Engineering and Urology Society Saturday May 19 , 2012

Engineering and Urology Society  Saturday May 19 , 2012
Engineering and Urology Society
27th Annual Meeting
Saturday May 19th, 2012
Georgia World Congress Center
Atlanta, GA
http://engineering-urology.org/
Following a long tradition, the Annual meeting of the Engineering and Urology
Society offers the delegates of the American Urological Association an opportunity
to present and learn about the latest research developments in urologic technology.
Among other medical specialties, Urology has traditionally been at the forefront of
technology innovation and continues to adapt or develop novel technologies at a
fast pace. The Engineering and Urology Society offers a unique forum where
engineering innovation meets clinical demand in a collaboration that leads to
unparalleled exchange of ideas.
This year's meeting is organized by the program chairmen Jeff Cadeddu and Koon Rha. The first session
will focus on combination presentations with engineers and urologists. Additional talks will discuss a range
of topics that are just beyond the horizon including next daVinci instruments, historipsy, and innovations in
focal therapy. The focus then shifts to horizons in surgical robotics with an international flavor and
advanced imaging techniques. The afternoon sessions highlight advances and debates in prostate cancer
imaging and the latest in the areas of Laparoendoscopic Single Site Surgery and Natural Orifice
Translumenal Endoscopic Surgery. Additional symposiums will be held for Image Guided Therapy and
Stents. Finally, engineers and clinicians will present their latest research in the two afternoon poster
sessions.
The review of the abstracts for the poster sessions has been performed online by a group of 85 reviewers
from around the world. Each paper received between 25 and 28 reviews. We would like to thank the
reviewers, listed at the end of this program book, for their constructive comments and essential contribution
to the quality of the meeting.
Based on the peer review, the Best Paper Award goes to abstract "Preclinical Safety and Efficacy of
Ultrasonic Propulsion of Kidney Stones" from the University of Washington and Indiana University, and the
Outstanding Paper Award to abstract "Robot-Assisted Direct MRI-Targeted Transrectal Prostate Biopsy"
from the Johns Hopkins University and the Memorial Sloan-Kettering Cancer Center. The Top 10 abstracts
are listed in the program. Their authors will be invited to submit full articles to the Journal of Endourology.
We gratefully thank all reviewers for their hard work, objective scoring, and contribution to the success of
the meeting. The society presents Best Reviewer Awards for the online review process, based on the grading
performance and the number of reviews performed. The Best Reviewer Awards are presented to Drs.
Riccardo Autorino, Thorsten Bach, Mahesh Desai, Mohamed Elkoushy, Arvind Ganpule, Petrisor Geavlete,
Bodo Knudsen, Thomas Lawson, Kamol Panumatrassamee, and Sutchin Patel. We congratulate all award
winners and welcome all urologists, engineers, and scientists to join us for this unique multi and
interdisciplinary experience. As always, we are grateful to Dr. George Nagamatsu, the founder and first
president of the society for setting the foundations based upon which we meet.
Please visit the website http://engineering-urology.org for a complete version of this program including the
abstracts presented.
Thank you for your continued scientific support,
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Stephen Nakada
Sean Hedican
Dan Stoianovici
Page 2 of 97
CONTINUING MEDICAL EDUCATION
Accreditation: The American Urological Association Education & Research, Inc. (AUAER) is
accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide
continuing medical education for physicians.
Credit Designation: The American Urological Association Education & Research, Inc. designates this
live activity for a maximum of 8.25 AMA PRA Category 1 Credit(s). Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
The AUAER takes responsibility for the content, quality, and scientific integrity of this CME activity.
AUAER Disclosure Policy: As a provider accredited by the ACCME, the AUAER must ensure balance,
independence, objectivity and scientific rigor in all its activities.
All faculty and program planners participating in an educational activity provided by the AUAER are
required to disclose to the provider any relevant financial relationships with any commercial interest.
The AUAER must determine if the faculty’s relationships may influence the educational content with
regard to exposition or conclusion and resolve any conflicts of interest prior to the commencement of
the educational activity. The intent of this disclosure is not to prevent faculty with relevant financial
relationships from serving as faculty, but rather to provide members of the audience with information
on which they can make their own judgments.
Off-label or Unapproved Use of Drugs or Devices: It is the policy of the AUAER to require the
disclosure of all references to off-label or unapproved uses of drugs or devices prior to the
presentation of educational content. The audience is advised that this continuing medical education
activity may contain reference(s) to off-label or unapproved uses of drugs or devices. Please consult
the prescribing information for full disclosure of approved uses.
Disclaimer: The opinions and recommendations expressed by faculty, authors, and other experts
whose input is included in this program are their own and do not necessarily represent the viewpoint
of the AUAER.
Evidence Based Content: As a provider of continuing medical education accredited by the ACCME, it
is the policy of the AUAER to review and certify that the content contained in this CME activity is valid,
fair, balanced, scientifically rigorous, and free of commercial bias.
Special Assistance/Dietary Needs
The American Urological Association Education & Research, Inc. (AUAER), an
organization accredited for Continuing Medical Education (CME), complies with
the Americans with Disabilities Act §12112(a). If any participant is in need of
special assistance or has any dietary restrictions, a written request should be
submitted at least one month in advance. For additional assistance with your
request please call 800-908-9414.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 3 of 97
CONTINUING MEDICAL EDUCATION
FACULTY DISCLOSURES:
Autorino, Riccardo: Nothing to disclose.
Cadeddu, Jeffrey A.: Ethicon Endosurgery, Inc: Consultant or Advisor, Scientific Study or Trial, Owner, Product
Development; Applied Medical: Meeting Participant or Lecturer.
de la Rosette, Jean: BSC: Consultant or Advisor, Meeting Participant or Lecturer; Angiodynamics: Consultant or
Advisor, Scientific Study or Trial; Storz: Meeting Participant or Lecturer; Cook: Meeting Participant or Lecturer;
Lilly: Meeting Participant or Lecturer.
Del Pizzo, Joseph J.: Nothing to disclose.
Desai, Mihir: Hansen Medical: Consultant/Advisor
Fernandez, Raul: Ethicon Endo-Surgery: Scientific Study or Trial
Ganzer, Roman: Nothing to disclose.
Gettman, Matthew T.: Nothing to disclose
Hall, Tim: Histosonics, Inc.: Consultant or Advisor, Owner, Product Development
Han, Misop: Nothing to disclose
Irwin, Brian Hilbert: Nothing to disclose.
Janetschek, Gunter: Terumo: Meeting Participant or Lecturer
Jeong, Byong Chang: Nothing to disclose.
Jeong, Chang Wook: Nothing to disclose.
Kaouk, Jihah H.: Endocare: Meeting Participant or Lecturer; Intuitive Surgical: Consultant or Advisor; Covidien:
Meeting Participant or Lecturer; Ethicon: Meeting Participant or Lecturer
Knoll, Thomas: Nothing to disclose.
Laguna Pes, Pilar Maria: Nothing to disclose.
Leveillee, Raymond J.: Applied Medical: Meeting Participant or Lecturer; Intuitive: Meeting Participant or Lecturer;
Intio: Scientific Study or Trial.
Loch, Tillmann: Fresenius Kabi, Germany: Consultant or Advisor, Meeting Participant or Lecturer; Takeda, GSK,
DGU, BDU, EAU, and others when asked for: Meeting Participant or Lecturer; Nucletron: Consultant or
Advisor; DGU, EAU, AUA, WJU: Other: Member, AKBS, ESUI, EAU – Guideline Office, Reviewer.
Naito, Seiji: Novartis: Consultant or Advisor, Meeting Participant or Lecturer.
Peltier, Alexandre: Nothing to disclose.
Rane, Abhay: Nothing to disclose.
Rassweiler, Jens: Nothing to disclose.
Rha, Koon Ho: Nothing to disclose.
Roberts, William: Terumo Cardiovascular Systems: Consultant or Advisor; HistoSonics, Inc.: Consultant or Advisor,
Scientific Study or Trial, Investment Interest, Owner, Product Development
Saglam, Remzi: ELMED LITHOTRIPSY SYSTEMS: Consultant or Advisor, Scientific Study or Trial, Owner,
Product Development
Salas, Nelson: Nothing to disclose.
Schips, Luigi: Nothing to disclose.
Stoianovici, Dan: Nothing to disclose.
Teber, Dogu: Nothing to disclose
van Velthoven, Roland F.P.: Nothing to disclose
Villers, Arnauld A.: Astellas: Meeting Participant or Lecturer; Sanofi-Aventis: Meeting Participant or Lecturer;
Intuitive Surgical: Scientific Study or Trial; Janssen: Consultant or Advisor, Meeting Participant or Lecturer,
Scientific Study or Trial; IPSEN: Meeting Participant or Lecturer; AMGEN: Meeting Participant or Lecturer
Walz, Jochen C.: Nothing to disclose
Wijkstra, Hessel: Nothing to disclose
Addendum with additional disclosures for Poster Authors and Reviewers to follow
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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CONTINUING MEDICAL EDUCATION
SPONSORS
The Engineering and Urology Society thanks the following companies for their support of this course:
Boston Scientific Corp, Inc.
EXHIBITORS
Cook Medical
Cook Medical was one of the first companies to help popularize interventional medicine, pioneering many of the
devices now commonly used worldwide to perform minimally invasive medical procedures. Today, the company
integrates minimally invasive medical device design, biopharma, gene and cell therapy, and biotech to enhance patient
safety and improve clinical outcomes in the fields of aortic intervention; interventional cardiology; critical care
medicine; gastroenterology; radiology, peripheral vascular, bone access and oncology; surgery and soft tissue repair;
urology; and assisted reproductive technology, gynecology and high-risk obstetrics. Founded in 1963 and operated as
a family-held private corporation, Cook is a past winner of the prestigious Medical Device Manufacturer of the Year
Award from Medical Device & Diagnostic Industry magazine.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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PROGRAM
27th Annual Meeting
Saturday, May 19th, 2012
Atlanta, Georgia
Room A302
Georgia World Congress Center
Program Chairmen: Jeffrey Cadeddu and Koon Ho Rha
7:15 – 7:30 Registration
7:30 –9:00 SESSION 1: ENGINEERS IN UROLOGY
Combo presentations of MD and PHD
7:30 AM Direct Image-Guided Robots for the Prostate
7:50 AM MAGS for LESS and NOTES
8:10 AM State-of-the-art Science of Thermal Ablation
8:30 AM Histotripsy: Mechanical Tissue Ablation
Jeffrey Cadeddu
Misop Han
Dan Stoianovici
Jeffrey Cadeddu
Raul Fernandez
Raymond Leveillee
Nelson Salas
William Roberts
Tim Hall
8:50 AM Questions and Answers
9:00 – 9:40
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
SESSION 2: NEW HORIZONS IN SURGICAL ROBOTICS
Surgical Robotics: Germany/Austria
Surgical Robotics: Canada
Surgical Robotics: Japan
Surgical Robotics: Korea
Questions and Answers
10:15 – 10:30 AWARDS PRESENTATIONS
10:20 AM Best Paper Award: Preclinical Safety and Efficacy of Ultrasonic
Propulsion of Kidney Stones
10:30–12:00 SESSION 3: ESUT SESSION
10:30 AM Lymph Node Illumination with Cyanine Green
10:40 AM Photodynamic Diagnosis During Laparoscopic Radical
Prostatectomy
10:50 AM Optical Coherence Tomography for Bladder & Kidney
11:00 AM Update on Navigation
11:10 AM 3D-Endoscopy-Where are we Apart from daVinci
11:20 AM MRI Sonography Image Fusion Biopsy of the Prostate
11:30 AM Robotic Flexible Ureterorenoscopic Surgery
11:40 AM Questions and Answers
Koon Ho Rha
Gunther Janetschek
David Albala
Seji Naito
Chang Wook Jeong
Dan Stoianovici
Mathew Sorensen
Jens Rassweiler
Roland van Velthoven
Pilar Laguna
Günter Janetschek
Roman Ganzer
Jean de la Rosette
Dogu Teber
Thomas Knoll
Alexandre Peltier
Remzi Saglam
12:00–1:00 LUNCH BREAK
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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PROGRAM
1:00-2:00 SESSION 4: ESUI SESSION
Jochen Walz
Where are We in Prostate Cancer Imaging? An Update on the Most
Promising Imaging Tools for Prostate Cancer
1:00 PM Contrast Enhanced Ultrasound (CEUS) in the Management of
Prostate Cancer
1:15 PM Real Time Elastography in the Management of Prostate Cancer
1:30 PM ANNA/C-TRUS in the Management of Prostate Cancer
1:45PM Multiparametric MRI in the Management of Prostate Cancer
2:00-3:00 SESSION 5: NOTES AND LESS
LESS Donor Nephrectomy: Is this the new gold standard?
LESS Adrenalectomy
Retroperitoneal LESS
Advances in LESS:
- Single port instrument delivery extended reach (Spider)
- Imaging, Dissection & Retraction
Robotic LESS: Current Status
Update on NOTES: What’s out there so far
LESS: Where’s the Evidence? – New Studies
1:50-2:25 PM
1:50 PM
1:57 PM
2:04 PM
2:11 PM
2:18 PM
TALKS
Little LESS
Pitfalls in LESS
What’s New in LESS
What’s New in NOTES
White paper on LESS trials, Inclusion Criteria
Hessel Wijkstra
Jochen Walz
Tillmann Loch
Arnauld Villers
Abhay Rane
Matthew Gettman
Joseph DelPizzo
Luigi Schips
B. C. Jung
Raymond Leveillee
Mihir Desai
Jihad Kaouk
Riccardo Autorino
Brian Irwin
Matthew Gettman
Ed Cherullo
Jay Raman
Inderbir Gill
Mitchell Humphreys
Brian Irwin
POSTER SESSIONS:
Session 1A
1:00–2:30PM Poster Session 1
Room: A315
Li-Ming Su
Petrisor Geavlete
Session 1B
Room: A316
William Roberts
Nelson Salas
Session 2A
Room: A315
Manoj Monga
Christian Chaussy
Session 2B
Room: A316
John Denstedt
Hessel Wijkstra
3:00–4:30PM Poster Session 2
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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PROGRAM
1:00 PM – 2:30 PM
Moderators
Li-Ming Su
Petrisor Geavlete
No.
Title
Presenting Author
1
NOVEL LAPAROSCOPE DEFOGGING AND CLEANING
DEVICE UTILIZED DURING ROBOT-ASSISTED
LAPAROSCOPIC PROSTATECTOMY (RALP): 20 CASE
EXPERIENCE
SPARKER ARRAY FOR LITHOTRIPSY
Carson Wong
3
PULSED FLUOROSCOPY IN URETEROSCOPY AND
PERCUTANEOUS NEPHROLITHOTOMY
Mohamed Elkoushy
4
FIVE ARM ENHANCED OPTICAL MAGNIFICATION
APPROACH FOR ROBOTIC ASSISTED MICROSURGERY
Ahmet Gudeloglu
5
NEPHRON SPARING SURGERY WITH ZERO ISCHEMIA
Eric Taylor
6
ROBOTIC ULTRASOUND PROBE IN ROBOTIC PARTIAL
NEPHRECTOMY
Bartosz Kaczmarek
7
NONINVASIVE HISTOTRIPSY OF THE PROSTATE USING
VORTX RX™: FEASIBILITY IN A CANINE MODEL
William Roberts
8
NOVEL ULTRA-LOW DOSE NON-CONTRAST CT (NCCT)
FOR UROLITHIASIS: PROSPECTIVE COMPARISON OF
DIAGNOSTIC ACCURACY WITH CONCURRENT
STANDARD DOSE IMAGING
SURGTRAK: EVOLUTION OF A MULTI-STREAM
SURGICAL PERFORMANCE DATA CAPTURE SYSTEM FOR
THE DA VINCI SURGICAL ROBOT
TOP 10 ABSTRACT
XENX: EVOLUTION OF DESIGN BASED ON CLINICAL
EVALUATION
Sri Sivalingam
RAPID EXTRACORPOREAL STONE COMMINUTION:
MECHANISTIC INSIGHTS IN-VITRO
Alexander Duryea
POSTER SESSION 1A
2
9
10
11
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Michael
Grapperhaus
Lee White
Ofer Zigman
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PROGRAM
12
DESIGN OF AN AUTOMATED CYSTOSCOPE FOR
BLADDER CANCER SURVEILLANCE
TOP 10 ABSTRACT
Xianming Ye
13
A NOVEL VAS CLAMP FOR USE IN NONINVASIVE LASER
VASECTOMY
Christopher Cilip
14
A COMPARISON OF DIFFERENT ACUTE ANGLES
BETWEEN STRAIGHT INSTRUMENTS USED DURING
LAPAROSCOPIC SUTURING AND KNOT TYING
Ernesto Iii Arada
15
INITIAL EXPERIENCE WITH PERCUTANEOUS
MICROWAVE ABLATION OF RENAL TUMORS:
MULTICENTER EVALUATION OF SAFETY AND EFFICACY
Sara Best
16
TARGETED ROBOTIC ASSISTED MICROSURGICAL
DENERVATION OF THE SPERMATIC CORD FOR CHRONIC
ORCHIALGIA
Ahmet Gudeloglu
17
A NOVEL SYNTHETIC VAS DEFERENS MODEL FOR
MICROSURGICAL TRAINING
Ahmet Gudeloglu
18
EVALUATION OF SCOPESAFE FIBERS AND THE SCOPE
GUARDIAN SHEATH IN PREVENTION OF URETEROSCOPE
ENDOLUMINAL WORKING DAMAGE
Achim Lusch
19
PRECLINICAL SAFETY AND EFFICACY OF ULTRASONIC
PROPULSION OF KIDNEY STONES
BEST PAPER AWARD
Mathew Sorensen
20
HOW TO USE AN OPTICAL TRACKER FOR MORE
ACCURATE MEASUREMENTS
Ryan Decker
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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PROGRAM
1:00 PM – 2:30 PM
Moderators
William Roberts
Nelson Salas
21
15 YEARS TRANSRECTAL HIGH INTENSITY FOCUSED
ULTRASOUND IN LOCALIZED PROSTATE CANCER
THERAPY: IMPACT OF NEOADJUVANT TURP BEFORE
HIFU ON ONCOLOGICAL EFFICACY
IN VITRO COMPARISON OF OUR NOVEL SPEAR HEADED
PNEUMATIC INTRACORPOREAL LITHOTRIPTOR WITH
HOLMIUM YAG LASER
Christian Chaussy
23
CYSTOLITHALOPAXY USING CYBERWAND IS EFFICIENT
AND SAFE FOR LARGE BLADDER STONE BURDENS
Matthew Maurice
24
COMPARISON BETWEEN SYSTEMATIC AND MRI
TARGETED PROSTATE BIOPSY FOR PATIENT WITH NO
HISTORY OF PROSTATE CANCER ATTENDING A FIRST
ROUND OF TRANS-RECTAL ULTRASOUND BIOPSY
ROBOTIC TRANS-RECTAL ULTRASONOGRAPHY DURING
ROBOTIC-ASSISTED RADICAL PROSTATECTOMY
Pierre Mozer
26
COMPARATIVE IN VITRO EVALUATION OF XENX
Carl Sarkissian
27
URETEROSCOPIC VERSUS FLUOROSCOPIC GUIDED
RENAL ACCESS: A COMPARATIVE ANALYSIS OF
INTRAOPERATIVE OUTCOMES FOR PCNL
Wahib Isac
28
A NOVEL DEVICE TO PREVENT MIGRATION OF STONE
FRAGMENTS DURING PERCUTANEOUS LITHOTRIPSY
Stephen Faddegon
29
APPLYING THEORETICAL CHEMISTRY TO THE STUDY OF
CALCIUM OXALATE NEPHROLITHIASIS
Julie Riley
30
DESIGN AND EVALUATION OF IMAGE GUIDANCE
SYSTEMS FOR RARP
S. Thompson
31
HISTOTRIPSY TREATMENT OF FORMALIN FIXED TISSUE
Sarah Darnell
POSTER SESSION 1B
22
25
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
A V Rawandale
Sunao Shoji
Page 10 of 97
PROGRAM
32
LASER INTERSTITIAL THERMOTHERAPY FOR SMALL
RENAL MASSES: PRELIMINARY INVESTIGATION IN EXVIVO PORCINE KIDNEYS
Nelson Salas
33
QUALITY MEASUREMENT OF SYSTEMATIC
TRANSRECTAL PROSTATE BIOPSY: AN IN-VITRO STUDY
TOP 10 ABSTRACT
Doyoung Chang
34
LIVE ROBOTIC SURGERY: ARE OUTCOMES
COMPROMISED?
TOP 10 ABSTRACT
Jeffrey Mullins
35
ROBOT-ASSISTED DIRECT MRI-TARGETED
TRANSRECTAL PROSTATE BIOPSY
OUTSTANDING PAPER AWARD
Chunwoo Kim
36
TACTILE MEMS-BASED SENSOR ELEMENT FOR ROBOTIC
SURGERY
Young Soo Park
37
VISUAL MEASUREMENT OF SUTURE TENSION FOR
MINIMALLY INVASIVE SURGERY
Young Soo Park
38
MINI-PERCUTANEOUS NEPHROLITHOTOMY WITHOUT
MINI INSTRUMENTS: A NOVEL TECHNIQUE
Edan Shapiro
39
WHAT IS THE BEST METHOD TO DELIVER ADJUVANT
THERAPY TO THE UPPER URINARY TRACT FOR
UROTHELIAL CARCINOMA? AN EVALUATION OF THREE
TECNIQUES IN AN EX VIVO PORCINE MODEL
Matthew Pollard
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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PROGRAM
3:00 PM – 4:30 PM
Moderators
Manoj Monga
Christian Chaussy
40
15 YEARS TRANSRECTAL HIGH INTENSITY FOCUSED
ULTRASOUND IN PROSTATE CANCER THERAPY:
DEVELOPMENT OF SIDE EFFECTS
Christian Chaussy
41
TREATMENT OF LOCALLY ADVANCED PROSTATE
CANCER WITH TRANSRECTAL HIGH INTENSITY
FOCUSED ULTRASOUND (HIFU) DELAYS ANDROGEN
DEPRIVATION THERAPY (ADT)
RETROGRADE CHEMOTHERAPEUTIC IRRIGATION OF
THE UPPER TRACT
Stefan Thueroff
IS THERE A DIFFERENCE IN LATERALITY DURING
ROBOT ASSISTED RADICAL PROSTATECTOMY?
ASSESSMENT OF LYMPH NODE YIELD AND
NEUROVASCULAR BUNDLE DISSECTION
PRELIMINARY EVALUATION OF THE ENDOGO HD
PORTABLE CYSTOSCOPIC CAMERA
Michael Lipsky
45
BIOHEAT MODEL FOR UNINTENDED FREEZE
DETERMINATION
Cervando OrtizVanderdys
46
BIPOLAR PLASMA VAPORIZATION OF SECONDARY
BLADDER NECK SCLEROSIS – MORE EFFICIENT THAN
STANDARD TUR?
Bogdan Florin
Geavlete
47
RENAL TUMOR CONTACT SURFACE AREA: A NOVEL CTPARAMETER FOR PREDICTING PERI-OPERATIVE
OUTCOMES USING ADVANCED IMAGE-PROCESSING
SOFTWARE
SIMULATION FOR TRAINING INTRA-DETRUSOR
INJECTION OF BOTULINUM TOXIN TO TREAT URINARY
INCONTINENCE
Scott Leslie
49
THE "AL DENTE" RADIOFREQUENCY ABLATION OF
RENAL TUMORS: USE OF PERIPHERAL FIBEROPTIC
TEMPERATURE MONITORING SAVES NEPHRONS.
Vladislav Gorbatiy
50
PRELIMINARY TESTING OF A TRANSURETHRAL
DEXTEROUS ROBOTIC SYSTEM FOR BLADDER
RESECTION
TOP 10 ABSTRACT
Ryan Pickens
POSTER SESSION 2A
42
43
44
48
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Matthew Maurice
William Berg
Yunhe Shen
Page 12 of 97
PROGRAM
51
RELIABILITY OF PROSTATE HISTOSCANNING IN
LOCALIZATION OF PROSTATE CARCINOMA: INDIAN
EXPERIENCE
Arvind Ganpule
52
3D-HOLOSCOPIC IMAGING: A NEW DIMENSION TO
ENHANCE IMAGING IN MINIMALLY INVASIVE THERAPY
IN UROLOGICAL ONCOLOGY
TOP 10 ABSTRACT
GREENLIGHT HPS-120W VS GREENLIGHT XPS-180W
LASER VAPORIZATION OF THE PROSTATE FOR BENIGN
PROSTATIC HYPERPLASIA: A PROSPECTIVE
COMPARATIVE OUTCOMES ANALYSIS
AUTOMATED ANALYSIS OF RETROPERITONEAL
ABNORMALITIES USING BOX COUNTING ALGORITHMS
Jonathan K.
Makanjuola
55
ROBOT ASSISTED TRANSVAGINAL NOTES
RETROPERITONEAL NEPHRECTOMY: FEASIBILITY
STUDY IN THE CADAVER
Humberto Laydner
56
USER FEEDBACK FOR SUTURING USING BLACK LIGHT
ASSESSMENT OF SURGICAL TECHNIQUE (BLAST) AND
IMAGE PROCESSING
Lauren Poniatowski
57
THE XENXTM – A NEW DEVICE TO PREVENT STONE
MIGRATION DURING LASER LITHOTRIPSY
Eugene
Kramolowsky
58
IN VITRO AND IN VIVO COMPARISON OF OPTICS AND
PERFORMANCE OF A DISTAL SENSOR URETEROSCOPE
(STORZ FLEX-XC) VS. A STANDARD FIBEROPTIC
URETEROSCOPE (STORZ FLEX-X2)
Achim Lusch
53
54
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Kevin Zorn
Cristian Surcel
Page 13 of 97
PROGRAM
3:00 PM – 4:30 PM
Moderators
John Denstedt
Hessel Wijkstra
59
PHANTOM STUDY OF A NOVEL STEREOTACTIC
PROSTATE BIOPSY SYSTEM INTEGRATING
PREINTERVENTIONAL MRI AND LIVE US FUSION
TOP 10 ABSTRACT
“VERSION 2- 5 PART PERCUTANEOUS ACCESS NEEDLE
WITH GLIDEWIRE (5-PANG)”: A MULTIUTILITY
PUNCTURE SYSTEM FOR PERCUTANEOUS RENAL
ACCESS
AUTOMATED VOLUMETRIC ASSESSMENT BY
NONCONTRAST COMPUTED TOMOGRAPHY IN THE
SURVEILLANCE OF NEPHROLITHIASIS
TIMUR H KURU
62
ROBOTIC ASSISTED LAPAROSCOPIC PARTIAL
NEPHRECTOMY IN PATIENTS WITH PREVIOUS
ABDOMINAL AND PLEVIC SURGERY
WAHIB ISAC
63
ROBOTIC VERSUS OPEN URETERONEOCYSTOSTOMY: A
SINGLE INSTITUTION COMPARATIVE OUTCOME
ANALYSIS
WAHIB ISAC
64
REGISTRATION OF ULTRASOUND AND HISTOLOGY
DATA FOR VALIDATION OF EMERGING PROSTATE
CANCER IMAGING TECHNIQUES
MASSIMO MISCHI
65
MULTI-INSTITUTIONAL ANALYSIS OF ROBOTIC PARTIAL
NEPHRECTOMY FOR SOLITARY KIDNEY
SHAHAB
HILLYER
66
SYSTEMATIC PROSTATE BIOPSIES MAY DETECT MORE
INSIGNIFICANT CANCER THAN MRI LESION TARGET
PROSTATE BIOPSIES
PIERRE MOZER
67
LONG-TERM OUTCOMES OF INTRA-RENAL BCG/IFN FOR
BIOPSY-PROVEN UPPER-TRACT CARCINOMA IN SITU
EDAN SHAPIRO
68
PROSTATIC SWELLING AND SHIFT OF INTRA-PROSTATIC
TARGET DURING HIFU: IMPLICATION FOR TARGETED
FOCAL THERAPY
SUNAO SHOJI
69
NOVEL MICRO-ULTRASOUND PROBE TO IDENTIFY
MICROVESSELS IN THE SPERMATIC CORD
AHMET
GUDELOGLU
POSTER SESSION 2B
60
61
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
A V RAWANDALE
SUTCHIN PATEL
Page 14 of 97
PROGRAM
70
NEUROPROTECTIVE WRAP FOR THE SPERMATIC CORD
AFTER DENERVATION PROCEDURES
AHMET
GUDELOGLU
71
ROBOTIC ASSISTED PARTIAL NEPHRECTOMY IN
PATIENTS WITHOUT HILAR CLAMPING - A MULTIINSTITUTIONAL STUDY
BARTOSZ
KACZMAREK
72
APPLICATIONS OF SPIDER IN UROLOGY, THE
UNIVERSITY OF MIAMI EXPERIENCE
ARTURO JR.
CASTRO
73
DEVELOPMENT AND VALIDATION OF A RAPID
CIRCUMCISION DEVICE TO FACILITATE DISSEMINATION
OF SAFE ADULT MALE CIRCUMCISION AMONG U.S.
VETERANS
FIBER OPTIC SUCTION AND PULLING OF URINARY
STONE PHANTOMS USING A HIGH PULSE RATE THULIUM
FIBER LASER
JAMES HOTALING
75
ROBOTIC ASSISTED LEGO® CONSTRUCTION AS A
MODEL FOR ROBOTIC MICROSURGERY SKILLS
TRAINING
AHMET
GUDELOGLU
76
RAPID DETERMINATION OF SYSTEMIC LEVELS OF
OXALATE USING A NEWLY DEVELOPED OXOMETER
TOP 10 ABSTRACT
BENJAMIN
CANALES
77
PROSPECTIVE EVALUATION OF THE DURABILITY OF
REFURBISHED FLEXIBLE URETEROSCOPES IN AN 860
BED TERTIARY CARE CENTER WITH MULTIPLE
SURGEONS.
ROBERT CAREY
74
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
RICHARD
BLACKMON
Page 15 of 97
ABSTRACTS
ABSTRACT 1
NOVEL LAPAROSCOPIC DEFOGGING AND CLEANING DEVICE UTILIZED
DURING ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY (RALP): 20
CASE EXPERENCE
Carson Wong, MD1,2,3 and Xiao Gu, MD, PhD4
1
SouthWest Urology, Inc.
Ahuja Medical Center, University Hospitals
3
Parma Community General Hospital
4
The First Clinical Medical College at Yangzhou University
2
Introduction: Maintaining efficiency and optimal visualization are critical components of any surgical
procedure, particularly in robot-assisted cases, where removal of the laparoscope to defog or clean the lens
requires time and can be cumbersome. We evaluate the Advanced Laparoscopic Care Kit (New Wave
Surgical, Coral Springs, FL) as a novel set of accessories that defogs and cleans the laparoscope during
RALP.
Methods: Laparoscope warming and cleaning equipment were replaced in our operating suite with the
Advanced Laparoscopic Care Kit (“Care Kit”) for 20 consecutive patients who underwent transperitoneal
RALP. Our observations and the features of the Care Kit are reviewed.
Results: The Care Kit includes a defogging device that heats an internal reservoir of surfactant based
alcohol-free anti-fog solution to 120° F. The device remains heated for 5 hours. The heated surfactant acts
as a soap that can quickly remove dried debris from the lens. Because the device is self-contained and hand
held, it can be brought to the laparoscope with minimal displacement of the laparoscope from the trocar.
The Care Kit also includes microfiber cleaning pads (fibers 2000 times smaller than surgical gauze) that
clean oils better than surgical gauze and avoid scratching the delicate lens. A trocar cleaning sponge for
removing debris that can be trapped inside the trocar cannula is also supplied. Subjectively, the Care Kit
proved to be simple to use by the bedside assistant and effective at maintaining optimal laparoscope
visualization. Transfer of the laparoscope to the back table for warming intraoperatively was not required in
all 20 cases. The Care Kit protects the laparoscope while it is initially lying flat on the back table from the
dangers of scratching and falling associated with using traditional laparoscope warmers.
Conclusions: The Care Kit was effective in preventing fogging of the laparoscope during RALP. It has the
potential to minimize delays that can result from laparoscope defogging and cleaning, thereby reducing
operative times. Further studies will be required to quantify the potential time savings and determine
whether there is a reduction in laparoscope damage and subsequent repair costs associated with use of this
device.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 2
ABSTRACTS
SPARKER ARRAY FOR LITHOTRIPSY
Michael Grapperhaus, Raymond Schaefer
Phoenix Science & Technology, Inc.
Introduction: Despite the positive clinical outcomes (greater than 90% success rate) of early electro-hydrodynamic
lithotripters (EHLs), such as the Dornier HM3, the use of shock wave lithotripsy (SWL) has decreased in the last 20
years. This is attributable to several factors, including the short lifetime of sparker electrodes in the HM3, which
prompted a move to non-sparker shock-wave sources in 2nd and 3rd generation lithotripters. As a result, the success
rate of SWL has decreased to less than 50% in recent years, while the success rate of invasive techniques, such as
flexible ureteroscopy, have success rates greater than 90%. We have developed a new shock wave source using an
array of small sparker sources for use in SWL that can resolve lifetime and other issues of sparker based SWL.
Methods: Two arrays of 7 sparkers were built and operated simultaneously, with the sparkers arranged along the
circumference of a circle in a single plane. The pressure field was measured with PVDF hydrophones (Onda HGL0400 at low pressure and Onda HNS-0500 at higher levels) both at focus and along three axes around focus. The
pressure field from a single sparker was also measured and used to simulate the pressure field from different array
configurations and operating conditions. The sparker arrays were also used to break artificial stones made with
Ultracal-30 gypsum.
Results: The sparker array produced a pressure pulse that delivered a peak pressure of 40 MPa with a pulse width of
0.7 msec to the focus. The planar sparker array produced a pressure field with a focal spot (50% of peak) that is 38
mm long the direction normal to the plane of the array, 2.5 mm within the plane of the array and perpendicular to the
direction of propagation and 15 mm long in the direction of propagation. The pressure pulses were highly repeatable,
with a coefficient of variation of 1.5%. Simulation of the pressure field reproduced this, and also predicted a more
symmetric focal region for a compact 3-dimenstional arrangement with the sparkers on a spherical surface. The model
predicts that this configuration will produce a focal region approximately 5 mm in the plane perpendicular to
propagation and 50 mm long in the direction of propagation. The sparker array was used to break artificial stones in 7
tests using 2400 shock wave pulses in each test. Additional testing resulted in the array delivering more than 20,000
pulses without a decrease in output pressure.
Conclusion: The sparker array provides a consistent, configurable electro-hydrodynamic shock wave source that lasts
multiple shock wave lithotripsy procedures. The configurable array allows the inclusion of in-line diagnostics during
the procedure without altering the pressure pulse delivery.
Seven element sparker array
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 3
PULSED FLUOROSCOPY IN URETEROSCOPY AND PERCUTANEOUS
NEPHROLITHOTOMY
Mohamed A. Elkoushy, Walid Shahrour, and Sero Andonian
Division of Urology, Department of Surgery, McGill University Health Center,
McGill University, Montreal QC, Canada
Introduction and Purpose: Urologists strive to minimize the use of intra-operative fluoroscopy during
endourological procedures that usually associated with small but measurable amounts of radiation exposure.
The aim of the present study was to assess the impact of pulsed fluoroscopy on the total fluoroscopy time
during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL).
Methods: A retrospective review of prospectively collected data was performed for consecutive patients
undergoing URS and PCNL by a single surgeon between July 2009 and July 2011. Pulsed Fluoroscopy (PF)
at a rate of 4 frames per second (4 fps) was routinely used in all URS procedures since January 2011 and in
all PCNL procedures since November 2010. Prior to these, Standard Fluoroscopy (SF) at a rate of 30 fps
was used. Therefore, for each procedure, patients were divided into 2 groups based on whether standard or
pulsed fluoroscopy was used. Patient and stone characteristics together with operative data were compared
between both groups of each procedure using univariate and multivariate analyses to correct for patients,
stone and surgical variables.
Results: A total of 163 URS (117 SF and 46 PF) and 100 PCNL (50 SF and 50 PF) consecutive procedures
were included in the study. In the URS cohort, there were no significant differences between both SF and PF
groups in terms of age, gender, BMI, stone location, and multiplicity (p≥0.20). The SF group in the URS
cohort had significantly larger stone size (12.9 vs. 10.2 mm; p=0.03) which lost its significance in the
multivariate analysis. Duration of surgery and stone-free rates were also comparable in both groups of URS
and PCNL (p≥0.06). Compared with SF groups, patients in the PF groups were exposed to significantly less
fluoroscopy during URS (109.1 vs. 44.1 sec, p<0.001) and PCNL (341.1 vs. 121.5 sec, p<0.001). These
differences in mean fluoroscopy time retained their significance in the multivariate analyses (p<0.001).
Female gender, right sided stones, increased number of punctures and post-operative double-J stenting were
significantly higher in the pulsed fluoroscopy in PCNL group in the multivariate model.
Conclusion: The use of PF during URS and PCNL was associated with significantly lower fluoroscopy
time thus, reducing radiation exposure.
Figure 1: Difference in image quality between
standard (30 fps), the left image, and pulsed (4
fps) fluoroscopy, the right image, in a patient
undergoing balloon dilation of a mid-ureteral
stricture
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 4
ABSTRACTS
FIVE ARM ENHANCED OPTICAL MAGNIFICATION APPROACH FOR
ROBOTIC ASSISTED MICROSURGERY
Ahmet Gudeloglu, Jamin Brahmbhatt, Karen Priola, Sijo Parekattil
Winter Haven Hospital & University of Florida
Introduction: Previous studies have shown the potential benefits of robotic assistance in microsurgery.
However, one caveat of the robotic platform is the limited 12-15x digital magnification with the standard
3D HD camera that reveals pixilation when microsurgeons are performing complex reconstructive
procedures at high magnification. This study presents an enhanced optical high magnification camera (1618x optical magnification) that can be incorporated to the robotic platform to provide the microsurgeon with
a real-time enhanced multi-view experience.
Methods: Review of 191 robotic assisted microsurgical cases performed with the new platform from Dec
2010 to March 2012 by a single microsurgeon. Case breakdown was: 56 vasectomy reversals, 90
microsurgical denervation of the spermatic cord, 37 varicocelectomies and 8 micro TESE (testicular sperm
extraction). The VITOM (Karl Storz Inc, Tuttlingen, Germany) optical high magnification lens-camera
system was utilized with the TilePro (Intuitive Surgical, Sunnyvale, CA) robotic surgical console software
system to provide three simultaneous real-time video images to the microsurgeon during robotic assisted
microsurgery. Figure 1 illustrates this tri-view: 1) a 12-15x 3D digital magnification image via the HD
robotic camera, 2) a 16-18x optical high magnification view via the VITOM system and 3) a 40x optical
microscopic view of fluid being examined by the laboratory technician (for example - vasal fluid evaluation
for sperm). The VITOM camera system was held by a nitrogen powered 5th arm (Point setter arm, Karl
Storz Inc, Tuttlingen, Germany).
Results: All cases were completed successfully without any technical difficulties. The enhanced platform
provided the microsurgeon with improved visual acuity at higher magnifications. The microsurgeon had a
cockpit view of all three simultaneous video images in the surgeon console. This allowed for improved
efficiency in terms of being able to visualize complex reconstructive maneuvers from two different angles
and at two different focal lengths (for standard microsurgery – it common to have to zoom in and out at
various stages of the procedure – this platform obviates the need for this).
Conclusion: This novel five-arm robotic microsurgical approach appears to overcome the magnification
caveat of the standard robotic platform.
Figure 1: A view from the surgeon console: 3
simultaneous real-time video images
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 5
ABSTRACTS
NEPHRON SPARING SURGERY WITH ZERO ISCHEMIA
Eric R. Taylor, Aaron D. Benson, Bradley F. Schwartz
Division of Urology, Southern Illinois University, Springfield, IL
Introduction: Detection of incidental renal lesions has risen sharply. Most are small, < 7 cm-sized
lesions. During robotic or laparoscopic nephron sparing surgery renal hilar clamping is often
employed. Unfortunately, there is no simple technique to cool renal parenchyma during laparoscopic
surgery and longer warm ischemia times are associated with renal damage. Our purpose was to
analyze outcomes of patients undergoing laparoscopic and robotic partial nephrectomies without
hilar clamping.
Methods: A retrospective database of patients undergoing partial nephrectomy from 2003-2010 was
reviewed. Small renal masses suspicious for malignancy were excised by conventional laparoscopic
partial nephrectomy (LPN) or robotic-assisted laparoscopic partial nephrectomy (RALPN) without
renal vessel clamping. Data from these clinical interactions was retrospectively collected and
analyzed, which included patient age, pathologic diagnosis, operative time, surgical margins, serum
creatinine change, EBL, post-operative hemoglobin change, transfusion rate, length of follow up,
recurrences, and complications.
Results: Twenty-nine patients underwent partial nephrectomy without renal hilar clamping; 15 were
performed by LPN while 14 underwent RALPN. No intra-operative complications occurred and 6
(20%) post-operative complications occurred without any reoperation. The mean pre- and postoperative serum creatinine levels were 1.2 and 1.1, respectively. The mean hemoglobin change was 2.7(g/dL), with 3 (10.3%) patients requiring a blood transfusion. Of the masses, 72.4% were
malignant, with a mean size of 2.2 cm. One positive margin occurred, but at a median follow -up of 34
months there have been no recurrences in these patients.
Conclusion: Laparoscopic partial nephrectomy with or without robotic assistance can be performed
safely without hilar clamping in select patients providing renal functional protection.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 6
ABSTRACTS
ROBOTIC ULTRASOUND PROBE IN ROBOTIC PARTIAL NEPHRECTOMY
Bartosz F Kaczmarek, Shyam Sukumar, Quoc-Dien Trinh, Navneet Mander, Roger Chen,
Nolan Desa, Mireya Diaz-Insua, Mani Menon, Craig G Rogers
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan, USA
Introduction: Precise tumor identification during partial nephrectomy (PN) is important for successful
oncologic control. Intraoperative ultrasound can help with tumor identification during partial nephrectomy.
Robotic partial nephrectomy (RPN) using a laparoscopic ultrasound probe (LUP) for tumor identification
requires the probe to be controlled by the bedside assistant. A robotic ultrasound probe (RUP) allows the
surgeon to control intraoperative ultrasound, but the use of the RUP has not yet been evaluated in
comparison to LUP. We evaluate robotic partial nephrectomy using a RUP in comparison to a LUP.
Methods: Data from 75 consecutive RPNs performed with a LUP between January 2009 and November
2010 were analyzed retrospectively against 75 consecutive RPNs performed with a RUP between November
2010 and November 2011.
Results: A total of 72 patients underwent 75 consecutive RPN using the LUP with a mean tumor size
followed by 73 patients that underwent 75 consecutive RPNs using the RUP. The patient population data
did not differ significantly. The robotic group had a larger tumor endophytic percentage (42.8 vs. 55.3%,
p=0.004), but other perioperative factors, such as mean OR time (233 vs. 218 mins), mean console time
(173 vs. 156 mins, p=0.095) and mean blood loss (164ml vs. 171 mL, p=0.79) and positive pathologic
margin rates (1 vs. 2, p=1) did not achieve statistically significant difference. All patients are free of cancer
recurrence after a mean FU of 25.7 months in the LUP group and 10.2 months in the RUP group.
Conclusion: A RUP under surgeon control during RPN offers comparable tumor identification and margin
rates as a LUP with advantages of increased surgeon autonomy.
Figure: robotic ultrasound probe utilizes articulation range of a robotic instrument
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 7
NONINVASIVE HISTOTRIPSY OF THE PROSTATE USING VORTX RX™:
FEASIBILITY IN A CANINE MODEL
William W. Roberts, MD*1, Dejan Teofilovic,*2, Russell C. Jahnke*2,
M. Christine Gibbons*2, Jack M. Risdahl, DVM, PhD3, James A. Bertolina, PhD*2
University of Michigan, Department of Urology1, HistoSonics, Inc.2, The Integra Group3
Introduction: Histotripsy is a noninvasive, pulsed, focused ultrasound technology that uses controlled acoustic
cavitation to homogenize targeted tissue. The objective of this study was to demonstrate treatment safety and
noninvasive debulking of prostate tissue in a canine model using the VORTX RX™ prototype system developed by
HistoSonics, Inc. for treatment of BPH.
Methods: Following animal care and use committee approval, histotripsy treatment of the prostate was performed on
ten male canine subjects. The therapy transducer (36-element, 700 kHz, 11 cm focal distance) delivered acoustic
bursts (3-cycle, 500 Hz pulse repetition frequency) transabdominally to the prostate. The resultant cavitation cloud
was manually translated throughout the targeted volume for 60 minutes in each subject followed by TRUS and
cystoscopic assessment. Laboratory tests (CBC, comp, UA) were collected pretreatment, POD 2, 7 and weekly.
Prostates were harvested on POD 2 (2 subjects) or POD 28 (8 subjects) following repeat TRUS and cystoscopic
evaluation.
Results: A treatment cavity was apparent within each prostate on TRUS and cystoscopy. On POD 2, the cavity
contained necrotic debris and was lined by inflammatory cells, hemorrhage and edema. By POD 28, the targeted zone
was a widely patent cavity lined by urothelium with minimal to no residual debris. In the subjects harvested at POD
28, pre-treatment prostate size averaged 38.6 cm3 (range 30.6-44.1 cm3). A mean of 14.2 cm3 (range 7.1-20.8 cm3) of
prostate tissue was removed, corresponding to an average debulking of 36% (range 19-53%) of total prostate volume.
Expected changes in urinalysis (hematuria, pyuria, and proteinuria) and transient elevation in WBC were observed
following treatment.
Though not producing clinical signs or symptoms, notable pathologic findings at necropsy
consisted of rectal wall muscle degeneration (2 subjects) concerning for potential histotripsy effect and 1 cm diameter
areas of fibrosis in the abdominal rectus muscle (2 subjects) consistent with thermal injury along the acoustic
propagation path to the prostate.
Conclusion: Transabdominal application of histotripsy to prostate tissue in the canine model from the VORTX RX™
system produced cavitation activity that was easily identified with TRUS imaging. A substantial treatment cavity was
apparent at harvest in all subjects and
generally appeared well healed by
POD 28. Although not producing clinical
effects, the pathologic findings of
degeneration of muscle in the rectal wall
and zones of fibrosis in the abdominal
rectus muscle are of concern as they may
represent suboptimal confinement of
cavitation activity and heating of
overlying tissues respectively. Further
work is underway to quantify the pre- and
post-focal acoustic and thermal fields to
eliminate these effects prior to human
application.
Funding: HistoSonics, Inc., *Financial
interest / other relationship with
HistoSonics, Inc.
Prototype system (left). Sagittal US images of canine prostate before treatment
(top) and on POD 28 demonstrating central treatment cavity (bottom).
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 8
NOVEL ULTRA-LOW DOSE NON-CONTRAST (NCCT) FOR UROLITHIASIS:
PROSPECTIVE COMPARISION OF DIAGNOSTIC ACCURACY WITH
CONCURRENT STANDARD DOSE IMAGING
Sri Sivalingam1, Perry J Pickhardt2, Julie Ruma2, Stephen Y Nakada1
1
2
University of Wisconsin, Department of Urology, Madison, WI
University of Wisconsin, Department of Radiology, Madison, WI
Introduction: NCCT is the gold-standard diagnostic study for urolithiasis evaluation. However, concerns
over the potential risks related to ionizing radiation may limit its use. Ultra-low dose (ULD) NCCT could
potentially lower radiation exposure below that of a conventional KUB, but an acceptable level of
diagnostic accuracy must be maintained. We report preliminary results of our ongoing prospective ULD
NCCT trial for renal stone detection.
Methods: Following informed consent, NCCT for urolithiasis evaluation was performed in 10 consecutive
adults (mean age, 55.8 years; mean BMI, 27.5), using our standard-dose (SD) protocol immediately
followed by a matched ULD series. All scans were performed on a GE Discovery CT750 HD scanner and
two software rendering protocols for image reconstruction were used, FDP and ASiR. Axial and coronal
5x3mm reconstructions were obtained for each series. The 40 total series were anonymized and interpreted
in random order for urolithiasis detection.
Results: For the ULD series, the range of dose reduction relative to SD was 82-90% (mean, 87% reduction),
with a mean effective dose ranging from 0.88 mSv to 1.54 mSv (mean, 0.99 mSv). Seven cases were below
1.0 mSv. A total of 29 renal calculi (range, 1-22 mm; mean, 4.1 mm) were identified at SD NCCT, of
which 22 (75.9%) and 22 (75.9%) were detected at ULD with FBP and ASiR, respectively. Overall
sensitivity was 76%, however, subgroup analysis by stone size showed improved detection rates for stones
≥3 mm, i.e. all 19 calculi ≥3 mm were seen on both ULD reconstructions. Only 10-30% of stones ≤2 mm
was prospectively identified on the ULD series.
Conclusion: Ultra-low dose NCCT for urolithiasis in the 1 mSv range can accurately detect calculi ≥3 mm
but fails to detect most stones ≤2 mm. Typically the clinical ramifications of these stones (≤2 mm) is less
relevant acutely. The degree of dose reduction that preserves diagnostic accuracy for tiny calculi remains
uncertain, but may be influenced by further improvements in iterative reconstruction techniques.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 9
TOP 10 ABSTRACT
SURGTRAK: EVOLUTION OF A MULTI-STREAM SURGICAL PERFORMANCE
DATA CAPTURE SYSTEM FOR THE DA VINCI SURGICAL ROBOT
Lee W White1, Timothy M Kowalewski2, Blake Hannaford2, Thomas S Lendvay3
1
2
BioEngineering Department, University of Washington
Electrical Engineering Department, University of Washington
3
Department of Urology, University of Washington
Introduction: The da Vinci surgical robot lacks open access to the surgeon motion data which is the foundation
of automated and objective performance assessment. Thus we developed a robotic tool and video tracking
platform, SurgTrak (White, et. al., SAGES 2011). The system uses readily adaptable custom software to merge
streams of tool position and orientation data with the motion of the end-effectors and high definition (HD) video. We
have since expanded the system to record three new wireless data sources: intraoperative electroencephalogram
(EEG) of surgeons, surgeon hand motion data, and end-effector motion data. This enables unencumbered data capture
in the operating room.
Methods: This generation of SurgTrak features the following improvements:
•
Record surgeon EEG during surgery using the B-Alert X10 by Advanced Brain Monitoring, Inc. which
evaluates the surgeon’s level of engagement, distraction, and cognitive workload.
•
Time synchronized hand motion data is recorded using a pair of AcceleGloves from Anthrotronix, Inc.
•
End-effector motion data produced by the rotation of the spindles in the proximal portion of the da Vinci tool
are wirelessly transmitted by custom electronics featuring a 16 Mhz. Atmel microprocessor and an XBee
wireless serial module capable of communicating at 115.2 kbps.
•
Standard Transmission Control Protocol (TCP) and User Datagram Protocol (UDP) allow the system to
receive data streams from other data sources.
Results: The system was tested for reliability and is in use in two studies currently underway: 1) recording
simultaneous HD video and surgeon EEG during robotic assisted prostatectomy, and 2) recording da Vinci tool
motion, HD video, and surgeon hand motions while performing bladder cystotomy closures on a live porcine model.
The objective of both studies is to elucidate the potential benefit of virtual reality based training and warm-up on
surgical performance.
Conclusion: The SurgTrak system is configurable, deployable and capable of capturing many facets of surgical
performance on the da Vinci surgical robot
including surgeon motion, cognitive and
psychomotor skills, mental workload, and
surgery video documentation.
Figure 3: (Top from left) Unmodified da Vinci Large Needle
Driver, SurgTrak wireless tracking system electronics, finished
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 10
ABSTRACTS
XenX: EVOLUTION OF DESIGN BASED ON CLINICAL EVALUATION
Ofer Zigman, Carl Sarkissian, Idan Tamir, Manoj Monga
Introduction: The XenX (Xenolith Medical, Ltd) is a new ureteral occluding device intended to serve as a safety
guidewire, prevent retrograde stone migration during ureteroscopic lithotripsy, and place ureteral stents. A total of 13
ureteroscopy procedures for ureteral stones were performed with the XenX at two institutions by five board certified
physicians. We present results from in vitro testing designed to validate modifications based on issues encountered
during the first clinical evaluations. Physician feedback with regard to the ability to gain ureteral access, deploy the
occluding braid, prevent stone migration, basket alongside the device, radiopacity, kink resistance, and retrieval of the
device, was used to identify the most effective modifications for improving performance. Some modifications include
increasing the occluding braid diameter for retention in dilated ureters, varying floppy tip length for improved
maneuverability, and reducing sheath diameter for improved stent compatibility.
Methods: Device migration as a result of ureteroscope manipulation within the ureter was found to affect several
feedback areas and reduce overall efficiency associated with the use of this device during multiple cases. Accordingly,
an in vitro set-up was devised to evaluate the extent to which the most recent design modification (PTFE-coating over
the polyimide sheath and nitinol core wire) affects frictional characteristics between the device and ureteroscope. A
2.99 mm outer diameter 43 cm long stainless steel (SS) tube was placed within a 4.0 mm inner diameter PTFE tube,
designed to model a semi-rigid ureteroscope within a non-dilated ureter. The XenX polyimide sheath was attached to
a load cell and motorized test stand, placed alongside the SS tube within the model ureter, and extracted from the
tubing for a distance of 80 mm at a speed of 100 mm/min. Forces were measured throughout the entire extraction,
and a total of 5 repetitions were conducted using a new device each time. Individual trials were conducted with the
PTFE coated and uncoated models of both the sheath and core wire. A similar set-up was used to conduct a
comparative assessment of the extent to which device migration occurs as a result of scope movement. The SS tube
was extracted 300 mm, and total displacement of the wire/sheath from the original position was measured. The
average displacement of 5 repetitions was calculated and compared to results using a Sensor (Boston Scientific)
guidewire.
Results: Forces associated with movement of the uncoated core wire and sheath alongside the SS tube ranged from
14-64.3 g and 26.4-40 g, respectively, increasing in a linear fashion as a function of total displacement (see figure 1).
The PTFE coated core wire and sheath were found to produce forces ranging from 3.3-15.1 g and 18.5-30.2 g,
respectively, demonstrating a slope reduction trend as a function of displacement in comparison with the uncoated
units. The uncoated and PTFE coated core-wire migrated an average of 64.8±4.6mm and 6.6±1.8 mm, respectively,
while the outer sheath demonstrated a similar reduction in migration from 63.8±5.1 mm to 36.6±4.6 mm. The Sensor
guidewire migrated an average of 31.4±5.4 mm.
Conclusion: PTFE-coated wire and sheath components
significantly reduced static and dynamic friction and resulting
migration when compared to uncoated components. Recent
modifications suggest the XenX holds promise for performing
similar to commercially available guidewires, such as the
Sensor, in an in vivo setting with regard to ureteroscope
compatibility.
Figure: Force (g) vs. displacement (mm) for coated
(magenta) and uncoated (blue) XenX sheath
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 11
RAPID EXTRACORPOREAL STONE COMMINUTION: MECHANISTIC
INSIGHTS IN VITRO
Alexander P. Duryea1, *William W. Roberts1,2, *Charles A. Cain1, *Timothy L. Hall1
1
Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
2
Department of Urology, University of Michigan, Ann Arbor, MI
Introduction: Previous work has demonstrated that cavitationally-based pulsed ultrasound therapy
(histotripsy) effectively comminutes model stones, eroding the surface to fine debris <100-μm in size. Here,
histotripsy was evaluated as a potential adjunct to conventional SWL procedures, with the hypothesis that a
synergistic interplay of the two modalities will yield faster and more complete stone comminution.
Methods: Composite model stone cylinders (d=10-mm) formulated to mimic naturally occurring cystine
calculi were treated in-vitro with a research system capable of delivering electrohydraulic SWL (1 Hz) and
histotripsy (100 Hz) confocally. Five stones were sonicated with each of five different treatment schemes: 1
- Ten minutes electrohydraulic SWL; 2 - Seven minutes histotripsy; 3 - Treatment 1 (SWL) followed by 2
(histotripsy); 4 - Treatment 2 (histotripsy) followed by 1 (SWL); 5 - Ten minutes electrohydraulic SWL
interleaved with histotripsy pulses. Following each treatment, stone debris was collected and sequentially
sieved through 8-mm, 6-mm, 4-mm, and 2-mm filters.
Results: Stone debris size distributions are displayed in Figure 1. Following ten minutes of electrohydraulic
SWL, stones were reduced to a broad range of fragment sizes, with an average of 33% of the original stone
mass remaining >6-mm. The addition of histotripsy therapy (Treatments 3, 4, and 5) resulted in a higher
degree of stone comminution, with electrohydraulic SWL followed by histotripsy achieving the most
complete state of stone subdivision.
Conclusion: Incorporating histotripsy with electrohydraulic SWL enhanced the degree of stone
comminution following truncated stone sonication. When applied prior to lithotripsy, it is likely that surface
defects induced by histotripsy erosion act as nuclei for shockwave crack propagation. When applied after
lithotripsy, the increased stone surface area afforded by shockwave stone subdivision enhances the efficacy
of histotripsy stone erosion. It is likely that both these effects are at play to some extent during the
interleaved therapy. However, further optimization of this interleaved pulse scheme is required in order to
minimize potential microbubble shielding effects of remnant histotripsy nuclei on subsequent shockwaves.
Figure 1: Stone Debris Size Distributions
Funding: NIH R01-DK09126701
*Financial interest/other relationship with HistoSonics, Inc.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 12
ABSTRACTS
TOP 10 ABSTRACT
DESIGN OF AN AUTOMATED CYSTOSCOPE FOR BLADDER CANCER
SURVEILLANCE
Xianming Ye, W. Jong Yoon
Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
Introduction: Bladder cancer has the highest recurrent rate. Several years of diligent and accurate
postoperative surveillance are necessary to monitor the recurrences of tumors. The current surveillance
procedure is carried out by an urologist who manually manipulates a cystoscope to visually inspect the
bladder inner surface. In order to improve the efficiency and accuracy of cystoscopies, an automated
cystoscope is proposed to scan the entire bladder surface by steering an imaging probe to follow an optimal
pre-programmed scan trajectory. Images abstracted from the cystoscopic video can be used for building a
3D panorama of the bladder surface [1].
Methods: The proposed cystoscopic system consists of a three-segment bending mechanism (Fig. 1). With
the flexibility of multi-segmented mechanism, the positions and the orientations of the camera located at the
tip of the imaging probe can be controlled independently. Therefore, perpendicular views on the bladder
surface and the safety distance between the camera and the bladder wall are guaranteed. Compared to the
previous design based on shape-memory alloy actuators [2], the proposed design is driven by thin
mechanical wires (Fig. 2), thus eliminates the possibility of intrinsic thermal hazards to tissues. Kinematic
simulations of following spiral scan trajectories are performed in MATLAB.
Results: The simulation results prove that with synchronized bending motions of all three segments, the
distal camera can follow different specified scan trajectories. Using an optimized spiral scan trajectory with
minimized translation/rotation motions and appropriate view center (camera position) density control, the
anticipated time required for a complete scan is simulated as less than three minutes. In order to maintain
the best quality in 3D panorama construction, this optimized trajectory maintains 50% spatial overlap
between the adjacent image frames.
Conclusion: A new automated cystoscopic procedure is
designed to improve the overall performance of the
bladder cancer surveillance and this can reduce the
workload of urologists as well. The simulated results
show a significant reduction in surveillance time for a
complete scan compared to the previous study. The
miniaturized flexible robotic articulation combined with
the
3D image reconstruction is under construction and may
open
up the new potential to revolutionize the bladder cancer
examination.
Fig. 1: Multi-segmented cystoscope for automatic
[1] E.J. Seibel, T.D. Soper, M.R. Burkhardt, M.P. Porter, W.J. Yoon, Multimodal
scanning. This spiral scan trajectory ensures 50%
image overlap.
cystoscopy for creating co-registered panoramas of the bladder urothelium,
Photonic Therapeutics and Diagnostics VIII, Proc. of SPIE Vol. 8207, 82071A
(2012)
[2] W.J. Yoon, S. Park, P.G. Reinhall, and E.J. Seibel, Development of and Automated
Steering Mechanism for Bladder Urothelium Surveillance, Journal of Medical
Devices, 2009, 3(1): 11004.
Fig. 2: Bigger scale proof-of-concept prototype
of the proposed bending mechanism.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 27 of 97
flexible
ABSTRACT 13
ABSTRACTS
A NOVEL VAS CLAMP FOR USE IN NONINVASIVE LASER VASECTOMY
Christopher M. Cilip1, Mohamad E. Allaf 2, Nathaniel M. Fried1,2
1
Optical Science and Engineering Program, University of North Carolina at Charlotte, NC
2
Department of Urology, Johns Hopkins Medical Institutions, Baltimore, MD
Introduction: Approximately 500,000 vasectomies are performed in the United States per year, making it the most
common urological procedure in the U.S. Although vasectomy is more effective and less likely to have complications
than tubal ligation, the number of men undergoing surgical sterilization is about three times less than women. Fear of
complications related to surgical vasectomy is a major factor in a couples’ choice of surgical sterilization. A
completely noninvasive technique for male sterilization may improve acceptance of vasectomy. Our laboratory is
currently developing a noninvasive vasectomy technique using near-infrared laser irradiation in conjunction with
cryogen spray cooling of the scrotal skin for thermal occlusion of the vas. During preliminary studies, we reported
successful thermal occlusion and scarring of the vas in ex vivo and in vivo canine models, with the thermally
coagulated vas segment withstanding burst pressures over twice that of normal ejaculation pressures. However, rare
complications associated with sub-optimal alignment of laser and cryogen spots with the vas (e.g. scrotal skin laserinduced heat and cryogen-induced freeze burns) resulted in delays and aborted procedures. These problems were in
part due to misalignment and may be solved using an improved vas clamp.
Methods: We describe the design and testing of a novel vasectomy ring clamp attachment which allows the surgeon
to rapidly and precisely co-align both the laser spot and cryogen spot with the vas deferens for consistent and
reproducible targeting of the vas. This design allows the surgeon to continue to use a standard no-scalpel vasectomy
(NSV) ring clamp to isolate the vas, and to maintain a field-of-view during non-contact delivery of the laser radiation
to the vas.
Results: If a NSV ring clamp is used as the main axis of reference, it is possible to achieve any orientation necessary
for a successful procedure with only four degrees of freedom. Three orthogonal degrees of freedom allow the
necessary components to be placed anywhere, spatially, in relation to the ring of the NSV clamp. An additional fourth
degree of freedom, roll, provides the user with the ability to correct for any rotation of the clamp inside the secured
device. By using a cylindrical coordinate system it is possible to minimize the material necessary to achieve all three
orthogonal degrees of freedom (ρ,φ,z), and thus provide a lightweight, handheld stainless steel design. Roll is then
added by allowing the stabilizing arm which controls the ρ component to rotate freely before it is locked into place
with a set screw (Figure 1).
Conclusion: A prototype NSV clamp attachment was
designed and successfully tested during noninvasive laser
vasectomy procedures performed in an in vivo canine
model. Previous problems involving misalignment of the
laser and cryogen spots with the vas were eliminated.
Azospermia and recanalization studies are currently being
conducted to determine the long-term efficacy of this
technique.
Detachable clamp
extension
Cryogen
spray valve
roll
Laser delivery fiber
and collimating lens
Isolated vas illuminated with
laser guide beam; skin
protected by cryogen guard
ρ
φ
z
No scalpel vas
ring clamp
Figure: Clamp attachment allowing precise co-location of
laser spot, cryogen spot, and vas segment grasped in standard
NSV clamp.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 28 of 97
ABSTRACT 14
ABSTRACTS
A COMPARISON OF DIFFERENT ACUTE ANGLES BETWEEN
STRAIGHT INSTRUMENTS USED DURING
LAPAROSCOPIC SUTURING AND KNOT TYING
Ernesto V. Arada III MD, Jun Dy MD, Luis Florencio MD, Michael Macalalag MD,
Frederick Mendiola MD, Ceasar Ballesteros MD, Ma. Zsarin Tuason MD
Quirino Memorial Medical Center, Quezon City, Philippines
Introduction: Traditionally, laparoscopic suturing and knot tying are done using straight needle holders and graspers
at acute angles between these instruments. Our objective is to compare angles of 15°, 25° and 45° between straight
instruments used during laparoscopic suturing and knot tying.
Methods: Timed exercises by six urologists were done by making five sutures and tying three knots with 3-O
Polyglycolic acid with HR-26 needle in a 2 cm. incision model inside the “Home-made Laparoscopic Suturing and
Knot-Tying Angle-Trainer.” Straight laparoscopic needle drivers and graspers were placed at instrument angles
between them of 15°, 25° and 45° respectively. Two sets of exercises were done by suturing penrose drain in oblique
135° (simulating laparoscopic suturing in pyeloplasty, partial nephrectomy, or ureteral surgery) and perpendicular
90° positions relative to telescope axis (simulating laparoscopic suturing in prostatectomy or cystorrhapy)
respectively.
Results: In the first exercise of sutured-object position in oblique 135° relative to telescope axis: at 15° instrument
angle, suturing and knot tying was 1046 seconds (range 698 - 1454); at 25° instrument angle, suturing and knot tying
was 785 seconds (range 487 - 1313); and at 45° instrument angle, suturing and knot tying was 744 seconds (range 480
- 1128). In the second exercise of suturedobject position in perpendicular 90° relative
to telescope axis: at 15° instrument angle,
suturing and knot tying was 929 seconds
(range 360 - 1576); at 25° instrument angle,
suturing and knot tying was 736 seconds
(range 345 - 1325); and at 45° instrument
angle, suturing and knot tying was 695
seconds (range 408 - 1157). Using Wilcoxon
Signed Rank Test, suturing and knot tying
was significantly longer (p = 0.0061) at 15°
instrument angle compared with 25°
instrument angle and with 45° instrument
angle, in both 135° and 90° sutured-object
positions. No significant difference (p =
0.1167) in suturing and knot tying was noted
at 25° instrument angle compared with 45°
instrument angle.
Conclusion: The more acute 15° angle
between straight instruments, compared to
both 25° and 45° angles between instruments,
result in significantly longer duration of
laparoscopic suturing and knot tying.
However, comparing 25° and 45° angles
between
instruments,
no
significant
difference was noted in duration of
laparoscopic suturing and knot tying.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 29 of 97
ABSTRACTS
ABSTRACT 15
INITIAL EXPEREINCE WITH PERCUTANEOUS MICROWAVE ABLATION OF
RENAL TUMORS: MULTICENTER EVALUATION OF SAFETY AND EFFICACY
Sara L. Best,1 Timothy J. Ziemlewicz,2 Aaron M. Fischman,3 E. Jason Abel,1 J. Louis Hinshaw,2 Fred T.
Lee Jr.,2 Christopher L. Brace,2 Meghan G. Lubner,2 Stephen Y. Nakada,1,2
Marci L. Center,2 Anna J. Moreland2
1
2
University of Wisconsin School of Medicine and Public Health, Dept of Urology
University of Wisconsin School of Medicine and Public Health, Dept of Radiology
3
Mount Sinai School of Medicine, Dept of Radiology
Introduction: Microwave ablation offers the potential advantages of high temperature and faster tissue
heating, but prior instrument development has been limited by overheating of the antenna shaft and supply
cables. Recently, a novel gas-cooled microwave generator and antenna has been developed and approved
for tumor ablation by the FDA. We report the feasibility, safety, and preliminary effectiveness of this highpowered, gas-cooled microwave ablation system in the treatment of renal parenchymal tumors.
Methods: Between 1/2011 and 3/2012, renal parenchymal tumors (n=17) were treated at two medical
centers with intent to cure using ultrasound and CT-guided microwave ablation with a high-powered, gascooled microwave ablation system (NeuWave Medical, Madison, WI). Tumors included biopsy-proven
renal cell carcinoma (n=13; grade 1=4; grade 2=6, ungraded=3), oncocytoma (n=1), insufficient tissue for
diagnosis (n=1), and angiomyolipoma (n=2, diagnosis made by imaging). Mean patient age was 66 years,
with 13 males and 4 females. Post-procedure imaging was performed by contrast-enhanced CT or MRI to
evaluate for recurrence.
Results: Mean maximum tumor diameter was 3.0 cm (range: 1.9-5.4). Tumor diameter decreased by a mean
of 13% (range: 0-30%; SD = 8%) as assessed on immediate post-ablation CT. A mean of 1.5 antennae were
used per tumor, and the mean and median duration of power application was 6.1 and 5.0 minutes,
respectively. Mean and median generator powers were 83.0 and 70.0 W, respectively (range: 55-140).
Technical success (no residual enhancing tumor) was achieved for all tumors. No major complications were
reported. Two minor complications occurred, each consisting of small, asymptomatic sub-capsular
hematomas. Length of hospitalization following the ablation procedure was 1 day in each case. Mean and
median length of follow-up was 3.4 and 2.0 months, respectively. Among the patients who have reached
follow-up imaging time-points, no local tumor progression was identified in any case (n=1, 4-month; n=1,
6-month; n=1, 12-month).
Conclusion: Preliminary experience with high-powered, gas-cooled percutaneous renal microwave ablation
demonstrates immediate technical success in treatment of small renal tumors. Further studies are warranted
to demonstrate long-term oncologic outcomes and optimal surveillance protocols after ablation.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 30 of 97
ABSTRACT 16
ABSTRACTS
TARGETED ROBOTIC ASSISTED MICROSURGICAL DENERVATION OF THE
SPERMATIC CORD FOR CHRONIC ORCHIALGIA
Ahmet Gudeloglu, Jamin Brahmbhatt, Jessica Wharton, Karen Priola, Sijo Parekattil
Winter Haven Hospital & University of Florida
Introduction: Previous groups have shown microsurgical denervation of the spermatic cord (MDSC) as a
less invasive treatment option for chronic orchialgia. Pathology and anatomical studies have identified
specific nerve bundles within the spermatic cord that may be responsible for chronic pain in these men. This
study presents outcomes for a robotic assisted targeted MDSC approach (RMDSC) utilizing a mapped nerve
protocol to maximize preservation of vessels and lymphatics.
Methods: Review of a prospectively maintained consented outcomes database. A four-arm RMDSC
technique was developed using the da Vinci platform (Intuitive Surgical, Sunnyvale, CA). Analysis of 371
RMDSC cases from Oct 2008-Mar 2012 was performed (median follow up 21 months: 1 to 41). Patient
selection criteria for RMDSC: chronic testicular pain (>3 months), failed all other standard pain
management treatments and negative urologic workup. Pain scores where recorded based on a standardized
externally validated pain assessment tool - PIQ-6 (QualityMetric Inc., Lincoln, RI) preoperatively and then
postoperatively at 1, 3, 6, 9 &12 months.
Results: 86.5% (321/371) of the patients had a significant decrease in their pain defined as a score of ≤50
(no impact on quality of life) or a greater than 50% reduction in pain by 6 months post-op. The procedure
failed to provide pain relief in 50 patients. The median operative duration was 15 min (10-150).
Complications were: 1 testicular ischemia, 9 hematomas, and 2 seromas. There were two testicular artery
and one vasal injury: these were repaired intra-operatively with robotic assisted microsurgical techniques
without any further sequela. The 4th robotic arm allowed the surgeon to control one additional instrument
(micro Doppler) leading to less reliance on the microsurgical assistant.
Conclusion: Targeted robotic assisted microsurgical denervation of the spermatic cord is feasible and the
preliminary results appear promising. Further follow up and evaluation is warranted
Figure: The peri-vasal nerve fibers are being ablated
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 31 of 97
ABSTRACTS
ABSTRACT 17
A NOVEL SYNTHETIC VAS DEFERENS MODEL FOR MICROSURGICAL
TRAINING
Ahmet Gudeloglu1, Jamin Brahmbhatt1, Karen Priola1, Karl Hastings2,
Christopher Sakezles2 and Sijo Parekattil1.
1
Winter Haven Hospital & University of Florida,
2
SynDaver Labs.
Introduction: Microsurgical vasovasostomy is a technically challenging procedure. Our current training
models for microsurgical skills training for this procedure include live rodent and cadaver vas deferens
models – both of which are expensive and require appropriate training lab facilities. The goal of this study
was to develop an inexpensive, easily accessible synthetic vas deferens (SVD) model for microsurgical
skills training.
Methods: A synthetic vas deferens (SVD) model was developed based on an inexpensive hydrocarbon
material (SynDaver Labs, Tampa). Mechanical tissue shear and puncture properties where modeled to
mimic human vas deferens tissue. The shape, diameter and lumen size was based on 6 human vas deferens
samples. The new model was then tested on 21 trainee microsurgeons during a hands-on microsurgical
training lab. Measures recorded where ease of use, tactile similarity to human vas and suturing ability.
Results: Mean width and wall thickness for the human vas was 5.08mm and 1mm, respectively. For SVD,
5.08mm and 2mm, respectively. For shear (break point) testing, the mean break stress was 12.07psi for SVD
and 12.16psi for human vas (parametrically congruent). For puncture testing (1mm blunt needle inserted
into tissue at 50mm/min), the mean peak load for 7 SVD samples was 9.71N, and 14.53N for 6 human vas
samples (p = 0.02). During the 21 microsurgeon trainee lab, all the surgeons reported ease of use, tactile
sensation similar to human vas and ability to suture an anastomosis similar to human vas. There were 3
minor complaints: 1) lack of consistency of the vas lumen size along the length of the SVD in some
samples, 2) diffusion of the microdots placed on the transected SVD surface (used during the microdot
vasovasostomy technique), and 3) difficulty in securing the SVD to the vasovasostomy holder in some cases
where the SVD outer lining was very smooth and slippery.
Conclusion: The preliminary results in the mechanical and clinical testing of the synthetic vas deferens
model appear promising. Further refinements to the model have been made based on the above feedback.
This model may provide a very cost-effective, portable alternative to our current microsurgical training
models.
Figure: Synthetic vas deferens during
robotic assisted microsurgical
vasovasostomy training.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 32 of 97
ABSTRACT 18
ABSTRACTS
EVALUATION OF SCOPESAFE FIBERS AND THE SCOPE GUARDIAN SHEATH
IN PREVENTION OF URETEROSCOPE ENDOLUMINAL WORKING DAMAGE
A. Lusch, C. Abdelshehid, J.A. Graversen, E. McDougall, J. Landman
Department of Urology, University of California, Irvine, Orange CA 92868, USA
Introduction: The Holmium:YAG/Neodymium:YAG laser is an adjunct for endoscopic stone treatment.
While endoscope damage due to laser energy is well recognized, mechanical damage to the working channel
due to repeated insertions of laser fibers is a less understood and appreciated mechanism for ureteroscope
damage via working channel perforation. We evaluated ureteroscope performance metrics and working
channel damage with ScopeSafe fibers and the Scope Guardian Sheath.
Material and Methods: A 200µm/272µm ScopeSafe fiber with Scope Guardian Sheath (Optical Integrety
Inc., Panama City Beach, Florida) was objectively assessed in a new 7.5 Fr flexible distal sensor chip
ureteroscope (Storz XC). We measured active upward and downward deflection (up and down) and
irrigation flow rates with this novel fiber and sheath system, and with standard 200µm/272µm laser fiber
(Cook Urological Inc., Spencer, Indiana). Additionally 8 non assembled working channel elements from the
Storz XC ureteroscope were tested in a 90° and 210° deflection model. 200µm/272µm ScopeSafe fibers with
Scope Guardian Sheath and 200µm/272µm standard laser fibers were inserted into an irrigated working
channel (0.9% NaCl) in cycles of 10 insertions. After 40 insertions the insertion cycle was reduced to 5
insertions. Test cycles were followed by an external inspection and an endoluminal video examination of the
working channel by a 2.4Fr flexible Storz fiberscope. Damage to the working channel was classified as
superficial scratches, demarcated abrasions, or perforations.
Results: There were no channel perforations or damage with one hundred laser fiber insertions with the
200µm/272µm ScopeSafe fibers with Scope Guardian Sheath in the 90° model as well as in the 210° model.
With the standard laser fiber, in the 210° model superficial scratches and demarcated abrasions were visible
after 10 and 60–70 insertions for the 272µm laser fiber and after 30 insertions (superficial scratches) for the
200µm laser fiber. In the 90° model, superficial scratches occurred after 20 insertions for the 272µm fibers
and after 40 insertions for the 200µm laser fibers. No demarcated abrasions were seen after 100 insertions.
In the 210° model we saw 1 perforation after 110 insertions with the 272µm fiber, but none with 200µm
fiber. The Scope Guardian Sheath resulted in a 4.7°/3.8° (1.2%/1.5%) diminishment in deflection (up/down)
for the 200µm and a 3.5°/4.3° (1.8%/1.5%) diminishment for 272µm laser fiber compared to standard
200/272µm laser fiber. Irrigation flow rate was diminished with the use of the sheath on both the 200µm
and 272µm laser fiber by 9.33ml/s (28.7%) and 9.13ml/s (32.6%), respectively.
Conclusion: In this in vitro study, the scope Guardian Sheath prevented damage to ureteroscope working
channels. There was some limited diminishment of deflection and irrigation flow rate compared to standard
laser fibers alone.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 33 of 97
ABSTRACTS
ABSTRACT 19
BEST PAPER AWARD
PRECLINICAL SAFETY AND EFFICACY
OF ULTRASONIC PROPULSION OF KIDNEY STONES
Mathew Sorensen1, Jonathan Harper1, Ryan Hsi1, Bryan Cunitz2, Julianna Simon2,
Yak-Nam Wang2, Marla Paun2, Frank Starr2, Wei Lu2, Andrew Evan3, Michael Bailey2
1
2
Department of Urology, University of Washington School of Medicine
Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington
3
Department of Anatomy and Cell Biology, Indiana University School of Medicine
Introduction: Our research group is pursing FDA approval for a human feasibility study of a non-invasive
transcutaneous ultrasound device to expel small kidney stones or fragments from the kidney. The goal is to facilitate
clearance of small stones or residual fragments post-treatment. Extensive testing of this device has been completed in
the porcine model. The purpose of this study was to evaluate the safety and efficacy of ultrasonic propulsion of
surgically implanted stones in a live porcine model.
Methods: In each kidney of 8 domestic female swine (50-60 kg) human stones and metalized glass beads (1-6 mm)
were implanted by retrograde ureteroscopy. A bead was placed in the upper pole as a position reference and
additional stones/beads were placed in the mid and lower pole to reposition. Ultrasonic propulsion was performed
using a Verasonics ultrasound engine and a Philips HDI C5-2 commercial imaging transducer. Stone propulsion was
visualized ureteroscopically, using fluoroscopy and our ultrasound system. The kidneys were perfusion-fixed with
glutaraldehyde and evaluated for injury by a blinded independent expert.
Results: Stones were successfully implanted in 14 kidneys. Over 75% of stones/beads were moved from the lower
pole calyx to the ureteropelvic junction or ureter. Ultrasound procedure time was less than 20 minutes to move each
stone. No damage was identified from the ultrasound propulsion procedure other than that created by the
ureteroscopic stone implantation.
Conclusion: In preclinical trials in a porcine model, ultrasonic propulsion is effective with most stones being
relocated to the ureteropelvic junction or ureter in a timely fashion. The procedure appears safe with no evidence of
tissue damage. The angle and alignment of directional force is critical for the efficacy of stone propulsion. There was
an improvement over the study period emphasizing this skill likely requires training.
Work supported by NIH DK43881, DK092197 and NSBRI through NASA NCC 9-58.
Figure: Real-time B-mode imaging and guidance inherent in the system. The blue arrow indicates the stone
and direction of stone motion in the collecting system. After targeting (red dot), a single 0.5 second burst of
ultrasound pulses is applied and the stone makes a single movement from the calyx to the proximal ureter. All
motion occurs in about 1 second.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 34 of 97
ABSTRACTS
ABSTRACT 20
HOW TO USE AN OPTICAL TRACKER
FOR MORE ACCURATE MEASUREMENTS
Ryan Decker1, Changhan Jun1, Alex Vacharat1, Dan Stoianovici1
1
Urology Robotics Lab, Johns Hopkins University, Baltimore, MD
http://urobotics.urology.jhu.edu/
Introduction: Optical and magnetic tracking systems are widely used to measure the location of medical instruments
in order to provide image-based intraoperative navigation. The basic tracking device measures the 3D coordinates of
one or more special markers. Tracker manufacturers typically provide a global upper limit of these systems’
measurement accuracy and precision. In our studies we observed that these values can be substantially improved
under ideal conditions. This would allow optical trackers to be used for applications with stricter measurement
requirements, such as validating the kinematics of a medical robot. Here, we present an optimized setup and data
acquisition protocol for the Polaris Hybrid optical tracker (NDI, Canada) which may improve its precision and
accuracy of measurement.
Methods: A passive optical marker was placed in the spindle of a Computer Numerically Controlled (CNC) Vertical
Machining Center (Haas VF-1), as shown in Figure 1. A Polaris Hybrid position sensor was attached with an
extension to the table of the CNC. As such, the marker can be moved relative to the tracker with three CNC axes
translations. This allowed the marker to be precisely positioned within 2μm. A CNC program commands the marker
to a set of predefined points and sends the respective coordinates to a PC over a serial port. The PC records the
coordinates and triggers the Polaris to take a series of
marker location measurements. The CNC data is used as
a gold-standard for evaluating the Polaris. The CNC-toPolaris space registration is performed using Arun’s
point-cloud method. Precision and accuracy follow their
standard definitions. The set of predefined marker points
includes 91 locations in a pyramid shape with 6 square
point arrays growing away from the tracker, chosen to be
as close as possible to the tracker within the working
envelope of the CNC.
Results: Figure 2 shows the cumulative average of
samples acquired successively at the same static location
of the marker plotted in the XYZ Polaris directions. As
expected, these show that the cumulative average
provides a more stable measurement. 500 static samples
were acquired and averaged at each location of the
predefined set of points. Table 1 shows the global
precision and accuracy over this set. The similar factorystated value (Spec) of global accuracy norm is 350μm.
Figure 1: Test setup showing optical tracker and CNC machine
Conclusion: The precision and accuracy of the Polaris
tracker can be improved if the measurements are
performed statically and averaged. The measurement
performance deteriorates in the depth (Z) direction from
the scanner. If possible, measurements should be taken
closer to the scanner and/or preferentially using the
frontal plane (XY). In most ideal conditions the Polaris
may provide extremely accurate and precise
measurements.
Acknowledgement: The authors would like to thank Professor
Russell H. Taylor of the Johns Hopkins Computer Science
Department for his guidance on registration methods and the
varying models of optical trackers.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Figure 2: Cumulative average at two static locations along Z
Table 1: Precision and accuracy over 500 samples
[μm]
Precision
Accuracy
X
13
15
Y
53
35
Z
404
190
Norm
408
195
Spec
200
350
Page 35 of 97
ABSTRACTS
ABSTRACT 21
15 YEARS TRANSRECTAL HIGH INTENSITY FOCUSED ULTRASOUND IN
LOCALIZED PROSTATE CANCER THERAPY: IMPACT OF NEOADJUVANT
TURP BEFORE HIFU ON ONCOLOGY EFFICACY
Chaussy Christian^*, Thüroff Stefan°*
^ Dept. of Urology University of Regensburg,
° Dept. of Urology, Klinikum Muenchen Harlaching,
* Krebshilfe Harlaching e.V.
Introduction: Goal of the study was to analyze the efficacy of combined TURP and HIFU as definitive therapy for
localized prostate cancer (PCa) according to PSA Nadir. Three different strategies of HIFU therapy were compared:
“HIFU Monotherapy”, “TURP and HIFU in one session” and “TURP one month before HIFU”. Furthermore, the
relative influence of neoadjuvant TURP on PSA levels before HIFU was evaluated.
Material & Method: The prospective monocentric “Harlaching HIFU Database” (n>2.300, since 96) was used as
data source for analysis. 3 patient cohorts (T1-2, N0, M0): were analyzed: A) 1998-2000 (HIFU Monotherapy), B)
2001-2004: (TURP & HIFU), C) 2005-2010: (TURP 1 month before HIFU): None of the patients had any previous
PCa/PSA influencing therapy. All patients were treated completely with Ablatherm ® (EDAP-Lyon-France). Prostate
volume, PSA at diagnosis and in follow up were analyzed.
Results: During a median follow up time of 5.5 years (range 0.5 – 15 years) a PSA Nadir
< 0.1 ng/ml and a PSA velocity of <0.05 ng/ml/year were observed. Patients with initial PSA values of >10 ng/ml
showed median levels of < 0.3 ng/ml after 5 years of median follow up.
Conclusion:
• PSA Nadir <0.1 ng/ml, PSA velocity/year of < 0.05 and last PSA levels after 5 years of < 0.3 ng/ml proved
the oncological efficacy of HIFU.
• The decrease of PSA Nadir in the three cohorts is caused by radical debulcking TURP and development in
HIFU technology.
• Debulcking TURP leads only to a moderate PSA decrease.
• TURP before HIFU resolves technical restrictions, expands the indications and enables the inclusion of any
prostate.
Source of Funding: Harlachinger Krebshilfe e.V. and Lingen foundation. Thanks to Mrs. Regina Nanieva for HIFU
database management.
Ablatherm® device:
Period of use
Prototype
19961999
evaluable T1-2 patients 170
Prostate volume (cc) 23
median
PSA
at
diagnosis 9.9
(median)
% resected volume
0%
Prostate volume at 22
HIFU
PSA at HIFU (median)
6
PSA Nadir (median)
0.2
Prostate volume final 10
(cc)
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Maxis
20002004
358
38
Integrated
imaging
since 2005
176
45
11.5
9.6
40%
22
49%
21
5.9
0.06
7
5.4
0.06
5
Page 36 of 97
ABSTRACTS
ABSTRACT 22
IN VITRO COMPARISON OF OUR NOVEL SPEAR HEADED PNEUMATIC
INTRACORPOREAL LITHOTRIPTOR WITH HOLMIUM YAG LASER
Rawandale-Patil AV, Kurane C S, Patni L G.
Institute of Urology Dhule, Maharastra, India 424001
Introduction: We describe and compare the stone pulverisation properties of our innovative Spear headed
intracorporeal lithotripter with Holmium YAG laser
Methods: The conventional pneumatic intracorporeal lithotriptor probe has a flat disc like or minimally
champered tip. The Spear Headed lithotripter probe has a conical tip (Fig1). Pulverisation dynamics of the
Spear headed lithotriptor (at 2,3, 4 bars) was compared with Holmium laser (6, 10, & 15 watts) using a
standard hands-free in vitro system and phantom stones. The predetermined end points were:
Impacts at which 1. A dent was produced in the stone (First hit effect), and 2. The stone bivalved or the
probe bore through the stone. The data was analysed using SPSS for different energy subgroups.
Results: The Spear head at 2,3 and 4 bars was equally efficient to 6, 10 and 15 watts laser, respectively, in
causing the first dent (P<0.05). The spear head bivalves the stone. This ability increases with increasing bar
settings. The laser bores through the stones.
The Spear head generates impact pressure of 3570 bars at the “First Hit” comparable to Holmium.
As opposed to holmium as fragmentation progresses (“Followup Hits”):
1. Centrifugal vectors of force result in mechanical separation/ bivalving of stones
2. Tip pressure exponentially decreases
Conclusion: The Spear head generates:
Highly focused impact force comparable to laser at the first hit.
Graduated tip impact force (exponentially decreasing)
Centrifugal vectors of force: Augments pulverisation into larger fragments (suitable for PCNL)
Laser bores through (suitable for ureteroreoscopy)
Figure: Spear Headed Lithotriptor with the Conventional
Lithotriptor
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 23
CYSTOLITHALOPAXY USING CYBERWAND IS EFFICIENT AND SAFE FOR
LARGE BLADDER STONE BURDENS
Matthew Maurice, MD1; John McGill, MD1; Hui Zhu, MD, PhD1, 2
1
2
University Hospitals Case Medical Center, Cleveland, OH
Louis Stokes Cleveland VA Medical Center, Cleveland, OH
Introduction: Open suprapubic cystolithotomy is traditionally reserved for large bladder stone burdens.
Laser cystolitholapaxy (CLP), while minimally invasive, is often laborious and time-consuming. We report
a case series using the Cyberwand® (CW) lithotripter (Gyrus ACMI; Southborough, MA) for large bladder
stone burdens.
Methods: Three cases using CW for large stone burdens were retrospectively reviewed. The stone burden
was calculated by the volume formula for ellipsoids. The CW was inserted via a 24F right angle
nephroscope transurethrally. The calculi were fragmented and evacuated simultaneously with the CW.
Results: The mean stone volume was 260 cc (103 to 429 cc). The mean stone attenuation was 1222 HU
(722 to 1498 HU). After laser and electrohydraulic lithotripters failed to make progress, the CW achieved
complete stone clearance. The mean combined operative time was 269 min (174 to 436 min), including time
using other lithotripters (2 cases) and performing transurethral prostate resection (1 case). For the largest
stone volume, 4 CW probes were required. There were no complications perioperatively or during follow up
(median: 3 months).
Conclusion: Transurethral CLP with the CW is a highly efficient and safe option for large stone burdens
that can be performed via a standard nephroscope to avoid suprapubic cystolithotomy.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 24
ABSTRACTS
COMPARISON BETWEEN SYSTEMATIC AND MRI TRAGETED PROSTATE
BIOPSYS FOR PATIENTS WITH NO HISTORY OF PROSTATE CANCER
ATTENDING A FIRST ROUND OF TRANS-RECTAL ULTRASOUND BIOPSY
PROCEDURE
Coffin G1,2, Chevreau G1, Renard-Penna R3, Comperat E4, Vitrani MA2,
Torterotot C2, Conort P1, Bitker MO1, Mozer P1,2
1
Academic Department of Urology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
2
ISIR laboratory, University Pierre and Marie Curie, CNRS-UMR7222, Paris, France
3
Academic Department of Radiology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
4
Academic Department of Anatomopathology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris,
France
Introduction: Localized prostate cancer diagnosis is a challenging topic which impacts on health policy because of
the increasing number of prostate biopsy procedures and their side effects which can be related to the number of
biopsy cores. Development of prostate MRI imaging allows better characterization of prostate radiological lesions and
it is now possible to perform lesion targeted biopsies. We wanted to compare the effectiveness of systematic biopsies
and MRI targeted biopsies for a first round of prostate biopsy procedure among a population of men at risk of
localized prostate cancer with no history of prostate cancer.
Methods: We retrospectively reviewed all patients who came at our department for a first round of prostate biopsies
and who were at risk of localized prostate cancer.
Exclusion criteria were: history of prostate cancer, previous prostate biopsy, local advanced (≥T3a TNM stage)or
metastatic prostate cancer at examination (digital rectal and clinical examination, PSA serum level>20ng/mL, prostate
MRI staging ≥T3a). Inclusion criteria were:prostate multiparametric MRI showing suspicious intra-prostatic lesion.
All patients attended trans-rectal ultrasound biopsies with a Medison V10 Ultrasound system and the Urostation®
registration device (Koelis, France): 12 systematic cores were realized and 2 or 3 additional cores in the MRI targeted
lesion. Positive core was defined by the presence of prostate cancer on anatomopathological examination.
Results:
Table 1. Patients Characteristics. Results are showed as Mean±Sd[Range] . DRE: Digital Rectal Examination
Table 2. Anatomopathological results of prostate biopsy cores
Conclusion: MRI targeted cores seem to be more accurate than systematic cores to detect localized prostate cancer
and could prevent the use of systematic prostate biopsies to detect cancer and consequently decrease the number of
cores for a prostate biopsy diagnosis procedure.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 25
ABSTRACTS
ROBOTIC TRANS-RECTAL ULTRASONOGRAPHY DURING ROBOTICASSISTED RADICAL PROSTATECTOMY
Sunao Shoji, Andrew J. Hung, André Luís De Castro Abreu, Alvin C. Goh, Andre K. Berger,
Toyoaki Uchida, Mihir M. Desai, Monish Aron, Inderbir S. Gill, Osamu Ukimura
USC Institute of Urology, Center for Image-Guided Surgery, and Center for Advanced Robotic & Laparoscopic
Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
Introduction: We evaluate the use of robotically-manipulated transrectal ultrasound (TRUS) for real-time monitoring of
prostate/peri-prostatic anatomy during robotic-assisted prostatectomy (RAP).
Methods: Ten patients with clinically organ-confined prostate cancer undergoing RAP underwent pre-operative and real-time
intra-operative bi-planar TRUS evaluation utilizing a robotically-manipulated TRUS device (ViKY® system, EndoControl
Medical, Grenoble, France). Median patient age was 66 years (range 54-88), baseline PSA was 5.3 (1.3-17.9), and 4 patients
(40%) had clinical high-grade and high-stage disease. Bilateral or unilateral nerve-sparing was performed in 9 patients (90%).
Results: Median time for VIKY device setup-to-insertion of TRUS probe was 7 minutes (4-12). Complete robotic TRUS
evaluation was successful in all patients. Five patients (50%) had TRUS-visible hypoechoic lesion, confirmed cancerous on preoperative biopsy. Relevant intraoperative TRUS findings were relayed real-time to the robotic surgeon, particularly a) during
dissection of bladder neck and prostatic apex, b) during neurovascular bundle preservation, and c) when hypo-echoic prostate
lesions approximated nerve-preserving dissection. Negative margins were achieved in 9 patients (90%), including cases where
significant intra-prostatic lesions abutted or extended through the prostate capsule. No complications occurred.
Conclusion: Real-time robotic TRUS guidance during RAP is feasible and safe. Robotic TRUS can provide the console surgeon
with valuable anatomic information, thus maximizing functional preservation and oncologic success.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 26
COMPARATIVE IN VITRO EVALUATION OF THE XENX
Sarkissian C1, Zigman O2 Dias F1, Tamir I2, Monga M1
1
2
Cleveland Clinic – Cleveland, OH
Xenolith Medical - Kiryat-Gat, Israel
Objective: To conduct a comparative assessment of two stone retention devices to several commercially available guidewires for
an evaluation of safety and functionality.
Methods: An in vitro ureter model (4.76 mm ID silicone tubing) was used to manually evaluate maneuverability through
measurement of insertion forces (unsuccessful attempts to pass impacted stone), passing forces (force required for successful
stone passage), number of attempts and time until successful stone passage. Guidewires evaluated included the Sensor (Boston
Scientific), Glidewire (Boston Scientific), RoadRunner PC Nimble (Cook Medical), RoadRunner PC Firm (Cook Medical),
HiWire (Cook Medical), and retention devices included the XenX (Xenolith Medical) and Accordion (PercSys). A motorized test
stand and digital force gauge were used to evaluate tip bending characteristics as a function of distance (10 mm) in an occluded
10 mm diameter tube. The ability of each device to pass through a range of five fixed apertures (3.0-5.0F) was evaluated, and
retention capabilities of the XenX and Accordion were compared by flushing a controlled distribution of gypsum stones through 4
and 10 mm diameter tubing.
Results: The RoadRunner Firm was found to have the lowest average insertion force (14.18 ± 2.32 g) when compared to all
devices (p<0.035), and a significantly lower passing force (12.76 ± 6.39 g) than the RoadRunner Nimble (18.70 ± 5.56 g,
p=0.031), Accordion (24.51 ± 7.00, p=0.00055), and HiWire (28.47 ± 12.15 g, p=0.0013). Aside from the Roadrunner Firm, the
average insertion and passing forces of all other devices demonstrated minor significant differences, with values ranging between
21.36 – 26.37 g and 17.49 - 28.47 g, respectively. The HiWire was found to require the most time (13.13 ± 5.10 sec, p<0.0001)
and number of attempts (12.08 ± 5.18, p<0.0002) among all devices, while other devices were found to have passing times
ranging between 2.43 - 4.81 sec, and average number of attempts between 1.42 - 4.9, with the Glidewire requiring the least
number of attempts on average. Measurements of tip bending force as a function of distance revealed a similar force response
pattern among all devices for the first 5 mm traveled, characterized by a plateau of forces indicating the “safety bending zone” for
each device (Figure 1). A more dramatic increase in force was noted for the Accordion from a distance of 6-9 mm, until resulting
in a final force measurement more than double that of all others (40 vs. <16 g), which was also found to correlate to the extent of
tip buckling that was observed. All devices were able to pass through an aperture diameter of 5.0F, while more significant
differences were found when attempting to pass devices through a 3.0F aperture. No discernable particle migration was observed
for the Accordion and XenX using 4 mm tubing, while over 30 particles were up to 3 mm in diameter were observed to migrate
beyond the Accordion in 10 mm tubing.
Conclusion: The XenX and Accordion both provide a similar degree of maneuverability and safety when compared to several
commercially available guidewires, with more significant differences observed in tip bending and retention ability in large
diameter tubing. In vivo evaluations are warranted to confirm if such differences translate to clinical advantages.
45
40
35
30
Accordion
Sensor
XenX
RRF
Hiwire
RRN
25
20
15
10
5
0
-2
-5 0
2
4
6
8
10
12
Figure 1: Tip bending force (g) vs. distance (mm)
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 27
ABSTRACTS
URETEROSCOPIC VERSUS FLUOROSCOPIC GUIDED RENAL ACCESS: A
COMPARATIVE ANALYSIS OF INTRAOPERATIVE OUTCOMES FOR PCNL
Wahib Isac1, Emad Rizkala1, Xiaobo Liu2, Mark Noble1, Manoj Monga1
1. Glickman Urological and Kidney institute, Cleveland Clinic, Cleveland, Ohio
2. Quantitative Health Sciences department, Cleveland Clinic, Cleveland, Ohio
Introduction: An accurate puncture is the most critical step for percutaneous nephrolithotomy (PCNL). Renal access
is achieved using fluoroscopy (FGA), ultrasound or ureteroscopic guidance (UGA). Herein we present our technique
(fig.1) of gaining renal access under UGA and comparing intraoperative outcomes with those who had FGA.
Methods: Retrospective review of charts of patients who underwent PCNL at our institute, categorized based on the
method of achieving renal access. Patient demographics, baseline characteristics, operative and postoperative
outcomes were compared. Univariable and multivariable analysis were used to evaluate the relationship between
access and outcomes of interest.
Results: One hundred and fifty nine patients, who underwent PCNL at our institute from the 8/2010 to 1/2012, were
included. Sixty two patients (39.2%) underwent UGA, as compared to 96 (60.8%) for RGA. No significant difference
was observed between groups as regarding age (p=0.06), ASA (p=0.7), number (p=0.058) and volume of stones
(p=0.051), number of calyces involved (p=0.82), and stone density (p=0.49). Patients undergoing UGA had higher
BMI (p=0.013). Patients undergoing UGA had shorter fluoroscopy time (3.2 min vs. 16.8min, p<0.001), lower access
number (1.03 vs. 1.22 p= 0.002), and shorter hospital stay (1.8 days vs. 2.7 days p=0.001). Radiation time was
longer for FGA as compared to UGA after adjusting for BMI, staghorn stones, access number (p<0.001). No
significant difference was noted in change in hemoglobin and rate of blood transfusion, operative time, or occurrence
of intraoperative complications between groups. Procedures were aborted due to bleeding more commonly in the FGA
(8%) compared to the UGA group (0%, p=0.02) Three (6.7 %) of the UGA group had a secondary procedure for stone
management as compared to 12 (12.5%) of the FGA group.
Conclusion: the UG approach provides a safe and effective renal access for the percutaneous management of kidney
stones in the hands of the urologist, leading to decreased fluoroscopy time, shorter hospital stay and decreased need
for multiple access.
Fig 1: Gaining access using ureteroscopic guided puncture. A:
An appropriate posterior renal calyx is identified, showing
the air bubble at a posterior calyx. B,C: Using the
ureteroscope the Chiba needle is visualized through the tip of
the papillae. D, E the halo basket is advanced to grasp the
Benston wire introduced through the Chiba needle. F: the
Bentson has been exchanged for an Amplatz superstiff using
a 5-Fr. Open-ended catheter. G, H: the balloon dilator is
introduced along the wire under vision to avoid
underdilation (into parenchyma) or overdilation (causing
perforation of the collecting system). I: the Amplatz sheath is
introduced along the balloon dilator and visualized to ensure
accurate positioning.
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ABSTRACT 28
ABSTRACTS
A NOVEL DEVICE TO PREVENT MIGRATION OF STONE FRAGMENTS
DURING PERCUTANEOUS LITHOTRIPSY
Stephen Faddegon, M.D.1, Heather Beardsley, Ph.D.2, Yung K Tan, M.D. 1, Ephrem O Olweny M.D. 1,
Gang Yin, M.D. 1, Woong Han. 1, M.D., Zhuo-Wei Liu. 1, M.D., Raul Fernandez, Ph.D. 2, Margaret S.
Pearle, M.D. 1, Jeffrey A Cadeddu, M.D. 1
1
Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
2
Department of Engineering, University of Texas Arlington, Dallas, TX
Introduction: Up to 50% of patients with residual stone fragments after percutaneous nephrolithotomy
(PCNL) will experience a stone-related event which might require secondary surgical intervention. We
sought to create a device that can capture large stones in an enclosed bag, thereby enabling stone
fragmentation during PCNL or cystolithopaxy without fragment migration.
Methods: The ‘PercSac’ device slides over a rigid nephroscope and opens beyond the tip of the scope to
accommodate a renal stone. The bag opening is then cinched closed to prevent any stone fragments from
escaping. It can be advanced and retracted to facilitate stone capture. The stone can then be treated by
ultrasonic lithotripsy through the nephroscope and within the 'PercSac’.
Results: Stones as large as 3 cm in diameter could be reliably entrapped within the ‘PercSac’. The cinching
mechanism allowed closure of the bag and did not allow escape of fragments during lithotripsy and stone
evacuation.
Conclusions: Although the device was tested in a bladder model, the ‘PercSac’ has the potential to reduce
residual fragments after PCNL by maintaining the stone and fragments in an enclosed space until all
fragments are aspirated, thereby preventing migration of stone fragments into inaccessible calyces. Further
in vitro testing in both bladder and kidney models using a control comparison is planned.
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ABSTRACTS
ABSTRACT 29
APPLYING THEORETICAL CHEMISTRY TO THE STUDY OF CALCIUM
OXALATE NEPHROLITHIASIS
Julie M Riley1, Hyun Jin Kim2, Timothy D Averch1, Hyung Kim2
1
University of Pittsburgh Medical Center
2
Carnegie Mellon University
Introduction: Many questions exist regarding the interactions of molecules during stone formation, particularly how
promoters and inhibitors of stones actually produce their effects. Currently there are no inexpensive, easily accessible
models to evaluate real time molecular interactions of these compounds. With collaboration of physical chemistry and
practicing urologists, a theoretical model allows for the study molecular interactions in regards to calcium oxalate
stone disease.
Methods: Molecular dynamics computer simulation techniques were utilized to evaluate the interaction of Ca2+ and
oxalate ions (Oxa2-) in water. The model was used to examine the interaction of Ca2+ and Oxa2- alone and then in the
presence of known stone promoters and inhibitors. All ions are described at an atomic level using force field models.
The short-range repulsion and dispersion (Lennard-Jones interactions) and long-range Coulombic forces are evaluated
during the molecular interactions. The ions are allowed to move throughout the simulation box until they form stable
crystalline structures.
Results: Initial studies allow for measurement of interaction forces between Ca2+ and Oxa2- in the presence of
physiologic concentrations of known stone promoters and inhibitors. The model allows for real-time monitoring of
crystal structure formation and evaluating the forces between Ca2+ and Oxa2-. With very short (<200 nanoseconds),
Calcium oxalate crystal formation was already observed (Figure 1). This model has also allowed us to understand
what happens to the crystal structure when promoters and inhibitors are added to the theoretical box (Figure 2). In
addition free energy calculations are possible during the interactions to provide real-time monitoring of Ca2+ and
Oxa2- interactions.
Conclusion: While our model is not completely realistic due to the limited number of ionic species present in the
experiments, it provides a system to examine the formation of calcium oxalate crystals in the presence of inhibitors
and promoters at physiologic concentrations. Future studies will allow for expansion of ions used and understanding
how promoters and inhibitors exert their effect on calcium oxalate binding
Figure 1: Calcium Oxalate crystal.
Left is expected structure, right is
achieved structure from
simulation
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Figure 2: Calcium Oxalate crystal
structure in the presence of
Magnesium
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ABSTRACTS
ABSTRACT 30
DESIGN AND EVALUATION OF
IMAGE GUIDANCE SYSTEMS FOR RARP
S. Thompson1, G. Penney2 , B. Challacombe3 , D. Hawkes1 , P. Dasgupta3
1
Centre for Medical Image Computing, UCL, London, UK
Interdisciplinary Medical Imaging Group, Kings College London, London, UK
3
Centre for Transplantation, NHIR Biomedical Research Centre, Guy's Hospital, London, UK
2
Introduction: There is a strong appetite amongst laparoscopic surgeons for image guidance during the procedure. It seems
intuitively obvious that providing the surgeon with additional information on the location of unseen anatomy can only improve
patient outcomes. This is not necessarily the case however. If the system gives information that is not relevant to the procedure it
becomes a distraction. Similarly, if the system has large alignment errors the information may be dangerously wrong. One danger
is that image guidance systems can be developed on an ad-hoc basis based not on targeted clinical goals but on the technical
expertise and research goals of the scientists and engineers involved. Such a system may or may not benefit the patient. However,
there is a real danger, as discussed by [1], that such systems will be introduced into surgical practice without proper assessment.
We present our minimalist image guidance system for robot assisted radical prostatectomy together with a design and evaluation
framework built upwards from the desired clinical outcomes.
Methods: Our system allows the surgeon to refer to pre-operative MRI images of the patient aligned to the visible anatomy. The
MRI is aligned manually to the intra-operative scene as shown in Figure 1. The surgeon is able to intuitively match anatomy
shown in the MRI to its intra-operative location.
Results: We have measured the system accuracy and so far tested the system during 11 clinical cases. Despite having a very low
accuracy (around 2cm) the system has scored highly when rated by the surgeons. Table 1 lists the desired clinical outcomes and
the design goals.
Conclusion: We present a simple image guidance
system and a framework to evaluate its
performance. The framework will also be used to
evaluate the performance of comparable systems.
Despite its limitations our current system has been
very well received clinically and been used to
inform intra-operative decision making. This
indicates that careful thought must be given to the
real surgical needs before the development of more
complex systems.
Align
Overlay MRI
Figure: The patient’s MRI is aligned to the surgical scene using a
Table 1: The design and development
wireframe image of the visible inner surface of the pubic arch (left).
process begins with the identification of desired
The process takes less than 30 seconds. Once aligned the patients MRI
clinical outcomes.
These inform a list of
can be shown to the surgeon overlaid on the surgical scene (right).
system design goals, which are linked to
underlying system parameters. Correlations between the system parameters and how well the design goals are met are
use d to control the design and development process.
System Parameters
Accuracy
Update rate
Visualisation design
User interface design
Design Goals
Show Tumour location
Show Bladder/Prostate Interface
Show Extent of Prostate Capsule
Show rectum
Show Neuro- Vascular Bundles
Aid Pre-Op. Planning
Clinical Outcomes
Positive margin rate
Biochemical PSA Reccurence
Urinary Continence
Erectile Function
Damage to rectum
Conversion to open
[1] McCulloch, P et al. "No surgical innovation without evaluation: the IDEAL recommendations." Lancet 2009;374 (9695):1105
-1112.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 31
ABSTRACTS
HISTROTRIPSY TREATMENT OF FORMALIN-FIXED TISSUE
Sarah E. Darnell1, Xu Cheng2, *Timothy L. Hall1, *William W. Roberts1,2
Departments of Biomedical Engineering1 and Urology2 University of Michigan
Introduction: Histotripsy is a non-invasive, pulsed, focused ultrasound technology based on controlled acoustic
cavitation to achieve tissue homogenization. Previous attempts to validate transperineal delivery of histotripsy for
noninvasive prostate tissue debulking in human cadavers were confounded by the presence of tissue gas from
decomposition. Accumulation of this non-physiologic gas within tissue impedes transmission of US energy. It seems
plausible that tissue fixation would ameliorate the difficulties with interstitial gas production, facilitate specimen
degassing, and thereby allow better assessment of adequate acoustic aperture for human cadaveric prostate histotripsy.
However, formalin fixation induces protein cross-linking and alters tissue characteristics that may impact mechanical
homogenization. The objective of this study was to elucidate the threshold for histotripsy homogenization of formalin
fixed tissue compared to fresh tissue and thereby assess the use of formalin fixed tissue as a relevant model for
histotripsy experimentation.
Methods: Fresh and formalin-fixed canine kidneys were submerged in de-gassed water and renal cortex targeted with
histotripsy (750 kHz, 5 cycle pulses, 500Hz pulse repetition frequency). Real-time in-line US imaging allowed
confirmation of cavitation cloud location and monitoring of targeted tissue. In experiment #1, histotripsy was applied
to each focal volume for 10-90 seconds. In total, 46 lesions in 8 fixed kidneys were created and compared to 25
lesions produced in 6 fresh kidneys. For experiment #2 the focal volume was translated along a prescribed path (1-8
times) at 2mm/s to uniformly treat a 1 cm3 target volume. 14 volumes were targeted in 8 fixed kidneys and were
compared to 9 targeted volumes in 4 fresh kidneys. In experiment #3 a fixed human cadaveric prostate was treated
with the volume protocol (10 passes) at two locations. After treatment, specimens were sectioned through each
treatment zone to assess treatment effect.
Results: A cavitation cloud was observed with US during all treatments. In experiment #1 homogenization was
grossly visible upon sectioning and revealed minimal homogenization with 10 seconds of treatment and complete
homogenization (thin liquid) by 30 seconds. In fixed tissue, no visible damage was seen with less than 20 seconds of
treatment. Complete homogenization required 60 seconds of treatment. In experiment #2, 2 passes through the target
volume resulted in thick homogenate with 4 passes producing liquefaction of the cortical tissue in both fresh and fixed
tissue specimens. In experiment #3, homogenate consisting of thick paste was produced after 10 passes.
Conclusion: Formalin-fixed tissue can be used as a reasonable model to study histotripsy tissue effects. Cavitation is
easily monitored with real-time US. When targeting a single focal volume, double the number of histotripsy pulses
are required to achieve equivalent homogenizationi in fixed tissue compared to fresh tissue. However no dose
adjustment appears necessary when scanning through a volume of tissue. Research is underway to assess prostate
histotripsy in formalin-fixed human cadaveric whole pelvis specimens.
Funding: NIH R01-DK087871
*Financial interest / other relationship with HistoSonics, Inc.
Histotripsy transducer targeted on a formalin fixed
kidney in a tank of degassed water. Liquefaction of
cortical tissue apparent after treatment.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 32
ABSTRACTS
LASER INTERSTITIAL THERMOTHERAPY FOR SMALL RENAL MASSES:
PRELIMINARY INVESTIGATION IN EX-VIVO PORCINE KIDNEYS
Nelson Salas, PhD1,2, Samuel Dordick1,2, Matthew Ishahak1,2, Raymond J. Leveillee, MD, FRCS-G1,2
1
Joint Bioengineering and Endourology Developmental Surgical (JBEDS) Laboratory, Department of Urology,
University of Miami Miller School of Medicine, Miami, FL
2
Department of Biomedical Engineering, University of Miami, Coral Gables, FL
Introduction: Laser interstitial thermotherapy (LITT) is a minimally-invasive treatment modality that utilizes heat to
treat small tumors. Heat is induced by the absorption of near-infrared radiation emitted from an optical fiber inserted
within the tumor site under MRI, ultrasound, or computed tomography guidance. Despite its use in other organs,
there are few studies concerning the feasibility of LITT for small renal masses, according to our literature search,
when implementing a diffusing tip optical fiber (Figure 1) and a 980 nm diode laser. The purpose of this investigation
is to determine the feasibility of LITT in ex-vivo porcine kidneys when using a 980 nm diode laser and a diffusing tip
optical fiber.
Methods: Ten ex-vivo porcine kidneys (average dimensions = 10.1 ± 1.0 x 5.2 ± 0.3 x 2.1 ± 0.3 cm) were used in this
study. Each kidney was heated in a water bath to approximately 35.5±2.0 C and irradiated continuously for ten
minutes with an AOC 25, 980 nm, diode laser system (AOC Medical Systems, South Plainfield, NJ) coupled to a 1.0
cm diffusing tip optical fiber (Indigo Corp, Palo Alto, CA) while in the water bath. Temperatures were recorded
during irradiation with 12 T-type copper-constantin thermocouples placed 5, 10, and 15 mm from the fiber axis. Five
kidneys were irradiated at an output power of 2 W and 4 W, respectively. After irradiation, photocoagulation
dimensions were measured with a ruler. The average maximum temperature and photocoagulation dimensions were
calculated for each output power and compared using a paired t-test (OriginLab, Northampton, MA).
Results: The geometry of the photocoagulation zone was elliptical (Figure 1). Average axial length, cross-sectional
maximum, and cross-sectional minimum radius at 2 W and 4 W were 1.9±0.3 x 0.8±0.2 cm x 0.4±0.2 cm and 2.8±0.3
x 1.4±0.3 x 0.92±0.1, respectively. Average maximum temperatures at 2 W and 4 W ranged from 51.3±2.3–67.7±6.5
C and 77.1±7.4–87.5±6.9 C, respectively, at 5 mm, 41.9±0.8–51.2±1.7 C and 52.4±1.6–66.8±6.6 C, respectively, at
10 mm, and 41.7±1.0–45.2±1.4 C and 47.8±1.2–49.7±2.5 C, respectively, at 15 mm from the fiber axis. Thermal
damage dimensions and maximum temperatures were significantly different between 2 and 4 W (p<0.05) with
exception for one thermocouple at 15 mm from the fiber axis.
Conclusion: Elliptical photocoagulation zones up to 2.8 cm in length and temperatures greater than 60 oC at 10 mm
from the fiber axis were achieved in ex-vivo porcine kidneys when irradiated at 980 nm with a 1 cm diffusing tip
optical fiber within 10 minutes at low power. Future in-vivo studies utilizing a larger tip size are warranted before
LITT can be considered a viable, nephron-sparing alternative treatment for small renal masses.
Figure: (a) Indigo 1.0 cm diffusing tip optical fiber and (b)
photocoagulation zone observed after laser irradiation with a 980
nm diode laser at 4 W and a diffusing tip optical fiber
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 33
ABSTRACTS
TOP 10 ABSTRACT
QUALITY MEASUREMENT OF SYSTEMATIC
TRANSRECTAL PROSTATE BIOPSY: AN IN-VITRO STUDY
Doyoung Chang, Chunwoo Kim, Doru Petrisor, Bruce Trock, Alan W. Partin,
Ronald Rodriguez, H. Ballentine Carter, Mohamad Allaf, Misop Han, Dan Stoianovici
Department of Urology, Johns Hopkins University
http://urobotics.urology.jhu.edu/
Introduction: Extended sextant biopsy under transrectal ultrasound (TRUS) guidance is the most common
method to diagnose prostate cancer (PCa). The results of the biopsy rely on two major factors: the biopsy
schema and the physician’s ability to accurately target the gland with the biopsy needle. However, the
accuracy of the freehand TRUS-guided biopsy is typically unknown due to the difficulty of measurement
and quantification.
Methods: To determine the accuracy of freehand TRUS biopsy invitro, a biopsy simulation system with a gelatin-based pelvic mockup
and optical tracking system was used to measure the orientation and
relative position of the biopsy needle. The gold standard schema was
defined using a 12-core, extended sextant biopsy template.
Five experienced urologists and the TRUS Robot, a novel robotic
device that can precisely manipulate the TRUS probe, performed 6
sets of extended sextant template biopsies. The exact geometric
distribution of biopsy cores was measured and the biopsy targeting
error, accuracy and precision of repeat biopsies were determined.
Also, a probability-based model was used to estimate the “significant”
PCa (> 0.5 cc) detection rate by freehand- versus TRUS Robotassisted biopsy.
Results: The urologists acquired cores in clustered patterns and left a
significant portion of the prostate under-sampled while the TRUS
robot closely followed the biopsy schema. The mean targeting error
by the urologists and the TRUS Robot was 9.0 mm and 1.0 mm,
respectively. Robot assistance improved the accuracy and precision of
repeated biopsy from 10.1 mm to 1.7 mm and 23.6 mm to 0.6 mm,
respectively. The mean “significant” PCa detection rate by the
urologists and the TRUS Robot was 36% and 43%, respectively.
Figure 1: Biopsy simulation system
Figure 2: Golden standard biopsy schema
(green) and core distribution of freehand
biopsy (red).
Conclusion: Systematic biopsy with freehand TRUS guidance does
not closely follow the intended sextant biopsy plan and may result in
suboptimal sampling and cancer detection. Both initial and repeat
freehand biopsy following a biopsy schema is challenging. Robotassistance can potentially improve targeting, precision and accuracy.
Further research is needed to determine an optimized biopsy schema
that improves PCa detection rates.
Acknowledgements: The project described was supported in part by
Award Number R21CA141835 from the National Cancer Institute, the
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, and
Hitachi-Aloka Medical Ltd. The content is solely the responsibility of
the authors and does not necessarily represent the official views of the
NCI, NIH, SKCCC, or HAM.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Figure 3: Initial and repeated biopsy error of a)
Freehand biopsy, b) Robot assisted biopsy
Page 48 of 97
ABSTRACT 34
ABSTRACTS
TOP 10 ABSTRACT
LIVE ROBOTIC SURGERY: ARE OUTCOMES COMPROMISED?
Jeffrey K. Mullins2, Michael S. Borofsky1, Mohamad E. Allaf2, Sam Bhayani3, Jihad H. Kaouk4, Craig C.
Rogers5, Shahab P. Hillyer4, Bartosz F. Kaczmarek5, Youssef S. Tanagho3, and
Michael D. Stifelman1
1
Department of Urology, New York University, Langone Medical Center, New York, NY
2
Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
3
Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, MO
4
The Glickman Urological Institute, Cleveland Clinic, Cleveland, OH
5
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI
Introduction: Live educational surgery provides a powerful educational platform for academic urologists.
However, education must not place patients at increased risk. The objective of this study is to determine the
outcomes of patients treated during live educational surgery compared to a matched cohort treated without
observers.
Methods: From 2007 – 2011 39 robotic partial nephrectomies were performed as live educational cases by
1 of 5 high volume surgeons. Live educational cases were defined as cases viewed by visiting urologists via
live teleconference in which the visitor were able to interact with the operating surgeon. Live educational
cases were matched with cases performed under standard operating procedure. Demographic,
clinicopathologic, and peri-operative outcomes were compared between groups. Univariate analysis was
performed to the test the association between educational surgery and adverse peri-operative outcomes.
Results: Demographic and clinicopathologic data were similar between both groups. Both groups
experienced equivalent operative times (196.3 vs. 190.4 minutes, p=0.75), EBL (187.8 vs. 177.8, p=0.82),
WIT (20.8 vs. 20.1, p=0.75), LOS (2.8 vs. 2.6 days, p=0.44), and rates of post-operative complications
(5.1% vs. 10.3%, p=0.40). There were no Clavien III – V complications in either group. Univariate analysis
demonstrated that live observational surgery was not associated with any unfavorable peri-operative
parameter (all p> 0.05).
Conclusions: Live educational surgery is associated with excellent patient outcomes which compare
favorably to cases done under normal operating procedures. Live educational surgery represents a useful
educational tool which does not increase patient morbidity.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 49 of 97
ABSTRACTS
OUTSTANDING PAPER AWARD
ABSTRACT 35
ROBOT-ASSISTED DIRECT MRI-TARGETED
TRANSRECTAL PROSTATE BIOPSY
Chunwoo Kim1, Govindarajan Srimathveeravalli2, Peter Sebrechts1, Doru Petrisor1,
Paula Ezell2, Jonathan Coleman2, Stephen B. Solomon2, Hedvig Hricak2, Dan Stoianovici1
1
Urology Robotics Lab, Johns Hopkins University, Baltimore, MD
2
Radiology Department, Memorial Sloan Kettering Cancer Center, New York, NY
http://urobotics.urology.jhu.edu/
Introduction: Transrectal ultrasound (TRUS) guided prostate biopsy is the most frequently performed means for
detecting prostate cancer (PCa) with over 1.2 million procedures performed annually in the US alone. However,
standard gray-scale ultrasound imaging provides minimal cancer specific information in regard to localizing tumors,
relying instead on non-targeted, systematic biopsy strategies. Accordingly, TRUS biopsies have typically low
sensitivity and low negative predictive value. These uncertainties contribute to disease overtreatment. Prostate MRI
offers better image sensitivity for identifying prostate cancers yet is difficult to use for directly guiding biopsies
although indirect means for doing so are being developed using MRI-TRUS fusion techniques. Alternatively, we
present a direct MRI targeting method that avoids co-registration errors typical of image fusion. We report the
development and pre-clinical tests of a robot for transrectal prostate biopsy in the MRI scanner. Animal test results
show the feasibility of the approach and approximately 2mm MRI-based targeting accuracy.
Methods: A pneumatic robot for transrectal prostate biopsy was developed. The robot is entirely made of nonmetallic materials and is electricity free, using a new type of MRI motor (Pneumatic Stepper Motor, PneuStep). The
robot presents 3 degrees of freedom (DoF), 2 for orienting a needle-guide and 1 for adjusting the depth of needle
insertion. Needle insertion and biopsy are performed manually through the needle-guide. A registration marker and
MRI coil are built within the endorectal extension. Image-to-model registration and navigation algorithms are
developed with custom C++ modules in Amira Visualization (San Diego, CA).
In-vitro CT-guided experiments were completed to verify targeting accuracy. MRI-guided animal tests on 4 dogs were
performed to verify the feasibility of approach and overall targeting accuracy, with approval of the Institutional
Animal Care and Use Committee. The accuracies were measured by comparing the position of the needle tip with the
selected target in the image.
Results: The presence and activation of the robot at the isocenter does not affect the MRI. The device is “MRI
Stealth”. The accuracy of in vitro experiments was 1.1 mm. In the animal experiments 4-6 biopsies per dog (total 21)
were targeted due to size. Overall targeting accuracy was 2.2 mm. All dogs recovered and have been adopted.
Conclusion: Direct MRI-guided biopsy with robotic assistance is feasible. The device was successfully verified in
pre-clinical tests. Its accuracy is adequate for targeting small lesions of MRI abnormality. This may provide an
instrument for correlating MRI-abnormality with pathological finding from the biopsy samples, and increasing the
sensitivity of biopsy.
Acknowledgement: Project supported by Award Number W81XWH0810221 from the Prostate Cancer Research
Program of the Department of Defense. The content is solely the responsibility of the authors and does not necessarily
represent the official views of the PCRP or the DOD.
Figure: Animal experiment setup on the MRI table and 3D robot navigation based on MRI
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 50 of 97
ABSTRACT 36
ABSTRACTS
TACTILE MEMS-BASED SENSOR ELEMENT FOR ROBOTIC SURGERY
Young Soo Park1, Nachappa Gopalsami1, Mohan Gundeti2
1
Nuclear Engineering Division, Argonne National Laboratory
2
Department of Surgery, University of Chicago
Introduction: To provide delicate haptic feedback in minimally invasive robotic surgery, a new type of
tactile microsensor element is developed based on micro-electromechanical systems (MEMS) technology.
The essential tactile feedback will broaden the applicability of robotic surgery.
Methods: The tactile microsensor element is designed as diaphragm form. The sensor element consisting of
multiple diaphragm form is expected to be capable of detecting contact conditions with high spatial
resolution and wide stiffness measurement range. Based on MEMS-technology, the sensor elements are
fabricated using SU-8 as substrate and gold as piezoresistor. The advantages of the design are robustness of
material, low fabrication cost and complexity, and low temperature process. Also the fabricated sensor
element is highly flexible in structure. To measure the stiffness of the diaphragms of different sizes,
characteristic tests were performed in which the diaphragm was deflected with a probe and the change in
resistance was measured.
Results: Four sizes of diaphragms having 300, 500, 700 and 900µm-side length respectively were tested.
Larger diaphragms having lower stiffness show lower rate of changes in resistance as a function of
displacement of the probe. Test results show linear relationship between the resistance and deflection from
which stiffness of the sensor elements were estimated.
Conclusion: We proposed a new type of flexible tactile sensor for haptic feedback in MIS. Based on
MEMS technology, prototype sensor elements of high spatial resolution were fabricated. Characteristic tests
revealed linear sensing characteristics. The integrated array of sensors of different sizes will prove
measurement over wide stiffness range.
Figure. (a) Schematic of testing setup (b) 600µm-side square diaphragm with 1.2kΩ resistor
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 51 of 97
ABSTRACTS
ABSTRACT 37
VISUAL MEASUREMENT OF SUTURE TENSION FOR MINIMALLY INVASIVE
SURGERY
Young Soo Park1, John Martell2, Pawel Dworzanski3, Thomas Elmer1, Nachappa Gopalsami1
1
Nuclear Engineering Division, Argonne National Laboratory
2
Department of Surgery, University of Chicago
3
Department of Mathematics, University of Illinois-Chicago
Introduction: We have demonstrated feasibility of real-time video image processing to measure suture
strain during surgery. This will be instrumental for visual-haptic feedback in robotic and laparoscopic
surgery.
Methods: A video image processing algorithm is developed which incorporates functionalities of suture
line detection, intensity profiling, frequency analysis, and strain computation. The algorithm was
implemented in C++ with image/data processing libraries. Particular data processing techniques are added
to improve the accuracy and robustness of the measurement. The optimized code was validated to run at 25
frames per second. A series of cyclic strain tests was performed on barbed surgical suture using Instron
strain test system. The algorithm was applied on the test video and the strain computation was evaluated
against the test reference profile.
Results: The program was able to detect up to 0.2% strain, which is an order of magnitude (60 times)
smaller than the lowest breaking strain of commercially available surgical sutures. In addition, the frequency
based approach is expected to be more robust in real situations, such as occlusion, and applicable to wide
variety of surgical sutures.
Conclusion: The developed non-contact approach will require minimal installation with existing
endoscopy, and yet to provide sensory feedback with highly accurate measurement of suture strain. The
sensing method will enable highly delicate sensory feedback during robotic and laparoscopic surgery.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 38
ABSTRACTS
MINI-PERCUTANEOUS NEPHROLITHOTOMY WITHOUT MINI
INSTRUMENTS: A NOVEL TECHNIQUE
Edan Shapiro, Michael J. Lipsky, Doh Yoon Cha, Ketan K. Badani, Mantu Gupta
Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY
Introduction: Minimally invasive PCNL (mini-PCNL) has the potential advantages of decreased bleeding and pain
with a smaller sized tract of 14-20F. Various mini-PCNL techniques have been described in literature, most utilizing
the ureteroscope as a surrogate for the nephroscope, and a laser fiber for fragmentation. These techniques, however,
can be limited by decreased visualization, poor irrigation, the need for specialized instruments, and difficult fragment
extraction. We assessed the efficacy, safety, and morbidity of a modified PCNL technique that allows for the use of
standard PCNL equipment and lithotripters through a tract that is smaller than traditional PCNL (30F) but larger than
reported for mini-PCNL.
Methods: A total of 118 consecutive patients undergoing mini-PCNL and standard PCNL from December 2010 to
October 2011 were retrospectively reviewed. Mini-PCNL was performed using a 24F balloon dilating catheter (BDC)
and standard PCNL was performed with a 30F BDC. Operative time, blood loss (EBL), use of stent, nephrostomy
tube placement, post-operative pain scale, analgesic requirement, length of hospital stay (LOS), and stone-free rates
(SFR) were compared.
Results: Fifty-two patients underwent mini-PCNL (group 1) and 66 underwent standard PCNL (group 2). Mean age
at surgery was 54 and 56 years for group 1 and group 2, respectively. The mean stone burden was significantly lower
in group 1 compared to the group 2 (19.4 mm vs. 28.1 mm, p=0.003). Mean operative time and length of hospital stay
were significantly lower in group 1 compared to those in group 2 (116 min vs. 151 min, p<0.001; 1.19 days vs. 1.68
days, p=0.002). EBL was lower on average in group 1, but this was not statistically significant. The rates of ureteral
stent and/or percutaneous nephrostomy tube placement, as well as the rate of totally tubeless procedures, were similar
between the two groups. Postoperative analgesia with Ketorolac and morphine equivalents did not vary by group. Of
the 118 total patients, 60 (51%) patients underwent PCNL for stones > 2cm. Of these, 42 (70%) patients underwent a
standard PCNL and 18 (30%) patients underwent our modified mini-PCNL technique. In a subset analysis of patients
with stone burdens greater than 2.0 cm, mean operative time was shorter for group 1 than for group 2 (p=0.026). In
addition, EBL was lower in group 1 than for group 2 (p=0.045). No difference was demonstrated in stent or
nephrostomy tube placement rate, or post-operative analgesia. Mean hospital length of stay was significantly lower in
group 1 (p=0.008). There was a 100% stone-free rate in both cohorts.
Conclusion: Our data suggest that a new, modified mini-PCNL can be safely performed using standard PCNL
instruments, eliminating the need for special instruments associated with traditional mini-PCNL techniques. This
technique offers comparable outcomes with the benefit of shorter operative time and LOS compared to that of the
standard technique, even for stone burdens >2 cm. This warrants further studies that may elucidate other potential
advantages for this new technique.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 39
WHAT IS THE BEST METHOD TO DELIVER ADJUVANT THERAPY TO THE
UPPER URINARY TRACT FOR UROTHELIAL CARCINOMA? AN
EVALUATION OF THREE TECNIQUES IN AN EX VIVO PORCINE MODEL
Matthew E Pollard1, Edan Shapiro2, Doh Yoon Cha2, Ketan K. Badani2, Mantu Gupta2,
Adam W Levinson1
1
Department of Urology, Mount Sinai School of Medicine, New York, NY
Department of Urology, Columbia University College of Physicians and Surgeons, New York, NY
2
Introduction: Although nephroureterectomy (NU) remains the gold standard for the treatment of upper tract
urothelial tumors, developments in percutaneous and endoscopic techniques have made nephron-sparing surgery
feasible in select patients. In an effort to reduce disease recurrence, these minimally invasive approaches are often
combined with adjuvant chemotherapy that is delivered directly to the upper tracts. Several delivery techniques have
been described, including antegrade infusion through a nephrostomy tube, retrograde instillation through an open
ended-ureteral catheter, or via reflux from the bladder with an indwelling double pigtail stent. Ideally the
chemotherapeutic agent should coat the entire upper tract urothelium. However, no publications to date have
evaluated the efficacy of these delivery methods. We developed a porcine model to evaluate the degree and extent of
urothelial exposure to the treating agents using each of the three delivery methods.
Methods: An ex vivo model was created using excised, en bloc porcine urinary tracts. To evaluate the various
techniques, an indigo-carmine solution was infused into the urinary tract using each of the 3 methods; each technique
was performed in 3 renal units and the results were averaged. Following a 1 hour dwell time, the urinary tracts were
evaluated to determine the degree and extent of urothelium exposure by measuring the staining intensity at 6
predefined points (3 in the renal pelvis, 3 in the ureter). The staining intensity was compared to a reference sample of
maximally stained urothelium to calculate mean color difference using a previously validated equation from the
International Commission on Illumination (CIE76); lower values represent more efficient staining. In addition, the
percentage of total surface area stained by the three delivery protocols was compared.
Results: Mean color difference for nephrostomy tube, double pigtail stent, and ureteral catheter delivery were 40.9,
33.4, and 20.4, respectively (p = 0.023). In terms of percent of total surface area stained, mean values were 50.6%,
55.4%, and 75.2%, respectively (p = 0.018).
Conclusion: Our initial results suggest that delivery of topical therapies to the upper urinary tract appears to be most
efficient when the agent is infused in a retrograde manner via a ureteral catheter, as opposed to either nephrostomy
tube or double pigtail stent. In-vivo models and larger studies should be performed to further validate these findings.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 54 of 97
ABSTRACT 40
ABSTRACTS
15 YEARS OF TRANSRECTAL HIGH INTENSITY FOCUSED ULTRASOUND IN
PROSTATE CANCER THERAPY:
DEVELOPMENT OF SIDE EFFECTS
Chaussy Christian^*, Thüroff Stefan°*
° Dept. of Urology, Klinikum Muenchen Harlaching,
^ Dept. of Urology, University of Regensburg, * Krebshilfe Harlaching e.V.,
Introduction: There were three topics for this study: 1st to analyze the overall side effects of combined
TURP and HIFU as definitive therapy of localised prostate cancer (PCa).
2nd to analyze the influence of 3 different current therapeutic strategies in HIFU therapy, as there are “HIFU
only”, “TURP and HIFU in one session” and “TURP one month before HIFU”. 3rd to evaluate the relative
influence of neoadjuvant TURP on side effects.
Material & Method: The prospective monocentric “Harlaching HIFU Database” (n>2.380, since 96)
served as data source for analysis. 3 patient cohorts (T1-2, N0, M0): were evaluated:
A) 1998-2000 (HIFU only), B) 2001-2004: (TURP&HIFU), C) 2005-2010: (TURP 1 month before HIFU):
all patients without any previous PCa/PSA influencing therapy, treated completely with Ablatherm ®
(robotic HIFU at 3 MHz, EDAP-Lyon-France).
Peri- and postoperative side effects for the 3 consecutive cohorts were analyzed.
Results: In a median follow up of 5.5 years, side
effects were registered. Furthermore, possible
side effects which are described in other PCa
therapies - though never occurred after HIFU were identified. The range, timing and profile of
TURP & HFU related side effects are listed
below.
Rate of side effects
Prototype
Maxis
n
Incontinence < 3 months (%)
Incontinence > 3 months (%)
Recto-urethral fistula
(%)
Urinary tract infections (%)
Perineal discomfort
(%)
Others perioperative
(%)
2nd endouro intervention (%)
Others in follow up
(%)
96-99
170
4.2
5.1
0.42
2.5
1.26
11.7
24
1.26
2000-2004
358
4.2
3.1
0.23
1.87
0.23
1.17
19
0.0
Integrated
imaging
since 2005
176
3.1
1.5
0.0
3.08
0.51
2.56
24
0.0
Conclusion:
• Only a low number of severe side effects was observed
• TUR did not influence the overall side effect rate.
• ¼ of the patients needed 2nd endourological intervention during follow up.
• The spectrum of potential side effects, “which never occurred” showed the low invasiveness of the
procedure.
Source of Funding:
Harlachinger Krebshilfe e.V. and Lingen foundation
Thanks to Mrs. Regina Nanieva for HIFU database management
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 41
ABSTRACTS
TREATMENT OF LOCALLY ADVANCED PROSTATE CANCER WITH
TRANSRECTAL HIGH INTENSITY FOCUSED ULTRASOUND (HIFU) DELAYS
ANDROGEN DEPRIVATION THERAPY (ADT)
Thüroff Stefan°*, Chaussy Christian^*,
° Dept. of Urology, Klinikum Muenchen-Harlaching
^ Dept. of Urology, University of Regensburg, * Krebshilfe Harlaching e.V.,
INTRODUCTION: Goal of the study was to evaluate the efficacy of local HIFU treatment in a patient
group with locally advanced Prostate Cancer and its consecutive influence on the necessity of ADT.
METHODS: Since 2000 146 PCa patients (T3-4, N0, M0) without previous long term androgen deprivation
therapy (ADT) were included in this prospective, monocentric study. Three studygroups according to
progression risk were established: A): initial PSA <20 (n=89); B): initial PSA 21-50 (n= 39); C): initial PSA
>50 ng/ml (n= 18). Mean follow up was 3 years (0.3-9), staging: T3: 90%, T4: 10%, age: 70 (49-84).
Overall mean initial PSAi was 26.5 ng/ml (0.6-211) and mean PSA at HIFU was 12.4 ng/ml (0-131). Short
term ADT<3months in 38% (62% had no ADT at all). Single HIFU treatment with Ablatherm® (EDAPTMS, Lyon) after debulcking TURP. Mean 662 HIFU lesions applied in 111 min. Patients did not receive
any ADT after HIFU.
RESULTS: Mean follow up time was 36 (4.4-108) months, time to Nadir 2.5 months. Median PSA Nadir
was for group A) 0.14 / B) 0.5 / C) 0.93 ng/ml respectively. Group related median PSA velocity was for A)
0.17, B) 0.42 and C) 5.94 ng/ml respectively. Last median PSA was A) 0.51 / B) 1.58 / and C) 5.08. Last
PSA after 2 years was in 93 % still below initial PSA levels. Within the median follow up period of 3 years
95.5% of the patients remained without ADT.
CONCLUSION:
• TUR & HIFU ablation in this T3-4, N0, M0 PCa cohort of 146 patients resulted in an overall PSA
Nadir of 0.28 ng/ml and a median PSA velocity of 0.26 (ng/ml/year).
• Until a mean follow up of 3 years, 95.5 % of the patients remained without ADT !
• Level of initial PSA showed to be a significant predictive value for therapeutic success.
Source of Funding:
Harlachinger Krebshilfe e.V. and Lingen foundation
Thanks to Mrs. Regina Nanieva for HIFU database management
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 42
RETROGRADE CHEMOTHERAPEUTIC IRRIGATION
OF THE UPPER TRACT
Matthew Maurice, MD1; Debby Chuang, MD1; Rabii Madi, MD,2; Robert Abouassaly, MD, MS1
1
University Hospitals Case Medical Center, Cleveland, OH
2
Georgia Health Sciences Medical Center, Augusta, GA
Introduction: Upper tract urothelial carcinoma (UTUC) has a high recurrence rate after endoscopic
treatment. Immediate post-operative topical chemotherapy may reduce recurrences, as is the case with
bladder UC. Currently, no reliable method of UT chemotherapeutic delivery exists.
Methods: Following retrograde fulguration of a recurrent, bulky UTUC in a solitary kidney, contrast was
infused into the renal pelvis via a 5-Fr ureteral catheter and IV pump. Serial fluoroscopy was performed.
Intra-pelvic pressures were transduced. The infusion was repeated post-operatively with Mitomycin C
(MMC). Systemic toxicity was assessed clinically.
Results: Contrast (100 ml/hour x 30 minutes) filled the renal pelvis and calyces uniformly without pyelorenal backflow. Mean intra-pelvic pressure = 4.9 cm H2O (1.4 to 6.8 cm H2O). The patient denied symptoms
during MMC infusion (40 mg/100 ml for 1 hour). No systemic toxicity or recurrence occurred in 13 months.
Conclusion: We are the first to describe retrograde UT chemotherapeutic irrigation with an IV pump. This
technique may facilitate and standardize the delivery of intracavitary chemotherapy. Further investigation to
determine whether it translates into improved safety and/or efficacy is warranted.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 43
IS THERE A DIFFERENCE IN LATERALITY DURING
ROBOT-ASSISTED RADICAL PROSTATECTOMY?
ASSESMENT OF LYMPH NODE YIELD AND
NEUROVASCULAR BUNDLE DISSECTION
Michael J. Lipsky1, William Berg1, Piruz Motamedinia1, Woo Jin Ko1,2, Greg W. Hruby1, Ketan K. Badani1
1
2
Department of Urology, Columbia University Medical Center, New York, NY
Department of Urology, National Health Insurance Corporation Ilsan Hospital, Goyang, South Korea
Introduction: The da Vinci surgical system (dVSS) has been reported to eliminate innate hand dominance
of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its
own inherent ‘handedness’ resulting from the fixed left-right preference of specific instrument docking and
assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB)
dissections as well as positive surgical margin rates as procedure points during robot assisted radical
prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency.
Methods: Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010
were identified. Surgeon instrument preference and port placement were consistent across all cases.
Pathological LN yield was stratified by the intended limits of dissection (limited or extended) and laterality.
Additionally, fascial widths (FW) were prospectively measured for 93 consecutive patients; a narrower FW
indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections.
Results: A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections
were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right
compared to the left (3.26 vs. 2.76, p=0.010). This difference was not seen in the extended LN dissection
(p=0.96). Average FW was narrower on the right surgical margin compared to the left surgical margin (1.99
vs. 2.64mm, p<0.001).
Conclusion: Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved
on the right compared to the left using the dVSS during RARP. This can be attributed to surgeon
handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these
potential differences is important for the pre-operative planning prior to RARP.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 44
ABSTRACTS
PRELIMINARY EVALUATION OF THE ENDOGO HD PORTABLE
CYSTOSCOPIC CAMERA
William Berg, Christopher M. Deibert, Doh Cha, Ketan Badani, Mantu Gupta
Department of Urology, Columbia University College of Physicians and Surgeons, New York NY
Introduction: During office cystoscopy and hospital consultations, urologists may only have direct
visualization cystoscopy available. The field of view and usability is often characterized as suboptimal
compared to video tower based camera models. The EndoGo HD (Cook Medical), a portable battery
powered cystosopic camera that attaches to a standard cystoscope, was created to more closely mimic the
usability of the normal cystoscopic camera that connects to the video tower. We sought to objectively
evaluate the utility of this new device.
Methods: 30 urology residents, fellows and students were consented and randomized to perform standard
video tower cystoscopy, direct cystoscopy without a camera, and cystoscopy with the EndoGo HD on a
previously used bladder model (Uro-Scopic Trainer, Limbs&Things, USA). Participants were timed and
evaluated using a previously validated Objective Structured Assessment of Technical Skills (OSATS). Each
participant then rated the usability and preferences for each of the 3 systems. All participants completed the
three types of cystoscopy.
Results: Users found the field of view to be significantly better for the EngoGo compared to the direct
cystoscopy ((p=0.03) and similar for the EndoGo and standard tower (p=0.7). Although the time needed to
perform the cystoscopy was significantly longer for EndoGo versus Tower and Direct cystoscopy (71.9 sec
vs. 43.3 and 46.8; p=0.01), the overall participant rating of ease of assembly and procedure was not
significantly different for any type of cystoscopy (p=0.3 and p=0.1 respectively). Comparing novices to
experts (>200 cases), experts completed all procedures more quickly, regardless of camera type. Tower
cystoscopy was significantly less difficult, more comfortable, and was preferred by the majority of
participants.
Conclusion: On objective and subjective measures, the EndoGo HD portable cystoscopic camera received
similar marks to other types of cystoscopy currently widely available. It did require ½ minute longer time to
set up on average and overall, participants preferred standard video tower cystoscopy. The EndoGo HD
may be useful in the emergency department or office setting where no video tower is available. Further
work exploring its utility as a teaching tool and the learning curve of use and will be evaluated.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 45
ABSTRACTS
BIOHEAT MODEL FOR UNINTENDED FREEZE DETERMINATION
Cervando G. Ortiz-Vanderdys1, Bernardo Ortiz-Vanderdys2
1
Urology Research, University of California Irvine, 2American University of Antigua
Introduction: The importance of reaching low temperatures below -20°C and -40°C has been established in
cryoablation. Bioheat models can give guidance not only in planning but also in monitoring cryotherapy. Different
probes run at different temperatures and the result of adjusting freezing power at settings other than 100% is not well
described. A second goal is to illustrate significance of these settings on cryoablation effectiveness.
Methods: A Pennes Bioheat model was run to 2 cm diameter ice ball size with a model of a Galil 17 gauge icerod
running at different freezing temperatures. Time to freeze to goal and size of -20°C and -40°C isotherms are recorded.
The simulation was done with values used by Rabin et al for simulations in saline and a cell size of 0.5 mm on the
side. The interval between iterations was 0.01 seconds. The models are calibrated with temperature data from
cryoprobes run in gel.
Results: A relationship between the minimum temperature a probe effectively delivers and the time it takes to
generate an ice ball to 2 cm in diameter was graphed with 95% confidence intervals calculated (Fig. 1). Isotherm
profiles for the different probe temperature was plotted with 95% CI(Fig 2). The data at -60°C corresponds with the
effective probe temperatures of the Galil IceRod, and -80°C to the effective probe temperature achieved with the
Endocare Perc-17 tested in gel. Freeze times and 0°C isotherms were also calibrated with animal study data.
Conclusion: Extending a freeze beyond the time required to achieve the desired size of freeze necessarily
compromises effective freezing, unintended freezing or both. Using a computer model and calibrating against focused
lab runs results in efficient data gathering when compared to other models. It also allows the generation of graphs and
tables to guide procedures. Using the goal of -20°C we also found that the unintended freeze area grew dramatically
as the temperature of the probe was raised or as the freeze was extended in time. The data obtained provide tables that
can guide clinical procedures to optimize effectiveness and minimize unintended consequences.
Figure 1: Time to generate an ice ball and a -20°C isotherm 2 cm in
diameter. Can be used to estimate probe temperature from imaging.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Figure 1: †Determined with goal of ice ball at 2 cm in diameter.
‡Determined with goal of -20°C isotherm of 2 cm in diameter.
Page 60 of 97
ABSTRACT 46
ABSTRACTS
BIPOLAR PLASMA VAPORIZATION OF SECONDARY BLADDER NECK
SCLEROSIS—MORE EFFICIENT THAN STANDARD TUR?
Geavlete B, Moldoveanu C, Geavlete P
Saint John Emergency Clinical Hospital, Department of Urology
Bucharest, Romania
Introduction and Objective: This trial aimed to assess the therapeutic efficiency, overall safety and shortterm postoperative results of bipolar plasma vaporization (BPV) in cases of secondary bladder neck
sclerosis (BNS). A prospective, randomized comparison to the standard monopolar transurethral resection
TUR was also performed.
Materials and Methods: A total of 60 patients (mean age of 72) with BNS secondary to TURP (41 cases),
to open surgery for BPH (open prostatectomy – 14 cases) and to radical prostatectomy for prostate cancer (5
cases) were enrolled in the trial. The inclusion criteria consisted of Qmax < 10 ml/s and IPSS >19. All
patients were evaluated preoperatively and at 1, 3 and 6 months after surgery by International Prostate
Symptom Score (IPSS), quality of life score (QoL), maximum flow rate (Qmax) and post-voiding residual
urinary volume (RV).
Results: Similar preoperative parameters were determined for patients from both series. BPV and TUR
were successfully performed in all cases (30 patients each). The mean operative time, catheterization period
and hospital stay were significantly reduced in the BPV series (16.5 versus 27 minutes, 18 versus 46.5 hours
and 34.5 versus 73 hours). Capsular perforation only occurred in 2 cases of the TUR study arm, while the
rate of irritative symptoms was similar in the 2 series (13.3% versus 16.7%). The 1, 3 and 6 months’ followup emphasized superior parameters for the BPV group by comparison to the TUR group in terms of IPSS
(3.4 versus 6.3, 3.6 versus 6.5 and 3.7 versus 6.8, respectively) and Qmax (23.8 versus 21.1 ml/s, 23.7 versus
20.6 ml/s and 23.0 versus 20.7 ml/s, respectively). At the same time intervals, QoL was also significantly
improved in the BPV arm (1.2 versus 1.4, 1.4 versus 1.6 and 1.4 versus 1.7), while no significant differences
were established in terms of RV between the 2 series. Only 2 patients of the TUR group required retreatment during the follow-up period.
Conclusions: BPV constitutes a valuable endoscopic treatment alternative for secondary BNS. In a
randomized analysis, the method emphasized superior efficacy, a satisfactory safety profile and significantly
improved short-term follow-up parameters by comparison to the standard TUR.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 47
RENAL TUMOR CONTACT SURFACE AREA: A NOVEL CT-PARAMETER FOR
PREDICTING PERI-OPERATIVE OUTCOMES USING ADVANCED IMAGEPROCESSING SOFTWARE
Scott Leslie1, Andre Luis de Castro Abreu1, Eric Yi-Hsiu Huang1, Syed Rahmanuddin2, Tania S Gill1, Andre K
Berger1, Jie Cai1, Vinay A Duddalwar2, Inderbir S Gill1, Mihir M Desai1
1
Institute of Urology, Catherine & Joseph Aresty Department of Urology and the
Department of Radiology, University of Southern California, Los Angeles, CA, 90089
2
Introduction: The surface area of contact that a tumor has with the adjacent renal parenchyma considerably
determines the extent of resection of kidney tissue during partial nephrectomy (PN), and thus may impact on
peri-operative outcomes. We present a novel method of calculating renal tumor contact surface area (CSA)
using advanced image-processing technology and correlate it with peri-operative variables in patients
undergoing PN.
Methods: From 01/2010-08/2011, 95 patients underwent minimally invasive PN for tumor, and had CSA
data available using image rendering software (3D Synapse – Fuji film©). CSA was correlated with baseline
demographics and peri-operative outcomes.
Results: Mean tumor size was 3.1cm and mean CSA was 18 cm2. CSA significantly correlated with blood
loss (p=0.026), operative time (p=0.001) and length of hospital stay (p=0.003). Matched-pair comparison of
patients receiving or not receiving peri-operative transfusion demonstrated similar tumor size, R.E.N.A.L
score, PADUA score and C-index between the groups, yet a significantly higher CSA in those who required
transfusion (24.7 vs. 17.1 cm2, p=0.007). Patients with tumor CSA greater than 20 cm2 were 6.9 times more
likely to require peri-operative transfusion than patients whose tumor CSA was less than 20 cm2 (p=0.01).
Conclusion: In patients undergoing partial nephrectomy, tumors with greater contact surface area with
surrounding renal parenchyma require a
more extensive resection, thus impacting
on
peri-operative
outcomes,
including
bleeding requiring transfusion. If these
findings are validated in larger cohorts,
future
nephrometry
systems
could
incorporate
CSA
measurements
to
objectively
quantify
renal
tumor
complexity and predict peri-operative
outcomes of partial nephrectomy surgery.
Figure 1. Contact Surface Area (CSA)
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 62 of 97
ABSTRACT 48
ABSTRACTS
SIMULATION FOR TRAINING INTRA-DETRUSOR INJECTION OF
BOTULINUM TOXIN TO TREAT URINARY INCONTINENCE
Yunhe Shen1, 5, Jayesh Iyer1, 2, Pankaj Vasandani1, 3, Arjune Gunasekaran1, 2,
Daniel Burke1, 5, Dennis Dykstra4 and Robert Sweet1, 5
1
Center for Research in Education and Simulation Technologies, University of Minnesota
2
Department of Computer Science and Engineering, University of Minnesota
3
Department of Electrical and Computer Engineering, University of Minnesota
4
Department of Physical Medicine & Rehabilitation, University of Minnesota
5
Department of Urology, Medical School, University of Minnesota
Introduction: We have built new simulation prototypes for training the urological procedure of intradetrusor injection of Botox®, recently FDA approved for treating overactive bladder. Using this computer
simulation tool, the cystoscopic injections can be practiced on virtual models. Quantitative data are
measured as performance metrics during training for objective assessment of learning outcomes. The
curriculum design is guided and verified by several expert urologists.
Methods: Physically-based modeling algorithms are derived from previous work and applied in this virtual
environment, where 30 cystoscopic injections per exercise inside a virtual bladder are interactively
simulated by the integrated system. Functional modules handle soft tissue deformation and swelling/blebs
per injection, penetration/contact between tissue and needle/scope, graphics rendering and motion tracking
of instruments – cystoscope body, camera, needle/syringe, plunger and irrigation-fluid controls. Bladder
capacity ranges from 75cc to 250cc with anatomy presented by high-resolution mesh model suitable to
interact with a 22 gauge needle model. An embedded sensor introduces dome deformation on the virtual
bladder as the user physically pushes down on an artificial abdominal wall.
Results: Robust and realistic simulation methods have been implemented and integrated in two
prototypes, which collect performance metrics, e.g., injected amounts, locations and penetration
depths. On gaming laptops, simulation as well as graphics rendering of a bladder mesh with a surface
resolution of 50k vertices or 100k polygons can be updated above 100Hz. The prototypes have been
test-run at EAU 2012 Annual Congress, Paris, and will be refined according to feedback.
Conclusion: Using computer simulation technologies to train cystoscopic procedure of botulinum toxin
injection is a practical and promising approach.
Figure: Simulation screen capture and the hardware interface
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 63 of 97
ABSTRACT 49
ABSTRACTS
THE "Al dente" RADIOFREQUENCY ABLATION OF RENAL TUMORS:
USE OF PERIPHERAL FIBEROPTIC TEMPERATUVE MONITORING
SAVES NEPHRONS
Vladislav Gorbatiy1, Scott M. Castle1, Nicolas Ortiz1, Michael A. Gorin1, Vincent Bird2, Raymond J. Leveillee1
1
Division of Endourology, Laparoscopy, and Minimally Invasive Surgery, Department of Urology,
University of Miami Miller School of Medicine, Miami, FL
2
Department of Urology, University of Florida, Gainesville, FL
Introduction & Objective: Nephron-sparing renal cancer surgery is aimed to preserve normal parenchymal
volume while treating the malignancy. Though most centers have reported oncological and renal functional
outcomes after radiofrequency ablation (RFA) of renal masses, the associated loss of normal parenchymal
volume is yet to be described. The objective was to measure normal parenchymal volume loss with RFA of
renal masses and whether the use of real-time peripheral temperature monitoring (PTM) around the tumor
during RFA reduces renal volume loss.
Methods: We reviewed our prospectively collected database of patients with renal masses treated between
November 2001 and January 2011 with laparoscopic (LRFA) or Computerized Tomography (CT) guided
percutaneous RFA (CTRFA) with and without simultaneous real-time fiberoptic PTM. Patients with
multiple tumors and those without available contrasted CT imaging were excluded from analysis.
DICOM data was exported and analyzed in the open-source, FDA approved, OsiriX Medical Imaging
software. Volumetric calculation was internally validated and used to measure the normal, enhancing
bilateral renal parenchyma and tumor volumes. Clinical outcomes were collected and analyzed. For
continuous variables, independent student's t-test was used and for discrete variables Fisher's exact test was
used. Multivariable linear regression was performed.
Results: A total of 63 patients (42 male) aged 36-86 years (mean 67.8) and 63 renal tumors underwent
LRFA without PTM (17), LRFA with PTM (16) and CTRFA with PTM (30). Mean tumor size, volume and
Nephrometry score were (2.6cm, 9.0cm3, 6.8), (2.9cm, 11.4cm3, 7.4) and (2.6cm, 9.6cm3, 7.6) in each
group respectively. Average time interval between pre and postoperative imaging used in analysis is 23.6mo
(3-65mo). Univariate analysis revealed a statistically significant (p=0.0001) average percent parenchymal
volume loss in kidneys treated without PTM (-29.2%) compared to those treated with temperature
monitoring (-11.7%) irrespective of the LRFA with PTM (-12.6%) or CTRFA with PTM (-11.2%) methods.
Multivariate analysis looking at gender, age, time interval between pre and postoperative CT imaging,
nephrometry, tumor volume and total parenchymal preoperative volume revealed that the only factor
leading to a significant loss in normal renal volume was the lack of PTM (OR=4, 95% CI -7.9-23.6,
p=0.001).
Conclusion: Our retrospective volumetric analysis of renal parenchyma before and after RFA of renal
masses reveals that the use of peripheral real-time fiberoptic thermometry produced a statistically significant
40% relative reduction in normal parenchymal renal loss. We therefore encourage a wider adaptation of this
technique to enhance the nephron-sparing qualities of renal RFA.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
ABSTRACT 50
TOP 10 ABSTRACT
PRELIMINARY TESTING OF A TRANSURETHRAL DEXTEROUS
ROBOTIC SYSTEM FOR BLADDER RESECTION
Ryan B. Pickens, M.D.3,4, Andrea Bajo 1,4, Nabil Simaan, PhD 1,4, S. Duke Herrell, M.D2,3,4
1
Vanderbilt University Departments of Mechanical Engineering and 2Biomedical Engineering;
3
Vanderbilt University Medical Center, Department of Urologic Surgery;
4
Vanderbilt Initiative in Surgery and Engineering (VISE)
Introduction: Transurethral resection of bladder tumor (TURBT) and pathological staging are both standard surgical
therapy for non-muscle invasive bladder (NMIB) cancer and integral parts of the diagnostic evaluation and
progression monitoring of all bladder tumors. Anterior and bladder dome tumors can provide difficult sites of
resection due to anatomy, visualization, and limitations of the instruments. We developed and tested a dexterous robot
that can fit through a standard resectoscope for evaluation for possible en-bloc resection of bladder tumors especially
tumors along the dome and anterior wall of the bladder.
Materials and Methods: Our dexterous robotic slave uses a continuum (snake-like) mechanical architecture with
three working channels through which a fiberscope, biopsy graspers, and a holmium laser were placed (Fig. 1). The
continuum robot has two segments. Each segment provides two degrees of freedom in bending. The two seriallyconnected segments allow the continuum robot to retroflex on itself providing an adequate view of the anterior wall of
the bladder. Using indigo carmine, injections were performed through the detrusor muscle into the mucosa of the exvivo bovine bladders at a total of 11 positions throughout all quadrants of the bladder. The snake robot was used in
conjunction with the holmium laser to ablate 9 of the lesions, 2 additional lesions were resected en bloc using the
grasper and the laser down through the muscle layer. The bladder was then opened and all areas were checked for
completion of ablation as well as the resection beds were taken down to the muscle layer.
Results: Both experiments showed that the robotic system was able to directly visualize all 11 targets. In both
bladders, we were able to resect en bloc two tumors using the grasper and 200 micron holmium laser fiber down to the
muscle layer indicating a good resection. All of the other targets were completely ablated using the holmium laser.
Conclusion: The dexterous robotic slave robot for TURBT allowed for visualization as well as provided adequate
ablation and en bloc resection of bladder lesions throughout the entire bladder. Potential advantages of this system
over standard rigid and flexible scopes would include: increased dexterity, using multiple tools simultaneously and en
bloc tumor resection with controlled depth. Future applications of this system could be the use of optical time
integration for robotically controlled en bloc tumor resection etc.
Figure 1: (left) Robot-assisted bovine bladder resection showing inflated bladder,
(right) view of the robot inside the bladder
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 65 of 97
ABSTRACT 51
ABSTRACTS
RELIABILITY OF PROSTATE HISTOSCANNING IN LOCALIZATION OF
PROSTATE CARCINOMA: INDIAN EXPERIENCE
Arvind Ganpule
Division of Laproscopic and Robotic Surgery
Muljibhai Patel Urological Hospital
Nadiad, Gujarat, India
Background: Prostate HistoScanning TM (PHS), a new ultrasound-based technology which uses
computer-aided analysis to quantify tissue disorganization induced by malignant processes, can
identify and characterize foci of prostate cancer as compared with step-sectioned radical
prostatectomy (RP) specimens. This study was done to determine the extent to which PHS can
identify tumor foci that correspond to a volume of ≥ 0.50 mL.
Material and methods: Between October 2011 and February 2012, 16 men underwent
HistoScanning before scheduled radical prostatectomy. The three dimensional raw (grey-scaled) data
required for Histoscanning analysis were acquired by transrectal ultrasonography, and analyzed
using organ-specific tissue-characterization algorithms. The Histoscanning analysis results were
compared with the histology of the whole mounted prostate, step-sectioned coronally at 5-mm
intervals, and each slide analyzed by grid analysis.
Results: A total of 96 sextants were studied in 16 patients. The prostate size and the PHS identified
lesion size were 13.49± 13.85 and 3.10± 2.06 ml, respectively. PHS correlated well with step
sectioned radical prostatectomy specimen total tumor volume (Spearman's coefficient of rank
correlation of 0.624,p=0.009). Thus, using the clinically accepted volume threshold of 0.50 mL, the
sensitivity, specificity, and positive and negative predictive values of Histoscanning were 94.4%, 50%,
85%, and 75%, respectively.
Conclusion: PHS has the capability to accurately detect cancer foci more than 0.5 mL within the
prostate. Further studies to explore its role for the preoperative imaging in cancer prostate are
required.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 66 of 97
ABSTRACTS
ABSTRACT 52
TOP 10 ABSTRACT
3D-HOLOSCOPIC IMAGING: A NEW DIMENSION TO ENHANCE IMAGING IN
MINIMALLY INVASIVE THERAPY IN UROLOGICAL ONCOLOGY
Makanjuola JK1, Aggoun A2, Swash M2, Grange P3, Challacombe BJ1, Dasgupta P4
1
Department of Urology, Guys and St Thomas Hospital, London, UK, 23D Visual Information Engineering (3D VIE)
Research Group, School of Engineering and Design, Brunel University, UK, 3 Department of Urology, Kings College
Hospital, London, UK, 4MRC Centre for Transplantation, NIHR Biomedical Research Centre,
King's Health Partners Guys Hospital, London, UK
Introduction: Existing image representation of urological pathology (from CT/MRI) is limited by its 3-dimensional (3D)
representation on a 2-dimentional screen (2D). Performing procedures like partial nephrectomy remains a technical challenge
especially when the tumour is not always evident macroscopically and difficult anatomy of the arterial system complicates tumour
removal. Accurate localisation of tumours and surrounding structures will enhance preoperative diagnosis, biopsy, therapeutic
planning and intraoperative visualisation. We present 3D-Holoscopic imaging (figure 1) as a novel method of representing
DIACOM data images (CT /MRI) to produce 3D-Holographic representations of anatomical structures that can be viewed pre
and intra operatively (using augmented reality concept) without special eyewear in natural light.
Figure 1: Recording and replay of the 3D-Holoscopic imaging
Figure 2: 3D-Holoscopic content on the autostereoscopic
display
Methods: We have developed proof of concept static display models (figure.2). The proposed 3D-imaging technology allows
natural accommodation and convergence to accomplish stress-free viewing. We are performing feasibility studies using the
Alioscopy 3D-Display and have created software tools that allows 3D-Holoscopic images to be converted in the appropriate
format supported by a commercial auto-stereoscopic display for viewing (figure 3).
Results: The results are extremely satisfactory and for the first time it is proved that medical 3D-Holoscopic content can be
displayed on commercially available multi-view auto-stereoscopic display. As a result we are able to display a ground-breaking
3D-Holoscopic images relevant to minimally invasive urology. We are further developing display screen prototypes and
advancing our algorithms required to convert DICOM data from CT, MRI and US into dynamic 3D images an a auto-stereoscopic
display to facilitate development of true image-fusion surgical systems.
Conclusion: Our application to the
medical field of this emerging
technology may revolutionize the
visualization spectrum from diagnosis,
to staging investigations, simulation
training and we believe will add a new
dimension to augmented reality in
tumour location during technically
challenging procedures like partial
nephrectomy.
Figure 3: Principle of DIACOM data capture to 3D-Holoscopic image (optical model) display
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 67 of 97
ABSTRACT 53
ABSTRACTS
GREENLIGHT HPS-120W VS GREENLIGHT XPS-180W LASER VAPORIZATION OF
THE PROSTATE FOR BENIGN PROSTATIC HYPERPLASIA: A PROSPECTIVE
COMPARATIVE OUTCOMES ANALYSIS
Zorn KC, Liberman D, Hueber PA, Ben-zvi T , Peloquin F.
University of Montreal Hospital Center, Montreal, Quebec, Canada
Introduction: To evaluate the safety, efficacy and short-term outcome of the new 532nm Greenlight XPS 180W
laser system(AMS,Minnetonka, MI,USA) in comparison to the former generation HPS-120W system for treating
benign prostatic hyperplasia(BPH) in a prospective non-randomized single-centre study.
Methods: From June 2010 to September 2011, 145 consecutive patients with lower urinary tract symptoms
secondary to BPH were included; 60 patients were treated with HPS-120W and 85 with XPS-180W laser
vaporization of the prostate. Perioperative variables, and complications were evaluated. International Prostate
Symptom Score (IPSS), maximum flow rate (Q(max)), post-void residual urine (PVR), Sexual Health Inventory
for Men (SHIM), and quality of life score (Qols) were recorded at baseline, 1-, 3- and 6-months. Serum PSA was
assessed at baseline and 6-month follow-up.
Results: Mean(range) age of the patients was 69.6(48-87) years(HPS) and 67.2(50-85) years(XPS), with a
mean preoperative TRUS-prostate volume of 81.7(31-187) and 78.2(33-229)mL, respectively. Patient
preoperative characteristics were comparable including retention rate (52% and 47%,respectively). Mean
operative duration was significantly shorter for the XPS group (79vs44.2min;p<0.01) as was mean laser time
(37vs24min;p<0.01). Mean energy delivery was however comparable between HPS and XPS
groups(222.5vs188.7KJ;p=0.12). Mean fibre use (1.6vs1.0;p<0.01) and 3L Saline bags (4.1vs7;p<0.01) were
significantly lower for the XPS group. The rate of visual impairment from bleeding (3% vs 4%;p< 0.74) and
prostate capsule perforation (0% in each), were comparable. There were no significant differences in 30-day
complication rate including dysuria(17% vs 21%), incontinence (3.3% vs 3.5%), retention (5% vs 7%),
retrograde ejacuation (65% vs 60%) or erectile dysfunction (1.6%vs2.3%). With a mean follow-up of 11.8 and
7.5 months, no urethral strictures or retreatments were observed. Clinical follow-up is summarized in Fig.1.
6m-PSA reduction was significantly greater for the XPS group (54%vs78%;p<0.01).
Conclusion: Both Greenlight systems provide safe and effective tissue vaporization properties with significant
clinical relief of BPH obstruction. The XPS-180W laser system appears to be more favorable with regards to
reduced operative time, fibre need and PSA-reduction suggesting more effective tissue removal.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 68 of 97
ABSTRACT 54
ABSTRACTS
AUTOMATED ANALYSIS OF RETROPERITONEAL ABNORMALITIES USING
BOX COUNTING ALGORITHMS
Cristian Surcel
Introduction: The retroperitoneal space contains multiple organs (abdominal aorta, inferior vena cava,
lymphoid tissue, etc) which can be affected by multiple diseases, especially lymphoproliferative disorders
and inflammatory/sclerosis processes. The most frequently used imaging technique for differential diagnosis
is computed tomography, but its accuracy in discriminating between lymphoma and idiopathic
retroperitoneal fibrosis (IRF) is small. The aim of this study is to evaluate an automated analysis of the CT
scans using a fractal analysis-based software in order to differentiate between retroperitoneal lymphoma and
IRF
Materials and method: We conducted a retrospective comparative study in our center which included 32
patients with histologically-proven IRF (19 patients) and retroperitoneal follicular non Hodgkin lymphoma
type B (13 patients). We analyzed their CT scans using a using a fractal analysis-based software program.
The groups were homogenous and well balanced according to age, sex, and CT protocol of image
acquisition. The inclusion criteria were absence of ureteric involvement, normal kidney function, and only
retroperitoneal involvement. All images were transferred after acquisition to a separate workstation and the
contour of the region of interest (ROI) was extracted using a box counting algorithm. The results were
compared to the readout performed by a diagnostic radiologist, considered as reference.
Results: The fractal dimension (FD) of the ROI’s in IRF scans varied in the interval 1.33±0.57 while in the
retroperitoneal lymphoma scans, the fractal dimension varied in the interval 2.14±1.14 (p=0.04), confirming
the hypothesis that a higher FD is present in malignant cases. The concordance index between the
automated and manual analysis of the IRF images was 0.874 (95% confidence interval 0.862, 0.884) and
0.912 (95% confidence interval 0.862, 0.924) for the retroperitoneal lymphoma scans, respectively.
Conclusion: There is a significant difference between the fractal dimension of the ROI of idiopathic
retroperitoneal fibrosis and retroperitoneal lymphoma. The software provides equivalent results to the
manual examination and can be used to differentiate between malignant and benign lesions of the
retroperitonum
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 69 of 97
ABSTRACT 55
ABSTRACTS
ROBOT-ASSISTED TRANSVAGINAL NOTES RETROPERITONEAL
NEPHRECTOMY: FEASIBILITY STUDY IN THE CADAVER
Humberto Laydner, Riccardo Autorino, Wahib Isac, Ali Khalifeh, Kamol Panumatrassamee,
Ahmad Kassab, Robert J. Stein, Jihad H. Kaouk
Center for Laparoscopic and Robotic Surgery, Urology, Cleveland Clinic, Cleveland, OH, USA
Introduction: Despite the feasibility of NOTES using laparoscopic instruments, technical difficulty of this approach
significantly limits its clinical application. Hybrid robot assisted NOTES (R-NOTES) techniques have been described
in the animal model. Herein, we evaluate the feasibility of R-NOTES retroperitoneal nephrectomy in a cadaver model.
Methods: Two R-NOTES retroperitoneal nephrectomies were attempted in 2 female cadavers. Transvaginal access to
the retroperitoneum was obtained with the cadaver placed in a semi-prone jackknife position.
Results: In the first cadaver, a right transvaginal R-NOTES retroperitoneal nephrectomy was successfully completed
without the addition of extra ports with no injuries to retroperitoneal organs or vessels. Time for setup was 128 min.
Time to identify the ureter was 53 min. Dissection and control of the renal pedicle was completed in 21 min. Time to
dissect the kidney out from its attachments and extract the specimen was 36 min. Total time to complete the procedure
was 238 min. In the second cadaver, rectal injury occurred during the access and the completion of a left nephrectomy
was not possible because the robotic instruments did not reach the kidney.
Conclusion: Transvaginal R-NOTES retroperitoneal nephrectomy in the cadaver model is feasible. Improvements in
the technique and instrumentation are necessary in order to make this approach safe and reproducible.
Figure 2: Identification of the right
ureter (U) anterior to the iliac
artery (IA)
Figure 3: A- intraoperative view: right
iliac artery (IA); right kidney (RK); right
ureter (U); right gonadal vein (GV);
peritoneum (P); B- figure A inserted into
the context of a schematic representation
of the whole retroperitoneal cavity; left
kidney (LK);
C- External view
Figure 1:
A and B- semi-prone jackknife position;
C- retroperitoneal access through the
vaginal posterior fornix (*rectum);
Figure 4: A- hilar control; B- placement
D- QuadPort+™;
of the kidney into a laparoscopic
E- GelPoint™;
endocatch bag;
F- Home-made port.
C- extraction of the specimen through
the vagina; D- closure of the vaginal
incision
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 56
ABSTRACTS
USER FEEDBACK FOR SUTURING USING BLACK LIGHT ASSESSMENT OF
SURGICAL TECHNIQUE (BLAST) AND IMAGE PROCESSING
Lauren Poniatowski, Troy Reihsen, Robert Sweet, MD
Department of Urology, University of Minnesota, Minneapolis, MN, USA
Introduction: Tissue analog models are used in simulation for the training and assessment of surgical technique,
particularly for suturing skills. We have designed synthetic physical tissue simulators with integrated assessment
lines allowing for Black Light Assessment of Surgical Technique (BLAST). Additionally, we have designed a
method for giving quantitative and visual feedback to the user using image processing techniques in MATLAB®.
Methods: UV sensitive assessment lines were integrated into organosilicate-based material recipes with reference to
mechanical properties of human tissue from the Center for Research in Education and Simulation Technologies
(CREST) Human Tissue Database. Two models with integrated assessment lines are presented. An analog model for
training laparoscopic pyeloplasty is presented to demonstrate patient specific modeling of anatomy using 3D printed
molds. A skin analog model was also developed to demonstrate image
processing analysis techniques of the integrated assessment lines in 2D in
MATLAB®.
Results: The assessment lines worked well in that they were invisible to the
user during a suturing exercise (Figure 1a) and then appeared with sufficient
brightness under UV light to be captured as an image (Figure 1b). Image
processing techniques were determined to be useful in giving user feedback
quantitatively through an overlap percentage value as well as by visually
showing overlapped and non-overlapped regions of an image (Figure 2). A
model for training laparoscopic pyeloplasty was also completed for
demonstration of using BLAST for applications specific to urology (Figure 3).
It was premiered at the AUA hands on laparoscopic training course.
Conclusion: Analysis of suturing skills is possible using assessment lines in
tissue analog models using BLAST (2D and 3D) and image processing
techniques (2D).
Figure 1. Sutured synthetic skin under (a)
room lighting conditions and (b) UV light.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Figure 2. MATLAB®output
image showing overlap
between the unsutured and
sutured image (green) and no
overlap (red).
Figure 3. Pyeloplasty model under (a)
room lighting conditions and (b) UV light.
Page 71 of 97
ABSTRACTS
ABSTRACT 57
THE XENXTM – A NEW DEVICE TO PREVENT STONE MIGRATION DURING
LASER LITHOTRIPSY
Eugene Kramolowsky1, Idan Tamir2, Ofer Zigman2, David Murphy1, Isaac Koziol1
1
Virginia Urology, Richmond, VA
2
Xenolith Medical, Kiryat-Gat, Israel
Introduction: Stone migration during ureteroscopic laser lithotripsy is a well-known phenomenon resulting in
lengthened procedures and increased technical difficulty. Several stone retention devices are available commercially,
but have various shortcomings, such as the need to introduce them in addition to a guide-wire and a tendency to
disintegrate when exposed to the laser. We report here the results of clinical development and evaluation of the XenX
(Xenolith Medical) - a novel stone retention device for proximal and distal stones during holmium laser lithotripsy.
The XenX integrates into one device a self-expanding retention element, which fits itself to the ureter anatomy, and a
guide wire. Moreover, due to its unique design, holmium laser lithotripsy may be conducted in close proximity to the
retention element without compromising its ability to prevent stone migration.
Methods: Between January and March 2012, ten ureteroscopy procedures using the XenX device were performed by
four board certified urologists. The device evaluation included deployment, positioning, stone entrapment, and
urologist's perception of value. The mean patient age was 47 years (range 25-72). Seven patients had a single stone
and the remainder had two or more. Stones were located in the distal (70%), mid (10%) or proximal (20%) ureter.
Mean stone size was 53 mm2 (range 16-81). Secondary endpoints were reduction in operation time, intraoperative
complications, and stone migration. Patients were followed for 30 days post-operatively.
Results: The ureteroscopy and laser fragmentation was successfully completed in ten patients. The braided mesh that
comprises the stone retention element was deployed between the stone and the kidney and effectively blocked
retrograde stone migration during holmium laser lithotripsy while allowing free fluid flow in all cases. Stones
fragmented to sub-mm size did not pass through the mesh and were removed or flushed into the bladder. The device
allowed increased irrigation rates (300mm Hg pressurized system and employment of higher laser power settings,
typically, 8J, 8Hz, 6.4W), and ease in stone engagement with
the laser fiber. Initial clinical data indicated that friction
between the device and both the cystoscope's working channel
and the ureteroscope was too high, which resulted in device
migration along the ureter. The XenX device was improved by
coating both its core wire and outer layer of the overlay tube
(which houses the self-expanding braid) with PTFE, resulting
in significant reduction in both static and dynamic friction
coefficients. Re-testing the device in the clinical setting
indicated that device migration was no longer significant. No
intra- or post-operative complications were encountered and
all patients were stone-free 30 days post-operatively. Survey
of operating surgeons revealed a perception of increased ease
of performing the procedure and a decrease in procedure
Figure: Visualization of stone using Xenolith device
duration.
Conclusion: The XenX device provides a significant improvement to holmium laser lithotripsy by effectively
preventing retrograde stone migration, improving ureteroscopic visualization, and significantly reducing procedure
complexity and apparent operative time. The device may also have application during percutaneous nephrolithotripsy
to prevent stone efflux down the ureter.
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ABSTRACT 58
ABSTRACTS
IN VITRO AND IN VIVO COMPARISON OF OPTICS AND PERFORMANCE OF A
DISTAL SENSOR URETEROSCOPE (STORZ FLEX-XC) VS. A STANDARD
FIBEROPTIC URETEROSCOPE (STORZ FLEX-X2)
A. Lusch, C. Abdelshehid, J.A. Graversen, K. Osann, S. Olamendi, R. Alipanar,
E. McDougall, J. Landman
Department of Urology, University of California, Irvine, Orange CA 92868, USA
Purpose: Recent advances in distal sensor technologies have made distal sensor ureteroscopes
commercially technically feasible. We evaluated the performance characteristics and optics of a new
generation distal sensor (Flex-XC, Karl Storz, Tuttlingen, Germany)(Xc) and a standard flexible fiberoptic
ureteroscope (Flex-X2, Karl Storz, Tuttlingen, Germany)(X2).
Material and Methods: The two ureteroscopes were compared for active deflection, irrigation flow rates
and optical characteristics. Each ureteroscope was evaluated with an empty working channel and with
various accessories. Optical characteristics (resolution, grayscale imaging and color representation) were
measured using USAF test targets. The ureteroscopes were tested in vivo in a porcine model using a HD
monitor and an HD recording system. We digitally recorded a renal porcine ureteroscopy and laser ablation
of a stone with the X2 and with the XC. Edited footage of the recorded procedure was shown to different
surgeons (n=8) on a HD monitor for evaluation by questionnaire for image quality and performance.
Results: The XC had a higher resolution than the X2 at 20 and 10 mm 3.17 lines/mm vs. 1.41 lines/mm, 10.1
vs 3.56, respectively (p=0.003,p=0.002). Color representation was better in the XC. There was no difference
in contrast quality between the two ureterosopes. For each individual scope, the upward deflection was
greater than the downward deflection both with and without accessories. When compared to the X2, the XC
manifested superior deflection and irrigant flow (p<0.0005, p<0.05) with and without accessory present in
the working channel. When an accessory was present, the X2 demonstrated less diminishment of deflection
compared to empty working channel deflection than the XC (p<0.0005 for combined up and down
deflection). Deflection (up/down) of both ureteroscopes was most impaired by a 3.2 Fr grasper (98.5%/99%
reduction for the XC and 99%/99% for the X2) and least impaired by a 1.7 Fr Nitinol Stone Basket
(48%/45% reduction for the XC and 52%/55% for the X2). Irrigation flow rate was also most impaired by a
3.2 Fr grasper (98.5% reduction for the XC and 99% for the X2) and least impaired by a 200 µm laser fiber
(48% reduction for the XC and 52% for the X2). Observers deemed the distal sensor ureteroscope superior in
visualization in clear and bloody fields, as well as for illumination. (p=0.0005, p=0.002, p=0.0125)
Conclusion: In this in vitro and porcine evaluation the distal sensor ureteroscope appears to provide
significantly improved resolution and color representation as compared to a standard fiberoptic
ureteroscope. The overall deflection was also better in the XC and deflection, as well as flow rate, was less
impaired by the various accessories.
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ABSTRACT 59
ABSTRACTS
TOP 10 ABSTRACT
PHANTOM STUDY OF A NOVEL STEREOTACTIC PROSTATE BIOPSY
SYSTEM INTEGRATING PREINTERVENTIONAL MRI AND LIVE US FUSION
Timur H. Kuru1, Matthias Roethke2, Dogu Teber1, Boris A. Hadaschik1*, Markus Hohenfellner1*
1
2
Department of Urology, Heidelberg University Hospital, Heidelberg, Germany
Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
Introduction: To determine the targeting error of a novel stereotactic prostate biopsy system, which
integrates preinterventional MRI with periinterventional ultrasound for perineal navigated prostate biopsies.
Methods: We performed stereotactic biopsies on 5 prostate phantoms (one CIRS 053-MM and four CIRS
066). Phantom 053-MM incorporates three MRI- and TRUS-visible lesions, while lesions within phantom
066 are only detectable on MRI. In both phantoms the 0.5cc volume lesions are randomly placed. The
phantoms were examined by 3T-MRI preinterventionally. Then 3 stereotactic biopsies from one lesion in
phantom 053-MM and from all ultrasound-invisible lesions in the 066 phantoms were taken under livefusion-imaging guidance. During intervention a mix of blue ink and gadobutrol was injected into each
biopsy channel. Afterwards 3T-MRI was obtained again. These MRI images were then fused again with the
intraoperative TRUS-data. Thus, the targeting error (TE) between the planned and performed biopsy cores
could be measured. Additionally, the procedural targeting error (PTE) between the virtually planned biopsy
trajectory and the manually registered three-dimensional needle position of every single biopsy core taken
was calculated.
Results: The overall targeting error (TE) of the 39 biopsy-cores taken was 0.83mm (SD: 0.48mm) with the
highest TE in the sagittal plane (1.09±0.54mm), followed by the coronal (0.72±0.43mm) and axial
(0.69±0.34mm) planes. The procedural targeting error, which is provided intraoperatively, was 0.26mm in
average (SD: 0.46mm). Comparing PTE and TE, there was no statistically significant difference (p=0.39).
Conclusion: The targeting error of stereotactic biopsies using our novel perineal prostate biopsy system
(BiopSee®, MedCom, Germany) is below 1mm and can be estimated in vivo by the automatically calculated
procedural targeting error. Stereotactic prostate biopsies guided by the combination of MRI and ultrasound
allow effective and precise examination of MRI-lesions.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 60
ABSTRACTS
VERSION 2-5 PART PERCUTANEOUS ACCESS NEEDLE WITH GLIDEWIRE (5PANG): A MULTIUTILITY PUNCTURE SYSTEM FOR PERCUTANEOUS RENAL
ACCESS
Rawandale-Patil AV, Kurane C S, Patni L G.
Institute of Urology Dhule, Maharastra, India 424001
Introduction: We describe and analyse our innovative 5-PANG (version 2) needle to make inital tract
dilatation during PCNL. Also describe the other utilities of this puncture system.
Methods: The 5-PANG(version 2) needle (fig 1) (designed, fabricated, patented by our institute) consists of
5 parts allowing puncture and inital tract dilatation to 12 Fr during PCNL. Puncture is performed with the
inner 2 parts. Part 1 is removed and a glide wire parked into the pelvicalyceal system. Parts 3,4 & 5 are
telescoped over part 2. Part 2,3&4 removed. Safety wire/ balloon dilator/ Rigid telescopic dilator rod /
flexible or rigid ureterorenoscope (4.5 Fr) can then be passed through part 5. Part 5 is then retained or
removed depending on the procedure performed. Successively 364, “5-PANG PCNLs” were carried out.
Advantages, disadvantages, safety, efficacy of the 5-PANG technique were prospectively evaluated.
Results: Of 40 renal accesses, 12 had history of previous renal surgeries. Average time from successful
puncture to rod/balloon/ureteroscope placement was 51.32 secs with an average radiation time of 3.31 secs.
No failure, limitations, early or late complications were observed. 4 cases with stone size of 1.5 cms
underwent the 12 Fr 5-PANG miniperc
Conclusion: 5-PANG (version 2) needle makes initial tract dilatation during renal access easy, safe and
cheap. It prevents extrarenal wire kinking and slippage, straightens curved puncture tracts, avoids
extravasation of contrast, decreases procedure and radiation time required for initial tract creation; is cheap
and reusable. It can also be used as a 12 Fr miniperc system and allows antegrade flexible ureterorenoscopy
Figure: 5-PANG (version 2) Needle
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 61
AUTOMATED VOLUMETRIC ASSESSMENT BY NONCONTRAST COMPUTED
TOMOGRAPHY IN THE SURVEILLANCE OF NEPHROLITHIASIS
Sutchin R Patel MD1, Shane Wells MD2, Julie Ruma MD2, Scott King MD2,
Meghan Lubner MD2, Stephen Y Nakada MD1, Perry J Pickhardt MD2
1
Department of Urology, 2 Department of Radiology
University of Wisconsin School of Medicine and Public Health, Madison WI
Introduction: Assessment of size and interval change of renal calculi via noncontrast computed
tomography (NCCT) is generally performed using linear measurement in the axial plane in clinical practice.
We evaluate the use of automated volumetric assessment for stone surveillance via NCCT and compare the
results with manual linear measurement.
Methods: We retrospectively reviewed patients seen in our stone clinic that had undergone two NCCT
scans without stone intervention during the interval between scans. Thirty patients met our inclusion criteria
and underwent longitudinal assessment for urolithiasis via NCCT (mean interval:583.2 days; range:1222,030 days). A total of 52 discrete calculi were analyzed. Three board-certified radiologists measured
maximal linear stone size in the axial plane using electronic calipers on soft tissue (ST) and bone windows
(BW). Automated stone volume was also obtained by each reader using a dedicated prototype software tool
(Ziosoft, Redwood City, CA) for stone evaluation.
Results: Mean stone linear size and volume was 4.9±2.8mm(ST), 4.5±2.6mm(BW), and 116.2±194.6
mm3(window independent), respectively. Mean inter-observer variability for linear size measurement was
16.4±10.5%(ST) and 20.3±13.8%(BW). Inter-observer variability for volumetric measurement was 0%. Of
the 52 persistent stones, the mean % change in linear stone size between CT studies was 39.3±46.7%(ST)
and 42.9±53.1%(BW) growth, compared with 171.4±320.1%(window independent) growth for automated
volume measurement over a mean of 583.2 days. However, discordant results for increased vs. decreased
interval size were seen between linear and volumetric assessment in 19/52 stones (36.5%).
Conclusion: Automated volumetric measurement of renal calculi via NCCT is independent of specific
reader and window settings. Volumetric assessment amplifies smaller linear changes over time, while up to
one-third of cases show linear-volume measurement discordance.
Volumetric assessment is therefore
preferable, particularly for longitudinal surveillance of renal calculi.
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ABSTRACTS
ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY IN
PATIENTS WITH PREVIOUS ABDOMINAL AND PELVIC SURGERY
Isac WE, Autorino R, Rizkala E, Hillyer S, Laydner H, Long JA, Kassab A, Khalifeh A, Panumatrassamee
K, Eyraud R, Haber GP, Stein RJ, Kaouk J
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
Introduction: To assess the outcomes of robot assisted laparoscopic partial nephrectomy (RALPN) in
patients with history of previous abdominal or pelvic surgery and to describe our access technique in this
patient population
Methods: Retrospective review of our IRB approved database yielded 369 patients who underwent
(RALPN) from June 2006 to August 2011. Patients were divided into those who had previous abdominal or
pelvic surgery (PAS group) and with no previous abdominal surgery (NPAS). Perioperative outcomes were
compared between the two groups. The access site was modified to be as far as possible from the previous
abdominal scar and an open access was preferred in selected cases.
Results: Overall, two hundred and eleven patients had a history of previous abdominal surgery (57.1%). Of
them, 97 (45%) had history of multiple abdominal surgeries. One hundred and twelve patients of the PAS
group were females (53%) as compared to 46 patients (29.1%) (p= 0.0001). RENAL nephrometry score was
significantly higher in the PAS group (7.2 versus 6.7) (p=0.04). Otherwise there was no significant
difference between groups in terms of other baseline characteristics. Similarly, there was no difference in
terms of operative time (p=0.6), estimated blood loss (p=0.8) and warm ischemia time (p=0.08). The
surgical access was accomplished using Veress needle in 97.2% in the PAS group versus 97.4% in the nonPAS group (p=0.8). Intra-operative complications were comparable between both groups (p=0.9). No
complications related to the use of the Veress needle to gain primary access were encountered.
Conclusion: By applying appropriate modifications to the access technique, RALPN results to be a safe and
effective minimally invasive treatment option for the management of small renal masses in the setting of
previous abdominal surgery.
Figure: Drawing shows the usual initial access site (A), alternative access
site in case of presence of previous abdominal surgery scar (A1)
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ABSTRACT 63
ABSTRACTS
ROBOTIC VERSUS OPEN URETERONEOCYSTOSTOMY: A SINGLE
INSTITUTION COMPARATIVE OUTCOME ANALYSIS
Isac WE1, Kaouk J1, Altunrende F2, Rizkala E1, Autorino R1, Hillyer S1, Laydner H1, Long JA1, Kassab A1, Khalifeh
A1, Panumatrassamee K1, Eyraud R1, Falcone T3, Haber GP1, Stein RJ1
1
Glickman Urological and Kidney institute, Center for Reproductive Medicine, Obstetrics and Gynecology and
Women's Health Institute3, Cleveland Clinic, Cleveland, Ohio, 2Istanbul Bilim University Medical Faculty, Department
of Urology
Introduction: Ureteroneocystosctomy is used for the treatment of a wide variety of ureteral diseases. Over the last
decade, robotic surgery has become more commonly used as a minimally invasive approach for reconstructive upper
urinary tract procedures. The aim of this study is to present our experience with robotic ureteroneocystosctomy (RUNC)
and compare them to those of open ureteroneocystosctomy (OUNC) in a tertiary care institution.
Methods: Medical records of patients who underwent robotic (RUNC, 26 patients) and open (OUNC, 56 patients)
ureteroneocystostomy at our institution between 2000 and 2010 were retrospectively analyzed. Main perioperative and
postoperative data including patient demographics, surgical outcomes and clinical and radiographic findings at
postoperative follow-up were considered in the comparative analysis.
Results: No significant differences were detected in terms of baseline patient characteristics between the two groups.
The OUNC procedures were performed with a shorter median operative time (270 vs. 214 min., p=0.0005) whereas
RUNC patients had a shorter hospital stay (median 3 versus 4, p=0.0007), less narcotics pain requirement (median
morphine equivalent, mg 104.6 versus 279, p=0.0001) and less estimated blood loss (median 100 versus 150mg,
p=<0.0001). The rate of reoperation was similar between the two groups, RUNC 2/26 (7.6 %), OUNC 5/56 (8.9 %).
Conclusion: RUNC provides excellent outcomes with shorter hospital stay and less narcotic pain requirement when
compared to the open procedure. Advantages of the robotic platform for dissection and suturing can be useful for
complex minimally invasive urologic reconstructive procedures.
Figure 1: Creation of the Boari Flap:
a: A bladder flap is developed.
b: the ureter is anastomosed to the tip of the flap .
c: Tubularization of the boari flap.
d: Completion of the procedure
ABSTRACT 64
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACTS
REGISTRATION OF ULTRASOUND AND HISTOLOGY DATA FOR
VALIDATION OF EMERGING PROSTATE CANCER IMAGING TECHNIQUES
M. Mischi1, S. Schalk1, M. Smeenge2, F. Brughi1, T. Saidov1, M.J.P. Kuenen1,2, R.P. Kuipers2, M.P. Laguna
Pes2, J.J.C.M.H. De La Rosette2, H. Wijkstra1,2
1
Eindhoven University of Technology, Dept. of Electrical Engineering, Eindhoven, the Netherlands
2
Academic Medical Center, Urology, Amsterdam, the Netherlands
Introduction: Several ultrasound (US) methods are emerging for prostate cancer imaging, aiming at
enabling targeted biopsies as well as focal-therapy guidance. However, any of these methods, such as
elastography and contrast-enhanced US, requires accurate validation prior to introduction in clinical
practice. As the gold standard reference for prostate cancer detection remains histological Gleason scoring
after radical prostatectomy, validation requires accurate mapping of the histology results on the imaging
results. This task is complicated by misalignment between histology slices and US imaging planes, and by
prostate deformations in the ultrasound image, due to insertion of the transrectal US (TRUS) probe, as well
as in the histology, due to fixation processes. In addition, except for the prostate contour, US images do not
provide reliable landmarks for accurate mapping. This abstract proposes a solution to these problems by a
dedicated 3D elastic registration method.
Methods: A 3D US image of the prostate is reconstructed based on two 2D TRUS imaging sweeps,
longitudinal and lateral. Also a 3D reconstruction of the histology results, including cancer location, is
realized by integration and interpolation of 4-mm prostate slices. Two 3D triangulated meshes of the
prostate surface are then realized on the reconstructed US and histology volumes. A combination of rigid
and elastic registration is applied for 3D mapping of the histology on the US surface. The deformation of the
inner volume is estimated on the basis of the surface deformation, without need for additional landmarks.
Results: In vitro validation was performed by a prostate mimicking phantom with inserted elastic wires.
The proposed registration method was applied to estimate the wire displacement due to an externallyapplied pressure. The resulting accuracy was 2.2 mm, smaller than the histology resolution (4 mm). The
method feasibility was tested in two patients referred for radical prostatectomy. Figure 1 shows two
registered planes with the contours of the US image and the corresponding mapped histology. Cancerous
tissue, according to the histology, is depicted in red.
Figure: Mapping of two registered planes from histology to US.
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ABSTRACT 65
MULTI-INSTITUTIONAL ANALYSIS OF ROBOTIC PARTIAL NEPHRECTOMY
FOR SOLITARY KIDNEY
Shahab P. Hillyer1, Sam B. Bhayani2, Mohamad E. Allaf3, Craig G. Rogers4, Michael D. Stifelman5, Youssef
Tanagho2, Jeffrey K. Mullins3, Yichun Chiu5, Bartosz F. Kaczmarek4, and Jihad H Kaouk1
1
The Glickman Urological Institute, Cleveland Clinic, Cleveland, OH
Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, MO
3
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD
4
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI
5
Department of Urology, New York University, Langone Medical Center, New York, NY
2
OBJECTIVE: We evaluated the outcomes of robot-assisted partial nephrectomy (RPN) for solitary kidney
in a large multicenter series.
MATERIALS AND METHODS: A retrospective review of 887 consecutive patients who underwent
RPN for a renal mass at five academic institutions from June 2006 to November 2011. A total of 22
patients with a solitary kidney were identified. Data was collected prospectively in an IRB approved
protocol with all cases being performed by experienced robotic surgeons. Patient demographics, functional,
peri-operative and early oncological outcomes of RPN in a solitary kidney were analyzed.
RESULTS: Demographics demonstrated a median body mass index of 31 (IQR 28.8, 34.1), American
society of anesthesiologist score of 3 (IQR 2, 3), Charleston comorbidity index 4 (IQR 2.75, 4),
nephrometry score 4.5 (IQR 5, 7) and median tumor size was 3.7 cm (IQR 2.9, 5). Peri-operative outcomes
included a median blood loss 100 ml (IQR 100, 313), warm ischemia time 17 minutes (IQR 11, 18),
operative time 166 minutes (IQR 1125, 234) and hospital stay of 2 days (IQR 2, 3.5). Intra-operative
complications were 2 blood transfusions along with 1 renal vein injury that was repaired intra-operatively
without sequela and an injury to an aortic vessel. There were 3 post-operative complications (13.6%), which
included a urinary leak requiring stenting, atelectasis requiring oxygen, and significant increase creatinine
not requiring dialysis. Pre-operative median creatinine of 1.2 (IQR 0.9, 1.6) and glomerular filtration rate
(GFR) of 58.9 (45.9, 77.4). Last follow-up median creatinine and GFR were 1.7 (IQR 1.2, 2.1) and 43.9
(IQR 37.1, 58.7) respectively. The percent change in GFR was -15.8% (p=0.13). No patients required
dialysis. Positive margins occurred in 1 patient (5.5%) with 68% of patients having either papillary or clear
cell carcinoma. Two solitary kidneys had multiple tumors (n= 2). There was 1 (4.5%) recurrence of disease
from malignant ascites one year after partial nephrectomy. Fourteen patients (64%) had solitary kidneys
secondary to previous malignancy. Median follow-up was 6 months (IQR 5-9.7).
CONCLUSION: RPN offers a safe alternative to treatment of small renal masses in patients with a solitary
kidney. Functional decline was comparable to previous open partial nephrectomy series. This represents the
largest multi-institutional series in the literature regarding RPN in solitary kidney.
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ABSTRACTS
SYSTEMIC PROSTATE BIOPSIES MAY DETECT MORE INSIGNIFICANT
CANCER THAN MRI LESION TARGET PROSTATE BIOPSIES
Coffin G1,2, Chevreau G1, Renard-Penna R3, Comperat E4, Vitrani MA2, Torterotot C2,
Conort P1, Bitker MO1, Mozer P1,2
1
Academic Department of Urology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
2
ISIR laboratory, University Pierre and Marie Curie, CNRS-UMR7222, Paris, France
3
Academic Department of Radiology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
4
Academic Department of Anatomopathology, La Pitié-Salpêtrière hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
Introduction: We wanted to compare pathological characteristics of biopsy cores among patient
undergoing a first round prostate biopsy, between MRI lesion-targeted cores and systematic cores.
Methods: We retrospectively reviewed 80 patients who came at our department for a first round of
transrectal ultrasound guided prostate biopsy and who were at risk of localized prostate cancer.
Exclusion criteria were: history of prostate cancer, previous prostate biopsy, local advanced (≥T3a TNM
stage) or metastatic prostate cancer at examination (digital rectal and clinical examination, PSA serum
level>20ng/mL, prostate MRI staging ≥T3a).
Inclusion criteria were: prostate multiparametric MRI showing suspicious intra-prostatic lesion.
MRI/TRUS fusion and lesion targeting was performed using Urostation® system (Koelis, France).
For each patient, 12 cores were taken from systematic sampling, then 2 to 3 additional cores were taken in
the index MRI lesion.
Positive core was defined by the presence of prostate cancer from histological examination.
Cancer was insignificant if it responded to all of the following criteria:
- Maximum cancer length by core ≤ 5mm
- Maximum Gleason score by core ≤ 6
- Number of positive cores by patient ≤ 2
Results:
Table 1. Cross-relation of pathological outcomes between MRI lesion targeted and systematic
biopsy
Table 2. Effectiveness of systematic (STD +/-) and MRI targeted (MRI +/-) biopsy.
Systematic biopsy may be more sensitive than MRI targeted biopsy but it may detect more
insignificant prostate cancer. However we could not show significant differences because of the too
small number of patient.
Conclusion:
MRI lesion-targeted biopsies tend to detect significant lesions more specifically than systematic biopsy,
however the study must be continued on a larger number of patients.
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ABSTRACT 67
ABSTRACTS
LONG-TERM OUCOMES OF INTRA-RENAL BCG/IFN FOR BIOPSY-PROVEN
UPPER TRACT CARCINOMA IN SITU
Edan Y. Shapiro, Michael J. Lipsky, Doh Yoon Cha,
James M. McKiernan, Mitchell C. Benson, Mantu Gupta
Department of Urology, Columbia University Medical Center, NY
Introduction: Isolated carcinoma-in-situ (CIS) of the upper-tract is a relatively rare disease. While
nephroureterectomy remains the gold-standard treatment for upper-tract CIS (UT-CIS), it may be
unnecessarily aggressive in comparison to the treatment of bladder CIS. Upper-tract administration of BCG
has shown promise for UT-CIS, but with limited reports and varied results. We report our experience using
a novel technique to directly instill BCG with Interferon-α2B (BCG/IFN) into the upper-tract in patients
with UT-CIS.
Methods: Following biopsy evidence of UT-CIS, patients received a 6-week induction course of BCG/IFN,
administered under low pressure gravity drip via an open-ended ureteral catheter. Initial follow-up was
scheduled one month following the completion of the intra-renal therapy, and consisted of flexible
ureteroscopy, selective urinary cytology, retrograde pyelography, and re-biopsy of the upper-tract. Complete
response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology,
and absence of clinical progression. Absence of visualized lesions with persistently positive cytology was a
partial response (PR), while persistence of lesions after induction was a non-response (NR). New upper-tract
lesions after an initial CR were considered recurrences. Patients with a CR were placed on maintenance
therapy for 2 years. Surveillance was performed every 3 months with ureteroscopy, selective cytology, and
imaging.
Results: Eight patients (mean age = 75 years) were followed for a median of 35.8 months. Five patients
(63%) had an initial CR, 2 (25%) had a PR, and 1 (12%) had NR. Both patients with a PR underwent a
second induction course, and while 1 had a CR, the other had a recurrence 7 months later. Total kidneypreservation rate was 88% (7/8). There were no treatment related adverse events.
Conclusion: This study demonstrates the safety and efficacy of intra-renal BCG/IFN for patients with UTCIS. Unlike other mechanisms of delivery, including percutaneous administration or reflux via double
pigtail stents, this office-based technique spares the morbidity of a chronically indwelling nephrostomy tube
or ureteral stent.
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ABSTRACT 68
ABSTRACTS
PROSTATIC SWELLING AND SHIFT OF INTRA-PROSTATIC TARGET DURING
HIFU: IMPLICATION FOR TARGETED FOCAL THERAPY
Sunao Shoji, Toyoaki Uchida, Masahiro Nakamoto, Andre L.C. Abreu, Scott Leslie, Yoshinobu Sato,
Inderbir S. Gill, and Osamu Ukimura
USC Institute of Urology, Hillard and Roclyn Herzog Center for Prostate Cancer Focal Therapy, Keck
School of Medicine, University of Southern California, Los Angeles, CA
Introduction: Prostatic swelling during high-intensity focused ultrasound (HIFU) during whole gland therapy can be intraoperatively observed, but has not been quantitatively documented. The objective of our study is to quantify (a) intra-operative
swelling of the prostate and (b) shift of intra-prostatic targeted points during HIFU.
Methods: Forty-four patients with clinically localized prostate cancer (without neoadjuvant hormonal therapy or transurethral
resection) underwent whole gland HIFU (Sonablate 500®, version 4 or TCM, Focus Surgery, IN, USA). Whole gland HIFU
consisted of 3 consecutive treatment sessions to focus initially on the anterior zone, followed by the middle zone, and finally on
the posterior zone of the prostate. Three-dimensional (3D) models of the prostate were reconstructed from the routinely acquired
3-mm step-sectional images of the intra-operative transrectal ultrasound (TRUS) before and after each of the treatment sessions.
The 3D models were compared to identify changes in prostate volume and any positional change of identical intra-prostatic
calcifications. Inter-observer variability of prostate volume measurements was assessed in 20 cases using a Cohen’s kappa
statistics. An agreement >0.81 was defined as a significant correlation.
Results: Mean prostate volume significantly increased from 30 ml to 36 ml (20% increase) during the anterior zone treatment
(p<0.001), from 40 ml to 41 ml (2.5% increase) during the middle zone treatment (p=0.027), and from 41 ml to 43 ml (5%
increase) during the posterior zone treatment (p<0.001). The volume of transition zone (TZ) during the anterior zone treatment
significantly increased from 16 ml to 20 ml (25% increase) (p<0.001), while the peripheral zone (PZ) did not change during the
posterior zone treatment (p=0.5). The mean shift of the identical targeting point measured 3.6 mm in the transition zone (n=88),
and 4.1 mm in the peripheral zone (n=102) (p=0.2). Detailed vector (distance and direction) shifts of the identical targeting points
in each quadrant of the TZ and PZ are demonstrated in the Figure1. Inter-observer variability demonstrated a Cohen’s kappa
value of 0.839 indicating significant agreement.
Conclusion: Comparative analysis of reconstructed 3D prostate models from step-sectional TRUS images during HIFU
demonstrated significant intra-operative swelling of the prostate and definitive shifts of the intra-prostatic points. Our findings
suggest a need for intra-operative adjustment of the treatment plan during energy-based targeted ablative treatment of the prostate
such as focal HIFU therapy. Adjustment of the treatment plan can be facilitated by the quantitative prediction and real-time
image-based monitoring of intra-operative swelling and target shifts.
Figure: Change in prostate volume (
shifts of the identical target (→).
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
) and vector (distance and direction)
Page 83 of 97
ABSTRACT 69
ABSTRACTS
NOVEL MICRO-ULTRASOUND PROBE TO IDENTIFY MICROVESSELS IN THE
SPERMATIC CORD
Ahmet Gudeloglu, Jamin Brahmbhatt, Karen Priola, Sijo Parekattil.
Winter Haven Hospital & University of Florida
Introduction: Previous studies have shown the benefit of real-time intra-operative audio flow Doppler
identification of testicular arteries during microscopic subinguinal varicocelectomy. This prevents
inadvertent testicular artery injury during such microsurgical procedures. This study evaluates the use of a
novel micro-ultrasound probe for the localization of the testicular arteries during such procedures.
Methods: A new micro-ultrasound probe (Aloka-Hitachi Ltd., Tokyo, Japan) was utilized during three
robotic assisted sub-inguinal microsurgical varicocelectomy procedures, to localize the testicular arteries
real-time during the procedure. The ultrasound image was fed into the TilePro (Intuitive Surgical,
Sunnyvale, CA) robotic surgical console software system to provide three simultaneous real-time video
images to the microsurgeon during the procedure: 1) a 12-15x 3D image via the HD robotic camera, 2) a 1618x optical high magnification view via the VITOM camera (Karl Storz Inc, Tuttlingen, Germany) and 3) a
real time visual ultrasound image from the new micro-ultrasound probe (Figure 1). Localization of the
testicular arteries was validated against the current gold standard, which is audio flow Doppler mapping
using a micro Doppler probe (Vascular Technology Inc, Nashua, NH).
Results: The new ultrasound probe was able to identify all arteries in the spermatic cord (testicular artery &
deferential artery). The probe also allowed visualization of small veins (1-5 mm diameter) in the spermatic
cord to aid in identification of posterior varicose veins. The location of the arteries was verified with the
audio Doppler probe. No arteries where missed by the micro-ultrasound probe based on the additional
Doppler scanning.
Conclusion: Accurate localization of the arteries in the spermatic cord vessel is critical to minimize
inadvertent injury during microsurgical varicocelectomy. The new micro-ultrasound probe appears to be
effective in micro-vessel localization in this preliminary study.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 70
ABSTRACTS
NEUROPROTECTIVE WRAP FOR THE SPERMATIC CORD AFTER
DENERVATION PROCEDURES
Ahmet Gudeloglu, Jamin Brahmbhatt, Karen Priola, Sijo Parekattil.
Winter Haven Hospital & University of Florida
Introduction: Previous studies have shown that microsurgical denervation of the spermatic cord is a
possible treatment option for chronic orchialgia with success rates in the 75-85% range. Recurrent or
persistent pain after such procedures is very disappointing for these patients. One cause for this phenomenon
could be neuroma formation or irritation of the ligated ends of the nerve fibers in the spermatic cord.
Neuroprotective wraps have been safely and successfully utilized by microsurgeons in peripheral nerve
repair procedures to minimize such neuroma or scar formation. This study evaluates the impact of a
neuroprotective wrap placed around the spermatic cord after the denervation procedure.
Methods: We reviewed a prospectively maintained database of six patients with bilateral chronic orchialgia
who underwent bilateral robotic assisted microsurgical denervation of the spermatic cord by a single
microsurgeon from March to July 2010. A neuroprotective wrap (bio-inert matrix derived from porcine gut:
Axoguard, Axogen Inc., Gainesville, FL) was placed on one side of each patient around the spermatic cord
after completion of the denervation procedure (side was randomly selected). The contra-lateral side (with no
wrap) was the control for each patient. Pain was assessed preoperatively and post-operatively at 1, 3, 6 and
12 months using an externally validated pain impact questionnaire (PIQ-6, QualityMetric Inc, Lincoln, RI).
Results: The median pain impact scores were less on both sides after surgery compared to pre-op (median
pre-op score = 77). Median PIQ-6 scores on the wrap side were: 52, 40, 50 and 59 at 1, 3, 6 and 12 months
post-op respectively. The median scores on the non-wrap side were: 59, 56, 60 and 68 respectively (Figure
1). The median pain scores on the side with the wrap were significantly less than the non-wrap side (a score
difference of 5 indicates a p value of <0.05).
Conclusion: This study, despite its small sample size, seems to indicate a possible benefit to using a
neuroprotective wrap around the spermatic cord after denervation procedures for chronic orchialgia. Further
evaluation and longer follow-up is needed.
Figure: Pre-op and post-op median PIQ scores in the both sides.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 85 of 97
ABSTRACTS
ABSTRACT 71
ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY IN PATIENTS WITHOUT
HILAR CLAMPING—A MULTI-INSTITUTIONAL STUDY
Bartosz F. Kaczmarek1, Sam B. Bhayani4, Michael D. Stifelman3, Jihad H. Kaouk2,
Mohamad E. Allaf5, Youssef Tanagho4, Shahab P. Hillyer2, Jeffrey K. Mullins5, Craig G. Rogers1
1
Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA;
Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA;
3
Department of Urology, NYU Langone Medical Center, New York, NY, USA;
4
Division of Urological Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO,
USA;
5
Department of Urology, Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD, USA
2
Introduction: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robotassisted partial nephrectomy (RPN). We evaluate the outcomes of RPN without hilar clamping using data
from a large multi-center series.
Methods: We performed a multi-institutional analysis of prospectively maintained databases of RPN
performed by high-volume surgeons across 5 academic institutions. Our series combined operative data of
886 RPN collected between 2007-2011. A total of 66 patients who underwent RPN without hilar clamping
were identified and retrospectively analyzed. Patient demographics, perioperative, functional, and early
oncological outcomes of RPN without hilar clamping were assessed.
Results: Mean patient age was 60 years (18-88). Mean Charlson Comorbidity Index was 3.5 (SD=1.99) and
mean ASA score was 2.5 (SD=0.68). Mean tumor size was 2.5 cm (range 0.7-11) and eight patients (12%)
had tumors over 4cm in size. Mean nephrometry score was 5.3 (range 4-10) with 30 tumors (45%) >50%
exophytic and 45 (68%) tumors in a polar location. Indications for an off-clamp approach included
eGFR≤60 in 13 patients (20%), solitary kidney in 4 patients (6%), and multiple or bilateral tumors in 2
patients (3%). Perioperative outcomes included a median blood loss of 150 ml (IQR 50-300), mean
operative time 157min (range 59-267), and hospital stay of 2 days (SD 1.8). There were no intraoperative
complications. There were 8 postoperative Clavien I-II complications (12%) but no Clavien III-V
complications. Preoperative mean eGFR was 81 (20-119). The mean postoperative change in eGFR was
0.4% and no patients required dialysis. Positive surgical margins occurred in two patients (3%). There were
no disease recurrences at a mean followup of 21 months.
Conclusion: Off-clamp RPN is safe and feasible in appropriately selected patients and with surgeon
experience. Off-clamp RPN may help optimize renal function by eliminating renal ischemia. This represents
the largest multi-institutional series in the literature regarding off-clamp RPN.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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ABSTRACT 72
ABSTRACTS
APPLICATIONS OF SPIDER IN UROLOGY
THE UNIVERSITY OF MIAMI EXPERIENCE
Arturo P. Castro Jr., Vladislav Gorbatiy, Nelson Salas, Raymond J. Leveillee
Division of Endourology, Department of Urology
Joint Bioengineering and Endourology Developmental Surgical Laboratories
University of Miami
Introduction: The use of the Single Port Instrument Delivery Extended Reach (SPIDER) surgical system
(Transenterix, Durham NC) in conjunction with Laparoendoscopic Single Site Surgery (LESS) is an emerging
alternative in the field of minimally invasive surgery. In the past few years institutions with centers of excellence for
laparoscopy and minimally invasive surgery have explored its use in Urology (1,2,3). Its intuitive design that affords
good triangulation and avoids instrument collision endemic in single port surgeries have been documented in recent
publications (3,4). We present our cumulative experience of its different applications in Urology.
Methods: We performed SPIDER-LESS surgery on 6 patients. The procedures were: 2 simple nephrectomies, 2
decortication of cysts, 1 Pyeloplasty and 1 radical nephrectomy. Both the first and second generation SPIDER along
with its long flexible instruments were used. Use of an accessory port for retraction was required in two cases. The
extirpative and reconstructive surgeries were performed by two experienced laparoscopists while a surgical resident
was given a major role in one of the SPIDER-LESS decortication of cysts.
Results: The radical nephrectomy and one simple nephrectomy were converted to hand-assisted laparoscopy. These
were done so because of dense adhesions and because of failure to progress. The need to use an extra 5 mm port was
encountered in 2 cases: in the pyeloplasty where we found the extra port necessary to facilitate suture insertion and in
1 of the cyst decortication where it was necessary to use a 3mm Karl Storz rigid dissector grasper to facilitate
retraction of the flaccid cyst wall. The comparable operative times between the resident and the experienced surgeon
performing SPIDER-LESS decortication of cysts points to the intuitive design of the device which facilitates ease of
use and rapid learning regardless of laparoscopic skill or experience. Figure 1 shows the second generation SPIDER
mounted on its docking station.
Conclusion: Our experience demonstrates the utility of the SPIDER in laparoendeoscopic single site urologic
surgery. SPIDER-LESS surgery is feasible in extirpative surgery of benign lesions and even in challenging
reconstructive procedures. Its use however, in cancer cases remains to be proven. Our experience points to the need to
strictly screen patients to undergo this challenging procedure. It is through sound patient selection that the success of
this minimally invasive surgery hinges on. The relative concurrence of surgical variables between novice and
experienced surgeon in the conduct of SPIDER-LESS decortication of cysts points to the operator-friendly nature of
this device. As for future directions: there is a need to conduct prospective studies to truly document the advantages of
this device compared to standard multi-port laparoscopy and also when compared to other single port access devices.
It is only through these further studies that we can conclusively say that SPIDER surgery is truly less.
Figure: Second generation SPIDER mounted on its dock
ABSTRACT 73
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 87 of 97
ABSTRACTS
DEVELOPMENT AND VALIDATION OF A RAPID CIRCUMCISION DEVICE TO
FACILITATE DISSEMINATION OF SAFE ADULT MALE CIRCUMCISION
AMONG U.S. VETERANS
Jim Hotaling, MD MS1, Laura S. Leddy, MD1, Natalya Lopushnyan MD1,
Michael R. Bailey PhD2, John N. Krieger, MD1
1
Department of Urology, University of Washington, Seattle, WA USA
2
Applied Physics Lab, University of Washington, Seattle, WA USA
Introduction: The purpose of this study is to evaluate a new device to simplify adult male circumcision
procedures. Male circumcision rates are lower in the VA population than in many other US populations.
Circumcision offers a number of health benefits including lower rates of urinary tract infection, several
sexually transmitted diseases and penile cancer. Medical circumcision is indicated for treatment of certain
penile malignancies and other urological conditions such as balanitis, phimosis and paraphimosis. Recently
circumcision has been proven in three large randomized controlled trials to reduce the rate of HIV
transmission by roughly 65%.
Methods: We have developed a circumcision device that can be used in a single procedure. Following IRB
approved protocols, we will pilot this proprietary device, formulated to US standards in eight consenting
VAPSHCS patients who have indications for circumcision. This device was developed in conjunction with
UW urologists following a landscape review of available devices. In contrast to other adult male
circumcision devices undergoing evaluation this device may allow a non-surgeon to perform adult male
circumcision under local anesthesia with the device being removed at the end of the procedure.
Results: Standardized evaluation forms will be deployed to validate the device for procedural
complications, pain and patient satisfaction.
Conclusion: Successful completion of this pilot project is required to support applications to other funding
agencies for comparative studies to increase acceptability and availability of male circumcision in VA
populations as well as scale up of circumcision efforts to reduce HIV transmission. Work supported by the
UW Institute of Translational Health Sciences.
Figure: Adult Circumcision Device
Incision
Glans
Foreskin
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 88 of 97
ABSTRACT 74
ABSTRACTS
FIBER OPTIC SUCTION AND PULLING OF URINARY STONE PHANTOMS
USING A HIGH PULSE RATE THULIUM FIBER LASER
Richard L. Blackmon1, Pierce B. Irby2, Nathaniel M. Fried1,3
1
Optical Science and Engineering Program, University of North Carolina at Charlotte, NC
2
Department of Urology, Carolinas Medical Center, Charlotte, NC
3
Department of Urology, Johns Hopkins Medical Institutions, Baltimore, MD
Introduction: Previous investigators have transiently observed attraction of urinary stones to the fiber optic tip
during Holmium:YAG laser lithotripsy procedures. This effect, if reproducible, could potentially be exploited to
suction and pull small stone fragments inside the urinary tract without insertion of a mechanical grasping tool, thus
saving the urologist time and space in the working channel of the flexible ureteroscope. Our laboratory is studying
the Thulium fiber laser (TFL) (λ=1908 nm) as a potential alternative lithotripter to that of the conventional
Holmium:YAG laser (λ=2120 nm). The TFL has a number of potential advantages over the Holmium laser including
a lower stone ablation threshold, an improved spatial beam profile for transmission of higher laser powers through
smaller optical fibers, and more flexible laser parameters (e.g. variable pulse duration, pulse rate, and duty cycle). In
this study, we take advantage of the TFL’s high pulse rate/low pulse energy operation mode to provide a rapid and
repetitive chain of vapor bubble explosion and implosion events to promote attraction of the stone to the fiber tip
while simultaneously minimizing undesirable retropulsion effects.
Methods: A Thulium fiber laser (TLR-110, IPG Photonics, Oxford, MA) with a wavelength of 1908 nm, pulse
energy of 35 mJ, and pulse duration of 500 µs was used with a 270-µm-core silica fiber. Spherical Plaster-of-Paris
(PoP) stone phantoms of ~4 mm diameter and ~40 mg mass (similar to human calcium oxalate monohydrate urinary
stones) were used for all studies. The TFL pulse rate was adjusted from 10-350 Hz. The fiber optic tip was applied in
non-contact mode in close proximity to the stone submerged in a saline bath. Stone drag speed was calculated by
recording distance moved per unit time with a camera and video. At least 5 samples were tested for each set of laser
parameters.
Results: The drag speed increased between 10-150 Hz, and then began to plateau and decrease at higher pulse rates
between 150-350 Hz, possibly due to the retropulsion force dominating the attractive force. Figure 1 summarizes the
results plotting the drag speed as a function of laser pulse repetition rate for 4-mm-diameter PoP stone phantoms.
Velocity (mm/s)
Conclusion: This preliminary study demonstrates that it is feasible in an idealized setting to use the fiber optic tip to
4.5
attract and pull urinary stone phantoms. Thulium
4.0
fiber laser operation at higher pulse rates (~150 Hz)
3.5
than typical Holmium lasers (~10 Hz) increases
3.0
stone drag speed. This technique may potentially be
2.5
used in the clinic to manipulate stone fragments in
2.0
the urinary tract. Future studies will explore the
1.5
effects of varying other parameters (e.g. pulse
1.0
energy, pulse duration, fiber diameter, and stone
0.5
size) on this phenomenon for both PoP and human
0.0
urinary stone samples.
0
50
100
150
200
250
300
350
400
Pulse Repetition Rate (Hz)
Figure: Drag speed as a function of laser pulse repetition rate for
4-mm-diameter Plaster-of-Paris stone phantoms. Thulium fiber
laser irradiation was performed through a 270-µm-core fiber
optic tip in near contact mode at 35 mJ, 500 µs, and 10-350 Hz.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 89 of 97
ABSTRACT 75
ABSTRACTS
ROBOTIC ASSISTED LEGO® CONSTRUCTION AS A MODEL FOR
ROBOTIC MICROSURGERY SKILLS TRAINING
Ahmet Gudeloglu, Jamin Brahmbhatt, Karen Priola, Sijo Parekattil.
Winter Haven Hospital & University of Florida
Introduction: The application of robotic assisted microsurgery has been expanding over the last few years. However,
there are limited structured training protocols for robotic microsurgical skill development. The existing microsurgical
training models (rodent and cadaver models) are also quite tedious and expensive. Our goal was to assess the use of
robotic assisted Lego® construction for robotic microsurgical skills training and compare it to our current standard.
Methods: 10 trainees (6 medical students and 4 urology residents) were enrolled in the study (all where robotic
surgery naïve). The trainees where randomized into two arms: 1) a test group and 2) a control group. The test group
performed 5 sessions: 1 robotic assisted microsurgical vasovasostomy on a biosynthetic vas deferens model
(anastomosis with 4 double armed 10-0 nylon sutures using microdot technique) – this was the pre-training test
procedure, 3 training sessions where the trainee built a 77 piece Empire State Building Lego® set to completion with
robotic assistance using all 3 instrument arms, and then a final test session vasovasostomy on the vas deferens model.
The control group also performed 5 sessions: they performed 5 repetitive robotic assisted vasovasostomy procedures
on the vas deferens model – an initial pre-training test anastomosis, 3 training vasovasostomy sessions and then a final
test anastomosis. The pre-training vasovasostomy was then compared to the post-training vasovasostomy for all
trainees: duration, number of sutures used, suture breaks, needle bends, distance between suture placement and
microdot where compared (a scoring methodology was developed).
Results: The mean pre-training vasovasostomy measures did not differ significantly between the Lego® and control
arms. Mean duration of the anastomosis before and after training was 64.5min and 28.3min (Lego® test group);
88.5min and 34min (control group), respectively. Mean number of sutures used, needle bends and suture breaks
significantly decreased after training in both arms. The mean quantitative scores of the first test anastomosis were 2
(Lego® group) and 0.5 (control group). These scores improved after training to 10.25 (Lego® group) and 5.5 (control
group). The score improvement after training did not differ significantly between the Lego group and the control
group (p = 0.25).
Conclusion: Although this is a small sample size, this preliminary study appears to indicate that robotic assisted
Lego® construction may provide a comparable training model to develop robotic assisted microsurgical skills.
Figure: Robotic Assisted Lego® Construction Training
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 90 of 97
ABSTRACTS
ABSTRACT 76
TOP 10 ABSTRACT
RAPID DETERMINATION OF SYSTEMIC LEVELS OF OXALATE USING A
NEWLY DEVELOPED OXOMETER
Benjamin K. Canales MD, MPH1, Nigel Richards PhD2, Ammon Peck PhD1
Department of Urology1, Chemistry2, and Pathology, Immunology and Laboratory Medicine3
University of Florida, Gainesville, FL
Introduction: Increased levels of oxalate are associated with multiple disease states, including renal
disease, urolithiasis, malabsorption, hepatic dysfunction, and even some neurological conditions. Because
no standardized test exists for measuring blood oxalate, patients with these conditions monitor their
systemic oxalate levels in the form of 24 hour urine collections. We sought to develop a user-friendly, pointof-care device that would permit rapid determination of blood or urine oxalate at home.
Methods: Based on technology similar to the glucometer, we designed and impregnated blood glucose test
strips with the enzyme oxalate oxidase (from Hordeum vulgare). An enzyme electrode was created to
measure the production of hydrogen perioxide from the reaction, and human blood, spiked with various
amounts of sodium-oxalate, was placed onto the strip.
Results:
Oxalate levels in blood specimens exhibited a linear correlation over significantly large
concentration ranges (Figure). Spotting the test strips with increasing levels of oxalate-degrading enzyme
(defined as IU of activity) resulted in incrementally shorter measurement times.
Conclusion: A first generation oxometer that rapidly determines oxalate levels in biological fluid has been
developed for use as a point-of-care device for both physicians and patients. Its design, similar to latest
generation glucometers, permits one to closely follow temporal levels of systemic oxalate as a means to
initiate remediation in a more rapid and practical manner than a 24 hour urine specimen. Further
development of this system and clinical testing are now planned.
Oxalate Readout
(mg/dL)
Oxalate levels in blood serum specimens using the LifeScan glucometer
(Values minus glucose levels)
Nonadjusted for
volume
Adjusted
for
volume
Δ= 63 u/0.702 mM
Oxalate solution added to blood serum sample
** Oxalate oxidase enzyme (5 μL / reaction) added to 7.5 μL of stated oxalate
solution (1 min), mixed with 12.5 μL blood specimen, one drop then placed
on meter strip.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 91 of 97
ABSTRACT 77
ABSTRACTS
PROSPECTIVE EVALUATION OF REFURBISHED FLEXIBLE URETEROSCOPE
DURABILITY SEEN IN A LARGE PUBLIC TERTIARY CARE CENTER WITH
MULTIPLE SURGEONS
Robert I. Carey, Christopher J. Martin, Marco Ferrara, Jacob Knego
Florida State University College of Medicine, Sarasota Campus, Sarasota, FL
Purpose: Poor durability of flexible ureteroscopes results in significant maintenance and repair costs. The
frequency, cause, and cost of ureteroscope damage in our facility was assessed prospectively.
Methods and Materials: Ureteroscope usage and repair was prospectively recorded over a 365 day period
at an 865 bed public tertiary care center. Cases were performed by 14 different board certified urologists
using refurbished DUR-8 and DUR-8 Elite ureteroscopes. Retrograde cases involving calculi, urothelial
carcinoma, stricture, and diagnostic evaluations were included. Ureteroscope repairs were performed by a
single out-sourced repair vendor, not the original manufacturer.
Results: A total of 501 ureteroscopic cases involving 550 ureteroscope uses were performed over a 365 day
period. Semi-rigid ureteroscopes were used for 281 (56.1%) cases, refurbished flexible ureteroscopes for
220 (43.9%). The reason for the ureteroscopy was calculi in 386 (77.0%) cases, urothelial carcinoma in 32
(6.4%), stricture in 36 (7.2%), and diagnostic in 47 (9.4%). No repairs were needed during this time period
for semi-rigid scopes. Ureteral access sheaths were employed in 82 (37.7%) of the flexible ureteroscope
cases. A total of 32 instances of catastrophic flexible ureteroscope breakage requiring send out for full
repair was documented, thus indicating an average of 6.9 usages of a newly refurbished ureteroscope were
obtained prior to incurring yet further catastrophic damage and requiring repair.
Conclusions: Refurbished flexible ureteroscopes that have undergone comprehensive repair are extremely
fragile in the setting of multiple surgeon users in a large public tertiary care center that uses central
processing for sterilization and storage. The high frequency of damage and repair seen in this study results
in significant administrative inconvenience and cost. The durability of flexible ureteroscopes and cost of
repair must be considered as well as the initial purchase cost.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 92 of 97
SOCIETY OFFICERS:
Presidents
Stephen Nakada
Sean Hedican
Vice-Presidents
Evangelos Liatsikos
Frank Keeley
Secretary
Jack Vitenson
Treasurer
John Denstedt
Councilor
Louis Kavoussi
Executive Director
Dan Stoianovici
ADVISORY BOARD
Jeffrey Cadeddu
Ralph Clayman
Jean de la Rosette
John Denstedt
Misop Han
Thomas Lawson
Pierre Mozer
Stephen Nakada
Jens Rassweiler
Koon Ho Rha
William Roberts
Arthur Smith
Li-Ming Su
Gerald Timm
Hessel Wijkstra
Kevin Zorn
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 93 of 97
AWARDS:
Best Paper Award:
PRECLINICAL SAFETY AND EFFICACY OF ULTRASONIC PROPULSION OF KIDNEY STONES
Mathew Sorensen1, Jonathan Harper1, Ryan Hsi1, Bryan Cunitz2, Julianna Simon2, Yak-Nam Wang2, Marla Paun2,
Frank Starr2, Wei Lu2, Andrew Evan3, Michael Bailey2
1
Department of Urology, University of Washington School of Medicine
2
Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington
3
Department of Anatomy and Cell Biology, Indiana University School of Medicine
Outstanding Paper Award:
ROBOT-ASSISTED DIRECT MRI-TARGETED TRANSRECTAL PROSTATE BIOPSY
Chunwoo Kim1, Govindarajan Srimathveeravalli2, Peter Sebrechts1, Doru Petrisor1, Paula Ezell2,
Jonathan Coleman2, Stephen B. Solomon2, Hedvig Hricak2, Dan Stoianovici1
1
Urology Robotics Lab, Johns Hopkins University, Baltimore, MD
2
Radiology Department, Memorial Sloan Kettering Cancer Center, New York, NY
Top 10 Abstracts:
3. PRELIMINARY TESTING OF A TRANSURETHRAL DEXTEROUS ROBOTIC SYSTEM FOR
BLADDER RESECTION, Ryan B. Pickens, Andrea Bajo, Nabil Simaan, Duke Herrell; Vanderbilt University
Departments of Mechanical Engineering and Biomedical Engineering; Vanderbilt University Medical Center,
Department of Urologic Surgery; Vanderbilt Initiative in Surgery and Engineering (VISE)
4. PHANTOM STUDY OF A NOVEL STEREOTACTIC PROSTATE BIOPSY SYSTEM INTEGRATING
PREINTERVENTIONAL MRI AND LIVE US FUSION, Timur H. Kuru, Matthias Roethke, Dogu Teber,
Boris A. Hadaschik, Markus Hohenfellner; Department of Urology, Heidelberg University Hospital, Heidelberg,
Germany; Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
5. SURGTRAK: EVOLUTION OF A MULTI-STREAM SURGICAL PERFORMANCE DATA CAPTURE
SYSTEM FOR THE DA VINCI SURGICAL ROBOT, Lee W White, Timothy M Kowalewski, Blake
Hannaford, Thomas S Lendvay; BioEngineering Department, University of Washington; Electrical Engineering
Department, University of Washington; Department of Urology, University of Washington.
6. QUALITY MEASUREMENT OF SYSTEMATIC TRANSRECTAL PROSTATE BIOPSY: AN INVITRO STUDY, Doyoung Chang, Chunwoo Kim, Doru Petrisor, Bruce Trock, Alan W. Partin, Ronald
Rodriguez, H. Ballentine Carter, Mohamad Allaf, Misop Han, Dan Stoianovici; Department of Urology, Johns
Hopkins University.
7. 3D-HOLOSCOPIC IMAGING: A NEW DIMENSION TO ENHANCE IMAGING IN MINIMALLY
INVASIVE THERAPY IN UROLOGICAL ONCOLOGY, Makanjuola JK, Aggoun A, Swash M, Grange P,
Challacombe BJ, Dasgupta P; Department of Urology, Guys and St Thomas Hospital, London, UK; Visual
Information Engineering (3D VIE) Research Group, School of Engineering and Design, Brunel University, UK;
Department of Urology, Kings College Hospital, London, UK; MRC Centre for Transplantation, NIHR
Biomedical Research Centre, King's Health Partners Guys Hospital, London, UK.
8. RAPID DETERMINATION OF SYSTEMIC LEVELS OF OXALATE USING A NEWLY DEVELOPED
OXOMETER, Benjamin K. Canales, Nigel Richards, Ammon Peck; Department of Urology, Chemistry, and
Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL.
9. DESIGN OF AN AUTOMATED CYSTOSCOPE FOR BLADDER CANCER SURVEILLANCE, Xianming
Ye, W. Jong Yoon; Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar.
10. LIVE ROBOTIC SURGERY: ARE OUTCOMES COMPROMISED? Jeffrey K. Mullins, Michael S.
Borofsky, Mohamad E. Allaf, Sam Bhayani, Jihad H. Kaouk, Craig C. Rogers, Shahab P. Hillyer, Bartosz F.
Kaczmarek, Youssef S. Tanagho, and Michael D. Stifelman; Department of Urology, New York University,
Langone Medical Center, New York, NY; Brady Urological Institute, Johns Hopkins Medical Institutions,
Baltimore, MD; Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, MO; The
Glickman Urological Institute, Cleveland Clinic, Cleveland, OH; Vattikuti Urology Institute, Henry Ford
Hospital, Detroit, MI.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 94 of 97
AWARDS:
Best Reviewer Awards:
2007
2008
2009
2010
2011
☼
2012
☼
Riccardo
Autorino
Thorsten
Bach
Mahesh
Desai
Mohamed
Elkoushy
Arvind
Ganpule
☼
Petrisor
Geavlete
☼
Bodo
Knudsen
Thomas
Lawson
Kamol
Panumatrassamee
Sutchin
Patel
David
Albala
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Ernesto III
Arada
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Vincent
Bird
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Jean
de la Rosette
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Brian
Eisner
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Michael
Gong
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Hrishikesh
Joshi
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Wareef
Kabbani
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Avinash
Kambadakone
Kazumi
Kamoi
Watid
Karnjanawanichkul
Salvatore
Micali
Koon Ho
Rha
Cristian
Surcel
Kazuo
Suzuki
Hessel
Wijkstra
Daniel
Yachia
Kevin
Zorn
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27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
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Page 95 of 97
REVIEW COMMITTEE:
The paper review committee has been assembled by e-mail solicitation. Eighty-five reviewers from around
the world participated. We gratefully acknowledge their contribution to the success of the meeting and thank
them for taking the time to help the society.
Ronney Abaza
V. Ambert
Ernesto III Arada
Motoo Araki
Mohan Gundeti
Mantu Gupta
Wahib Isac
Matthew Ishahak
Pierre Mozer
Zhamshid Okhunov
Ephrem Olweny
Cervando Ortiz-Vanderdys
Riccardo Autorino
Timothy Averch
Thorsten Bach
Ketan Badani
Viorel Bucuras
Benjamin Canales
Arturo Jr. Castro
Doh Cha
Ben Challacombe
Christian Chaussy
Haixin Chen
Grégoire Coffin
Rogers Craig
Sarah Darnell
Marco De Sio
Mahesh Desai
Mohamed Elkoushy
Andrew Evan
Arvind Ganpule
Petrisor Geavlete
Bogdan Florin Geavlete
Vladislav Gorbatiy
Michael Gorin
Ahmet Gudeloglu
Bartosz Kaczmarek
Avinash Kambadakone
Watid Karnjanawanichkul
Mathias Keil
Chunwoo Kim
Bodo Knudsen
Eugene Kramolowsky
John Krieger
Timur H Kuru
Pilar Laguna
Thomas Lawson
Humberto Laydner
Hak Lee
Thomas Lendvay
Adam Levinson
Enrique Ian S. Lorenzo
Michael Macalalag
Jonathan K. Makanjuola
Salvatore Micali
Cristian Mirvald
Massimo Mischi
George Mitroi
Rezia Molfino
Manoj Monga
Kim Ramil Montaniel
Kamol Panumatrassamee
Sutchin Patel
Alexandru Patriciu
Thomas Polascik
Wayne Poll
Syed Rahmanuddin
Koon Ho Rha
Cassio Riccetto
William Roberts
Georgios Sakas
Luiz Santos
Yunhe Shen
Stephen Solomon
Mathew Sorensen
Petros Sountoulides
Govindarajan Srimathveeravalli
Dan Stoianovici
Cristian Surcel
Alex Vacharat
Lee White
Hessel Wijkstra
Daniel Yachia
Xianming Ye
Yingchun Zhang
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 96 of 97
THANKS:
George Nagamatsu, M.D.
Society Founder
Special thanks to Dr. Thomas Lawson for his help formatting this program.
We thank Michelle Paoli and Debra Caridi for organizing the Annual Meeting.
27th EUS Annual Meeting, May 19, 2012, Atlanta, GA
Page 97 of 97
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