Technology in Urology PDF

Technology in urology UĞUR BOYLU, M.D. Professor of Urology Istinye University, Faculty of Medicine, Department of Urology Liv Hospital Ulus, Istanbul Technology used in urology ESWL (extracorporeal shock wave lithotripsy) Ureterosc...

Technology in urology UĞUR BOYLU, M.D. Professor of Urology Istinye University, Faculty of Medicine, Department of Urology Liv Hospital Ulus, Istanbul Technology used in urology ESWL (extracorporeal shock wave lithotripsy) Ureteroscopy PCNL (percutaneous nephrolithotomy) Open or laparoscopic surgery – Ureterolithotomy – Anatrophic nephrolithtomy Lasers Laparoscopy Robotic surgery ESWL extracorporeal shock wave lithotripsy “Bath tub” treatment Shock waves to break stones Non-invasive  Electrohydroli c (Spark gap) Energy Sources and Configuratio ns Electromagneti c Piezoelectric Mechanism of Action – Electrohydraulic Power source at F1 Generated in water medium Contained in a ellipsoid shield Waves (energy) concentrated at F2 Contraindications to ESWL Pregnancy Coagulopathy UTI Intrarenal vascular calcifications Renal artery aneurysm or AAA Complications of ESWL Retroperitoneal Hematoma – >25% incidence on imaging – 2cm) Stones likely to be struvite Difficult anatomy (calyceal diverticulum, etc) ESWL failures Extracorporeal shock wave lithotripsy PCNL Percutaneous nephrolithotomy http://www.actasurologicas.info Lithotripsy for PCNL Ultrasonic Lithotriptor Pneumatic Lithotriptor Laser (Ho:YAG)  Ultrasonic Lithotriptor Electric current stimulates piezoelectric crystal Crystals expand and contract Creates vibrations at ~25,000 Hz Transmitted to tip of probe “Drills” the stone Strictly mechanical energy No heat, cavitation or shock waves Suctions fragments through the center of the wand Pneumatic Lithotripsy Like a jackhammer Depression of foot pedal forces compressed air to handpiece Metal projectile is propelled Repetitive mechanical pounding Mechanical energy transferred to tip Fragmentation by compression forces Success Rates PCNL Renal stones (even staghorns) – 80-90% Proximal ureteral stones – 85% Stone clearance rates are affected by renal anatomy and adequacy of access Complications of PCNL Bleeding – Kidney is very vascular – each one gets 10% of cardiac output Complications of PCNL Sepsis – highest risk is with infection stones (struvite) Pneumo/Hydrothorax – Highest risk with upper pole puncture Up to 10% of upper pole punctures in some studies Colon/Spleen injury – Very rare  Open surgery Long incision Prostate accessed directly Blood loss: 900 ml (about 2 units) Hospital stay: 3.5 days Catheterization: 15 days Data on blood loss, LOS and catheterization from Menon M. Robotic Radical Retropubic Prostatectomy. BJU Int. 91(3): 175. February 2003.  Conventional laparoscopy Small incisions Better visualization Less blood loss: 380 ml (≤ one unit) Shorter hospital stay: 1.3 days Reduced risk of infection Shorter catheterization: 7-10 days 5 small incisions 1-1.5 cm (less than half an inch) Data on blood loss, LOS and catheterization from Menon M. Robotic Radical Retropubic Prostatectomy. BJU Int. 91(3): 175. February 2003. Conventional laparoscopy drawbacks Instruments controlled at a distance - fulcrum effect 2–D flat image video Rigid instruments – with decreased range of motion Decreases the surgeon’s precision and dexterity Surgeon fatigue Is more difficult with complex operations like radical prostatectomy How can we overcome these drawbacks? da Vinci® Surgical System State-of-the-art robotic technology 3-D Visualization Intuitive Movement Improved Dexterity Vision System Surgeon immersed in 3D image of the surgical field  The surgeon directs the instruments Surgeon directs the instrument movements using Console controls  Wrist and finger movement Conventional laparoscopic instruments are rigid with no wrists EndoWrist® Instrument tips move like a human wrist Allows increased dexterity and precision Small instruments, small incisions EndoWrist® Instruments fit through dime-sized incisions A wide range of instruments are available  da Vinci Prostatectomy access Open Surgical Incision da Vinci® Prostatectomy Incision Typical Prostatectomy incisions da Vinci® Robotics HIFU  WHAT IS HIFU? High Intensity Focused Ultrasound: Sound waves are generated by an ultrasound transducer These low power waves are focused into a small area, generating very  HIFU Energy Delivery High Intensity Focused Ultrasound: Low Intensity at Translates to Very High Transducer Face Site Intensity at the (20-40 Watts/cm2) Focal Point (1600 - 2000 Watts/cm2) HIFU Kills Tissue § Thermal (80-100 oC) § Cavitation § Mechanical (Shearing forces) HIFU As opposed to radiation, this ultrasound energy is non- ionizing This means that any tissue in the unfocused path of HIFU is NOT injured or damaged in any way Procedure Overview: This is a very minimally invasive procedure It utilizes a transrectal approach for imaging and treating There are no incisions or stab wounds Procedure takes 2-4 hrs Spinal/Epidural Anesthesia Sonablate 500 Ablatherm Sonablate Therapy Mode HIFU computer control allows very precise tissue targeting, allowing us to fine tune therapy Prostate Edge (NVB) External Sphincter Subtotal Ablation - Indiana University Medical Center Canine Studies on Prostate Sub-Total Ablation Protocol - No Damage to Rectal Wall or Prostate Capsule