Advances in Camera, Video, and Imaging Technologies in Laparoscopy

0094--0143/01 $15.00 + .00

ADVANCED UROLOGIC LAPAROSCOPY

ADVANCES IN CAMERA, VIDEO, AND IMAGING TECHNOLOGIES IN LAPAROSCOPY John K o u r a m b a s , a n d Glenn M. Preminger, M D

Since its inception, laparoscopic surgery has increasingly become accepted as an alternative to traditional open urologic surgical techniques. Recent advances in laparoscopic surgery are largely attributable to technological improvements in endoscopic equipment. In particular, advances in video cameras and other imaging technologies have decreased the steep learning curve associated with laparoscopic procedures. These changes have helped to solve the problems related to diminished depth perception, reduced visual field, and lack of a three-dimensional view. Advances in imaging technologies, virtual reality, and teleconsultation have allowed a broadening of laparoscopic applications, improved training, decreased morbidity, increased physician acceptance, and enhanced patient care. This article reviews recent advances in laparoscopic imaging technology, teleconsultation, and laparoscopic surgical simulation.

ENHANCED IMAGING TECHNOLOGIES Video Digital Endoscopy When compared with preexisting analog imaging systems, video endoscopic surgery

has been enhanced by several major improvements.18, 22,30 Most notable has been the development of the charged coupled device (CCD) chip camera and digital video imaging. CCD chip cameras have supplanted tube cameras, which were the first video systems on the market. Once an optical image is focused on the CCD chip, there is a conversion of the optical (analog) image to electronic information. 1 This design increases the sensitivity and the amount of information that is captured by the video camera. Recently, three-chip cameras have been introduced that contain three CCD units within a single camera head. Slightly larger than a single-chip camera, the three-chip camera captures more information and provides a superior image. Digital imaging technology is expected to supplant standard analog video imaging over the next few years. In standard analog video processing (NTSC format), images or signals remain as voltages (Fig. 1). Small errors in recording and reproducing these voltages are inevitable, and the errors accumulate with each generation of the video image. In contrast, a digital converter changes all video signals into precise numbers (binary codes), such as 0 or 1 in the digital video formats (Y/C and RGB) (Fig. 2). Conversion to a digital signal gives the video image immunity to noise buildup or

From The Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina

UROLOGIC CLINICS OF NORTH AMERICA VOLUME 28 • NUMBER 1 • FEBRUARY2001

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image quality degradation and creates images that have significantly better color, sharpness, contrast, and field depth than do analog systems2, 5 Moreover, once an image is digitally converted, it can be modified and improved through the use of enhancement and filtering modalities. Enhancement is accomplished using clusters of pixels known as kernels. When contrast e n h a n c e m e n t is activated, the center pixel in each kernel determines the state of its surrounding pixels~ If variations are present in the levels of contrast between the center pixel and the average of its surrounding pixels, those differences are enhanced2 When no variations are present, no changes occur. This process allows finer details to become discernible to the naked eye, Figure 3 demonstrates how an endoscopic image can be improved with digRal enhancement. These beneficial effects were definitively demonstrated in a clinical trial using the Karl Storz Image Processing Module in conjunction with a Tricam SL camera (Karl Storz Ira-

aging, Goleta, CA). 3 Digitally enhanced and filtered images were superior to their unenhanced counterparts when comparing parameters such as image detail, the presence of background noise/interference, and structure identification. Such digital image enhancement will prove valuable for superior imaging during urologic laparoscopic procedures. Digital video imaging has become the new standard of video performance, and digital signal processing is expected to replace analog video technology. The most desirable de~ sign of a video endoscope incorporates placement of the CCD chip in the proximal end (tip) of the endoscope, just behind the objec~ tire lens system. 2 In this video endoscope design, no lens systems run through the shaft of the endoscope. The image is immediately captured by the CCD chip and transmitted by cables through the shaft of the endoscope directly to the camera sitting on the video cart. Placement of the CCD chip at the endo~ scope tip reduces the number of fiberoptic image bundles, thereby resulting in a better video image, reduced chance of camera and scope damage, and a video system with less bulky cables. This change in endoscope de~ sign may permit further downsizing of lapa~ roscope shafts, allowing small-diameter access ports. Smaller, stronger, and longer-lasting endoscopes with higher-image resolution should become a reality in the near future. Currently, only a few video endoscopes are available that incorporate CCD chip technology. Such integrated video endoscopes should rapidly come onto the market within the next few years, and their use will greatly enhance laparoscopic surgery.

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Digital technology not only erthances laparoscopic imaging in real time but allows more accurate image recording in the operating room. In the past, the physician needed a personal computer or laptop computer in the operating room equipped with a video frame grabber to create a digital hard copy of video images. With time, other types of equipment became available for acquiring images onto specialized types of storage media, such as optical disks or tapes. Although these systems provide a means of acquiring and converting images, the storage devices are awkward and

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do not provide a simple interface between the endoscopy cart and the physician's office2 ~ One of the newest devices available to facilitate digital image recording in the operating room is the MaviCap Digital Still Image Capture Adapter (model MVC-FDR3, Sony Corporation, Tokyo, Japan). This unit can be connected to existing endoscopic carts by a cable between the camera output and monitor input ports. This image capture device has a 2.~ inch diagonal LCD display screen that provides previews of still images as flley are captured (Fig. 4). This feature is useful when the device is connected on a parallel circuit to the main camera or monitor video. The

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main monitor. In the operating room, a cordless remote control or a specially designed foot pedal can be used to capture and record specific images. The images attained are saved with a 640 x 480 pixel resolution using the joint photographic expert group (JPEG) compression format. Images are recorded directly onto standard 3.5-inch floppy disks, which, in turn, can then be quickly transferred onto a computer hard drive for permanent archival purposes. The digital still image device can be used

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KOURAMBAS & PREMINGER

during laparoscopic procedure to acquire still images illustrating various medical conditions. These images can be captured on standard 3.5-inch floppy disks. When they return to their offices, physicians can insert the disks into their personal computers to retrieve the images. Images captured in this manner can be sent to colleagues by the Internet, added to procedure reports using various word-processing programs, or posted to Web sites for education and training. 7 Because the images are saved in a JPEG format, they are easily imported into any standard Windows-based programs that support imaging. This modified digital still image capture device provides a reliable, cost-effective solution to acquire quality digital still images during laparoscopic procedures that can easily be used in a variety of different applications, including communications, teaching, and Internet-based correspondence. This device allows the use of existing endoscopic equipment for new applications without incurring excessive expense. Three-Dimensional

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Currently, most commercially available video imaging systems are of the standard two-dimensional variety. To mimic normal three-dimensional vision, three-dimensional video systems have been developed. These systems incorporate a stereoendoscope, which captures an object as two separate offset right and left images (Fig. 5). These images, which are in a slightly different orientation to each other, are then viewed with the aid of shutter glasses. After image processing by the brain, the object appears to be threedimensional (Fig. 6).

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Three-dimensional video imaging enhances the ability to perform delicate endoscopic maneuvers, such as dissection or precise laparoscopic suturing. 14 Indeed, skill tests performed assessing laparoscopic suturing and knot tying have demonstrated a 25% increase in speed and accuracy of these laparoscopic tasks when using a three-dimensional video system as compared with a standard twodimensional endoscopic video system, a, 9 When viewing a particular object with normal (binocular) vision, an individual normally would perceive that object in three dimensions. If one eye is closed, a flattening of the image might be noted. Because of the capability of the image center within the brain to capture and recall images, the viewed object may appear with somewhat limited depth (e.g., in two-and-a-half dimensions). This

ADVANCESIN CAMERA,VIDEO,AND IMAGINGTECHNOLOGIESIN LAPAROSCOPY ability to process visually two-dimensional flat images off a standard video screen and view them in a partial three-dimensional manner may be a significant factor in the ability of experienced laparoscopic surgeons to perform complex surgical tasks. This innate ability to perceive standard flat video images in three dimensions is significantly reduced when the surgeon is confronted with a scene that has not been viewed before, and the introduction of three-dimensional video systems should facilitate the performance of laparoscopic surgical procedures, especially tasks that require intricate dissection or reconstructive techniques. Three-dimensional imaging also facilitates training to perform minimally invasive laparoscopic surgery and may lessen the learning curve for these technically demanding procedures. It is anticipated that three-dimensional video imaging will significantly improve the performance of current laparoscopic procedures and facilitate the development of more advanced, minimally invasive surgical techniques.S, 13

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tion found in current standard NTSC, PAL, or SECAM video images. Current applications of HDTV in medicine include diagnostic and therapeutic m a n e u v e r s during endoscopic surgery. This increased resolution and clarity has been shown to facilitate surgical performance. 31 In fact, some surgeons have likened the extremely high-resolution image afforded by HDTV to a three-dimensional video image. Although not a true three-dimensional image, the increased video information almost gives the perception of depth. High-definition television should eventually become the standard format used in the operating room. The large size of current HDTV cameras and the prohibitive cost of a complete HDTV video system (between $250,000 and $500,000) makes the use of such systems during endoscopic surgical procedures unreasonable at present. Once broadcast formats for HDTV are standardized and increased consumer applications are introduced, the cost and size of these video systems will drop precipitously, allowing the endourologist to use this format during video laparoscopic procedures.

High-Definition Television The Future

Along with the improvements of three-dimensional laparoscopy, improvements in digital video imaging systems are expected to enhance laparoscopic imaging. One such imaging system on the horizon is high-definition television (HDTV). HDTV systems are currently available from manufacturers such as Sony, Panasonic, and Toshiba, and this technology is just being introduced into the consumer marketplace. The major advantages of HDTV include its extremely high-resolution image (greater than 1100 lines of resolution as compared with 500 to 600 lines of resolution with standard video images) in a widescreen format (Table 1). These two factors combined provide an HDTV image with more than 10 times the amount of informaTable 1. BROADCAST FORMATS Format

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It is anticipated that three-dimensional digital video imaging and HDTV will rapidly be introduced into the entertainment, manufacturing, and military industries. As increased uses are identified and more applications developed, these types of a d v a n c e d imaging technologies will be rapidly introduced into medical and surgical fields24 Once these enhancements become commonplace in laparoscopic surgery, the clinician can expect to see even further advances in the form of further miniaturization and improvement of the technologies. These i m p r o v e m e n t s in imaging systems will ultimately lead to improved surgical technique and enhanced patient care during laparoscopic procedures.

E N H A N C E D CONSULTATION AspectRatio

4:3 (Standard screen) 4:3 16:9 (Wide screen) 16:9

Although mastery of laparoscopic technique is greatly augmented by improvements in imaging, a physician cannot become a laparoscopic surgeon w i t h o u t ascending the well-documented and steep learning curve. 12 Adequate exposure to a great number of cases

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is required to become trained sufficiently as a competent laparoscopic surgeon. Unfortunately, aside from major medical centers, exposure to laparoscopic urologic cases is often limited. Smaller hospitals often lack access not only to equipment but also to experts, especially in a specialized field such as laparoscopy, which often results in compromised training and skill acquisition. To meet these needs, the concept of telemedicine and, recently, telesurgery has emerged.

vantages associated with video teleconferencing. Although the costs associated with these systems have greatly decreased, the expense is still substantial enough to make the systems inaccessible to all but the largest medical centers. 21 In addition, a teleconferencing system can be inherently inconvenient to use because clinicians must be present at the same time to interact with one another. This requirement can be problematic when physicians or patients are in locations separated by multiple time zones.

Telemedicine Store and Forward Telemedicine Simply stated, telemedicine (and telesurgery) is defined as the delivery of health care from a distance. By linking medical centers or practices through audio and visual media, medical expertise can be exchanged rapidly and patient care improved as a result. The advent of the Internet, coupled with the increased data-carrying capacity of current telecommunications systems, has made telemedicine a viable tool in the medical environment. Laparoscopic surgery, with its increasing reliance on instrumentation such as robotics, has become the most amenable surgical technique to the concept of telemedicine and telesurgery. Early telemedicine systems allowed live interaction between physicians and patients using closed-circuit television. 39 Unfortunately, high cost, poor quality images, and the lack of consistent transmission precluded clinical use and thwarted further development. Two major advances in technology, digital imaging and the Internet, have had a profound influence on telemedicine systems. Currently, there are two main types of telemedicine systems. The first involves real-time video teleconferencing, which often incorporates audio input to provide interactive capabilities. Video teleconferencing is made possible by using a code-decode (CODEC) unit, which takes analog inputs and converts them into digital equivalents that can be sent over telephone lines. TM 15,21 In general, real-time motion requires that images be generated at a speed of 30 frames per second25 To preserve the resolution and clarity of the video images, the data-carrying capacity of the transmission line must be large. To accommodate this necessity, most video teleconferencing systems use T1 lines, which are comprised of 24 standard telephone lines. 11 Unfortunately, there are also several disad-

Telemedicine can also be accomplished using store and forward systems that allow data to be transmitted over the Internet and saved on the recipient's e-mail account for retrieval at a later time. 29 Although these systems do not allow real-time interaction to take place, they remain effective tools that promote patient care. Most instances of store and forward telemedicine involve images that are sent from remote physicians to tertiary care centers for consultative purposes. This form of telemedicine can be accomplished easily with the aid of dedicated software that allows images and scanned medical records and text to be sent simultaneously in an encrypted format. 19 Store and forward telemedicine is generally less expensive than real-time video teleconferencing, with the only equipment required being a personal computer system used to send and receive data and an image-capturing device, such as a digital camera or scann e t 29, 42

Laparoscopic Applications Despite the shortcomings outlined previously, telemedicine and even telesurgery have become reality. In 1994 Kavoussi and colleagues 17 demonstrated their initial laboratory experience in telerobotic-assisted laparoscopic surgery. Recently, urologic laparoscopic telesurgery has been performed in a clinical setting. In this study, five patients in Rome, Italy, underwent laparoscopic procedures in a center where laparoscopy was only recently introduced, a6 Nine thousand kilometers away in Baltimore, Maryland, a more experienced team oversaw the procedures in real time, offered advice, provided quality

ADVANCES IN CAMERA, VIDEO, AND IMAGING TECHNOLOGIES IN LAPAROSCOPY

control, and even operated instruments remotely. The cases performed included a laparoscopic nephrectomy. This revolutionary approach to telemedicine has o p e n e d the door for more widespread applications of laparoscopic techniques, enhanced training, and improved patient care. In the twenty-first century, the future of telemedicine only looks brighter. Advances in digital imaging resolution and improvements in transmission bandwidth will make telesurgery and decision making through telemedicine more accurate. Technological improvements will lower the cost of imaging devices and of using specialized telecommunications lines. These d e v e l o p m e n t s will make telemedicine systems even more affordable and will greatly enhance the performance of laparoscopic procedures in urology.

SURGICAL SIMULATION Virtual Reality As telemedicine and telesurgery improve laparoscopic training and skill acquisition, the advent of virtual reality surgical simulation will further lessen the well-documented steep learning curve in laparoscopy. Although animals have been used as learning models, differences in anatomy and social issues have limited interest in animal models for surgical training. Virtual reality offers exciting opportunities for the urologic laparoscopist to perfect his or her skills in an inanimate but dynamic model wherein anatomic structures are accurately reproduced, and the feel of the actual procedure is captured. Virtual reality is defined as a computergenerated environment in which detail is faithfully reproduced and objects within the environment have characteristics akin to their reaMife counterparts. 1°, 2o,35 The earliest concepts of virtual reality were described b y Sutherland in the 1960s. 16 This t e c h n o l o g y was further refined in the 1970s by the military and the National Aeronautics and Space Administration. 31Most recently, virtual reality has been used to develop simulation systems in specialties such as pulmonary medicine, otolaryngology, general surgery, and urology20, 20,31,35,40 Anatomic objects in virtual reality are visually created using two-dimensional structures named polygons. Multiple polygons are then joined together to form a smooth three-di-

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mensional object. 1°, 25, 35 To mimic normal three-dimensional vision, a simulation must incorporate the principle of stereopsis, which is the resultant image produced by the brain after fusion of separate views of an object as seen by both eyes. 13,25, 43 This effect can be accomplished using a head-mounted display unit with two separate liquid crystal displays, one slightly offset from the other, or on a special three-dimensional video monitor that incorporates active shutter glasses (Fig. 7). 14' 24 Actual laparoscopic instruments can be incorporated into the simulation and the sensation of pressure conveyed directly through the instruments. 32 Acquisition of adequate laparoscopic skills can take months to years of training. 27, 28 By using virtual reality simulation tools, the surgeon can perfect such skills outside of the operating room or animal laboratory through repetitive simulation. As a result, the surgeon is better prepared for actual cases. This increased efficiency should translate into a reduced operating time and an improvement in overall patient safety. In addition, the opportunity to gain operative experience without direct patient involvement may allow the duration of residency training to be reduced, resulting in a substantial cost reduction. Virtual reality also allows the construction of simulation models tailored to specific patient pathology. 33 For example, a surgeon can take a patient's abnormal CT scan and develop a virtual reality model that incorporates a pathologic mass within the normal structures. This simulation allows the surgeon to practice various operative approaches before the actual case and to determine the optimal surgical approach for removal of the mass. Once again, operative time and risk to the patient can be minimized. A virtual reality simulator may provide an objective assessment of a surgeon's skills. 27,2s Testing modules can assess a surgeon's competence; when all conditions are satisfied, the surgeon can be certified as competent in the tested skills. A recent study using a virtual reality laparoscopic simulator to assess surgical skills revealed that experienced surgeons were able to complete the tasks significantly faster and made fewer errors in movement than less experienced laparoscopistsY

Current Virtual Reality Laparoscopic Applications Current virtual reality surgical simulation systems are limited by an inability to repro-

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duce accurately open surgical scenarios Endoscopic and laparoscopic scenarios are more realistically produced because the clinician can. avoid the complexities of recreating the tactile sensation needed for open cases. Because real instruments can be incorporated into virtual reality minimally invasive simulations, it is much easier to generate realistic sensations of pressure and force feedback through the laparoscopic tools25, 3~ An early urologic virtual reality simulation was devel~ oped by HT Medical (Rockville, MD). ~4 The user was able to perform a virtual laparoscopic lymph node dissection with standard laparoscopic instrumentation; however, this simulation lacked true anatomic relationships, and the graphics were produced in a

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cartoonlike fashion, an example of which is shown in Figure 8. Recent advances have im~ proved on the original systems, notably, the concept of " c u l l i n g " and "collision detection/,6, 2~,32 When culling is applied in a vir~ tual reality simulation, only anatomic structures that can be seen at a specific point of time are revealed to the user2 ~ This effect is crucial to the maintenance of realism. The creation of too many complex objects in a virtual environment can overwhelm even the fastest of computers. When collision detection is applied, the simulation gains the ability to recognize instances of contact between the virtual endoscope and virtual anatomy, ensuring that the virtual instrument does not unwittingly pass through solid structures.

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ADVANCES IN CAMERA, VIDEO, AND IMAGING TECHNOLOGIES IN LAPAROSCOPY

The Future of Virtual Reality Surgical Simulation Although current virtual reality laparoscopic s i m u l a t i o n s s h o w m u c h p r o m i s e , inherent limitations can o n l y be o v e r c o m e w i t h the d e v e l o p m e n t of m o r e p o w e r f u l c o m p u t ers a n d interface devices. It m a y take 3 to 5 years before s i m u l a t i o n s will be able to p r o d u c e virtual e n v i r o n m e n t s in w h i c h a s u r g e o n can interact in a m a n n e r i n d i s t i n g u i s h a b l e to real clinical situations. M a n y c o m p o n e n t s of virtual reality syst e m s are in the p r o c e s s of d e v e l o p m e n t . These c o m p o n e n t s i n c l u d e i m p r o v e m e n t s in the reso l u t i o n capability of h e a d - m o u n t e d displays, the use of laser t e c h n o l o g y to eliminate visual d i s p l a y s altogether (by projecting i m a g e s directly o n t o the s u r g e o n ' s retinas), a n d imp r o v e m e n t s in c o m p u t e r p r o c e s s i n g s p e e d a n d m e m o r y capacity. B,16,35,38,41 A n o t h e r t e c h n i q u e t h a t is r a p i d l y p r o gressing is the use of f e e d b a c k m e c h a n i s m s that p r o v i d e tactile i n f o r m a t i o n to the user. A n e w l y d e s i g n e d f e e d b a c k device i n c o r p o r a t e s 16 degrees of f r e e d o m b y a c o m p l e x a p p a r a tus w i t h m u l t i p l e joints a n d m o t i o n control m a n i p u l a t o r s . 36 Virtual reality will be c o u p l e d w i t h o t h e r modalities, s u c h as telemedicine, to e x p a n d the scope of urologic practice. W i t h a d v a n c e s in virtual reality a n d robotics, it m a y be possible to r e c o n s t r u c t a virtual m o d e l of a real p a t i e n t a n d h a v e a s u r g e o n p e r f o r m or assist in s u r g e r y o n that p a t i e n t w h i l e n o t b e i n g p h y s i c a l l y p r e s e n t in the r o o m . These techn i q u e s will result in greater efficiency a n d better p a t i e n t care.

SUMMARY The i n t r o d u c t i o n of t e c h n o l o g i c a l a d v a n c e s , s u c h as H D T V , t h r e e - d i m e n s i o n a l l a p a r o s c o p y , a n d f u r t h e r m i n i a t u r i z a t i o n of h i g h resolution digital v i d e o c a m e r a s , will allow significantly e n h a n c e d o p p o r t u n i t i e s for laparoscopic surgical proficiency and further b r o a d e n i n g of l a p a r o s c o p i c a p p l i c a t i o n s in urology. These e n h a n c e m e n t s , c o u p l e d w i t h the recent a d v a n c e s in telemedicine a n d surgical simulation, will i m p r o v e l a p a r o s c o p i c training a n d skill acquisition, decrease o p e r a tive times a n d costs, m i n i m i z e morbidity, a n d i m p r o v e overall p a t i e n t care.

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References 1. Allhoff E, Bading R, Hoene E, et al: The chip camera: Perfect imaging in endourology. Endoscopy 6:6-7, 1988 2. Amory SE, Forde KA, Tsai JL: A new flexible videoendoscope for minimal access surgery. Surg Endosc 7:200-202, 1993 3. Aslan P, Kuo RL, Hazel K, et al: Advances in digital imaging during endoscopic surgery. J Endourol 13:251-255, 1999 4. Babayan RK, Chiu AW, Este-McDonald J, et al: The comparison between 2-dimensional and 3-dimensional laparoscopic video systems in a pelvic trainer. J Endourol 7:$195, 1993 5. Berci G, Wren SM, Stain SC, et al: Individual assessment of visual perception by surgeons observing the same laparoscopic organs with various imaging systems. Surg Endosc 9:967-973, 1995 6. Bro-Nielsen M, Helfrick D, Glass B, et al: VR simulation of abdominal trauma surgery. In Westwood JD, Hoffman HM, Stredney D, et al (eds): Medicine Meets Virtual Reality: Art, Science, Technology: Healthcare (R)Evolution. Amsterdam, IOS Press and Ohmsha, 1998, pp 117-123 7. Bruno D, Delvecchio FC, Preminger GM: Digital still image recording during video endoscopy. J Endourol 13:353-357, 1999 8. Chan AC, Chung SC, Yim AP, et al: Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery. Surg Endosc 11:438440, 1997 9. Chiu AW, Babayan RK: Retroperitoneal laparoscopic nephrectomy utilizing three-dimensional camera: Case report. J Endourol 8:139-141, 1994 10. Coleman J, Nduka CC, Darzi A: Virtual reality and laparoscopic surgery. Br J Surg 81:1709-1711, 1994 11. Crump WJ, Pfeil T: A telemedicine primer: An introduction to the technology and an overview of the literature. Arch Fam Med 4:796-803, 1995 12. Daneshgari F, Chandhoke PS: Basic laparoscopic instrumentation. In Smith A (ed): Smith's Textbook of Endourology. St. Louis, Quality Medical Publishing, 1996, pp 710-730 13. Durrani AF, Preminger GM: Advanced endoscopic imaging: 3-D laparoscopic endoscopy. Surgical Technology International III:141-147, 1994 14. Durrani AF, Preminger GM: Three-dimensional video imaging for endoscopic surgery. Comput Biol Med 25:237-247, 1995 15. Goldberg MA: Teleradiology and telemedicine. Radiol Clin North Am 34:647-664, 1996 16. Kaltenborn KF, Rienhoff O: Virtual reality in medicine. Methods Inf Med 32:407-417, 1993 17. Kavoussi LR, Moore RG, Partin AW, et al: Telerobotic assisted laparoscopic surgery: Initial laboratory and clinical experience. Urology 44:15-19, 1994 18. Kennedy TJ, Preminger GM: Impact of video on endourology. J Endourol 1:75-80, 1987 19. Kuo RL, Asian P, Dinlenc CZ, et al: Secure transmission of urologic images and records over the Internet. J Endourol 13:141-146, 1999 20. Kuppersmith RB, Johnson R, Jones SB, et al: Virtual reality surgical simulation and otolaryngology. Arch Otolaryngol Head Neck Surg 122:1297-1298, 1996 21. Kvedar JC, Menn E, Loughlin KR: Telemedicine: Present applications and future prospects. Urol Clin North Am 25:137-149, 1998

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KOURAMBAS & PREMINGER

22. Litwiller SE, Preminger GM: Advances in electronic imaging for laparoscopy. J Endourol 7:$195, 1993 23. McCarthy AD, Hollands RJ: A commercially viable virtual reality knee arthroscopy training system. In Westwood JD, Hoffman HM, Stredney D, et al (eds): Medicine Meets Virtual Reality: Art, Science, Technology: Healthcare (R)Evolution. Amsterdam, IOS Press and Ohmsha, 1998, pp 302-308 24. Merril JR, Merril GL, Raju R, et al: Photorealistic interactive three-dimensional graphics in surgical simulation. In Satava RM, Morgan K, Sieburg HB, et al (eds): Interactive Technology and the New Paradigm for Healthcare. Amsterdam, IOS Press, 1995, pp 244-252 25. Merril JR, Preminger GM, Babayan RK, et al: Surgical simulation using virtual reality technology: Design, implementation and implications. Surgical Technology International III:53-60, 1994 26. Micali S, Vespasiani G, Finazzi-Agro E, et al: Feasibility of telesurgery between Baltimore, USA and Rome, Italy: The first five cases. J Endourol 13:A145, 1999 27. Noar MD: Endoscopy simulation: A brave new world? Endoscopy 23:147-149, 1991 28. Ota D, Loftin B, Saito T, et al: Virtual reality in surgical education. Comput Biol Med 25:127-137, 1995 29. Perednia DA, Allen A: Telemedicine technology and clinical applications. JAMA 273:483-488, 1995 30. Preminger GM: Video-assisted transurethral resection of the prostate. J Endourol 5:161-164, 1991 31. Preminger GM: Video imaging and documentation. In Smith AD, Badlani GH, Bagley DH, et al (eds): Smith's Textbook of Endourology. St. Louis, Quality Medical Publishing, 1996, pp 29-59 32. Preminger GM, Babayan RK, Merril GL, et al: Virtual reality surgical simulation in endoscopic urologic surgery. In Sieburg H, Weghorst S, Morgan E (eds): Health Care in the Information Age. Amsterdam, IOS Press and Ohmsha, 1996, pp 157-163 33. Satava RM: Medical applications of virtual reality. J Med Syst 19:275-280, 1995 34. Satava RM: Robotics, telepresence and virtural real-

35. 36.

37.

38.

39. 40.

41.

42.

43.

ity: A critical analysis of the future of surgery. Minimally Invasive Therapy 1:357-363, 1992 Satava RM: Virtual reality surgical simulator: The first steps. Surg Endosc 7:203-205, 1993 Suzuki N, Hattori A, Ezumi T, et al: Simulator for virtual surgery using deformable organ models and force feedback system. In Westwood JD, Hoffman HM, Stedney D, et al (eds): Medicine Meets Virtual Reality: Art, Science, Technology: Healthcare (R)Evolution. Amsterdam, IOS Press and Ohmsha, 1998, pp 227-233 Taffinder N, Sutton C, Fishwick RJ, et al: Validation of virtual reality to teach and access psychomotor skills in laparoscopic surgery: Results from randomized controlled studies using the MIST VR laparoscopic simulator. In Westwood JD, Hoffman HM, Stedney D, Weghorst SJ (eds): Medicine Meets Virtual Reality: Art, Science, Technology: Healthcare (R)Evolution. Amsterdam, IOS Press and Ohmsha, 1998, pp 124-130 Takashi M, Hasegawa S, Ohmuta M, et al: Significant elevation of urinary 28-kD calbindin-D and N-acetylbeta-D-glucosaminidase levels in patients undergoing extracorporeal shock wave lithotripsy. Int Urol Nephrol 30:407-415, 1998 Thrall JH, Bokand G: Telemedicine in practice. Semin Nucl Med 28:145-157, 1998 Vining DJ, Liu K, Choplin RH, et al: Virtual bronchoscopy: Relationships of virtual realty endobronchial simulations to actual bronchoscopic findings. Chest 109:549-553, 1996 Viirre E, Pryor H, Nagata S, et al: The virtual retinal display: A new technology for virtual reality and augmented vision in medicine. In Westwood JD, Hoffman HM, Stedney D, et al (eds): Medicine Meets Virtual Reality: Art, Science, Technology: Healthcar¢ (R)Evolution. Amsterdam, IOS Press and Ohmsha, 1998, pp 252-257 Wirthlin DJ, Buradagunta S, Edwards RA, et al: Telemedicine in vascular surgery: Feasibility of digital imaging for remote management of wounds. J Vasc Surg 27:1089-1100, 1998 Zobel J: Basics of three-dimensional endoscopic vision. Endo Surg Allied Technol 1:36-39, 1993 Address reprint requests to

Glenn M. Preminger, MD Division of Urology Box 3167, Room 305 Baker House Duke University Medical Center Durham, North Carolina 27710 e-mail: [email protected]