“Robotic laparoscopic radical cystectomy inhalational versus total intravenous anesthesia: A pilot study.”
Atallah, M. M. and M. M. Othman (2009).
Middle East Journal of Anesthesiology 20(2): 257-264.
Background: Robotic assistance may refine laparoscopic radical cystectomy. Steep Trendelenburg tilt (TT) and pneumoperitoneum (PP) are challenging anesthesia maneuvers. In view of those maneuvers, would inhalational anesthesia or total intravenous anesthesia (TIVA) be the more appropriate anesthetic management for this kind of surgery?. This issue is under consideration in this clinical trial. Methods: 15 patients scheduled for robotic laparoscopic radical cystectomy (RLRC) were randomly allocated into two groups to be anesthetized by either isoflurane anesthesia (ISO n=8) or ketamine-midazolam-fentanyl total intravenous anesthesia (TIVA n=7). The hemo-respiratory dynamics, oxygenation and biochemical variables were monitored taking into consideration the system organ function as primary outcomes, and operative conditions and recovery profile as secondary outcomes. Results: The PP and TT increased the mean arterial and airway pressures and decreased lung compliance, and were associated with respiratory acidemia, while changes in heart rate remained within normal range. The duration of PP was shorter in TIVA patients but mean arterial pressure was higher than ISO group. ISO was associated with increased plasma concentrations of prothrombin, fibrinogen and aspartate aminotransferase. Conclusions: Though the number of patients is small in this study (n=15), it nevertheless brings to light the advantages of TIVA during the robotic laparoscopic radical cystectomy (RLRC), by shortening the duration of PP without an increase in prothrombin and fibrinogen concentrations. A larger number of clinical trial are needed to further clarify this issue.
“Robot-Assisted Laparoscopic Bladder Diverticulectomy Combined with Photoselective Vaporization of Prostate: A Case Report and Review of Literature.”
Kural, A. R., F. Atug, et al. (2009).
Abstract Purpose: Open surgery, endoscopic technique, and standard laparoscopic technique are surgical options for the management of bladder diverticuli. In this article, we report robot-assisted bladder diverticulectomy (RABD) and photoselective vaporization of prostate (PVP) in the same patient sequentially. To the best of our knowledge, this is the first case report of RABD combined with PVP. Materials and Methods: A 63-year-old patient with benign prostatic hyperplasia and a secondary large bladder diverticulum underwent sequential PVP and RABD. Cystoscopic examination revealed obstructing prostate lobes and a large diverticulum at posterior wall of bladder. After completion of PVP procedure, a 16F urethral catheter was inserted into the diverticulum via outer sheath of optic urethrotome and another 16F urethral catheter was left in bladder for urinary drainage. A transperitoneal approach was preferred. The diverticulum was distended with saline infusion via the Foley catheter inside the diverticulum. The distended diverticulum was seen easily and dissected from the surrounding tissue. The bladder was closed in two separate layers. Results: Total operative time, including diverticulectomy with PVP procedure, was 230 minutes, and console time was 90 minutes. The length of stay was 7 days. Conclusions: There has been always concern about the high intravesical pressures secondary to irrigant instillation that may disrupt the bladder repair. To avoid this problem we combined robotic diverticulectomy with PVP. Because of hemostatic properties of potassium-titanyl-phosphate laser, we did not encounter with bleeding after prostatectomy procedure. Moreover, we did not use irrigation, and the suture line of the bladder was kept safe. Therefore, we recommend to use greenlight laser in combined prostate and RABD operations. RABD is a feasible and safe procedure. RABD and PVP can be performed safely in the same patient sequentially.
“Ureteropelvic Junction Obstruction: Which Surgical Approach?”
Nadu, A., A. Mottrie, et al.
European Urology, Supplements.
Context: Open pyeloplasty has been considered the referral standard of treatment for ureteropelvic junction obstruction (UPJO). Minimally invasive procedures, however, have evolved and have gradually replaced open surgery, with various success and complication rates. The ideal universal treatment for UPJO is still elusive and controversial. Objectives: The current status of three surgical approaches to the treatment of UPJO are reviewed: laparoscopic pyeloplasty (LP), robotic-assisted pyeloplasty, and endopyelotomy. Evidence acquisition: The interactive discussion among the expert presenters and urologists participating at the Second Congress on Controversies in Urology in Lisbon, Portugal, is summarized. Evidence synthesis: A review of the relevant literature and the experts’ opinions seem to indicate that LP, either conventional or robotic, should be considered as the treatment of choice for UPJO, because it achieves the highest success rates (90%) while still offering the patient the advantages of minimally invasive surgery. The conventional laparoscopic approach demands a high level of surgical expertise and dedicated training that can be partially obviated by the robotic system. Evidence proving clear advantages of robotic pyeloplasty over conventional laparoscopy, however, is lacking due to short follow-up. Additionally, in its current version, the robotic system is financially prohibitive for many centers worldwide. In experienced hands, endopyelotomy performed either percutaneously or by the retrograde ureteroscopic approach can achieve long-standing satisfactory results in carefully selected patients (short strictures, minimal hydronephrosis, no crossing vessel). Additionally, endopyelotomy is the procedure of choice for failed pyeloplasty, with success rates of up to 80%. Conclusions: It can be concluded from the presented data that, given the surgical expertise, LP should be considered the current standard of care for UPJO, with high success rates comparable to the open procedure. The advantages of the robotic system for the patient remain to be proved by scientific data. Endopyelotomy is still indicated in selected cases as a primary therapeutic option and should be considered the procedure of choice for pyeloplasty failures. Â© 2009 European Association of Urology.
“Robotic cystectomy and the Internet: Separating fact from fiction.”
Pruthi, R. S., J. Belsante, et al. (2009).
INTRODUCTION: Patients commonly use the Internet to acquire health information. While a large amount of health-related information is available, the accuracy is highly variable. We sought to evaluate the current web-based information that exists with regard to robotic cystectomy. METHODS: Two common search engines (Google and Yahoo) were used to search the term “robotic cystectomy” and obtain the top 50 websites for each. These 100 sites were analyzed with regard to type of site, presence and accuracy of information on bladder cancer, and of information related to robotic cystectomy outcomes (surgical/oncologic, functional, and recovery). In addition, information taken from Intuitive Corp website was identified, as was the presence (or absence) and literature-based references. RESULTS: Of the 100 sites, 61 were surgeon/provider sites, 23 links to articles, 8 news stories, 3 patient support sites, 3 meeting program, and 2 were the Intuitive site. Analysis of all 61 provider sites showed that 13% provided factually accurate information, 7% had both factual and erroneous information, and 80% had no information on bladder cancer. With regard to the purported benefits and outcomes of the robotic approach, a significant number of the sites had nonevidence-based claims with regard surgical/oncologic aspects (54%), functional recovery (26%), and surgical recovery (47%). Information taken directly from the Intuitive site was found on 33% sites, with 16% sites having a direct link. Only 4 provider sites (7%) had listed any references. CONCLUSIONS: These findings suggest that surgeons provide the majority of Internet information but do not often present evidence-based information and often over-state claims and outcomes of the robotic approach. This highlights the need for providers to deliver factual and evidence-based information to the public, and not suggest untrue/unproven claims that seem to presently occur.
“Robot-assisted laparoscopic distal ureteral surgery.”
Schimpf, M. O. and J. R. Wagner (2009).
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 13(1): 44-49.
BACKGROUND: The use of robotic assistance in adult genitourinary surgery has been successful in many operations, leading surgeons to test its use in other applications as well. METHODS: Based on our use during prostatectomy, we have applied robotic surgery to complex distal ureteral surgeries since 2004 with successful outcomes. RESULTS: A series of 11 patients who underwent robot-assisted laparoscopic distal ureteral surgery is presented. These surgeries include distal ureterectomy for ureteral cancer with reimplantation, as well as reimplantation with and without Boari flap or psoas hitch for benign conditions. CONCLUSIONS: Robot-assisted laparoscopic surgery can be successfully applied to patients requiring distal ureteral surgery. Maintenance of the principles of open surgery is paramount.
“Robotic-assisted Ileovesicostomy: Initial Results.”
Vanni, A. J., M. S. Cohen, et al. (2009).
OBJECTIVES: To assess the safety and efficacy of robotic-assisted ileovesicostomy in treating patients with a neurogenic bladder that is unsuitable for clean intermittent self-catheterization. METHODS: Robotic-assisted ileovesicostomy was performed using a 5-port approach for patients with a neurogenic bladder unable to tolerate clean intermittent or chronic bladder catheterization. Intraperitoneal operative steps included the creation of a full thickness U-shaped posterior bladder wall flap, intracorporeal harvesting of 15 cm of terminal ileum for use as a urinary conduit, and intracorporeal enterovesical anastomosis. Then, a counter incision was made over the marked stoma site on the abdominal wall, and bowel continuity was restored through an extracorporeal side-side anastomosis by the stomal incision. Ileovesicostomy stoma maturation was then completed. RESULTS: Eight robotic ileovesicostomies were performed. The median patient age was 53 years, body mass index was 29.0 kg/m(2), and preoperative bladder compliance was 5.7 mL/cm/H(2)O. The median blood loss was 100 mL. The median operative time was 330 minutes (range 240-420). No intraoperative complications occurred. Four patients had postoperative complications, including urethral incontinence (2) and ileus (2). No wound complications occurred. Bowel function returned after a median of 4.8 days after surgery, and median hospital stay was 7.7 days. Over a median 14-month follow-up, all patients had a functioning ileovesicostomy, and median postoperative residual bladder volume was 10 mL. CONCLUSIONS: This study is the first to describe the robotic ileovesicostomy procedure. Robotic ileovesicostomy appears to be safe and effective, with low morbidity.
“Robot Assisted Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Tumors: A Multi-Institutional Analysis of Perioperative Outcomes.”
Benway, B. M., S. B. Bhayani, et al. (2009).
PURPOSE: Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS: We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS: The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS: Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naive surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.
“Reply to Ben Challacombe, Anthony Costello and Dinesh Agarwal’s Letter to the Editor re: Brian M. Benway, Agnes J. Wang, Jose M. Cabello and Sam B. Bhayani. Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes. Eur Urol 2009;55:592-9.”
Benway, B. M., A. J. Wang, et al. (2009).
“Re: Brian M. Benway, Agnes J. Wang, Jose M. Cabello and Sam B. Bhayani. Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes. Eur Urol 2009;55:592-9.”
Challacombe, B., A. Costello, et al. (2009).
“Robot-assisted Partial Nephrectomy: Current Perspectives and Future Prospects.”
Gautam, G., B. M. Benway, et al. (2009).
The widespread adoption of laparoscopic partial nephrectomy (LPN) has been curtailed by its technical complexity. With the introduction of robotic technology, there is a potential for a shorter learning curve for minimally invasive nephron-sparing surgery (NSS). Initial published data on robot-assisted partial nephrectomy show promising perioperative outcomes comparable to large LPN series performed by highly experienced laparoscopic surgeons. Intraoperative parameters (operating room time, warm ischemia time, and blood loss) and short-term oncologic results demonstrate that this technique, unlike LPN, has a relatively short learning curve. Economic factors, as well as the necessity of an experienced bedside assistant, present the potential shortcomings of the procedure.
“Robot assisted laparoscopic partial nephrectomy: A viable and safe option in children.”
Lee, R. S., A. S. Sethi, et al. (2009).
International Braz J Urol 35(1): 98-98.
Purpose: The safety, benefits and usefulness of laparoscopic partial nephrectomy have been demonstrated in the pediatric population. We describe our technique, and determine the safety and feasibility of robot assisted laparoscopic partial nephrectomy based on our initial experience. Materials and methods: We retrospectively reviewed robot assisted laparoscopic partial nephrectomy performed at our institution between 2002 and 2005. The technique was conducted via a transperitoneal approach with the da Vinci Surgical System using standard laparoscopic procedural steps. Clinical indicators of outcomes included estimated blood loss, complications, in hospital narcotic use and length of stay. Results: Robot assisted laparoscopic partial nephrectomy was completed successfully in 9 cases. Mean patient age was 7.2 years and mean follow-up was 6 months. Mean operative time was 275 minutes and mean estimated blood loss was 49 mL. Operative times improved significantly with experience. Overall patients had a mean hospitalization of 2.9 days and required 1.3 mg morphine per kg. All patients had a normal remaining renal moiety confirmed on Doppler ultrasound. The only complication was an asymptomatic urinoma discovered on ultrasound, which was treated with percutaneous drainage and ultimately resolved. Conclusions: Our initial experience shows the safety and feasibility of robot assisted laparoscopic partial nephrectomy in children. Operative time decreases with experience. The enhanced visualization and dexterity of a robotic system potentially offer improved efficiency and safety over standard laparoscopy. Robot assisted laparoscopy is an option for partial nephrectomy and may become the minimally invasive treatment of choice. Â© 2009 Sociedade Brasileira de Urologia.
“Tumor enucleoresection in robot-assisted partial nephrectomy.”
Mottrie, A., N. Koliakos, et al. (2009).
Journal of Robotic Surgery 3(2): 65-69.
The objective of this study is to describe our technique and results of the enucleoresection technique in robot-assisted partial nephrectomy. The patient is positioned in full flank position. Three robotic arms of a da Vinci system and an assistant’s port are used. The renal hilus is freed, the kidney mobilized and the site of the partial excision prepared. The vessels are clamped with a bulldog. The capsula of the kidney is incised circular about 5 mm around the tumor. A pseudocapsula of compressed healthy tissue around the tumor is found and mainly blunt dissection is done with the cold scissors. At the base of the dissection, the resection is completed sharply. Possible calyceal defects and major vessels are stitched. Fibrinogen coagulation enhancer and cellulose coagulation sponge are used to lessen the gap and the renal defect is closed with absorbable suture. The kidney is re-perfused and observed for bleeding. We have performed 17 cases with warm ischemia time 16-35 min (mean 24 min) and tumor size 2.2-5.3 cm (mean 3.8 cm). All surgical margins were tumor free. No postoperative complications were identified except one clot retention. Robot-assisted enucleoresection of kidney tumors is a feasible and very promising technique that needs to be further evaluated for results. Â© 2009 Springer-Verlag London Ltd.
“Nerve-sparing Prostatectomy and Urinary Function: A Prospective Analysis Using Validated Quality-of-life Measures.”
Abel, E. J., T. A. Masterson, et al. (2009).
Urology 73(6): 1336-1340.
Objectives: To prospectively study whether urinary function and bother are directly related to neurovascular bundle preservation at radical prostatectomy using validated quality-of-life questionnaires. Methods: A total of 91 consecutive patients undergoing radical prostatectomy were prospectively studied using the University of California, Los Angeles, Prostate Cancer Index and the International Prostate Symptom Score. The patients were divided into 2 groups (>50% nerve sparing vs â‰¤50% nerve sparing). To control for differences in the 2 groups, linear mixed models were performed to adjust for the time after surgery, preoperative sexual ability, and urinary function. Results: Of the 91 patients, 62 (68%) had >50% nerve-sparing during prostatectomy. Their mean age at surgery was 59 Â± 6 years, and the mean follow-up was 16 Â± 9 months. Of the 91 patients, 29 (32%) had â‰¤50% nerve sparing during prostatectomy. Their mean age at surgery was 64 Â± 8 years, and the mean follow-up was 13 Â± 7 months. Increased nerve sparing was associated with better urinary function (P = .014) and less urinary bother (P = .043). After adjusting for preoperative variables, the increased nerve-sparing group scored 8.4 points (95% confidence interval 1.3-15.4) higher for urinary function and 8.5 points (95% confidence interval 0.3-16.8) higher for urinary bother compared with the group. The International Prostate Symptom Score improved in both groups of patients, and no significant differences were found between the 2 groups. Conclusions: The results of our study have shown that nerve-sparing prostatectomy is associated with improvement in urinary function and bother. This improvement was modest and is of unknown clinical significance. Â© 2009 Elsevier Inc. All rights reserved.
“The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy.”
Awad, H., S. Santilli, et al. (2009).
Anesth Analg 109(2): 473-478.
BACKGROUND: Intraocular pressure (IOP) increases in steep Trendelenburg positioning, but the magnitude of the increase has not been quantified. In addition, the factors contributing to this increase have not been studied in robot-assisted prostatectomy cases. In this study, we sought to quantify the changes in IOP and examine perioperative factors responsible for these changes while patients are in the steep Trendelenburg position during robotic prostatectomy. METHODS: In this prospective study, we measured IOP using a Tono-pen XL in 33 patients undergoing robot-assisted prostatectomy. The IOP was measured before anesthesia while supine and awake (baseline T1), anesthetized and supine (T2), anesthetized after insufflation of the abdomen with carbon dioxide (CO(2)) (T3), anesthetized in steep Trendelenburg (T4), anesthetized in steep Trendelenburg at the end of the procedure (T5), anesthetized supine before awakening (T6), and 1 hr after awakening in the supine position (T7). RESULTS: On average, IOP was 13.3 +/- 0.58 (mean +/- SE) mm Hg higher at the end of the period of steep Trendelenburg position (T5) compared with supine position T1 (P < 0.0001). The least square estimates for each time point in mm Hg were as follows: T1 = 15.7, T2 = 10.7, T3 = 14.6, T4 = 25.2, T5 = 29.0, T6 = 22.2, T7 = 17.0. Using univariate mixed effects models for the T1-T5 time periods, peak airway pressure, mean arterial blood pressure, ETco(2), and time were significant predictors of the IOP increase, whereas age, body mass index, blood loss, volume of IV fluid administered, mean airway pressure, and desflurane concentration were not predictive. In T4-T5, which involved no significant positional or perioperative interventions, we performed a multivariate analysis to evaluate predictors of IOP increases. Surgical duration (in minutes) and ETco(2) were the only significant variables predicting changes in IOP during stable and prolonged Trendelenburg positioning. On average, IOP increased 0.21 mm Hg per mm Hg increase in ETco(2) after adjusting for time. An increase of 0.05 mm Hg in IOP per minute of surgery on average was observed during this period in the Trendelenburg position after adjusting for ETco(2). CONCLUSIONS: IOP reached peak levels at the end of steep Trendelenburg position (T5), on average 13 mm Hg higher than the preanesthesia induction (T1) value. Surgical duration and ETco(2) were the only significant predictors of IOP increase in the Trendelenburg position (T4-T5).
“No Proof of Inferiority: Open Radical Retropubic Prostatectomy Remains State-of-the-Art Surgical Technique for Localized Prostate Cancer.”
Blute, M. L. (2009).
Journal of Urology 181(6): 2421-2423.
“Critical appraisal of robotic-assisted radical prostatectomy.”
Brandina, R., A. Berger, et al. (2009).
Current opinion in urology 19(3): 290-296.
PURPOSE OF REVIEW: To perform a contemporary critical appraisal of robotic-assisted radical prostatectomy (RaRP) through a review of the recent literature. RECENT FINDINGS: Most studies of RaRP are observational and report perioperative, functional and short-term oncological outcomes. RaRP is associated with less blood loss and blood transfusion than open radical prostatectomy (ORP), has a positive margin rate of 9.4-20.9%, potency rate of 79.2-80.4% at 1 year and a continence rate of 90.2-97% at 1 year. Costs of the da Vinci system remain a limitation of this technique. SUMMARY: RaRP has shown rapid dissemination over the past few years in the US urological community. However, prospective randomized clinical trials with long-term follow-up of RaRP, ORP and laparoscopic radical prostatectomy are still necessary.
“Prediction of sexual function after radical prostatectomy.”
Briganti, A., U. Capitanio, et al. (2009).
Cancer 115(SUPPL 13): 3150-3159.
Radical prostatectomy (RP) is a commonly used procedure in the treatment of clinically localized prostate cancer. For this report, the authors critically analyzed the factors associated with recovery of erectile function after surgery. A systematic review of the literature using the Medline and CancerLit databases was conducted. Keywords for the literature search included prostate cancer, radical prostatectomy, erectile dysfunction, impotence, treatment, and prophylaxis. Accurate patient selection (based on patient age, preoperative erectile function, and comorbidity profile) and adequate surgical technique (ie, the preservation of neurovascular bundles) were the major determinants of postoperative erectile function. Moreover, better results were achieved when an appropriate pharmacologic treatment using either oral or local approaches was given. Therefore, the authors concluded that, if patients are stratified correctly according to preoperative, intraoperative, and postoperative factors, then a satisfactory functional recovery may be expected after surgery. For these reasons, an ideal multivariate model predicting the restoration of erectile function after surgery should include patient, surgeon, and postsurgical treatment variables. The authors also concluded that the stratification of patients with regard to their risk of developing erectile dysfunction after surgery was feasible based on several parameters, which should be taken into account for correct patient treatment and counseling. To address this objective, accurate tools for predicting the likelihood of complete functional recovery after surgery are needed. Â© 2009 American Cancer Society.
“Editorial Comment on: Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up.”
Cestari, A. and G. Guazzoni (2009).
European Urology 55(6): 1367.
“Salvage HIFU for recurrent prostate cancer after radiotherapy.”
Chalasani, V., C. H. Martinez, et al. (2009).
Prostate Cancer and Prostatic Diseases 12(2): 124-129.
Recurrent disease following primary radiotherapy for localized prostate cancer is a common problem, occurring in up to 46% of patients. For these patients, therapeutic options include salvage prostatectomy, salvage cryotherapy, salvage high-intensity focused ultrasound (HIFU), hormonal therapy or observation. This review will focus on the emerging evidence for salvage HIFU. There are no randomized or prospective studies in this area. Efficacy results of 17-57% have been reported from retrospective case series, with reported toxicity including rectal fistula in 0-16%, and incontinence in 10-50%. The ideal patient, while yet to be clearly defined, should have preradiotherapy low or intermediate risk disease. Salvage HIFU appears most appropriate for those patients with histologically proven local recurrence only, with a life expectancy of at least 5 years and with some medical comorbidities rendering them not ideal for salvage prostatectomy.
“Are prostate needle biopsies predictive of the laterality of significant cancer and positive surgical margins?”
Frota, R., R. J. Stein, et al. (2009).
OBJECTIVE To determine whether data obtained from preoperative prostate needle biopsy can predict the laterality of significant cancer and positive surgical margins on final-specimen pathology after laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS Data from 490 patients undergoing LRP by one surgeon were reviewed retrospectively. The demographic characteristics, intraoperative data and pathological results were analysed. Univariate and multivariate analyses were used to determine which factors before and during LRP influenced the positive surgical margin status. RESULTS There was only minor agreement between the laterality of positive needle biopsies and laterality of any cancer and significant cancer on final-specimen pathology (kappa = 0.135 and 0.151, respectively). This was irrespective of the number of needle cores obtained or final-specimen Gleason grade. Similarly, the laterality of dominant cancer on needle biopsy had only a minor agreement with the location of positive surgical margins (kappa = 0.050) and fair agreement with the location of extracapsular extension on final-specimen pathology (kappa = 0.235). CONCLUSIONS Preoperative needle biopsy data have only a minor correlation with the laterality of significant cancer and positive surgical margins at final pathology of LRP specimens. Recognition of this fact, and the frequent bilaterality of significant cancer, with its potential for contralateral positive surgical margins even when the biopsies are positive only unilaterally, is an important consideration when planning nerve-sparing, and potentially for focal therapy.
“Robotic and open radical prostatectomy: is there reason to be receptive to change now and in the future?”
Ghavamian, R. (2009).
Expert Rev Anticancer Ther 9(7): 863-865.
“Surgery illustrated – Surgical atlas Robot-assisted ascending-descending laparoscopic nerve-sparing prostatectomy.”
Gillitzer, R., J. W. ThÃ¼roff, et al. (2009).
BJU International 104(1): 129-153.
“Pure laparoscopic versus robotic-assisted laparoscopic radical prostatectomy: Comparative study to assess functional urinary outcomes.”
Gosseine, P. N., P. Mangin, et al.
Prostatectomie totale laparoscopique standard versus laparoscopique robot-assistÃ©eÂ : Ã©tude comparative sur les rÃ©sultats fonctionnels urinaires.
Purpose: To compare urinary functional outcomes after LP prostatectomy or robotic assisted laparoscopic prostatectomy performed by a single surgeon regarding to his initial experience. Material: Between March 2005 and April 2007, 247Â consecutive patients underwent radical prostatectomy, either by LP approach (125) or by robotic-assisted laparoscopic (RALP) approach (122). The only criteria to chose robot or not, was the Robot Da VinciÂ®’s availability. Results: There was no statistical difference between the two groups in terms of preoperative characteristics. The continence rate was 83% in PL group versus 81% in RALP group. More precisely, among men wearing at least one pad, 71% of patients in PL groups wear one pad/day versus 87% of patients in RALP group. Multivariate analysis on continence appears to be in favors of RALP group (Odd Ratio 2.1 [CI: 0,86-5,48]). Conclusion: Incontinence appears to be less severe and frequent in the RALP group. In practice, surgeon’s impression of the robot’s interest is evident, but more important number of patients and longer follow-up is necessary. Â© 2009 Elsevier Masson SAS. All rights reserved.
“Technique for ureteral stent placement during robot-assisted radical prostatectomy: safety measure during vesicourethral anastomosis when ureteral orifices are too close for comfort.”
Katz, M. H., M. K. Eng, et al. (2009).
Journal of endourology / Endourological Society 23(5): 827-829.
“Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy?”
Martin, A. D., P. J. Desai, et al. (2009).
BJU International 103(12): 1696-1698.
OBJECTIVE To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial ‘learning curve’, as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.
“An analysis of sexual health information on radical prostatectomy websites.”
Mulhall, J. P., C. Rojaz-Cruz, et al. (2009).
OBJECTIVE To define the nature of information posted on websites related to radical prostatectomy (RP), specifically its accuracy and comprehensiveness, as RP is associated with erectile dysfunction (ED). METHODS We reviewed 70 robotic RP (RARP) and 20 open RP (ORP) medical centres. Their websites were reviewed for various factors, by two separate reviewers whose reviews were not seen by each other. Websites were graded based on accuracy and comprehensiveness of information by the senior investigator. RESULTS Of the academic and community-based RARP centres, 55% and 79% had specific websites (P < 0.05); 45% of RARP sites had generic information copied directly from the website of Intuitive Surgical (Sunnyvale, CA, USA; the manufacturer of the robotic system). ED was mentioned by only 54% of RARP sites and 45% of ORP sites; 17% of RARP sites were deemed accurate, compared with 30% of ORP sites (P < 0.05). Just over 1% of RARP sites were considered comprehensive, vs 10% of ORP sites (P < 0.05). A third of RARP sites had a direct link to the Intuitive Surgical website (16% academic vs 53% community, P < 0.05), compared to 10% of open sites (P < 0.05). Of most interest was that half of the RARP sites suggested that ED rates were lower for RARP than for ORP; this compared to ED rates being cited as lower for ORP on 5% of the ORP sites (P < 0.05). CONCLUSIONS Despite the stature of RP as a treatment option for men with prostate cancer, and the recent increase in the use of RARP, the accuracy of information pertaining to sexual health on RP websites is poor, with many making false statements about the long-term outcomes for erectile function. This inadequacy appears to be greater on RARP than on ORP websites.
“Re: White et al.: Comparative Analysis of Surgical Margins Between Radical Retropubic Prostatectomy and RALP: Are Patients Sacrificed During Initiation of Robotic Program? (Urology 2009;73:567-571).”
Otto, T., H. Gerullis, et al. (2009).
Urology 74(2): 475-476.
“Robotic-Assisted radical prostatectomy:anesthetic considerations and management.”
Ouellette, R. G. (2009).
Current Reviews for Nurse Anesthetists 31(20): 243-249.
The use of video, endoscopic systems and novel instrumentation has led to the development and widespread use of new, minimally invasive techniques, including robotic-assisted procedures. The anesthesia provider must have an understanding of the physiological challenges that arise due to steep Trendelenburg position and pneumoperitoneum. The physiological changes must be considered when developing an anesthesia plan for patines with coexisting diseases. Although long-term results are still lacking, minimally invasive robotic-assisted laparoscopic radical prostatectomy seems to fulfill the highest standards of radical prostatectomy in terms of cure, functional results, and morbidiity, A standardization will be indispensable for a better comparison.
“Periurethral Suspension Stitch During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of the Technique and Continence Outcomes.”
Patel, V. R., R. F. Coelho, et al. (2009).
European Urology 56(3): 472-478.
Background: Several studies have shown that robot-assisted laparoscopic radical prostatectomy (RALP) is feasible, with favorable complication rates and short hospital times. However, the early recovery of urinary continence remains a challenge to be overcome. Objective: We describe our technique of periurethral retropubic suspension stitch during RALP and report its impact on early recovery of urinary continence. Design, setting, and participants: We analyze prospectively 331 consecutive patients who underwent RALP, 94 without the placement of suspension stitch (group 1) and 237 with the application of the suspension stitch (group 2). Surgical procedure: The only difference between the groups was the placement of the puboperiurethral stitch after the ligation of the dorsal venous complex (DVC). The periurethral retropubic stitch was placed using a 12-in monofilament polyglytone suture on a CT-1 needle. The stitch was passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone. The stitch was passed again through the DVC, and then through the pubic bone in a figure eight, and then tied. Measurements: Continence rates were assessed with a self-administered validated questionnaire (Expanded Prostate Cancer Index Composite [EPIC]) at 1, 3, 6, and 12 mo after the procedure. Continence was defined as the use of no absorbent pads or no leakage of urine. Results and limitations: In group 1, the continence rate at 1, 3, 6, and 12 mo postoperatively was 33%, 83%, 94.7%, and 95.7%, respectively; in group 2, the continence rate was 40%, 92.8%, 97.9%, and 97.9%, respectively. The suspension technique resulted in significantly greater continence rates at 3 mo after RALP (p = 0.013). The median/mean interval to recovery of continence was also statistically significantly shorter in the suspension group (median: 6 wk; mean: 7.338 wk; 95% confidence interval [CI]: 6.387-8.288) compared to the nonsuspension group (median: 7 wk; mean: 9.585 wk; 95% CI: 7.558-11.612; log rank test, p = 0.02). Conclusions: The suspension stitch during RALP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the procedure. Â© 2009 European Association of Urology.
“The effect of body characteristics on mean operative times while experiencing the learning curve for robotic prostatectomy.”
Resnick, M. J. and D. I. Lee (2009).
Journal of Robotic Surgery 3(2): 71-74.
We reviewed our series of robotic-assisted radical prostatectomy to assess the effect of certain patient body characteristics on the mean operative time over the course of a single surgeon’s learning curve. The operating room times were recorded for the first 210 cases performed. These cases were broken down into thirds and then patient characteristics were stratified by height, weight, body mass index (BMI) and final prostate volume. Mean body characteristics were equal for all groups. The average time for the first group (70 cases) was 157.9 min, the second group 148.5 min and the third 135.0 min. Times were significantly shorter for the patients <72 in. in height in the first 70 cases (168 vs. 153 min, P < 0.003). Cases were shorter in the first 70 for weight <200 lbs (142 vs. 173 min, P < 0.001). Patients with a BMI of 25-30 had a significantly shorter time (153 min) than those <25 (163 min, P < 0.02) and those >30 (164 min, P < 0.006). With regard to prostate volume, there was a significant shorter operative time for those patients with glands <60 g in the first group. Patients <72 in., <200 lbs, with a BMI of between 25 and 30, and prostate size <60 g had significantly shorter operative times in the first 70 cases of a single surgeon’s learning curve. Â© 2009 Springer-Verlag London Ltd.
“Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-assisted Laparoscopic Radical Prostatectomy.”
Shah, G., F. Vogel, et al. (2009).
Urology 73(6): 1375-1376.
Objectives: Delayed urinary anastomotic leak after transperitoneal robot-assisted radical prostatectomy (RALP) is an uncommon complication. After failure of conventional measures, we successfully managed this problem using a nephroureteral stent placed on intermittent suction. Methods: A 62-year-old man with clinical stage T1c prostate cancer (Gleason 3 + 3) developed a persistent urinary anastomotic leak after RALP. Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction. Results: Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity. Conclusions: In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak. Â© 2009.
“Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics.”
Shikanov, S., J. Woo, et al. (2009).
OBJECTIVES: To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). METHODS: A prospective database was analyzed for RARP patients with bilateral IF- or EF-NSP technique. Collected parameters included age, body mass index, prostate-specific antigen, clinical and pathologic Gleason score and stage, estimated blood loss, operative time, and PSM characteristics. Functional outcomes were evaluated with the use of the University of California Los Angeles Prostate Cancer Index questionnaire. Men receiving postoperative hormonal or radiation therapy were excluded from sexual function analysis. RESULTS: A total of 110 and 703 cases with bilateral EF- and IF-NSP, respectively, were analyzed. EF-NSP patients had higher prostate-specific antigen, clinical, pathologic stage, and pathologic Gleason score. PSM rate did not achieve statistically significant difference between groups. There was a trend toward lower pT3-PSM in the EF group (51% vs 28%; P = .08). Mid- and posterolateral PSM location were lower in the EF-NSP group, 11% vs 37% and 11% vs 29%, respectively (P < .001). The IF-NSP group patients achieved statistically significant better sexual function (P = .02) and potency rates (P = .03) at 12 months after RARP. CONCLUSIONS: In lower risk patients, bilateral IF-NSP technique does not result in significantly higher PSM rates. EF-NSP appears to reduce posterolateral and mid-prostate PSM. Men with bilateral IF-NSP demonstrate significantly better sexual function outcomes.
“Trifecta Outcomes After Robotic-assisted Laparoscopic Prostatectomy.”
Shikanov, S. A., K. C. Zorn, et al. (2009).
OBJECTIVE: To evaluate the trifecta outcomes following robotic-assisted laparoscopic prostatectomy (RALP) and compare the results applying definitions of continence and potency as reported in the literature vs validated questionnaire. The trifecta rate of achieving continence, potency, and undetectable prostate-specific antigen (PSA) following radical prostatectomy has been estimated to be approximately 60% at 1-2 years in open radical prostatectomy series. The definitions of continence and potency were not standardized, which poses difficulty in comparing published results. METHODS: A prospective, institutional RALP database was analyzed for preoperatively continent and potent men with >/= 1 year follow-up after bilateral nerve-sparing surgery. Continence and potency were evaluated preoperatively and at 3, 6, 12, and 24 months after surgery by surgeon interview (subjective) and using University of California Los-Angeles Prostate Cancer Index self-administered questionnaire (objective). Biochemical recurrence was defined as a detectable (> 0.05 ng/mL), increasing PSA on 2 consecutive tests. RESULTS: Among 1362 consecutive RALPs, 380 patients were preoperatively potent and continent underwent surgery with bilateral nerve-sparing technique and had sufficient follow-up. Trifecta rates applying subjective continence and potency definitions were 34%, 52%, 71%, and 76% at 3, 6, 12, and 24 months, respectively. The corresponding trifecta rates using objective continence and potency definitions stood at 16%, 31%, 44%, and 44%. The difference was statistically significant at each time point (P < .0001). CONCLUSIONS: RALP provides trifecta outcome rates comparable to open surgery. The outcome rates vary significantly depending on the tools used for continence and potency evaluation.
“Scientific and technical advances in continence recovery following radical prostatectomy.”
Tan, G. Y., Y. El Douaihy, et al. (2009).
Expert Rev Med Devices 6(4): 431-453.
The advent of prostate-specific antigen screening has changed the global epidemiology of prostate cancer, with men being diagnosed with organ-confined cancer at a younger age. Radical prostatectomy with curative intent for these patients, while delivering excellent long-term survival outcomes, still has significant side effects, chiefly postprostatectomy incontinence. Increasing age, shorter pre- and post-operative membranous urethral length, anastomotic strictures, obesity, low surgeon volume, variations of surgical technique and previous prostate surgery have been reported as negative risk factors for delayed continence recovery and/or permanent incontinence following radical prostatectomy. Significant progress in elucidating the functional anatomy and physiology of the male continence mechanism from cadaveric and videourodynamic studies have enabled surgeons to propose innovative surgical techniques during radical prostatectomy for augmenting continence preservation and early return. These have included optimizing the preservation of urethral rhabdosphincter length; avoiding rhabdosphincter injury; posterior reconstruction of Denonvilliers’ musculofascial plate; preservation of the bladder neck and internal sphincter; bladder neck intussusception; bladder neck mucosal eversion; preservation of the puboprostatic ligaments and arcus tendineus; and preservation of putative nerves supplying the continence mechanism. We review the scientific and technical advances in continence recovery following radical prostatectomy, identify the key principles undergirding early return of continence, highlight various treatment strategies for early and refractory postprostatectomy incontinence and describe our experience with a paradigm of these unified key principles. Increasing application of these principles in computer-aided (robotic), minimally invasive and minimal-access (i.e., single-port or natural orifice transluminal) approaches will hopefully enable patients to derive maximal benefit from curative prostatectomy while experiencing early return of continence in the not too distant future.
“Training, Credentialing, Proctoring and Medicolegal Risks of Robotic Urological Surgery: Recommendations of the Society of Urologic Robotic Surgeons.”
Zorn, K. C., G. Gautam, et al. (2009).
PURPOSE: With the exponential growth of robotic urological surgery, particularly with robot assisted radical prostatectomy, guidelines for safe initiation of this technology are a necessity. Currently no standardized credentialing system exists to our knowledge to evaluate surgeon competency and safety with robotic urological surgery performance. Although proctoring is a modality by which such competency can be evaluated, other training tools and guidelines are needed to ensure that the requisite knowledge and technical skills to perform this procedure have been acquired. We evaluated the current status of proctoring and credentialing in other surgical specialties to discuss and recommend its application and implementation specifically for robot assisted radical prostatectomy. MATERIALS AND METHODS: We reviewed the literature on safety and medicolegal implications of proctoring and the safe introduction of surgical procedures to develop recommendations for robot assisted radical prostatectomy proctoring and credentialing. RESULTS: Proctoring is an essential mechanism for robot assisted radical prostatectomy institutional credentialing and should be a prerequisite for granting unrestricted privileges on the robot. This should be differentiated from preceptoring, wherein the expert is directly involved in hands-on training. Advanced technology has opened new avenues for long-distance observation through teleproctoring. Although the medicolegal implications of an active surgical intervention by a proctor are not clearly defined, the role as an observer should grant immunity from malpractice liability. CONCLUSIONS: The implementation of guidelines and proctoring recommendations is necessary to protect surgeons, proctors, institutions and, above all, the patients who are associated with the institutional introduction of a robot assisted radical prostatectomy program. With no current guidelines we anticipate this article will serve as a catalyst of interorganizational discussion to initiate regulatory oversight of surgeon certification and proctorship.
“Pelvic Lymphadenectomy During Robot-assisted Radical Prostatectomy: Assessing Nodal Yield, Perioperative Outcomes, and Complications.”
Zorn, K. C., M. H. Katz, et al. (2009).
Urology 74(2): 296-302.
Objectives: To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. Methods: PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score â‰¥4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. Results: The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. Conclusions: Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered. Â© 2009 Elsevier Inc. All rights reserved.