“Is pure laparoscopic radical cystectomy still an attractive solution for the treatment of muscle-invasive bladder cancer?”
Chlosta, P., T. Drewa, et al. (2010).
Urologia Internationalis85(3): 291-295.
Objective: The aim of this study is to report our experience with laparoscopic radical cystectomy (LRC), evaluating the technique and perioperative and pathological outcomes. Methods: 47 LRCs were performed due to muscle-invasive bladder cancer. Conduits were performed in 23 patients and neobladders in 23 (one bi-intestinal). One ureterocutaneostomy was created. Results: In 43 patients LRC was performed with minilaparotomy for urinary diversion. The mean operation time was 290 min. Four operations were converted. Complications included sigmoid colon injury, urinary leak, lymphatic leak, short-term paralytic ileus, and heart attack. Mean blood loss was 220 ml. Hospitalization time was 6 days. Tumor stage was pT2b, pT3a, pT3b, and pT4a in 28, 13, 5, and 1 patient, respectively. No positive margins were found. The mean number of lymph nodules was 17, while in the last 25 procedures it was 21. 17% of patients had tumor in the lymph nodes. The mean follow-up was 10 months. Local recurrence and dissemination was observed in 2%. Continence in patients receiving neobladder was fully satisfactory. Conclusions: More complications are related to neobladder than to ileac conduit. LRC with minilaparotomy seems to be an attractive treatment option for patients with muscle-invasive bladder cancer. Radical cystectomy performed intracorporeally could be reserved for ‘robot-assisted’ operations. Copyright © 2010 S. Karger AG, Basel.
“Robot Assisted Extended Pelvic Lymphadenectomy at Radical Cystectomy: Lymph Node Yield Compared With Second Look Open Dissection.”
Davis, J. W., K. Gaston, et al. (2010).
Journal of Urology.
Purpose: Robot assisted radical cystectomy outcomes show feasibility and potential benefits for patient recovery. However, it is difficult to judge the completeness of extended robot assisted vs open pelvic lymph node dissection using only the lymph node count and template description. We performed a prospective protocol in which radical cystectomy and pelvic lymph node dissection done in robot assisted fashion were followed by second look open pelvic lymph node dissection. Our primary objective was to determine the fraction of lymph nodes yielded by robot assisted pelvic lymph node dissection. Materials and Methods: Patients with pure transitional cell carcinoma and no locally advanced features were selected for robot assisted radical cystectomy. A team of 2 urological oncologists performed radical cystectomy and pelvic lymph node dissection in robot assisted fashion, followed by second look open pelvic lymph node dissection. Lymph nodes from robot assisted dissection were submitted in up to 8 separate specimens by anatomical location. Any additional specimens retrieved at open dissection were submitted separately. Results: The protocol was completed in 11 patients from October 2007 to June 2009. The median yield of robot assisted and second look open pelvic lymph node dissection was 43 (range 19 to 63) and 4 (range 0 to 8), respectively, for an overall robot assisted yield of 93%. Of second look open pelvic lymph node dissections 67% were clear of residual tissue, 13% had tissue without lymph nodes and 20% had 1 or more lymph nodes. Median operative time for robot assisted pelvic lymph node dissection was 117 minutes. Concurrently open radical cystectomy without required multiple lymph node specimen submission yielded a median 24 nodes. Conclusions: Our data showing a robot assisted pelvic lymph node dissection yield of 93% of that of open surgery should allay concern that the robot assisted technique limits the completeness of pelvic lymph node dissection. © 2011 American Urological Association Education and Research, Inc.
“Robotic Enterocystoplasty: Technique and Early Outcomes.”
Gould, J. J. and J. T. Stoffel (2010).
Journal of Endourology.
Abstract Objective: Enterocystoplasty is an established treatment for patients with refractory neurogenic bladder symptoms. We assessed the feasibility, safety, and efficacy of a robot-assisted enterocystoplasty in this population. Materials and Methods: Five neurogenic bladder patients, median age of 43.8 years, underwent the procedure. Using a five-port technique, intraperitoneal robotic enterocystoplasty was performed through the following steps: (1) creation of a U-shaped full-thickness detrusor cystotomy, (2) intracorporeal harvesting of 30 cm of ileum, (3) intracorporeal construction of a detubularized ileal patch, and (4) anastomosis of the ileal patch to the cystotomy. An extracorporeal side-to-side bowel anastomosis re-established bowel continuity. After surgery, urinary continence, bladder capacity, upper tract protection, and complications were assessed. Results: Mean operative time was 6.4 hours, estimated blood loss was 180 mL, and length of stay was 7 days. Postoperatively, all patients had a functioning enterocystoplasty, urethral continence, and normal upper tract imaging. One patient was rehospitalized for an ileus/urinoma, which resolved with conservative treatment. Conclusions: Robot-assisted enterocystoplasty can be effectively and safely performed with minimal morbidity.
“Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield.”
Lavery, H. J., H. J. Martinez-Suarez, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVES: To report our initial experience with robot-assisted extended pelvic lymph node dissection (ePLND) using a standardized open template. MATERIALS AND METHODS: In total, 15 consecutive patients underwent robotic radical cystectomy at a single center by a single surgeon using a standard dissection template. Operating time, time to perform ePLND, pathological stage, estimated blood loss, length of hospital stay, number of nodes obtained and nodal positivity were assessed. Postoperative complications and re-admissions were reviewed. RESULTS: The mean (range) age and body mass index was 66 (46-87) years and 29 (22-43) kg/m(2) , respectively. The mean (range) operating time and ePLND time was 423 (300-506) min and 107 (66-160) min. Mean (range) estimated blood loss was 160 (50-500) mL. The mean (range) and median length of hospital stay were 3.4 (3-7) days and 3 days, respectively. The mean (range) nodal yield was 41.8 (18-67) nodes, with greater than 25 nodes in 13 patients. Three patients were found to have nodal positivity. Of the fifteen patients, four received neoadjuvant chemotherapy. Two patients were re-admitted for postoperative complications within 30 days. There were no complications directly resulting from the ePLND. CONCLUSIONS: Robot-assisted ePLND at the time of cystectomy can be safely and effectively performed on the robotic platform with comparable nodal yields to open series at centers of excellence for cystectomy. Nodal yields are likely to comprise a factor related to the effort of the surgeon, and not the method by which the lymphadenectomy is performed.
“Progress in treatment of genitourinary malignancies.”
Pow-Sang, J. M. (2010).
Cancer Control17(4): 212.
“Robotic Radical Cystectomy: Where are We Today, Where will We be Tomorrow?”
Richards, K. A., K. Kader, et al. (2010).
While open radical cystectomy remains the gold-standard treatment for muscle-invasive bladder cancer and high-risk non-muscle invasive disease, robotic assisted radical cystectomy (RARC) has been gaining popularity over the past decade. The robotic approach has the potential advantages of less intraoperative blood loss, shorter hospital stay, less post-operative narcotic requirement, quicker return of bowel function, and earlier convalescence with an acceptable surgical learning curve for surgeons adept at robotic radical prostatectomy. While short to intermediate term oncologic results from several small RARC series are promising, bladder cancer remains a potentially lethal malignancy necessitating long-term follow-up. This article aims to review the currently published literature, important technical aspects of the operation, oncologic and functional outcomes, and the future direction of RARC.
“Robot-assisted laparoscopic ureterolysis: Case report and literature review of the minimally invasive surgical approach.”
Seixas-Mikelus, S. A., S. J. Marshall, et al. (2010).
Journal of the Society of Laparoendoscopic Surgeons14(2): 313-319.
Objectives: To evaluate our case of robot-assisted ureterolysis (RU), describe our surgical technique, and review the literature on minimally invasive ureterolysis. Methods: One patient managed with robot-assisted ureterolysis for idiopathic retroperitoneal fibrosis was identified. The chart was analyzed for demographics, operative parameters, and immediate postoperative outcome. The surgical technique was assessed and modified. Lastly, a review of the published literature on ureterolysis managed with minimally invasive surgery was performed. Results: One patient underwent robot-assisted ureterolysis at our institution in 2 separate settings. Operative time (OR) decreased from 279 minutes to 191 minutes. Estimated blood loss (EBL) was less than 50mL. The patient has been free of symptoms and both renal units are unobstructed. According to the published literature, 302 renal units underwent successful laparoscopic ureterolysis (LU), and 6 renal units underwent RU. There were 9 open conversions (all in LU). Mean OR in LU was 248 minutes for unilateral and 386 minutes for bilateral cases. In RU, mean OR was 220 minutes for unilateral and 390 minutes for bilateral cases. EBL averaged 200mL in LU and 30 mL in RU. Conclusions: Our data reveal that robot-assisted ureterolysis is safe and feasible. Published data demonstrate the advantages of minimally invasive surgery. © 2010 by JSLS.
“Robotic renal transplantation: first European case.”
Boggi, U., F. Vistoli, et al. (2010).
A kidney from a 56-year-old mother was transplanted to her 37-year-old daughter laparoscopically using the daVinci HDSi surgical system. The kidney was introduced into the abdomen through a 7-cm suprapubic incision used also for the uretero-vescical anastomosis. Vascular anastomoses were carried out through a total of three additional ports. Surgery lasted 154 min, including 51 min of warm ischemia of the graft. Urine production started immediately after graft reperfusion. Renal function remains optimal at the longest follow-up of 3 months. The technique employed in this case is discussed in comparison with the only other two contemporary experiences, both from the USA. Furthermore, possible advantages and disadvantages of robotics in kidney transplantation are discussed extensively. We conclude that the daVinci surgical system allows the performance of kidney transplantation under optimal operative conditions. Further experience is needed, but it is likely that solid organ transplantation will not remain immune to robotics.
“Two-year outcomes after robotic renal surgery: a single surgeon’s experience.”
Uffort, E. E. and J. C. Jensen (2010).
Journal of Robotic Surgery: 1-6.
The purpose of this study is to validate the feasibility of the robotic technology for various types of renal surgery and to outline the 2-year clinical and pathological outcomes post surgery. In a retrospective chart review with IRB approval of 55 robotic renal surgeries, clinical data and pathological outcomes were recorded, including estimated glomerular filtration rate (eGFR), serum creatinine, radiological surveillance of tumor recurrences and overall quality of life on pre- and postoperative visits at 6, 12, 18 and 24 months. There were 26 robotic partial nephrectomy (RPN), 23 radical nephrectomy (RRN), 3 simple nephrectomy (RSN), and 3 radical nephroureterectomy (RNU) procedures. Twelve patients in the RPN group, 17 in the RRN group and all in the RSN and RNU groups had eGFR <60 ml/min/1.73 m<sup>2</sup> and one or more risk factors for chronic kidney disease (CKD) preoperatively. Mean serum creatinine was 1.2, 1.3, 1.2, and 1.8, and eGFR was 66.4, 61.2, 55.8, and 41.0, respectively. There were two distant metastasis and four local recurrences in the RRN group, and two local recurrences in the RNU group. Serum creatinine and changes in eGFR were statistically similar in all groups postoperatively. Cancer-specific survival was 100% for RPN, 83% for RRN, and 100% for RNU while overall survival was 100% for RPN, 76% for RRN, 100% for RSN, and 100% for RNU at 2 years. Robotic renal surgery is a feasible, minimally invasive alternative with promising outcomes in our short-term follow-up. Long-term and comparative studies with open or conventional laparoscopic approaches are needed. © 2010 Springer-Verlag London Ltd.
“Annual surgical caseload and open radical prostatectomy outcomes: Improving temporal trends.” Budäus, L., F. Abdollah, et al. (2010).
Journal of Urology184(6): 2285-2290.
Purpose Radical prostatectomy is the standard of care for localized prostate cancer. Numerous previous reports show the relationship between surgical experience and various outcomes. We examined the effect of surgical experience on complications and transfusion rates, and determined individual surgeon annual caseload trends in a contemporary radical prostatectomy cohort. Materials and Methods We analyzed annual caseload temporal trends in 34,803 patients who underwent surgery between 1999 and 2008 in Florida. Logistic regression models controlled for clustering among surgeons addressed the relationship of surgical experience, defined as the number of radical prostatectomies done since January 1, 1999 until each radical prostatectomy, with complications and transfusions. Results During the study period the proportion of surgeons in the high annual caseload tertile (24 radical prostatectomies or greater yearly) and the proportion of patients treated by those surgeons increased from 5% to 10% and from 20% to 55%, respectively. Conversely complication and transfusion rates decreased from 14.3% to 9.2% and 12.6% to 6.9%, respectively. Radical prostatectomies done by surgeons in the high surgical experience tertile (86 or greater radical prostatectomies) decreased the risk of any complication by 33% and of any transfusion by 30% vs those in patients operated on by surgeons in the low surgical experience tertile (27 or fewer radical prostatectomies). Conclusions The proportion of surgeons in the high annual caseload tertile and the proportion of patients treated by these surgeons steadily increased during the last decade. Complication and transfusion rates decreased with time. The implications of these encouraging findings may result in improved outcomes in patients with surgically managed prostate cancer. © 2010 American Urological Association Education and Research, Inc.
“Robot-assisted laparoscopic prostatectomy: A 2010 update.”
Duthie, J. B., J. E. Pickford, et al. (2010).
New Zealand Medical Journal123(1325): 30-34.
Aim: To build on the previous article and further explore the safety and efficacy of robotic-assisted laparoscopic prostatectomy (RALP) in the first 100 cases from a single institution in New Zealand. Method: A prospective database was created to monitor perioperative and postoperative outcomes of men undergoing RALP for clinically localised carcinoma of the prostate. Results: The first 100 cases were followed prospectively with a mean follow-up of 13.9 months. There were no conversions to open surgery, or re-operations. Average blood loss was 281 ml, and there was only one blood transfusion. Mean hospital stay was 1.1 nights. Mean console time improved from 251.4 minutes over the first 10 cases to 104.6 minutes over the last 10. The overall positive margin rate was 18%. The positive margin rate from pT2 tumours was 8%. The majority of patients had well-differentiated, organ-confined disease. Postoperatively, five have a detectable PSA level. 68% use no incontinence pads at 12 months. At one year, 12% of the men who were previously fully potent have achieved full potency again without assistance Conclusion: The results further support RALP as a safe, effective, and well tolerated procedure for the management of carcinoma of the prostate. The early local experience compares favourably with other published early series. ©NZMA.
“Prostate cancer: Robotic debate dampened by long-term data?”
Farley, S. J. (2010).
Nature Reviews Urology7(11): 589.
“MRI of the prostate: Potential role of robots.”
Fütterer, J. J., S. Misra, et al. (2010).
Imaging in Medicine2(5): 583-592.
Prostate cancer is the most frequently diagnosed malignancy in the male population. Transrectal ultrasound-guided biopsy is still the imaging modality of choice in detecting prostate cancer. However, with prostate cancer being detected at an earlier stage, most prostate cancers tend to be isoechoic to the surrounding healthy prostatic tissue and, therefore invisible, resulting in transrectal ultrasound-guided biopsy having a positive predictive value of only 15.2%. MRI of the prostate has a superior soft-tissue contrast resolution, high spatial resolution and multiplanar capability. The ability to localize prostate cancer with MRI provides an opportunity to utilize magnetic resonance (MR) guidance for prostate biopsy. A number of MR-compatible robots, ranging from a simple manipulator to a fully automated system, have been developed to biopsy suspicious prostate cancer areas. When combining MRI with fast imaging sequences, it is possible to track the needle or organ deformation in real time. As technology matures, precise image guidance for prostate interventions performed or assisted by specialized MR-compatible robotic devices may provide a uniquely accurate solution for guiding the intervention, directly based on MR findings and feedback. Such an instrument would become a valuable clinical tool for biopsies directly targeting imaged tumor foci and for delivering tumor-centered focal therapy. © 2010 Future Medicine Ltd.
“Tandem-robot Assisted Laparoscopic Radical Prostatectomy to Improve the Neurovascular Bundle Visualization: A Feasibility Study.”
Han, M., C. Kim, et al. (2010).
Objectives: To examine the feasibility of image-guided navigation using transrectal ultrasound (TRUS) to visualize the neurovascular bundle (NVB) during robot-assisted laparoscopic radical prostatectomy (RALP). The preservation of the NVB during radical prostatectomy improves the postoperative recovery of sexual potency. The accompanying blood vessels in the NVB can serve as a macroscopic landmark to localize the microscopic cavernous nerves in the NVB. Methods: A novel, robotic transrectal ultrasound probe manipulator (TRUS Robot) and three-dimensional (3-D) reconstruction software were developed and used concurrently with the daVinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a tandem-robot assisted laparoscopic radical prostatectomy (T-RALP). Results: After appropriate approval and informed consent were obtained, 3 subjects underwent T-RALP without associated complications. The TRUS Robot allowed a steady handling and remote manipulation of the TRUS probe during T-RALP. It also tracked the TRUS probe position accurately and allowed 3-D image reconstruction of the prostate and surrounding structures. Image navigation was performed by observing the tips of the daVinci surgical instruments in the live TRUS image. Blood vessels in the NVB were visualized using Doppler ultrasound. Conclusions: Intraoperative 3-D image-guided navigation in T-RALP is feasible. The use of TRUS during radical prostatectomy can potentially improve the visualization and preservation of the NVB. Further studies are needed to assess the clinical benefit of T-RALP. © 2010 Elsevier Inc. All rights reserved.
“Early release of pedicles and posterior development of the ‘Veil of Aphrodite’ in robotic-assisted laparoscopic prostatectomy (RALP).”
Ischia, J., S. Sengupta, et al. (2010).
BJU International106(11): 1856-1861.
“A novel method of urethrovesical anastomosis during robot-assisted radical prostatectomy using a unidirectional barbed wound closure device: Feasibility study and early outcomes in 51 patients.”
Kaul, S., J. Sammon, et al. (2010).
Journal of Endourology24(11): 1789-1793.
Purpose: To describe the safety and feasibility of a running urethrovesical anastomosis (UVA) in robot-assisted radical prostatectomy (RARP) using a unidirectional self-locking barbed suture. Patients and Methods: Fifty-one consecutive patients with organ-confined prostate cancer underwent RARP by one of two experienced surgeons. UVA was performed in two layers, using a unidirectional barbed suture fashioned into a double-ended stitch. Perioperative outcomes and 30-day complications were recorded. Results: All anastomoses were performed without assistance and without tying a knot. Median time for entire dual-layer anastomosis was 14.0 minutes (interquartile range [IQR]: 12-20) and that for urethrovesical anastomosis was 11 minutes (IQR: 9-15). Not having to rely on an assistant to follow the suture decreased instrument clashes, entangling of the suture around an instrument, and made the anastomosis faster. Eight patients underwent anterior/lateral reconstruction of the bladder neck, and there were no leaks on cystography at 1 week. Conclusions: We describe the first reported clinical experience with a novel technique of performing UVA during RARP that is safe and efficient. Using the barbed wound closure device prevents slippage, precluding the need for assistance, knot tying, and constant reassessing of anastomosis integrity. Copyright 2010, Mary Ann Liebert, Inc.
“Role of surgery in high-risk localized prostate cancer.”
Lawrentschuk, N., G. Trottier, et al. (2010).
Current Oncology17(SUPPL. 2).
Men with high-risk localized prostate cancer (pca) remain a challenge for clinicians. Until recently, surgery was not the preferred approach, in part because risk of subclinical metastatic disease, elevated rates of positive surgical margins, absence of randomized studies, and suboptimal cancer control did not justify the morbidity of surgery. No randomized data comparing surgery with radiation therapy are yet available. Data for and comparisons between treatment options should therefore be analyzed with extreme caution. When selecting the best treatment for patients with clinically localized high-risk pca, considerations should include the life expectancy of the patient, the natural history of pca, the curability of the disease, and the morbidity of treatment. High-grade pca managed with noncurative intent greatly reduces life expectancy, but overall, it must also be remembered that radical prostatectomy (rp) and radiotherapy (rt) appear to have similar effects on quality of life. In this population, rp necessitates an extended pelvic lymph node dissection (plnd), but in selected cases, nerve-sparing is a therapeutic possibility and may offer a significant advantage over rt in terms of local control and-although absolutely not yet proved-maybe even in survival. One clear advantage is the ease of administering adjuvant or salvage external-beam rt (ebrt) after rp; conversely, salvage rp after failed ebrt is an exceedingly difficult surgery, with major complications. Surgery therefore has its place, but must be considered in the context of multimodality treatment and the risk of micrometastatic disease. Awaited trial results will help to further refine management in this group of patients. © 2010 Multimed Inc.
“Evidence-based comparison of robotic and open radical prostatectomy.”
Lowrance, W. T., T. V. Tarin, et al. (2010).
The rapid adoption of robotic-assisted laparoscopic radical prostatectomy (RALP) has occurred despite a lack of high-quality evidence demonstrating its oncologic advantages, safety, or cost effectiveness compared with open radical retropubic prostatectomy (ORP). This review examines the current literature comparing ORP and RALP, focusing on perioperative, oncologic, functional, and economic outcomes.
“Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching.”
Magheli, A., M. L. Gonzalgo, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVES: To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes. SUBJECTS AND METHODS: A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate-specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. Pathological and biochemical outcomes of the three cohorts were examined. RESULTS: Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. Kaplan-Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups. CONCLUSIONS: RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence-free survival between groups. Further prospective studies are warranted to determine whether any particular technique is superior with regard to long-term clinical outcomes.
“Impact of Prostate Weight on Probability of Positive Surgical Margins in Patients With Low-Risk Prostate Cancer After Robotic-Assisted Laparoscopic Radical Prostatectomy.”
Marchetti, P. E., S. Shikanov, et al. (2010).
Objective: To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. Methods: The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. Results: A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. Conclusions: Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing. © 2010 Elsevier Inc. All rights reserved.
“The role of preoperative endo-rectal coil magnetic resonance imaging in predicting surgical difficulty for robotic prostatectomy.”
Mason, B. M., A. A. Hakimi, et al. (2010).
Objectives: To determine whether pelvimetry on endo-rectal coil magnetic resonance imaging (eMRI) predicts surgical difficulty of robot-assisted laparoscopic prostatectomy (RALP). Methods: Patients’ records with preoperative eMRI in our RALP database from April 2008 thru May 2009 were reviewed. Demographic, preoperative clinical data, and eMRI anatomic measurements, including calculated prostate volume (PV) and the pelvic cavity index (PCI), were recorded. PCI is the pelvic inlet multiplied by the interspinous distance and divided by the pelvic depth; PCI estimates the robotic working space. Correlative and multiple regression analyses of clinical and pelvimetric data were performed for prediction of estimated blood loss (EBL), operative time (OT), positive surgical margin (PSM), and transfusion rate as surrogates of surgical difficulty. Results: Prostatic transverse diameter, PV, and the PV-to-PCI ratio were significantly correlated with both OT and EBL (P <.05). Body mass index also correlated with EBL (P <.05). Multiple linear regression analysis demonstrated that the PV-to-PCI ratio significantly predicts OT and EBL. No factor significantly predicted PSM status or transfusion rate on regression analysis. Analysis within the PSM group revealed that those with an apical PSM had statistically narrower and deeper pelvises. Conclusions: Patients with larger prostates and with narrow, deep pelvises are predicted to have a more difficult RALP. The PV-to-PCI ratio statistically predicts lengthier and bloodier procedures. However, that ratio does not predict PSM or transfusion risk on regression analysis. The eMRI predicts the level of surgical difficulty and is a valuable adjunctive study to obtain before RALP. © 2010 Elsevier Inc. All Rights Reserved.
“The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon.”
Ou, Y. C., C. R. Yang, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVES: To analyse the learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy (RALP) performed by a single surgeon in Taiwan. PATIENTS AND METHODS: Complication rates were prospectively assessed in 200 consecutive patients undergoing RALP (Group I: cases 1-50; Group II: cases 51-100; Group III: cases 101-150 and Group IV: cases 151-200). Complications were classified using the Clavien system: grade I: deviation normal postoperative course without treatment; grade II: drug or bedside treatment; grade III: endoscopic or surgical intervention; grade IV: life-threatening problem; and grade V: death. Operative parameters and peri-operative complications were evaluated, including operative and console time, blood loss and transfusion rate, Gleason scores, positive surgical margin (PSM) rate, specimen volume, tumour size, tumour percentage, node positive rate and intra- and postoperative complications. RESULTS: RALP console time was gradually lowered from Group I to Group IV (P < 0.05). Significantly less blood loss occurred after every 50 cases of RALP (Group I 275 mL, Group II 179 mL, Group III 145 mL, Group IV 102 mL, P < 0.001). Blood transfusion incidence was 8%, 4%, 2% and 0% in Groups I, II, III and IV, respectively. Complication rates were 18%, 12%, 18% and 0% in Groups I, II, III and IV, respectively. Major complications (grade III-IV) were 6%, 2%, 4% and 0% in Groups I, II, III and IV, respectively. Bowel injury occurred in three cases (Group II: 1; Group III: 2); one received intra-operative repair without sequelae and two received a transient colostomy and later colostomy closure. CONCLUSIONS: The learning curve for every 50 cases of RALP showed significantly less blood loss and blood transfusion rate. The learning curve for significantly decreasing complications is 150 cases.
“Critical appraisal of management of rectal injury during radical prostatectomy.”
Roberts, W. B., K. Tseng, et al. (2010).
Objectives: To critically evaluate the perioperative management of rectal injury during radical prostatectomy. Methods: Rectal injuries were identified from the departmental morbidity and mortality records and radical prostatectomy databases. The electronic patient records were reviewed for management and outcomes. Results: From January 1997 to August 2007, 11 452 men underwent radical prostatectomy. Of these men, 10 183 underwent radical retropubic prostatectomy (RRP) and 1269, laparoscopic retropubic prostatectomy (LRP) with or without robotic assistance. Rectal injury occurred in 18 men12 in the RRP group (0.12%) and 6 in the LRP group (0.47%). Of these rectal injuries, 16 were recognized intraoperatively and primarily repaired in multiple layers without a diverting colostomy. A pedicle of omentum was used as an interposing layer in 4 of these cases. Despite primary repair, 2 patients without omental interposition developed a rectourethral fistula. In 1 man in the RRP group, the fistula closed with prolonged catheterization (9 weeks). In the other patient, in the LRP group, the fistula persisted; thus, a diverting colostomy was performed. Eventually, a transrectal advancement flap was required. Two rectal injuries (1 each in the RRP and LRP groups) were unrecognized during radical prostatectomy but were discovered within 4 days. Despite conservative management, the rectourethral fistulas persisted in both men, requiring subsequent repair with a transrectal advancement flap. Conclusions: Rectal injury is an infrequent complication of radical prostatectomy. When recognized intraoperatively and primarily repaired, rectourethral fistula was prevented in 87.5% of men. Primary repair performed with vascularized tissue interposition prevented rectourethral fistula development. In men with unrecognized rectal injury, the rectourethral fistula tended to persist and eventually required delayed surgical repair. © 2010 Elsevier Inc. All Rights Reserved.
“The learning curve for laparoscopic radical prostatectomy: An international multicenter study.”
Secin, F. P., C. Savage, et al. (2010).
Journal of Urology184(6): 2291-2296.
Purpose It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. Materials and Methods We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. Results Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. Conclusions The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience. © 2010 American Urological Association Education and Research, Inc.
“Transperitoneal versus extraperitoneal laparoscopic radical prostatectomy during the learning curve: Does the surgical approach affect the complication rate?”
Siqueira Jr, T. M., A. I. Mitre, et al. (2010).
International Braz J Urol36(4): 450-457.
Purpose: To compare the perioperative complication rate obtained with the transperitoneal laparoscopic radical prostatectomy (TLRP) and with the extraperitoneal LRP (ELRP) during the learning curve (LC). Materials and Methods: Data of the initial 40 TLRP (Group 1) were retrospectively compared with the initial 40 ELRP (Group 2). Each Group of patients was operated by two different surgeons. Results: The overall surgical time (175 min x 267.6 min; p < 0.001) and estimated blood loss (177.5 mL x 292.4 mL; p < 0.001) were statistically better in the Group 1. Two intraoperative complications were observed in Group 1 (5%) represented by one case of bleeding and one case of rectal injury, whereas four complications (10%) were observed in Group 2, represented by two cases of bleeding, one bladder and one rectal injuries (p = 0.675). Open conversion occurred once in each Group (2.5%). Overall postoperative complications were similar (52.5% x 35%; p = 0.365). Major early postoperative complications occurred in three and in one case in Group 1 and 2, respectively. Group 1 had two peritonitis (fecal and urinary), leading to one death in this group. Conclusions: No statistical differences in overall complication rates were observed. The transperitoneal approach presented more serious complications during the early postoperative time and this fact is attributed to the potential chance of intraperitoneal peritonitis not observed with the extraperitoneal route.
“Neuroanatomic basis for traction-free preservation of the neural hammock during athermal robotic radical prostatectomy.”
Srivastava, A., S. Grover, et al. (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: Much of the progress achieved in the past two decades in improving potency outcomes after radical prostatectomy has resulted from an improved appreciation of the anatomic basis of the nerves responsible for erection. We review the current literature evaluating the neuroanatomy of prostate and operative strategies for better preservation of sexual function. RECENT FINDINGS: Recent studies suggest an alternative and more complex course of nerves than previously described. Periprostatic nerves can be divided into three broad surgically identifiable zones: the proximal neurovascular plate, the predominant neurovascular bundle, and the accessory neural pathways. Better appreciation of the variable and often invisible anatomical course of the cavernosal nerves continues to engender innovations in surgical technique to optimize their preservation. SUMMARY: Improved anatomic understanding has optimized surgical technique in order to improve potency outcomes following radical prostatectomy.
“Randomized controlled trial of barbed polyglyconate versus polyglactin suture for robot-assisted laparoscopic prostatectomy anastomosis: Technique and outcomes.”
Williams, S. B., M. Alemozaffar, et al. (2010).
European Urology58(6): 875-881.
Background: Transperitoneal robot-assisted laparoscopic prostatectomy (RALP) urethrovesical anastomosis is a critical step. Although the prevalence of urine leaks ranges from 4.5% to 7.5% at high-volume RALP centers, urine leaks prolong catheterization and may lead to ileus, peritonitis, and require intervention. Barbed polyglyconate sutures maintain running suture line tension and may be advantageous in RALP anastomosis for reducing this complication. Objective: To compare barbed polyglyconate and polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) running sutures for RALP anastomosis. Design, setting, and participants: This was a prospective, randomized, controlled, single-surgeon study comparing RALP anastomosis using either barbed polyglyconate (n = 45) or polyglactin 910 (n = 36) sutures. Surgical procedure: RALP anastomosis using either barbed polyglyconate or polyglactin 910 sutures was studied. Measurements: Operative time, cost differential, perioperative complications, and cystogram contrast extravasation by anastomosis suture type were measured. Results and limitations: Although baseline characteristics and overall operative times were similar, barbed polyglyconate sutures were associated with shorter mean anastomosis times of 9.7 min versus 9.8 min (p = 0.014). In addition, anastomosis with barbed polyglyconate rather than polyglactin 910 sutures was associated with more frequent cystogram extravasation 8 d postoperatively (20.0% vs 2.8%; p = 0.019), longer mean catheterization times (11.1 d vs 8.3 d; p = 0.048), and greater suture costs per case ($51.52 vs $8.44; p < 0.001). After 8 of 29 (27.6%) barbed polyglyconate anastomosis sites demonstrated postoperative day 8 cystogram extravasation, we modified our technique to avoid overtightening, reducing cystogram extravasation to 1 (6.3%) of 16 subsequent barbed polyglyconate anastomosis sites. Potential limitations include small sample size and the single-surgeon study design. Conclusions: Compared to traditional sutures, barbed polyglyconate is more costly and requires technical modification to avoid overtightening, delayed healing, and longer catheterization time following RALP. © 2010 European Association of Urology.
“Surgical clip-related complications after radical prostatectomy.”
Yi, J. S., C. Kwak, et al. (2010).
Korean Journal of Urology51(10): 683-687.
Purpose: The aim of this study was to describe the surgical clip-related complications that can occur after open retropubic prostatectomy (RRP), pure laparoscopic prostatectomy (LRP), and robot-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods: A database of 641 patients who underwent RRP (n=439), LRP (n=49), and RALP (n=153) at our institution between January 2006 and April 2009 was reviewed to identify patients with complications related to the use of surgical clips. The median follow-up time for the entire cohort was 19.0 months (range, 1-42 months). Results: Of the 641 patients, 25 (5.7%), 1 (2.0%), and 2 (1.3%) had a bladder neck contracture after RRP, LRP, and RALP, respectively. Two RRP patients had a bladder stone. In total, 6 patients had surgical clip-related complications. Metal clip migration was associated with 2 (8%) of the 25 RRP cases of bladder neck contracture and both (100%) of the RRP cases of bladder stone. Moreover, both (100%) of the RALP cases of bladder neck contractures were associated with Hem-o-lok clip migration into the anastomotic site. Conclusions: Surgical clips are prone to migration and may cause, or significantly contribute to, bladder neck contracture or the formation of bladder stones after radical prostatectomy. These findings also suggest that because the incidence of bladder neck contracture after RALP is low, the migration of Hem-o-lok clips should be suspected when voiding difficulty occurs after RALP. © The Korean Urological Association, 2010.
“Persistent vesicourethral anastomotic leak after radical prostatectomy: A novel endoscopic solution.”
Yossepowitch, O. and J. Baniel (2010).
Journal of Urology184(6): 2452-2455.
Purpose A vesicourethral anastomotic leak after radical prostatectomy is a common postoperative sequela. Rarely additional intervention is required for a persistent or high output urinary leak. We describe a novel solution to this uncommon complication. Materials and Methods With the patient under general or spinal anesthesia the technique included 19Fr rigid cystoscopy in a partially distended bladder and insertion of 5Fr Single J® ureteral stents over a hydrophilic guidewire under fluoroscopic guidance. The 2 stents were exteriorized via the urethra beside an 18Fr Foley catheter. We monitored urine output and the relative amount of leak. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain leak resolution before stent removal. Time to continence was estimated using Kaplan-Meier analysis. Results Seven of 1,480 patients (0.5%) required intervention for a prolonged or high output anastomotic leak after radical prostatectomy. Mean time from surgery to stent insertion was 6.2 days (range 2 to 12). Stents were retained an average of 9 days (range 6 to 11), enabling complete resolution of the leak within a mean ± SD of 1.8 ± 0.9 days. Median time to recovery of urinary continence was 20 ± 1.7 weeks. Conclusions Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anastomotic leak after radical prostatectomy. Recovery of urinary continence may be delayed in this setting but long-term urinary function appears to be unaffected in most patients. © 2010 American Urological Association Education and Research, Inc.