“Chewing Gum Has a Stimulatory Effect on Bowel Motility in Patients After Open or Robotic Radical Cystectomy for Bladder Cancer: A Prospective Randomized Comparative Study.”
Choi, H., S. H. Kang, et al. (2010).
OBJECTIVES: To determine whether chewing gum during the postoperative period facilitates the recovery of bowel function and has different efficacy according to operative method used in patients with radical cystectomy. METHODS: From July 2007 to September 2009, we randomized open radical cystectomy (ORC) patients into Group AI (ORC without gum chewing) and Group AII (ORC with gum chewing). Robot-assisted radical cystectomy (RARC) patients were randomized into Group BI (RARC without gum chewing) and Group BII (RARC with gum chewing). RESULTS: A total of 32 ORC (17 Group AI and 15 Group AII) and 28 RARC (13 Group BI and 15 Group BII) patients were completed. The patient’s perioperative data between the control (AI + BI) and chewing gum (AII + BII) group showed no differences. The median time to flatus and to bowel movement were significantly reduced in chewing gum group compared with the control patients: 57.1 vs. 69.5 hours 76.7 vs. 93.3 hours. In the ORC patients, decrease in time to flatus and bowel movement were observed in gum chewing (AII) group than control (AI) group: 64.3 vs. 80.3 hours 83.8 vs. 104.2 hours. In RARC patients, decrease in time to flatus and bowel movement were found in gum chewing (BII) group than control (BI) group: 48.8 vs. 60.3 hours 69.1 vs. 84.6 hours. No adverse effects were observed with chewing gum. CONCLUSIONS: Chewing gum had stimulatory effects on bowel motility after cystectomy and urinary diversion. Chewing gum was safe and could be used for postoperative ileus regardless of the operative method (ORC or RARC).
“Robot-assisted intracorporeal ileal conduit: Marionette technique and initial experience at Roswell Park Cancer Institute.”
Guru, K., S. A. Seixas-Mikelus, et al. (2010).
Urology 76(4): 866-871.
OBJECTIVES: To present our technique and initial experience with patients who underwent robot-assisted intracorporeal creation of ileal conduit and to compare them with patients who underwent extracorporeal ileal diversion after robot-assisted radical cystectomy. METHODS: Twenty-six patients diagnosed with invasive transitional cell carcinoma of the bladder underwent a robot-assisted radical cystectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Total intracorporeal ileal conduit creation was performed in the last 13 patients. Operative data and short-term outcomes between the 2 groups were assessed. The novel surgical technique for intracorporeal ileal conduit will be presented. RESULTS: The intracorporeal group (IC) included 2 female and 11 male patients (mean age 71 years). The extracorporeal group (EC) included 4 female and 9 male patients (mean age 66 years). No significant differences were noted between the groups in terms of patient age, BMI, sex, prior surgery, or pathologic stage. Overall operative time and intraoperative complications were similar. No significant differences were noted between the 2 groups in terms of diversion time or estimated blood loss. There were 4 complications recorded in IC patients, including nonspecific colitis, small bowel obstruction requiring exploratory laparotomy with lysis of adhesions, a urine leak that eventually resolved but required a temporary nephrostomy tube, and a fever of unknown origin that resolved without intervention. CONCLUSIONS: Robot-assisted intracorporeal ileal conduit can be accomplished safely with acceptable operative times even during early experience. Larger series with favorable results will be required to add this new paradigm to minimally invasive surgery for bladder cancer. © 2010 Elsevier Inc.
“Robot-assisted radical cystectomy and pelvic lymph node dissection: A multi-institutional study from Korea.”
Kang, S. G., S. H. Kang, et al. (2010).
Journal of Endourology 24(9): 1435-1440.
Purpose: To report short-term retrospective perioperative and pathologic outcomes of the first robot-assisted radical cystectomy (RARC) series in Korea. Patients and Methods: Between April 2007 and August 2009, 104 nonconsecutive patients, including 22 women, underwent RARC across seven institutions. We evaluated the outcomes in these cases, including operative variables, hospital recovery, pathologic outcomes, and complication rate. Results: The mean age of all patients was 63.6 years (range 39-82 years), and the mean body mass index was 23.6 kg/m<sup>2</sup> (range 16.0-31.8 kg/m<sup>2</sup>). Among the 104 patients, 60 had an ileal conduit and 44 had an orthotopic neobladder. The mean total operative time was 554 minutes, and the mean blood loss was 526 mL. The time to flatus and bowel movement was about 3 days, and the time until hospital discharge was about 18 days. The mean number of lymph nodes removed were 18, and 10 patients had node metastatic disease on final pathologic evaluation. Postoperative complications occurred in 28 (26.9%) patients. Conclusions: Our initial experience with RARC appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. The current series suggests that RARC is becoming more prevalent, not only in Western countries, but also in Asian countries, just as robot-assisted radical prostatectomy has also gained widespread acceptance. Data from long-term, large, prospective, multicenter, ideally randomized comparative studies with open radical cystectomy are needed to confirm the outcome of the novel operation reported here. © 2010, Mary Ann Liebert, Inc.
“Early oncologic outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy.”
Kauffman, E. C., C. K. Ng, et al. (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE: * To determine oncologic outcomes including early survival rates among unselected bladder urothelial carcinoma (BUC) patients treated with robotic-assisted radical cystectomy (RRC). PATIENTS AND METHODS: * Clinicopathologic and survival data were prospectively gathered for 85 consecutive BUC patients treated with RRC. * The decision to undergo a robotic rather than open approach was made without regard to tumor volume or surgical candidacy. * Kaplan-Meier survival rates were determined and stratified by tumor stage and LN positivity, and multivariate analysis was performed to identify independent predictors of survival. RESULTS: * Patients were relatively old (25% >80 years; median 73.5 years), with frequent comorbidities (46% with ASA class >/=3). Of these patients 28% had undergone previous pelvic radiation or pelvic surgery, and 20% had received neoadjuvant chemotherapy. * Extended pelvic lymphadenectomy was performed in 98% of patients, with on average 19.1 LN retrieved. * On final pathology, extravesical disease was common (36.5%). * Positive surgicalmargins were detected in five (6%) patients, all of whom had extravesical tumors with perineural and/or lymphovascular invasion, and most of whom were >80 years old. * At a mean postoperative interval of 18 months, 20 (24%) patients had developed recurrent disease, but only three (4%) patients had recurrence locally. Disease-free, cancer-specific and overall survival rates at 2 years were 74%, 85% and 79%, respectively. Patients with low-stage/LN(-) cancers had significantly better survival than extravesical/LN(-) or any-stage/LN(+) patients, with stage being the most important predictor on multivariate analysis. CONCLUSION: * RRC can achieve adequately high LN yields with a low positive margin rate among unselected BUC patients. * Early survival outcomes are similar to those reported in contemporary open series, with an encouragingly low incidence of local recurrence, however long-term follow-up and head-to-head comparison with the open approach are still needed.
“Robot-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion.”
Zhu, J., J. P. Gao, et al. (2009).
Zhonghua wai ke za zhi [Chinese journal of surgery] 47(16): 1242-1244.
OBJECTIVE: To present the technique and experience of robotic-assisted laparoscopic radical cystectomy (RARC) by da Vinci surgical system. METHODS: From December 2007 to September 2008, 4 patients underwent RARC and urinary diversion. The age of patients was 44 to 63 years old. The body mass index was 22.8 to 27.7. All their clinical stages were lower than T2N0M0. The technique for RARC involving ureters dissection, posterior dissection, lateral pedicle control, anterior dissection, dorsal vein complex control, neurovascular bundles sparing, lymphadenectomy, ureter-ileal anastomosis, urethra-neobladder anastomosis to either ileal conduit urinary diversion or neobladder reconstruction performed extracorporeally. RESULTS: All the operations were accomplished successfully. The urinary diversion of 2 case was ileal conduit and others was ileal orthophoria neobladder. The operation time was 300 to 450 min. The time of radical cystectomy was 150 to 180 min. The estimated blood loss was 100 to 500 ml. The postoperative hospital stay was 9 to 35 d. The bed rest time was 4 to 9 d. There was 1 patients who had incomplete intestinal obstruction at 8th postoperative day cured by conservative therapy. The patients were followed up for 3 to 12 months, all patients survived without tumor recurrence. The patients have satisfied urinary continence and normal renal functions without hydronephrosis after the operation. CONCLUSIONS: RARC is small incision and safe, the results are definite. It is one of the direction of minimally invasive urologic surgery.
“Feasibility of robotic partial nephrectomy in a UK Cancer Centre.”
Alleemudder, A., T. Dudderidge, et al. (2010).
British Journal of Medical and Surgical Urology.
Objective: To present our initial peri-operative and pathological outcome data of 23 patients to establish the feasibility of robotic partial nephrectomy (RPN) in a UK cancer centre. Patient and methods: Clinical data from 23 patients who underwent RPN in a single institution between April 2008 and January 2010 were analysed. The RENAL Nephrometry Scoring System was applied to our series. Results: Mean patient age was 54.6 years with a mean tumour size of 2.53 cm. The median operative time was 198 min and warm ischaemia time (WIT) 30 min. There were two conversions and four patients required transfusion, with no other major complications. Histology confirmed renal cell carcinoma in 17 cases. All surgical margins were negative and to date there have been no local or distant recurrences. A mean RENAL score of 5.56 suggested that all the lesions had a low-moderate complexity and were therefore suitable for partial nephrectomy. Conclusion: RPN achieved acceptable WITs, blood loss and complication rates and oncological outcomes. We conclude that this technique is a feasible alternative to open surgery and conventional laparoscopic partial nephrectomy. The urological community need to establish the place for each technique although surgeon preference is likely to be a significant factor. Crown Copyright © 2010.
“Robot-assisted pyeloplasty: Follow-up of first Canadian experience with comparison of outcomes between experienced and trainee surgeons.”
Erdeljan, P., Y. Caumartin, et al. (2010).
Journal of Endourology 24(9): 1447-1450.
Background and Purpose: Robot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates. Patients and Methods: Eighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 ± 8.5 months. Results: The mean operative time was 167.7 ± 43.2 minutes, and the mean anastomotic time was 41.9 ± 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 ± 55.4 mL, and the mean hospital stay was 2.5 ± 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28). Conclusions: In the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study. © 2010, Mary Ann Liebert, Inc.
“”Zero Ischemia” Partial Nephrectomy: Novel Laparoscopic and Robotic Technique.”
Gill, I. S., M. S. Eisenberg, et al. (2010).
BACKGROUND: Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. OBJECTIVE: Describe a novel technique of “zero ischemia” laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. DESIGN, SETTING, AND PARTICIPANTS: Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n=12), RAPN (n=3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n=9; 60%), hilar (n=1), in solitary kidney (n=1), in patients with chronic kidney disease grade 3 or greater (n=3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. MEASUREMENTS: Intraoperative and early postoperative data were collected prospectively. RESULTS AND LIMITATIONS: All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5cm (range: 1-4); operative time was 3h (range: 1.3-6); blood loss was 150ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65mm Hg (median: 60), typically for 1-5min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n=5) included urine retention (n=1), septicemia from presumed prostatitis (n=1), atrial fibrillation (n=1), urine leak (n=2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9mg/dl and 0.95mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. CONCLUSIONS: A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.
“Robotic kidney implantation for kidney transplantation: initial experience.”
Hagen, M. E., F. Pugin, et al. (2010).
Journal of Robotic Surgery: 1-6.
Despite improvements in minimally invasive techniques over recent decades, kidney implantation into the iliac fossa has remained a domain of open surgery. However, it was hypothesized that it would be feasible to perform robotic transplant kidney implantation as a means of reducing surgical trauma. Two robotic kidney transplantations into the iliac fossa were attempted in human cadavers. In the first cadaver, a 5 cm incision was placed in the right lower abdomen, the peritoneum was mobilized in a cranial direction, the iliac vessels were identified, and the kidney placed in the pre-peritoneal space. The incision was sealed with a gel port through which the Vinci<sup>©</sup> Surgical System was installed. In the second cadaver, a robotic kidney implantation with robotically sutured vascular and ureteric anastomoses was performed trans-abdominally. Open incision, identification, placement of gel port, and robotic docking were feasible. Robotic performance of vascular anastomosis was not possible in the first cadaver because of advanced decay and excess fat in the surgical field. Robotic kidney positioning was feasible and anastomoses were performed successfully in the second cadaver within 35, 25, and 20 min (arterial, venous, and ureteric, respectively). Robotic kidney transplantation seems feasible in human cadavers if tissue condition is suitable, but is very technically challenging. Because of the delicacy of anatomical structures, the cadaveric model with the risk of advanced decay and the absence of circulation sets limits on the exploration of this complex procedure. Hence, further research and animal work in this area is critical to improve understanding of the benefits and limitations of robotic kidney implantation. © 2010 Springer-Verlag London Ltd.
“Robotic partial nephrectomy: the real benefit.”
Rogers, C., S. Sukumar, et al. (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: Robot-assisted partial nephrectomy (RPN) is an option for patients desiring minimally invasive nephron-sparing surgery. RPN outcomes, including safety, functional results, and oncological control, continue to be reported as the technique emerges. In the current review, we chronicle the development, recent advances, and current status of RPN. RECENT FINDINGS: RPN appears to have a shorter learning curve when compared to alternative minimally invasive techniques. Outcomes from recent series have confirmed the safety and feasibility of RPN in the management of small renal masses, many of them in complex locations. Recent comparative studies have demonstrated favorable-to-equivalent outcomes for RPN when compared to laparoscopic partial nephrectomy (LPN), particularly in regards to decreased warm ischemia time. Novel technical developments include use of TilePro, the fourth robotic arm, sliding-clip renorrhaphy, and selective clamping techniques. SUMMARY: RPN appears to have favorable early-to-intermediate stage outcomes. RPN helps with the technical challenges of LPN, potentially extending the benefits of minimally invasive nephron-sparing surgery to a wider audience of patients and surgeons.
“Robotic versus laparoscopic resection of liver tumours.”
Berber, E., H. Y. Akyildiz, et al. (2010).
HPB (Oxford) 12(8): 583-586.
Background: There are scant data in the literature regarding the role of robotic liver surgery. The aim of the present study was to develop techniques for robotic liver tumour resection and to draw a comparison with laparoscopic resection. Methods: Over a 1-year period, nine patients underwent robotic resection of peripherally located malignant lesions measuring <5 cm. These patients were compared prospectively with 23 patients who underwent laparoscopic resection of similar tumours at the same institution. Statistical analyses were performed using Student’s t-test, chi(2) -test and Kaplan-Meier survival. All data are expressed as mean +/- SEM. Results: The groups were similar with regards to age, gender and tumour type (P= NS). Tumour size was similar in both groups (robotic -3.2 +/- 1.3 cm vs. laparoscopic -2.9 +/- 1.3 cm, P= 0.6). Skin-to-skin operative time was 259 +/- 28 min in the robotic vs. 234 +/- 17 min in the laparoscopic group (P= 0.4). There was no difference between the two groups regarding estimated blood loss (EBL) and resection margin status. Conversion to an open operation was only necessary in one patient in the robotic group. Complications were observed in one patient in the robotic and four patients in the laparoscopic groups. The patients were followed up for a mean of 14 months and disease-free survival (DFS) was equivalent in both groups (P= 0.6). Conclusion: The results of this initial study suggest that, for selected liver lesions, a robotic approach provides similar peri-operative outcomes compared with laparoscopic liver resection (LLR).
“Robotic-assisted resection of liver and diaphragm recurrent ovarian carcinoma: Description of technique.”
Holloway, R. W., L. A. Brudie, et al. (2010).
GOALS: To describe port placement and operative technique for resection of right hepatic and full-thickness diaphragm metastatic ovarian carcinoma in a patient with recurrent disease using the da Vinci(R) Surgical System. CASE: A 60-year-old female with recurrent platinum sensitive ovarian cancer presented with disease confined to the liver by PET-CT scan. The lesion measured 3.4cm on the dome of the right hepatic lobe. After two attempts at intra-hepatic arterial chemo-embolization the lesion remained stable. She subsequently agreed to robotic-assisted resection of the right lobe liver mass after refusing laparotomy for 9months. PROCEDURE: Pnuemoperitoneum was established in the left upper quadrant by directly inserting a 5-mm laparoscope. There were no midline adhesions. The 12-mm camera port was placed in the midclavicular line on the right 10cm off the costal margin with the right and left operative arms 10cm from the camera near the costal margin, and the third arm in the right flank. The robot was docked from the right shoulder. Resection was accomplished with a monopolar spatula in the right, fenestrated bipolar grasper in the left, and double fenestrated grasper in the third operative arm. Adhesions between diaphragm and liver were separated, the liver lesion was excised, the diaphragm lesion was resected full thickness, and diaphragm was closed with running prolene. Surgicel(R) was placed on the liver for hemostasis. Console time was 82min and the patient discharged on day-5 after drainage of a cytology negative pleural effusion day-4. CONCLUSIONS: Robotic resection of liver and full-thickness diaphragm lesions is possible. The port placement used in this patient was efficient and without operative arm collisions. Patients with isolated upper-abdominal recurrence are candidates for robotic secondary cytoreduction.
“Significance of prostate weight on peri and postoperative outcomes of robot assisted laparoscopic extraperitoneal radical prostatectomy.”
Allaparthi, S. B., T. Hoang, et al. (2010).
Can J Urol 17(5): 5383-5389.
INTRODUCTION: To determine the significance of prostate weight (PW) on clinical and pathological outcomes in patients undergoing da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP). METHODS: From November 2008 to January 2010, 295 men underwent EP-RARP at our institution. We retrospectively reviewed our database and stratified patients into four groups based on pathologic PW: Group 1, less than 30 g; Group 2, 30 g to less than 50 g; Group 3, 50 g to less than 80 g; and Group 4, 80 g or larger. We prospectively compared these groups with respect to patient age, body mass index, prostate-specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate and length of stay. Statistical analysis was performed using SYSTAT 13 software. An analysis of variance (ANOVA) model was used to compare the continuous variables among the groups. Chi-square and Fisher’s exact tests were used to compare categorical variables. RESULTS: Of the 295 patients, 10, 182, 91, and 12 had a PW of less than 30 g; 30 g to less than 50 g; 50 g to less than 80 g; and 80 g or larger, respectively. A significant difference was found in age, prostate weight and prostate-specific antigen values among the four groups (p < 0.05). Patients in Group 4 had larger prostates, were older (mean age 65 years), had higher pretreatment prostate-specific antigen (median 5.85 ng/mL) and lower Gleason score (mean 6.2). Based on the D’Amico risk stratification, our study showed a trend toward higher risk disease, presence of extra capsular extension, seminal vesicle invasion and positive margin status in Groups 1, 2 and 3 rather than in Group 4. No significant differences in operative time, estimated blood loss, transfusion rate, hospital stay, and postoperative complication rate were observed among the four groups. CONCLUSIONS: Da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP) is feasible in patients with larger prostates, offering acceptable operative times, blood loss, hospital stay and complication rates. In our cohort of patients, we found pathologically smaller prostates are generally associated with higher Gleason score, higher risk group stratification and positive surgical margin status. Although technically challenging, increased prostate weight should not be considered a contraindication for EP-RARP if performed by experienced surgeons.
“Retropubic, Laparoscopic, and Robot-Assisted Radical Prostatectomy: A Critical Review of Outcomes Reported by High-Volume Centers.”
Coelho, R. F., B. Rocco, et al. (2010).
Journal of Endourology.
Abstract Purpose: To critically review perioperative outcomes, positive surgical margin (PSM) rates, and functional outcomes of several large series of retropubic radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted radical prostatectomy (RARP) currently available in the literature. Methods: A Medline database search was performed from November 1994 to May 2009, using medical subject heading search terms “prostatectomy” and “Outcome Assessment (Health Care)” and text words “retropubic,” “robotic,” and “laparoscopic.” Only studies with a sample size of 250 or more patients were considered. Weighted means were calculated for all outcomes using the number of patients included in each study as the weighing factor. Results: We identified 30 articles for RRP, 14 for LRP, and 14 for RARP. The mean intraoperative and postoperative RRP transfusion rates for RRP, LRP, and RARP were 20.1%, 3.5%, and 1.4%, respectively. The weighted mean postoperative complication rates for RRP, LRP, and RARP were 10.3% (4.8% to 26.9%), 10.98% (8.9 to 27.7%), and 10.3% (4.3% to 15.7%), respectively. RARP revealed a mean overall PSM rate of 13.6%, whereas LRP and RRP yielded a PSM of 21.3% and 24%, respectively. The weighted mean continence rates at 12 month follow-up for RRP, LRP, and RARP were 79%, 84.8%, and 92%, respectively. The weighted mean potency rates for patients who underwent unilateral or bilateral nerve sparing, at 12 month follow-up, were 43.1% and 60.6% for RRP, 31.1% and 54% for LRP, and 59.9% and 93.5% for RARP. Conclusion: RRP, LRP, and RARP performed in high-volume centers are safe options for treatment of patients with localized prostate cancer, presenting similar overall complication rates. LRP and RARP, however, are associated with decreased operative blood loss and decreased risk of transfusion when compared with RRP. Our analysis including high-volume centers also showed lower weighted mean PSM rates and higher continence and potency rates after RARP compared with RRP and LRP. However, the lack of randomized trials precludes definitive conclusions.
“Incidence of venous gas embolism during robotic-assisted laparoscopic radical prostatectomy is lower than that during radical retropubic prostatectomy.”
Hong, J. Y., J. Y. Kim, et al. (2010).
British Journal of Anaesthesia.
BACKGROUND: /st> Robotic-assisted laparoscopic radical prostatectomy (RALRP) is gaining popularity as a less traumatic and minimally invasive alternative to open radical retropubic prostatectomy (RRP). The aim of this study was to evaluate the incidence and grade of venous gas embolism (VGE) during RALRP compared with those during RRP using transoesophageal echocardiography (TOE). METHODS: /st> Fifty-two patients undergoing RRP (n=26) or RALRP (n=26) were consecutively enrolled. TOE was continuously applied during surgery and VGE was graded by an independent researcher. RESULTS: /st> The total incidence of VGE (proportion, 95% CI) in the RRP group was higher than that in the RALRP group [20/25 (0.80, 0.60-0.92) and 10/26 (0.38, 0.22-0.58), respectively]. Most VGE in the RALRP group occurred during the transection of the deep dorsal venous complex. There was no difference in the incidence of severe VGE between the two groups. No patients with cardiorespiratory instabilities even with severe VGE were observed in this study. CONCLUSIONS: /st> In contrast to general belief, VGE occurred less frequently during RALRP. Although the VGE in this study did not cause any cardiorespiratory instability, close monitoring for possibly fatal VGE must be considered during both types of radical prostatectomy because those who undergo radical prostatectomy frequently have cardiopulmonary co-morbidities.
“‘Mohs surgery of the prostate’: the utility of in situ frozen section analysis during robotic prostatectomy.”
Lavery, H. J., G. Q. Xiao, et al. (2010).
Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To evaluate a novel technique to lower positive surgical margin rates while preserving as much of the neurovascular bundles as possible during nerve-sparing robotic prostatectomy. MATERIALS AND METHODS In situ intraoperative frozen section (IFS) was performed during robotic-assisted laparoscopic prostatectomy (RALP) when there was macroscopic concern for a positive margin or residual prostate tissue. When IFS was positive, additional sections were taken from the same area until the IFS was negative, similar to the procedure of Mohs micrographic surgery. Positive surgical margin and biochemical recurrence rates were compared between the patients who underwent IFS and those who did not. RESULTS Of 970 patients consecutively undergoing RALP at a single institution, IFS was performed on 177 (18%). Eleven patients (6%) had IFS positive for carcinoma, whereas another 25 (14%) had benign prostatic tissue in the IFS specimen. IFS and non-IFS patients had similar pathological and nerve-sparing characteristics. The IFS group had significantly lower rates of positive surgical margins, 7% vs 18% (P= 0.001) but similar rates of biochemical recurrence (5%) at a median follow-up of 11 months. CONCLUSIONS In situ IFS is an effective way of reducing positive margins during RALP. Twenty percent of patients who underwent IFS, representing 4% of the overall RALP population, had either malignant or benign prostate tissue removed from their prostatic fossa. Although a reduction of biochemical recurrence was not demonstrated, the follow-up is short and a difference may become apparent as the data mature.
“Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes.”
Lei, Y., M. Alemozaffar, et al. (2010).
BACKGROUND: Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP). OBJECTIVE: To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC). DESIGN, SETTINGS, AND PARTICIPANTS: Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures. SURGICAL PROCEDURE: RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection. MEASUREMENTS: Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day. RESULTS AND LIMITATIONS: Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p<0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p<0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147min, p<0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6ml, p=0.033), and one DVC-SSL versus zero SL-DVC were transfused (p=0.442). Overall (12.2% vs 12.0%, p=1.0) and apical (1.3% vs 2.7%, p=0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p<0.001) and continence (61.4% vs 39.6%, p<0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE]+/-standard error [SE]: 16.84+/-2.56, p<0.001), and better 5-mo urinary function (PE+/-SE: 19.93+/-3.09, p<0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p<0.001). CONCLUSIONS: DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.
“Does a perioperative belladonna and opium suppository improve postoperative pain following robotic assisted laparoscopic radical prostatectomy? Results of a single institution randomized study.”
Lukasewycz, S., M. Holman, et al. (2010).
Can J Urol 17(5): 5377-5382.
INTRODUCTION: Robotic assisted laparoscopic radical prostatectomy (RALP) is a common treatment for localized prostate cancer. Despite a primary advantage of improved postoperative pain, patients undergoing RALP still experience discomfort. Belladonna, containing the muscarinic receptor antagonists atropine and scopolamine, in combination with opium as a rectal suppository (B & O) may improve post-RALP pain. This study evaluates whether a single preoperative B & O results in decreased postoperative patient-reported pain and analgesic requirements. MATERIALS AND METHODS: Patients undergoing RALP at Virginia Mason Medical Center between November 2008 and July 2009 were offered the opportunity to enter a randomized, double-blind, placebo-controlled trial. Exclusion criteria included: glaucoma, bronchial asthma, convulsive disorders, chronic pain, chronic use of analgesics, or a history of alcohol or opioid dependency. Surgeons were blinded to suppository placement which was administered after induction of anesthesia. All patients underwent a standardized anesthesia regimen. Postoperative pain was assessed by a visual analog scale (VAS) and postoperative narcotic use was calculated in intravenous morphine equivalents. RESULTS: Ninety-nine patients were included in the analysis. The B & O and control groups were not significantly different in terms of age, body mass index, operative time, nerve sparing status or prostatic volume. Postoperative pain was significantly improved during the first two postoperative hours in the B & O group. Similarly, 24-hour morphine consumption was significantly lower in patients who received a B & O. No adverse effects secondary to suppository placement were identified. CONCLUSION: Preoperative administration of B & O suppository results in significantly decreased postoperative pain and 24-hour morphine consumption in patients undergoing RALP.
“Robotic reconstructive urology: possibilities for the urological surgeon beyond the prostate.”
Mehta, S., P. Dasgupta, et al. (2010).
BJU International 106(9): 1247-1248.
“Biochemical Recurrence Following Robot-Assisted Radical Prostatectomy: Analysis of 1384 Patients with a Median 5-year Follow-up.”
Menon, M., M. Bhandari, et al. (2010).
Background: There is a paucity of data on long-term oncologic outcomes for patients undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer (PCa). Objective: To evaluate oncologic outcomes in patients undergoing RARP at a high-volume tertiary center, with a focus on 5-yr biochemical recurrence-free survival (BCRFS). Design, setting, and participants: The study cohort consisted of 1384 consecutive patients with localized PCa who underwent RARP between September 2001 and May 2005 and had a median follow-up of 60.2 mo. No patient had secondary therapy until documented biochemical recurrence (BCR). BCR was defined as a serum prostate-specific antigen ≥0.2 ng/ml with a confirmatory value. BCRFS was estimated using the Kaplan-Meier method. Event-time distributions for the time to failure were compared using the log-rank test. Univariable and multivariable Cox proportional hazards regression models were used to determine variables predictive of BCR. Intervention: All patients underwent RARP. Measurements: BCRFS rates were measured. Results and limitations: This cohort of patients had moderately aggressive PCa: 49.0% were D’Amico intermediate or high risk on biopsy; however, 60.9% had Gleason 7-10 disease, and 25.5% had ≥T3 disease on final pathology. There were 189 incidences of BCR (31 per 1,00 person years of follow-up) at a median follow-up of 60.2 mo (interquartile range [IQR]: 37.2-69.7). The actuarial BCRFS was 95.1%, 90.6%, 86.6%, and 81.0% at 1, 3, 5, and 7 yr, respectively. In the patients who recurred, median time to BCR was 20.4 mo; 65% of BCR incidences occurred within 3 yr and 86.2% within 5 yr. On multivariable analysis, the strongest predictors of BCR were pathologic Gleason grade 8-10 (hazard ratio [HR]: 5.37; 95% confidence interval [CI], 2.99-9.65; p < 0.0001) and pathologic stage T3b/T4 (HR: 2.71; 95% CI, 1.67-4.40; p < 0.0001). Conclusions: In a contemporary cohort of patients with localized PCa, RARP confers effective 5-yr biochemical control. © 2010 European Association of Urology.
“Urorectal fistulae following the treatment of prostate cancer.”
Mundy, A. R. and D. E. Andrich (2010).
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE: * To evaluate the management of urorectal fistulae (URF) in light of new technology in prostate cancer treatment, which has changed the nature of these URF and, therefore, the approach to treatment. PATIENTS AND METHODS: * Between 2004 and 2009 we repaired URF after treatment for prostate cancer in 40 patients with a minimum of 1-year follow-up since their last intervention. * In 23 patients (post-surgical group) the URF resulted from open, laparoscopic or robotic radical prostatectomy. In the other 17 patients (post-irradiation group) the URF resulted from either external beam radiation (EBRT) or brachytherapy (BT), or both, salvage cryotherapy or salvage high-intensity focused ultrasound (sHIFU). * In the 23 patients in the post-surgical group a transperineal repair was performed. In the post-irradiation group a transperineal repair was performed in three of the 17 patients. A transabdominal or abdominoperineal repair was performed in the remaining 14 patients, combined with salvage radical prostatectomy in those eight patients in whom a discrete prostate still existed, and in whom this was possible. RESULTS: * The URF were cured in all patients. * A bladder-neck contracture (BNC) developed in two patients, one of whom is being managed by interval dilatation and the other of whom had a revision of his vesico-urethral anastomosis. Sphincter weakness incontinence required further treatment in eight patients by implantation of an artificial urinary sphincter. * A specific category of complex URF with cavitation was identified, which is particularly common after sHIFU following the combination of previous EBRT and BT, but which may result from the sequential application of any ‘new technology’. CONCLUSIONS: * URF of any degree of complexity can be managed without the need for a transanorectal sphincter-splitting approach or a covering colostomy and without the need for an interposition flap when the circumstances are appropriate and the surgeon is sufficiently experienced. URF with cavitation and in the post-irradiation group are an exception and do require an interposition flap. * The role of salvage radical prostatectomy in patients with a URF who still have a prostate, needs to be defined. * We suggest that cavitation, BNC and extensive ischaemia due to the serial application of external energy sources confer ‘complexity’. Post-surgical URF are simple except for those with cavitation or a BNC. Most post-irradiation URF are complex even in the absence of cavitation or a BNC.
“Effect of penile rehabilitation on erectile function after bilateral nerve-sparing robotic-assisted radical prostatectomy.”
Novara, G., V. Ficarra, et al. (2010).
Journal of Andrological Sciences 17(1): 17-22.
Introduction. Penile rehabilitation has been regards as a standard after radical prostatectomy. However, the REINVENT study recently demonstrated that the use of nightly PDE-5 inhibitors failed to increase the potency recovery after. Methods. We collected prospectively the clinical records of all patients who underwent robot-assisted radical prostatectomy for clinically localized prostate cancer at the University of Padua. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up ≥ 12 months. Results. Penile rehabilitation was performed in 151 patients (66%) of 229 patients. Twelve months after bilateral nerve-sparing robot-assisted radical prostatectomy, 142 patients (62%) were potent. The median time to recovery of erectile function was 6 months (IQR: 2.5-11). Specifically, age (hazard ratio [HR]: 1.093; p < 0.001), Charlson score (HR: 0.863; p = 0.003), baseline IIEF-6 score (HR: 0.954; p < 0.001), and penile rehabilitation (HR: 0.800; p = 0.018) were predictors of erectile function recovery in univariable analysis. In multivariable analysis, penile rehabilitation did not retain an independent predictive role (HR: 1.663; p = 0.188), once adjusted for the effect of age (HR: 1.048; p = 0.005), and baseline IIEF-6 score (HR: 0.803; p < 0.001) Conclusions. About 60% of the patients were potent 12-mo after underwent robot-assisted radical prostatectomy series. Patients age and preoperative erectile function were the most powerful predictor of erectile function recovery. Adoption of postoperative rehabilitation was not significantly associated with improved postoperative erectile function, once adjusted for the effect of the other covariates.
“Trifecta outcomes after robot-assisted laparoscopic radical prostatectomy.”
Novara, G., V. Ficarra, et al. (2010).
Study Type – Therapy (outcomes research) Level of Evidence 2c OBJECTIVE To evaluate the trifecta outcome and its preoperative predictors in a series of consecutive patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). MATERIALS AND METHODS We collected prospectively the clinical data of 242 consecutive patients with a minimum 12-month follow-up undergoing RALP for clinically localized prostate cancer. International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and the International Index of Erectile Function (IIEF)-6 were used to evaluate the functional outcomes. Patients receiving adjuvant therapies or with a PSA at follow-up >0.2 ng/mL were censored for the biochemical recurrence-free analysis. Logistic regression was used to perform univariable and multivariable analyses. RESULTS Twelve months after surgery, 216 patients (89%) were continent and 145 (60%) were potent. At a median follow-up of 14 mo, 11 patients (4.5%) had either adjuvant radiation therapies within 3 months of surgery, when PSA was still undetectable (n= 6, 2.5%), or salvage radiation or hormone plus radiation therapy for PSA relapse (n= 5, 2%). A trifecta outcome was achieved by 137 patients (57%). On univariable regression analysis, patients’ age at surgery (P < 0.001), body-mass index (P= 0.028), preoperative IIEF-6 score (P < 0.001) and prostate volume (P= 0.036) were significantly associated with trifecta rates. On multivariable analysis, only patients’ age at surgery (odds ratio 1.095; P= 0.005) and preoperative IIEF-6 score (odds ratio 0.803; P < 0.001) were independent predictors of trifecta rates. CONCLUSION Using validated questionnaires to assess functional outcomes, we found that 57% of our patients undergoing nerve-sparing RALP achieved the trifecta outcome 12 months after surgery. Patient age at surgery and preoperative erectile function were the only independent predictors of trifecta rates.
“Surgical anatomy of radical prostatectomy: Periprostatic fascial anatomy and overview of the urinary sphincters.”
Secin, F. P. and F. J. Bianco (2010).
Anatomía quirúrgica de la prostatectomía radical: Fascias y esfínteres urinarios 63(4): 255-266.
Advances in the understanding of prostate and pelvic anatomy in recent years made a substantial contribution to improve the surgical technique for the treatment of prostate cancer (PC) with the potential preservation of anatomic structures responsible for erectile and urinary function postoperatively. Knowledge of these anatomic structures is key to achieve a complete removal of the prostate and seminal vesicles while preserving the best possible quality of life. The literature on prostate and pelvic anatomy has been reviewed and an updated notion of the surgical anatomy is herein provided.
“Dorsal Vein Complex Control After Apical Dissection Results in Low Apical Positive Surgical Margins, But Other Surgical Maneuvers Are Required to Optimize Early Continence Recovery.”
Sooriakumaran, P. and A. Tewari (2010).
“Optimizing Vesicourethral Anastomosis Healing After Robot-Assisted Laparoscopic Radical Prostatectomy: Lessons Learned from Three Techniques in 1900 Patients.”
Tan, G., A. Srivastava, et al. (2010).
Journal of Endourology.
Abstract Background and Purpose: Creation of an optimally apposed, tension-free, well-supported vesicourethral anastomosis remains the cornerstone for anastomotic healing after radical prostatectomy. We report the effect of three techniques of bladder neck reconstruction during robot-assisted radical prostatectomy on anastomotic leak, stricture formation, and continence recovery. Patients and Methods: Between January 2005 to September 2009, 1900 consecutive patients underwent robotic-assisted laparoscopic prostatectomy (RALP) by a single surgeon. Of these, the first 214 underwent vesicourethral conventional anastomosis (CA); the next 303 men underwent anterior reconstruction (AR) only; and last 1383 men underwent total anatomic restoration (TR). Data elements included patient age, body mass index, preoperative biopsy Gleason score and prostate-specific antigen level, prostate volume, total operative time, console time, time for performing vesicourethral anastomosis, estimated blood loss, tumor stage, and margin status on final pathologic findings. Primary end points were rates of clinically significant anastomotic leaks, bladder neck contractures, and time to return of continence. Chi-square and Fisher exact tests were used for analysis of categoric variables. The Cox proportional hazard model was used for both univariate and multivariate analysis. Results: Clinically significant anastomotic leakage and bladder neck strictures were significantly fewer in the reconstructed groups (2.3% vs 1.0% vs 0.3% and 3.7% vs 1.3% vs 0.5% in the CA, AR, and TR groups, P < 0.01). Continence rates at 1, 6, 12, 26, and 52 weeks after RALP were also significantly better at all time points with anatomic restoration and AR compared with CA alone (P < 0.001). Conclusions: AR of the continence mechanism optimizes vesicourethral anastomosis healing and hastens early continence return after RALP.
“Radical retropubic prostatectomy and robotic-assisted laparoscopic prostatectomy: Likelihood of positive surgical margin(s).”
Walsh, P. C. (2010).
Journal of Urology 184(5): 1984-1985.