“Robot-Assisted Bladder Neck Reconstruction, Bladder Neck Sling, and Appendicovesicostomy in Children: Description of Technique and Initial Results.”
Bagrodia, A. and P. Gargollo (2011).
Journal of Endourology.
Abstract Purpose: To describe robot-assisted complex reconstruction of the lower urinary tract in children with neurogenic bladder and sphincteric incompetence. Patients and Methods: Four sequential patients with spinal dysraphism, neurogenic bladder, and sphincteric incompetence based on urodynamic parameters had persistent urinary incontinence on maximal anticholinergic therapy and clean intermittent catheterization (CIC). They underwent robot-assisted Mitrofanoff appendicovesicostomy along with Leadbetter/Mitchell bladder neck reconstruction and bladder neck sling. All patients received cystography 3 weeks postoperatively. Patient demographics, medical history, perioperative parameters, and urinary continence status were collected prospectively. Results: Mean predicted bladder capacity was 353 mL (range 210-450 mL) while actual preoperative bladder capacity was 216 mL(range 180-275 mL). Preoperatively, one-patient demonstrated uninhibited bladder contractions; none had trabeculated bladders. Mean detrusor leak point pressure was 29 cm H(2)0. Three of four (75%) cases were completed robotically; one necessitated conversion to open and Monti channel creation because of a marginal appendix. Mean operative time (hours:minutes) was 7:45 (range 5:56-12:18). Mean length of stay and blood loss were 85.7 hours and 117.8 mL, respectively. Postoperatively, all patients were completely dry on CIC and anticholinergics. None of the bladders demonstrated trabeculation on follow-up cystography. Unilateral de novo grade II vesicoureteral reflux developed in two patients, and anticholinergics were dose escalated. Conclusion: Our initial series of robot-assisted appendicovesicostomy with bladder neck reconstruction and sling placement expands the scope of complex robotic reconstruction in children. The preliminary data demonstrate the procedure to be feasible and safe. Comparison with traditional “open” series of the same procedure is necessary.
“Peritoneal carcinomatosis after robotic-assisted radical cystectomy.”
Epplen, R., D. Pfister, et al. (2011).
Peritonealkarzinose nach roboterassistierter radikaler Zystektomie: 1-3.
Among patients with metastatic urothelial cancer of the bladder, 16-25% develop peritoneal carcinomatosis. In the majority of cases peritoneal carcinomatosis is associated with multiple metastatic sites. Peritoneal metastases as the single site of metastatic deposits are rare and they have been described following laparoscopic radical nephroureterectomy or cystectomy. We report on a patient who developed peritoneal carcinomatosis as the single site of metastases 8 months after robotic-assisted radical cystectomy, extended pelvic lymphadenectomy and extracorporeal formation of an ileal neobladder for organ-confined, muscle-invasive and poorly differentiated bladder cancer. The indication for robotic-assisted radical cancer surgery for urothelial carcinoma of the upper or the lower urinary tract in patients with locally advanced or poorly differentiated cancer should be made with caution. © 2011 Springer-Verlag.
“Robotic cystectomy and the Internet: Separating fact from fiction.”
Pruthi, R. S., J. Belsante, et al. (2011).
Urologic Oncology: Seminars and Original Investigations 29(4): 393-397.
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. © 2011 Elsevier Inc.
“Clinical Pathway for 3-Day Stay After Robot-Assisted Cystectomy.”
Shah, A. D. and R. Abaza (2011).
Journal of Endourology.
Abstract Background and Purpose: Typical lengths of stay after open cystectomy are 5 to 7 days, without dramatic differences reported for laparoscopic or robot-assisted cystectomy. We developed a clinical pathway for early discharge after robot-assisted cystectomy, attempting to take advantage of potentially decreased morbidity with this minimally invasive procedure and analyzed our initial outcomes. Patients and Methods: The initial 30 consecutive patients undergoing robot-assisted cystectomy who were treated on a clinical pathway developed at our institution were reviewed. This included an extraction incision of </=3 inches also used for urinary diversion, no intensive care unit stay, no nasogastric tube, and avoidance of intravenous narcotics. Ambulation is begun on postoperative day (POD) zero, with clear liquids uniformly on POD 1, then regular diet on passing flatus. Patients are discharged when tolerating diet, with a target of POD 3. Results: Mean age was 67 years (45-87 y), and mean operative time was 411 minutes. All ambulated by POD 1. Only 4 of 30 needed any intravenous narcotics. Twenty-one patients were discharged on POD 3 and 8 on POD 4 for an overall mean of 3.3 days, including 2 who were discharged on POD 2 and 1 on POD 7. One was seen in the emergency department on POD 6 for emesis, and one was readmitted on POD 7 for candidal infection. No others returned to the clinic or hospital within a week after discharge (POD 10). Conclusion: Our clinical pathway after robot-assisted cystectomy allows shorter hospital stays than typical and is, to our knowledge, the shortest reported after cystectomy by any technique. Only two unplanned visits occurred during the first 10 days. Further experience will be necessary to confirm the initial success.
“Feasibility and early outcomes of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in patients with prune belly syndrome.”
Wille, M. A., G. Jayram, et al. (2011).
Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? There is a single case reported in the literature describing this approach in Prune-Belly Syndrome. To our knowledge there are two case reports and two series in which laparoscopic appendicovesicostomy using the da Vinci robotic system was performed with good results. There are also several case reports of appendicovesicostomy creation using a pure laparoscopic approach. Additionally several case reports have described combined procedures involving pure laparoscopic and robotic assisted techniques, including appendicovesicostomy with concurrent augmentation, nephrectomy, orchiopexy, antegrade continence enema and cecostomy tube placement. Nguyen et al. have a similar experience in terms of number of patients (ten) who have undergone RALMA, but have not operated on patients with PBS. To our knowledge this is the largest series of patients undergoing RALMA in patients with Prune-Belly Syndrome. OBJECTIVES: * To evaluate the feasibility and report our initial experience with Robotic- Assisted Laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) in patients with prune belly syndrome. * The Mitrofanoff appendicovesicostomy procedure uses the appendix to create an easily accessible continent, catheterizable channel into the urinary bladder. Historically, the procedure is performed by an open surgical approach in prune belly patients. We describe our initial experience herein. MATERIALS AND METHODS: * Between October 2008 and February 2010 three patients with prune belly syndrome underwent RALMA. * The appendicovesicostomy anastomosis was performed on the anterior bladder wall and the stoma was brought to the umbilical site or right lower quadrant. * At least 4 cm of detrusor backing was ensured. * The appendicovesicostomy stent was left in place for 4 weeks postoperatively before initiation of catheterization. RESULTS: * Mean age at surgery was 9.7 years (range 5-14 years). * Blood loss volume was 20 mL in each case. Overall mean operative time was 352 min (range 319-402 min). There were no intraoperative complications and no open conversions. * There was one postoperative complication in the form of wound infection. * All patients are catheterizing their stomas and are continent at an average follow-up of 14.7 months (range 5-21 months). CONCLUSION: * In our initial experience, RALMA is a feasible option with encouraging early experience for creating a continent catheterizable channel into the urinary bladder in patients with prune belly syndrome.
“Two-port Robot-assisted vs Standard Robot-assisted Laparoscopic Partial Nephrectomy: A Matched-pair Comparison.”
Arkoncel, F. R., J. W. Lee, et al. (2011).
OBJECTIVES: To compare the outcomes between 2-port robot-assisted partial nephrectomy (2-portRALPN) and standard robot-assisted laparoscopic partial nephrectomy (sRALPN). METHODS: From May 2009 to February 2010, 35 2-portRALPN were done by a single surgeon in a university-based tertiary referral center. A cohort of 35 patients who underwent sRALPN from September 2006 to July 2009 was selected for retrospective comparison and matched for tumor complexity. All patients underwent partial nephrectomy (PN) using the daVinci surgical robotic platform (Intuitive Surgical, Sunnyvale, CA). In the 2-portRALPN, a homemade umbilical port and an infraumbilical assistant port were used, whereas standard laparoscopic port placement was used for sRALPN. The clinical, operative, pathologic, and follow-up information were collected. RESULTS: The operative time (187.5 vs 171.7 minutes, P = .110), warm ischemia time (29.5 vs 28.8 minutes, P = .209), blood loss (257 vs 242.5 mL, P = .967), complication rate (17.1 vs 11.4%, P = .495), and transfusion rate (8.6 vs 2.9%, P = .303) were comparable in both groups. The pain scores on the first postoperative day (4.5 vs 3.9, P = .236) and on the day of discharge (2.3 vs 1.9, P = .433), in-hospital morphine requirement (130.5 vs 122.2 mg, P = .115), and length of hospital stay (4.2 vs 4.2 days, P = .875) were likewise similar in both groups. CONCLUSIONS: This matched-pair study design comparing 2-portRALPN with sRALPN shows that the outcomes of both techniques are comparable. The 2-portRALPN technique is a viable option until a more advanced robotic platform specifically designed for laparoendoscopic single-site surgery is developed and a pure robot-assisted laparoendoscopic single site surgery PN can be safely performed.
“Transperitoneal robotic pyeloplasty: Our initial experiences.”
Başataç, C., U. Boylu, et al. (2011).
Transperitoneal robotik piyeloplasti: İlk deneyimlerimiz 37(2): 118-122.
Objective: To evaluate surgical and functional outcomes of the robotic assisted pyeloplasty cases. Materials and methods: Between August 2008 and November 2010, 12 patients underwent transperitoneal robotic (4 ports) pyeloplasty. Patients were evaluated with preoperative physical examination, intravenous urography, and diuretic renography. The presence of crossing vessels, blood loss, operative time, mean follow-up period, and perioperative complications were analyzed. Results: The mean age was 33 years (range 14-62 years). All patients underwent robotic-assisted dismembred pyeloplasty. Ureteral stent was placed in an antegrade fashion. Mean operative time was 124 min, and estimated blood loss was 80 cc. Crossing vessels were observed in 4 patients, and transposition was performed. The drain was removed after a mean of 3 days. The mean length of hospital stay was 3.6 days. One patient needed blood transfusion postoperatively. No evidence of obstruction was observed at a mean of 16-month follow-up. Conclusion: Robotic-assisted pyeloplasty with its high success rates and low morbidity is an effective, safe, and minimally invasive approach for the treatment of ureteropelvic junction obstruction.
“Robotic assisted laparoscopy in renal surgery: A review.”
Bodin, T., B. Faivre D’Arcier, et al. (2011).
Chirurgie rénale cœlioscopique robot assistée: Revue de la littérature 21(2): F49-F54.
The laparoscopy robot-assisted in the renal surgery is a recent technology. The indications of the laparoscopic surgery robot-assisted in the renal surgery are not codified yet and the open surgery and the traditional laparoscopic are still the recommended procedures. The objective of this article was to analyze the literature on the renal laparoscopic surgery robot assisted to specify the indications. The laparoscopic surgery robot-assisted does not bring major benefit in the realization of a total nephrectomy with regard to the conventional laparoscopy. The technical difficulty of the partial nephrectomy gives an advantage to the laparoscopic surgery robot assisted in particular at the level of the speed of the learning curve for the feasible tumors in laparoscopy. The laparoscopic surgery robot assisted countered satisfactory at the carcinologic level during a nephro-ureterectomy without demonstrating and the main disadvantage with regard to the laparoscopy is the necessity of a change of position of the robot and the patient during the procedure. The pyeloplasty by robot assisted laparoscopic surgery is becoming the new “gold standard” due to the technical ease of the suture. The live donor nephrectomy with the robot assisted laparoscopic surgery develops by its technical ease and of learning towards the laparoscopy but rest limited by its cost. © 2011 – Elsevier Masson SAS – Tous droits réservés.
“Predictive value of R.E.N.A.L. nephrometry score in robotic assisted partial nephrectomy.”
Boylu, U., R. Güzel, et al. (2011).
Robotik parsiyel nefrektomide R.E.N.A.L. nefrometri skorunun prediktif deǧeri 37(2): 81-85.
Objective: In this study, we evaluated the predictive value of R.E.N.A.L. Nephrometry Score (RNS), a system to standardize the renal tumors according to size, location, and depth, for surgical outcomes of robotic partial nephrectomy. Materials and methods: Twenty-nine cases who underwent robotic partial nephrectomy in two institutions between 2008 and 2010 were included in the study. RNS was calculated from preoperative computed tomography and/or magnetic resonance images by considering tumor size, exophytic/endophytic properties, distance to the collecting system, anterior or posterior location, and distance to the polar lines. Total RNS less than 7 was considered as low and ≥7 as high complexity lesions. Operative time, estimated blood loss, warm ischemia time, and positive surgical margin were analyzed. Results: There were 14 low complexity tumors with a mean RNS of 5 and 15 high complexity tumors with a mean RNS of 7.9. The mean warm ischemia time was 18.6 min in low complexity tumors and 29.8 min in high complexity tumors (p=0.01). There was a strong positive correlation between RNS and warm ischemia time (r=0.57, p=0.002). The difference between low and high complexity tumors was not statistically significant in terms of operative time, estimated blood loss, length of hospital stay, and positive surgical margins. Conclusion: Preoperative RNS can predict the warm ischemia time in robotic assisted partial nephrectomy. High RNS results in longer warm ischemia time. RNS may be useful in determining surgical approach to preserve renal function in high-risk patients.
“Robotic partial nephrectomy in the setting of prior abdominal surgery.”
Dasgupta, P. (2011).
BJU International 108(3): 419.
“Comparison of the Operation Time and Complications between Conventional and Robotic-Assisted Laparoscopic Pyeloplasty.”
Garcia-Galisteo, E., E. Emmanuel-Tejero, et al. (2011).
Actas Urologicas Espanolas.
OBJECTIVE: To compare the different times into which the convention and robotic-assisted laparoscopic pyeloplasty can be divided. To compare the rate of complications between both procedures. MATERIAL AND METHODS: A retrospective study was performed of the patients diagnosed of pyeloureteral junction stenosis and treated with convention and robotic laparoscopic pyeloplasty with more than one year of follow-up. All of the interventions were recorded and visualized. The different times in which the pyeloplasty can be divided were measured. All of the peri- and post-operative complications that occurred by the patients were collected. The non-parametric tests of Kolmogorov-Smirnov and Mann-Whitney U-Test for independent samples were applied using a significance level of 0.05. RESULTS: A total of 50 patients were validated. Thirty three were treated with convention laparoscopy and 17 with robotic laparoscopy. The suture time, total intervention time and time of hospital stay were lower with a statistically significant difference in the robotic-assisted pyeloplasty. The robotic pyeloplasty had a lower percentage of complications (76.5% vs 48.5%). The most frequent complications were urinary infections, in relationship to the double J. Two restenoses occurred in the conventional laparoscopy and one in the robotic-assisted. Success rate was 93.9% for the conventional laparoscopy and 94.1% for the robotic-assisted one. CONCLUSIONS: Although the success rate is similar in both procedures, the robotic pyeloplasty is a very fast procedure and has lower rates of complications than the conventional laparoscopy.
“Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: Feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up – Commentary.”
Hemal, A. K. (2011).
Journal of Endourology 25(6): 908.
“Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?”
Phé, V., O. Cussenot, et al. (2011).
BJU International 108(1): 130-138.
The resection of the distal ureter and its orifice is an oncological principle during radical nephroureterectomy which is based on the fact that it represents a part of the urinary tract exposed to a considerable risk of recurrence. After removal of the proximal part it is hardly possible to image or approach it by endoscopy during follow-up. Recent publications on survival after nephroureterectomy do not allow the conclusion that removal of distal ureter and bladder cuff are useless. Several techniques of distal ureter removal have been described but they are not equivalent in term of oncological safety. • The standard treatment of upper urinary tract urothelial carcinomas (UUT-UCs) must obey oncological principles, which consist of a complete en bloc resection of the kidney and the ureter, as well as excision of a bladder cuff to avoid tumour seeding. • The open technique is the ‘gold standard’ of treatment to which all other techniques developed are necessarily compared, and various surgical procedures have been described. • The laparoscopic stapling technique maintains a closed system but risks leaving behind the ureteric and bladder cuff segments. • Transvesical laparoscopic detachment and ligation is a valid approach from an oncological stance but is technically difficult. The major inconvenience of the transurethral resection of the ureteric orifice and intussusception techniques is the potential for tumour seeding. • Management of the distal ureter via the robot-assisted laparoscopic method is technically feasible, but outcomes from these procedures are still preliminary. • Therefore, prospective comparative studies with more thorough explorations of these techniques are needed to solve the dilemma of the management of the distal ureter during nephroureterectomy. However, bladder cuff excision should remain the standard of care irrespective of the stage of the disease. © 2010 BJU International.
“Robot-assisted retroperitoneal partial nephrectomy: technique and perioperative results.”
Weizer, A. Z., G. V. Palella, et al. (2011).
Journal of Endourology 25(4): 553-557.
Abstract Growing evidence supports the use of nephron-sparing techniques for the management of appropriately selected renal masses up to 7 cm. Compared with the surgical standard of open partial nephrectomy, minimally invasive approaches have demonstrated equivalent cancer control with reduced patient morbidity. Robot assistance has the potential to provide patients and physicians greater access to minimally invasive nephron-sparing surgery. We describe a robot-assisted retroperitoneal approach for the management of posterior renal masses. Our early results suggest reduced perioperative morbidity with the ability to manage more complex tumors.
“Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of >/=7.”
White, M. A., G. P. Haber, et al. (2011).
Urology 77(4): 809-813.
OBJECTIVES: To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. METHODS: We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (>/=7) (tumor size-[R]adius, location and depth-[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS: The median body mass index was 29.6 kg/m(2) (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m(2) (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. CONCLUSIONS: Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.
“Editorial comment for Weizer et al.”
Bhayani, S. B. (2011).
Journal of Endourology 25(4): 557-558.
Ghazi, A. (2011).
Urology 77(4): 967-968; author reply 968.
“Surgical case volume in Canadian urology residency: A comparison of trends in open and minimally invasive surgical experience.”
Mamut, A. E., K. Afshar, et al. (2011).
Journal of Endourology 25(6): 1063-1067.
Background and Purpose: The application of minimally invasive surgery (MIS) has become increasingly common in urology training programs and clinical practice. Our objective was to review surgical case data from all 12 Canadian residency programs to identify trends in resident exposure to MIS and open procedures. Materials and Methods: Every year, beginning in 2003, an average of 41 postgraduate year 3 to 5 residents reported surgical case data to a secure internet relational database. Data were anonymized and extracted for the period 2003 to 2009 by measuring a set of 11 predefined index cases that could be performed in both an open and MIS fashion. Results: 16,687 index cases were recorded by a total of 198 residents. As a proportion, there was a significant increase in MIS from 12% in 2003 to 2004 to 32% in 2008 to 2009 (P=0.01). A significant decrease in the proportion of index cases performed with an open approach was also observed from 88% in 2003 to 2004 to 68% in 2008 to 2009 (P=0.01). The majority of these shifts were secondary to the increased application of MIS for nephrectomies of all type (29%-45%), nephroureterectomy (27%-76%), adrenalectomy (15%-71%), and pyeloplasty (17%-54%) (P<0.0001 for all). While there was a significant increase in MIS experience with radical prostatectomy (2%-18%, P<0.0001), the majority of these were still taught in an open fashion during the study period. Conclusion: MIS constitutes an increasingly significant component of surgical volume in Canadian urology residencies with a reciprocal decrease in exposure to open surgery. These trends necessitate ongoing evaluation to maintain the integrity of postgraduate urologic training. © Copyright 2011, Mary Ann Liebert, Inc.
Rubinstein Dr, M. (2011).
International Braz J Urol 37(2): 159.
“Robotic vasovasostomy: description of technique and review of initial results.”
Santomauro, M. G., C. H. Choe, et al. (2011).
Journal of Robotic Surgery: 1-5.
Vasovasostomy (VV) for iatrogenic infertility is commonly employed for patients with obstructive intervals of less than 15 years, with the microsurgical technique gaining favor over use of loupe magnification due to precision suture placement. We present our technique of a robot-assisted VV and compare surgical times of staff to resident. Twenty patients with iatrogenic infertility and obstructed intervals of less than 10 years underwent robot-assisted VV, 17 utilizing a single-layer reapproximation and 3 using a double-layer reapproximation. Average patient age was 32.9 years. Following vasal exposure, the staff performed the robot-assisted anastomosis on one side followed by the resident on the opposite side. Reanastomosis times and semen analyses were recorded. Twenty patients underwent successful single- or double-layer robot-assisted vasovasostomy. Mean console time for staff to complete the vasal reconstruction was 37.6 min compared to the resident time of 54 min. Mean total operative time for all procedures was 187 min (single-layer procedure averaged 182 min compared to double-layer repair which averaged 238 min). Thirteen patients returned for follow-up semen analysis, with twelve patients demonstrating sperm within the ejaculate. Additionally, two patients reported pregnancies for a patency rate of 93%. Mean sperm density was 14 million/ml with motility of 26.4%. Robot-assisted vasovasostomy is a technically feasible procedure demonstrating adequate results on follow-up semen analysis, and can be included in training residents in robotic surgery. Additional data are needed to determine its role in the management of iatrogenic infertility. © 2011 Springer-Verlag London Ltd.
Woo, S. H. and I. Y. Kim (2011). “Editorial comment for Rebuck et al.” Journal of Endourology 25(6): 960-961.
“Transverse Versus Vertical Camera Port Incision in Robotic Radical Prostatectomy: Effect on Incisional Hernias and Cosmesis.”
Beck, S., D. Skarecky, et al. (2011).
Objectives: To examine the incidence of incisional hernias (IHs) and propose a simple modification to reduce the incidence of IHs. Robot-assisted radical prostatectomy (RARP) historically uses a vertical midline camera port incision to extract the prostate. Methods: Of 900 consecutive RARPs, the initial 735 had a vertical and subsequent 165 transverse incisions. Two methods were used to identify IHs: clinic visits noted in the prospective database and screening using electronic mail. We compared the baseline factors between the vertical IH and IH-free cohorts. The maximal scar width was recorded in 178 consecutive men presenting to our clinic: vertical (n = 107) and transverse (n = 71). Results: IHs occurred significantly more often after a vertical incision (5.3% vs 0.6%, P = .005). The IH rates after a vertical incision could be estimated to be as great as 16.7% (18 of 108) using the electronic mail respondents or as low as 3.3% (21 of 627) according to clinic follow-up. On univariate analysis, baseline age, International Index of Erectile Function 5-item questionnaire, prostate weight, bother score (all P ≤ .05), and body mass index (P = .058) were associated with an increased risk of an IH. After adjusting for baseline factors on multivariate logistic regression analysis, the relative odds of developing an IH with a vertical versus transverse incision was 11 (95% confidence interval 1.5-82). The average maximal scar width was reduced from 5.5 to 2.0 mm (P < .0001). Conclusions: In the present sample population, the vertical IH rate was estimated to be potentially as low as 3.3% or as great as 16.7%. On multivariate analysis, a greater body mass index and larger prostate size significantly increased the risk of hernia development. Transverse incisions dramatically reduced the rate of IHs and the maximal scar width. The IH rates varied significantly by reporting method. © 2011 Elsevier Inc. All rights reserved.
“Safe Positioning for Robotic-Assisted Laparoscopic Prostatectomy.”
Chitlik, A. (2011).
AORN Journal 94(1): 37-48.
Robotic-assisted laparoscopic prostatectomy is a surgical procedure performed to eradicate prostate cancer. Use of robotic assistance technology allows smaller incisions than the traditional laparoscopic approach and results in better patient outcomes, such as less blood loss, less pain, shorter hospital stays, and better postoperative potency and continence rates. This surgical approach creates unique challenges in patient positioning for the perioperative team because the patient is placed in the lithotomy with steep Trendelenburg position. Incorrect positioning can lead to nerve damage, pressure ulcers, and other complications. Using a special beanbag positioning device made specifically for use with this severe position helps prevent these complications. © 2011 AORN, Inc.
“Effectiveness of Postgraduate Training for Learning Extraperitoneal Access for Robot-Assisted Radical Prostatectomy.”
Davis, J. W., M. Achim, et al. (2011).
Journal of Endourology.
Abstract Purpose: To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs. Materials and Methods: The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes. Results: The median setup time for EP was 26 minutes (range 15-65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001). Conclusions: Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.
“Biobanking after robotic-assisted radical prostatectomy: a quality assessment of providing prostate tissue for RNA studies.”
Dev, H., D. Rickman, et al. (2011).
J Transl Med 9(1): 121.
ABSTRACT: BACKGROUND: RNA quality is believed to decrease with ischaemia time, and therefore open radical prostatectomy has been advantageous in allowing the retrieval of the prostate immediately after its devascularization. In contrast, robotic-assisted laparoscopic radical prostatectomies (RALP) require the completion of several operative steps before the devascularized prostate can be extirpated, casting doubt on the validity of this technique as a source for obtaining prostatic tissue. We seek to establish the integrity of our biobanking process by measuring the RNA quality of specimens derived from robotic-assisted laparoscopic radical prostatectomy. METHODS: We describe our biobanking process and report the RNA quality of prostate specimens using advanced electrophoretic techniques (RNA Integrity Numbers, RIN). Using multivariate regression analysis we consider the impact of various clinicopathological correlates on RNA integrity. RESULTS: Our biobanking process has been used to acquire 1709 prostates, and allows us to retain approximately 40% of the prostate specimen, without compromising the histopathological evaluation of patients. We collected 186 samples from 142 biobanked prostates, and demonstrated a mean RIN of 7.25 (standard deviation 1.64) in 139 non-stromal samples, 73% of which had a RIN[greater than or equal to]7. Multivariate regression analysis revealed cell type – stromal/epithelial and benign/malignant – and prostate volume to be significant predictors of RIN, with unstandardized coefficients of 0.867(p=0.001), 1.738(p<0.001) and -0.690(p=0.009) respectively. A mean warm ischaemia time of 120min (standard deviation 30min) was recorded, but multivariate regression analysis did not demonstrate a relationship with RIN within the timeframe of the RALP procedure. CONCLUSIONS: We demonstrate the robustness of our protocol – representing the concerted efforts of dedicated urology and pathology departments – in generating RNA of sufficient concentration and quality, without compromising the histopathological evaluation and diagnosis of patients. The ischaemia time associated with our prostatectomy technique using a robotic platform does not negatively impact on biobanking for RNA studies.
“A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy.”
Douaihy, Y. E., P. Sooriakumaran, et al. (2011).
International Urology and Nephrology 43(2): 405-415.
Introduction: Robotic assisted radical prostatectomy (RARP) is gaining widespread acceptance for the management of localized prostate cancer. However, data regarding patient expectations and satisfaction outcomes after RARP are scarce. Methods: We developed a structured program for preoperative education and evidence-based counseling using a multi-disciplinary team approach and measured its impact on patient satisfaction in a cohort of 377 consecutive patients who underwent RARP at our institution. Responses regarding overall, sexual, and continence satisfaction were assessed. Results: Fifty percent of our patient cohort replied to the questionnaire assessments. Ninety-three percent of responding patients expressed overall satisfaction after RARP with only 0.5% expressing regret at having had the operation. Biochemical recurrence and lack of continence correlated significantly with low levels of satisfaction, though sexual function was not significantly different among those satisfied and those not. Most patients (97%) valued oncologic outcome as their top priority, with regaining of urinary control being the commonest second priority (60%). Conclusions: RARP appears to be associated with a high degree of patient satisfaction in a cohort of patients subjected to a structured preoperative education and counseling program. Oncologic outcomes are most important to these patients and have the largest influence on satisfaction scores. © 2010 Springer Science+Business Media, B.V.
“Surgery: Robotic prostatectomy proven to provide sexual outcome benefit.”
Engel, J. D. (2011).
Nature Reviews Urology 8(7): 357-358.
“Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy?”
Ferronha, F., F. Barros, et al. (2011).
International Braz J Urol 37(2): 146-158.
Purpose: To compare the perioperative, short-term and long-term postoperative results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robotic assisted laparoscopic prostatectomy (RALP) in the most recent studies evaluable. Materials and Methods: Using PubMed we have undertaken a search based on references from major and recent articles with considerable sample sizes. Results: The operative blood loss and the risk of transfusion were lower in the laparoscopic and robotic-assisted approaches. The surgical duration was shorter in the open and robotic group. Regarding the positive margins, continence and potency no substantial differences between the RRP, LRP, and RALP were found. Conclusions: Our results suggest that no one surgical approach is superior in terms of functional and early oncologic outcomes. Potential advantages of any surgical approach have to be confirmed through longer-term follow-up and adequately designed clinical studies.
“A short-term cost-effectiveness study comparing robot-assisted laparoscopic and open retropubic radical prostatectomy.”
Hohwü, L., M. Borre, et al. (2011).
Journal of Medical Economics 14(4): 403-409.
Objective: To evaluate cost effectiveness and cost utility comparing robot-assisted laparoscopic prostatectomy (RALP) versus retropubic radical prostatectomy (RRP). Methods: In a retrospective cohort study a total of 231 men between the age of 50 and 69 years and with clinically localised prostate cancer underwent radical prostatectomy (RP) at the Department of Urology, Aarhus University Hospital, Skejby from 1 January 2004 to 31 December 2007, were included. The RALP and RRP patients were matched 1:2 on the basis of age and the DAmico Risk Classification of Prostate Cancer; 77 RALP and 154 RRP. An economic evaluation was made to estimate direct costs of the first postoperative year and an incremental cost-effectiveness ratio (ICER) per successful surgical treatment and per quality-adjusted life-year (QALY). A successful RP was defined as: no residual cancer (PSA <0.2 ng/ml, preserved urinary continence and erectile function. A one-way sensitivity analysis was made to investigate the impact of changing one variable at a time. Results: The ICER per extra successful treatment was €64,343 using RALP. For indirect costs, the ICER per extra successful treatment was €13,514 using RALP. The difference in effectiveness between RALP and RRP procedures was 7% in favour of RALP. In the present study no QALY was gained 1 year after RALP, however this result is uncertain due to a high degree of missing data. The sensitivity analysis did not change the results noticeably. Limitations: The study was limited by the design resulting in a low percentage of information on the effect of medication for erectile dysfunction and only short-term quality of life was measured at 1 year postoperatively. Conclusion: RALP was more effective and more costly. A way to improve the cost effectiveness may be to perform RALP at fewer high volume urology centres and utilise the full potential of each robot. © 2011 Informa UK Ltd All rights reserved.
“The impact of anterior urethropexy during robotic prostatectomy on urinary and sexual outcomes.”
Johnson, E. K., R. C. Hedgepeth, et al. (2011).
Journal of Endourology 25(4): 615-619.
OBJECTIVES: We determined the effect of an anterior urethropexy (AU) stitch on postoperative urinary continence, irritative urinary symptoms, and sexual function after robotic radical prostatectomy (RP). METHODS: Consecutive patients undergoing robotic RP for prostate cancer were prospectively evaluated. The Expanded Prostate Cancer Index Composite (EPIC) questionnaire was administered pre- and postoperatively to all patients. Patients were then grouped by AU status. A linear mixed model was used to compare the rate of recovery in incontinence (UIN), irritative (UIR), and sexual domain scores between the two groups. A t-test was used to compare UIN, UIR, and sexual domain scores at specific time points. RESULTS: A total of 229 patients underwent robotic RP and filled out a preoperative and at least one postoperative EPIC questionnaire. In this population, 87 did have and 142 did not have an AU performed. The mean EPIC-UIN score at 3 months was 68 in the AU group and 58 in the non-AU group (p = 0.015). Comparison of all other time points and overall urinary scores revealed no other statistically significant differences after surgery. Sexual domain scores were also improved at 3 months in the AU group (p = 0.002). CONCLUSIONS: AU during robotic RP leads to improved urinary continence and sexual functioning at 3 months of follow-up. An earlier return to continence may facilitate an earlier return to sexual activity. AU may offer a short-term quality-of-life advantage for patients undergoing robotic RP.
“Achieving realistic postoperative expectations in the prostatectomy populationis it possible?”
Krupski, T. L. (2011).
Journal of Urology 186(2): 373-374.
“Complications and Nerve Preservation in Prostatectomy According to the Time Interval from Diagnostic Biopsy.”
Martin-Lopez, J. E., A. M. Carlos-Gil, et al. (2011).
Actas Urologicas Espanolas.
OBJECTIVES: To summarize the available evidence on complications and bilateral nerve preservation in radical prostatectomy in patients according to the time interval from diagnostic biopsy (more or less than six weeks). MATERIAL AND METHODS: Relevant studies were identified by using structured and specific search strategies for each of the databases consulted, without limitations. The methodological quality of each of the studies included was evaluated and the data were extracted independently. RESULTS: For open radical prostatectomy, two of the studies concluded that a time interval of less than 4 or 6 weeks between prostate biopsy and surgery had no influence on the postsurgical complications rate or on nerve preservation during surgery. For laparoscopic robotic-assisted radical prostatectomy, the study included concluded that performing this type of intervention in an interval of less than 4 or 6 weeks after diagnostic biopsy was associated with a higher risk of postsurgical complications. However, all these studies had major methodological limitations. CONCLUSIONS: The time interval between diagnostic biopsy and open surgery has no influence on the complications rate or nerve preservations. In contrast, an interval of less than 4 weeks between diagnostic biopsy and laparoscopic surgery is associated with a higher risk of surgical complications.
“Comparison of Extraperitoneal and Transperitoneal Pelvic Lymph Node Dissection During Minimally Invasive Radical Prostatectomy.”
Mullins, J. K., M. E. Hyndman, et al. (2011).
Journal of Endourology.
Introduction: Pelvic lymph node dissection (PLND) during radical prostatectomy (RP) has prognostic and possible therapeutic benefits. We assessed whether an extraperitoneal minimally-invasive RP (MiRP) allows for standard-template PLND comparable to transperitoneal MiRP+PLND. Materials and Methods: A retrospective clinicopathologic study of 914 consecutive patients who underwent MiRP (laparoscopic or Da VinciTM robot-assisted laparoscopic) with bilateral PLND by one surgeon (CPP) from 2001- 2010 was performed. Low-risk patients generally received a limited dissection (external iliac nodes) when PLND was performed. Those with intermediate and high-risk disease generally received a standard PLND (external iliac and obturator nodes). Patients were stratified into groups based on operative approach (extraperitoneal vs. transperitoneal) for most analyses. Results: Overall, 192 patients had transperitoneal MiRP+PLND, and 377 had extraperitoneal MiRP+PLND. The extraperitoneal group had higher BMI (p=0.03), a higher percentage of low-risk (p=0.003) and a lower percentage of intermediate-risk disease (p=0.006). Lymph node yield (LNY) was higher with extraperitoneal PLND overall (6.5 vs. 5.3, p=0.003). When stratified by risk category, LNY was greater in the extraperitoneal group for patients with low-risk disease only (6.6 vs. 4.9, p=0.008). There was no difference in nodal yield in intermediate/high-risk patients receiving standard PLND by either transperitoneal or extraperitoneal approach (6.0 vs. 5.5, p=0.36 and 8.0 vs. 5.8, p=0.14, respectively). Lymph node involvement was rare overall. Estimated blood loss and complication rates were comparable between operative approaches. Conclusions: The extraperitoneal MiRP approach does not compromise the oncologic efficacy or safety of routine PLND.
“Learning curve of robotic-assisted radical prostatectomy with 60 initial cases by a single surgeon.”
Ou, Y. C., C. R. Yang, et al. (2011).
Asian Journal of Surgery 34(2): 74-80.
We tracked various proficiency indicators for the learning curve as a single Taiwanese surgeon became familiar with robotic-assisted laparoscopic radical prostatectomy surgeries by performing 60 initial procedures. Between December 2005 and December 2007, 60 consecutive patients were classified into Group 1 (Cases 1-30) or Group 2 (Cases 31-60). Pre-operative clinical characteristics, operative parameters, and postoperative parameters were assessed. Pre-operative biopsy Gleason scores were significantly higher in Group 2 than in Group 1 (7.03 vs. 6.13, P < 0.01). The vesicourethral anastomosis time showed a statistically significant reduction from 46.38 minutes in Group 1 to 31 minutes in Group 2 (p < 0.01). The continence rate at 3 months in Group 2 was higher than that in Group 1 (97.6 vs. 76.7, p = 0.052); the mean duration to continence was shorter in Group 2 than Group 1 (70.26 ± 67.37 days vs. 39.63 ± 36.48 days, p = 0.056). Group 2 had shorter postoperative stays (3.93 vs. 7.33) and longer durations of Foley catheter removal (9.0 vs. 7.7) than Group 1, representing a statistically significant difference (p < 0.01). After gaining experience by performing an initial 30 robotic-assisted laparoscopic radical prostatectomies, the subsequent 30 surgeries established proficiency as determined by vesicourethral anastomosis time and early continence rate. © 2011 Asian Surgical Association.
“Comparative assessment of a single surgeon’s series of laparoscopic radical prostatectomy: conventional versus robot-assisted.”
Park, J. W., H. Won Lee, et al. (2011).
Journal of Endourology 25(4): 597-602.
PURPOSE: To directly compare the outcome of laparoscopic radical prostatectomy (LRP) with robot-assisted laparoscopic prostatectomy (RALP) performed by a single laparoscopic surgeon with intermediate experience-one who is between a novice and an expert. PATIENTS AND METHODS: Consecutive 106 patients with prostate cancer who were treated with radical prostatectomy (62 with LRP and 44 with RALP) were included. The preoperative characteristics, the perioperative surgical outcomes, and the functional outcomes were compared between the two groups. RESULTS: The mean operative time was longer in the RALP group (371 min vs 308 min, P = 0.00), conceivably because of more nerve-sparing procedures (84% vs 57%). The other perioperative parameters, including the surgical margin, were comparable, except for two major complications (rectourethral fistula and ureteral injury) in the LRP group. The RALP group recovered continence faster than those in the LRP, but the eventual continence rate at 12 months was similar (95% for LRP vs 94.4% for RALP, P = 1.00). The potency rate >/= 6 months postsurgery was 47.6% in the LRP group and 54.5% in the RALP group (P = 0.65). CONCLUSIONS: RALP was beneficial for the earlier recovery of continence, although LRP and RALP had comparable safety and efficacy as minimally invasive surgery for prostate cancer when performed by a laparoscopic surgeon with intermediate experience. Long-term follow-up data are needed for further evaluation of oncologic and functional outcomes for both techniques.
“Anastomosis During Robot-assisted Radical Prostatectomy: Randomized Controlled Trial Comparing Barbed and Standard Monofilament Suture.”
Sammon, J., T. K. Kim, et al. (2011).
OBJECTIVES: To compare perioperative and functional outcomes after urethrovesical anastomosis (UVA) with barbed polyglyconate and monofilament poliglecaprone in robot-assisted radical prostatectomy (RARP). Barbed polyglyconate suture was first used for the UVA during RARP beginning in January 2010; safety and feasibility were previously demonstrated in 51 patients. METHODS: From May to September 2010, 64 patients meeting all the inclusion criteria participated in the present multisurgeon prospective, randomized, controlled trial and underwent posterior repair and UVA during RARP with either barbed polyglyconate (n = 33) or monofilament poliglecaprone (n = 31) suture. The primary outcomes were the anastomotic (UVA) and posterior reconstruction times. Secondary outcomes included cystogram leak, bladder neck reconstruction rate, and 6-week functional outcomes assessed by a self-administered validated patient questionnaire. RESULTS: Posterior reconstruction was performed within 3.3 minutes with the barbed suture versus 4.3 minutes with the monofilament poliglecaprone suture (23.3% reduction) and UVA within 10.1 versus 13.8 minutes, respectively (26.8% reduction). The absolute time difference for the 2-layer anastomosis was 4.7 minutes (a 26.0% reduction in the total anastomosis time). All other perioperative outcomes were equivalent between the 2 groups. Urinary functional outcomes, including the pad use and leakage rates, were equivalent at 6 weeks. CONCLUSIONS: Anastomosis during RARP with the V-Loc barbed suture can be performed safely and more efficiently than with standard monofilament suture. We demonstrated a 26% decrease in the anastomotic time with no increase in the adverse events, no instances of urinary retention and equivalent functional outcomes were measured with the self-administered patient questionnaire.
“Searching robotic prostatectomy online: what information is available?”
Steinberg, P. L. and R. Ghavamian (2011).
Urology 77(4): 941-945.
OBJECTIVES: To search online using the Google search engine to determine what information for robotic-assisted radical prostatectomy (RARP) is available and whether the claims made on the Internet are supported by the published peer-reviewed urologic data. METHODS: The term “robotic prostatectomy” was searched using Google on September 29, 2009. The first 50 Web sites were reviewed for RARP specific outcomes, including oncologic outcomes, potency, continence, recovery, and blood loss. All claims were compared with the accepted standards supported by the existing published urologic data. RESULTS: Of the first 50 Web sites, 9 were rejected. Of the remaining 41, 29 were from academic practices and 8 from nonacademic practices; for 4, this distinction was not applicable. Also, 19 sites had direct links, photographs, or text from the Intuitive Surgical Web site, and 22 sites did not. Of the 41 Web sites, 20 made no mention of surgeon experience with RARP and 21 did, with an average experience of 1487 +/- 1206 cases. More than 60% of the sites claimed better potency outcomes with RARP than with radical retropubic prostatectomy, although 32% of sites omitted this information. Similarly, 63% of the Web sites claimed improved continence with RARP than with radical retropubic prostatectomy, and 29% of the sites made no mention of continence. Data on oncologic efficacy was missing from 22% of the Web sites, 22% suggested the cancer outcomes were equivalent between RARP and radical retropubic prostatectomy, and 56% suggested the cancer outcomes were better with RARP. Concerning postoperative recovery and blood loss, 85% of the sites stated that both were improved with RARP, and only 15% omitted these data. CONCLUSIONS: Overall, an online search using the Google search engine for robotic prostatectomy yielded many Web sites with unsubstantiated information of variable accuracy.
“Clinicians’ use of guidelines as illustrated by curative treatment of prostate cancer at a comprehensive cancer center.”
Stensvold, A., A. A. Dahl, et al. (2011).
Acta Oncologica 50(3): 408-414.
BACKGROUND: We studied compliance to guidelines of curative treatments in prostate cancer (PCa), which were of special interest due to recent introduction of new treatment technologies and the fact that there existed a real choice between surgery and radiotherapy. MATERIAL AND METHODS: We did retrospective analyses of guidelines adherence for all PCa patients receiving curative treatment at the Norwegian Radium Hospital from 2004 to 2007 after the introduction of robot-assisted prostatectomy and after-loading brachytherapy. The patients were classified into three groups in relation to guidelines: the accordance, accordance after discussion, and the deviance groups. In time Period I (2004-2005) the 2003 EAU guidelines were used and in Period II (2006-2007) in-house guidelines with minor modifications of EAU were applied. RESULTS: During the observation period 859 patients had curative treatment for PCa, and 83% of the patients were treated according to guidelines. In the deviance group (N=146), 119 men (82%) got prostatectomy instead of radiotherapy. The reasons for deviation in the second period were age >65 years (N=70) and surgery in cases with T3 tumors (N=10), Gleason score >8 (N=13) and combinations (N=26). Deviances from guidelines in the radiotherapy group (N=27) mainly concerned patient selecting this treatment due to expectations of preserving sexuality and/or fertility. CONCLUSIONS: In spite of acceptable overall compliance to guidelines for curative PCa treatment, the proportion of non-adherence should not been overseen, in particular when new treatment technologies are introduced. Guidelines for PCa need to be monitored regularly, and the compliance to guidelines has to be assessed on a regular basis. Guidelines should avoid too strict criteria, particularly in relation to age.
“Surgeon perception is not a good predictor of peri-operative outcomes in robot-assisted radical prostatectomy.”
Stern, J., S. Sharma, et al. (2011).
Journal of Robotic Surgery: 1-6.
Surgeons have always used their cognitive intuition for the execution of skilled tasks and real-time perception of intra-operative outcomes. We attempted to measure the overall accuracy of intra-operative surgeon perception on the functional outcome of early continence after robot-assisted radical prostatectomy (RARP). A single experienced surgeon (D.I.L.) used a scoring sheet to prospectively capture his subjective opinion of how well a particular portion of the RARP procedure was completed. Surgeon perception of factors affecting post-operative continence such as quality of bladder neck preservation, nerve sparing, urethral length, anastomosis, striated sphincter thickness, quality of Rocco repair and bladder neck plication suture (total 7 variables) were graded as “poor”, “average” or “good”. Urinary continence was graded as either total continence [0 pads per day (PPD) or social continence (security pad or one PPD)]. A total of 273 (39 patients × 7 variables) responses were recorded: 58.6% were rated as “good”, 32.2% as “average” and 8.4% as “poor”. A log-rank test for all perception variables showed no significant differences in subsequent achievement of continence (either 0 or 1 PPD) (P > 0.05) at both the 1- and 3-month time points. In the case of some perception variables, patients with “bad” scores gained continence a median of 3 weeks sooner than patients with “good” scores. Surgeon perception of intra-operative performance during RARP is a poor predictive indicator of subsequent functional outcome in terms of urinary continence. Inter-surgeon variability of perception may vary and needs further investigation. © 2011 Springer-Verlag London Ltd.
“Trends in the care of radical prostatectomy in the United States from 2003 to 2006.”
Williams, S. B., S. M. Prasad, et al. (2011).
BJU International 108(1): 49-55.
There is an increasing trend of minimally invasive treatments for prostate cancer with increased utilization of robotic technology contributing largely to this trend. Our study found that increased utilization of MIRP corresponded with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. OBJECTIVE • To determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS • We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS • Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P= 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P= 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P= 0.049), miscellaneous surgical complications (3.6 to 2.3%, P= 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P= 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P= 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period. CONCLUSION • The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control. © 2010 BJU International.
“The learning curve for laparoscopic radical prostatectomy: An international multicenter study – Commentary.”
Winfield, H. N. (2011).
Journal of Endourology 25(6): 898-899.
“Evaluation of combined oncologic and functional outcomes after robotic-assisted laparoscopic extraperitoneal radical prostatectomy: Trifecta rate of achieving continence, potency and cancer control.”
Xylinas, E., X. Durand, et al. (2011).
Urologic Oncology: Seminars and Original Investigations.
Objectives: Outcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP). Materials and methods: We included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses. Results: Median age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men < 60 years. Age < 60 years, PSA level < 10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome. Conclusion: Two years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men. © 2011 Elsevier Inc. All rights reserved.