Abstrakt URO Březen 2010 | Česká společnost robotické chirurgie ČLS JEP

“Robot-assisted laparoscopic cystoprostatectomy with extended pelvic lymphadenectomy, extracorporeal enterocystoplasty, and intracorporeal enterourethral anastomosis: initial Montsouris experience.”

Kasraeian, A., E. Barret, et al. (2010).

Journal of Endourology 24(3): 409-413.

BACKGROUND AND PURPOSE: Radical cystectomy is the gold standard for management of invasive and recurrent high-grade superficial bladder cancer. We present our initial experience with robot-assisted laparoscopic cystoprostatectomy (RALCP) with extended pelvic lymphadenectomy (epLAD) and intracorporeal enterourethral anastomosis (IEUA). A video demonstrating our technique is available online at www.liebertonline.com/end. PATIENTS AND METHODS: Between April 2008 and March 2009, nine patients underwent RALCP with epLAD and IEUA at our institution. Operative technique, as described in detail (with video), was assessed for feasibility. A video demonstrating this technique is available online at www.liebertonline.com/end. Preoperative patient characteristics, operative data, as well as perioperative and pathologic outcomes were analyzed. All data were collected prospectively. RESULTS: Median total operative time was 270 minutes (range 210-330): 60 minutes, bilateral epLAD; 90 minutes, RALCP; 60 minutes, open enterocystoplasty; 60 minutes (range 45-90), IEUA. Median blood loss was 400 mL (range 200-900 mL). All surgical margins were negative. Median number of lymph nodes removed was 11 (range 4-21). Postoperative complications were noted in three patients and included urinoma (n = 1), pyelonephritis (n = 1), and hematoma (n = 1). CONCLUSION: RALCP is feasible and can be performed safely and effectively with acceptable operative, pathologic, and short-term clinical outcomes. More experience with longer follow-up is necessary to further assess clinical and oncologic outcomes of robotic assisted laparoscopic cystectomy for treatment of bladder cancer.

“Perianesthetic management of the first robotic partial cystectomy in bladder pheochromocytoma. A case report.”

Pandey, R., R. Garg, et al. (2010).

Minerva Anestesiologica 76(4): 294-297.

The authors report the perianesthetic considerations of a rare case of pheochromocytoma of the urinary bladder for which the first reported robotic partial cystectomy and ureteric reimplantation were performed. A 59-year-old male patient, known to be hypertensive, was posted for transurethral resection of a bladder tumor. In the operation room, after attaching the monitors, a subarachnoid block was given. Upon manipulation of the tumor, the blood pressure and heart rate increased markedly. A pheochromocytoma was suspected and was later confirmed by raised urine catecholamine levels and meta-iodobenzyl-guanidine scan. The patient was started on tablet prazosin and atenolol. After optimization, a robotic partial cystectomy was planned. In the operating room, an epidural catheter and a radial artery cannula were inserted. After the induction of anesthesia and the securing of the airway, surgery was started. After the insertion of the verres needle, pneumoperitoneum was created very slowly, and then the patient was positioned in 40 degrees Trendelenburg. Surges in arterial blood pressure (ABP) were managed with titrated doses of sodium nitroprusside and nitroglycerine and boluses of esmolol and labetalol. ABP drops postoperatively were managed with fluid and dopamine infusion. Robotic surgery is a safe alternative to the open technique for pheochromocytoma of the urinary bladder. Care should be taken during the positioning of the patient for robot placement and during pneumoperitoneum creation.

“Robot Assisted Laparoscopic Pelvic Lymphadenectomy at the Time of Radical Cystectomy Rivals That of Open Surgery: Single Institution Report.”

Richards, K. A., A. K. Hemal, et al. (2010).

Urology.

OBJECTIVE: The purpose of this study was to analyze the pelvic lymph node dissection (PLND) and margin status using a standard technique in the first 35 patients undergoing robot-assisted radical cystectomy (RARC) at our institution while establishing a robotics program, and then to compare the results to the past 35 open radical cystectomy (ORC) performed at our institution. MATERIALS AND METHODS: After obtaining institutional review board approval, we reviewed the clinical and pathologic data from 70 consecutive patients with clinically localized bladder cancer who underwent radical cystectomy with PLND from April 2007 to June 2009. Thirty-five operations were performed open and 35 used the da Vinci robotic system. The PLND was performed in all patients using the same template. RESULTS: There was no significant difference between the ORC and RARC group in regards to patient characteristics, tumor stage (43% ORC and 40% RARC having pT3/pT4 disease), and node status (29% N+ in each group). The median total lymph node yield was similar, with 15 (interquartile range [IQR] 11, 22) in the ORC group and 16 (IQR 11, 24) in the RARC group (P = 0.5). One patient who underwent RARC had a positive margin compared with 3 patients in the ORC group. CONCLUSIONS: The initial 35 RARC with PLND performed at our institution compared with the last 35 ORC resulted in equivalent lymph node yield and similar rates of positive margins. RARC with PLND is feasible, safe, and effective when performed at a high-volume center by an experienced team.

“A Review: The Application of Minimally Invasive Surgery to Pediatric Urology: Lower Urinary Tract Reconstructive Procedures.”

Traxel, E. J., E. A. Minevich, et al. (2010).

Urology.

This paper is one-half of a 2 part review on minimally-invasive procedures in pediatric urology. This article focuses on lower tract procedures, including ureteroureterostomy, anti-reflux surgeries, creation of continent catheterizable channels, and augmentation cystoplasty. We note important articles on pure laparoscopic as well as robotic-assisted laparoscopic lower urinary tract surgeries, concentrating on their techniques and outcomes.

“Robotic Partial Nephrectomy: New Beginnings.”

Brandina, R. and I. S. Gill

European Urology.

“Functional outcomes after pure laparoscopic or robot-assisted pyeloplasty.”

Ferhi, K., M. Rouprêt, et al. (2009).

Resultados funcionales de la pieloplastia laparoscópica pura y asistida por robot 33(10): 1103-1107.

The management of ureteropelvic junction obstruction (UPJ) has evolved over the past 20 years in response to development of new technology. Open surgery continues to be the reference standard so far, against which all other surgical modifications must be measured. The surgical approach has, however, gone through rapid changes, and the open procedure initially described has evolved considerably in the last two decades. Endoscopic and laparoscopic approaches have largely supplanted open pyeloplasty for the majority of primary ureteropelvic junction obstruction cases. Laparoscopic approaches provide a balance between a highly successful technique in all patients and improved postoperative recovery. It has been shown to improve postoperative outcomes with shorter recovery times and hospital stays and to provide equivalent functional results with a success rate of 95%. Nevertheless, laparoscopic pyeloplasty is not a simple procedure. There is certain number of disadvantages such as limited range of laparoscopic instrument movement, the two dimensional image, the unfamiliar hand-eye coordination and the relatively inefficient ergonomic position. From 2000, the robot has offered a magnified three-dimensional vision associated with a greater degree of freedom. This system has simplified suturing and has improved precision of the operative technique. Despite the financial cost, it seems easier for beginners to learn the robotic technique if the system is available in their institution, presenting similar success rates (radiological and clinical) to those obtained with open techniques. © 2009 AEU.

“Progression from laparoscopic to robotic renal surgery: The next frontier.”

Ghani, K. R., A. Mottrie, et al. (2010).

BJU International 105(7): 902-904.

“Novel Use of the Gelport to Expedite Transition to Robot-Assisted Partial Nephrectomy.”

Kalra, P., J. E. Leech, et al. (2010).

Journal of Endourology.

Abstract Robot-assisted partial nephrectomy is associated with a learning curve, necessitating proficiency in robotic renal dissection, hilar control, and subsequent mass excision and renorrhaphy. The Gelport can be used during these procedures to expedite initial control of the renal pedicle and to add to the surgeon’s comfort level while transitioning to this procedure.

“The minimally invasive management of ureteropelvic junction obstruction in horseshoe kidneys.”

Lallas, C. D., R. W. Pak, et al. (2010).

World Journal of Urology.

PURPOSE: Data regarding the treatment of ureteropelvic junction obstruction (UPJO) in horseshoe kidneys are limited. We performed a retrospective analysis of our experience with minimally invasive treatment of UPJO in patients with this anomaly. METHODS: Between March of 1996 and March 2008, 9 patients with horseshoe kidneys were treated for UPJO at our institution. Of these patients, 6 were managed with retrograde endopyelotomy, 2 with laparoscopic pyeloplasty, and one by robotic pyeloplasty. Outcomes of these procedures were retrospectively reviewed. RESULTS: A total of nine patients were available for analysis. Four of six patients who underwent endopyelotomy had available follow-up, with a mean of 56 months. The success rate for these patients was 75%. Two of three patients (67%) in the laparoscopic/robotic cohort were successfully treated with a mean follow-up of 21 months. CONCLUSIONS: UPJO in horseshoe kidneys can pose a therapeutic dilemma. The minimally invasive treatment of these patients is feasible with good success rates for both endopyelotomy and laparoscopic/robotic pyeloplasty.

“Robot-assisted laparoscopic partial nephrectomy: Current review of the technique and literature.”

Singh, I. (2009).

Journal of Minimal Access Surgery 5(4): 87-92.

Aim: To visit the operative technique and to review the current published English literature on the technique, and outcomes following robot-assisted laparoscopic partial nephrectomy (RPN). Materials and Methods: We searched the published English literature and the PubMed(TM) for published series of ′robotic partial nephrectomy′ (RPN) using the keywords; robot, robot-assisted laparoscopic partial nephrectomy, laparoscopic partial nephrectomy, partial nephrectomy and laparoscopic surgery. Results: The search yielded 15 major selected series of ′robotic partial nephrectomy′; these were reviewed, tracked and analysed in order to determine the current status and role of RPN in the management of early renal neoplasm(s), as a minimally invasive surgical alternative to open partial nephrectomy. A review of the initial peri-operative outcome of the 350 cases of select series of RPN reported in published English literature revealed a mean operating time, warm ischemia time, estimated blood loss and hospital stay, of 191 minutes, 25 minutes, 162 ml and 2.95 days, respectively. The overall computed mean complication rate of RPN in the present select series was about 7.4%. Conclusions: RPN is a safe, feasible and effective minimally invasive surgical alternative to laparoscopic partial nephrectomy for early stage (T1 ) renal neoplasm(s). It has acceptable initial renal functional outcomes without the increased risk of major complications in experienced hands. Prospective randomised, controlled, comparative clinical trials with laparoscopic partial nephrectomy (LPN) are the need of the day. While the initial oncological outcomes of RPN appear to be favourable, long-term data is awaited.

“Radiofrequency ablation-assisted robotic laparoscopic partial nephrectomy without renal hilar vessel clamping versus laparoscopic partial nephrectomy: a comparison of perioperative outcomes.”

Wu, S. D., D. P. Viprakasit, et al. (2010).

Journal of Endourology 24(3): 385-391.

OBJECTIVES: Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy (LPN) may allow for improved hemostasis without need for renal hilar vessel clamping and elimination of warm ischemia to the kidney. We compare outcomes in patients undergoing radiofrequency ablation-assisted robotic clampless partial nephrectomy (RF-RCPN) and LPN. METHODS: Thirty-six patients and 42 patients underwent LPN and RF-RCPN, respectively. In the RF-RCPN group, the Habib 4x RFA device was used to coagulate a margin of normal parenchyma around the renal mass to allow excision of the mass within a bloodless plane. Unlike in the LPN group, renal hilar vascular occlusion was not performed in the RF-RCPN group. RESULTS: Tumors treated in the RF-RCPN group tended to be larger (2.8 vs. 2.0 cm) and more often endophytic (52.6% vs. 16.1%). Collecting system reconstruction occurred more often in the RF-RCPN group (78.6% vs. 30.6%). Operative duration was longer in the RF-RCPN group (373 vs. 250 minutes), but this included time for cystoscopy, ureteral stenting, and repositioning of the patient. Blood loss, transfusion rates, renal function, and complication rates did not differ between the two groups. No patients required renal hilar vessel clamping or nephrectomy to control bleeding in the RF-RCPN group. CONCLUSIONS: The use of RFA-assistance during robotic partial nephrectomy allows excision of renal tumors without hilar vascular clamping, thus eliminating renal warm ischemia. Larger and more centrally located tumors were excised with RF-RCPN. No differences in blood loss, complication rate, postoperative bleeding, renal function, or recurrence rate were noted compared with LPN.

“Endopyelotomy in the Age of Laparoscopic and Robotic-Assisted Pyeloplasty.”

Yong, D. and D. M. Albala (2010).

Current Urology Reports: 1-6.

Ureteropelvic junction obstructixon (UPJO) management has undergone significant changes in the past few years. The aim of this review is to establish the role of endopyelotomy in the age of laparoscopic and robot-assisted laparoscopic pyeloplasty (RALP). Open pyeloplasty (OP) has been the gold standard of care for UPJO for the past six decades. Due to lower long-term efficacy, endopyelotomy has failed to replace OP. However, laparoscopic pyeloplasty (LP) has been able to reproduce the high success rates of OP, while also achieving minimal morbidity. Unfortunately, the steep learning curve and technical difficulties have hindered its use. Recently, robot-assisted systems have enabled LP to overcome its disadvantages, and this may render endopyelotomy obsolete. Although LP and RALP are emerging as the gold standard of treatment for UPJO, endopyelotomy could carve out a niche area as a salvage procedure. Endopyelotomy will continue to have a role in the management of UPJO, albeit a smaller one. © 2010 Springer Science+Business Media, LLC.

“Early Experience of Robotic-Assisted Reconstructive Operations in Pediatric Urology.”

Chan, K. W., K. H. Lee, et al. (2010).

Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A.

Abstract Objectives: Laparoscopic pyeloplasty and ureteric reimplantation are complex urologic operations requiring delicate surgical skill. The use of a robot may provide benefits in performing these reconstructive operations. In this article, we report our early experience in the use of the robot in pediatric urologic operations. Methods: Children who underwent robotic-assisted reconstructive urologic operations were reviewed and analyzed. Results: From November 2005 to April 2008, 8 children underwent robotic-assisted reconstructive urologic operations. Three children had extravesical ureteral reimplantation performed for vesicoureteric reflux (VUR), and 5 children had pyeloplasty performed for pelvic-ureteric junction obstruction. There was no conversion to open procedure and no intraoperative complication. The operative time ranged from 105 to 420 minutes (mean, 219). Postoperatively, 1 patient had urinary retention and 1 patient had postoperative fever. Hospital stay ranged from 3 to 10 days (mean, 4.8). Mean follow-up time was 38 months (range, 17-46). VURs were resolved for the 2 children with simple VUR and was downgraded for the child with duplex kidney. All patients who underwent pyeloplasty showed satisfactory urinary drainage after the operation. Conclusions: From this early experience, robotic-assisted urologic operations in children were safe and feasible. It was particularly useful in reconstructive operations that required precise suturing, such as ureteric reimplantation and pyeloplasty.

“Robot-assisted laparoscopic extended right hepatectomy with biliary reconstruction.”

Giulianotti, P. C., F. Sbrana, et al. (2010).

Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A 20(2): 159-163.

Robotic surgery represents one of the most advanced developments in the field of minimally invasive surgery. In this article, we describe the case of an extended right hepatectomy with a left hepaticojejunostomy performed for radical resection of a hilar cholangiocarcinoma. This operation was performed by using the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). In this case, the operative time was 540 minutes, with an intraoperative blood loss of 800 mL. The postoperative course was uneventful, and the patient was discharged at postoperative day 11. This report confirms the technical feasibility and safety of robot-assisted extended hepatic resections with biliary reconstruction. Further experience and a long follow-up are required to validate this initial report.

“Residency Training Program Paradigms for Teaching Robotic Surgical Skills to Urology Residents.”

Grover, S., G. Y. Tan, et al. (2010).

Current Urology Reports: 1-6.

The advent of laparoscopic and robotic techniques for management of urologic malignancies marked the beginning of an ever-expanding array of minimally invasive options available to cancer patients. With the popularity of these treatment modalities, there is a growing need for trained surgical oncologists who not only have a deep understanding of the disease process and adept surgical skills, but also show technical mastery in operating the equipment used to perform these techniques. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution, as it involves a huge cost, especially in the purchasing and maintenance of the robot. Residency programs often face many challenges when trying to establish a balance between costs associated with robotic surgery and training of the urology residents, while maintaining an acceptable operative time. Herein we describe residency training program paradigms for teaching robotic surgical skills to urology residents. Our proposed paradigm outlines the approach to compensate for the cost involved in robotic training establishment without compromising the quality of education provided. With the potential advantages for both patients and surgeons, we contemplate that robotic-assisted surgery may become an integral component of residency training programs in the future. © 2010 Springer Science+Business Media, LLC.

“Current trends in pediatric minimally invasive urologic surgery.”

Lee, D. J., P. H. Kim, et al. (2010).

Korean Journal of Urology 51(2): 80-87.

Over the past two decades, laparoscopic and robotic surgery in children has been described as a viable minimally invasive alternative to open surgery for many pediatric urologic conditions. With the goal of reducing the morbidity associated with open surgery, minimally invasive surgery in children is increasingly being performed as laparoscopic and robotic patients appear to be experiencing shorter hospital stays, decreased pain medication requirements, and the potential for improved cosmesis. This article provides an overview of the existing literature in laparoscopic and robotic-assisted laparoscopic urologic surgery in children. Laparoscopic and robotic-assisted laparoscopic surgery appears to be safe and effective in children for a wide range of ablative and reconstructive procedures. Conventional laparoscopic surgery is effective for ablative procedures, while robotic surgery may be ideally suited for reconstructive cases requiring advanced suturing and dissection. Overall, more prospective studies are needed to study the long-term outcomes of minimally invasive surgery in pediatric patients, and the appropriate use of the available technology. © The Korean Urological Association, 2010.

“Image-guided surgery in minimally invasive urology.”

Ukimura, O. (2010).

Current Opinion in Urology 20(2): 136-140.

PURPOSE OF REVIEW: Image-guided surgery (IGS) is a new type of surgery in which indirect visualization of the surgical anatomy helps the surgeon to enable minimally invasive percutaneous, laparoscopic, or robotic-aided treatment more precisely and safely, to achieve complete tumor removal and sparing of the function of critical organs. RECENT FINDINGS: Although 2D ultrasonography has played a main role as conventional intraoperative image guidance, image-fusion system of ultrasonography with computed tomography (CT) or MRI, 3D ultrasonography imaging, MRI-compatible navigation system, and image-overlay technology of augmented reality navigation system have emerged with computer aid. Development of augmented reality in soft tissue navigation is challenging, especially in tracking of organ motion and deformation. In IGS, the surgeon may see any angled tomogram of the patient’s body, or 3D anatomies beyond the direct vision. IGS would not only provide the delivery of energy or medicines to the therapeutic target, but also monitor the precision and effectiveness of the treatment. SUMMARY: Emerging imaging technology gives surgeons a new powerful opportunity to realize where surgical pathological targets and vital healthy anatomies are located beyond the surgeon’s direct vision.

“Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival.”

Barocas, D. A., S. Salem, et al. (2010).

Journal of Urology 183(3): 990-996.

PURPOSE: We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution. MATERIALS AND METHODS: A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence. RESULTS: There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not. CONCLUSIONS: The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed.

“Simplifying patient positioning and port placement during robotic-assisted laparoscopic prostatectomy.”

Cestari, A., N. M. Buffi, et al. (2010).

European Urology 57(3): 530-533.

Proper patient positioning and port placement is of critical importance in robotic-assisted laparoscopic radical prostatectomy (RALP). Not having the patient in the correct Trendelenburg position or not being able to move the surgical instruments freely in the abdominal cavity can be frustrating, especially for naive robotic surgeons (ie, those at the beginning of the learning curve for this procedure), and can lead to further difficulties in performing the intervention. We describe the use of a nautical inclinometer and a plastic, double-equilateral triangle with an 8-cm-long border to reach the correct Trendelenburg position easily and to place trocars correctly during RALP.

“Radical prostatectomy: Respective roles and comparisons of robotic and open surgeries.”

Choi, Y. D. and J. S. Chung (2010).

Journal of the Korean Medical Association 53(2): 119-125.

Over the years, several surgical modifications have been incorporated into radical prostatectomy in order to improve the surgical outcome. Despite the rapid dissemination of robot-assisted laparoscopic prostatectomy (RALP) through the urologic community, comparative studies on the practicality of RALP compared to open radical prostatectomy (OP) are lacking. Thus, it remains difficult to draw any conclusions regarding cancer control and postoperative morbidity. This review will introduce the evolution of surgical technique and the current status of RALP in relation to OP in the management of localized prostate cancer focusing on the perioperative, oncological and functional outcomes. Based on the review of literatures, perioperative outcomes, such as blood loss, transfusion rates, hospitalization duration and complication rates, all favored RALP. The positive surgical margin rates of RALP were similar to those of OP with regard to the oncological outcomes. With regard to the functional outcomes, OP and RALP also showed similar continence and potency rates. However, refinements in technique employed during RALP have improved the early return of continence postoperatively. Although OP remains the gold standard treatment in localized prostate cancer, robotic surgery and continued technical advancements will ultimately improve patient outcomes. However, further prospective randomized comparative clinical trials with a long-term follow-up utilizing validated questionnaire are needed to prove the superiority of either surgical approach in terms of functional and oncological outcomes. In addition, RALP technique will need a substantial decrease in the cost of the robotic system to achieve wider global acceptance and application.

“Oncologic, Functional, and Cost Analysis of Open, Laparoscopic, and Robotic Radical Prostatectomy.”Djavan, B., E. Eckersberger, et al.

European Urology, Supplements.

Context: Although open radical retropubic prostatectomy (ORRP) remains the gold standard, the past years have seen a rise in both laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP), and many patients seem to prefer the so-called minimally invasive procedures despite insufficient data demonstrating superiority over the established standard (ORRP). Objective: This article seeks to review the most recent data on a variety of aspects of the different techniques for performing prostatectomies, such as cost, oncologic outcomes, continence, quality of life, and marketing and propaganda as well as the learning curve for each. Evidence acquisition: A search of the most recent literature was performed using PubMed, and data from lectures and presentations given at international conferences were used. Evidence synthesis: The review showed that, overall, LRP and RARP outcomes have not proved superior to ORRP outcomes or resulted in anticipated benefits to patients. In addition, current data seem to suggest that results of any of the procedures depend more on the surgeon’s ability than on the approach, with rates of blood loss, positive surgical margins, incontinence, and erectile dysfunction varying widely from surgeon to surgeon with all three techniques. The aggressive marketing associated with RARP has also led to significantly higher rates of dissatisfaction and regret in patients. Conclusions: Considering the evidence, ORRP remains the gold standard in radical prostatectomies. Moreover, although the differences among major outcomes are minor and associated with shorter lengths of stay, the costs associated with LRP and RARP are significantly higher than with ORRP. In the absence of solid scientific evidence, patient education, and counselling are crucial parts of the decision-making process, during which patients will opt for one treatment over another. © 2010 European Association of Urology.

“Radical prostatectomy: Does surgical technique influence margin control?”

Gettman, M. T. and M. L. Blute (2010).

Urologic Oncology: Seminars and Original Investigations 28(2): 219-225.

The goal of radical prostatectomy (RP) is complete removal of the prostate and seminal vesicles with negative surgical margins. Regardless of approach, the occurrence of positive surgical margins (PSMs) remains a risk associated with RP. In addition, PSMs can adversely affect biochemical and cause-specific survival. With the advent of PSA screening and introduction of new RP approaches, surgical technique has become increasingly debated in relationship to margin positivity. The issue, however, is controversial, as underlying clinical and pathologic characteristics of prostate cancer also influence margin control. This article evaluates the impact of surgical technique on margin control during RP. In addition, we evaluate the influence that stage migration, the individual surgeon, new technologic adjuncts, and specimen handling have had on margin control. © 2010 Elsevier Inc. All rights reserved.

“Urethral catheter-less robotic-assisted radical prostatectomy.”

Haute, W. V. and P. Dasgupta (2010).

BJU International.

“Robot-assisted laparoscopic radical prostatectomy in the Asian population: Modified port configuration and ultradissection: Procedure.”

Jeong, W., M. Araki, et al. (2010).

International Journal of Urology 17(3): 297-300.

We have carried out over 360 cases of robot-assisted laparoscopic radical prostatectomy (RARP) to date. In the present study, we detail our current technique at Yonsei University College of Medicine. The six-port transperitoneal approach is utilized. The most lateral two ports were placed medially and caudally in patients with a small pelvis to avoid interference between the ports and the pelvis (modified port configuration). Lymph node dissection is carried out in the external iliac, obturator and infraobturator area. The dissection on the lateral border of the bladder neck is carried out until it reaches the seminal vesicle (ultradissection). After transection of the bladder neck, vasa seminal vesicles are dissected further. Neurovascular bundles are preserved in selected patients. The dorsal venous complex (DVC) and the urethra are transected without suturing. Urethrovesical anastomosis is carried out with 3-0 monocryl running suture, incorporating with the edge of DVC. The puboprostatic collar and bladder are incorporated by 3-0 monocryl running suture (puboperineoplasty). Between November 2007 and September 2008, RARP was carried out using this technique in 182 patients. Median height, weight, body mass index and prostate-specific antigen (PSA) were 168 cm, 68 kg, 24 kg/M2 and 7.1 ng/mL, respectively. Mean operative time was 192 min and average blood loss was 250 mL. Median catheterization time was 8 days. Positive surgical margin rates for pT2, pT3 and pT4 disease was 12.7, 48 and 100%, respectively. Intraoperative complication rate was 2.7%. Fifty-five patients completed a minimum of 10 months follow up. Their continence rate was 91%. RARP is a safe and feasible surgical modality for prostate cancer among Asian patients with a small pelvis. Our technique achieves a precise bladder neck dissection. © 2010 The Japanese Urological Association.

Kasraeian, A., E. Barret, et al. (2010).

Journal of Endourology 24(3): 409-413.

“Malfunction of the da Vinci Robotic System During Robot-Assisted Laparoscopic Prostatectomy: An International Survey.”

Kaushik, D., R. High, et al. (2010).

Journal of Endourology.

Abstract Purpose: To determine how urologists manage technical malfunction of the Da Vinci robotic system during robot-assisted radical prostatectomy (RARP). Materials and Methods: A web-based survey was sent to urologists performing RARP. The survey questions were related to the stage of operation during which robotic malfunction occurred, management of malfunctions, and most common types of robotic malfunction. In addition, data were collected concerning surgical volume and training. Results: One hundred (56.8%) of the 176 responding surgeons had experienced an irrecoverable intraoperative malfunction. Eighty respondents experienced mechanical failure before starting RARP, of which 46 (57.5%) rescheduled, 15 (18.8%) performed an open radical approach, 12 (15%) performed standard laparoscopic prostatectomy, and 4 (4.9%) docked another robot. Sixty-three respondents experienced mechanical failure before starting urethrovesical anastomosis, of which 26 (41.2%) converted to an open procedure, 20 (31.7%) converted to standard laparoscopy, 10 (15.8%) finished with one less arm, and 3 (4.7%) aborted the procedure. Thirty-two respondents experienced malfunction before completion of the anastomosis, of which 20 (62.5%) converted to standard laparoscopy, while 12 (37.5%) converted to open surgery. Fellowship trained surgeons were more likely to complete the prostatectomy using standard laparoscopy (P = 0.05). No significant differences existed between surgeons performing a high volume or low volume of prostatectomies in regard to management of malfunctions. Conclusion: Intraoperative breakdown of the Da Vinci robot is uncommon, but patients should be counseled preoperatively and a plan devised on how breakdown will be managed. Intracorporeal suturing skills allow conversion to a pure laparoscopic approach, if necessary. Consequently, standard laparoscopic suturing skills should remain in the residency curriculum.

“You can’t resist the charms of the robot.”

Kirby, R. S. (2010).

BJU International 105(5): 582.

“Rapid implementation of a robot-assisted prostatectomy program in a large health maintenance organization setting.”

Kwon, E. O., T. C. Bautista, et al. (2010).

Journal of Endourology 24(3): 461-465.

PURPOSE: We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States. MATERIALS AND METHODS: A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes. RESULTS: A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined. CONCLUSIONS: We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.

“Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious.”

Lavery, H. J., F. Nabizada-Pace, et al.

Urologic Oncology: Seminars and Original Investigations.

Objective: Given the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D’Amico risk group classification, and stratified by nerve-sparing status. Materials and methods: An institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes. Results: Adequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The “trifecta” of continence, potency, and freedom from recurrence was achieved in 28 patients (23%). Conclusions: Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts. © 2010 Elsevier Inc. All rights reserved.

“Benign prostate glands at the bladder neck margin in robotic vs open radical prostatectomy.”

Loeb, S., J. I. Epstein, et al. (2010).

BJU International.

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To compare the prevalence and extent of benign glands at the bladder neck (BN) margin in a large population undergoing open retropubic radical prostatectomy (RRP) and robotic-assisted laparoscopic RP (RALP), as RALP was previously suggested to be associated with a higher rate of benign glands at the surgical margin than RRP. PATIENTS AND METHODS From 2005 to 2008, 137 RRP and 152 RALP were performed by one surgeon. Pathology slides were re-reviewed while unaware of origin to examine the extent of benign glands at the BN margin (minimal, moderate, or extensive). Statistical analysis was used to assess the prevalence and extent of benign glands in the two procedures. RESULTS Benign prostatic glands were present at the margins in 89 (58.2%) RALP and 57 (41.6%) RRP specimens (P= 0.005). There were also a significantly greater extent of benign glands in RALP vs RRP (P= 0.031). After multivariate adjustment for prostate-specific antigen (PSA) level, clinical stage, and biopsy Gleason score, RALP maintained a significant association with both the presence (P= 0.019) and extent (P= 0.018) of benign glands at the BN. Two patients with organ-confined disease (no cancerous margins) with benign glands at the BN margin had an initially high postoperative PSA level. CONCLUSIONS Benign prostate glands were present at the BN margin in a greater proportion of RALP than RRP specimens, possibly due to differences in the surgical approach to BN dissection. Additional study is necessary to determine the long-term biological significance, if any, of these histological differences.

“Quality of Life After Open or Robotic Prostatectomy, Cryoablation or Brachytherapy for Localized Prostate Cancer.”

Malcolm, J. B., M. D. Fabrizio, et al. (2010).

Journal of Urology.

PURPOSE: Health related quality of life concerns factor prominently in prostate cancer management. We describe health related quality of life impact and recovery profiles of 4 commonly used operative treatments for localized prostate cancer. MATERIALS AND METHODS: Beginning in February 2000 all patients treated with open radical prostatectomy, robot assisted laparoscopic prostatectomy, brachytherapy or cryotherapy were asked to complete the UCLA-PCI questionnaire before treatment, and at 3, 6, 12, 18, 24, 30 and 36 months after treatment. Outcomes were compared across treatment types with statistical analysis using univariate and multivariate models. RESULTS: A total of 785 patients treated between February 2000 and December 2008 were included in the analysis with a mean followup of 24 months. All health related quality of life domains were adversely affected by all treatments and recovery profiles varied significantly by treatment type. Overall urinary function and bother outcomes scored significantly higher after brachytherapy and cryotherapy compared to open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. Brachytherapy and cryotherapy had a 3-fold higher rate of return to baseline urinary function compared to open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. Sexual function and bother scores were highest after brachytherapy, with a 5-fold higher rate of return to baseline function compared to cryotherapy, open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. All 4 treatments were associated with relatively transient and less pronounced impact on bowel function and bother. CONCLUSIONS: In a study of sequential health related quality of life assessments brachytherapy and cryotherapy were associated with higher urinary function and bother scores compared to open radical prostatectomy and da Vinci(R) prostatectomy. Brachytherapy was associated with higher sexual function and bother scores compared to open radical prostatectomy, robotic assisted laparoscopic radical prostatectomy and cryotherapy.

“Fusion of the seminal vesicles discovered at the time of robot-assisted laparoscopic radical prostatectomy.”

Méndez-Probst, C. E. and S. E. Pautler (2010).

Journal of Robotic Surgery: 1-3.

The reported incidence of seminal vesicle anomalies is low, and it usually occurs in association with other genitourinary anomalies, thus frequently diagnosed by a cluster of fertility, pain or obstructive symptoms. We present a case of a clinically silent seminal vesicle fusion encountered during a robotic assisted radical prostatectomy. Awareness of potential congenital anomalies is crucial for surgeons, to prevent surgical complications or adverse outcomes as a result of the altered anatomy. © 2010 Springer-Verlag London Ltd.

“Commentscomments the robotic revolution: The seduction continues.”

Nickel, J. C. (2010).

BJU International 105(5): 583.

“The Role of Laparoscopic Radical Prostatectomy in the Era of Robotic Surgery.”

Rassweiler, J., M. Hruza, et al.

European Urology, Supplements.

Context: In the United States, >70% of all radical prostatectomies are performed by use of the da Vinci robot. In Europe, laparoscopic radical prostatectomy (LRP) still plays a significant role. Objective: To evaluate the actual and future position of LRP based on the current literature and personal experience with robotic and laparoscopic radical prostatectomy. Evidence acquisition: PubMed and Medline were used to review the recent literature focusing on ergonomic aspects, marketing, and current functional and oncologic results of both procedures as well as of the open counterpart. Evidence synthesis: The advantages of robot-assisted laparoscopic prostatectomy (RALP) are mainly related to ergonomic aspects of the procedure, such as the sitting position of the surgeon and the clutch function that enables comfortable handling of the manipulators. Laparoscopic surgery would benefit from significant improvements in ergonomics, such as a chair for the surgeon, specially designed operating room tables, and ergonomically designed instrument handles. Future modifications of the laparoscopic technique, such as a single-port surgery (eg, laparoendoscopic single-site surgery [LESS]), may also have an impact on the application and use of LRP. Conclusions: RALP is here to stay mainly due to improved ergonomics resulting in a shorter learning curve. Ergonomics of laparoscopy require significant improvement, including the design of new operating room tables, supports for the surgeon with integrated foot pedals, mobile high-definition television monitors, and new instrument handles to minimise mental and physical stress. Implementing the latter to such new approaches as LESS will close the gap between robot-assisted and pure laparoscopic surgery. © 2010.

“Preventing Complications in Robotic Prostatic Surgery.”

Sanchez-Salas, R., V. Flamand, et al.

European Urology, Supplements.

Context: The urologic community has embraced robot-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) as a surgical therapeutic approach to localised prostate cancer (PCa). Safety, efficacy, and potential complications of RALP should be clearly known and emphasised in order to improve outcomes. Objective: To provide an overview of the prevention and reduction of complications in RALP to aid the understanding of the multivariable nature of a surgical procedure incorporating highly developed technology. Evidence acquisition: The present manuscript is based on a presentation on the prevention of complications in robotic prostatic surgery held at the European Association of Urology Section of Oncological Urology meeting in Vienna, Austria, in January 2010. The scope of this article is such that no attempt has been made to include all available evidence on the topic but rather a selection based on practical considerations. Experience with RALP gained at the Institut Montsouris is also reflected in the body of the manuscript. Evidence synthesis: Despite the lack of standardisation when talking about complications, RALP seems to be at least equivalent to laparoscopic radical prostatectomy, and recently, it appears to provide even better results. To prevent complications, RALP should be considered in its entirety from patient evaluation to postoperative care, not just the surgery itself. The surgeon remains the first actor, and no place is left for improvisation. Thus, every step of the procedure must be perfectly understood and mastered. One must remember that years of training stand behind these high levels of control and technique. Conclusions: Prevention and management of complications in RALP require a high level of team expertise. Perfect standardisation of the procedure and the communication of the procedure’s results are mandatory to lowering the incidence of complications and to facilitating its diffusion to the urologic community. © 2010.

“Robotic prostatectomy: hit or myth?”

Scardino, P. T. (2010).

Nat Rev Urol 7(3): 115.

“Robotic Radical Prostatectomy for Elderly Patients: Probability of Achieving Continence and Potency 1 Year After Surgery.”

Shikanov, S., V. Desai, et al. (2010).

Journal of Urology.

PURPOSE: We assessed the probability of achieving continence and potency after robotic radical prostatectomy in elderly patients. MATERIALS AND METHODS: The cohort included 1,436 robotic radical prostatectomy cases performed at our institution between 2003 and 2008. Continence (pad-free) and potency (erection sufficient for intercourse) at baseline and 1 year after surgery were evaluated by the UCLA-PCI questionnaire. Point estimates of the predicted probabilities of continence and potency for age 65, 70 and 75 years were calculated from multivariate logistic regression models adjusting for age, nerve sparing status, baseline International Prostate Symptom Score and baseline Sexual Health Inventory for Men score. Patients who were impotent before surgery or those who received hormones or radiation within 1 year after surgery were censored. RESULTS: Mean patient age was 60 years (range 38 to 85) with 25% older than 65 years and 77 (5%) 70 years old or older. Age (OR 0.97, p = 0.002), baseline I-PSS (OR 0.98, p = 0.02) and Sexual Health Inventory for Men scores (OR 1.02, p = 0.005) were independently associated with being pad-free. Age (OR 0.92, p <0.0001), baseline Sexual Health Inventory for Men score (OR 1.1, p <0.0001) and bilateral nerve sparing (OR 2.92, p <0.0001) were independently associated with achieving potency. Predicted probabilities (95% CI) of postoperative 1-year continence at age 65, 70 and 75 years were 0.66 (0.63, 0.69), 0.63 (0.57, 0.68) and 0.59 (0.52, 0.66), respectively. The corresponding probabilities of postoperative 1-year potency after bilateral nerve sparing were 0.66 (0.62, 0.71), 0.56 (0.49, 0.64) and 0.46 (0.36, 0.56). CONCLUSIONS: In our experience there is an acceptable probability of achieving continence and potency after robotic radical prostatectomy in selected elderly patients.

“Margin control in robotic and laparoscopic prostatectomy: what are the REAL outcomes?”

Weizer, A. Z., S. Strope, et al. (2010).

Urol Oncol 28(2): 210-214.

Our institutional experience and relevant literature on surgical margin rates with laparoscopic and robotic-assisted radical prostatectomy are summarized. Differences in surgical margins were assessed between patients undergoing open or robotic-assisted prostatectomy by experienced surgeons, and placed in context with a review of the literature. Surgical margins and location were similar between patients undergoing open or robotic prostatectomy. Pathologic stage, baseline prostate-specific antigen, and Gleason score all impacted the risk of a positive surgical margin. Experienced surgeons can achieve comparable outcomes in terms of surgical margins. Disease burden plays a significant role in positive surgical margins.

“Margin control in robotic and laparoscopic prostatectomy: What are the REAL outcomes?”

Weizer, A. Z., S. Strope, et al. (2010).

Urologic Oncology: Seminars and Original Investigations 28(2): 210-214.

“Radical Retropubic Prostatectomy and Robotic-assisted Laparoscopic Prostatectomy: Likelihood of Positive Surgical Margin(s).”

Williams, S. B., M. H. Chen, et al. (2010).

Urology.

OBJECTIVES: To evaluate whether the surgical approach influenced the likelihood of a positive surgical margin (PSM) adjusting for known preoperative predictors of PSM, year of radical prostatectomy, body mass index, use of nerve sparing, and patient age at radical prostatectomy. METHODS: The study cohort comprised 950 consecutively treated men with clinically localized prostate cancer who underwent open radical retropubic (RRP, n = 346) or robotic-assisted (RALP, N = 604) prostatectomy by a single surgeon (J.P.R., J.C.H.) at the Brigham and Women’s Hospital from 2005 to 2008 and had complete information on baseline patient and tumor characteristics. Univariate and multivariate logistic regression analyses were performed to identify clinical factors significantly associated with the likelihood of a PSM. RESULTS: Men undergoing RALP compared with RRP were more likely to have a PSM (adjusted odds ratio 1.9; 95% confidence interval: 1.2-3.1, P = .0095). Significant interaction (P = .0085) was noted between the type of surgical approach and whether nerve sparing was performed on the likelihood of a PSM. Specifically, a significantly lower PSM rate was observed for men undergoing nerve sparing and RRP compared with nerve sparing and RALP (7.6% vs 13.5%, P = .007), whereas opposite trend was noted (P = .09) for men undergoing a non-nerve-sparing approach. CONCLUSIONS: Men undergoing RALP compared with RRP seem to have a greater likelihood of a PSM. Further study is needed to delineate whether this increase is due to an intrinsic limitation of RALP or unknown confounders.