A Robotic System for Solo Surgery in Flexible Ureterorenoscopy

Urolithiasis is a common disease with increasing prevalence across all ages. A common treatment option for smaller kidney stones is flexible ureterorenoscopy (fURS), where a flexible ureteroscope (FU) is used for stone removal and to inspect the renal collecting system. The handling of the flexible ureteroscope and end effectors (EEs), however, is challenging and requires two surgeons. In this article, we introduce a modular robotic system for endoscope manipulation, which enables solo surgery (SSU) and is adaptable to various hand-held FUs. Both the developed hardware components and the proposed workflow and its representation in software are described. We then present and discuss the results of an initial user study. Finally, we describe subsequent developmental steps towards more extensive testing by clinical staff

Cerebral oxygenation in 45-degree trendelenburg position for robot-assisted radical prostatectomy: a single-center, open, controlled pilot study

Background!#!Within the last decade, robotically-assisted laparoscopic prostatectomy (RALP) has become the standard for treating localized prostate cancer, causing a revival of the 45° Trendelenburg position. In this pilot study we investigated effects of Trendelenburg position on hemodynamics and cerebral oxygenation in patients undergoing RALP.!##!Methods!#!We enrolled 58 patients undergoing RALP and 22 patients undergoing robot-assisted partial nephrectomy (RAPN) (control group) in our study. Demographic patient data and intraoperative parameters including cerebral oxygenation and cerebral hemodynamics were recorded for all patients. Cerebral function was also assessed pre- and postoperatively via the Mini Mental Status (MMS) exam. Changes in parameters during surgery were modelled by a mixed effects model; changes in the MMS result were evaluated using the Wilcoxon signed rank test.!##!Results!#!Preoperative assessment of patient characteristics, standard blood values and vital parameters revealed no difference between the two groups.!##!Conclusions!#!Applying a 45° Trendelenburg position causes no difference in postoperative brain function, and does not alter cerebral oxygenation during a surgical procedure lasting up to 5 h. Further studies in larger patient cohorts will have to confirm these findings.!##!Trial registration!#!German Clinical Trial Registry; DRKS00005094; Registered 12th December 2013-Retrospectively registered; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005094

Tyrosine Kinase Inhibitors in the Treatment of Metastasised Renal Cell Carcinoma—Future or the Past?

Background: To review and discuss the literature on applying tyrosine kinase inhibitors (TKIs) in the treatment of metastasised renal cell carcinoma (mRCC). Materials and Methods: Medline, PubMed, the Cochrane database, and Embase were screened for randomised controlled trials, clinical trials, and reviews on treating renal cell carcinoma, and the role of TKI. Each substance’s results were summarised descriptively. Results: While TKI monotherapy is not currently recommended as a first-line treatment for metastasized renal cell carcinoma, TKIs are regularly applied to treat treatment-naïve patients in combination with immunotherapy. TKIs depict the first-choice alternative therapy if immunotherapy is not tolerated or inapplicable. Currently, seven different TKIs are available to treat mRCC. Conclusions: The importance of TKIs in a monotherapeutic approach has declined in the past few years. The current trend toward combination therapy for mRCC, however, includes TKIs as one significant component of treatment regimens. We found that to remain applicable to ongoing studies, both when including new substances and when testing novel combinations of established drugs. TKIs are of major importance for the treatment of renal cancer now, as well as for the foreseeable future

A robotic system for solo surgery in flexible ureteroscopy: development and evaluation with clinical users

Purpose The robotic system CoFlex for kidney stone removal via flexible ureteroscopy (fURS) by a single surgeon (solo surgery, abbreviated SSU) is introduced. It combines a versatile robotic arm and a commercially available ureteroscope to enable gravity compensation and safety functions like virtual walls. The haptic feedback from the operation site is comparable to manual fURS, as the surgeon actuates all ureteroscope DoF manually. Methods The system hardware and software as well as the design of an exploratory user study on the simulator model with non-medical participants and urology surgeons are described. For each user study task both objective measurements (e.g., completion time) and subjective user ratings of workload (using the NASA-TLX) and usability (using the System Usability Scale SUS) were obtained. Results CoFlex enabled SSU in fURS. The implemented setup procedure resulted in an average added setup time of 341.7 ± 71.6 s, a NASA-TLX value of 25.2 ± 13.3 and a SUS value of 82.9 ± 14.4. The ratio of inspected kidney calyces remained similar for robotic (93.68 %) and manual endoscope guidance (94.74 %), but the NASA-TLX values were higher (58.1 ± 16.0 vs. 48.9 ± 20.1) and the SUS values lower (51.5 ± 19.9 vs. 63.6 ± 15.3) in the robotic scenario. SSU in the fURS procedure increased the overall operation time from 1173.5 ± 355.7 s to 2131.0 ± 338.0 s, but reduced the number of required surgeons from two to one. Conclusions The evaluation of CoFlex in a user study covering a complete fURS intervention confirmed the technical feasibility of the concept and its potential to reduce surgeon working time. Future development steps will enhance the system ergonomics, minimize the users' physical load while interacting with the robot and exploit the logged data from the user study to optimize the current fURS workflow