Initial Experimental Evaluation of Wireless Capsule Endoscopes in the Bladder: Implications for Capsule Cystoscopy

Background

Cystoscopy remains one of the most important diagnostic procedures for the lower urinary tract. Wireless capsule endoscopy was introduced in the 1990s but use to date is limited to gastroenterology.

Objective

We evaluated the feasibility in the pig model of using wireless capsule endoscopes (WCEs) for cystoscopy.

Design, setting, and participants

Experimental evaluation of capsule cystoscopy was performed in a 50-kg farm pig. The capsule was deployed into the bladder through a custom access sheath. Images were continuously transmitted at a rate of four frames per second to a laptop computer and processed using proprietary software. Manipulation of the WCE within the bladder was performed using a set protocol. The animal was then euthanized and gross inspection was performed.

Measurements

We measured the ability to deploy and manipulate the capsule within the bladder. Feasibility of capturing and retrieving images in real time was also assessed.

Results and limitations

The WCE was efficiently deployed and manipulated within the bladder passively and with the use of external magnets. The entire bladder mucosa was visualized. Real-time image transmission and capture were successful. No complications were seen during capsule cystoscopy. Minor urethral bleeding was observed after the experiment, likely related to placement of the access sheath required for deployment of the WCE. Limitations are that the evaluation of WCE was performed in the pig model, in only one female animal, using a nonsurvival approach. Furthermore, the study was not designed to differentiate normal from abnormal mucosal findings and focused solely on inspection of the bladder.

Conclusions

This report suggests that cystoscopy with a WCE is feasible. With this device, all aspects of the bladder mucosa could be visualized, and ongoing technologic and procedural developments are warranted for this new approach.     

Radical prostatectomy for prostatic adenocarcinoma: a matched comparison of open retropubic and robot-assisted techniques

OBJECTIVE

To assess the perioperative complications and early oncological results in a comparative study matching open radical retropubic (RRP) and robot‐assisted radical prostatectomy (RARP) groups.

PATIENTS AND METHODS

From August 2002 to December 2005 we identified 294 patients undergoing RARP for clinically localized prostate cancer. A comparison RRP group of 588 patients from the same period was matched 2:1 for surgical year, age, preoperative prostate‐specific antigen level, clinical stage and biopsy Gleason grade. Perioperative complications were compared. Patients completed a standardized quality‐of‐life questionnaire. Pathological features were assessed and Kaplan‐Meier estimates of biochemical progression‐free survival (PFS) were compared.

RESULTS

There was no significant difference in overall perioperative complications between the RARP and RRP groups (8.0% vs 4.8%, P = 0.064). Wound herniation was more common after RARP (1.0% vs none, P = 0.038), and development of bladder neck contracture was more common after RRP (1.2% vs 4.6%; P < 0.018). The hospital stay was less after RARP (29.3% vs 19.4%, P = 0.004, for a stay of 1 day). At the 1‐year follow‐up there was no significant difference in continence (RARP 91.8%, RRP 93.7%, P = 0.344) or potency (RARP 70.0%, RRP 62.8%, P = 0.081) rates. The biochemical PFS was no different between treatments at 3 years (RARP 92.4%, RRP 92.2%; P = 0.69).

CONCLUSION

There was no significant difference in overall early complication, long‐term continence or potency rates between the RARP and RRP techniques. Furthermore, early oncological outcomes were similar, with equivalent margin positivity and PFS between the groups.     

Can cost utility evaluations inform decision making about interventions for low back pain?

Background contextLow back pain (LBP) is associated with high health-care utilization and lost productivity. Numerous interventions are routinely used, although few are supported by strong evidence. Cost utility analyses (CUAs) may be helpful to inform decision makers.PurposeTo conduct a systematic review of CUAs of interventions for LBP.Study designSystematic review.MethodsA search strategy combining medical subject headings and free text related to LBP and health economic evaluations was executed in MEDLINE. Cost utility analyses combined with randomized controlled trials for LBP were included. Studies that were published before 1998, non-English, decision analyses, and duplicate reports were excluded. Search results were evaluated by two reviewers, who extracted data independently related to clinical study design, economic study design, direct cost components, utility results, cost results, and CUA results.ResultsThe search produced 319 citations, and of these 15 met eligibility criteria. Most were from the United Kingdom (n=8), published in the past 3 years (n=12), studied chronic LBP or radiculopathy (n=13), and had a follow-up >12 months (n=13). Combined, there were 33 study groups who received a mean 2.1 interventions, most commonly education (n=17), exercise therapy (n=13), spinal manipulation therapy (n=7), surgery (n=7), and usual care from a general practitioner (n=7). Mean baseline utility was 0.57, improving to 0.67 at follow-up; the mean difference in utility improvement between study groups was 0.04. Based on available data and converted to US dollars, the cost per quality-adjusted life year ranged from $304 to $579,527, with a median of $13,015.ConclusionsFew CUAs were identified for LBP, and there was heterogeneity in the interventions compared, direct cost components measured, indirect costs, other methods, and results. Reporting quality was mixed. Currently published CUAs do not provide sufficient information to assist decision makers. Future CUAs should attempt to measure all known direct cost components relevant to LBP, estimate indirect costs such as lost productivity, have a follow-up period sufficient to capture meaningful changes, and clearly report methods and results to facilitate interpretation and comparison.     

Advances in robotic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.     

Thermal effects of laparoscopic saline-enhanced radiofrequency cautery on renal parenchyma in a porcine model

PURPOSE: Advances in the field of surgery have recently developed a number of devices and materials to improve surgical hemostasis. The effects of one such device, saline-cooled monopolar radiofrequency electrocautery, has been well scrutinized in splenic and hepatic applications. Despite the utilization of this device in urologic surgery, the classification of the thermal effects has been poorly characterized to date. The purpose of this study was to discern the thermal characteristics of the device in the laparoscopic environment when used on renal parenchyma. MATERIALS AND METHODS: After institutional approval, four domestic swine were randomized to receive laparoscopic renal lesions randomly generated by either saline-cooled (25 W with saline flow rate of 4 mL/min) or standard monopolar radiofrequency electrocautery. The energy source was applied for between 1 and 11 seconds for each device in order to create a total of 64 renal lesions. Each kidney was harvested and examined by a genitourinary pathologist blinded to the treatment interval. RESULTS: The saline-cooled device provided a greater depth of coagulation effect compared to standard monopolar electrocautery at all points in time (P < 0.05). The diameter of the lesions created using saline-cooled monopolar electrocautery was greater than those created with standard electrocautery (P < 0.05). CONCLUSIONS: The saline-cooled monopolar electrocautery provided an improved coagulation effect compared to standard electrocautery in the laparoscopic setting. Recognition of the time and resultant thermal consequences can help the laparoscopic surgeon plan surgical approaches for renal lesions and improve hemostasis.