Endocytoscopy: novel endoscopic imaging technology for in-situ observation of bladder cancer cells

BACKGROUND AND PURPOSE

Recent advances in endoscopy have enabled microscopic imaging of live bladdercancer cells in situ. The newly developed Endocystoscopy system (Olympus Medical Systems Co., Tokyo, Japan) is a flexible digital endoscope that has more than a 450-fold magnifying power on a video monitor.

PATIENTS AND METHODS

This supermagnifying endoscope was used to evaluate bladder carcinoma in five patients through the working channel of a rigid cystoscope.

RESULTS

The cell structure and nuclear morphology were imaged adequately compared with conventional hematoxylin and eosin staining of a biopsy specimen. The tumors were graded correctly in four of five cases.

CONCLUSION

This novel technology appears to be useful for histologic diagnosis during endoscopic examinations, potentially allowing us to avoid a conventional biopsy.

Bladder perforation of the tension-free vaginal tape detected with a flexible cystoscope

A 67-year-old woman who presented with stress urinary incontinence underwent a tension-free vaginal tape (TVT) operation. Postoperatively, she complained of urgency, gross hematuria and dysuria, which persisted for one week. Cystoscopy with a flexible cytoscope revealed penetration of the bladder wall by the tape, which had been missed during the TVT procedure by rigid cystoscopy. After the penetrating portion of the tape was excised, her symptoms were resolved and continence was preserved. This case suggests that employment of a flexible cytoscope is useful to detect the placement of tape in the bladder wall, which may be missed with a rigid cytoscope.

A new minimally invasive technique for treating radiation cystitis: the argon-beam coagulator

OBJECTIVE

To assess the effectiveness of the argon-beam coagulator used endoscopically for treating radiation cystitis, as radiotherapy is commonly used for treating pelvic tumours of urological origin, but intractable bleeding related to radiation cystitis remains a serious complication and requires a difficult long-term follow-up, for which cystoscopic methods of management have traditionally had limited success.

PATIENTS AND METHODS

We assessed seven patients with radiation cystitis; they were treated with argon-beam coagulation after a cystoscopic evaluation.

RESULTS

With a mean follow-up of 15 months, one treatment was used in six patients, with a second treatment required in one.

CONCLUSION

The argon-beam coagulator appears to be a safe, well tolerated and minimally invasive treatment in patients with radiation cystitis.

[Ultrasound role in assessment of vesicoureteral reflux endoscopic treatment results]

INTRODUCTION

Since the beginning of the application of the RVU treatment, the use of the ultrasound was used taking into account two main indications/symptoms: a) identification of the complications; b) assessment of the result (visualization of the implanted material and the presence of the "uretheral jet" by means or through/of ecodoppler-color).

OBJECTIVE

To determine the value of the ultrasound in the assessment of the result of the endoscopic treatment of the RVU and in the detection of its complications.

MATERIAL AND METHOD

From 2001-2002 we have carried out the endoscopic treatment to an overall of 261 ureteral units of all degree and etiology. 246 were assessed post-operation with an ultrasound per month and all of them were evaluated with a cistography after 3 months. In a random sample of 92 units, the result of the isotopic cistography has been compared with the visualization of the implanted material in the bladder; and in a random sample of 56 units, the result of the isotopic cistography has been compared with the presence of ureteral jet in the study with ecodoppler-color after moisturizing of the patient. In order to do, we have done two corresponding comparative charts 2 x 2 and we have calculated the Sensibility and Specificity of the tests, as well as their predictive positive and negative values, the degree of similarity of both tests with the Kappa index, and the degree of statistical relevance with Chi squared.

RESULTS

The ultrasound did not show significant changes if compared to previous studies in 213 units (86,58 %) although in 5 patients an ectasia has been identified as attributed to the treatment. 3 of this patients have developed renoureteral pain, and in 2 pain has spontaneously disappeared as shown in later tests. The S and the E of the presence of implanted material is 94% and 10%respectively and its VPP and VPN of 80% and 10% and estadistical. The S and E of the jet visualization is 82% and 30%, with a VPP of 84% and a VPN of 27%, a level of statistical relevance of 0.836 and a degree of correlation of 0.121.

CONCLUSIONS

Ultrasound is not a useful technique in the assessment of the result of the endoscopic treatment of the RVU. The role it plays in the assessment of complications is a small one and its use is only indicated to confirm the suspicion of ectasia in those patients that present renoureteral pain.

Vaginal revision of intravesical tension-free vaginal tape 44 h after initial placement: a case report

Unintentional cystotomy is a known complication of the tension-free vaginal tape procedure and is commonly diagnosed intraoperatively. Delayed diagnosis does occur and various reparative techniques have been described, some requiring laparotomy with intentional cystotomy and repair. We report a case where a 46-year-old woman underwent vaginal reconstructive surgery including placement of a tension-free vaginal tape, which was complicated by unilateral cystotomy. A delayed diagnosis of intravesical tape placement was made requiring reoperation. The patient underwent a minimally invasive transvaginal procedure for removal and immediate replacement of the malpositioned arm of the tape. We conclude that a transvaginal approach may be an acceptable technique for revision and replacement of the tension-free vaginal tape where cystotomy is identified within 44 h after the initial procedure. With this technique, a more invasive surgery including laparotomy with cystotomy might successfully be avoided.

[Injections of botulinum toxin a into the detrusor vesicae for treatment of refractory detrusor hyperactivity in non-neurological patients]

PURPOSES

Botulinum toxin has been recognised as one of the strongest toxins since its discovery approximately 190 years ago. As the first describer, Scott performed medical therapy with botulinum-A-toxin in 1980. Since that time the spectrum of indications for the drug has increased constantly. Urologists use it, e. g., for treatment of detrusor hyperreflexia in neurogenic bladders. Several groups have evaluated the efficacy of the substance in patients with an anticholinergic-refractory detrusor hyperactivity without neurological disease.

MATERIALS AND METHODS

The present authors have analysed 16 cases with this symptoms-complex treated with intravesical botulinum-A-toxin injections.

RESULTS

No severe side effects were observed. The urodynamic parameters of the bladder were improved clearly in all patients, subjective satisfaction was reached in 72.7 %.

Milestones in endoscope design for minimally invasive urologic surgery: the sentinel role of a pioneer

Endoscopically based techniques have revolutionized the entire field of surgical specialties over the past 50 years. Currently, minimal access surgery is commonplace for considerable segments of surgical procedures across specialty lines. Central to this revolution, and arguably foremost in its impact on the development of minimally invasive endoscopic surgery, was the development of the rod-lens optical system by Professor Harold H. Hopkins and the almost simultaneous development of the fiberoptic cold-light light source by Karl Storz. It was George Berci who acted as the catalyst in bringing these two men together in the early 1960s, and from that meeting ensued one of the most successful cooperations in the design of endoscopic equipment. Innovative surgeons quickly recognized the enormous potential of these inventions, and in this context, George Berci's work and vision provided the hallmark events leading to the clinical applications from which surgeons and their patients so greatly benefit currently. In urology, Berci's early work has been recognized as a sentinel event bringing endoscopic endoluminal surgery from the lower urinary tract (urethra, bladder, prostate) to the upper urinary tract (ureter, kidney), and eventually to extraluminal laparoendoscopic surgery. This work has been recognized by the Journal of Urology as a "milestone in urology" leading to the clinical application in the field of endoscopic surgery currently referred to as endourology. In this article, the current state-of-the-art urologic surgery for the management of stone disease, urologic tumors, and anatomic abnormalities is presented, which to a great extent has its roots in George Berci's contributions to the field of innovative endoscope design.

Novel everting urologic access sheath: potential advantages of decreased cellular advancement

BACKGROUND AND PURPOSE

Axial forces are imposed on the urothelium during advancement of instruments across the urinary tract, potentially transferring cellular debris, bacteria, or urothelial carcinoma from one anatomic location to another. A prototype access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) was created that everts and radially dilates but does not provide axial forces during deployment that can be used in a variety of anatomic systems. We created a urinary-tract model to evaluate the in-vitro advancement of cells to compare this technology with using instruments alone.

MATERIALS AND METHODS

Blocks of sterile agar were created with 17F tracts of three lengths (2.7, 5.5, and 11 cm) with 5 mL of Luria-Bertani broth/ampicillin solution in a well at the end. The tips of a Cystoglide sheath and a traditional urologic instrument of the same diameter were dipped into a suspension of ampicillin-resistant Escherichia coli and advanced through the tracts. After a 10-second exposure, 4 mL of broth was collected and cultured. Bacterial growth was compared by measuring the optical density (OD) of the broth at multiple time points.

RESULTS

The mean overall OD of the broth was significantly lower (P < 0.001) in the novel-sheath cultures than with a traditional instrument for all advancements at all tract lengths.

CONCLUSION

The Cystoglide sheath significantly reduces the advancement of cells within an artificial urinary tract compared with a non-everting instrument. Clinical studies are needed to assess the utility of this technology in vivo.

Use of resectoscope to aid in bladder stone extraction

We describe a modified technique of standard cystoscopic manipulation to facilitate bladder stone extraction. This technique decreases the overall time required for stone manipulation by allowing larger size stone fragments to be removed from the urethra under direct visualization.

Sterile disposable sheath system for flexible cystoscopes

Flexible cystourethroscopy is an accepted routine procedure in urology. The sterilization of instruments is time consuming and may damage flexible instruments. However, it must be performed to prevent contamination of the endoscopes. This study is the first to document experience using a flexible cystoscope with a disposable sheath in a urologic setting.

Comparison of optical resolution with digital and standard fiberoptic cystoscopes in an in vitro model

OBJECTIVES

To compare two different distal sensor flexible endoscopes with standard fiberoptic cystoscopes for optical resolution. Distal video sensor flexible endoscopy may represent the cusp of a new endoscopic revolution.

METHODS

Twenty-three participants evaluated the optical resolution capabilities of six flexible cystoscopes. The two presently available distal sensor flexible cystoscopes, ACMI DCN-2010 digital flexible cystoscope and Olympus CYF-V EndoEYE flexible video cystoscope, were compared with the four leading fiberoptic cystoscopes, ACMI ACN-2 fiberoptic cystoscope, Olympus CYF-4 Cystofiberscope, Karl Storz 11272CU1 Flexible Cystoscope, and Richard Wolf Flexible Fibre Urethro-Cystoscope, in an in vitro model. The participants recorded the numerical digits they were able to visualize through five solutions with progressively increasing concentrations of hematoxylin dye (C1 to C5). The cystoscopic images were viewed on a 13-in. medical grade Olympus monitor with an Olympus Visera camera system.

RESULTS

No differences were detected among the cystoscopes at the lowest concentrations of hematoxylin dye (C1 and C2). At C3 to C5, the mean percentage of visualized numbers for the ACMI and Olympus distal sensor flexible cystoscopes was significantly greater than for all fiberoptic cystoscopes (P <0.01). At the highest concentration (C5), the ACMI distal sensor cystoscope performed significantly better than did the Olympus distal sensor flexible cystoscopes (P <0.01), although at all other concentrations, the two digital video cystoscopes performed equivalently.

CONCLUSIONS

The results of this in vitro study suggest that cystoscopes with distal sensor technology improve visibility in a simulated challenging working environment compared with fiberoptic cystoscopes.

Use of Amplatz sheath in male urethra during cystolitholapaxy of large bladder calculi

Large-burden bladder stones often require percutaneous cystolithotomy or an open procedure. These approaches may not be feasible in certain patients who are at increased risk of operative complications. We present a novel technique for transurethral cystolitholapaxy using Amplatz sheath in the male urethra.

Simplified Bladder Botulinum-Toxin Delivery Technique Using Flexible Cystoscope and 10 Sites of Injection

Recently, the use of botulinum toxin A has been extended to patients with non-neurogenic urologic disorders such as refractory idiopathic overactive bladder. We describe a modification of our original injection technique that allows one to deliver botulinum toxin into the bladder quickly and efficiently in an office setting with reliable results and no local or systemic side effects.

Flexible Cystoscopy Assisted by Hexaminolevulinate Induced Fluorescence: A New Approach for Bladder Cancer Detection and Surveillance?

OBJECTIVE

The aim of this study was the assessment of flexible cystoscopy assisted by hexaminolevulinate (HAL) fluorescence.

METHODS

This study was a prospective controlled, within-patient comparison of flexible HAL cystoscopy with standard flexible cystoscopy, HAL rigid and standard white light rigid cystoscopy. Eligible patients received an intravesical instillation of 50 ml hexylaminolevulinate 8 mM solution. First flexible than rigid cystoscopy was performed in each patient using a Combilight PDD system (Richard Wolf, Germany), which provided standard white light and blue light at 375 to 440 nm, with mapping of all lesions detected. All tumors and suspicious areas identified under white light and by red fluorescence with flexible or rigid cystoscopy were then resected by TUR or biopsied. The specimen was assessed by an independent blinded pathologist.

RESULTS

In the 45 patients studied 41 (91%) patients had exophytic tumors, of which 39 (95.1%) were detected by HAL flexible cystoscopy and 40 (97.5%) by HAL rigid cystoscopy. 17 (37.8%) patients had concomitant or carcinoma in situ only, which was identified by HAL flexible cystoscopy in 14 (82.3%), by HAL rigid cystoscopy in 15 (88.2%), by flexible standard in 11 (64.7%) and by standard white light rigid cystoscopy in 13 (76.7%) patients.

CONCLUSION

HAL fluorescence flexible cystoscopy compared to HAL rigid cystoscopy showed almost equivalent results in detecting papillary and flat lesions in bladder cancer patients. Both procedures were superior to standard white light flexible cystoscopy.

Comparison of Hexaminolevulinate Based Flexible and Rigid Fluorescence Cystoscopy with Rigid White Light Cystoscopy in Bladder Cancer: Results of a Prospective Phase II Study

INTRODUCTION AND OBJECTIVE

Several studies have shown that rigid fluorescence cystoscopy (RFC) with hexaminolevulinate (HAL) is superior to standard rigid white light (RWLC) cystoscopy in diagnosing bladder tumours, with a clinically relevant impact on the patient's management. These studies, however, have been done with rigid cystoscopes. We carried out a study to evaluate whether the technique of fluorescence cystoscopy with HAL was also feasible with a specially designed flexible fluorescence cystoscope (FFC).

METHODS

20 patients with known or suspected bladder cancer were included in a comparative within patient controlled Phase II study. All patients signed informed consent. All patients received 50 ml of HAL (Hexvix) 8 mM 1h prior to transurethral resection. Using a D-light-C system (Storz, Germany), FFC and RFC were performed followed by RWLC. All lesions visible during these three cystoscopies were mapped, taped and resected.

RESULTS

In these 20 patients (mean age 71 years (49-89), 3 females) mean HAL instillation time was 81 min. Overall 27 histologically confirmed lesions were found in 19 patients. Detection rates in these 19 patients were 14 with FFC, 17 with RFC and 15 with RWLC. Of the 27 lesions 19 were detected with FFC, 23 with RFC and 20 with RWLC. Overall fluorescence intensity using the flexible system was 76% (30-147%) as compared to RFC using a visual analogue score. No side effects were noted which were attributable to HAL.

CONCLUSION

The use of FFC is feasible and seems to be comparable to RWLC and slightly inferior to RFC. Larger studies should determine the role of flexible fluorescence cystoscopy.

New Ultrasonic Cystofiberscope for Staging Bladder Tumors

We report on a new ultrasonic cystofiberscope for staging bladder tumors. The endoscope makes it possible to view endoscopic and ultrasound images of bladder tumors at any location, either alternately in full screen or simultaneously on the same monitor, with higher resolution. The cystofiberscope is useful for assessing the depth of bladder tumor invasion accurately.

Neodymium:YAG laser incision of congenital obstructive posterior urethral membrane in boys with urinary incontinence and low uroflow

BACKGROUND AND PURPOSE

Congenital obstructive posterior urethral membrane (COPUM) is associated with sub-clinical lower urinary tract symptoms in boys. Urethral stricture following cystoscopic fulguration of the membrane and a relatively small urethral caliber make the treatment of this condition difficult.

METHODS

Fifteen boys (mean age, 10.0 years) with COPUM were treated with neodymium:YAG (Nd:YAG) contact laser incision of the membrane through a cystourethroscope (n = 7) or a ureteroscope (n = 8).

RESULTS

Presenting symptoms were bedtime incontinence in 15, frequency/urgency in 10, daytime incontinence in 7, lazy bladder in 3 and urinary tract infection in 2. All patients had an obstructive urinary flow pattern with a maximal flow rate (Q(max)) < 15 mL/s. The mean follow-up period was 10.5 months. After the surgery, the number of wet nights per week reduced > 90%, 50-90% and < 50% in 9 (60%), 5 (33.3%), and 1 (6.7%), respectively. Mean (Q(max)) increased from 11.3 to 14.9 mL/s (p = 0.003).

CONCLUSION

Nd:YAG laser incision of COPUM with the aid of a ureteroscope or a cystourethroscope is a safe and effective method for improving urinary flow and bedtime incontinence.

PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE FOR THE TREATMENT OF BENIGN PROSTATIC HYPERPLASIA: 12-MONTH RESULTS FROM THE FIRST UNITED STATES MULTICENTER PROSPECTIVE TRIAL

PURPOSE

We report the 1-year efficacy and safety of photoselective vaporization of the prostate (PVP) for symptomatic and obstructive benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

A prospective clinical trial was performed in 139 men clinically diagnosed with symptomatic bladder outlet obstruction secondary to BPH who were enrolled and treated with a high power, 80 W, quasicontinuous wave potassium-titanyl-phosphate laser at 6 American medical centers across the country. Efficacy parameters were mean and percent changes from baseline in the American Urological Association Symptom Index (AUA-SI) score, quality of life score (QOL), peak urinary flow rate (Qmax), post-void residual urine volume (PVR) and transrectal ultrasound prostate volume measurement. Patients were evaluated 1, 3, 6 and 12 months following treatment. At each followup evaluation side effects were elicited.

RESULTS

Significant improvements in AUA-SI score, QOL score, Qmax and PVR were noted as early as 1 month after PVP treatment. At 12 months the mean AUA-SI score decreased from 23.9 to 4.3 (p <0.0001) and the QOL score decreased from 4.3 to 1.1 (p <0.0001), while mean Qmax increased from 7.8 to 22.6 ml per second (p <0.0001). PVR decreased from 114.3 to 24.8 ml (p <0.0001), while the transrectal ultrasound volume reduction went from 54.6 ml at baseline to 34.4 ml. There was no significant blood loss or fluid absorption during or immediately after PVP. Complications consisted of transient hematuria, dysuria and urinary retention in 12 (8.6%), 13 (9.3%) and 7 (5%) patients, respectively.

CONCLUSIONS

PVP is a unique, safe and effective outpatient modality that provides immediate symptomatic and urodynamic relief of bladder outlet obstruction secondary to BPH. Long-term followup is needed to validate further the maintenance of clinical efficacy beyond 1 year.

Use of 7.5F flexible pediatric cystoscope in the staging and management of urethral stricture disease

BACKGROUND AND PURPOSE

In the evaluation and treatment of patients with urethral strictures, assessment of the stricture is of paramount importance. To date, urologists have relied on retrograde or antegrade urethrography or both to define stricture length and associated characteristics. Antegrade urethrography typically requires suprapubic access to the bladder, adding to the morbidity of stricture treatment. Herein, we describe the feasibility of using a new method for diagnosing, staging, and managing urethral stricture disease.

PATIENTS AND METHODS

Twenty-four men with urethral strictures underwent urethroscopy with a 7.5F, 26-cm "pediatric" flexible cystoscope to stage and manage their disease. Comparison of urethroscopy with retrograde urethrography was made with respect to characterizing the stricture.

RESULTS

In all cases, the urethral strictures could be navigated with the 7.5F cystoscope. Documentation of the stricture length and the density of scar tissue and identification and characterization of additional pathology (urethral calculi proximal to the stricture in two patients) were possible in all cases, including four patients with recurrent stricture after complex urethroplasty.

CONCLUSION

The 7.5F, 26-cm pediatric flexible cystoscope represents a useful tool in the diagnosis and management of urethral stricture disease. Further studies will be necessary to determine the cost-effectiveness, patient morbidity, and ability to tailor therapy appropriately in comparison with standard retrograde urethrography or voiding cystourethrography.

Improved Patient Compliance using Pediatric Cystoscope during Office Hysteroscopy

STUDY OBJECTIVE

To evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

Maccabi Outpatient Women's Health Center.

PATIENTS

One thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal.

INTERVENTION

Office diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women.

CONCLUSION

The combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.

Practical cystoscopy: care of the instruments and preparation for a cystoscopic examination

Periodically, a look at the past helps health care professionals see how much practice has changed as well as how some concepts and practices remain similar to the original rationales and techniques. Two chapters from a 1911 textbook on cystoscopy have been reprinted that describe catheter and instrument care and preprocedure requirements for cystoscopy performed in the hospital, office, or home. Sterilization methods and instruments for cystoscopy have improved in the century since this book was written but the rationale for the procedure and concepts guiding the instrumentation have some similarity with the practices performed nearly 100 years ago. Some comments also provide a bit of comic relief. One example, "this undoubtedly shortens the life of the catheter, but it lengthens the life of the patient" appears in the discussion about catheter cleaning after use in a pus case.

Hands-free hook for endourological procedures

We present here a hook that can be used to free both hands from holding the endoscope during endourological procedures. We made the hook from a wire hanger, and thus, it is a convenient, cheap and easy tool to make using this everyday item. As this hook makes the insertion of the endoscope into the urethra easier, it allows urologists to perform endourological procedures, which require the handling of biopsy forceps, a basket wire and lithotripsy probes, unassisted.

Successful diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy

PURPOSE

In the orthotopic animal bladder tumor model noninvasive evaluation of the tumor establishment and the therapeutic effect has been difficult. To our knowledge we present the first diagnosis of orthotopic rat superficial bladder tumor model by ultrathin cystoscopy.

MATERIALS AND METHODS

The established AY-27 rat bladder carcinoma cell line was transplanted orthotopically into 22 female Fischer F344 rats. A cell suspension containing 4 x 10 AY-27 cells was instilled into the bladder, which had been conditioned with mild acid washing. To evaluate tumor growth serial cystoscopy was performed via the urethra with an ultrathin endoscope (diameter 0.75 mm.) 5 to 14 days after tumor cell inoculation. At intervals after cystoscopic tumor detection the rats were sacrificed for autopsy and histological examination.

RESULTS

In all 22 rats the orthotopic bladder tumor was established 7 to 10 days after tumor cell implantation and in most it was superficial. Cystoscopy permitted inspection of the urethra and whole bladder surface. We detected all tumors as broad based papillary mass (minimal lesion 1 mm. or less) and inspected its detailed appearance and accurate location.

CONCLUSIONS

The orthotopic rat superficial bladder tumor model and the diagnostic procedure by ultrathin cystoscopy would be ideal system for preclinical evaluation of new potential intravesical therapies.

Validation of a flexible cystoscopy course

OBJECTIVE

To examine the instructional effectiveness of a course for nurses wishing to learn flexible cystoscopy, using a virtual reality flexible cystoscopy simulator to measure the outcome.

SUBJECTS AND METHODS

Fourteen urology nurse practitioners with no previous experience of cystoscopy were taught the basic techniques of flexible cystoscopy. They then had supervised group instruction during which they practised flexible cystoscopy on an inanimate latex model, and were taught how to handle the cystoscope, followed by unsupervised practice, including use of the virtual reality (VR) simulator (URO Mentor, Simbionix, Israel). They then undertook a cystoscopy task on the simulator; within the bladder there were 10 flags (numbered 1-10) at key positions. By visualizing and photographing each of the flags the subject would have visualized the entire bladder mucosa. The number of flags seen was thus used as a measure of how much of the bladder mucosa was examined. The VR simulator also measured the total procedure time. After a day of training the subjects were reassessed and the changes in performance evaluated. Subjects were also asked their opinion of the use of VR for flexible cystoscopy.

RESULTS

The median (range) time to complete the procedure before the course was 3.33 (2-5.5) min and the number of flags seen 7 (6-9). After the course, the median time decreased to 2.85 (1.5-4.42) min and the number of flags seen increased to 8 (6-9). The change in time was significant (P = 0.03) but the difference in the number of flags was not (P = 0.12). All 14 subjects enjoyed the use of VR for learning flexible cystoscopy; they all reported that they were more confident in handling a flexible cystoscope and in undertaking flexible cystoscopy.

CONCLUSION

The virtual reality simulator was an effecctive tool for teaching flexible cystoscopy.

Virtual reality flexible cystoscopy: a validation study

OBJECTIVES

To validate a flexible cystoscopy simulator by determining if it could differentiate between expert and novice cystoscopists.

SUBJECTS AND METHODS

Seventeen subjects (10 novices with no previous endoscopic experience and seven urologists who had all carried out > 1000 flexible cystoscopies each) were asked to undertake a flexible cystoscopy task on the URO Mentor (Simbionix, Israel) virtual reality (VR) machine. In the task used the bladder mucosa has 10 flags (numbered 1-10) at key positions in the bladder; by visualizing each of the 10 flags and photographing them the subject will have indirectly visualized the entire mucosa. Subjects were asked to carry out the task 10 times, to allow their rate of acquisition of skill to be assessed. The total time taken for the task and the number of flags visualized were used as measures of performance.

RESULTS

The experienced urologists were significantly better at flexible cystoscopy than the medical students on the first trial for the mean number of flags seen (9.57 vs 8.0, P = 0.01) and the mean time to complete the task (2.33 vs 4.89 min, P = 0.03). At the 10th trial there was still a significant difference for the time taken, between the medical students and the urologists (2.33 vs 0.81 min, P = 0.01) but not for the number of flags seen (9.2 vs 9.6, P = 0.46). The medical students improved between the first and the 10th attempt, being significantly quicker for trial 10 than trial 1 (P = 0.005). However, although the medical students appeared to see more flags (8.0 vs 9.2) this was not significant (P = 0.05). The urologists did not differ in the number of flags visualized between the first and 10th trial, although they were significantly quicker in completing the task (P = 0.02). The urologists were significantly faster in trial 2 than trial 1, but no faster thereafter (P = 0.04).

CONCLUSIONS

Using the URO Mentor simulator, it was possible to assess the level of experience of flexible cystoscopy, and therefore the system has construct validity. As in the real situation there is a period of learning during which the subject becomes familiar with the computer/machine/human interface, the task and the handling of the instruments. These results support the view that there is a role for VR simulators in urological training.

Endoscopic removal of intravesical thermometer using a rigid nephroscope and forceps

Intravesical thermometers are occasionally encountered in urologic practice. In the present paper, we describe the removal of a thermometer from the bladder of a woman who presented with irritable bladder symptoms. The thermometer was removed intact transurethrally using a rigid nephroscope and forceps, even though both ends of the thermometer were embedded in the bladder wall. Our retrieval technique may be of general use in such cases, and it should be attempted before resorting to open surgery.

Chemo-ablation of the prostate with dehydrated alcohol for the treatment of prostatic obstruction

PURPOSE

We confirmed clinically whether chemo-ablation of the prostate with absolute ethanol may be an innovative transurethral approach for the relief of obstructive benign prostatic hyperplasia.

METHODS

Using the InjecTx endoscopic device (Injectx Inc., San Jose, California) an initial cohort of 15 patients, including 13 who have now been followed more than 1 year, underwent elective transurethral chemo-ablation of the prostate.

RESULTS

Preoperative and postoperative comparisons of the American Urological Association symptom score, maximum urine flow rate and prostatic volume reveal significant improvement with minimal discomfort and no major complication.

CONCLUSIONS

The InjecTx technique proved encouragingly successful in this initial small-scale clinical trial.

Flexible video cystoscope with built-in high-frequency cauterizing element for transurethral resection of bladder tumor

The major advantage of the flexible video cystoscope is that a digital signal can be obtained while high frequency cauterization is carried out. Cauterization while observing a digital signal picture was not possible before this new model was developed. We decided to use this new cystoscope to resect a bladder tumor and coagulate the bleeding because the patient could tolerate only local anesthesia due to severe heart disease complications. We successfully treated the patient with this technique and no complications were noted. This new flexible video cystoscope was found to be safe for resecting bladder tumor under local anesthesia.

Clinical evaluation of a newly developed endoscopic resection device (Rotoresect): physical principle and first clinical results

BACKGROUND

Endoscopic resection techniques on benign prostatic tissue aim at a high ablation rate and a minimal bleeding rate. Although commercial resection electrodes are effective, they either cause high blood loss (loop electrode) or reduce the bleeding rate with a compromised ablation rate (electrovaporization electrode). To resolve these problems, a new electrosurgical resection device, The Rotoresect, has been developed.

METHODS

The Rotoresect incorporates a specially designed working element. The resection electrode is driven by a micromotor with a high-frequency current that enables simultaneous coagulation and vaporization during rotoresection. To date, 40 patients with benign prostatic hyperplasia have undergone transurethral rotoresection of the prostate with this new device.

RESULTS

The actively rotating resection electrode enables tissue coagulation and vaporization as well as mechanical tissue ablation. Only slight bleeding was observed during the entire resection procedure. Postoperatively, no significant changes in hemoglobin and sodium concentration were detected. The deobstructive effect of the Rotoresect was comparable to that of the standard loop.

CONCLUSIONS

The simultaneous tissue vaporization, coagulation, and mechanical removal by the Rotoresect enables a high ablation rate combined with minimal blood loss. Initial clinical results gained in the transurethral resection of benign prostatic tissue are promising.

In utero therapy for lower urinary tract obstruction

Lower urinary tract obstruction has a significant impact on neonatal and child health. Pulmonary hyperplasia and renal impairment could be direct or indirect consequences of this condition leading to significant morbidity and mortality. Evaluation of fetuses with suspected lower urinary tract obstruction is performed not only to confirm the diagnosis but also to assess renal prognosis. Ultrasound examination and urinary analysis aid in the evaluation of these fetuses. The decision to perform fetal intervention in these cases is a difficult one. Vesico-amniotic fetal shunting, open fetal surgery and more recently endoscopic fetal surgery for this condition are available as possible modalities of fetal intervention. Case selection for fetal intervention is extremely important in order to both avoid unnecessary intervention in those unlikely to survive, and also to avoid procedure related complications in fetuses likely to do well without intervention. Vesico-amniotic shunting has the advantage of bypassing the obstruction, however it is often associated with complications. Open fetal surgery is not usually recommended because of the complications and high fetal loss rate. Endoscopic surgery to visualise and treat the cause of lower urinary tract obstruction has been tried. Fetal endoscopic surgery is in its infancy and endoscopic procedures are limited to a few groups. This current review addresses evaluation, case selection and therapeutic options for lower urinary tract obstruction in utero. It also discusses the limited data against which the efficacy of the various options can be assessed. The current state of fetal intervention is detailed in the present review.

Flexible cystoscopy: is the volume and content of the urethral gel critical?

PURPOSE

To determine whether volume (10 or 20mL) or the presence of 2% lidocaine (lignocaine) in the gel used for urethral lubrication alters the discomfort felt during flexible cystoscopy.

PATIENTS AND METHODS

A randomized double-blind trial was performed in men attending for flexible cystoscopy. Patients were assigned to one of four groups: 10 mL of gel with or without lidocaine and 20 mL with or without lidocaine. Gel was retained for 10 minutes prior to cystoscopy. Pain felt during both the instillation of the gel and the cystoscopy itself was evaluated using a visual analog scale (0-10).

RESULTS

Interim analysis after 147 patients had been recruited revealed a significant difference between the groups in terms of the pain felt on instillation of the gel, leading to an early termination of the trial. There was a significant reduction in pain on cystoscopy in patients receiving 20 mL of gel if this contained lidocaine.

CONCLUSION

The least pain on cystoscopy occurred in patients receiving 20 mL of gel containing lidocaine.

A large bullet in the bladder

All manner of foreign bodies have been extracted from the bladder. Introduction into the bladder may be through self-insertion, iatrogenic means or migration from adjacent organs. Extraction should be tailored according to the nature of the foreign body and should minimise bladder and urethral trauma. We report a case of a bullet injury to the bladder, which finally presented as a gross hematuria after remaining asymptomatic for four years. We present here an alternative to suprapubic cystostomy with a large bladder foreign body treated via a combined transurethral unroofing followed by removal using a grasper passed through a suprapubic laparoscopic port.

[Transurethral rotoresection - a new method of benign prostatic hyperplasia treatment]

Karl Storz company (Germany) offers a novel endoscopic technology in the treatment of benign prostatic hyperplasia (BPH) i.e. rotoresection which combined mechanic and electrosurgical methods of removal of the hyperplastic tissue. The operation is performed with application of a special rotoresectoscope connected with a rotor electrode which, in its turn, is connected with mechanical rotor generator making it to rotate and with powerful electrogenerator (radiotome). The hyperplastic tissue is removed both mechanically (by high-frequency rotation of the rotor tip) and due to electrovaporization with simultaneous coagulation of the underlying tissue layers. Transurethral rotoresection was performed in 40 patients with BPH. Intraoperative and postoperative complications were not observed. Examination at discharge and 1 month after surgery showed a 4-fold decrease in the prostatic symptoms by IPSS scale, residual urine decreased 3-fold, maximal urine flow rate rose 2.5-fold. Transurethral rotoresection combines effective removal of BPH tissue with minimal intraoperative bleeding. It is a good alternative to conventional TUR. For more detailed evaluation further studied are needed.

Performing flexible ureteroscopy through a cystoscopy introducer sheath

Performing flexible ureteroscopy through a cystoscope sheath positioned with its tip near the orifice of the ureter prevents buckling of the ureteroscope and decreases the friction against the ureteroscope. This results in more precise translation of the surgeon's movements to the tip of the instrument and facilitates the procedure.

The re-use of irrigating equipment for flexible cystoscopy is not safe

OBJECTIVE

To determine the incidence of fluid reflux from the lower urinary tract into the connecting tubing used for irrigation in patients undergoing flexible cystoscopy.

PATIENTS AND METHODS

The study was conducted in 94 consecutive male and female patients attending routine outpatient flexible cystoscopy lists. A sensor was designed and constructed to determine the presence of any retrograde flow of irrigating fluid, and the volume of any reflux through the connecting tubing. The mean (sd) cystoscope internal channel volume was 2.56 (0.25) mL; the level of significant reflux was set at >/=2. 25 mL.

RESULTS

Reflux of irrigating fluid occurred in 11 males (17%) and was significant in six (9%) of 65 male patients, with the irrigating fluid reservoir set at a height of 0.78 m above the patient's mid-coronal level. No reflux occurred in the 29 females studied.

CONCLUSIONS

Significant reflux can occur in males and hence the connecting tubing should be regarded as contaminated. Infection-control measures must include the prevention of transmission of blood-borne infections, e.g. hepatitis B and C viruses, and human immunodeficiency virus, because of the risk that blood may contaminate urine, and they should be implemented in all cases regardless of patient risk factors. From the available evidence, flexible cystoscopy should always be performed with single-use irrigation systems.

DiHA Dextran Copolymer, a new biocompatible material for endoscopic treatment of stress incontinent women. Short term results

BACKGROUND

This study was undertaken to investigate the safety and effect of DiHA, dextranomers in hyaluronan, a new biocompatible material for endoscopic treatment of stress incontinence, and to further develop the injection technique.

METHODS

Twenty women aged 38 to 90 years with genuine stress incontinence participated. Seventeen were followed for a minimum of 6 months after treatment and three for a minimum of 3 months. The DiHA implants were administrered by transurethral endoscopically controlled submucosal injections under local anesthesia. Safety was assessed mainly in terms of infection, need for catheterization, residual urine and dysuria. The treatment efficacy was estimated objectively by a short-term pad test with standardized physical exercise and a 48 h pad-test, 7 days, and 1, 3 and 6 months after treatment. The patient's subjective experience of the effect was also studied.

RESULTS

The implantation procedure was well accepted by the patients. Four patients required catheterization due to voiding problems during the first 24 postoperative hours. One patient had urinary retention 14 days postoperatively. No UTI or local infection was detected. Some patients had transient urgency. In 17 or 20 patients the treatment resulted in objective cure or improvement.

CONCLUSIONS

This substance shows promising qualities for endoscopic treatment of stress incontinence.

[Voice-directed robotic cystoscopy]

OBJECTIVE

In line with our previous studies in the field of robotics, a new application of our robotic arm is presented: voice-directed cystoscopy.

METHODS

Cystoscopy was performed in a sow using a voice-directed robotic arm to which a cystoscope had been attached. The computer executes all the processes that enable interaction with the surgeon and communication with the robotic system. The surgeon directs the movements of the cystoscope by voice, using instructions easily recognizable by the voice identifier.

RESULTS/CONCLUSIONS

This system is easy to operate and carries out the commands given by the surgeon with great precision and safety.