Care is taken at this point as the IVC (for a right nephrectomy) or the aorta (for a left nephrectomy) is medial and in close proximity to the ureter. For a left nephrectomy, as the ureter is traced to the renal hilum, dissection should be performed bluntly with the suction irrigator in case an ascending lumbar vein is encountered entering the renal vein. If found, the vein is clipped and divided before proceeding to the renal hilum. The ureter is traced superiorly along the medial aspect of the psoas muscle. This helps to keep the dissection in proper orientation and posterior to the kidney. The renal hilum is identified based on ­pulsation of the renal artery. Gerota’s fascia is incised over the pulsation to expose the renal artery and vein. The artery and vein are isolated and divided as described for the transperitoneal approach. After the kidney has been completely freed from the renal fossa and the ureter divided, the kidney is placed in a laparoscopically deployed organ entrapment device. If the mass and kidney are small, the initial port can be extended in order to deliver the kidney. In cases where the specimen is large, a Pfannenstiel incision is made and the space of Retzius is entered. Matin and Gill described a modified Pfannenstiel incision that is lateralized to the side of the surgery [34]. Dissection is carried down to the anterior rectus fascia and a vertical incision is created along the lateral rectus border. With the fascia and rectus muscle retracted, the transversalis fascia is divided near the pubis and the extraperitoneal space is entered.

1081

1082

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

(a)

(b)

Figure 92.3  Port placement for a hand‐assisted laparoscopic (a) right and (b) left radical nephrectomy. The extra (dotted line) 5 mm port may be utilized for liver retraction. Source: Visible Health, Inc., USA. Reproduced with permission of Visible Health, Inc.

Careful blunt dissection into the retroperitoneum through the Pfannenstiel incision can allow for delivery of larger specimens through a lower abdominal incision [34]. See accompanying Video 92.1.

­Hand‐assisted laparoscopic nephrectomy Advantages/disadvantages Surgeons with limited experience in pure laparoscopy may find hand‐assisted laparoscopic nephrectomy (HALN) advantageous. It is particularly helpful when large renal masses are encountered and significant risk for intraoperative bleeding is anticipated. HALN also allows for the use of tactile sensation, which is useful in cases where the anatomy is obscured. Finally, it may also be used as a technique to convert from a pure laparoscopic approach to open. One disadvantage of this approach, however, is that it often results in a cosmetically suboptimal incision compared to the Pfannenstiel incision when used for specimen extraction. Additionally, maintaining adequate pneumoperitoneum, and thus proper visualization, may be a challenge if the hand port leaks or if the incision for the port is too long. Position and trocar placement Patient position is the same as for the laparoscopic approach. The details of trocar placement and nuances of various hand ports are beyond the scope of this chapter. Briefly, for a right nephrectomy, the hand port is placed in the right lower quadrant, a 12 mm trocar at the umbilicus, another 12 mm camera port in the midline approximately 8 cm cephalad to the umbilicus, and a 3 or 5 mm port immediately inferior to the subxiphoid

process for a liver retractor (Figure  92.3a). For a left nephrectomy, the hand port is placed immediately below the umbilicus in the midline, followed by a 12 mm trocar 8–10 cm lateral to and at the level of the umbilicus. Finally, a third 12 mm port is placed 8 cm cephalad to the umbilicus for the camera (Figure 92.3b). Procedure The white line of Toldt is incised sharply while the nondominant hand through the hand port places traction on the colon medially. After the correct plane between the colonic mesentery and Gerota’s fascia is entered, the colon is swept medially with the nondominant hand and the suction irrigator. For a right nephrectomy, the renocolic ligament is divided while the nondominant hand retracts the hepatic flexure medially. This exposes the duodenum and Gerota’s fascia. As with the pure laparoscopic approach, the duodenum is reflected sharply. At this point, a liver retractor may be placed through the subxiphoid port to elevate the liver and allow better access to the renal hilum. For a left nephrectomy, the splenorenal and splenophrenic ligaments are divided. The hand provides gentle medial traction on the spleen to allow for exposure to the upper pole. The psoas muscle is identified and the ureter and gonadal vessels are isolated. For a right nephrectomy, the ureter is retracted anteriorly with the hand while the gonadal vessels are swept medially with the suction irrigator. On the left, the vessels are taken with the ureter. The ureter is then traced toward the renal hilum. At this point, the lower pole of the kidney is mobilized and retracted anteriorly and cephalad with the hand, while the renal vessels are dissected free with a combination of blunt and energy‐based dissection. In cases where a large renal mass partially obscures the renal hilum, it may help for the surgeon to use an index finger to palpate

92  Laparoscopic Radical Nephrectomy

the renal artery. After sufficient exposure of the vein and artery is achieved, the endovascular stapler or clips are used to divide the renal artery, followed by the vein, while maintaining exposure of the renal hilum with the surgeon’s hand. At this point, the decision must be made whether to keep the adrenal or remove it with the kidney. On the right side, if the adrenal gland is to be taken with the kidney, the nondominant hand is used to retract the kidney laterally while the suction irrigator is used to bluntly dissect the adrenal vein. After the short adrenal vein is exposed, it can be clipped and divided sharply. Once divided, a combination of energy‐based dissection and finger‐fracturing of the surrounding renal attachments expeditiously mobilizes the kidney and adrenal gland. While doing this, the surgeon is also simultaneously palpating and securing parasitic vessels feeding the tumor. Finally, the ureter is ligated and divided, completely freeing the specimen. If the decision is made to preserve the adrenal gland, dissection of the adrenal is performed by retraction on the adrenal with the off‐hand and division of the adrenal gland from the kidney with energy‐based dissection. The remaining portion of the nephrectomy is completed as described above. We recommend the use of a laparoscopically deployed entrapment device for HALN. This helps protect the exposed incision from the unnecessary risk of tumor spillage/implantation. (a)

­ obot‐assisted laparoscopic radical R nephrectomy Advantages/disadvantages RLRN allows urologic surgeons with minimal laparoscopic skills to more easily transition open surgical techniques into a minimally invasive procedure. In addition, some surgeons prefer the use of robotic assistance in cases where hilar and/or retroperitoneal lymph node dissection is indicated. Disadvantages of this procedure include the lack of a haptic interface and the increased operating room costs imposed when using the robotic approach. Furthermore, operative time may be increased as a result of docking and undocking the robot [35]. The following will describe the use of the da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) for a radical nephrectomy. Positioning Robotic renal surgery can be performed both transperitoneally and retroperitoneally. For a transperitoneal approach, the robot is docked from the back of the patient at a 20° angle toward the head of the patient (Figure 92.4a). When performing retroperitoneal robotic renal surgery, the robot is docked directly over the head of the patient (Figure 92.4b). The patient is positioned in

(b)

Figure 92.4  Robot docking position for (a) transperitoneal and (b) retroperitoneal laparoscopic radical nephrectomy.

1083

1084

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

the modified lateral decubitus position as previously described for the transperitoneal approach with attention paid to the arm ipsilateral to the affected kidney. This arm should be positioned medial and cephalad, as it could limit the movement of the subcostal robotic instrument. Procedure With the patient properly positioned, pneumoperitoneum is achieved to a pressure of 15–20 mmHg, as described above. A 12 mm umbilical trocar is placed and the abdominal contents are inspected for adhesions and to rule out bowel injury after establishment of pneumoperitoneum. Two additional 8 mm robotic trocars are placed, each 8 cm from the umbilical trocar and from each other. A 12 mm assistant trocar is placed approximately 8 cm inferior to the umbilical trocar. An additional 5 mm assistant trocar is placed superior to the umbilical port if needed for organ retraction. When using the standard system, the trocars need to be spaced out further to avoid robotic arm collisions. When using the da Vinci Xi robotic series, the slimmer profile of the robot allows the trocars to be placed in  closer proximity to each other. Using the robotic Maryland forceps or fenestrated bipolar and electrocautery shears, the white line of Toldt is identified and incised sharply while the assistant is retracting medially on the bowel. Once the proper plane between the mesocolon and Gerota’s fascia is established, much of the bowel mobilization can be done bluntly. After adequate bowel mobilization, the ureter and gonadal vessels are exposed and lifted anteriorly to expose the psoas muscle. The assistant may retract anteriorly on the ureter, allowing the robotic surgeon to use both hands for additional dissection. An additional port for the robotic fourth arm could be placed and utilized for retraction. For a right nephrectomy, the gonadal vessel needs to be swept medially in order to prevent inadvertent injury to or avulsion of the gonadal vein. Blunt dissection using both robotic arms for traction–countertraction sweeping movements is performed when progressing cephalad along the psoas toward the hilum. For a left nephrectomy, the spleen is mobilized as described for the pure laparoscopic approach. In the case of a right nephrectomy, the Kocher maneuver is performed exclusively with sharp dissection in the same manner as previously described. With the lateral attachments of the kidney left in place, exposure of the hilum and renal vasculature is performed. The Maryland dissector or the fourth arm (with a Prograsp installed) is used to retract the kidney laterally to place mild traction on the hilum for dissection. The bedside assistant may also be utilized for this.

Electrocautery is often required to divide the dense lymphatic and fibrous tissue surrounding the renal artery. For large renal masses on the right, the robot may be helpful in dissecting an obscured renal artery from an interaortocaval approach. After the renal vasculature has been sufficiently exposed, the assistant inserts an endovascular stapler to divide the renal artery, followed by the renal vein. Alternatively, the assistant can ligate the vessels with clips. In addition, the robotic system allows the console surgeon to apply locking clips if the bedside assistant is unable to. With the renal vasculature divided, an adrenal‐sparing nephrectomy may be performed as indicated. After the kidney has been fully mobilized medially, it is freed from the surrounding renal fossa and lateral attachments. At this point, liberal use of electrocautery and bipolar energy through the Maryland forceps or fenestrated bipolar can help minimize bleeding from parasitic vessels. Finally, with the kidney completely free within the abdomen, the pneumoperitoneum is slowly dropped and the renal fossa observed for several minutes to inspect for bleeding. The robot is undocked and the specimen is removed through an extraction site that was marked previously on the patient.

­Results Since the original description of laparoscopic nephrectomy in 1991, the minimally invasive approach to radical nephrectomy has gained wide acceptance throughout the urologic community and is now considered the treatment of choice for isolated renal masses not amenable to nephron‐sparing surgery [32]. Compared to open surgery, laparoscopy has been shown to result in less postoperative pain, less analgesic requirement, early postoperative ambulation, faster return of bowel function, shorter hospital admissions, improved cosmesis, and overall decreased convalescence period [23, 36–40]. As urologic surgeons adopted LRN, multiple series published in the literature have reported oncologic outcomes comparable to those for open radical nephrectomy (Table 92.1). The longest current series runs over 11 years postoperatively. The overall, cancer‐ specific, and recurrence‐free survival rates at 10 years in this group were 65%, 92%, and 86%, respectively. From this series, 71% of renal masses were T1, 15% were T2, and 10% were T3a [41]. Several series have also demonstrated equivalent oncologic outcomes when comparing HALN to the open approach. Though these studies were limited by their retrospective nature, their results are nonetheless compelling [39, 42, 43]. Although RLRN should have similar outcomes to LRN, there are limited follow‐up data available.

92  Laparoscopic Radical Nephrectomy

Table 92.1  Outcomes of hand‐assisted laparoscopic (HALN), robotic‐assisted laparoscopic (RALRN), pure laparoscopic (Lap), and open nephrectomies.

Study

Cohort size

Surgical approach

Follow‐up durationa

Recurrence‐free survival (%)

Cancer‐specific survival (%)

Chung et al. [39]

54

HALN

47 months

91

94

Kawauchi et al. [42]

123

HALN

41 months

92

92

Miyake et al. [43]

63

HALN

38 months

85

92

Rogers et al. [44]

34

RALRN

15.7 months

100

NR

Berger et al. [41]

73

Lap

11.2 years

86

92

Colombo et al. [45]

48

Lap

65 months

91

91

Permpongkosol et al. [46]

67

Lap

73 months

94

97

Hemal et al. [47]

132

Lap

56 months

87

88

Portis et al. [48]

64

Lap

54 months

92

98

Saika et al. [49]

181

Lap

40 months

91

94

Tsui et al. [50] Javidan et al. [51]

b

Stage I 185

Open

47 months

NR

91

Stage IIb 57

Open

47 months

NR

74

Stage Ib 205

Open

64.5 months

NR

95

Stage IIb 53

Open

64.5 months

NR

88

a

 Mean or median.  Based on 1997 TNM Staging criteria. NR, not reported. b

­Conclusions Significant advances have been made in the field of minimally invasive surgery for kidney cancer, leading to improvements in patient convalescence, while providing comparable or equivalent oncological outcomes for

renal malignancies. With the development of robotic technology and incorporation into formal training programs, these advances can be adopted easily by those with limited laparoscopic skills, thus extending the reach of minimally invasive surgery to a greater number of patients.

­References 1 Clayman RV, Kavoussi LR, Soper NJ et al.

7 Campbell SC, Novick AC, Belldegrun A et al. Guideline

2

8

3

4 5

6

Laparoscopic nephrectomy. N Engl J Med 1991 May 9; 324(19):1370–1371. Gill IS and Rassweiler JJ. Retroperitoneoscopic renal surgery: our approach. Urology 1999 Oct;54(4):734–738. Nakada SY, Moon TD, Gist M, and Mahvi D. Use of the pneumo sleeve as an adjunct in laparoscopic nephrectomy. Urology 1997 Apr;49(4):612–613. Siegel RL, Miller KD, and Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016 Jan;66(1):7–30. Donat SM, Diaz M, Bishoff JT et al. Follow‐up for clinically localized renal neoplasms: AUA Guideline. J Urol 2013;190: 407–416. Ljungberg B, Bensalah K, Canfield S et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol 2015 May;67(5):913–924.

9

10

11

for management of the clinical T1 renal mass. J Urol 2009;182:1271–1279. Go AS, Chertow GM, Fan D et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004 Sep 23;351(13):1296–1305. Weight CJ, Larson BT, Fergany AF et al. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 2010 Apr;183(4):1317–1323. Rogers CG, Singh A, Blatt AM et al. Robotic partial nephrectomy for complex renal tumors: surgical technique. Eur Urol 2008 Mar;53(3):514–521. Touijer K, Jacqmin D, Kavoussi LR et al. The expanding role of partial nephrectomy: a critical analysis of

1085

1086

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

12

13

14

15

16

17

18

19

20

21

22

23

24

indications, results, and complications. Eur Urol 2010 Feb;57(2):214–222. Thompson RH, Siddiqui S, Lohse CM et al. Partial versus radical nephrectomy for 4 to 7 cm renal cortical tumors. J Urol 2009 Dec;182(6):2601–2606. Simmons MN, Weight CJ, and Gill IS. Laparoscopic radical versus partial nephrectomy for tumors >4 cm: intermediate‐term oncologic and functional outcomes. Urology 2009 May;73(5):1077–1082. Streja E, Kalantar‐Zadeh K, Molnar MZ et al. Radical versus partial nephrectomy, chronic kidney disease progression and mortality in US veterans. Nephrol Dial Transplant 2018 Jan 1;33(1):95–101. Mir MC, Derweesh I, Porpiglia F et al. Partial nephrectomy versus radical nephrectomy for clinical T1b and T2 renal tumors: a systematic review and meta‐analysis of comparative studies. Eur Urol 2017 Apr;71(4):606–661. de Castro Abreu AL, Chopra S, Azhar RA et al. Robotic transabdominal control of the suprahepatic, infradiaphragmatic vena cava to enable level 3 caval tumor thrombectomy: pilot study in a perfused‐cadaver model. J Endourol 2015 Oct;29(10):1177–1181. Sood A, Jeong W, Barod R et al. Robot‐assisted hepatic mobilization and control of suprahepatic infradiaphragmatic inferior vena cava for level 3 vena caval thrombectomy: an IDEAL stage 0 study. J Surg Oncol 2015 Dec;112(7):741–745. Kundavaram C, Abreu AL de C, Chopra S et al. Advances in robotic vena cava tumor thrombectomy: intracaval balloon occlusion, patch grafting, and vena cavoscopy. Eur Urol 2016 Jul 19;70(5):884–890. Chopra S, Simone G, Metcalfe C et al. Robot‐assisted level II–III inferior vena cava tumor thrombectomy: step‐by‐step technique and 1‐year outcomes. Eur Urol 2017 Aug;72(2):267–274. Flanigan RC, Mickisch G, Sylvester R et al. Cytoreductive nephrectomy in patients with metastatic renal cancer: a combined analysis. J Urol 2004 Mar;171(3):1071–1076. Parsons JK, Jarrett TJ, Chow GK, and Kavoussi LR. The effect of previous abdominal surgery on urological laparoscopy. J Urol 2002 Dec;168(6):2387–2390. Romero FR, Muntener M, Bagga HS et al. Pure laparoscopic radical nephrectomy with level II vena caval thrombectomy. Urology 2006 Nov;68(5):1112–1114. Salami SS, George AK, and Rais‐Bahrami S. Outcomes of minimally invasive urologic surgery in the elderly patient population. Current translational geriatrics and experimental gerontology reports. Curr Sci 2013 Mar 20;2(2):84–90. Blom JHM, van Poppel H, Maréchal JM et al. Radical nephrectomy with and without lymph‐node dissection:

25

26

27

28

29

30

31

32

33

34

35

36

final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 2009 Jan;55(1):28–34. Canfield SE, Kamat AM, Sánchez‐Ortiz RF et al. Renal cell carcinoma with nodal metastases in the absence of distant metastatic disease (clinical stage TxN12–M0): the impact of aggressive surgical resection on patient outcome. J Urol 2006 Mar;175(3 Pt 1):864–869. Crispen PL, Breau RH, Allmer C et al. Lymph node dissection at the time of radical nephrectomy for high‐ risk clear cell renal cell carcinoma: indications and recommendations for surgical templates. Eur Urol 2011 Jan;59(1):18–23. Blute ML, Leibovich BC, Cheville JC et al. A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma. J Urol 2004 Aug;172(2):465–469. Pantuck AJ, Zisman A, Dorey F et al. Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. J Urol 2003 Jun;169(6):2076–2083. Herati AS, Andonian S, Rais‐Bahrami S et al. Use of the valveless trocar system reduces carbon dioxide absorption during laparoscopy when compared with standard trocars. Urology 2011 May;77(5):1126–1132. Bucur P, Hofmann M, Menhadji A et al. Comparison of pneumoperitoneum stability between a valveless trocar system and conventional insufflation: a prospective randomized trial. Urology 2016 Aug;94:274–280. Minervini A, Lilas L, Morelli G et al. Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery? BJU Int 2001 Aug;88(3):169–172. Varkarakis I, Rha K, Hernandez F et al. Laparoscopic specimen extraction: morcellation. BJU Int 2005 Mar;95(Suppl 2):27–31. McAllister M, Bhayani SB, Ong A et al. Vena caval transection during retroperitoneoscopic nephrectomy: report of the complication and review of the literature. J Urol 2004 Jul;172(1):183–185. Matin SF and Gill IS. Modified Pfannenstiel incision for intact specimen extraction after retroperitoneoscopic renal surgery. Urology 2003 Apr;61(4):830–832. Hemal AK and Kumar A. A prospective comparison of laparoscopic and robotic radical nephrectomy for T12–N0M0 renal cell carcinoma. World J Urol 2009 Feb;27(1):89–94. Fornara P, Doehn C, Frese R, and Jocham D. Laparoscopic nephrectomy in young‐old, old‐old, and oldest‐old adults. J Gerontol A Biol Sci Med Sci 2001 May;56(5):M287–291.

92  Laparoscopic Radical Nephrectomy

37 Kerbl K, Clayman RV, McDougall EM et al.

38

39

40

41

42

43

44

Transperitoneal nephrectomy for benign disease of the kidney: a comparison of laparoscopic and open surgical techniques. Urology 1994 May;43(5):607–613. Parra RO, Perez MG, Boullier JA, and Cummings JM. Comparison between standard flank versus laparoscopic nephrectomy for benign renal disease. J Urol 1995 Apr;153(4):1171–1173, discussion 1173–1174. Chung S‐D, Huang K‐H, Lai M‐K et al. Long‐term follow‐up of hand‐assisted laparoscopic radical nephrectomy for organ‐confined renal cell carcinoma. Urology 2007 Apr;69(4):652–655. Hemal AK, Kumar A, Kumar R et al. Laparoscopic versus open radical nephrectomy for large renal tumors: a long‐term prospective comparison. J Urol 2007 Mar;177(3):862–866. Berger A, Brandina R, Atalla MA et al. Laparoscopic radical nephrectomy for renal cell carcinoma: oncological outcomes at 10 years or more. J Urol 2009 Nov;182(5):2172–2176. Kawauchi A, Yoneda K, Fujito A et al. Oncologic outcome of hand‐assisted laparoscopic radical nephrectomy. Urology 2007 Jan;69(1):53–56. Miyake H, Hara I, Nakano Y, Takenaka A, and Fujisawa M. Hand‐assisted laparoscopic radical nephrectomy: comparison with conventional open radical nephrectomy. J Endourol 2007 Apr;21(4):429–432. Rogers C, Laungani R, Krane LS et al. Robotic nephrectomy for the treatment of benign and

45

46

47

48

49

50

51

malignant disease. BJU Int 2008 Dec;102(11): 1660–1665. Colombo JR, Haber G‐P, Jelovsek JE et al. Seven years after laparoscopic radical nephrectomy: oncologic and renal functional outcomes. Urology 2008 Jun;71(6):1149–1154. Permpongkosol S, Chan DY, Link RE et al. Laparoscopic radical nephrectomy: long‐term outcomes. J Endourol 2005 Jul;19(6):628–633. Hemal AK, Kumar A, Gupta NP, and Kumar R. Oncologic outcome of 132 cases of laparoscopic radical nephrectomy with intact specimen removal for T12–N0M0 renal cell carcinoma. World J Urol 2007 Dec;25(6):619–626. Portis AJ, Yan Y, Landman J et al. Long‐term followup after laparoscopic radical nephrectomy. J Urol 2002 Mar;167(3):1257–1262. Saika T, Ono Y, Hattori R et al. Long‐term outcome of laparoscopic radical nephrectomy for pathologic T1 renal cell carcinoma. Urology 2003 Dec;62(6): 1018–1023. Tsui KH, Shvarts O, Smith RB et al. Prognostic indicators for renal cell carcinoma: a multivariate analysis of 643 patients using the revised 1997 TNM staging criteria. J Urol 2000 Apr;163(4):1090–1095, quiz 1295. Javidan J, Stricker HJ, Tamboli P et al. Prognostic significance of the 1997 TNM classification of renal cell carcinoma. J Urol 1999 Oct;162(4):1277–1281.

1087

1088

93 Robotic Partial Nephrectomy: Advancements and Innovations Sameer Chopra, Mehar Bains, & Inderbir S. Gill USC Institute of Urology, Keck School of Medicine, University of South California, Los Angeles, CA, USA

­Introduction Despite recent debate about whether partial nephrectomy (PN) confers any overall survival advantage over radical nephrectomy in patients with small renal masses [1, 2], the relevance and importance of nephron‐sparing surgery remains unquestioned [3–7]. Minimally invasive techniques such as robotic PN provide oncologic and functional outcomes equivalent to those from open PN while decreasing patient morbidity [7], and have increased the utilization of PN surgery in the field. Post‐PN kidney function depends primarily on the volume and condition of the remnant renal parenchyma, and secondarily upon the duration of ischemic insult during PN [8]. To minimize renal damage during PN surgery, warm ischemia time is best restricted to less than 20–25 minutes [8, 9]. During PN surgery, the amount of kidney excised strongly correlates with the ischemia time required to achieve that excision and reconstruction. Almost always, the deeper, larger, and more complex a particular renal tumor, the longer the ischemia time required to excise that specific tumor and perform the necessary renal reconstruction; conversely, the smaller and simpler the renal tumor, the shorter the ischemia time needed to perform that particular PN. Thus, the volume of kidney excised/preserved during PN is inextricably interlinked with the ischemia duration. Recent surgical innovations seek to maximize PN outcomes by optimizing surgically modifiable factors, such as minimizing/eliminating global ischemia, performing tumor excision with a thin negative margin, meticulous point‐specific parenchymal hemostasis, careful renorrhaphy, all to secure maximal preservation of vascularized, functional, normal kidney parenchyma [10]. Minimally invasive technique aside, the initial

surgical innovations for reducing warm ischemic injury during PN were “early‐unclamping” techniques, which then evolved to selective arterial clamping aimed at achieving only tumor‐specific ischemia [11] and now zero‐ischemia, unclamped techniques in an attempt to maximally retain global kidney function. While minimizing ischemia during the PN, surgical techniques such as sculpted tumor excision, with pinpoint suturing to achieve hemostasis, further minimize functional parenchymal loss [12]. In this chapter, advancements of robotic PN technique are described. These technical nuances minimize global renal ischemia, maximize normal kidney parenchyma preservation, and perform meticulous sutured renal reconstruction with minimal blood loss and complications. We also discuss imaging modalities that assist in the propagation of these techniques.

­Preoperative preparation Preoperative evaluation Preoperative evaluation for PN consists of a detailed history and physical examination, baseline laboratory values such as serum creatinine and estimated glomerular filtration rate, which is calculated using the modification of diet in renal disease formula. A three‐dimensional renal‐dedicated computed tomography (CT) or magnetic resonance imaging (MRI) scan using 0.5–2 mm slice thickness provides details about tumor location, depth, proximity to the collecting system, and renal contact surface area. Arterial and venous phases of the CT scan provide detailed depiction of the extrarenal hilar vascular anatomy.

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

93  Robotic Partial Nephrectomy: Advancements and Innovations

During the initial clinical visit, the patient is counseled as to all treatment alternatives, including active surveillance with percutaneous renal mass biopsy [13] and various interventive surgical options. Risks, benefits, potential complications, and the possibility of conversion to open surgery or radical nephrectomy are ­discussed prior to obtaining surgical consent. Antiplatelet and anticoagulant medications are ­discontinued or bridged prior to surgery, as clinically indicated. Medical and anesthesia clearance is obtained. No routine formal bowel preparation is ­p erformed prior to surgery. However, per surgeon’s preference, a clear liquid diet can begin the prior evening to surgery, with/without bisacodyl suppository or an oral saline cathartic, such as magnesium citrate or sodium phosphates. Antibiotics, such as cefazolin, are administered intravenously preoperatively. To prevent deep venous thrombosis, pneumatic compressive stockings and 5000 U subcutaneous heparin are administered 2 hours prior to the procedure and continued 8–12 hourly postoperatively. Anticoagulation is continued for up to one month after discharge, per surgeon discretion. Upon commencement of the robotic procedure, 1.52 liters of crystalloid intravenous fluids are administered to expand the intravascular volume and initiate a brisk diuresis.

(usually minimally compared with open flank surgery), and copious padding is used and positioned to support the buttocks and flank. Pillow(s) are placed between the flexed lower and straight upper leg. The upper arm rests on a well‐padded arm board (or pillows) without tension on the brachial plexus. Tape is used to secure the patient around the hips, shoulders, and thighs to ensure stability when rolling the table to facilitate bowel retraction (Figure  93.2a). Care is taken to adequately pad all pressure points and place all limbs in neutral position to minimize positioning injuries. The abdominal skin is shaved with clippers and the patient is prepped and draped in standard sterile fashion for a transperitoneal robotic surgery. An 18 Fr urethral catheter is inserted and an orogastric tube is placed. A standard time‐out is called prior to incision. Instrumentation and equipment list Equipment ●● ●● ●● ●● ●● ●● ●●

Operative room setup We use a four‐arm technique for robotic PN; use of the fourth robotic arm provides fixed traction during key maneuvers, enhanced exposure for hilum and tumor dissection, retraction of overlying perirenal fatty tissue for further exposure, less dependence on the assistant, and increased diversity of surgical maneuvers. The bedside assistant is positioned facing the patient’s abdomen, and the scrub technician is positioned behind the assistant. Video monitors are placed at the head and foot end of the patient on the side of the robot for easy viewing by the surgical team. A Mayo stand is placed next to the assistant where frequently used instruments are placed. The da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) is docked posterior to the patient with the camera arm coming in to the patient at an angle of 15° in line with the camera trocar site (described in detail below) (Figure 93.1).

Trocars ●●

●● ●● ●●

Under general endotracheal anesthesia, the patient is placed in a modified (60–70°) lateral decubitus position, with the umbilicus over a mid break in the table. An axillary roll is placed, the table is flexed as necessary

12 mm visual obturator trocar (Visiport, Medtronic Parkway, Minneapolis, MN, USA) 5 mm trocar × 2 8 mm trocars × 2 Bariatric 8 mm trocars × 2.

Assistant instruments ●● ●● ●● ●●

●● ●● ●● ●● ●●

Patient positioning

Da Vinci® Si or Xi Surgical System (Intuitive Surgical Inc.) 0° and 30° robotic scope (Intuitive Surgical Inc.) Mono‐polar scissors (Intuitive Surgical Inc.) ProGrasp™ forceps (Intuitive Surgical Inc.) Bipolar Grasper™ forceps (Intuitive Surgical Inc.) Needle drivers (Intuitive Surgical Inc.) Clip appliers (Intuitive Surgical Inc.).

●●

●●

●●

Suction irrigator device (bariatric length) Laparoscopic spoon forceps 5 mm locking atraumatic grasper Hem‐o‐lok® applier  –  bariatric (Teleflex Medical, Research Triangle Park, NC, USA) Medium (purple) Hem‐o‐lok clips (Teleflex Medical) Laparoscopic needle driver Laparoscopic scissor 15 mm specimen entrapment bag Laparoscopic Doppler ultrasound probe Surgicel® hemostatic gauze (Ethicon, Johnson & Johnson, New Brunswick, NJ, USA) FloSeal hemostatic matrix and laparoscopic applier with obturator (bariatric length) (Baxter International, Deerfield, IL, USA) Laparoscopic bulldog clamps

1089

1090

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

(a)

eo Vid nitor mo Suctioncannister Anesthesia

Robot

Assistant

Scrub nurse

Video monitor

Mayo stand

Scrub table

Tower/ cautery

Surgeon console

Figure 93.1  Operating room setup. (a) For right partial nephrectomy and (b) left partial nephrectomy.

●●

●●

●● ●●

Neurosurgical aneurysm micro bulldog clamps (Bear™ disposable vascular clamp, AROSurgical, Newport Beach, CA, USA) Mini‐vessel loops (Devon Dev‐o‐loops, Tyco Healthcare, Mansfield, MA, USA) Indocyanine dye (Akorn, Lake Forest, IL, USA) Hemovac or Jackson–Pratt.

Recommended sutures ●●

●●

4‐0 Polypropylene suture or 3‐0 polyglactin suture on an SH needle (Ethicon, Johnson & Johnson) 4‐0 Poliglecaprone or V‐Loc barbed suture (Ethicon, Johnson & Johnson)

93  Robotic Partial Nephrectomy: Advancements and Innovations

(b)

Vid mo eo nito r Suctioncannister Anesthesia

Robot

Assistant

Scrub nurse

Scrub table

Tower/ cautery

Mayo stand

Video monitor

Surgeon console

Figure 93.1  (Continued)

­ tep‐by‐step technique: robotic S partial nephrectomy Step 1: Pneumoperitoneum and trocar placement (Figure 93.2b–c) For the vast majority of tumors, we prefer a transperitoneal approach. Our trocar placement configuration

allows for treatment of all renal tumors irrespective of location, whether upper pole, lower pole, or hilar. Four robotic trocars are employed with 1–2 assistant ports. Veress needle pneumoperitoneum is established at 13–15 mmHg and the first trocar (12 mm for the Si robot; 8 mm for the Xi) is inserted on the same level of the 12th rib just lateral to the pararectus line. The robotic camera is then inserted and the peritoneal cavity inspected to

1091

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

(a)

(b)

(c) HEAD

HEAD Liv

As As

ROBOT

ROBOT

1092

Cam

Cam

As As

FEET 8 mm Regular

8 mm Bariatric

FEET 12 mm 12 mm

8 mm Regular

8 mm Bariatric

12 mm 12 mm

Figure 93.2  Patient positioning and port placement. (a) Patient positioning. (b) Port placement for a left partial nephrectomy. (c) Port placement for a right partial nephrectomy.

ensure no organ damage occurred during entry. The bariatric 8 mm trocar is located at the costal margin slightly cepahald and lateral to the pubic bone (just lateral to the medial umbilical ligament). A traditional 8 mm trocar is placed two fingerbreadths above the anterior superior iliac spine. Assistant trocars are placed in their traditional locations: one trocar between the camera trocar and uppermost robotic arm, another between the camera and the lower robotic arm. Both assistant trocars are placed slightly more medial than the other trocars. The trocar configuration should form an equilateral triangle between the camera port, the lower bariatric port, and the lateral traditional robotic port to reduce instrument clashing. For a right robotic PN, an additional incision is made at the xiphisternum for the liver retractor. In this trocar configuration, the lower bariatric trocar is the most “active” arm, regardless of laterality. The use of a bariatric, and thus longer, trocar enhances

the reach of the robotic instruments when treating upper pole tumors. Specimen retrieval typically occurs in the more caudal assistant port, though this is patient dependent. The surgical table is tilted, and the da Vinci is docked posterior to the patient with the camera arm coming in to the patient at an angle of 15° in line with the camera port. Robotic instruments are inserted into the peritoneal cavity under direct vision. Steps 2–3: Bowel mobilization and hilum dissection These are standard procedural steps for robotic PN and have been discussed elsewhere. Briefly, the Gerota’s fascia‐covered kidney and the ureterogonadal packet are visualized and retracted laterally. The main renal artery and vein are circumferentially mobilized and each is encircled with minivessel loops.

93  Robotic Partial Nephrectomy: Advancements and Innovations

Figure 93.3  CT and 3D remodeling of kidney with vasculature and tumor reconstruction. This is done to allow the surgeon to gain a complete understanding of the relevant renal arterial branches to help guide and orient the surgeon during arterial microdissection.

Steps 4–5: Hilar microdissection and superselective arterial clamping Medially located tumors and visible confirmation of interrupted perfusion

Radiologic images from the preoperative CT are carefully examined, with or without 3D reconstruction, to gain a complete understanding of the relevant renal arterial branches to help guide and orient the surgeon during arterial microdissection (Figure  93.3). The main renal artery and vein remain unclamped during this procedure. Meticulous and selective vascular microdissection of only the arterial branches (tertiary, quaternary) that supply the tumor is performed toward the tumor and into the renal sinus in a medial‐to‐lateral direction. Microdissection of the tertiary renal arterial branches is advanced by dissecting into the renal sinus and developing the peripelvic plane of Gil‐Vernet [14]. A radial nephrotomy incision is created on the concave, hilar edge of the kidney directly overlying the arterial branch that supplies the tumor (Figure 93.4). Vessel loops are used to isolate and atraumatically retract arterial branches to allow advancement of the microdissection as it approaches the tumor. As the dissection is advanced intrarenally, the radial nephrectomy incision can be extended an additional 2–3 cm if necessary. The radial nephrotomy incision should be made on the hilar edge of the kidney that overlays the anterior surface of that specific arterial branch. Once the terminal, tumor‐ supplying vessel is identified, a neurosurgical aneurysm microbulldog is placed temporarily (Figure  93.5a). This is done to confirm selective devascularization of the tumor, which is confirmed by visual inspection (normal color and turgor), “fire‐fly” indigo‐cyanine green fluorescence, and, only if necessary, color Doppler

Figure 93.4  Radial nephrotomy. A radial nephrotomy is made to increase exposure of the tumor and its vasculature, in order to facilitate superselective arterial clamping.

ultrasound (Figure  93.5b). Ongoing perfusion of the surrounding normal kidney is also confirmed. Topical papavarine can be applied onto the renal hilar vessels to counteract any vasospasm. Laterally located and intrarenal tumors

We recommend clamping of the main renal artery during PN for lateral or intrarenal tumors. This is because the arterial supply of these tumors is multidirectional, which therefore does not lend itself to selective clamping. Steps 6–8: Tumor scoring, excision, and renorrhaphy These steps are detailed elsewhere in this book. Specific steps include circumferential scoring of the tumor and

1093

1094

Section 6  Laparoscopy and Robotic Surgery: Laparoscopy/Robotics for Malignant Disease

(a)

(b)

Figure 93.5  Superselective clamping to facilitate partial nephrectomy. (a) Drop‐in color Doppler ultrasound is used to observe the blood supply to the tumor prior to superselective clamping. (b) Following application of the microbulldog, color Doppler ultrasound is again used to demonstrate the observed arterial perfusion to the tumor and all non‐tumor‐bearing kidney.

tumor excision using both electrocautery and cold scissors. The tumor is bluntly and sharply dissected off the underlying intrarenal vessels, preserving intact the larger intrarenal and hilar vessels. Hemostasis is achieved in the partial nephrectomy bed using a combination of Hem‐o‐lok clips and point‐specific parenchymal suturing. Hem‐o‐lok clips are applied to the vessels directly supplying the tumor in the deep resection bed; these are then under‐sown to prevent clip migration into the calyceal system. The collecting system is suture‐repaired with a running 3‐0 polyglactin on SH‐1 needle. Sutured renorrhaphy of the partial nephrectomy bed is performed, typically without the use of a bolster; however, a bolster can certainly be used to maximize parenchymal hemostasis, per surgeon preference. Water‐tightness of the repair is confirmed by repeat retrograde injection of dilute methylene blue through the indwelling ureteral catheter. A biologic hemostatic agent is layered onto the partial nephrectomy bed. Step 9: Completely unclamped (zero‐ischemia), “minimal‐margin” partial nephrectomy This technique has now evolved into our preferred approach, and is a technical advancement to our prior, superselective segmental arterial clamping technique described above. With this approach, all vascular clamping is completely eliminated; there is no requirement for vascular microdissection or use of microbulldog clamps. In addition, tumor excision is performed with a minimal‐ margin (1–2 mm) adjacent to the capsular edge. This technique is based on the following anatomic considerations: (i) intrarenal architecture, both parenchymal and vascular, is radially oriented; (ii) the vast majority of small clinical T1 renal tumors possess a distinct intrarenal pseudocapsule; (iii) the tumor–parenchyma interface

is histologically altered with sclerotic changes; and (iv) the intrarenal arteries at this junctional interface immediately adjacent to the tumor edge are typically smaller in diameter and fewer in number. These facts form the reasoning for performing a sculpted enucleo‐ excision in the plane immediately adjacent to the tumor capsule – the “minimal‐margin” plane. The purpose of this technique is to maintain a uniform, 1 mm section of benign parenchymal tissue on the tumor capsular surface, without denuding the capsule, which occurs during traditional tumor enucleation. The renal parenchyma is scored approximately 2 mm from the tumor edge under ultrasound guidance using electrocautery. With the fourth robotic arm, the perirenal fat directly overlying the tumor is retracted, thus elevating the tumor from the kidney. A radial nephrotomy incision is deepened along the cephalad and caudal edges of the tumor, each about 2–3 mm in length. This is done along the scored margin with electrocautery at a setting of 100 W. This bloodless incision is further developed by placing the tip of the robotic bipolar forceps in the left robotic arm into the nephrotomy incision and gently and deliberately opening its jaws (Figure  93.6). This opens the parenchyma along the naturally existing radial plane adjacent to the tumor with cold dissection; point electrocautery is used only sparingly to coagulate any small intrarenal vessels and to guide the enucleative plane. The capsular incision is developed circumferentially around the tumor and then deepened with blunt dissection; the robotic forceps is used to retract the tumor away, off the partial nephrectomy bed. It is important to note that the renal parenchyma is bluntly separated and not incised during the excision. This allows for the dissection to be kept along the natural, relatively avascular intrarenal plane, minimizing injury to the interlobar vessels. If there are any larger intrarenal

93  Robotic Partial Nephrectomy: Advancements and Innovations

Figure 93.7  Intravenous indocyanine green dye is used to confirm tumor devascularization and ongoing global perfusion to the remaining normal kidney parenchyma. Figure 93.6  “Minimal‐margin” partial nephrectomy. The bloodless incision is further developed by placing the tip of the robotic bipolar forceps in the left robotic arm into the nephrotomy incision and gently opening its jaws. This opens the parenchyma along the naturally existing radial plane adjacent to the tumor with cold dissection; point electrocautery is used only sparingly to coagulate any small intrarenal vessels and to guide the enucleative plane.

vessels feeding the tumor, these can be specifically dissected and controlled with a Hem‐o‐lok clip before transection. During this procedure, two suction apparatuses are required, one for parenchymal compression and one for suction and irrigation. The assistant at bedside uses the suction cannula to compress any bleeding vessels transiently, while point‐specific suturing is performed to secure hemostasis. Once completed, the calyceal system is repaired in a water‐tight manner using 3‐0 polyglactin on an SH‐1 needle. Step 10: Near infrared fluorescence using indocyanine green Similar to the use of Doppler ultrasound to help facilitate superselective PN, intravenous indocyanine green dye is used to confirm tumor devascularization. It can also be used simultaneously to confirm ongoing global perfusion of the remaining normal kidney, providing visual confirmation that the clamping of the terminal artery does not compromise vascularity of the nontumor, normal kidney (Figure 93.7).

­Postoperative management Following the procedure, the patient is restricted to a clear liquid diet initially and advanced as tolerated. On postoperative day 1, parenteral antibiotics are discontinued and ambulation is encouraged throughout the hospital stay. The Jackson–Pratt (JP) drain is removed once the JP output has decreased to 13 Qmax 80 mL) benign prostatic hyperplasia: results of midterm follow‐up from Chinese population. BMC Urol 2015;15:33. Bilhim T, Pisco JM, Furtado A et al. Prostatic arterial supply: demonstration by multirow detector angio CT and catheter angiography. Eur Radiol 2011;21(5):1119–1126. Pancholy S, Coppola J, Patel T, and Roke‐Thomas M. Prevention of radial artery occlusion‐patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72(3):335–340.

1495

Part 3  Focal Therapy Lower Tract

130 The Role and Methodology of Multiparametric MRI and Fusion‐guided Biopsy in the Management of Prostate Cancer Patients Raju R. Chelluri,1 Arvin K. George,1,2 Joseph A. Baiocco,1 Baris Turkbey,3 & Peter A. Pinto1 1

Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA Department of Urology, Division of Urologic Oncology, University of Michigan, Ann Arbor, MI, USA 3 Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA 2

­Introduction The current standard for prostate cancer (PCa) diagnosis is transrectal ultrasound (TRUS)‐guided biopsy to obtain 12 cores of tissue from the prostate in a systematic fash­ ion. Systematic biopsy refers to standardized geographic sampling of regions, but this method is “blind” to specific areas that may harbor disease. Since the advent of pros­ tate specific antigen (PSA), TRUS biopsy data have shown that a proportion of PCa diagnosed is low risk, clinically indolent, and portends an excellent prognosis [1]. Given the current lack of comprehensive under­ standing of PCa biology, such early detection may lead to the overtreatment of cancers unlikely to affect a man in his lifetime. This is compounded by the underdetection of high‐risk cancers that may be missed given the current limitations of TRUS‐guided biopsy. There remains a need for interventions to better distinguish between clinically actionable disease that contributes to prostate cancer‐specific patient mortality and those that can be actively monitored safely. Unfortunately, there is no sin­ gle modality that provides cost‐effective, rapid, high‐­ resolution imaging to define potential PCa targets. Targeted prostate biopsy, derived from regions of inter­ est identified on magnetic resonance imaging (MRI) may provide such an opportunity. TRUS offers real‐time imaging while sacrificing spatial image quality, whereas MRI offers high‐resolution imaging to better delineate discrete lesions. Fusion of multiparametric MRI (mpMRI), which combines anatomic and functional sequences, with real‐time TRUS now facilitates a more precise prostate biopsy resulting in improved PCa ­diagnosis, risk stratification, and staging.

This chapter reviews the general paradigm of mpMRI‐ TRUS fusion biopsy (FBx), its indications, and provides an overview of the workflow for this novel technology. Finally, we will review the commercially available mpMRI‐TRUS FBx platforms on offer.

­Multiparametric prostate MRI The initial and most critical step in the process remains image acquisition. “Multiparametric” MRI refers to the combined anatomic and functional phases obtained, which are: T2‐weighted (T2W) anatomic sequences (T1 is also used as described later), diffusion‐weighted imag­ ing (DWI), and dynamic contrast‐enhanced (DCE) sequences (Figure  130.1) [2]. Magnet strength is either 1.5 or 3.0 tesla (T), with higher field strengths generally allowing for higher signal‐to‐noise ratios and spectral resolution, potentially facilitating higher spatial resolu­ tion. A body surface coil must always be used during image acquisition; although the images can be further augmented with an endorectal coil, this is not required [3]. The advantages of endorectal coil use are improved scan quality and improved PCa staging [3]. Yet coil use comes with associated costs, namely increased time of procedure, and significantly more patient discomfort. Dual coil use (surface and endorectal) has been shown to have a sensitivity of 76% and a positive predictive value of 80% for PCa detection, as compared to surface coil alone with a sensitivity of 45% and a positive predictive value of 64% [4]. Image interpretation relies on findings noted in cor­ responding locations across mpMRI sequences that

Smith’s Textbook of Endourology, Fourth Edition. Edited by Arthur D. Smith, Glenn M. Preminger, Louis R. Kavoussi, and Gopal H. Badlani. © 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/smith/textbookofendourology

1496

Section 7  Image-guided Diagnostics and Therapeutics: Focal Therapy Lower Tract

(a)

(b)

(c)

(d)

Figure 130.1  Representative multiparametric MRI images. (a) T2‐weighted axial; (b) apparent diffusion coefficient maps of diffusion‐ weighted imaging; (c) dynamic contrast‐enhanced; (d) high b‐value diffusion‐weighted imaging. Patient was 66 years old, PSA of 14.61, and history of negative standard biopsies. A large lesion is seen in the right to midline mid‐base peripheral zone (2.5 cm). This lesion has slight capsular bulge and a broad capsular base but no direct extracapsular extension. Seminal vesicles (SV) show possible invasion. Fusion‐guided biopsy confirmed Gleason 4 + 5 (9), with SV invasion.

are integrated to provide a diagnostic impression [5]. T1‐weighted imaging, which is a basic pulse sequence that produces images in which water‐filled compart­ ments are hypointense, is used to detect prior biopsy‐ related residual hemorrhage that may obscure suspicious lesions. T2‐weighted imaging defines organ architecture,

including the peripheral (PZ) and transition zones (TZ), as well as the central gland (CG), urethra, semi­ nal vesicles, and capsule. Lesions suspicious for PCa appear darker in the PZ compared to normal tissue; by contrast in the TZ lesions will be hypointense and more heterogeneous [3].

130  Multiparametric MRI and Fusion-guided Biopsy

DWI is a measure of the ability of water to diffuse freely within the organ. PCa lesions do not adhere to typical prostate architecture, with closer arrangement of cells and denser stroma. Thus the apparent diffusion coefficient (ADC) map, which is a display of ADC values for each voxel of an image, is lower for PCa lesions than for normal prostate parenchyma. “High b‐value” images, which use b‐values of ≥1400 s/mm2, can also be used to attempt to improve the detection of clinically significant PCa via identifying significant restriction of movement and thus lesions will appear bright/hyperintense [3]. The amount of diffusion restriction has been associated with PCa grade and reflects the biological aggressiveness of the lesion [3]. The final sequence is DCE. This is obtained through the venous injection of gadolinium‐based contrast, with scanning taking place before, during, and after adminis­ tration. T1 sequences are used to detect the speed with which contrast arrives at the lesion, reflecting hypervas­ cularity. Focal early hyperenhancement and early wash­ out of the lesion implies malignancy, yet caution must be undertaken as benign conditions (BPH, prostatitis) may also produce similar findings. DCE has the most utility in the setting of recurrent PCa after definitive surgical, ablative, or radiotherapy [3]. mpMRI imaging is sensitive for the detection of clini­ cally actionable, aggressive, PCa. Although each param­ eter has its own sensitivity and specificity, a meta‐analysis of combined mpMRI has a sensitivity of 0.74 (95% confi­ dence interval (CI) 0.66–0.81), and a specificity of 0.88 (95% CI 0.82–0.92) [6]. Correlation with pathology has shown a positive predictive value of 98–100% in detect­ ing PCa [7]. Furthermore, mpMRI‐TRUS FBx has been shown to be less sensitive for detecting low‐risk lesions, a potential advantage that may be exploited to avoid overdiagnosis of clinically indolent disease [8]. Once the MRI is completed, postprocessing of images is performed to delineate the borders of the prostate, suspicious lesions, assign suspicion scores to each lesion. Suspicion scores reflect the likelihood that clini­ cally significant cancer is present. Although multiple scoring systems have been developed (Likert, NIH scor­ ing system), a consensus has arrived via the Prostate Image Reporting and Data Systems version 2.0 (PI‐RADS 2.0) to standardize image interpretation and  reporting [3]. Lesions are scored from 1 to 5 based on the number and severity of imaging findings (Figure  130.2). Increasing scores have been demon­ strated to be associated with increasing detection of clinically significant PCa [9]. Due to the respective can­ cer diagnostic yield, recent recommendations advise lesions scored 1 or 2 do not need biopsy, while 4 or 5 do require biopsy. A suspicion score of 3 may require biopsy based on clinical findings [10]. The score assignment is

different based on the anatomic area (PZ vs. TZ). Scores for the various parameters are based on lesion size, hypo/hyperintensity (based on location and parameter), heterogeneity, and morphology (Figure 130.2).

­Magnetic resonance–transrectal ultrasound fusion‐guided biopsy Two major FBx techniques exist: cognitive fusion and mpMRI‐TRUS FBx. “In‐gantry” MRI biopsy is a targeted biopsy method that was initially employed; the patient is sedated and scanned within the MRI apparatus during sampling; thus this method is time consuming, costly, and requires special equipment. Because of this it is not feasible for broad use. Cognitive fusion is where the sur­ geon interprets the MRI and attempts to mentally target, on ultrasound, a lesion identified on MRI. Although the literature is not in full agreement, cognitive fusion is heavily operator dependent and requires extensive knowledge of prostate anatomy and image interpretation [11]. We focus this chapter on the mpMRI‐TRUS FBx method. This method and its delivery platforms have two distinct advantages: (i) targeted biopsy based on imaging; (ii) tracking of biopsy needle trajectories for repeat biopsies and management planning (i.e. surgical/ focal therapy planning based on lesion location). These systems semi‐automatically merge the real‐time TRUS image to the preanalyzed MRI, and allow for targeting of lesions and storage of biopsy needle trajectory. Indications for fusion biopsy There are recently described defined indications for the use of mpMRI and FBx in the management of PCa; how­ ever, the use of this novel technology is still an active area of research and its indications are evolving and expand­ ing rapidly. Currently four potential clinical scenarios for using mpMRI‐TRUS FBx exist and have been recently described in the National Comprehensive Cancer Network Guidelines: Biopsy‐naive patient who has suspicion of PCa

This indication describes using mpMRI in the initial workup of a patient who may have PCa, but has yet to be worked up and diagnosed by a urologist [12]. This is an area of great interest with a limited but growing body of data to support the use of mpMRI‐TRUS FBx in the ini­ tial biopsy setting. Pokorny et  al. published a report in 2014 which found that mpMRI‐TRUS FBx, when per­ formed in men with suspicious mpMRI lesions, increased the detection of intermediate/high‐risk PCa by 17.7%, while concomitantly reducing the detection of low‐risk PCa by 89.4% as compared to standard TRUS biopsy

1497

1498

Section 7  Image-guided Diagnostics and Therapeutics: Focal Therapy Lower Tract

(a)

Peripheral zone lesion

Final PI-RADS category

DWI score

1

No abnormality seen on DWI and ADC

1

2

Indistinct hypointensity on ADC

2

3

Focal mild/moderate hypointensity on ADC and isointense/mild hypersensitivity on high b-value DWI

Negative

4

5

Dynamic contrast enhancement

Focal markedly hypointense on ADC and markedly hyperintense on high b-value DWI;1.5 cm in maximal dimension or definite extraprostatic extension/invasive findings

focal and early enhancement

3

Positive focal and early enhancement 4

5

Figure 130.2  Prostate Image Reporting and Data Systems (PI‐RADS) version 2.0 scoring system. This system assigns suspicion to prostatic lesions detected on multiparametric MRI for (a) the peripheral zone (PZ) and (b) the transition zone (TZ). DWI, diffusion‐weighted imaging; ADC, apparent diffusion coefficient; T2W, T2‐weighted; BPH, benign prostatic hyperplasia.

(SBx) alone [13]. In contrast, Tonttila et al. published a randomized control trial of 130 men comparing SBx to mpMRI and cognitive FBx, and found that FBx did not improve PCa detection [14]. Using the Artemis (described later) mpMRI‐TRUS FBx system Mendhiratta et al. found in a cohort of biopsy naive men that mpMRI‐ TRUS FBx detected more Gleason Score (GS) ≥7 PCa than SBx (P = 0.037), and that most of the PCa found by SBx was low risk [15]. Continued suspicion of PCa despite a prior negative TRUS biopsy

This indication is for using mpMRI‐TRUS FBx to iden­ tify areas that may have been missed or undersampled during an initial SBx. A common presentation is a patient who has a rising PSA in light of a totally negative initial TRUS‐guided biopsy [10]. Anatomic areas that mpMRI‐ TRUS FBx has shown utility for PCa detection include

the anterior prostate [16], distal apex [17], and subcapsu­ lar prostate [18]. Vourganti et al. reported in 2013 that mpMRI‐TRUS FBx discovered PCa in 37% of men who had a prior negative SBx, and that 11% had high‐grade (≥GS 8) PCa that went undetected on SBx conducted at the time of FBx [19]. To investigate whether repeat standard biopsy is needed at the time of mpMRI‐TRUS FBx, Salami et al. found in 2015 that FBx was more likely to identify clinically significant (GS ≥7, or GS 6 with >2 cores positive and/or >50% of any core involved) PCa as compared to standard biopsy (P