The document discusses various types of radiation and imaging modalities. It provides radiation doses in mSv for different exams like CXR, CT, PET, etc. It notes that 10mSv increased cancer risk by 1 in 2000. Different components of ESWL are outlined along with mechanisms of stone fragmentation. Characteristics of different lithotripter generations including electrohydraulic, electromagnetic, and piezoelectric are summarized. Lasers used for stone treatment include holmium, KTP, and ND:YAG. Holmium is well absorbed by all stone types and has a high safety profile. The FREDDY laser produces dual pulses to mechanically fragment stones with low risk of tissue injury.

1. New Tech & Imaging
Edmond Wong

2. Radiation

3. Radiation mSv (millisieverts) CXR equivalent
Annual Background (UK) 2
CXR 0.02
KUB 0.5 (0.2-0.7)
IVU 2.5 120
NCCT 5 250
CT abd/pelvis + contrast 10 500
CT chest 7 (6.5-8)
PET 6 (5-7)
PET-CT 24 (23-26)
MAG3 0.5 (0.4-0.7)
DTPA
DMSA 1
MCUG 1
Bone scan 4
10mSv increased risk of cancer by 1in 2000

4. What are the important issues of
irradiation?
• The international unit of radiation dose is
Gray
• One gray is the radiation dose that results
in the energy deposition of 1J/kg
• The old unit was rad
• One gray is equivalent to 100 rad
• Fetuses are least vulnerable to radiation
between 0-4 week and most vulnerable
during organogenesis (8-15 weeks)

5. ESWL

6. What are the four components of
ESWL?
• Energy source
• Medium for transmission of energy (e.g
water)
• A focusing device
• Imaging modality

7. What is Electrohydrolic ESWL?
• Electrohydraulic
• 1st
generation Dornier HM3 spark-gap lithotripsy
• A spark is produced between two electrodes, causing sudden expansion
and collapse of gas bubble and energy transmission
• Focus device : Metal hemi-ellipsoid reflector to localize the energy
• Adv
– Most effective in stone fragmentation (Dornier HM3)
• Disadv
– Pain
– Substantial pressure fluctuation b/w shocks (haematoma 0.6%)
– Short electrode life
• Reference standard for comparison
– USA Cooperative study group
– Methodist Hospital of Indiana
• Nowadays, Dornier lithotripter S II
• 2nd
/3rd
generation
– Tight focal zone
– High ascoustic pressure

8. Electromagnetic
• Electromagnetic
• Energy: Rely on Cylindrical electromagnetic source
• Focus device : Acoustic lens.
• E.g : Storz Modulith SLX-F2
• Adv
– More controllable & reproducible SW
– Less pain due to low energy density at skin
– Small focal point
– Long electrode life
• Disadv
– ↑ subcapsular haematoma (3-12%) due to small focal
region of high energy

9. Piezoelectric
• Piezoelectric
• Energy: Ceramic elements produce electrical
discharge under stress or tension (direct effect)
• When electricity pass through element  movement
of source  shock wave (converse piezoelectic
effect)
• E.g: EDAP LT02
• Adv
– High focusing accuracy
– Long service life
– Least pain due to low energy density at skin, may be
anesthesia free
• Disadv
– Less effective due to lower power

10. Acoustic shock wave
• 2 phase:
• Short +ve phase:
– Erosion at entry and exit pt of stone
– Compressive effect of wave also cause shattering
internally
– Compression / tension-induced cracks (Spallation)
• Longer –ve pressure phase:
– Formation of microbubbles
– Collapse of these bubbles cause further erosion of
stone surface via formation of “microjet”

11. Campbell
• The newer lithotripter are less efficacious
than the original Dornier device, & no data
to suggest newer lithotripter produce fewer
adverse events for equivalent degree of
efficacy

12. Electroconductive (ECL)
• Electroconductive
– Large focal diameter of SW (12.8-25mm)
– Longer pulse duration
– Relatively lower peak pressure (<9MPa)
• highly conductive solution channels the discharge
between anode and cathode
• spark generation exactly at F1
• Compare to EHL:
– Reduction in shockwave pressure variability
– Improved energy transfer to the stone
– Improved stone fragmentation

13. ECL
• Tolley
– Patients treated with Sonolith between 2004
and 2006
– plain KUB and USG at 1 and 3 months
– stone-free rates
• 77% (<10mm), 69% (11-20mm), 50% (>20mm)
• 74% (lower), 70% (upper), 78.5 (middle), 74% (renal pelvis)
– Conclusion: Achieved a high success rate, comparable with that
using the HM-3 machine but with lower analgesic requirement and
very low re-treatment rates

14. ESWL
Mechanism of stone fragmentation
1. Spall fracture
2. Squeezing-splitting or circumferential
compression
3. Shear stress
4. Amplification of stress inside stone
5. Cavitation i.e. formation & subsequent
dynamic behavior of bubbles

16. ESWL
• Indications
– Renal pelvis stone <2cm
– Lower pole stone <1cm
– Upp ureteric stone <1cm
– Sandwich therapy in conjunction with PCNL
• Contraindication
– Absolute
1. Uncorrected coagulopathy
2. Uncontrolled HT
3. Active UTI
4. Pregnancy
5. Distal obstruction
– Relative
1. Morbid obesity
2. Hard stone (cystine or Ca oxalate monohydrate)
3. AAA
4. Abdominal pacemaker

18. How to consent pt for ESWL?
• Common complications:
– Hematuria
– Loin pain/ ureteric colic
– UTI require Antibiotic
• Occasional complications:
– Failed fragmentation of stone
– Repeat ESWL required
– Recurrence of stone
• Rare complications:
– Preinephric hematoma
– Steinstrasse
– Severe systemic infection
– Adjacent organ damage
– HT
– Arrhythmias

21. What is the mechanism of
Lithoclast?
• Pneumatically generated energy
• Compressed air delivered from external supply
fires the projectile in the handpiece into a probe
which in contact with stone to fragment it
• Adv: bounce off ureter, less damage
• Disadv:
– retrograde propelled stone in ureter
– Use only in rigid instrument
• Swiss lithoCloast Master

22. Laser

23. What is Laser?
• Light Amplification by Stimulated Emission of Radiation.
• Laser is formed by supplying energy to a lasing medium
(pumping), which release photons & undergo population
inversion & light amplification, producing light that is coherent
(parallel), monochromatic (same wavelength) & collimated (in
phase)
• Laser chamber fully reflective apart from an aperture that allow
light to escape when reach a certain intensity
• Population inversion: more light is release than absorbed
• Photothermal effects
– ↑ temp  heat production  incision & ablation
• Photomechanical effects
– Fluid evaporation-> small plasma cavitation bubble-> rapidly
expand & collapse-> shockwave-> stone fragmentation
• Photochemical effects

24. What are the different types of Laser?
• Most common usage
• Holmium: YAG
– Wavelength 2140nm, depth of penetration 0.4mm
– Rapidly absorbed by water  more of photothermal (weak
cavitation bubble only)
– Higher pulse energy but lower peak power than pulsed dye laser
– 200-um, 365um fiber
• KTP (potassium-titanyl-phosphate) / LBO (lithium triborate)
– ND-YAG pass thru a KTP crystal , ½ the WL & double frequency
– Wavelength 532mm, depth 2mm
– Selectively absorbed by Hb
• ND-YAG
– Wavelength 1064nm, depth 3-5mm
– Poorly absorbed by water/ body pigmentation-> coagulation

25. What are the Lasers used for BPH:
PVP?
• PVP (KTP 80W, LBO HPS 120W) Greenlight
– Side firing single use fibre
– Adv (most long term data from 80W)
1. Saline irrigation-> avoid TUR syndrome
2. Excellent haemostasis
– ↓ bleeding & blood transfusion
– Anticoagulants may not need to be stopped (largest series:
Ruszat)
3. Equally effective voiding improvement at 1 yr vs TURP
4. Effective & durable outcome in voiding parameters at 5 yrs
(Ruszat)
5. ↓ catheter time & ↓ hospital stay vs TURP (RCT by Bouchier-
Hayes)

26. What are the disadv / Limitations of
PVP?
1. Lack of tissue for histopathology
2. Cost
3. Impaired vision (esp 120W)
• Injury to UO/ bladder perforation
4. Higher re-op rate vs TURP (7% vs 4% at 5 yrs,
Ruszat)
5. Lack of long term data on 120W HPS

27. What is holmium: YAG laser: HOLEP?
• Most promising
– Morcellator, mimic open simple prostatectomy
• Adv
1. Saline irrigation-> avoid TUR synd
2. Good haemostasis properties
• ↓ blood transfusion vs TURP/ open prostatectomy (Kuntz)
3. Histology available (vs PVP)
4. Effective & durable outcome on voiding parameters at 6 yrs (RCT by Gilling)
5. Equal improvement in voiding parameters vs TURP at 3 yrs & open
prostatectomy at 5 yrs (both Kuntz)
6. ↓ catheter time vs TURP (Kuntz)
7. Late Cx similar to TURP at 3 yrs (Kuntz)
8. Re-op rate similar to open prostatectomy (Kuntz)
• Disadv/ Limitations
1. Deep learning curve
2. Cost
3. Insufficient data on anticoagulation patients

28. What are the lasers used for stone?
• Holmium: Adv
– All stone types can be fragmented
• excellent absorption by stone surfaces
– High safety profile
• Small cavitation bubble, depth 0.4mm only
– Transmission through small optic fibre e.g. 200µm
• Can be used in flexible URS
• Pulsed dye laser
– Greenlight 504nm, cavitation bubble & shockwave
– Selectively absorbed by stone but not ureter
– Relatively ineffective against harder stone
– Machine warm up time 20min
– Dark eyewear required

29. Laser safety precautions in OT
1. OT door closed throughout
2. Warning sign & light at OT door
3. Non-reflective wall coating
4. Staff number minimized
5. Laser safety officer present
6. Surgeons trained
7. Eye protection goggles
8. Laser “stanby” when not in use
9. Laser pedal has guard
10.Clear safety guidelines

30. Laser
• Mechanism
– Photothermal/ photomechanical
• BPH:
– KTP laser
• Selectively absorbed by haemoglobin
• At high power, rapid photo-thermal vaporisation of intracellular tissue
water
• PVP, photoselective vaporisation of prostate
• Side-firing, single use fibre with deflecting device at the tip
• Saline irrigation
• Excellent haemostatic properties
• Coagulation zone about 2mm deep
• Speed of tissue removal is limited to 0.3 – 0.5g/ min
• Tissue specimen for histological examination cannot be obtained

31. Laser: BPH
• One RCT comparing KTP laser vaporisation with
TURP
– Delivers equally good micturition outcome at 1 year
post-op (TURP 8.7 to 17.9 ml/s; PVP 8.5 to 20.6 ml/s)
– No need for blood transfusion
– Shorter catheter time (TURP mean 44.5 hrs; PVP
12.2 hrs)
– Shorter hospital stay (TURP mean 3.4 days; PVP
1.08 days)
Bouchier-Hayes DM (2006)

32. Laser: BPH
• Ho:YAG Laser
– Wavelength: 2,140 nm
• Close to the absorption peak of water: 1,910 nm
• Rapidly absorbed by tissue water
– Penetration depth of 0.4 mm
– Causes vaporisation without deep coagulative tissue
necrosis
– Tissue ablation (vaporisation), incision, resection &
enucleation by a clean char-free cut.
– Dissipating heat causes simultaneous coagulation of
small and medium-sized vessels to a depth of 2–3
mm.
– HoLAP, HoLRP, HoLEP

33. HoLAP
• Holmium laser ablation of prostate
• First performed in 1994
– Side-fire fibre with a deflecting device at the fibre tip with a 60W
machine
• Randomized comparison between HoLAP and TURP (Mottet, 1999)
– Less bleeding
– Shorter catheterisation
– Shorter hospital stay
– Similar efficacy after 1 year
• HoLAP was slow with the 60W machines, superseded by holmium
laser resection and enucleation of prostate
• High powered 100 W machine is now available allowing faster tissue
vaporisation
– Large series and RCTs of HoLAP with 100W machines are yet not
available

34. HoLRP
• Holmium laser resection of prostate
• The adenomatous tissue is resected down to the
capsule, and cut into pieces small enough to be
evacuated through the resectoscopes sheath.
• At the end of the procedure all adenomatous tissue is
removed, and the prostatic cavity is similar to that
produced by conventional TURP.
– About 50% of removed tissue is lost to vaporisation.
• Randomised clinical trials proved that HoLRP had
– Significantly less perioperative morbidity (Gilling PJ 1999)
– Equivalent efficacy in terms of peak flow, symptom scores,
potency and continence when compared with TURP after a
minimum of 4 years of follow-up (Westenberg A 2004)

35. HoLEP
• Holmium laser enucleation of prostate
• With the use of soft tissue morcellator
• The prostatic lobes can be enucleated in
their entirety, pushed into the bladder and
then be mechanically fragmented and
aspirated by the morcellator
• HoLEP mimics open prostatectomy via a
transurethral route

36. HoLEP
• Enucleation:
– Tip of laser fibre dissects the adenomatous tissue
away from the surgical capsule
• Haemostasis:
– Small and medium-sized vessels coagulated
“automatically” and large arteries are immediately
coagulated by “defocusing”
• A nearly bloodless procedure
• Use of NS as irrigating fluid
– No risk of TUR syndrome

37. HoLEP
• Prospective randomised trial (J Urol 2008)
100 consecutive patients with symptomatic
obstructive BPH randomised at 2 centres
n=52 HoLEP n=48 TURP
Mean OT time 74 min 57 min p < 0.05
Mean cath time 31 min 57 min p < 0.001
Mean LOS 59 min 86 min p < 0.001

38. Freddy laser

39. FREDDY Laser
• FREquency Doubled Double-pulse
Nd:YAG Laser (World of Medicine, Berlin,
Germany)
• Approved by FDA in January 2001
• Short pulsed, double frequency laser
• By incorporating a KTP crystal into the
resonator of a Nd:YAG laser, the FREDDY
laser produces two pulses (532 nm and
1,064 nm) simultaneously.
• Specially designed for stone
fragmentation

41. FREDDY Laser
• Photoacoustic effect: Laser light at 532 nm
initiates plasma formation at the stone
surface, while light at a wavelength of 1,064
nm heats the preformed plasma, causing
expansion and contraction, using pulse
durations of 0.3–1.5 microseconds ->
produces mechanical shock wave
• Safety: No plasma formation on issue -> low
risk of tissue injury

42. Evidence
• Experiments show the FREDDY laser is
capable of lithotripsy while both animal
and human model studies show little to no
effect on normal tissues
• Hochberger J, Bayer J, Tex S, Maiss J, Tschepe J, Hahn EG (1997) Frequenzverdoppelter Doppelpuls ND:YAG Laser
(FREDDY) fur die Gallensteinlithotripsie—Praklinische und erste klinische Ergebnisse. Biomedizinische Technik
“Laseranwendungen III” 442:330
• Zorcher T, Hochberger J, Schrott KM et al (1999) In vitro study concerning the effciency of the Frequency-doubled Double-
Pulse Neodymium:YAG Laser (FREDDY) for Lithotripsy of Calculi in the Urinary tract. Lasers Surg Med 25(1):38–42
• Delvecchio F, Zhu S, Weizer A, Silverstein A, Auge B, Pietrow P, Albala D, Zhong P, Preminger G (2001) In vitro
fragmentation analysis of the FREDDY laser. Oral presentation at the WCE 2001, Bangkok
• Bazo A, Chow WM, Coombs L, Barnes DG (2001) Freddy will crack it for you: a new device for urinary calculi lithotripsy. In:
BAUS conference proceedings, section of Endourology, SheYeld, UK
• Santa-Cruz RW, Leveillee RJ, Krongrad A (1998) Ex vivo comparison of four lithotripters commonly used in the ureter: what
does it take to perforate? J Endourol 12(5):417–422

43. Evidence
• A study of 50 patients using FREDDY
laser lithotripsy showed overall 95%
immediate stone free rates in treatment of
ureteral calculi with no complications
• Schafhauser W, Zorcher W et al (2000) Erste klinische Erfahrungen mit neuem frequenzverdoppeltem Doppelpuls
Neodym:YAG Laser in der Therapie der Urolithiasis. Poster presentation at the DGU, Hamburg, Germany
• A study showed an 87% combined stone
free rate for kidney, ureteric and bladder
stones, with no complications.
• Stark L, Carl P, Zauner R (2001) A new technique for Laser-Lithotripsy: FREDDY, the partially frequency-doubled double-
Pulse Nd:YAG Laser. Poster presentation at the 1st int. consultation on Stone Disease, Paris

44. Evidence
• A study of 21 patients showed 100% stone
free rates in kidney and ureteric stones,
but a 57% stone free rate for bladders
stones using the laser
• Bazo A, Chow WM, Coombs L, Barnes DG (2001) Freddy will crack it for you: a new device for urinary calculi lithotripsy. In: BAUS
conference proceedings, section of Endourology, SheYeld, UK

45. Evidence
• several studies have shown the FREDDY
laser ineffective in the treatment of “hard”
urinary calculi, such as calcium oxalate
monohydrate, cystine, and brushite stones
• Dubosq F, Pasqui F, Girard F, Beley S, Lesaux N, Gattengno B, Thibault P, Traxer O (2006) Ednoscopic lithotripsy and the FREDDY
laser: initial experience. J Endourol 20(5):296–299
• Stark L, Car P (2001) First clinical experiences of laser lithotripsy using the partially frequency-doubled double-pulse neodymium: YAG
laser (“FREDDY”) (abstract). J Urol 165:362A

48. Laser spectrum

49. What is it?
• Tm:YAG
• Laser with wavelength: 1930 – 2040 nm
(~2 micron)
• Continuous / pulsed mode
• Power: 5 – 120 W
• Proposed by Xia in 2005 for use in surgery
of prostate

50. Comparison with other laser
Wavelength
(nm)
characteristics Prostate
penetration
depth
Clinical use
Holmium
Ho:YAG
2100 – 2150 rapidly absorbed by
water and cell fluid
0.4 mm Enucleation of prostate
Ablation/ resection:
abanodoned
Greenlight
KTP/ LBO
532 Strongly absorbed by
Hb, not absorbed by
water
1-3 mm vaporization
Diode laser 940
980
1470
compared with KTP:
conflicting result on
tissue ablation,
hemostais
coagulation
zone:
4.5 mm
vaporization but limited
clinical study
Thulium
Tm:YAG
1930 – 2040 rapidly absorbed by
water, excellent
hemostasis,
vaporization and
resection
< 1 mm vaporesection,
vaporization,
vapoenucleation, laser
enucleation

51. Surgical techniques and outcomes
T. Bach et al. World J Urol (2010)
28:163–168

53. EHL

54. What is EHL?
• Underwater spark generation by applying
current to two electrodes which 1mm apart
and separated by insulation
• Sudden expansion and collapse of gas
bubbles generates a hydraulic shock wave
• Placed not more than 1mm from the stone
• Avoided using EHL in ureter due to risk of
perforation of ureter

55. What is USG lithotripsy?
• USG generator transmitted USG to hollow
probe > vibration of probe tip
• Vibration in contact with the stone
producing drilling or grinding action
• Avoided using USG in ureter due to
thermal effect

56. What is USG machine?
• Sound wave by passage current through piezoelectric
transducer and subsequently focused
• Lower frequency for deeper object
• 7MHz for transrectal
• 3.5MHz for transabdominal
• USG pass into body via interface of soft rubber coating
and gel
• Sound wave was deflected back to transducer forming
the image
• Larger density (fluid and stone) produced greater echo

57. Robots

58. What is the classification of
Robots?
1. Fixed path robots
– Pre-programmed, completely automated
– No interaction with surgeons
– Prostate & renal access
2. Surgeon-driven robots
– Copy surgeons movements in precise & tremor free
way
– Endoscopic manipulators
• AESOP, Naviot
– Master-slave system
• Zeus, Da Vinci system

59. What is Da Vinci robotic surgical system?
• It consists of powered control patient-side cart
with 3 or 4 robotic manipulator arms which is
linked to a surgeon console.
• The system provide 3D magnified vision
through a binocular lens camera, &
• with specialized articulatory joins at the tip of
robotic arms, the hand movements of surgeons
at the console are translated into a more
precise & tremor free manner

60. What are the advantages of Da Vinci?
1. Classical advantages of laparoscopy
2. Superior visualization
1. 3D
2. Magnified field 12x
3. High resolution; these -> more accurate tissue handling & dissection
3. Superior dexterity, precision & control
1. 7 degree of freedom (wristed instruments)
2. Tremor reduction
3. Motion scaling
4. 4th
arm-> ↓ assistance
4. Superior ergonomics
1. Operate in seating position
2. Natural hand-eye alignment at console
3. Added mechanical strength; these -> ↓ surgeon fatigue & ↑ pt safety
5. Relative short learning curve for surgeons with open skills
1. Due to direct translation of surgeon hand movements

61. What are the disadvantages of Da
Vinci?
1. Absence of haptic feedback (i.e. tactile & force)
– Compensated by superior visual quality & intra-op visual
cues
2. Cost of initial investment & maintenance
3. Large size
– May restrict use in paedi pts & adults with small body frame
– Large OT room
4. Set up time may be long esp initially e.g. docking
5. Expertise of surgeons & nurses, training required

62. What are the outcomes of Da Vinci?
• Lack of RCT
1. Intra-op Cx
– ↓ Intra-op bleeding & blood transfusion (3% ORP-> 0.5% RoRP,
Farnham, review by Ficarra)
– Overall Cx comparable with LRP
2. Oncological outcomes
– +ve margin rate similar to ORP & LRP
• 13% +ve margins, 7% biochem recurrence at 2 yr, Badani/ Menon)
– Longer FU required for long term biochem recurrence
3. Continence
– Continence (0 or 1 pad) at 1 yr similar to ORP & LRP (~90%)
– May be earlier continence (40% ORP -> 70%, Ficarra)
4. Potency recovery
– Similar to ORP & LRP
• ~70% at 1 yr after bilat NS (Menon)

63. Stent

64. What are the properties of a stent?
• Hollow tube and tapered end allows
insertion
• Coils prevent migration
• Some are hydrophillic
• They are impregnated to make them
radio-opaque

65. What are the stents?
• Characteristics of ideal stents (Tolley)
1. Good memory, with configuration to prevent migration
2. Excellent flow
3. Radio opaque (bismuth/ barium coating)
4. Biologically inert
5. Resist biofilm formation, encrustation & infection
6. Flexible material with high tensile strength
7. Easy to insert
8. Easy to remove or exchange
9. Reasonable price
10. Minimal Cx
• Duration:
– 6-12 mth due to encrustation, biofilm, infection & stone
• Configuration
– Complete coils, J-tip, pigtail
– 22-30cm long
– 4.7-8 Fr

66. What are the materials of
stents?
1. Polyurethane
– Combined silicone & polyethylene
– Disadv: Induce epithelial ulceration & erosion, cytotoxic
2. Silicone
– Resistant to encrustation, but stiffer and more irritation > difficulty to
manipulate, thicker wall & smaller lumen, up to 1 year
3. Metal
– Nitinol (nickel-titanium), in malignancy ureteric obstruction
– Epithelized & ↓ encrustation
4. Polyethylene
– Not used because prone to encrustation / UTI.
– Adv: stiff
5. C-Flex TPE
6. Percuflex
7. Biodegradable
– Polymer of polylactic & polyglycolic acid
– No need removal

67. What are the indications of stents?
1. Prophylactic
– Adjunctive treatment for upper tract stone
– Facilitate intra-op ureteric identification
2. Therapeutic
– Drainage of infection or obstructed collecting
system
– Urinary extravasations
– Protect anastomosis
• Extranatomical stent: Paterson-Forrester stent

68. What are the complications of
stent?
1. Irritative LUTS
– Solutions: Avoid unnecessary stent
– Avoid longer length
– Softer & smaller stent
– Patient explanation
– Early removal
2. Migration
3. Encrustation
4. Infection
5. Blockage

69. Recent advances in ureteric
stent
1. ↓ biofilm formation & UTI
– Triclosan-eluting DJ (not that useful Denstedt)
2. ↓ irritative symptoms
– Tapered & softer distal end
3. For malignancy obstruction
– Stent w/o side holes
– Dual-lumen stent
– Coiled metal wire stent (e.g. Resonance)
4. Facilitate small stone removal
– Self-expanding stent
5. Drug-eluting stent
– Paclitaxel-eluting stent to ↓ blockage ? Therapeutic usage
6. Biodegradable stent

70. What is some important issues
of ureteric stent?
• Ureteric stents in the absence of urteric obstruction will therefore cause
partial ureteric obstruction
• When positioned for uretric obstruction, JJ stent allows urine drainage
primarily around it and that is the reason for not functioning very well in
malignant ureteric obstruction where the tumour will occupy that space
between the stent and the ureteric wall.
• An alternative is to positon 2 stents that will allow drainage through the
interspace between the stents.
• Pearle J Urol 1998
– Randomized trial comparing JJ stent to nephrostomy as a treatment of
ureteric obstruction in the presence of infection
– equally good at resolving the infection and ensuring urine drainage
– Patients treated with nephrostomy were hospitalized for 1-2 days longer
but the JJ stent insertion was the more expensive mode of treatment
• In theory JJ stent insertion have the risk of causing pyelovenous /lymphatic
reflux with irrigation pressure potentially resulting in worsening sepsis

71. Catheter

72. What are different types of catheter?
1. Latex
2. Silicone covered latex - silastic
3. PTFE covered latex
4. 100% silicone
5. PVC (Polyvinyl chloride)
6. Coated silver alloy
• Different types of tip eg coude- or
whistle-tip

73. How is catheter size measured?
• According to the French system
• Remember the French size is the external
diameter multiplied by 3 ( it is not the
circumference )
• Similar value because circumference is
diameter multiplied by 3.142/Pi)

74. What is prostate stent?
• Temporary
– 1st
generation: Urospiral, Prostakath, Intraurethral catheter
– 2nd
generation: Memokath, Prostacoil
• Permanent
– Urolume wallstent (tubular mesh)
• Adv
– Insertion 15min under regional anaesthesia
– Bleeding minimal
– Same day discharge
• Disadv
– ↑ urination & incontinence
– Mild discomfort
– Dislodged-> obstruction/ total incontinence
– Difficult to remove if infected
– Fixed diameter-> limit subsequent endoscopy

75. Memokath

76. • Nickel-titanium alloy
• Closed, tight spiral structure: prevent urothelial ingrowth
• Adopt natural curves of urethra/ureter
• Lack of outward pressure: ↓risk of secondary ischemic
damage
• Titanium: resist corrosion in urinary tract
• Shape memory
– warm to 50 C : expand to original shape
– Cold saline < 10C  make it soft for removal

77. • Two types
–Urethral stent
–Ureteral stent

78. • 14 case series, 839 men
• High surgical risk
• Indications: LUTS or urinary retention
• FU period: 3 month to 7 year
• 4% unsuccessful initial insertion (due to incorrect stent
length)
• Reduction in IPSS of 11-19 points
• Comparable to that after TURP
• Long term failure rate ~ 25%
• Conclusions:
– Memokath appears to be safe and effective
– Inconsistent follow-up means that durability of Memokath cannot be drawn

79. • 74 stents, 55 patients
• Mean FU 16 months
• Indications: malignancy, recurrent benign disease
• Normal drainage in all but 3 patients
• Immediate complications
– Urinary extravasations (1)
– Poor thermo-expansion (1)
– Equipment failure (1)
• Late complications
– Migration (13)
– Encrustation (2)
– Fungal infection (3)
• 14 patients need re-insertion due to migration, encrustation,
stricture progression
• Conclusion: Memokath ureteric stents is a safe alternative to
conventional JJ sent

80. Guidewires

81. What are different types of guidewires?
• Guidewires
– Materials
1. Hydrophilic wire (Terumo)
2. PTFE (polytetrafluoroethylene) coated
– Configuration
• Hydrophilic (Terumo) wires
• Hydrophilic tip (Sensor)
• Stiff (Amplatz super stiff)
– 0.035-0.038 Inch in diameter
– 150cm long

82. Baskets

83. What are the various
baskets?
• Nitinol
• Tipped or flat wire (segura)
• Tipless in flexible scope
– Avoiding trauma to the collecting system
– Easier access with flexible URS
• Open in different ways
– Parachute or helical

84. Baskets
• Materials (2-3Fr)
– Nitinol: flexible, versatile
– Metal: strong
• Open in different
ways
• Tipped
• Tipless
– Avoid trauma to urinary tract
– Easier access with flexible URS

85. Telescope

86. Describe how a modern
telescope used in cystoscopy.
• Series of long glass rods in a metal cylinder
separated by lenses of air spaces – rigid
cystoscopy
• Optic-fibres are flexible glass (or plastic) fibres –
flexible cystoscopy
• Advantages – durable, superior light and image
passage
• Halogen light source, which emits yellowish light
– need white balance. Neon light source does
not need white balance, but expensive

87. Describe how a modern
telescope used in cystoscopy.
• Cystoscopy
– 30cm long
– 17-25Fr
• Semi-rigid URS
– 34cm long
– With tip 7-10Fr
– May have dual lumen
• Flexible URS
– 70-80cm long
– With tip <9Fr
– May have dual lumen
• Resectoscopy
– External sheath 26 or 28 Fr

88. Ureteric access sheath

89. What is ureteric access sheath?
• Indication: Intrarenal procedure with flex URS
• Adv:
1. Better drainage-> ↓ intrarenal pressure
2. Better flow & vision
3. Easier to insert & remove scope
4. May ↓ OT time
• Disadv
1. Costly
2. May be difficult to insert
3. May split ureter

90. Biofilm

91. What is Biofilm?
• Def: Accumulation of microorganisms & their extracellular
products to form a structured community on a surface
• How to form?
1. Proteinaceous molecules in body fluid are absorbed onto the
device forming a conditioning film
2. Bacteria esp with fimbriae attach onto the film
3. Bacteria up-regulate genes & produce exopolysaccharide to
form a glycocalyx matrix & lead to irreversible attachment
4. Further bacterial attachments, growth & multiplications form a
matrix-enclosed community i.e. biofilm
• Structures
1. Linking film which attach to surface of biomaterial
2. Base film of compact bacteria
3. Surface film on outer side where free-floating bacteria can
spread

92. What is Biofilm?
• Why resistant to Rx?
1. The glycocalyx matrix restrict access & diffusion of
antibiotics
2. Bacteria in biofilm have many phenotypes, & antibiotics
only targeted to free-floating bacteria, hence not effective &
may lead to antibiotic-resistant strains due to selective
pressure esp slow growing bacteria deep in biofilm
3. Bacteria can sense the external environment &
communicate & transfer genetic information with each
other
4. Bacteria in biofilm can survive despite 1000x usual
concentration of antibiotics

93. What is Biofilm?
• Solutions
1.To prevent instead of eradicate
2.Avoid unnecessary devices e.g. catheter & early
removal
3.Prophylactic peri-op antibiotics
4.Surgical techniques
5.Theater precautions
6.New advances to ↓ biofilm
• New biomaterial
• Surface coating e.g. silver, antibiotics (triclosan),
hydrogel (polyethylene glycol, heparin)

94. Intracorporeal Lithotriptors

95. What are the different types of
intracorporeal Lithotriptors?
• Pneumatic (lithoclast)
– Compressed air is used to fire metallic projectile in hollow tube which
strike a solid probe like a jackhammer & transmit kinetic energy to
fragment stone mechanically when in contact
– Adv
• Less trauma to urothelium-> wide margin of error
• Little heat production
• No cavitation bubble
• Cheap
– Disadv
• Rigid scope only
• Ultrasonic
– Ultrasound generator produce ultrasound waves down a hollow tube
leading to vibration of probe tip & a drilling action to fragment stone.
Often with suction.
– Disadv
• High temp at probe tip-> not used in ureters
• Rigid scope only

96. What are the different types of
intracorporeal Lithotriptors?
• Laser: Holmium, YAG, Freddy
– NdYAG laser had wavelength of 1064 and
penetration of 10mm
• EHL
– Electricity generate an underwater spark between 2
electrodes, which lead to vaporization , formation of
a cavitation bubble, which rapidly expand &
collapse , & generate shockwave to fragment stone
– Adv
• Can be used in flexible scope
– Disadv
• Traumatic to urothelium, usu only for bladder stone

97. Min. invasive Tx option for
small RCC

98. Minimal invasive therapy for RCC
• Cryotherapy, RFA, microwave ablation, HIFU
• Adv (vs partial nephrectomy)
1. Minimally invasive, no need pedicel control, low Cx
• Suitable for pts with limited LE & poor surgical risk
2. Rapid recovery, short hospitalization
• Disadv
1. Higher local recurrence (2-3x for Cryo & RFA) (Meta-analysis, Landman)
2. Lack of specimen for pathological staging
3. Poor definition of treatment success
4. Unable to confirm complete tumour eradication
5. Intentensive FU required
6. Salvage nephron-sparing surgery can be difficulty
• Renal Bx prior or at time of MIS
– Accuracy 90% to differentiate malignant from benign
– Inconclusive in 10%
– Cx
• Bleeding unusual
• Tumour seedling <0.01%
• Limitation in hybrid or cystic tumours

99. RCC – Cryo & RFA
• Mechanisms
• Suitable patients & tumour
• Advantages
• Disadvantages
• Long term results
• Comparison of thermal ablations with
partial nephrectomy?

100. RCC – cryo mechanism
• Mechanism
1. Based on Joule Thompson principle
2. Cell destruction during rapid & repeated freeze-thaw cycles
3. Rapid gas expansion of compressed argon leading to ultracold
condition (-19°c)
4. Extracellular ice formation & extracellular fluid became hyperosmotic
5. Fluid shift causing intracellular dehydration
6. Further cooling leads to intracellular ice formation
7. & disrupt cell organelles & cell membrane
8. Delayed microcirculatory failure
• Percutaneous or lap
• Inclusion
1. Small renal tumour (<3cm)
2. Exophytic & non-hilar tumour
3. Limited LE or poor surgical risk

101. RCC – cryo mechanism
• Advantages:
– Low complication rate (bleeding 1%), rapid recovery
– No need for hilar clamping
– Real time monitoring of ice-ball under USG possible (vs RFA)
– Longer FU data a/v than RFA
– ? Less local recurrence (cryo 5%, RFA 13%) & re-ablation than
RFA
• Disadv:
– NO RCT , pts highly selected
• Cx: bleeding , vascular thrombosis, ureteric stricture, urinary
fistula
• Ev: 8YCSS 90% , local and systemic recurrence 15% (Gill,
Clveland clinic)

102. RCC – cryo result
• Cleveland clinic experience in 66 patients:
– 5 year FU after lap cryoablation
– 5 year overall survival: 81%
– 5 year cancer specific survival: 98%

103. RCC - RFA
• Mechanism
1. High frequency (400-500kHz) alternating current flows
from needle electrode to target tissue
2. Cause ionic agitation & molecular friction
3. Generate heat (>50-100°c)
4. Denature of cellular protein & cell membrane
5. Cell death & coagulation necrosis
• Percutaneous or Lap
• Goal: maintain target tissue at 50-100° C
– Adequacy of ablation is assessed by temperature or
impedance from RF generators

104. RCC - RFA
• Suitable cases:
– small renal tumor less than 3cm
– non-hilar exophytic cases
– Limited LE or poor surgical risk
• Advantages:
– No need for hilar clamping
– no renal warm ischaemia
– low complication rate, rapid recovery
• Disadvantages:
– The process of RFA itself cannot be actively monitored in real
time imaging
– though impedance can be measured.
– No RCT, pt highly selected
– Lack of long term results
– Higher local recurrence (13%) than Cryo (5%)

105. RCC - RFA
• Results
– No long term results available
– Technology still evolving
– Medium term FU up to 20 months
– favorable cancer specific survival ranging
from 80-100%
– 4yr CSS 94%, local recurrence 5%
(McDougal)
• Cx: urinary fistula, ureteric stricture

106. Notes & LESS

107. What are Notes & LESS?
• NOTES
– Natural orifice transluminal endoscopic surgery
– Adv
• Cosmesis, no skin incision risk, less invasive, less physiological
impact
– Disadv
• Access navigation, peritonitis, fistula, intraop bleeeding
– For nephrectomy, bladder surgery
• LESS
– LaparoEndoscopic Single-site Surgery
– Instruments
• Access portals: Triport/ Quad port
• Instruments: Standard straight lap, fixed bent, articulating, robotics
• Scopes: End light source / Rt angle light cord; Articulating eye pieces
(Endoeye)
– Adv: Cosmesis, ↓ skin incision risk

108. Any other alternatives for
TURP?

109. BPH: min. invasive Tx options
• TUNA
– TU RF needle ablation
– Done under LA
– Heat → localized necrosis of prostate
– Modest improvement in SS and Qmax
– Min. invasive option for LUTS
– ? LT effectiveness
• TUMT
– IU catheter with cooling system
– Prostatic heating and coagulative necrosis
– SS improvement in 75% patient
– Long cath time, ↑ UTI and irritative voiding Sx
– For those avoid surgery

110. BPH: min. invasive Tx options
• HIFU
– Focused USG, ↑ temp to prostate.
– TR probe. GA.
– Investigational
• Prostatic stent
– Temp: usu. after procedure
– Permanent, metal coil Urolume
– Memokath: Nickel-Titanium stent with thermal
shape-memory effect for treating prostatic
obstruction and enlargement

111. BPH: stents
• Advantages
– They can be placed in less than 15 minutes under regional
anesthesia.
– Bleeding during and after surgery is minimal.
– The patient can be discharged the same day.
• Disadvantages
– They may cause increased urination and limited incontinence.
– They may cause mild discomfort
– They can become dislodged, leading to urinary obstruction or
total incontinence.
– They can become infected and can be very difficult to remove.
– Their fixed diameter limits subsequent endoscopic surgical
options.

112. TUNA and TUMT

113. What is TUNA ?
TUNA
• TU RF needle ablation
• Done under LA
• Low level RF energy  Heat → localized necrosis of prostat
• Modest improvement in SS and Qmax
• Not for: Prostate >75cc or BNO
• Adv:
– LA, Day case
– Min. invasive option for LUTS
• Disadv:
– Irritative symptoms lasting up to 4 weeks
– 20% require additional txn
– No long term result available
• Evidence:
– Only one RCT : Symptomatic improvement: 50%, flow rate 40%

114. What is TUMT?
• Transurethral microwave therapy
(Proststron)
• IU catheter with cooling system
• Prostates heating and coagulative
necrosis
• SS improvement in 75% patient
• Long cath time, ↑ UTI and irritative voiding
Sx
• For those avoid surgery

115. Bipolar TURP

116. BPH bipolar TUR
• Bipolar TURP (B-TURP) addresses a fundamental flaw
of monopolar TURP (M-TURP) by allowing performance
in normal saline, and the technique seems to be
promising
• 16 RCT
– Short term efficacy: no difference
– >12 months: scarce reports
– B-TURP is preferable due to a more favorable safety profile
(lower TUR syndrome and clot retention rates) and shorter
irrigation and catheterization duration.
– Well-designed multicentric/international RCTs with long-term
follow-up and cost analysis are still needed.
Eur Urol 5 6 ( 2 0 0 9 ) 7 9 8 – 8 0 9

117. What is bipolar TURP?
• Plasmakinetics, TURis
• Adv
1. ↑ Safety profile
• ↓ TUR syndrome due to normal saline irrigation (0 case, NNT 50)
• ↓ clot retention rate (NNT 20)
• ↓ post op irrigation duration
• ↓ catheterization duration
2. Equal short term efficacy (<1yr) in voiding parameters eg. Qmax, IPSS/QOL
3. No difference in OT time, tranfusion rate, retention after TWOC, urethral Cx
• Disadv
– ? ↑ Urethral stricture (Ho & S Yip, Singapore)
• Due to electric current return (leak) via resectoscope sheath
• ↑ diameter
• Higher ablative energy
• ↑ OT time
– Scare data on >12 month study
• Ev
– Meta-analysis by Mamoulakis 09: 1406 pt, 16 RCT.
• Limitation: Limited FU (12 mth)

118. Botox in BPH/ LUTS

119. LUTS/BPH: Botox
• Botulinum neurotoxin type A (BoNT-A)
intraprostatic injection seems to relieve
patients with lower urinary tract symptoms
(LUTS) due to benign prostatic
enlargement (BPE). However, the level of
evidence and grade of recommendation
are relatively low. Therefore, there is a
need for large placebo-controlled studies
and long-term results.
Eur Urol 2008 54(4): 765-777

120. What is Botox in BPH/
LUTS?
• Experimental/ animal studies
– Relaxation of prostate
– Atrophy
– Inhibit trophic effect of autonomic system-> ↓ size
• Clinical studies: 9 case controlled, only 1 RCT
• Meta-analysis by Oeconomon (FU<19mth)
– ↑ Qmax
– ↓ QOL/ IPSS, PVR, PSA, prostate vol
– If AROU-> All can void post-op
– Local or systemic S/E rare
– Effect can last 12 mth
• Limited evidence-> still experimental

121. Narrow band imaging (NBI)

122. Narrow Band Imaging (NBI)
• Traditional diagnosis is by white-light
imaging (WLI) cystoscopy
• WLI fails to detect small papillary and
subtle flat CIS lesions
• NBI improves the detection rate of above
lesions
• Other uses
– Barrett’s esophagus in OGD
– Ca lung in bronchoscopy
– Neoplastic polyp in colonoscopy

123. • Optical image enhancement
technology from the Olympus Lucera
sequential RGB endoscopy
• Narrow the bandwidth of light output
• Wavelength: 415 nm and 540 nm
• Strongly absorbed by haemoglobin
and penetrated only the surface of
tissue
• Urothelial carcinomas are vascular
• ↑ visibility of surface capillaries
and blood vessels in the
submucosa
• Enhance the contrast between
superficial tumors and normal
mucosa
Olympus Lucera

125. Evidence
WLI NBI
No. of
tumours
64 79
29 patients recruited
15 more tumor lesions were found in 12 patients
0.52 lesion / patient (P <0.001, Wilcoxon signed-rank test)
Richard T. Bryan, Lucinda J. Billingham and D. Michael A. Wallace. Narrow-band imaging flexible cystoscopy in the detection
of recurrent urothelial cancer of the bladder. BJU International 2008; 101, 702-706
NBI improves the detection of recurrent bladder tumours (esp CIS) in surveillance WLI
cystoscopy
Increase tumour detection rate
WLI NBI
Sensitivity 87% 100%
(p=0.05)
Specificity 85% 82% (NS)
PPV 66% 63% (NS)
NPV 96% 100% (NS)
Harry W. Herr and S. Machele Donat. A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect
bladder tumour recurrences. BJU Intenational 2008; 102,1111–1114
*nine showed CIS*
Check cystoscopy in NMIBC 427 patients

126. Evidence
• 26Fr resectoscope with Exera II Olympus
• 47 patients NBI assisted TURBT after WLI TURBT and 6 cores Bx
(2nd look TURBT)
• 40 more biopsies taken, 11/40 biopies were positive
• 6 more patients was found to have Ta high grade tumor / CIS
Adding NBI biopsies at the end of an extensive second TUR protocol in patients with newly
diagnosed high-grade NMIBC
Angelo Naselli, Carlo Introini, Franco Bertolotto, Bruno Spina and Paolo Puppo. Narrow band imaging for detecting residual/
recurrent cancerous tissue during second transurethral resection of newly diagnosed non-muscle-invasive high-grade bladder
cancer. BJU International 2009; 05, 208–211

127. New Optical techniques for Diagnosis of Ca
Bladder
2. Narrow band imaging
– An optical image enhancement technique to enhance contrast
b/w mucosal surface & microvascular structure w/o use of dye
during cystoscopy & aim to detect more CaB
– It is based on phenomenon that depth of light penetration into
mucosa ↑ with ↑ wavelength, & the mucosal surface is
illuminated with light of a narrow bandwidth, blue & green
spectrum, which are strongly absorbed by haemoglobin, hence
the vessels appear dark brown or green against a pink or white
normal mucosal background
– No RCT
– Results
• ↑ detection of tumour recurrence in NMICaB by 12% (Herr)
• Sn ↑ from 90 -> 100%

128. New Optical techniques for Diagnosis of Ca
Bladder
3. Raman spectroscopy
– An optical imaging technique that measure the
molecular components of tissue based on the
unique wavelength shift, of tissues molecules
with different histopathology
– Adv
• Real time, objective prediction of pathologic Dx
• Capable of differentiating inflammatory from malignant
tissue
– Disadv
• Experimental, no human in vivo studies
• Limited field of view

129. New Optical techniques for Diagnosis of Ca
Bladder
4. Optical coherence tomography
– An optical imaging technique which produce high resolution cross-
sectional imaging of tissues using elastic light scattering as the contrast
mechanism, which aims to improve prediction on histology
– Adv
• High resolution image comparable with histopathology
• Info about depth of tumour
– Disadv
• Experimental
Metaanalysis by
Cauberg, Mowatt
Sn Sp
White light
cystoscopy
70% 70%
Cytology 50% 90%
PDD 90% 60%
NBI 100% 80%

130. Photodynamic Diagnosis
Fluorescence cystoscopy

131. PDD
– An optical image enhancement technique which
– aims to improve visualization of bladder tumour by
using fluorescence as a contrast mechanism to
detect pathology
– e.g. 5-aminolevulinic acid (5-ALA), which is starting
point of haem biosynthesis pathway & is
predominantly accumulated in tumour tissue, & its
intermediate protoporphyrin appears red under blue-
violet light, while normal tissues appears blue.
– 5-ALA administered 2 hrs before cystoscopy through
catheter
– Special telescope & light source (D-light)-> switch
from white to blue light

132. Photodynamic diagnosis (Fluorescence
cystoscopy
– Adv
1. ↑ detection of CaB, esp CIS 40% (sn 70 (white)->
90%)
2. Improve tumor resection (↓ residual tumour in 2nd
TURBT)
3. ↑ recurrence-free survival (Meta-analysis, 5 RCT,
Kausch)
– Disadv
1. False +ve 30% (low specificity) e.g. inflammation,
scar, previous intravesical therapy
2. Expensive
3. Time consuming (2hr administration)

133. Additional – PDD (photodynamic
diagnosis)
• Meta-analysis
• 20% (95% CI, 8–35) more tumour-positive patients were
detected with PDD in NMIBC
• 39% (CI, 23–57) more in subgroup CIS only
• Residual tumour was significantly less often found after PDD
(odds ratio: 0.28; 95% CI, 0.15–0.52; p < 0.0001)
• Recurrence-free survival was higher at 12 and 24mo in the
PDD groups than in the WLI-only groups (p<0.0002)
Ingo Kausch et al, Photodynamic Diagnosis in Non–Muscle-Invasive Bladder Cancer: A Systematic Review and
Cumulative Analysis of Prospective Studies. European Urology, 57(2010) 595–606

134. Imaging

135. Ca prostate staging
• Bone scan equivocal:
– Any alternative?

136. Ca prostate staging
• SPECT
• PET

137. SPECT
• SPECT (Single Photon Emission CT)
– CT + radionuclide tracer
– Spine is a frequent site for degenerative joint disease,
• the diagnostic accuracy of planar BS is low, particularly for a
single focus of abnormal increased tracer uptake.
– SPECT can minimise the shortcomings of planar BS
in the assessment of the spine
• Optimised the use of planar BS, with improved Sn range of
87%-92% and Sp of about 91%, and a PPV of 82%, negative
predictive value of 94%, and an accuracy of 90%.
Semin Nucl Med. 2009 Nov;39(6):396-407. Review.

138. What is SPECT?
• Single photon emission CT
• A radionuclide scan with multiplanar & 3D
reconstructed CT images
• Used if bone scan equivocal
• ↑ bone met detection sn 90%, sp 90%
• Vs PET (exam question)
– Measure radionuclide directly, cheaper, but ↓
resolution

139. Contrast issues

140. Contrast nephropathy/ allergy
• Patient on metformin
• Contrast nephropathy
– Definition
– Mechanism
– Risk factors
– Interventions to minimise risks
• Contrast allergy
– Underlying cause
– Preventive measures

141. What are the CI to IV contrast ?
1. Allergy to contrast media
2. Impaired RFT (Cr > 130 umol/L)
3. Metformin usage
4. Untreated hyperthyroidism and
myelomatosis

142. Contrast nephropathy
• While patient is on metformin:
– Guideline from European Society of Urogenital
Radiology
– 1. if serum creatinine: normal
• stop metformin (at the time of exam until 48 hours passed and
serum Cr remain normal)
– 2. if serum creatinine: impaired
• stop metformin 48 hours before exam, resume metformin 48 hours
later if serum Cr remained at pre-exam level
– 3. if contrast given to patient taking metformin
• metformin stopped immediately
• hydration to ensure U/O 100ml/hr x 24 hours
• monitor serum Cr, lactic acid and blood gas

143. Contrast nephropathy
• Definition
– 25% increase in Serum Cr, or at least 44 umol/L
– during 3 days following contrast administration
• Mechanism:
– Direct toxic effect on tubular cells
– Vasoconstriction
– High osmolar content induce marked natriuresis and
diuresis
– This would trigger tubulo-glomerular feedback
response with constriction of glomerular afferent
arterioles

144. Lactic acidosis
• Symptoms:
–Vomiting, anorexia, hyperpnea, lethargy,
diarrhoea, thirst
• Lab results
–blood pH <7.25, lactic acid> 5mmol/L

145. Risk Factors for Contrast
Nephropathy
• Age >70
• Renal impairment
• Diabetes
• Dehydration
• Congestive heart failure
• Concurrent treatment with
nephrotoxic drugs

146. How to minimize the risk of
Contrast Nephropathy?
• stop nephrotoxic drugs if any
• adequate hydration
• administration of N-acetylcysteine
–600mg bd

147. Contrast ‘Allergy’
• Is it really allergy?
• What is the underlying cause?

148. Contrast medium
Adverse reactions
• Anaphalactoid
– Idiosyncratic reaction unpredictably and
independently of dosage and concentration of the
contrast media
• Related to ionic and high osmolar content of the
contrast
• Leading to release of different mediators
• Chemotoxic
– Severity related to dosage/concentration of
contrast media
– Also related to characteristics of the agent

149. Prevention of Contrast Adverse
reaction
• use low molecular non-ionic contrast
medium
• Corticosteroid

150. USG

151. What is USG machine?
• Diagnostic
• Sound wave by passage current through piezoelectric
transducer and subsequently focused
• Lower frequency for deeper object
• 7MHz for transrectal
• 3.5MHz for transabdominal
• Sound wave was deflected back to transducer forming
the image
• Larger density produced greater echo (like stone)
• Time taken for waves to come back to transducer can
determine the depth

152. What is USG machine?
• Therapeutic
• USG lithotriptsy
• HIFU
• Guidance for brachytherapy, cryotherapy
and ESWL

153. USG for CaP
• Power Doppler USG
– The magnitude of colour flow output is displayed rather
than Doppler frequency signal
– Not display flow direction or diff velocities
– Used to ↑ sensitivity to low flows & velocity
– Adv
1. Sensitive to low flow
2. ↑ CaP detection 50 (conventional TRUS) ->70%
– Disadv
1. No directional info
2. Poor temporal resolution
3. Susceptible to noise

154. Elastogram

155. Rationale
• Ca prostate
• Higher cell density
• Altered tissue
elasticity
• Measured and
displayed by US
elastography
• Aim detect ‘hard’
lesion
• For targeted biopsy

156. How it works?
• Visualize local
displacement on
compression
• Compare USG image
pairs (compressed vs
decompressed)
• System compute the
tissue strain by degree
of local displacement
• Stiffness displaced as
different colours

157. Role in Mx of Ca prostate
• For ca prostate
detection

158. Role in mx of Ca prostate
• For lesion guided
biopsy
• May decrease the no.
of cores needed to
detect a cancer

159. Role in Mx of Ca prostate
• Potential to illustrate
ECE and SVI (for
staging information
• Interrupted ‘soft rim
artifact’
• Increase stiffness of
SV

160. limitation
• Inter-observer variability of ‘stiffness’:
different degree of compression
• Not every hard nodule is cancer

161. What is 3D USG?
• ↑ detection of CaP
• Assessment of brachytherapy seed placement
• Cryoablation guidance
• Local staging in CaP / Ca bladder

162. Contrast USG

163. What is contrast USG?
• Based on microbubble-based contrast to detect
region of ↑ vascularity
• targeted Bx for CaP
1. ↑ CaP detection ~ 80%
2. Additional info on tumour size/ aggressiveness
3. ↓ no of Bx needed to obtain same detection rate
4. Tumour detected have ↑ Gleason score than random Bx
• Monitor minimal invasive/ medical treatment results
e.g. HIFU/ cryoablation/ hormone
• CE-USG Bx for RCC
– Better differentiation of malignancy & benign renal tumour

164. RenogramRenogram

165. Radiopharmaceuticals in renogram?
• 1. Glomercular: Technetium-99m(99m
Tc) diethylenetriamine pentaacetic acid (DTPA):
peak renal activity 3-4 min after injection; 90% glomerular filtration in first 2 hr; Used
to access renal blood flow, function and drainage; Measure GFR as only glomerular
filtration with no tubular reabsorption / excretion
• 2. Tubular: 99m
Tc-mercaptoacetyltriglycine (MAG-3): 90% promximal tubular excretion
and 10% glomerular filtration in animal study; Measure renal plasma flow, renal
function and drainage; Especially for patients with decreased renal function and of
infants
– Adequately hydrated, empty their bladder, frusemide is the diuretic of choice
– Vascular phase (0-60s), parenchymal phase (3-5 mins), excretory phase (>5
mins)
– Tc 99m has a half life of 6 hours
– IV frusemide in renography will increase the urine flow from 1ml/min to 20ml/min
within 3 min and 40ml/min after 15 mins
• 3. Cortical:99m
Tc-dimercaptosuccinic acid: uptake in distal convoluted tubules;
pelvicalyceal system not visualized; static image after 2-4hr, maximum activity 3rd
-6th
hr

166. Radionuclide scintigraphy
• DMSA for renal scarring/ static scan
• MAG3/ DTPA scan for differential function and
assessment of obstruction/ dynamic scan
MAG3 DTPA
Glomerular filration < 5% > 95%
Tubular secretion 95% Minimum
Clearance Predominantly by
tubular secretion;
small proportion by
glomerular filtration
Min. tubular secretion
or absorption
Almost completely by
glomerular filtration
Cost Higher Lower

167. Radionucline scintigraphy
• Patient prep:
– Adequate hydration
– Empty bladder before procedure
• Factors affecting the scan:
– Renal function
– Hydration status
– Collecting system capacity
– Bladder effect

168. How to describe renogram curves?

169. How to describe renogram curves?
• O’Reilly classify the renogram curves, during F+20 lasix renogram
• Type 1
– Normal curve of a nonobstructed kidney. It is characterized by early uptake of the
radioisotope pharmaceutical by the kidney and a prompt excretion of that. The excretion
part of the curve is characterized by an upward concavity
• Type 2
– Consistent with ureteric obstruction
• Type 3a
– Represent a dilated but non obstructed pelvicalyceal system
• type 3b
– An equivocal curve that need further investigation with F-15 renogram. Type 3b curve could
be secondary to partial ureteric obstruction or impaired renal function. An F-15 renogram
might be able to distinguish between the two by ensuring adequate diuresis
• Type 4 curve
– Homsy’s sign – obstruction with delayed decompensation. It represents a delay upward
deflection of the excretory part of the curve. It could represent VUR or significant
extravasation with recirculation of the radiopharmaceutical (more commonly seen in
children)
– Confirmed by F-15

170. What are the causes of nonobstructive
upper tract dilatation?

171. Whitaker test

172. What is Whitaker test?
• Indicated in equivocal ureteric obstruction
• When a F+20 renogram shows a type 3b curve, an F-15
renogram should be carried out before Whittaker test
which is invasive
• It involves establishing a percutaneous access to renal
pelvis, this allows infusion of saline or contrast at
10ml/min
• The nephrostomy line and a catheter are connected to
manometers and the pressure difference (PD) between
the bladder and the pelvis is recorded.
• <15 non obstructed, 15-22 equivocal, >22 obstructed

173. What is Xray safety precaution?
• Pregnancy test of childbearing female
• Theatre doors were closed
• Warning signal and red warming light
• Lead apron and thyroid shield
• ALARA
• Xray as close as the operating table so as
to keep distance from radiation source

174. Bone scan

175. Bone scan
• Aim: A radionuclide scan used to detect bone abnormalities which has increased
osteoblastic activity
• Technitium 99-medronate (methylenediphosphonate)
• 60% eliminated via kidney
• Rationale: high phosphate uptake by immature bone (Sv 95% in CaP)
• Procedure
– 99Tc-medronate injected
– Adequate hydration
– Empty bladder b/w injection & imaging, & just before imaging to ↓ bladder
shadow to pelvis
– Image collection at 3 hrs after injection (Ant, post)
• Radiation: 3.5mSV, T1/2: 6 hrs
• ↑ uptake (& false +ve)
– Bone metastasis
– Fractures
– Degenerative bone disease
– Paget’s disease
– Metaphyseal-epiphyseal growth in children
• False –ve
– Aggressive tumor that induce little osteoblastic attempt at repair

176. • reflects osteoblastic activity and skeletal
vascularity at sites of active bone
formation
• If IV bisphosphonate is use:
– it is recommended that bone scan be deferred
for 4 weeks after completion of intravenous
bisphosphonate therapy, because it reduce
tracer uptake in the normal bone

177. Man with disseminated Ca prostate
• What is this investigation? (0.5) Isotope used? (0.5)
• What is this picture commonly called? (1)

178. • Bone scan (0.5)
• Technetium-99m labelled methylene
diphosphate (MDP) (also known as
medronate or medronic acid) (0.5, no
mark for abbreviated name)
• Superscan (1)

179. SuperscanSuperscan
• Patients with disseminated CAP may
demonstrate a “superscan”
– A symmetrical increased uptake throughout
the skeleton
– Minimal soft tissue activity
– Absent or dim renal uptake
• Due to increase skeletal uptake  very
little tracer is distribute to the soft tissue or
excreted in the kidneys

180. What is DEXA?
• Dual energy Xray absortiometry
• Measure bone mineral density, to detect osteoporosis
• Mechanism
– 2 Xray beam with different energy levels aim at bone
– Subtract soft tissue absorption
– BMD calculated from absorption of each beam by bone
• Radiation: 1/10 of CXR
• T score (vs young adults), Z score (vs age matched)
• Osteoporosis (<-2.5 sd), osteopenia (-2.5 to -1 sd)
• Adv
– Simple & non invasive
– No anaesthesia
– Extremely low radiation
– Most accurate Dx of osteoporosis
– Equipment readily a/v
– No S/E
• Disadv
– Still radiation
– Pregnancy

181. On table IVU

182. On table IVU
– When, because of shock and need for immediate
laparotomy, a patient is transferred immediately to the
operating theatre without having had a CT scan, and
a retroperitoneal haematoma is found, a single shot
abdominal X-ray, taken 10 min after contrast
administration (2ml/kg of contrast), can establish the
presence/absence of a renal injury and the
presence of a normally functioning contralateral
kidney where the ipsilateral kidney injury is likely to
necessitate a nephrectomy.

183. New technology

184. Ca bladder
Any better option for cystoscopy?

185. Ca bladder - Dx
• Photodynamic Dx for bladder tumour
– Fluorochrome 5-aminolevulinic acid (5-ALA) and its ester
derivative hexaminolevulinate can be safely instilled in the
bladder
• where they preferentially accumulate in neoplastic tissue. Malignant
areas appear red, and normal tissue blue, when the bladder surface
is illuminated with blue–violet light via a rigid cystoscope.
• PDD detects more bladder tumour–positive patients,
especially more with CIS, than WLC. More patients have
a complete resection and a longer RFS when diagnosed
with PDD.
(Systemic Review: Eur Urol 2010)

186. How about urine markers for
Ca bladder

187. Urine Markers for Ca bladder
1. Fluorescence in situ hybridization (FISH)
2. ImmunoCyt
3. Nuclear matrix protein (NMP22)
4. BTA stat test (viva)
5. Telomerase (viva)
• All higher sn but lower sp than cytology
• Highest sn: Immunocyt (85%), FISH (75%), NMP22 (70%),
cytology (50%)
• Highest sp: Cytology (90%), FISH (85%), NMP22 (80%),
ImmunoCyt (75%)

188. TissueLink

189. What is it
• Device used to seal off blood vessels, as
pre-coagulation so enable ‘bloodless’
dissection
• Initial invented for hepatectomy
• Currently extend to kidney , pancreas ,
brain, colon, orthopedics surgery either
open or laparoscopic

190. Mechanism
• Simultaneously deliver radio-frequency ( RF )
energy and saline as thermal energy to the
tissue to seal off bleeding vessel
• The coupling of saline and RF allows the
device temperature to stay at approximately
100°C, nearly 200°C less than conventional
RF energy devices, resulting in a tissue effect
without associated charring.
• It stops bleeding by transforming collagen,
remodelling and resulting in a permanent
seal.

191. benefits
• No need to clip or tie during parenchymal
transection
• Bloodless transections, often no need for in-flow
occlusion
• Produces a sealed remnant organ bed that will not
crack and rebleed
• Single device for either pre-coagulation alone or
simultaneous pre-coagulation and blunt dissection
• No char and a virtually bloodless field make the
plane of dissection clear
• Simple set-up - all you need is a standard
electrosurgery generator and a bag of saline

192. Urology application
• Solid organ dissection  partial
nephrectomy
• Potentially bloodless dissection w/o
clamping pedicle

193. Energy source

194. What are the different types of
energy source?
• Diathermy
– High frequency alternating current
– 400kHz to 10MHz, / 0.25 to 2 MHz
– Up to 1000 degree
– Nerve and muscle are not stimulated with high
frequency current as no time for cell membrane to
become depolarised
– Large patient plate is required not for heat dissipation
– Radiofrequency ablation is not a form of diathermy
– Cutting mode – continuous sine wave, 125-250W, for
vaporisation and cutting, low charring
– Coagulation mode – pulsed sine wave, 10-75W, for
fulguration, high charring

195. What are the potential
complications of diathermy?
• Burn
• Explosion
• Obturator jerk
• End artery necrosis
• Pacemaker damage

196. Energy source
• Bipolar electrocautery
– Adv
• For haemostasis & also dissection
• Minimize damage of adjacent tissue
• Allow selection of depth of tissue damage by using diff sized forceps
– LigaSure
• Bipolar radiofrequency generator & lap Maryland forceps
• Combination of pressure & energy to create vessel fusion
• For vessels ≤6mm (inadequate for renal pedicle)
• Safe, cost effective, time-saving
• Monopolar electrocautery
– Tissue-link
• Monopolar radio-frequency energy with low-vol saline irrigation for haemostasis &
blunt dissection
• Disadv
– May cause carbonisation & impair vision of operative field
– Damage to significant margin of healthy tissue e.g. collecting system

197. What are the different types of
energy source?
• Harmonic scalpel
– High frequency ultrasound for
haemostasis(>55kHz) & dissection (25kHz)
– Adv
• Less collateral damage
• Avoid carbonisation of tissue
• ↓ local thermal damage
– Disadv
• For small vessels only (<4mm)

198. Tissue Sealants & Haemostatic
agents

199. Haemostasis in laparoscopy
• Proper case selection
• Intra-op measures to ↓ bleeding
– Primary prevention
• Proper tissue dissection
• Identification of supplying blood vessels
• ↓ pneumoperitoneum at the end to identify venous bleeding
– Haemostasis
1. Energy sources
– Bipolar electrocautery
» Ligasure, Plasmakinetic
– Monopolar electrocautery
» Argon beam coagulator, Tissuelink
– Ultrasonic device
» Harmonic scalpel
2. Clip system
– Self-locking ligation clip: Hem-o-lock
– Titanium clip: tend to slip
– Vascular endo-stapler: Endo-GIA: Insufficient sealing for major vessels; costly
3. Haemostatic & sealing agents
4. Surgical techniques
– Sutures, local compression

200. What are the tissue Sealants &
Haemostatic agents?
• Usage: Haemostasis, tissue adhesion, urinary tract sealing
• Renal trauma, partial nephrectomy, urinary tract fistula,
PCNL tract, RRP nerve sparing, promote wound healing
• Types
1. Enzymatic agents
• Fibrin: tisseal
• Thrombin: floseal
2. Cross linking sealants
• Coseal
3. Mechanical scaffold
• Porcine (pig) gelatin: Gelfoam
• Collagen
• Oxidized cellulose: Surgicel
• Cx in general
1. Thromboembolism due to intravascular use
2. Coagulopathy after repeated use of bovine (cow) products
3. Allergy to bovine antibrinolytic (tisseal)

201. What are the tissue Sealants &
Haemostatic agents?
1. Tisseal
– Fibrin sealant
– Human fibrinogen & thrombin & antifibrinolytic aprotinin (bovine/ synthetic)
– Contraindication: Intravascular use due to systemic thrombosis
– Delivered using a dual-chamber delivery system-> rapid clot formation
– Adv
1. Also for tissue adhesion & urinary tract sealing
2. Also promote wound healing due to ↓ dead space & induce fibroblast
migration
– Disadv
1. Required a dry (bloodless) surgical field
2. Viral transmission (human)
3. Not if bovine allergy

202. What are the tissue Sealants &
Haemostatic agents?
2. Floseal
– Matrix haemostat
– Combine 2 component :
• Human thrombin component
• bovine gelatin matrix granule  cross-linked gelatin granules
– Both enzymatic & mechanical haemostasis
– Gelatin matrix granule fill the wound & expand 20% within 10 min when in
contact with blood
– Form clot & matrix provide mechanical tamponade
– Matrix reabsorbed within 6-8 wk
– Adv
• Localized effect, only when blood present (due to no fibrinogen)
• Ease of application of flowable preparation
• ↓ Bleeding in lap partial nephrectomy (12 -> 3%) even w/o need to
renal ischaemia (Gill)
– Disadv
• Not tissue glue or urinary tract sealant, only pure haemostasis
• Do not inject or compress Floseal Matrix into blood vessels.
• Do not apply Floseal Matrix in the absence of active blood flow, eg.,
while the vessel is clamped or bypassed.
• Extensive intravascular clotting and even death may result
• May carry a risk of transmitting infectious agents, e.g., viruses, and
theoretically, the Creutzfeldt-Jakob disease (CJD) agent

203. What are the tissue Sealants &
Haemostatic agents?
3. Gelform
– Porcine gelatin sponge
– Mechanical scaffold for platelet adhesion & clot formation
– Absorbed within 4-6 wk
4. Surgicel
– Oxidized cellulose
– Acidic material to form a mechanical scaffold for clot formation
– Antibacterial
– ↓ urinary fistula & bleeding in LPN (Gill)
• e.g. surgical bolster
– Disadv
• Confusing in post-op imaging after PN
– ? Tumour recurrence / abscess

204. What are the tissue Sealants &
Haemostatic agents?
5. NovoSeven
– Recombinant activated factor 7 for haemophilia
– IV administration
• Bind to exposed tissue factor or activated platelets &
cause clotting at site of bleeding only
– Very limited evidence, only off label use in e.g.
trauma
– Reported elective use in urology: RRP & renal
transplantation
– ↓ bleeding in RRP (Friederich)
– Safe (Cx esp thromboembolism 1%)

205. PCA3

206. What is PCA3?
1. PCA3 (Prostate cancer gene 3 assay) (UPM3 test): PROGENSA
– A prostate specific non-coding mRNA that is over-expressed 100 times
in 95% of CaP specimen than in benign prostate
– Aim
1. To improve CaP detection
2. To guide decision for TRUS Bx
3. To differentiate clinically significant from indolent disease
– Suitable scenarios
1. ↑ tPSA & -ve Bx
2. ↑ tPSA 2.5-10
3. ↑ tPSA & concomitant urinary condition e.g. BOO/ prostatitis
4. Normal tPSA & FHx
– Measure PCA3 & PSA mRNA concentration in urine collected after DRE
– PCA test-> PCA3 score = PCA3 mRNA/ PSA mRNA x 1000 (abnormal if
>35)
– Adv
1. High sensitivity (70%) & specificity (90%) & similar in all PSA levels (Hessels)
2. Not affected by prostate vol, age , previous bx, tPSA level
3. Correlated with tumour vol
4. May be a predictor of extracapsular extension
5. Greater dx accuracy predicting outcome of repeat bx than tPSA and fPSA

208. Ca Prostate New Markers
1. Human Kallibrein 2 (hK2)
– Product of KLK2 gene. Predictor of ECE & SV
invasion
2. Prostate specific membrane antigen
(PSMA)
3. Prostate specific antibodies
4. Urokinase-type plasminogen activator
receptor (uPAR)
5. Early Prostate cancer antigen (EPCA)
6. GSTP-1 Hypermethylation

209. TMPRSS2-ERG fusion gene

210. What is TMPRSS2-ERG fusion
gene?
• TMPRSS2 gene - androgenregulated
gene
• Increased urine TMPRSS2-ERG fusion
transcript in Ca prostate
• Measured by Polymerase chain reaction
(qPCR)
• Noninvasive detection of prostate cancer

211. Ca Prostate
• Androgen responsive tumor
• Gene mutation
– TMPRSS2
• Prostatic specific androgen related
transmembrane protease serine 2
• Function of this gene unknown
– ERG
• ETS (Erythroblastosis virus 26) Related
Gene
• Family member of ETS transcript factors
• Act as positive or negative regulators of the
expression many genes and that are
implicated in cellular proliferation,
differentiation, hematopoiesis, apoptosis,
tissue remodeling, angiogenesis,
transformation
– Both located in chromosome 21
– Gene fusion by
• Deletion
• Insertion

212. Gene fusion
• TMPRSS2-ERG gene fusion
– TMPRSS2:ERG fusion in 50% of prostate cancer
– Absent in BPH
• Mechanism of action
– Fusion of untranslated sequences of TMPRSS2:
ETS
– Other molecular changes include loss of PTEN
(phosphatase and tensin homolog ), a tumor
suppressor.
– Increased expression of an ETS transcription
factor in response to activated androgen receptor
then occurs.
– The ETS transcription factor would then induce
transcription of genes that block checkpoints
triggered indirectly by inactivation of PTEN.
– This allows for down regulation of receptor tyrosine
kinases (RTKs)—allowing for unchecked activity of
AKT/PKB (protein kinase B), which promotes cell
proliferation and survival.

213. Clinical Implications
• Cancer Detection and Diagnosis
• Risk stratification
• Treatment

214. Detection and Diagnosis
• Urine based assay
– TMPRSS2-ERG fusion transcript in urine
– Sensitivity: 30-50%
– Specificity: >90%
– Detect 15-20% of men with Ca prostate but
have normal DRE and PSA <4
• Assist in tissue diagnosis
– Ongoing research on its association with
PIN/PINATYP

215. Risk stratification
• Untreated TMPRSS2-ERG prostate
cancer has more aggressive clinical
course than fusion-negative cancer
• Conflicting result about prognosis of
fusion-positive vs fusion-negative cancer
post prostatectomy
• No reports of association btw gene fusion
and RT/ADT/monitoring of recurrence

216. Treatment
• Potential therapeutic targeting of
ETS gene fusions:
– Androgen or estrogen signaling
– Short interfering RNA (siRNA) target on
chimeric ETS gene transcripts
– Interaction of encoded ETS proteins and
cofactors that regulate transcription of target
genes
– Binding of ETS genes to specific DNA
sequences present in the regulatory region
of downstream targets
– Some downstream target proteins that are
required for the phenotypic effects caused
by ETS gene fusions may also be targeted.

217. References

218. Prostate Core Mitomic Test

219. Mitomics Inc.
• Mitomics is a biotech company found in 2001,
headquartered in Ontario, Canada
• Works on mitochondrial DNA based on large-
scale deletions in mitochondrial DNA (mtDNA)
can indicate cellular changes that are associated
with the development of cancer
• Several test kits:
– Prostate Mitomic Test : CA prostate
– Breast Mitomic Test : CA breast
– Endometrial Mitomic Test : endometriosis

220. Prostate Core Mitomic Test™
- The First Choice for Avoiding Second Biopsies
• Indicated when initial prostate biopsy
negative but
– persistently elevated PSA or a rising PSA, or
abnormal DRE
– Atypical small acinar proliferation (ASAP)
– High-grade prostatic intraepithelial neoplasia
(HGPIN)
• Based on first biopsy specimen
– Sensitivity 80 - 84 %; Specificity 71 – 79 %

222. Artificial neural network

223. What is artificial neural network?
• Group of smaller elements called neurons
which each element has a set of inputs
and a single output
• Each input is multiplied by a weight and
the value of these weights is the one that
determines the output of the neuron
• The result of the operation of the inputs
and the weights is added together
providing an output

224. Artificial Neural Network
Biological Neural Network

225. Artificial Neural Network
A mathematical model or
computer model that is
inspired by the structure
and/or functional aspects
of biological neural
networks
Consists of an
interconnected group of
artificial neurons
They are usually used to
model complex / non-
linear relationships
between inputs and
outputs

226. Application
Tumor Field of
application
Reference
kidney Diagnostic aid Maclin PS et al. Using neural networks to
diagnose cancer. J med Syst 1991; 15: 11-9
Bladder Diagnostic aid Qureshi KN et al. Neural Network analysis of
clinicopathological and molecular markers in
bladder cancer. J Urol 2000; 163: 630-3
Determination
of prognosis
Fujikawa K et al. Predicting disease outcome of
non-invasive TCC of urinary bladder using an
artificial neural network model; results of patient
following up for 15 years or longer. Int J Urol
2003; 10: 149-52
Testicle Staging aid Moul JW, Proper staging techniques in testicular
cancer patients. Tech Urol 1995; 1: 126-32
Applications of ANNs in oncological urology

227. Application
• CA prostate
• Screening and early diagnosis
• Staging
• Disease progression

228. Randall’s plaques

229. What are Randall’s plaques?
• Are apatite deposits in the tip of renal papilla
which provide ideal site for overgrowth of
Calcium oxalate to form stone
• Microscopically the deposits are
hydroxyapatite, & in the medullary interstitial
space & originated in the basement membrane
of thin loop of Henle
• Present in 20% pts (Randall)

230. HIFU

231. What is HIFU for Ca
prostate?
• For CaP (Not recommended as 1st
line)
• Use focused ultrasound waves emitted from
rectal transducer to cause coagulative necrosis
through both mechanical & thermal effects
• Require GA/SA, can be time consuming

232. Sterilisation, disinfection,
cleaning and autoclaving

233. How do you classify surgical
equipment in terms of cleaning?
• Critical-high risk of infection, direct contact
with blood eg surgical instruments
• Semi-critical-intermediate risk of infection,
contact with intact mucous membranes eg
endoscopes
• Non-critical-contact with skin eg BP cuff

234. • How are rigid scopes cleaned ?
– Autoclave
• How are flexible scopes cleaned ?
– Have fragile optics and are heat sensitive, therefore
require liquid chemical sterilisation
• Glutaraldehyde, ethylene oxide (toxic) or Gamma
radiation
• Alcohol damage epoxy cement of scopes
• 2 parts : scope dismantled and working channel
cleaned, scope then immersed chlorine dioxide for 30
mins

235. What are sterilization,
disinfection and cleaning?
• Sterilization – complete destruction of living organisms,
e.g. critical instrument like surgical instrument used in
sterile tissue
• Disinfection – remove most viable organisms, not
necessarily inactivate viruses and bacterial spores, e.g.
semi-critical instrument used in mucosa
– Flexible cystoscopy was cleaned with brushes and
detergent and disinfected with chlorine dioxide
• Cleaning – physically remove contamination, but not
necessarily destroy microorganisms, intact skin e.g. non-
critical instrument like blood pressure cuff

236. What is autoclaving?
• Combination of heat and pressure to
sterilize instruments
• Temperature of liquids like water may be
raised above boiling points

237. Anti-coagulant

238. How does aspirin work and what are
you going to advise before OT?
• Binds irreversibly to platelets and prevents
the production of thromboxane
• Takes 7 days after aspirin is stopped for
platelet function to return to normal
• Stop 7 days prior to surgery

239. How does clopidogrel work and what are
you going to advise before OT?
• Anti-platelet effect by binding irreversibly
to ADP receptors on platelets
• Stop 7 days prior to surgery
• Discussion with cardiologist is required
particularly if recent acute coronary
syndrome, awaiting coronary stenting or
recently undergone coronary stenting

240. how does warfarin work and what are
you going to advise before OT?
• Interferes with VIT K metabolism and therefore results in
hepatic synthesis of non-functioning factor I, IX, VII, II
and protein C and S
• Stop 5 days prior to surgery
• Ensure INR less than 1.5 prior to operation
• In high risk cases of thromboembolism admit pre-
operatively for IV unfractionated heparin with appropriate
APTT measurements (1.5-2.5). Stop 6 hours pre-op and
restart 12 hours post-op
– All anti-coagulant / antiplatelet drugs the risk of stopping
medications should be balanced against the risk of a
thromboembolic event – discussion with haematologists and
cardiologists is helpful

241. Blood product

242. What blood products are you
aware of?
• Whole blood – source of all blood products
therefore its use is restricted by most centres
• Centrifuged whole blood produces packed red
cells and platelet-rich plasma
• Packed red cells stored at 4oC up to 35 days,
volume approx 350ml, oxygen affinity falls with
storage due to a decrease in 2,3-DPG
• Centrifuged platelet-rich plasma produces
platelets and plasma Platelets, Stored at room
temp. for 4-6 days, 1 adult dose increases
platelets by 30-60, have to have rhesus
compatibility and should have ABO compatibility

243. What blood products are you
aware of?
• FFP - Frozen at -30 oC for up to 12
months, contains all clotting factors,
volume approx 200mls, ABO compatibility
testing required
• Freezing and rapidly thawing plasma
produces cryoprecipitate - rich in factor
VIII and fibrinogen, no ABO compatibility
required

244. What blood conservation
techniques are you aware of ?
• Preoperative autologous donation –
patients donate a unit of blood in the
month prior to the operation
• Preoperative erythropoietin

245. Cystistat

246. What is cystistat and how it work?
• Sodium hyaluronate
• Structural backbone of the extracellular
protective layer
• Glycosaminoglycans protects the
epithelium against toxic agents and
bacteria

247. What are the indications?
• Interstitial cystitis
– Improve the symptoms and QOLs
• Radiation-induced cystitis
– Decrease radiation-induced toxicity and risk of
infection
• Bacterial cystitis
– Decreases in the average number of
recurrences per year

248. What is the recommended regimen?
• 40mg sodium hyaluronate
• Intravesical instillation after self voiding
• Retained in the bladder for as long as
possible (a minimum of 30 minutes)
• 4-12 Weekly dose regimen and then
monthly until symptoms resolve
• Well tolerated except mild irritative LUTS
secondary to catheterisation
• Not FDA approved drugs

249. Evidence

250. Evidence
• Ried et al
– Uncontrolled study
– 126 patients
– Mean FU 6.5months
– Questionnaire
– 85 % symptoms improvement
– 84% QOL improvement
– Mean VAS 8.5 to 3.5
• However, no significant advantage over placebo
in controlled studies

251. GVAX

252. GVAX®
• GVAX® (Cell Genesys, Inc., South San Francisco,
CA) vaccines are cancer treatment vaccines
comprised of genetically modified tumor cells
engineered to secrete granulocyte-macrophage
colony-stimulating factor (GM-CSF).
• GM-CSF is an ideal vaccine adjuvant because it is
a potent cytokine activator of dendritic-cell antigen
presentation, and it participates in the initiation of
danger signals needed to activate the immune
system, break tolerance, and develop an
antitumor immune response.

254. GVAX®
• A phase III trial comparing GVAX
immunotherapy (CG1940/CG8711) to docetaxel
plus prednisone was initiated in 2004. The study
was designed to enroll 600 patients (pts) with a
primary endpoint of superiority in overall survival
• Methods: Castration-resistant, chemotherapy-
naïve men without cancer-related pain requiring
opioid analgesics were eligible.

255. GVAX®
• GVAX CG1940/CG8711 (500 million cells prime/300
million cells boost doses q2 wks x 13 doses) was
administered in the experimental arm (G) followed by
maintenance GVAX immunotherapy (q4 wks).
• Docetaxel (75mg/m2
q3 wks x 9 cycles) plus
prednisone (10 mg daily) was given in the control arm
(D+P)
• Results and conclusions: Toxicity profile of GVAX is
favorable compared to D+P. While survival was not
significantly improved overall compared to
chemotherapy

256. ERBEJET

257. ERBEJET®

258. ERBEJET®
• The ERBEJET®
unique dissector, is an
innovation in tissue preservation
• The extremely thin laminar jet, rotated in a
helical fashion, forces softer, more water-
soluble tissue to separate, while fibrin-rich
structures are spared.
• This optimizes the preservation of vessels,
ducts, and nerves

259. ERBEJET®
• The preservation of structures is important
where cutting of vessels is common, such
as hepatic (liver) resection. The potential
for blood loss is minimized due to the
unique vessel-sparing capability
• Also offers a benefit in applications where
nerves are particularly at risk, such as
during nerve-sparing radical retropubic
prostatectomy.

260. ERBEJET®

261. Image guided Radiotherapy
(IGRT)
CF Kan

262. Why image-guided despite pre-op
planning?
• Change of position in each session
– Organ movement
– Setup errors
– Change in tumor size and shape during RT
• Decrease margin to protect healthy tissues
• More radiation to target organ to enhance
tumor control
• As a supplement to conformal RT / IMRGT
– IMRT associated with a steep decline in dose
outside target (Mackie TR, 2003)

263. Strategies
• Imaging by ultrasound and integrated linear
accelerator CT-scanner system
• Online approach – acquires and assesses
information from imaging before treatment
and makes corrections if deviation exceed a
predefined threshold
• Offline approach – Frequent acquisition of
images without immediate intervention
– Systemic component (mean offset)
– Random component (standard deviation)

264. Benefit and limitation
• Potential Benefit
– Measurement of tumour changes (e.g. bladder cancer) and
better planning
– Reduce the planning target volume (Millender, prostate position
error: right-left direction 11.4mm and superior-inferior direction
7.2mm)
– Dosimetric benefit (Ghilezan, increase target dose to prostate
from 96.8% to 98.9%)
– Biochemical- relapse free survival 95% to 63% if RT planning for
Ca prostate, 78 Gy, with full rectum (de Courvoisier, 2005)
• Clinical Benefit
– Reduce in toxicity
• Limitation
– Cost of new technology and man-power
– Extra radiation for image guidance with risk of second
malignancy
– No RCT on improvement in survival yet

266. Miscellanies

267. GeneticsGenetics
• C-erb is oncogene coding for EGF
receptor
• Bcl2 gene prevents programmed cell
death

268. AnatomyAnatomy
• Extravasation from bulbar urethra will not
go to buttocks
• Genitofemoral nerve supplies both
cremasteric and dartos muscles