19 research outputs found
Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy
Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better
understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications.
We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing
difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate.
The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous
complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of
the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is
identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along
with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and
safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next
performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal
vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper
traction to initiate Denovillier’s dissection and prostate pedicle/neurovascular bundle control
Recommended from our members
476: Medical Malpractice Trends in Contemporary Urological Laparoscopy: Results of an Internet Survey
1760: Adjuvant Bacillus Calmette-Guérin Therapy after Endoscopic Treatment of Upper Tract Transitional Cell Carcinoma: First Proof of Efficacy
Recommended from our members
Comparison of the mechanical, flow, and optical properties of contemporary flexible ureteroscopes
New designs have improved the ability of flexible ureteroscopes to assess the upper urinary tract. However, limitations of tip deflection may interfere with diagnosis and treatment of lower pole renal pathologic features and smaller working channels may impair irrigant flow. Our purpose was to compare the new flexible ureteroscopes with prior models to determine whether engineering advances have overcome these problems.
Two newly released flexible ureteroscopes, the ACMI DUR-8 Elite and the Storz 11278AU, were compared with four other ureteroscopes, the ACMI DUR-8, Storz 11274AAU, Olympus URF-P3, and Wolf 9F. Active tip deflection, irrigation flow rates, and intraluminal pressures with and without various endoscopic tools were assessed. The specifications, purchase prices, and repair costs were obtained from the individual manufacturers. Also, the field of view and screen image size of each scope were compared.
The ACMI DUR-8 Elite and Storz 11278AU had improved tip deflection of 79° and 144°, respectively, from previous ureteroscopes. Although the tip deflections of all ureteroscopes were compromised by the insertion of endoscopic tools, new ureteroscopes were less affected. With a 3F basket within the working channel, the ACMI DUR-8 Elite and the Storz 11278AU had a loss of downward deflection of only 0.7% and 2.8% compared with a loss of 9.6% and 5.0% for their older models, respectively. However, the flow rate of these new instruments was decreased.
The new flexible ureteroscopes have significantly better active tip deflection than previous models, both with and without endoscopic instrumentation inserted. However, improved flexibility comes at the expense of a decreased flow rate
Recommended from our members
Residual air persists in the renal collecting system following percutaneous nephrolithotomy
To determine the presence or absence of air in the renal collecting system 48 hours following percutaneous nephrolithotomy (PCNL).
The study was based on a review of the records of the last 100 consecutive patients undergoing PCNL for stone extraction. Two urologists and a uroradiologist reviewed post-PCNL nephrostogram films and determined the presence or absence of air in the urinary tract.
Nephrostography was routinely performed 48 hours after PCNL, and all films of the 100 patients were reviewed. Gas was detected in 98 (98%) of the 100 cases that appeared as gas pyelograms outlining the renal calyces. Of the 98 cases, 33 (34%) demonstrated gas in the upper calyx, 10 (10%) in the middle calyx, 12 (13%) in the lower calyx, and 43 (44%) in more than one calyx. Gas was not detected in the renal parenchyma or perirenal areas.
Gas is present within the renal collecting system 48 hours after a percutaneous procedure. Prospective studies should be performed to document the amount of time needed for complete resolution of gas from the collecting system