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- Transvesical route for NOTES urological applications: advances & controversiesPublication . Lima, E; Rolanda, C; Correia-Pinto, JNatural Orifice Transluminal Endoscopic Surgery (NOTES) has emerged recently in the experimental surgical field, innovating for the passage of luminal barrier, the absence of scars and reduction of post-operative pain. Among the various ports of access (transvaginal, transgastric, transvesical and transcolonic), this paper is an update on advances & controversies of transvesical port for NOTES Urological applications.
- All you always wanted to know about scarless surgery and never dare to askPublication . Autorino, R; Martínez-Salamanca, JI; Lima, E
- Three-dimensional vs standard laparoscopy: comparative assessment using a validated program for laparoscopic urologic skillsPublication . Cicione, A; Autorino, R; Breda, A; De Sio, M; Damiano, R; Fusco, F; Greco, F; Carvalho-Dias, E; Mota, P; Nogueira, C; Pinho, P; Mirone, V; Correia-Pinto, J; Rassweiler, J; Lima, EOBJECTIVE: To compare the last generation of 3-dimensional imaging (3D) vs standard 2-dimensional imaging (2D) laparoscopy. MATERIALS AND METHODS: A prospective observational study was conducted during the 4th Minimally Invasive Urological Surgical Week Course held in Braga (Portugal) in April 2013. The course participants and faculty were asked to perform standardized tasks in the dry laboratory setting and randomly assigned into 2 study groups; one starting with 3D, the other with 2D laparoscopy. The 5 tasks of the European Training in Basic Laparoscopic Urological Skills were performed. Time to complete each task and errors made were recorded and analyzed. An end-of-study questionnaire was filled by the participants. RESULTS: Ten laparoscopic experts and 23 laparoscopy-naïve residents were included. Overall, a significantly better performance was obtained using 3D in terms of time (1115 seconds, interquartile range [IQR] 596-1469 vs 1299 seconds, IQR 620-1723; P = .027) and number of errors (2, IQR 1-3 vs 3, IQR 2-5.5; P = .001). However, the experts were faster only in the "peg transfer" task when using the 3D, whereas naïves improved their performance in 3 of the 5 tasks. A linear correlation between level of experience and performance was found. Three-dimensional imaging was perceived as "easier" by a third of the laparoscopy-naïve participants (P = .027). CONCLUSION: Three-dimensional imaging seems to facilitate surgical performance of urologic surgeons without laparoscopic background in the dry laboratory setting. The advantage provided by 3D for those with previous laparoscopic experience remains to be demonstrated. Further studies are needed to determine the actual advantage of 3D over standard 2D laparoscopy in the clinical setting.
- Endothelial function in patients with metabolic syndrome and erectile dysfunction: a question of angiopoietin imbalance?Publication . Tomada, N; Tomada, I; Botelho, F; Pacheco-Figueiredo, L; Lopes, T; Negrão, R; Pestana, M; Cruz, FErectile dysfunction (ED) is a highly prevalent disease whose aetiology is mostly vasculogenic. It is nowadays considered a marker of future cardiovascular events reflecting the underlying endothelial dysfunction, the common link with the metabolic syndrome (MetS). The recent association between MetS, endothelial dysfunction and peripheral artery disease, but not with coronary artery disease (CAD), suggests that the pathophysiologies of CAD and peripheral artery disease may be distinct. Moreover, several recent studies support an emerging role for an imbalance of angiogenic growth factor levels like Angiopoietin 1 and 2 in cardiovascular disease, considering its intimate association with chronic low-grade inflammation. We aim to find a correlation between Angiopoietins levels and systemic and local endothelial function in MetS and ED patients. Forty-five MetS patients with ED were enrolled. ED severity was assessed by International Index of Erectile Function questionnaire (IIEF5) and penile duplex Doppler ultrasound (PDDU). Endothelial function was assessed by Peripheral arterial tonometry (PAT), and serum asymmetric dimethylarginine (ADMA), Ang1 and Ang2 levels. Obesity and hypertension were the most frequent MetS parameters (91.1 and 88.9% respectively). Severe ED was present in 35.6% of patients. Penile haemodynamic was impaired in 77.5%. Endothelial dysfunction (PAT criteria) was present in 40.9% of patients. Ang2 levels were significantly higher in men with abdominal obesity. We observed an inverse correlation between Ang1 and peak systolic velocity, and in patients with penile arterial dysfunction, Ang1 levels were significantly higher and Ang2/Ang1 ratio significantly lower, than patients with normal arterial function. Neither ADMA nor PAT parameters were correlated with ED severity evaluated by IIEF5 or PDDU exam. In conclusion, there is an imbalance of angiopoietins in MetS and ED patients. The absence of correlation with PAT or ADMA levels suggests that angiopoietins may be early markers of endothelial dysfunction in this population of higher cardiovascular risk.
- Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approachPublication . Rolanda, C; Lima, E; Pêgo, JM; Henriques-Coelho, T; Silva, D; Moreira, I; Macedo, G; Carvalho, JL; Correia-Pinto, JBACKGROUND: An isolated transgastric port has some limitations in performing transluminal endoscopic cholecystectomy. However, transvesical access to the peritoneal cavity has recently been reported to be feasible and safe. OBJECTIVE: To assess the feasibility and the technical benefits of transgastric and transvesical combined approach to overcome the limitations of isolated transgastric ports. DESIGN: We created a transgastric and transvesical combined approach to perform cholecystectomy in 7 consecutive anesthetized female pigs. The transgastric access was achieved after perforation and dilation of the gastric wall with a needle knife and with a balloon, respectively. Under cystoscopic control, an ureteral catheter, a guidewire, and a dilator of the ureteral sheath were used to place a transvesical 5-mm overtube into the peritoneal cavity. By using a gastroscope positioned transgastrically and a ureteroscope positioned transvesically, we carried out cholecystectomy in all animals. RESULTS: Establishment of transvesical and transgastric accesses took place without complications. Under a carbon dioxide pneumoperitoneum controlled by the transvesical port, gallbladder identification, cystic duct, and artery exposure were easily achieved in all cases. Transvesical gallbladder grasping and manipulation proved to be particularly valuable to enhance gastroscope-guided dissection. With the exclusion of 2 cases where mild liver-surface hemorrhage and bile leak secondary to the sliding of cystic clips occurred, all remaining cholecystectomies were carried out without incidents. LIMITATIONS: Once closure of the gastric hole proved to be unreliable when using endoclips, the animals were euthanized; necropsy was performed immediately after the surgical procedure. CONCLUSIONS: A transgastric and transvesical combined approach is feasible, and it was particularly useful to perform a cholecystectomy through exclusive natural orifices.
- Early experience in laparoscopic radical prostatectomy using the laparoscopic device for umbilical access SILS PortPublication . Bachiller Burgos, J; Alonso Flores, J; Sánchez De La Vega, J; Beltrán Aguilar, V; Salazar Otero, S; Brás Silva, CSince 2007, various urological procedures have been performed with laparoendoscopic single-site surgery (LESS surgery), including nephrectomy, pyeloplasty, simple prostatectomy and, with the refinement of laparoscopic instrumentation, radical prostatectomy. This paper reports our initial experience in radical prostatectomy using the SILS Port from Covidiem and two lateral 5-mm trocars for triangulation. The SILS Port allows for accurate, simple insertion through a Hadson incision. The flexible port accommodates three 5-mm cannulas or two 5-mm cannulas and a 12-mm port for easier instrument exchange through a single incision. This approach decreases morbidity from bleeding, hernia and/or internal organ damage and improves cosmetic. One-port single-incision laparoscopy is part of the natural development of minimally invasive surgery. Future research is required to assess the intraoperative and postoperative benefits of LESS surgery as compared to standard laparoscopy.
- Ceacum-ilio-cutaneous fistula. A rare complication of urinary tuberculosisPublication . Ribeiro, JC; Rolanda, C; Santos, A
- Hospital Resource Utilization and Treatment Cost of Skeletal-Related Events in Patients with Metastatic Breast or Prostate Cancer: Estimation for the Portuguese National Health SystemPublication . Félix, J; Andreozzi, V; Soares, M; Borrego, P; Gervásio, H; Moreira, A; Costa, L; Marcelo, F; Peralta, F; Furtado, I; Pina, F; Albuquerque, C; Santos, A; Passos-Coelho, JL; Portuguese Group for the Study of Bone MetastasesBACKGROUND: Skeletal-related events (SREs) occur frequently in patients with bone metastases as a result of breast (BC) and prostate (PC) cancers. They increase both morbidity and mortality and lead to extensive health-care resource utilization. METHODS: Health care resource utilization by BC/PC patients with at least one SRE during the preceding 12 months was assessed through retrospective chart review. SRE-treatment costs were estimated using the Portuguese Ministry of Health cost database and analyzed using generalized linear models. RESULTS: This study included 152 patients from nine hospitals. The mean (SD) annual SRE-treatment cost per patient was €5963 (€3646) and €5711 (€4347), for BC (n=121) and PC (n=31) patients, respectively. Mean cost per single episode ranged between €1485 (radiotherapy) and €13,203 (spinal cord compression). Early onset of bone metastasis (P = 0.03) and diagnosis of bone metastases at or after the occurrence of the first SRE (P < 0.001) were associated with higher SRE-treatment costs. CONCLUSION: These results reveal the high hospital SRE-treatment costs, highlighting the need for early diagnosis and treatment, and identify key factors determining the economic value of therapies for patients with skeletal metastases.
- Transvesical endoscopic port in abdominal surgery: an updated perspective.Publication . Lima, E; Autorino, R; Correia-Pinto, JNatural orifice transluminal endoscopic surgery (NOTES) generated a huge hope among surgeons because it promised scarless surgery and eventually less pain and surgical stress. However, serious limitations regarding reliable visceral closing methods remain unsolved. This article provides an update in development and future applications of transvesical access in the field of surgery.
- Transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney morcellation: a proof of concept studyPublication . Lima, E; Branco, F; Parente, J; Autorino, R; Correia-Pinto, JStudy Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Until now, the transvaginal approach has been the only method of removing larger specimens from the abdominal cavity using natural orifice transluminal endoscopic surgery. There has been no means of extracting larger specimens in men and the means are restricted even in women, particularly in young women. The present study shows that the difficulty of large specimen retrieval can be overcome, irrespective of the diameter of the chosen port, through natural orifices using morcellation. OBJECTIVE: To show, in a porcine model, the feasibility of a complete transvesical natural orifice transluminal endoscopic surgery (NOTES) nephrectomy with kidney extraction after morcellation through the same port. MATERIALS AND METHODS: Transvesical nephrectomy and morcellation were performed in six pigs at Minho University, Braga, Portugal after institutional review board approval. The transvesical port and the cystotomy were created under the guidance of a ureteroscope, while the remaining steps were done under the guidance of an operating telescope. Dissection of the renal vessels and kidney was performed using dissection grasping forceps and a vessel sealing system (LigaSure(™) ; Covidien, Mansfield, MA, USA) and morcellation was done using a Piranha(™) morcellator (Richard Wolf, Knittlingen, Germany). RESULTS: There were no complications related to the creation of transvesical access. The image provided by the telescope was superior to that of the ureteroscope, especially underwater. Morcellation was quick and effective, with the support of a fixing needle through the abdominal wall, designed to fix the kidney, after laceration of a bowel loop occurred in the first experiment. It was found that technical improvements are needed to ensure safety of NOTES morcellation. CONCLUSIONS: Kidney morcellation after nephrectomy, using a natural orifice exclusively, is feasible. Despite technical limitations, this proof of concept study can be regarded as a potential step towards the application of NOTES in urology.