“Robotic Distal Ureterectomy with Boari Flap Reconstruction for Distal Ureteral Urothelial Cancers: A Single Institutional Pilot Experience.”
Allaparthi, S., R. Ramanathan, et al. (2010).
J Laparoendosc Adv Surg Tech A.
Abstract Objective: Low-grade urothelial tumors of the distal ureter historically can be managed by open distal ureterectomy and ureteral reimplantation with or without bladder reconstruction. In recent years, the da Vinci((R)) surgical robotic system (DSRS) (Intuitive Surgical Inc., Sunnyvale, CA) has being increasingly used to perform complex urologic cancer surgeries. In this article, we report first on two consecutive patients undergoing robotic distal ureterectomy and Boari flap reconstruction (RDUBF) for distal ureteral cancer. Patients and Methods: Two consecutive patients underwent RDUBF, both with a diagnosis of low-grade papillary neoplasm of a distal ureter at our institution between August 2008 and November 2008. Perioperative parameters were prospectively collected and analyzed following institutional review board approval. Results: Two patients, male and female (age, 70 and 71 years, respectively) were included in the study. In both the patients, RDUBF was completed transperitoneally without the need for open conversion. The operative time, estimated blood loss, time to hospital discharge, and time to stent removal for both patients were 270 and 220 minutes, 25 and 35 mL, and 2 days and 6 weeks, respectively. The percentage change in hematocrit following surgery was within 5% in all patients. There were no postoperative complications in both patients. Final pathology demonstrated low-grade carcinoma pT1NxMx and pTaNxMx papillary urothelial carcinoma with negative margins in both patients. A MAG3 (mercapto-acetyl-tri-glycine) renal scan at 3 months demonstrated prompt drainage in both patients. At a median follow-up of 6 months, the patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytologic, or radiologic follow-up. Conclusions: RDUBF reconstruction is technically feasible with using DSRS in select patients with distal ureteral cancer without disease recurrence in the short term. A larger cohort, with long-term follow-up, is necessary to validate our results.
“Robotic partial cystectomy for bladder cancer: A single-institutional pilot study.”
Allaparthi, S., R. Ramanathan, et al. (2010).
Journal of Endourology 24(2): 223-227.
Objective: Open partial cystectomy has been used as a curative option for select group of patients with bladder cancer. In recent years, the da Vinci Surgical Robotic System<sup>®</sup> is being increasingly used to perform complex urologic cancer surgeries. We report first on a consecutive cohort of patients undergoing robotic partial cystectomy (RPC) for bladder cancer. Methods: Three consecutive patients underwent RPC, two with diagnosis of papillary neoplasm of bladder and one with urachal adenocarcinoma at our institution from July 2008 to January 2009. Perioperative parameters were prospectively collected and analyzed after Institutional Review Board approval. Results: All three patients in the study were men with a median age of 50 years (range, 24-70 years). The RPC was completed transperitoneally in all three patients without the need for open conversion. The operative time, estimated blood loss, and time to hospital discharge for the three patients undergoing RPC were 185, 135, and 165 minutes; 25, 20, and 20mL; and 5, 2, and 2 days, respectively. The percentage change in hematocrit after surgery was within 5% in all patients. There were no postoperative complications before discharge; however, one patient was readmitted and underwent small bowel resection secondary to bowel obstruction. Final pathology demonstrated high-grade carcinoma pT2bNxMx and pTaNxMx papillary urothelial carcinoma in two patients and invasive adenocarcinoma of the bladder pT3aNxMx in the remaining patient. The median follow-up was 6 months (range, 3-10 months). All three patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytological, or radiological follow-up. Conclusions: RPC is technically feasible using the da Vinci Surgical Robotic System in select patients with bladder cancer without disease recurrence in the short term. A larger cohort with long-term follow-up is necessary to validate our results. © 2010, Mary Ann Liebert, Inc.
“Robotic ureteroureterostomy in children with a duplex collecting system.”
Casale, P. and S. Lambert (2009).
Journal of Robotic Surgery 3(3): 161-164.
Duplex collecting system pathology can be handled using an ablative procedure or reconstructive procedure even in the light of a poorly functioning moiety. We propose that, when a reconstructive procedure is an option, a robotic ureteroureterostomy is safe and feasible. Fifteen children between the ages of 6 months and 10 years (mean 31.26 months) underwent transperitoneal robotic ureteroureterostomy for duplex collecting system pathology. The surgical procedure included transperitoneal robotic approach. Outcome measures included operative time, length of hospital stay, and resolution of symptoms. Mean operative time was 1.2 h (range 0. 75-2.2 h) for the entire procedure, including the cystoscopic evaluation. Length of stay averaged 20.8 h (range 15-26 h). All postoperative imaging demonstrated intact, well-draining collecting systems. The presenting symptomatology resolved in all the patients in whom symptoms were present. Robotic ureteroureterostomy is feasible and safe in the pediatric population and should be considered part of the surgical armamentarium when upper tract preservation seems warranted. © Springer-Verlag London Ltd 2009.
“Robotic-assisted partial cystectomy with en bloc excision of the urachus and the umbilicus for urachal adenocarcinoma.”
Correa, J. J., T. S. Hakky, et al. (2010).
Journal of Robotic Surgery 3(4): 235-238.
We report two cases of urachal adenocarcinoma managed with robotic-assisted partial cystectomy. A detailed description of the robotic technique including methods used to resect the tumor, urachus, and umbilicus en bloc is described. A review of the management of urachal adenocarcinoma is presented. The robotic approach is technically feasible and safe, and is an attractive alternative to traditional open or laparoscopic-assisted partial cystectomy for this uncommon genitourinary malignancy. © Springer-Verlag London Ltd 2009.
“Bladder cancer: Robotic cystectomy noninferior to open surgery.”
Drake, R. (2009).
Nature Reviews Urology 6(12): 633.
“Robotic salvage cystectomy in the nonagenarian.”
Eandi, J. A., K. G. Chan, et al. (2009).
Journal of Robotic Surgery 3(3): 191-194.
Radical cystectomy with pelvic lymphadenectomy remains the standard treatment for muscle-invasive bladder cancer. However, bladder preservation with radiotherapy, with or without chemotherapy, represents an alternative treatment strategy. In patients that fail this bladder conservation treatment, salvage cystectomy is then indicated to treat persistent or recurrent cancer. We report our experience with robotic-assisted laparoscopic salvage radical cystoprostatectomy with pelvic lymph node dissection in a 91-year-old man. This minimally invasive approach for treatment of persistent bladder cancer refractory to chemoradiation, even in the nonagenarian, is a safe and viable alternative to traditional open surgery. © Springer-Verlag London Ltd 2009.
“Editorial comment on: a comparison of postoperative complications in open versus robotic cystectomy.”
Gakis, G. and A. Stenzl (2010).
Eur Urol 57(2): 281-282.
“Robotic radical cystectomy for bladder cancer.”
Ismail, A. F., P. Dasgupta, et al. (2009).
Minerva Urologica e Nefrologica 61(4): 341-349.
This article will focus on the evolution of robotic-assisted radical cystectomy (RARC) as the treatment for muscle invasive or uncontrolled superficial bladder cancer. Authors describe the current implementation of technology in their patients. The results of published case series and comparative studies on RARC available to date are also reviewed, to identify the surgical, pathological, oncological and quality of life outcomes of RARC.
“Critical analysis of complications after robotic-assisted radical cystectomy with identification of preoperative and operative risk factors.”
Kauffman, E. C., C. K. Ng, et al. (2010).
BJU Int 105(4): 520-527.
OBJECTIVE: To better characterize short- and long-term complications in patients after robotic-assisted radical cystectomy (RRC) using standardized complications-reporting systems, and to identify preoperative and operative risk factors predicting their occurrence. PATIENTS AND METHODS: Data were collected for 79 consecutive patients with bladder cancer undergoing RRC with extracorporeal urinary diversion by one surgeon at our institution. Complications occurring < or =90 days after RRC were graded according to two standardized reporting methods (Memorial Sloan Kettering Cancer Center and Modified Clavien), and additionally stratified by organ system. Nineteen preoperative and operative variables were tested by univariate analysis for association with the occurrence of one or more postoperative complications. Variables with a significant (P < 0.05) or near-significant (P < 0.20) association on univariate analysis were included in multivariate analysis to identify independent risk factors. RESULTS: Patients were of relatively poor health, with 58% having an American Society of Anesthesiology class or Charlson Index score of > or =3. Advanced bladder disease was frequent (41% had pT3/pT4). After RRC, one or more complications occurred within 90 days of surgery for 39/79 (49%) patients. The vast majority of complications were low grade (79%), and mostly infectious (41%) or gastrointestinal (27%). Sixteen high-grade complications occurred in 13/79 (16%) patients. Urinary obstruction, abscess, enteric fistula, gastrointestinal bleeding and thromboembolism constituted most of the high-grade complications, nearly half (seven of 16) of which occurred 31-90 days after RRC. On multivariate analysis, only preoperative renal insufficiency and intraoperative intravenous (i.v.) fluids of >5000 mL were significantly associated with postoperative complications of any grade, with respective odds ratios (ORs) of 4.2 and 4.1. For high-grade complications, significant independent risk factors included an age of > or = 65 years, operative blood loss of > or =500 mL and intraoperative i.v. fluids of >5000 mL, with respective ORs of 12.7, 9.7 and 42.1. CONCLUSION: Even among relatively sick patients with frequent advanced disease, the vast majority of complications after RRC are low grade. High-grade complications are infrequent and similar in nature to high-grade events after open RC, and a notable proportion may occur at >30 days after RRC underscoring the importance of longer reporting intervals. The surgeon’s ability to limit blood loss and i.v. fluids during RRC may provide effective risk reduction, particularly for high-grade events.
“Status of robot-assisted radical cystectomy.”
Mansour, A. M., S. J. Marshall, et al. (2010).
Can J Urol 17(1): 5002-5011.
PURPOSE: Robot-assisted radical cystectomy (RARC) is an alternative approach for treatment of bladder cancer. We provide a critical review of the current status of RARC and pelvic lymph node dissection with a focus on feasibility, safety and oncological efficacy of the procedure. MATERIALS AND METHODS: The PubMed literature database was reviewed for RARC series that have been reported in the English language until the present time. Surgical technique, operative parameters, pathologic outcome, complications and quality of life were examined. RESULTS: RARC is progressing steadily. With nearly 500 published cases worldwide, RARC proves to be technically feasible and oncologically effective. It is associated with less blood loss, shorter hospital stay, and improved postoperative quality of life. Intracorporeal urinary diversion is still in the experimental phase, and effort is needed to make it technically easier and widely accepted. CONCLUSIONS: With the worldwide rapid spread of robot-assisted surgeries, RARC is evolving as a reliable minimally invasive alternative to standard open surgery. Awaiting long term oncological results, adequately powered prospective randomized trials comparing open, laparoscopic and robotic approaches are urgently needed.
Morgan, T. M. and P. E. Clark (2010).
Curr Opin Oncol.
PURPOSE OF REVIEW: To review the diagnosis and management of all stages of bladder cancer with an emphasis on studies and developments within the last year. RECENT FINDINGS: Cystoscopy remains the gold standard for diagnosis of bladder tumors, though fluorescent light and urinary biomarkers can both improve the sensitivity of cancer detection. Management of high-risk patients with nonmuscle invasive cancer continues to be controversial, with a number of risk assessment tools developed to help stratify patients to cystectomy or bladder-sparing regimens. Intravesical therapy is utilized both as a one-time perioperative regimen and as a weekly regimen, and research continues in the development of agents for bacillus Calmette-Guerin-refractory superficial bladder cancer. In patients undergoing cystectomy, evidence supports the need for an adequate lymphadenectomy. Although there are limited data on robotic assisted radical cystectomy, initial reports suggest that an appropriate lymph node dissection can be performed. The role of bladder-sparing modalities as well as the use of adjuvant and neoadjuvant therapies is still debated. Trials investigating these therapies continue to seek to improve both oncologic outcomes and quality of life for patients with invasive bladder cancer. SUMMARY: Progress continues in bladder cancer diagnosis and management, and we anticipate that future work will further advance the care of patients with this disease.
“Robot-assisted radical cystectomy: Recent advances and review of the literature.”
Woods, M. E., P. Wiklund, et al. (2010).
Current Opinion in Urology 20(2): 125-129.
Purpose of Review: Robot-assisted radical cystectomy (RARC) continues to provide a minimally invasive option to the management of bladder cancer. Its utilization appears to be steadily increasing. The purpose of this paper is to review recent advances and outcomes related to robot-assisted radical cystectomy. Recent Findings: There are an increasing number of publications and abstracts related to robot-assisted radical cystectomy. In a majority of these case series, the urinary diversion is performed extracorporeally due to improved operative times. There has been some larger series published within the last year, which have provided some meaningful insight into the perioperative and oncologic issues related to the procedure. Several of these reports have provided a retrospective comparison to open radical cystectomy. In experienced hands, this procedure can be accomplished in a reasonable amount of time with appropriate pathologic outcomes, whereas providing decreased complication rates, EBL, and transfusion rates as well as improved convalescence compared with open-radical cystectomy. Although no long-term survival data exists to date, intermediate-term follow-up is beginning to emerge and appears similar to open-radical cystectomy in nonrandomized comparisons. Summary: Robot-assisted radical cystectomy is a reproducible, minimally invasive approach to radical cystectomy. Patients appear to derive benefit from this approach in regards to complications and convalescence without evidence of compromise to early and intermediate oncological outcomes. Long-term oncologic follow-up and, ideally, randomized prospective comparisons to open radical cystectomy are needed to further validate this procedure. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“Robot-Assisted Partial Nephrectomy: An International Experience.”
Benway, B. M., S. B. Bhayani, et al.
Background: Robot-assisted partial nephrectomy (RAPN) is emerging as a viable approach for nephron-sparing surgery (NSS), though many reports to date have been limited by evaluation of a relatively small number of patients. Objective: We present the largest multicenter RAPN experience to date, culling data from four high-volume centers, with focus upon functional and oncologic outcomes. Design, setting, and participants: A retrospective chart review was performed for 183 patients who underwent RAPN at four centers between 2006 and 2008. Surgical procedure: RAPN was performed using methods outlined in the supplemental video material. Though operative technique was similar across all institutions, there were minor variations in trocar placement and hilar control. Measurements: Perioperative parameters, including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. In addition, we reviewed functional and oncologic outcomes. Results and limitations: Mean age at treatment was 59.3 yr. Mean tumor size was 2.87 cm. Mean total operative time was 210 min while mean ischemic time was 23.9 min. Calyceal repair was required in 52.1% of procedures. Mean estimated blood loss was 131.5 ml. Sixty-nine percent of excised tumors were malignant, of which 2.7% exhibited positive surgical margins. The incidence of major complications was 8.2%. At up to 26 mo follow-up, there have been no documented recurrences and no significant change in serum creatinine (1.03 vs 1.04 mg/dl, p = 0.84) or estimated glomerular filtration rate (eGFR) from baseline (82.2 vs 79.4 mg/ml per square meter, p = 0.74). The study is limited by its retrospective nature, and the outcomes are likely influenced by the robust prior laparoscopic renal experience of each of the surgeons included in this study. Conclusions: RAPN is a safe and efficacious approach for NSS, offering short ischemic times, as well as perioperative morbidity equivalent to other standard approaches. Moreover, RAPN is capable of providing patients with excellent functional and oncologic outcomes. © 2010 European Association of Urology.
“Camera and trocar placement for robot-assisted radical and partial nephrectomy: Which configuration provides optimal visualization and instrument mobility?”
Cabello, J. M., S. B. Bhayani, et al. (2009).
Journal of Robotic Surgery 3(3): 155-159.
Proper camera and trocar placement is critical to the success of minimally invasive procedures. For robot-assisted renal surgery, two basic trocar configurations have been described. The medial approach, using a 30° downward-angled lens mimics a traditional transperitoneal laparoscopic configuration. An alternative configuration, using a 0° or 30° upward-angled lens approach locates the camera laterally, evoking a position sense similar to a retroperitoneal approach. Our objective is to compare the differences between these two standard approaches for robot-assisted renal surgery. After performing a review and analysis of available literature, our group tested both the medial and lateral camera approaches during robotic renal surgery performed in human patients. The medial approach provides a wide field of view, because of the relatively greater distance to the target structures and a horizon line closer to the patient’s midline. The lateral configuration offers significantly different visualization. The relative proximity to the target structures and a higher horizon line results in a comparatively restricted field of vision. Instrument mobility is comparable between the two approaches. Meta-analysis of the literature reveals that both approaches provide comparable overall operative times for both radical and partial nephrectomy, though there is a trend towards shorter overall operative times for partial nephrectomy performed through a medial approach. The medial trocar configuration provides a familiar working environment for both surgeon and assistant; the wide-angle view enables enhanced visualization of surrounding structures and tracking of the instruments inserted by the assistant. The lateral approach offers the potential advantage of a closer view of the kidney, but does so at the expense of a significantly restricted field of view. In our experience, a medial trocar configuration offers significant advantages over the lateral trocar configuration, and is, therefore, the standard approach at our high-volume center. © Springer-Verlag London Ltd 2009.
“Laparoscopic pyeloplasty versus robotic pyeloplasty for ureteropelvic junction obstruction: a series of 60 cases performed by a single surgeon.”
Hemal, A. K., S. Mukherjee, et al. (2010).
Can J Urol 17(1): 5012-5016.
PURPOSE: To compare operative parameters and outcomes in 30 cases of robotic pyeloplasty (RP) versus 30 cases of laparoscopic pyeloplasty (LP), performed by a single surgeon, for ureteropelvic junction (UPJ) obstruction. METHODS: Patients with primary UPJ obstruction were included in the study. The same surgeon (AKH) performed RP (usually using a transperitoneal Anderson-Hynes technique) on 30 patients in Group I and employed LP on 30 patients in Group II, in a nonrandomized fashion. The patients were followed for 18 months postoperatively. Three robotic and one assistant port were required in Group I, and 3 or 4 ports were utilized in Group II. In Group I, 26 patients had antegrade double-J stenting, 1 patient had retrograde double-J stenting, and 3 patients had stentless RP. In Group II, 22 patients had antegrade double-J stenting and 8 patients had retrograde double-J stenting. RESULTS: The mean total operating times were 98 minutes and 145 minutes, the mean estimated blood losses were 40 mL and 101 mL, and the mean hospital stays of the patients were 2 days and 3.5 days, for patients in Group I and Group II, respectively. These patients were followed up postoperatively for 18 months. They received a clinical examination, an ultrasound, and a diuretic renal dynamic scan. At 18 months, imaging studies found no obstructions in the patients in Group I and found an obstruction in only one patient in Group II. One patient in Group II required a repeat open pyeloplasty following failed endoscopic management. CONCLUSION: In this patient series, UPJ obstruction was managed effectively with either RP or LP, and outcomes were durable. Compared to pure LP, pure RP enabled the surgeon to achieve quicker dissection, reconstruction, and intracorporeal suturing with fine sutures and with antegrade double-J stenting. With RP, the operating time was decreased, and the procedure offered greater ergonomic convenience to the surgeon. Long term postoperative success, however, was equivalent on follow up in both patient groups.
“Single-setting robotic radical nephrectomy and radical prostatectomy.”
Madi, R. (2009).
Journal of Robotic Surgery 3(3): 195-198.
Casale, P. (2010).
Journal of Urology 183(3): 1167.
“The training of Canadian urology residents: Whither open surgery?”
MacNeily, A. E. (2010).
Journal of the Canadian Urological Association 4(1): 47-48.
Martin, A. D. and E. P. Castle (2010).
Urology 75(2): 426.
“The robotic revolution: the seduction continues.”
Nickel, J. C. (2010).
BJU Int 105(5): 583.
“Survey of senior resident training in urologic laparoscopy, robotics and endourology surgery in Canada.”
Preston, M. A., B. D. Blew, et al. (2010).
Can Urol Assoc J 4(1): 42-46.
INTRODUCTION: We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery. METHODS: Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008. RESULTS: All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology. CONCLUSION: Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.
“Expansion of robotics in urology: The pioneer and the ostrich.”
Su, L. M. (2010).
Current Opinion in Urology 20(1): 55.
“Port-site complications after pediatric urologic robotic surgery.”
Tapscott, A., S. S. Kim, et al. (2009).
Journal of Robotic Surgery 3(3): 187-190.
The incidence of port-site hernia development after adult laparoscopic surgery is reported to be between 0.1% and 3.0%. There are no published reports concerning hernia incidence or related factors after pediatric urologic laparoscopic interventions. We present our experience with port-site complications following pediatric urologic robotic surgery (PURS). From July 2005 to June 2009 we prospectively followed the first 200 PURS cases performed at Children’s Hospital of Philadelphia. All cases had follow-up available for at least 2 months postoperatively. The data collected allowed for evaluation of the outcomes for each port site separately and compared its size, location, and fascial closure status. Median age was 3.2 years (0.4-18.8 years). All 200 patients had follow-up with median of 11 months (0.2-83.4 months). There were 600 port sites analyzed in the 200 cases. Of the 600 port sites, 200 were umbilical. The other 400 port sites were lateral to the rectus muscle, either subcostal or at the level of the anterior superior iliac spine. There was no wound irrigation prior to closure on any sites. All the patients received perioperative antibiotics. One umbilical port had a hernia diagnosed 2 weeks postoperatively. Four of the 600 ports (0.6%) developed skin dehiscence secondary to superficial wound infection within 1 week postoperatively. At our institution, the overall incidence of port-site complications after PURS was 0.83%. This is slightly lower than the published incidence in adults undergoing conventional laparoscopy. Due to the low incidence of complications it is difficult to draw conclusions on contributing factors. © Springer-Verlag London Ltd 2009.
“Robotics in urologic surgery.”
Zhao, L. C., J. J. Meeks, et al. (2009).
Minerva Urologica e Nefrologica 61(4): 331-339.
Robotic surgery is becoming rapidly integrated in urology. Nearly every open or laparoscopic procedure has been described with robotic assistance. While the da Vinci robot is recently applied to the upper urinary tract, it has become widely adopted for performing radical prostatectomy. Benefits of robotics include 3-D vision, blood-less field from pneumoperitoneum, and ease of intracorporeal suturing. Disadvantages include cost, lack of haptic feedback, surgical learning curve and longer operative times. Here, the authors describe the state of the art applications and outcomes of robotics in urologic surgery.
“The Impact of Positive Surgical Margins on Mortality Following Radical Prostatectomy During the Prostate Specific Antigen Era.”
Boorjian, S. A., R. J. Karnes, et al. (2010).
Journal of Urology 183(3): 1003-1009.
Purpose: The presence of a positive surgical margin at radical prostatectomy has been linked to an increased risk of postoperative biochemical recurrence. We evaluated the impact of margin status on subsequent clinical progression and mortality. Materials and Methods: We reviewed the records of 11,729 patients who underwent prostatectomy between 1990 and 2006. Survival was estimated for patients with vs without a positive margin and compared using the log rank test. Cox proportional hazards regression models were used to analyze the impact of margin status on survival. Results: Overall 3,651 (31.1%) men were identified with a positive margin. Median postoperative followup was 8.2 years (IQR 4.4, 12.1). The 10-year biochemical recurrence-free rate for patients with and without a positive margin was 56% and 77%, respectively (p <0.001), while 10-year local recurrence-free survival was 89% vs 95% (p <0.001). Margin status also stratified systemic progression-free survival (93% vs 97%, p <0.001), cancer specific survival (96% vs 99%, p <0.001) and overall survival (83% vs 88%, p <0.001). On multivariate analysis the presence of a positive margin was associated with increased risk of biochemical recurrence (HR 1.63, 95% CI 1.47-1.80, p <0.0001), local recurrence (HR 1.78, 95% CI 1.45-2.19, p <0.0001) and receipt of salvage therapy (HR 1.79, 95% CI 1.58-2.02, p <0.0001) but was not a significant predictor of systemic progression (p = 0.95), cancer specific death (p = 0.15) or overall mortality (p = 0.16). Conclusions: The presence of a positive margin increased the risk of biochemical recurrence, local recurrence and the need for salvage treatment but was not independently associated with systemic progression, cancer specific death or overall mortality. These results should be considered when evaluating patients for adjuvant therapy. © 2010 American Urological Association Education and Research, Inc.
“Guideline for optimization of surgical and pathological quality performance for radical prostatectomy in prostate cancer management: Evidentiary base.”
Chin, J. L., J. Srigley, et al. (2010).
Journal of the Canadian Urological Association 4(1): 13-25.
Background: The objective is to provide surgical and pathological guidelines for radical prostatectomy (RP) with or without concur-rent pelvic lymph node dissection (PLND) to achieve optimal benefit for patients, with minimal risk of harm. Methods: For surgical questions, a literature search of MEDLINE, EMBASE and the Cochrane database was performed. A literature search for the pathological questions was not conducted since the protocol for invasive carcinomas of the prostate gland developed by the College of American Pathologists (CAP) was endorsed. Urologists and pathologists were consulted for their assessment of the surgical and pathological recommendations. Results: Limited high-quality evidence from 95 primary studies was available and, therefore, the expert panel developed recommendations on the basis of a consensus of the expert opinion of the working group and through a consultation with urologists and pathologists. In addition to the CAP protocol, some technical recommendations related to the handling and processing of the specimen were made. Conclusion: Radical prostatectomy is recommended for the surgical treatment of prostate cancer, depending on a patient’s preoperative risk profile. The panel unanimously determined that the goals for RP are to attain a positive margin rate of <25% for pT2 disease, a mortality rate of <1%, rates of rectal injury of <1% and blood transfusion rates of <10% in non-anemic patients. Standard PLND should be mandatory in high-risk patients, should be recommended for intermediate-risk patients and should be optional for low-risk patients. The quality and effectiveness of this treat-ment and of subsequent patient care depend on good management, effective communication and reporting between surgeons and pathologists working together as part of a multidisciplinary team. The complete guideline document is posted on the Cancer Care Ontario website (www.cancercare.on.ca) search in their Toolbox, Quality Guidelines & Standards, Clinical Program category under “surgery.” © 2010 Canadian Urological Association.
“From conventional radiation therapy to robotic approach: Technological evolution and revolution of practice.”
Hannoun-Levi, J. M., E. Lartigau, et al. (2010).
De la radiothérapie conventionnelle á l’utilisation de la robotique: Des évolutions technologiques et une révolution des pratiques 12(1): 60-64.
Since the discovery of X-ray by Röntgen in 1895, the technological evolution of radiation therapy increased swiftly. However, the philosophy remained always the same: delivering higher radiation dose to the target volume while decreasing the dose to the organ at risk. Since the beginning of the 1990s, with conformal radiation therapy development (3DCT), differents techniques appeared. Some of them are derived from 3DCT, such as intensity-modulated radiation therapy, arctherapy, TomotherapyTM, or techniques using gating approach for breath holding. In the frame of stereotactic radiation therapy, the GammaKnifeTM is already used since 20 years, while new concepts, based on a robotic approach (CyberKnifeTM), are now available for treatment. Brachytherapy also took advantage from the technological evolution with the new approaches. In the frame of heavy ions, hadrontherapy represents an interesting technique dedicated to special clinical situations including pediatric tumors. In this article, we report an analysis of the technological evolution of radiation therapy. © 2010 Springer Verlag France.
“Epidemlology of urinary Incontinence in prostate cancer. Incidence, quality of life and farmacoeconomlc features.”
Orsola, A. and J. Morote (2009).
Epidemiología de la incontinencia urinaria en el cáncer de próstata. Incidencia, calidad de vida y aspectos farmacoeconómicos 62(10): 786-792.
OBJECTIVES: To present recent data on the epidemiology of urinary incontinence in prostate cancer (PCa). To review the incidence of urinary incontinence, its impact on quality of life and related pharmacoeconomic features. METHODS: We performed a bibliographic review about the complications of the various therapeutic options for PCa including radical prostatectomy (RP) (open, laparoscopic and robotic), external beam radiotherapy, brachytherapy, cryotherapy, and high intensity focused ultrasound (HIFU). RESULTS: The lack of uniformity for urinary incontinence definition, for its evaluation, and for the way to report it makes the interpretation of functional results and impact on quality of life after any treatment option difficult and uneven. Generally, we documented that urinary incontinence after treatment appears more often in patients undergoing radical surgery. Nevertheless, we stated that neurovascular bundle preservation, performance of the procedure in high volume centers, by high volume surgeons, and development of robotic surgery may positively influence the global outcomes of this technique. Moderate incontinence is less frequent after external beam radiotherapy, but the association of rectal pain and diarrhea, in up to 40% of the patients, worsens voiding symptoms. Irritative and obstructive voiding symptoms after perineal brachytherapy are especially associated with long term erectile dysfunction as well as rectal morbidity. In the case of cryotherapy and HIFU the available studies are case series and there are not randomized studies comparing them with the primary treatment of localized PCa. CONCLUSIONS: Each treatment modality for PCa is associated with a different pattern of changes in the urinary, sexual, intestinal and hormonal related quality of life domains. Two key factors when evaluating incontinence are information about continence before the procedure and the use of validated, self-administered evaluation means. Although technical improvements in all procedures should contribute to diminish the impact of complications, we should not forget the trend to the association of therapies- multimodal therapy- has a higher complication profile. Therefore, they should be reserved for patients in whom a benefit has been proved.
“Has the advent of minimally invasive surgery altered the risk profile of patients undergoing prostatectomy?”
Barlow, L. J., M. J. Mann, et al. (2010).
Urology 75(2): 427-430.
OBJECTIVES: To determine whether the decreased short-term morbidity associated with minimally invasive surgery (MIS) has resulted in an alteration in the disease-specific risk profile of prostatectomy patients. MIS in many fields has resulted in an expansion in the pool of patients willing to undergo surgery. METHODS: The Columbia Urologic Oncology Database was queried, and 1751 patients undergoing radical prostatectomy between 2000 and 2007 were identified. The cohort was divided into 2 groups: patients who received surgery before or after the initiation of robotic-assisted laparoscopic radical prostatectomy (RALRP) at our institution (from 2003 onward). Age at surgery, Kattan Nomogram (KN) score, prostate-specific antigen (PSA), Gleason score sum, and tumor stage were compared using unpaired t tests with Welch correction and Mann-Whitney tests. RESULTS: A total of 663 patients underwent prostatectomy from 2000 to 2002 (“pre-MIS era”), and 1088 patients had surgery in 2003 or later (“MIS era”), of which 519 and 569 underwent RALRP and open prostatectomy, respectively. There was no significant difference between the 2 eras regarding age, Kattan Nomogram score, or tumor stage. However, there was a significant difference in preoperative PSA (P = .01) and Gleason sum (P = .0002). In a comparison of the pre-MIS era with RALRP patients, only PSA differed significantly (P = .0002). CONCLUSIONS: The advent of MIS for prostate cancer did not significantly alter the characteristics of patients undergoing prostatectomy at our institution. Although advancements in surgical techniques may improve clinical outcomes, this study does not suggest a consequential effect on the risk stratification of patients choosing surgery for prostate cancer.
“Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer.”
Bolenz, C., A. Gupta, et al. (2010).
Eur Urol 57(3): 453-458.
BACKGROUND: Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking. OBJECTIVE: To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP). DESIGN, SETTING, AND PARTICIPANTS: The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008. MEASUREMENTS: Direct and component costs were compared. Costs were adjusted for changes over the time of the study. RESULTS AND LIMITATIONS: Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8-10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p<0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p<0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283-7369]; LRP: $5687 [IQR: $4941-5905]; RRP: $4437 [IQR: $3989-5141]; p<0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p<0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year. CONCLUSIONS: RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.
“Robot-assisted laparoscopic radical prostatectomy in patients with previous abdominal surgery: a novel laparoscopic adhesiolysis technique.”
Boylu, U., M. Oommen, et al. (2010).
J Endourol 24(2): 229-232.
PURPOSE: We evaluated the feasibility and outcomes of performing a novel laparoscopic adhesiolysis technique before robot-assisted laparoscopic radical prostatectomy (RALRP) in patients with previous abdominal surgery. PATIENTS AND METHODS: A total of 18 men with incision scars from previous abdominal surgeries underwent RALRP. A 12-mm trocar was placed at the lateral lower quadrant away from the incision site, and a teaching laparoscope was introduced into the peritoneal cavity. Meticulous adhesiolysis was performed through a single trocar to subsequently allow safe placement of additional robotic trocars. Age, type of previous surgery, total operative time, console time, anastomosis time, estimated blood loss, transfusion rate, complications, and conversion rate were recorded. RESULTS: All patients had multiple abdominal surgeries. Mean operative time was 297 minutes, mean console time was 194 minutes, and mean estimated blood loss was 241 mL. No access-related complication and no conversion to open surgery occurred. CONCLUSION: This novel laparoscopic technique of adhesiolysis with a teaching laparoscope through a single trocar facilitates safe placement of trocars and accomplishment of RALRP in patients with previous abdominal surgery.
Cadeddu, J. A., G. Gautam, et al. (2010).
J Urol 183(3): 858-861.
“Predictive Factors for Positive Surgical Margins and Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy.”
Coelho, R. F., S. Chauhan, et al.
Background: Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). Objective: We sought to identify predictive factors for PSMs and their locations after RARP. Design, setting, and participants: We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. Intervention: All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases. Measurements: Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. Results and limitations: In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p < 0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p = 0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0-1.3; p = 0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. Conclusions: Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs. © 2010.
“Early Complication Rates in a Single-Surgeon Series of 2500 Robotic-Assisted Radical Prostatectomies: Report Applying a Standardized Grading System.”
Coelho, R. F., K. J. Palmer, et al. (2010).
BACKGROUND: Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. OBJECTIVE: To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION: All patients underwent RARP performed by a single surgeon. MEASUREMENTS: The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeon’s experience (number of cases). RESULTS AND LIMITATIONS: Our median operative time was 90min (interquartile range [IQR]: 75-100min). The median estimated blood loss was 100ml (IQR:100-150ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p=0.0034) and in the number of anastomotic leaks (p<0.001) as the surgeon’s experience increased. CONCLUSIONS: RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon’s experience increased.
“A multi-institutional comparison of radical retropubic prostatectomy, radical perineal prostatectomy, and robot-assisted laparoscopic prostatectomy for treatment of localized prostate cancer.”
Coronato, E. E., J. D. Harmon, et al. (2009).
Journal of Robotic Surgery 3(3): 175-178.
To evaluate the pathological stage and margin status of patients undergoing radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP) and robot-assisted laparoscopic prostatectomy (RALP). We performed a retrospective analysis of 196 patients who underwent RRP, RPP, and RALP as part of our multi-institution program. Fifty-seven patients underwent RRP, 41 RPP, and 98 RALP. Patient age, preoperative prostate specific antigen (PSA), preoperative Gleason score, preoperative clinical stage, pathological stage, postoperative Gleason score, and margin status were reviewed. The three groups had similar preoperative characteristics, except for PSA (8.4, 6.5, and 6.2 ng/ml) for the retropubic, robotic, and perineal approaches. Margins were positive in 12, 24, and 36% of the specimens from RALP, RRP, and RPP, respectively (P = 0.004). The positive margin rates in patients with pT2 tumors were 4, 14, and 19% in the RALP, RRP, and the RPP groups, respectively (P = 0.03). Controlling for age and pre-operative PSA and Gleason score, the rate of positive margins was statistically lower in the RALP versus both the RRP (P = 0.046) and the RPP groups (P = 0.02). In the patients with pT3 tumors, positive margins were observed in 36% of patients undergoing the RALP and 53 and 90% of those patients undergoing the RRP and RPP, respectively (P = 0.015). Controlling for the same factors, the rate of positive margins was statistically lower in the RALP versus the RPP (P = 0.01) but not compared with the RRP patients (P = 0.32). The percentage of positive margins was lower in RALP than in RPP for both pT2 and pT3 tumors. RRP had a higher percentage of positive margins than RALP in the pT2 tumors but not in the pT3 tumors. © Springer-Verlag London Ltd 2009.
“Robot-assisted laparoscopic prostatectomy: Analysis of an experienced open surgeon’s learning curve after 300 procedures.”
Doumerc, N., C. Yuen, et al. (2010).
Journal of Robotic Surgery 3(4): 229-234.
To critically analyse the learning curve for a single experienced open surgeon converting to robotic surgery. From February 2006 to July 2009, 300 patients underwent a robot-assisted laparoscopic prostatectomy (RALP) by a single urologist. This study is a prospective analysis of the baseline patient and tumour characteristics, intraoperative and postoperative data, and histopathologic features. To analyse the RALP learning curve, the joinpoint regression method was used. Mean age of the patient was 61.3 years (range 46-76). Mean pre-operative PSA level was 7 ng/ml (range 0.7-41), and follow-up was 14 months (0.7-41). The mean operating time was 185 min (range 119-525). One hundred and ten cases were required to achieve 3-h proficiency. There were no conversions. The mean hospital stay was 2.8 days (range 2-7). Major complications rate was 1.3%. The blood transfusion rate was 0.6%. The overall positive surgical margin (PSM) rate was 21.3%. pT2 and pT3 PSM rate was 10 and 44%, respectively. The joinpoint regression method showed that the learning curve started to plateau for the overall PSM rate after 205 cases (95% CI 200-249). For pT2 and pT3, PSM rate, the learning curve tended to flatten after 130 and 170 cases, respectively. The analysis of an experienced open surgeon learning curve in transferring his skills to the robotic platform has shown that 3-h proficiency requires 110 cases. The overall, pT2, and pT3 PSM rate take approximately 200, 130, and 170 cases, respectively, to flatten. © Springer-Verlag London Ltd 2010.
“Synchronous trans-abdominal pre-peritoneal (TAPP) hernioplasty in a patient with robotic-assisted prostatectomy for carcinoma of prostate.”
Fan, J. K. M., P. C. Tam, et al. (2010).
Surgical Practice 14(1): 32-32.
“Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy.”
Freire, M. P., W. W. Choi, et al. (2010).
Urol Clin North Am 37(1): 37-47, Table of Contents.
Robotic-assisted laparoscopic radical prostatectomy (RALP) has been rapidly adopted in the last few years despite having a prolonged learning curve. This article describes the RALP learning curve, reviews in detail the challenging steps of the operation, describes the authors’ RALP technique, and concludes with tips to overcome the learning curve.
“Editorial comment on: Cost comparison of robotic, laparoscopic and open radical prostatectomy for prostate cancer.”
Graefen, M. (2010).
Eur Urol 57(3): 458.
“Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: A Problem Not Only in the Robotic Literature.”
Graefen, M. (2010).
Kalisvaart, J. F., K. E. Osann, et al. (2009). “Posterior reconstruction and anterior suspension with single anastomotic suture in robot-assisted laparoscopic radical prostatectomy: A simple method to improve early return of continence.” Journal of Robotic Surgery 3(3): 149-153.
Post-prostatectomy urinary incontinence is a major cause of morbidity from radical prostatectomy. Efforts have been made to develop techniques to hasten return of urinary control. Several authors have demonstrated improved early continence with anterior, posterior, or combined reconstruction of the urethral-pelvic attachments. In this study, we compare three-month urinary function and continence data for patients who underwent RALP with posterior reconstruction and anterior suspension with single anastomotic suture (PRASS). A prospective cohort of 50 patients underwent RALP with PRASS reconstruction and were compared to 50 control patients who underwent standard RALP. Continence was defined as use of 0-1 urinary pads and was evaluated at each follow-up visit using the EPIC-26 questionnaire. A weighted summary score was created and group differences were compared using a repeated measures analysis of variance model. After adjusting for age, baseline AUA symptom score, and SHIM scores, which were found to correlate with continence, patients who underwent the PRASS reconstruction had significantly improved urinary control at three months compared with the control group; 90.9% of the patients in the PRASS group wore 0-1 pads per day versus 48.2% in the control group (P = 0.014). Of the patients undergoing the standard prostatectomy 20.6% were totally pad-free compared with 42% of the patients undergoing the PRASS procedure (P = 0.042). In conclusion, the PRASS technique resulted in statistically significant improvement in urinary control three months post-operation. The PRASS reconstruction is technically straightforward, requires no additional sutures, and is a simple technique that is easily learned and adaptable to other robotic surgery. © The Author(s) 2009.
“Construct validity of a full procedure, virtual reality, real-time, simulation model for training in transurethral resection of the prostate.”
Källström, R., H. Hjertberg, et al. (2010).
Journal of Endourology 24(1): 109-115.
Purpose: To examine the content and construct validity of a full procedure transurethral prostate resection simulation model (PelvicVision). Materials and Methods: The full procedure simulator consisted of a modified resectoscope connected to a robotic arm with haptic feedback, foot pedals, and a standard desktop computer. The simulation calculated the flow of irrigation fluid, the amount of bleeding, the corresponding blood fog, the resectoscope movements, resection volumes, use of current, and blood loss. Eleven medical students and nine clinically experienced urologists filled in questionnaires regarding previous experiences, performance evaluation, and their opinion of the usefulness of the simulator after performing six (students) and three (urologists) full procedures with different levels of difficulty. Their performance was evaluated using a checklist. Results: The urologists finished the procedures in half the time as the students with the same resection volume and blood loss but with fewer serious perforations of the prostatic capsule and/or sphincter area and less irrigation fluid uptake. The resectoscope tip movement was longer and the irrigation fluid uptake per resected volume was about 5 times higher for the students. The students showed a positive learning curve in most variables. Conclusion: There is proof of construct validity and good content validation for this full procedure simulator for training in transurethral resection of the prostate. The simulator could be used in the early training of urology residents without risk of negative outcome. © Mary Ann Liebert, Inc. 2010.
“Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy.”
Kalmar, A. F., L. Foubert, et al. (2010).
Br J Anaesth.
BACKGROUND: /st> The steep (40 degrees ) Trendelenburg position optimizes surgical exposure during robotic prostatectomy. The goal of the current study was to investigate the combined effect of this position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during these procedures. METHODS: /st> Physiological data were recorded during the whole surgical procedure in 31 consecutive patients who underwent robotic endoscopic radical prostatectomy under general anaesthesia. Heart rate, mean arterial pressure, central venous pressure, Sp(o(2)), Pe’(co(2)), P(Plat), tidal volume, compliance, and minute ventilation were monitored and recorded. Arterial samples were obtained to determine the arterial-to-end-tidal CO(2) tension gradient. Continuous regional cerebral tissue oxygen saturation (Sct(o(2))) was determined by near-infrared spectroscopy. RESULTS: /st> Although patients were in the Trendelenburg position, all variables investigated remained within a clinically acceptable range. Cerebral perfusion pressure (CPP) decreased from 77 mm Hg at baseline to 71 mm Hg (P=0.07), and Sct(o(2)) increased from 70% to 73% (P<0.001). Pe’(co(2)) increased from 4.12 to 4.79 kPa (P<0.001) and the arterial-to-Pe’(co(2)) tension difference increased from 1.06 kPa in the normal position to a maximum of 1.41 kPa (P<0.001) after 2 h in the Trendelenburg position. CONCLUSIONS: /st> The combination of the prolonged steep Trendelenburg position and CO(2) pneumoperitoneum was well tolerated. Haemodynamic and pulmonary variables remained within safe limits. Regional cerebral oxygenation was well preserved and CPP remained within the limits between which cerebral blood flow is usually considered to be maintained by cerebral autoregulation.
“Prostate cancer: Medicoeconomic aspects.”
Kanso, C., J. Etner, et al. (2010).
Cancer de la prostate : aspects médicoéconomiques 20(2): 85-90.
Prostate cancer is the first cancer in men. Its incidence is constantly increasing. The significant evolution of diagnostic and therapeutic means during the two last decades contrasts with the scarcity of medicoeconomic studies. The aim of this review is to present a synthesis of the different studies published and to respond to questions about the economic aspects of this disease, with the evaluation of its direct and indirect costs. The cost-effectiveness and the benefits of the prevention and the screening are still being studied. The costs of the surgery and the radiotherapy are roughly similar. The new surgical techniques, especially the laparoscopic and the robotic surgeries, are not necessarily associated with higher costs, in condition of a high-volume laparoscopic surgery program and a faster discharge. The indirect costs of prostate cancer concern the loss of economic production associated with the disease and death and are more difficult to determine. © 2009 Elsevier Masson SAS. All rights reserved.
“Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy.”
Kordan, Y., D. A. Barocas, et al. (2010).
Study Type – Therapy (individual cohort) Level of Evidence 2b OBJECTIVE To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) is associated with a lower transfusion rate than radical retropubic prostatectomy (RRP). PATIENTS AND METHODS In this cohort study, we evaluated 1244 consecutive patients who underwent RALP (830) or RRP (414) between June 2003 and July 2006. Demographics, clinical characteristics, pathology, blood loss and transfusion data were collected prospectively. Groups were compared for baseline characteristics, blood loss, change in haematocrit and transfusion using univariate statistics, and an exploratory multivariate model was developed. RESULTS RALP was associated with lower blood loss (median 100 vs 450 mL, P < 0.001) and a smaller change in haematocrit (median 7% vs 10%, P < 0.001) than RRP. Although both groups had low transfusion rates, the RALP group required fewer transfusions than the RRP group (0.8% vs 3.4%, P= 0.002). On univariate analysis, surgical approach (RRP vs RALP), estimated blood loss >/=500 mL and change in haematocrit >/=10% were the only the significant predictors of transfusion. In the exploratory multivariate model RALP was the only significant predictor of reduced need for transfusion, with an odds ratio of 0.23 (95% confidence interval 0.09-0.58; P= 0.002). CONCLUSIONS This study shows that RALP is associated not only with less blood loss and a smaller decrease in haematocrit, but also a decreased need for transfusion.
“Advances and future directions in management of prostate cancer.”
Krane, L. S., M. N. Patel, et al. (2009).
Indian Journal of Surgery 71(6): 337-341.
Despite the high cure rates of patients diagnosed and treated with prostate cancer, there is still room for improvement in management of these patients. This includes the identification of patients at highest risk for progression, the usage of focal therapies in low risk disease, and the continued improvement on established modalities. Through these avenues, the morbidity associated with treatment for prostate cancer can be vastly reduced, and thus patient outcomes improved. This article reviews the current treatment modalities and future directions for the treatment of localised prostate cancer. © Association of Surgeons of India 2009.
“Robot-assisted radical prostatectomy in a patient with a preexisting three-piece inflatable penile prosthesis.”
Kyung, H. C., H. L. Seung, et al. (2010).
Korean Journal of Urology 51(1): 70-72.
We report a rare case of robot-assisted laparoscopic radical prostatectomy (RARP) in a patient with a preexisting penile prosthesis. In this case, we completed RARP without removing the reservoir by using a deflation-inflation technique, and there were no complications related to the prosthesis. The patient had a negative surgical margin. The preserved three-piece inflatable penile prosthesis continued to function properly in 1month. Reservoir-preserving RARP is technically feasible and safe. However, it is important to be aware of device-related complications. Long-term studies on the mechanical survival rate and patient satisfaction should be also performed. © The Korean Urological Association, 2010.
“An Unbiased Prospective Report of Perioperative Complications of Robot-assisted Laparoscopic Radical Prostatectomy.”
Lasser, M. S., J. Renzulli Ii, et al.
Objectives: To analyze and classified our single-institution experience with the perioperative complications associated with robot-assisted laparoscopic radical prostatectomy (RALRP). Methods: A total of 239 patients with a mean age of 60.6 years were evaluated (January 2007 to June 2008). Data were collected through an institutional review board-approved blinded prospective database by an independent third party committee. The data-points accrued were set forth by a 5-member panel including 3 robotic urological surgeons (J. R., G. H., G. P.), the chief of general surgery (H. S.), and a member of the hospital’s outcomes committee. The Modified Clavien system was used to grade complications, with grade I and II representing minor and grade III, IV, and V major complications. Results: Of our 239 patients, 198 (82.9%) had an uneventful postoperative course, defined as discharged home from the hospital within 2 days postoperatively with no unscheduled procedures/studies/hospital admissions or emergency room visits. On review of the remaining 41 patients, 55 complications were found. Of these, 24 were grade I, 17 grade II, 7 grade IIIa, 5 grade IIIb, 1 grade IVa, and 1 grade V complications. There was 1 perioperative mortality (0.4%) attributed to a pulmonary embolism on autopsy. Blood loss data revealed 1 (0.4%) intraoperative transfusion and 9 (3.8%) postoperative transfusions. Conclusions: RALRP is associated with major and minor complication rates of 5.0% and 14.6%, respectively. Prospective and blinded data on complications associated with RALRP are lacking in the published data. Our prospective, unbiased data provide an important tool to help counsel patients on complications associated with robot-assisted laparoscopic radical prostatectomy. © 2010 Elsevier Inc. All rights reserved.
“Penile rehabilitation protocol after robot-assisted radical prostatectomy: Assessment of compliance with phosphodiesterase type 5 inhibitor therapy and effect on early potency.”
Lee, D. J., P. Cheetham, et al. (2010).
BJU International 105(3): 382-388.
Objective: To evaluate factors that affect compliance in men who enrol in a phosphodiesterase type 5 inhibitor (PDE5I) protocol after nerve-sparing robot-assisted prostatectomy (RAP), and report on short-term outcomes, as PDE5Is may help restore erectile function after RAP and patient adherence to the regimen is a factor that potentially can affect outcome. PATIENT AND METHODS We prospectively followed 77 men who had nerve-sparing RAP and enrolled in a postoperative penile rehabilitation protocol. The men received either sildenafil citrate or tadalafil three times weekly. The minimum follow-up was 8 weeks. Potency was defined as erection adequate for penetration and complete intercourse. Compliance was defined as men adhering to the regimen for ≥2 months. Results: The mean age of the cohort was 57.8 years and the median follow-up was 8 months. In all, 32% of the men discontinued the therapy <2 months after RAP and were deemed noncompliant with an additional 39% discontinuing therapy by 6 months, with the high cost of medication being the primary reason (65%). Long-term compliance and preoperative erectile dysfunction were independent predictors of potency return after adjusting for age and nerve sparing. Conclusion:s: The high cost of medication remains a significant barrier to maintaining therapy. Noncompliance to PDE5I therapy in a tertiary care centre was much higher than reported in clinical trial settings. With longer-term follow-up, we need to further define the factors that improve overall recovery of sexual function after RAP. © 2009 BJU International.
“Learning curve for robot-assisted laparoscopic radical prostatectomy for pathologic T2 disease.”
Lee, J. W., W. J. Jeong, et al. (2010).
Korean Journal of Urology 51(1): 30-33.
Purpose: To investigate the learning curve for robot-assisted laparoscopic radical prostatectomy (RALP) for pathologic T2 disease, we examined differences in perioperative outcomes according to time period. Materials and Methods: Between July 2005 and June 2008, a total of 307 consecutive patients underwent RALP for prostate cancer and 205 patients had pathologic T2 disease. Patients were grouped into 6-month time periods. We collected and examined the patient’s perioperative data including age, body mass index (BMI), prostate-specific antigen (PSA), operation time, estimated blood loss, and positive surgical margin. Results: There were no significant differences among the groups in age (p=0.705), BMI (p=0.246), PSA (p=0.425), or prostate volume (p=0.380). Operation time (p<0.001) and estimated blood loss (p<0.001) decreased significantly with time. The positive surgical margin rate also showed a decreasing trend, but this was not significant (p=0.680). Conclusions: Operation time and estimated blood loss had a steep learning curve during the early 24 cases and then stabilized. A positive surgical margin rate, however, did not have a significant learning curve, although the positive surgical margin decreased continuously. © the Korean Urological Association, 2010.
“Short-term outcome of patients with robot-assisted versus open radical prostatectomy: For localised carcinoma of prostate.”
Lo, K. L., C. F. Ng, et al. (2010).
Hong Kong Medical Journal 16(1): 31-35.
Objective: To compare the short-term outcome of patients undergoing robot-assisted versus open radical prostatectomy. Design: Retrospective analysis of prospectively collected data. Setting: A university teaching hospital in Hong Kong. Patients: Twenty consecutive cases having robot-assisted radical prostatectomy were compared with the last 20 cases of open radical prostatectomy (prior to November 2005 when the robotic system was introduced). Main outcome measures: Perioperative functional evaluation (with special emphasis on continence) and oncological evaluation (included margin studies and prostate-specific antigen levels). Results: Regarding baseline clinical characteristics of the patients, there was no statistically significant difference between the robotic and open radical prostatectomy groups. For perioperative outcome, in the robotic group the blood transfusion rate was significantly lower (5 vs 65%), hospital stay was shorter (8 vs 17 days), and the catheter time was shorter (12 vs 18 days). For early oncological outcome, there was no statistically significant difference in the margin positive rate and early prostate-specific antigen results. Regarding continence (use of 0-1 pads/day), it was achieved by 95% in the robotic group with a mean follow-up of 6 months compared to 85% in the open group with a mean follow-up of 42 months. Conclusions: Robot-assisted radical prostatectomy offered the benefits of a minimally invasive operation with less blood loss, shorter catheter time and hospital stay, and earlier continence. It has therefore become the preferred surgical option in our institution.
“Single-setting robotic radical nephrectomy and radical prostatectomy.”
Madi, R. (2009).
Journal of Robotic Surgery 3(3): 195-198.
“Outpatient Prostatectomy: Too Much Too Soon or Just What the Patient Ordered.”
Martin, A. D., R. N. Nunez, et al. (2010).
Urology 75(2): 421-424.
Objectives: To evaluate the feasibility of performing a robot-assisted radical prostatectomy (RARP) as an outpatient procedure while maintaining patient satisfaction and safety. Herein we report our experience, selection criteria, and discharge criteria for outpatient RARP. Methods: We performed a prospective study with 11 patients undergoing extraperitoneal RARP. These patients were counseled before the procedure that they would go home the same evening of the procedure. The patients were then surveyed by a third party shortly after they returned home, using the Patient Judgement System-24, a previously validated instrument for patient satisfaction. Sociodemographic data, comorbidities, and outcomes were collected for analysis. Results: All patients were successfully discharged the same day of surgery. Mean patient age was 62.2 years with a mean body mass index of 26 kg/m<sup>2</sup>. Mean operative time was 117.6 minutes, console time was 76.7 minutes, and estimated blood loss was 168.2 mL. Mean indwelling catheter time was 7.5 days. No complications occurred in this series of patients. Satisfaction was unanimously high in all patients surveyed, with most scores over 90% on the Patient Judgement System-24. No patient reported any ill effects from the shortened stay or felt rushed to leave the hospital. Conclusions: The early experience with extraperitoneal RARP as a same day surgery is promising. Preoperative patient counseling and selection is paramount. Patient satisfaction is not adversely affected by the shortened stay. Surgeon experience, assessment of intraoperative findings, and adequate postoperative assessment are essential. © 2010 Elsevier Inc. All rights reserved.
“preoperative criteria to select patients for bilateral nerve-sparing robotic-assisted radical prostatectomy.”
Novara, G., V. Ficarra, et al. (2010).
Journal of Sexual Medicine 7(2 PART 1): 839-845.
Introduction.: To date, no study has analyzed the predictors of potency recovery in a robot-assisted laparoscopic radical prostatectomy (RALP) series. A novel risk stratification for erectile function recovery after retropubic radical prostatectomy (RRP) has been proposed recently by Briganti et al. from the University Vita-Salute San Raffaele in Milan, Italy. Aim.: To evaluate the potency rate in a series of consecutive patients who underwent bilateral nerve-sparing RALP, to identify the preoperative predictors of erectile function recovery, and to validate the risk-group stratification of Briganti et al. Methods.: The clinical records of all patients who underwent RALP for clinically localized prostate cancer between April 2005 and April 2009 were prospectively collected in the Prostate Cancer Padua Database. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up ≥12 months. Main Outcome Measures.: Twelve-month potency rate after RALP, defined as an International Index of Erectile Function 6 (IIEF-6) score ≥18. Results.: Data showed that 129 out of 208 enrolled patients (62%) were potent 12 months after surgery. Age (hazard ratio [HR]: 2.8; P < 0.001), Charlson score (HR: 2.9; P = 0.007), and baseline IIEF-6 score (HR: 0.8; P < 0.001) were independent predictors of potency recovery at multivariate analysis. According to Briganti et al.’s risk-group stratification, the 12-month potency rate following RALP was 81.9% in the low-risk group, 56.7% in the intermediate-risk group, and 28.6% in the high-risk group (P < 0.001). Conclusions.: In the era of robotic surgery, the key point for the success of the nerve-sparing technique remains the accurate selection of patients. Age ≤65 years, absence of associated comorbidities, and good preoperative erectile function are the most important preoperative factors to select those patients for whom bilateral nerve-sparing RALP can achieve the best results. © 2009 International Society for Sexual Medicine.
“Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: What About the Evidence for Open?”
Patel, V. R.
“Analysis of Continence Rates Following Robot-assisted Radical Prostatectomy: Strict Leak-free and Pad-free Continence.”
Reynolds, W. S., S. A. Shikanov, et al. (2010).
Urology 75(2): 431-436.
Objectives: To propose a strict and specific definition of continence (leak-free and pad-free [LFPF]) and apply it to robot-assisted radical prostatectomy (RARP) outcomes on the basis of University of California-Los Angeles-Prostate Cancer Index (UCLA-PCI), as postprostatectomy incontinence is not well defined. Methods: A single-institution RARP database was reviewed concerning continence variables prospectively recorded by the UCLA-PCI. Specific responses to urinary function and continence items were reviewed at baseline and 1, 3, 6, 12, and 24 months after surgery. Results: From February 2003 to September 2007, a total of 1005 of 1500 RARP patients had data available for review. At baseline, only 73% of these patients were LFPF. This decreased to 4%, 9%, 17%, 24%, and 28% at 1, 3, 6, 12, and 24 months after surgery, respectively. Applying less strict definitions, at 24 months, 68% of patients reported no pad use and 90% of patients reported no pad use or the use of a security pad. When stratified by baseline LFPF status, patients not LFPF at baseline had higher baseline international prostate symptom score scores, lower urinary function scores, lower urinary bother scores, and larger prostate weights. Patients LFPF at baseline disproportionately regained LFPF continence starting 6 months after surgery compared with those not LFPF at baseline: 20% vs 9% (P = .005), 27% vs 15% (P = .0009), and 33% vs 15% (P = .0146) at 6, 12, and 24 months, respectively. Conclusions: A strict definition of urinary continence results in more conservative postoperative outcomes. Preoperative LFPF status can be predictive of postoperative LFPF continence. However, only one-third of patients LFPF at baseline returned to LFPF at 24 months. © 2010 Elsevier Inc. All rights reserved.
“The case for open radical prostatectomy.”
Schaeffer, E. M., S. Loeb, et al. (2010).
Urol Clin North Am 37(1): 49-55, Table of Contents.
Radical prostatectomy is the gold standard surgical treatment for clinically localized prostate cancer. Over the years, many different approaches to surgical removal of the prostate have been described. Today, the most common techniques are open radical retropubic prostatectomy and robotic-assisted laparoscopic radical prostatectomy. Although there are many differences between the 2 approaches, the common goal is to optimize oncologic and functional outcomes. This article highlights the background, techniques, and outcomes of open and robotic prostatectomy.
“Robot assisted laparoscopic prostatectomy: Initial tips and tricks.”
Van Der Poel, H. G., E. Van Muilekom, et al. (2009).
Minerva Urologica e Nefrologica 61(4): 351-361.
Robot assisted laparoscopic prostatectomy (RALP) has become a widely accepted and applied surgical method of localized prostate cancer treatment Initial studies suggest a shorter learning curve for RALP when compared to conventional laparoscopic prostatectomy. Although dexterity for the RALP procedure is increased by the da Vinci surgical robotic system compared to laparoscopic approaches, the anatomical and technical approaches to prostatectomy still require considerable experience in anatomical variations to become proficient and improve oncological and surgical approaches. Several aspects with respect to that can be recognized in the early phases of training. The following aspects helped the author in his initial 150 cases to improve surgical skills: use intraoperative transrectal ultrasound for bladder neck recognition, record and review surgical procedures, experiment with port positioning, training of table assistance. The more recent da Vinci surgical robot systems allow for new dimensions in surgical approaches with particular intraoperative imav ging modalities not earlier so easy accessible during surgery. These properties render robot procedures appealing for the now-a-days more and more image-guided approach to surgery.
“Pathologic analysis of capsular and incisional denudation and positive margin status in the development of a robot-assisted laparoscopic prostatectomy program.”
Williams, S. B., D. E. Sutherland, et al. (2009).
Journal of Robotic Surgery 3(3): 137-140.
The aim of this study is to explore the use of pathologically confirmed capsular incision and denudation as a measure of adequacy of extirpation following robot-assisted laparoscopic prostatectomy (RALP). All patients who underwent RALP at the George Washington University Medical Center during the first 2 years of inception of the robotic prostatectomy program were included. All pathologic specimens were reviewed by a single pathologist. One hundred twenty-eight men who underwent RALP during the first 2 years were identified. Sixty-four patients underwent RALP during the first year (group 1) and all pathologic specimens were reviewed retrospectively. Sixty-four patients underwent RALP during the second year (group 2) after revision of our operative technique and all pathologic specimens were reviewed prospectively. Of patients in group 1, 18 (28%) had a positive surgical margin (PSM), and 18 (28%) with negative surgical margins were found to have capsular incision or denudation. In group 1, 32 (50%) patients had evidence of iatrogenic capsular violation. Group 2 consisted of 13 (20%) patients with a PSM and 9 (14%) margin-negative patients with capsular incision or denudation. Group 2 had a total of 22 (34%) patients with evidence of iatrogenic capsular violation. Overall reduction in positive margins was not statistically significant between the groups. Improvement in capsular incision/denudation rate and overall capsular violation between the two groups was statistically significant (P < 0.03 and < 0.0055). Surgical margin status alone underestimates the overall quality of surgical resection after RALP because not all capsular violations result in a PSM. Surgeon-guided pathologic review in addition to intraoperative experience may improve oncologic success during the RALP learning curve. © Springer-Verlag London Ltd 2009.
“Laparoscopic radical prostatectomy via single incision in treatment of early localized prostate cancer: A report of 5 cases.”
Xu, D. F., Y. Gao, et al. (2010).
Academic Journal of Second Military Medical University 31(1): 63-65.
Objective: To summarize our experience on laparoscopic radical prostatectomy via single incision in treatment of early localized prostate cancer. Methods: From June 2009 to August 2009, five patients with localized prostate cancer(T1c) received laparoscopic radical prostatectomy via single incision. A home-made multichannel port was inserted extraperitoneally through a 3 cm incision under the umbilicus. A 10 mm TROCAR and two 5 mm TROCAR were inserted. The prostate was isolated and excised, then the bladder urethral anastomosis was performed. Results The procedures were successful in all the five cases with no transversion to open or standard laparoscopic approach. The mean operating time, the mean operative time for prostate excision, and the mean time for urethrovesical anastomosis were (167±31. 5) min(ranging 135-210 min), (115±26) min (ranging 90-150 min), and (52±5. 7) min(ranging 45-60 min), respectively. The estimated blood loss averaged (90±62) ml (ranging 50-200 ml). Positive margin occurred in one case. Transient incontinence occurred in two cases after the catheter was removed one week later. All patients had a prostate-special antigen level < 0. 2 μg/L during a follow-up of 4-12 weeks. Conclusion: Laparoscopic radical prostatectomy via single incision is feasible and safety. Excellent instruments and skilled surgeon are the keys for the success of the operation.
“Intrafascial Nerve-Sparing Radical Prostatectomy with a Laparoscopic Robot-Assisted Extraperitoneal Approach: Early Oncological and Functional Results.”
Xylinas, E., G. Ploussard, et al. (2010).
Abstract Objective: We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. Methods: From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. Results: The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. Conclusions: An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.
“Extended Pelvic Lymph Node Dissection in Robotic-assisted Radical Prostatectomy: Surgical Technique and Initial Experience.”
Yee, D. S., D. J. Katz, et al. (2010).
OBJECTIVES: To describe, and show in the accompanying video segments, a technique for extended pelvic lymph node dissection (ePLND) in robotic-assisted radical prostatectomy (RARP) and report our clinicopathologic and perioperative outcomes. The extent of pelvic lymphadenectomy during radical prostatectomy has not been standardized. However, evidence demonstrates that an ePLND yields a greater number of positive nodes. METHODS: A total of 32 patients with clinically localized prostate cancer underwent RARP with ePLND by a single surgeon (J.C.) between January and August 2008. The template for the ePLND included the obturator, hypogastric, external iliac, and common iliac lymph nodes up to the bifurcation of the aorta. Systematic review and grading of adverse events were performed. RESULTS: The median number of lymph nodes retrieved was 18 (interquartile range [IQR] 12-28). Four patients (12.5%) had lymph node metastases. Of the 4 patients with lymph node metastases, 1 patient (25%) had the involved lymph node exclusively in the common iliac region. Median operative time for the ePLND was 72 minutes (IQR 66-86). Median hospital length of stay was 2.0 days (IQR 2.0-2.8). Graded complications included 13 grade 1 events and 1 grade 2 event, with 1 grade 1 event being considered related to ePLND. No clinically presenting lymphoceles or thrombotic events were encountered. CONCLUSIONS: An ePLND during RARP is technically feasible and appears to have minimal morbidity. It produces a high lymph node yield and may result in improved pathologic staging.