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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.
- 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.
- 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.
- Variations of the soft tissue thicknesses external to the ribs in Pectus Excavatum patientsPublication . Rodrigues, PL; Direito-Santos, B; Moreira, AH; Fonseca, JC; Pinho, AC; Rodrigues, NF; Henriques-Coelho, T; Correia-Pinto, J; Vilaça, JLBACKGROUND: Surgical repair of pectus excavatum (PE) has become more popular due to improvements in the minimally invasive Nuss procedure. The pre-surgical assessment of PE patients requires Computerized Tomography (CT), as the malformation characteristics vary from patient to patient. OBJECTIVE: This work aims to characterize soft tissue thickness (STT) external to the ribs among PE patients. It also presents a comparative analysis between the anterior chest wall surface before and after surgical correction. METHODS: Through surrounding tissue segmentation in CT data, STT values were calculated at different lines along the thoracic wall, with a reference point in the intersection of coronal and median planes. The comparative analysis between the two 3D anterior chest surfaces sets a surgical correction influence area (SCIA) and a volume of interest (VOI) based on image processing algorithms, 3D surface algorithms, and registration methods. RESULTS: There are always variations between left and right side STTs (2.54±2.05mm and 2.95±2.97mm for female and male patients, respectively). STTs are dependent on age, sex, and body mass index of each patient. On female patients, breast tissue induces additional errors in bar manual conception. The distances starting at the deformity's largest depression point at the SCIA are similar in all directions. Some diverging measures and outliers were found, being difficult to find similar characteristics between them, especially in asymmetric patients. CONCLUSION: The Nuss procedure metal bar must be modeled according to each patient's special characteristics. The studied relationships between STT and chest surface could represent a step forward to eliminate the CT scan from PE pre-surgical evaluation.
- 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.
- Low-cost reusable instrumentation for laparoendoscopic single-site nephrectomy: assessment in a porcine modelPublication . Autorino, R; Kim, FJ; Rane, A; De Sio, M; Stein, RJ; Micali, S; Correia-Pinto, J; Kaouk, JH; Lima, EPURPOSE: To test different sets of prebent instruments and a new reusable access device for laparoendoscopic single-site (LESS) surgery. MATERIALS AND METHODS: Three surgeons with previous experience in LESS performed 12 nephrectomies in six pigs. In all procedures, a multichannel access device (X-CONE) and a 5-mm extra-long telescope were used. Four sets of prebent instruments with different profiles (S-portal) were tested: Standard (one straight scissors and one curved grasper), Cuschieri, Carus, and Leroy set (each of them consisting of two curved instruments with different configurations). Assessment was performed based on both objective (procedure time; time to manage the pedicle; time to free kidney) and subjective parameters (entry/exit of instruments; triangulation; dissection up/down; dissection lateral; retraction; interdependence). The subjective assessment tool used was a Likert type scale (1 = easy to 5 = prohibitive). The access device was assessed by using objective (time to complete insertion of device after skin incision) and subjective (significant air leakage, movement constraint) parameters. RESULTS: Time to insertion of the X-CONE was <1 minute in all the cases. Surgeons reported significant insufflant leakage in 58% of cases. The procedure was completed in 10/12 (83%) cases. Mean operative time was 8.3 ± 4.2 minutes, being lower for the Carus group (4.5 min) and higher for the standard group (13 min). Among the different sets, the standard one obtained the best mean scores for all subjective parameters. CONCLUSIONS: X-CONE allows easy abdominal access, and its reusable properties represent cost savings for LESS compared with disposable devices. Prebent instruments might also represent attractive low-cost tools for LESS.
- Searching the best approach for third-generation cholecystectomyPublication . Rolanda, C; Lima, E; Correia-Pinto, J
- Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery.Publication . Lima, E; Rolanda, C; Pêgo, JM; Henriques-Coelho, T; Silva, D; Carvalho, JL; Correia-Pinto, JPURPOSE: Recently various groups reported successful attempts to perform intra-abdominal surgery through a transgastric pathway. We assessed the feasibility and safety of a novel transvesical endoscopic approach to the peritoneal cavity through a 5 mm port in a porcine model. MATERIALS AND METHODS: Transvesical endoscopic peritoneoscopy was performed in 8 anesthetized female pigs, including 3 nonsurvival and 5 survival animals. Under cystoscopic guidance a vesical hole was created on the ventral bladder wall with an open-ended ureteral catheter. An over tube with a luminal diameter of 5.5 mm was placed in the peritoneal cavity, guided by a 0.035-inch guidewire. In all animals we performed peritoneoscopy of the entire abdomen as well as liver biopsy and falciform ligament section. A vesical catheter was placed for 4 days in all survival animals, which were sacrificed by day 15 postoperatively. RESULTS: After a learning curve in the first 3 nonsurvival animals the creation of a vesical hole and placement of the over tube were performed without complication in all survival animals. In these animals we easily introduced an EndoEYEtrade mark into the peritoneal cavity, which provided a view of all intra-abdominal viscera, as well as a 9.8Fr ureteroscope, which allowed simple surgical procedures without complications. In survival experiments all pigs recovered. Necropsy examination revealed complete healing of the vesical hole and no signs of infection or adhesions into the peritoneal cavity. CONCLUSIONS: Transvesical endoscopic peritoneoscopy was technically feasible and it could be safely performed in a porcine model. This study provides encouragement for additional preclinical studies of transvesical surgery with or without combinations with other natural orifices approaches to design new intra-abdominal scarless procedures in what seems to be third generation surgery.
- Transvesical endoscopic peritoneoscopy: intra-abdominal scarless surgery for urologic applicationsPublication . Lima, E; Rolanda, C; Correia-Pinto, JFor many abdominal procedures, advantages such as minimal scarring, reduced pain, and faster recovery have made laparoscopy the favored approach over traditional open surgery. The most recent minimally invasive approach is natural orifice transluminal endoscopic surgery (NOTES), which limits morbidity because this surgery does not require incision. This article reviews the history, development, and current and future applications of NOTES in the field of urology.