Abstrakt Urologie Březen 2009

“Robotic-assisted laparoscopic pelvic lymphadenectomy for bladder cancer: A surgical atlas.” Pruthi, R. S. and E. M. Wallen (2009).

Journal of Laparoendoscopic and Advanced Surgical Techniques 19(1): 71-74.

Introduction: Recently, robotic approaches to cystectomy have been reported. Lymphadenectomy remains an important diagnostic component of cystectomy. As with resection of the primary tumor, the use of new technologies must not compromise the oncological benefits of lymphadenectomy, We describe our approach to and results of robotic-assisted laparoscopic pelvic lymphadenectomy in cystectomy. Technique: We describe the technique of standard and extended pelvic lymph node dissection during robotic-assisted cystectomy. The classic da Vinci® or the da Vinci S? robotic platform is utilized for lymphadenectomy. Results: Twenty-eight patients underwent a standard dissection with a mean number of lymph nodes removed of 19 (range, 8-33). Extended lymph node dissection has been performed in 22 patients with a mean of 30 lymph nodes removed (range, 12-39). No surgical complications have occurred related to the lymphadenectomy. Conclusions: Robotic laparoscopic pelvic lymphadenectomy is feasible and safe, and is equivalent in efficacy to open approaches in bladder cancer. © 2009 Mary Ann Liebert, Inc.

“Robotic-assisted laparoscopic ureterocalicostomy with long-term follow-up.”

Schimpf, M. O. and J. R. Wagner (2009).

Journal of Endourology 23(2): 293-295.

Background: Robotic-assisted laparoscopic surgery is being applied to a growing number of procedures. Patient and Methods: A 32-year-old woman with ureteropelvic obstruction underwent a robotic-assisted laparoscopic ureterocalicostomy in 2005. She had an uncomplicated surgery with minimal blood loss and post-operative course. Results: Imaging done serially after surgery remained stable. She became pregnant about 2 years later and ultimately required percutaneous nephrostomy for flank pain and worsening hydronephrosis in the third trimester. Nephrostogram after delivery showed a patent anastomosis, and the nephrostomy tube was removed. Conclusions: Robotic-assisted laparoscopy is an option for patients who require ureterocalicostomy. Long-term outcome at 3 years is favorable. © Mary Ann Liebert, Inc. 2009.

“Minimally invasive surgical options for ureteropelvic junction obstruction: A significant step in the right direction.”

Symons, S., V. Palit, et al. (2009).

Indian Journal of Urology 25(1): 27-33.

Open pyeloplasty is the gold standard treatment for adult ureteropelvic junction obstruction (UPJO) with published success rates consistently over 90%. In recent years, the management of UPJO has been revolutionized by the introduction of endoscopic procedures and laparoscopic techniques. We analyzed the long-term results of endoscopic and other minimal access approaches for the treatment of UPJO. Early results for endopyelotomy were promising but long-term results were not encouraging. Laparoscopic pyeloplasty technique is well defined and duplicates the surgical principles of conventional open pyeloplasty. With such a large variety of minimally invasive procedures for the treatment of UPJO available, the treatment choice for UPJO must be based on the success and morbidity of the procedures, the surgeon’s experience, the cost of the treatment, and the patient’s choice. We feel that with the technological advances in instrumentation coupled with a decrease in cost and improved training of urological surgeons, laparoscopic pyeloplasty may evolve to be the new “gold” standard for the treatment of UPJO.

“Expanding the horizons: robot-assisted reconstructive surgery of the distal ureter.”

Williams, S. K. and R. J. Leveillee (2009).

J Endourol 23(3): 457-61.

OBJECTIVES: To report our single-center experience with robotic ureteroneocystostomy for the treatment of distal ureteral obstruction. METHODS: We performed robot-assisted laparoscopic ureteroneocystostomies between May 2005 and October 2007. We retrospectively collected information on patient demographics, and compared renal scans with furosemide washout and radiographic imaging before and after repair to determine radiographic success. Statistical analysis was performed using statistical software via paired Student’s t test analysis. RESULTS: Eight robot-assisted laparoscopic ureteroneocystostomies on seven patients were performed over a 30-month period. The etiology of the ureteric stricture was iatrogenic injury after hysterectomy in three patients, impacted stone in three, and infiltrative endometriosis in one. Mean stricture length was 2.2 cm. Right ureteroneocystostomy was performed in five patients and on the left in one, while one patient had bilateral disease. Mean operative time was 247 minutes (range 120-480), and average blood loss was 109 mL (range 50-200). Mean length of hospital stay was 2 days. All the procedures were completed successfully robotically without open conversion. Of the seven patients, one patient experienced recurrent symptoms. Subsequent imaging confirmed an anastomotic narrowing, which was treated by balloon dilation. There were no intraoperative or postoperative complications. Subsequent (99m)Tc-mercaptoacetyltriglycine scans showed no evidence of obstruction. After a mean follow-up of 18 months (range 5-31), relative renal function of the entire group of patients improved after ureteroneocystostomy, although this did not achieve statistical significance (p = 0.26). CONCLUSIONS: Robotic ureteroneocystostomy is a safe and effective treatment option for the management of distal ureteric stricture disease.

“Short-term quality-of-life assessed after robot-assisted radical cystectomy: A prospective analysis.”

Yuh, B., Z. Butt, et al. (2009).

BJU International 103(6): 800-804.

Objective: To prospectively determine the effect of robot-assisted radical cystectomy (RARC) on quality of life (QoL) after surgery. Patients and methods: In all, 34 patients who had RARC for bladder cancer between January 2006 and December 2007 at one institution were prospectively enrolled in a study of QoL. All patients had RARC with extracorporeal urinary diversion by one surgeon. As part of the routine follow-up, QoL was assessed at intervals. Functional Assessment of Cancer Therapy-Bladder (FACT-BL) questionnaires were administered before and then over a 6-month period after RARC. Patients undergoing chemotherapy were not excluded. Follow-up FACT-BL and individual domain scores for physical, social, emotional and functional well-being were compared with those obtained before RARC. Results: The mean age of all patients was 65 years, 88% were men, and 13 (38%) had adjuvant chemotherapy. The mean time after RARC for the 1-, 3- and 6-month assessments was 29, 90 and 193 days, respectively; 19 patients completed three follow-up questionnaires. Initially, there were significant decreases in the physical and functional domains, with improvements in the emotional domain (P < 0.001). Total FACT-General and FACT-BL scores decreased in the initial period after RARC and then progressively improved. There was no statistically significant difference in total scores at 3 months after surgery; at the 6-month follow-up the total FACT-BL scores exceeded those before RARC (P = 0.048). Conclusions: QoL appears to return promptly to, or exceed, baseline levels by 6 months after RARC. The improvement in the short term might allow for more contented patients and quicker initiation of adjuvant chemotherapy.© 2008 BJU International.

“Cryoablation for renal tumors: current status.”

Berger, A., K. Kamoi, et al. (2009).

Curr Opin Urol 19(2): 138-42.

PURPOSE OF REVIEW: To review the evolution and current status of cryoablation for renal tumors. RECENT FINDINGS: Cryoablation is the most evaluated probe ablative method for the treatment of small renal masses. It is associated with high efficacy and low morbidity. New data on intermediate and long-term oncological outcomes are now available. Five and 10-year cancer-specific survival are 93 and 81%, respectively. Renal cryoablation is most commonly performed percutaneously or laparoscopically. Recently, single-port laparoscopic and natural orifice transluminal endoscopic surgery approaches have also been employed for renal cryotherapy. SUMMARY: With careful patient selection, the intermediate-term and long-term oncologic outcomes after cryoablation for kidney tumors are satisfactory. Combination with new technologies and further development of imaging techniques can potentially expand the range of indications of the procedure.

“Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year.”

Carson-Stevens, A. and D. Stevens (2009).

BJU Int 103(7): 994.

“The Motion: A Robot is Necessary for Laparoscopic Enucleation of Renal Masses.”

Mottrie, A., A. Cestari, et al.

European Urology.

“Description of a novel technique for suture ligation of the renal vessels during robotic nephrectomy.”

Patel, M. N., R. Laungani, et al. (2009).

Journal of Robotic Surgery: 1-3.

Minimally invasive techniques are frequently used for surgical treatment of suspected malignant renal masses. We previously reported on our experience with robotic nephrectomy and the feasibility of performing suture ligation of the renal vessels using robotic needle drivers. We describe a novel technique for suture ligation of the renal vessels during robotic nephrectomy utilizing the robotic hook and a suture with loops at each end. Our technique for suture ligation of the renal vessels recapitulates the open technique without the need for exchanging the robotic working instruments for robotic needle drivers and without the need for endovascular staplers. © 2009 Springer-Verlag London Ltd.

“Reply: Robotic nephrectomy for the treatment of benign and malignant disease.”

Rogers, C. (2009).

BJU International 103(6): 842.

“Robotic nephrectomy for the treatment of benign and malignant disease.”

Sharma, D., C. Brown, et al. (2009).

BJU International 103(6): 842.

“Open, laparoscopic and robotic radical prostatectomy: Optimizing the surgical approach.” Bivalacqua, T. J., P. M. Pierorazio, et al. (2009).

Surg Oncol.

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery.

“Salvage robotic-assisted radical prostatectomy: initial results and early report of outcomes.” Boris, R. S., A. Bhandari, et al. (2009).

BJU Int 103(7): 952-6.

OBJECTIVE: To evaluate the initial results of salvage robotic-assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer. PATIENTS AND METHODS: Between December 2002 and January 2008, 11 patients had SRARP with pelvic lymph node dissection by one surgeon from one institution. Six patients had brachytherapy, three had external beam RT (EBRT), one intensity-modulated RT, and one received brachytherapy with an EBRT boost. All patients had prostate cancer on biopsy after RT, with negative computed tomography and bone scan. The mean (range) follow-up was 20.5 (1-77) months. RESULTS: The mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/mL, the operative duration 183 min and the estimated blood loss 113 mL. One patient had prolonged lymphatic drainage, one had an anastomotic leak, and one had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days. Three patients had a biochemical recurrence, at 1, 2 and 43 months. In one of two patients with node-positive carcinoma of the prostate the PSA level failed to reach a nadir of zero after surgery. In patients with a minimum follow-up of 2 months, eight of 10 are continent (defined as zero to one pad per day) and two have erections adequate for intercourse with the use of phosphodiesterase-5 inhibitors. CONCLUSION: SRARP after RT-resistant disease recurrence is feasible with minimal perioperative morbidity. Early functional outcomes appear to be at least equivalent with historical salvage RP series. Robotic extended pelvic lymph node dissection is safe and can improve the accuracy of surgical staging. A longer follow-up is necessary to better assess the functional and oncological outcomes.

“Laparoscopic radical prostatectomy: Six months of fellowship training doesn’t prevent the learning curve when incorporating into a lower volume practice.”

Brown, J. A. and K. P. Sajadi (2009).

Urol Oncol 27(2): 144-8.

INTRODUCTION: To assess whether 6 months of standard laparoscopic radical prostatectomy (LRP) training reduces the learning curve. METHODS: A single urologist (JAB) performed two 3-month fellowships at medical centers with high-volume LRP surgeons (Thomas Jefferson University, 2002 and Massachusetts General Hospital, 2003). He participated in 29 transperitoneal and 23 extraperitoneal LRPs, performing part or all (2) of 28 cases. He subsequently initiated a LRP program at our institution in July 2003, performing 32 procedures between July 2003 and June 2006 (excluding a 3-month 2004 robotic surgery sabbatical). Six residents served as assistant. RESULTS: Median patient age, BMI, and preoperative PSA were 58 (46-71) years, 30 (21-37), and 5.4 (3.2-13.6) ng/ml, respectively. Median estimated blood loss (EBL) and operative time were 400 (50-1700) ml and 411 (282-652) minutes. Median hospital stay, catheterization, and follow-up were 2 (1-12) days, 15 (8-52) days, and 10 (1-30) months, respectively. Ten (31%) and 6 (19%) underwent pelvic lymphadenectomy and open conversion. Five patients (16%) received transfusion. Twenty-three (72%) were pathologic stage pT2 and 9 (28%) pT3. Thirteen, 15, and 3 specimens were Gleason 6, 7, and >/=8, respectively. Fifteen (47%) had positive surgical margins (14 apical and 7 other sites). Nineteen (59%) had complications and 4 (12.5%) salvage radiation therapy. Of 20 patients followed 12 months, 12 (60%) are continent (pad free) and 4 (27%) potent patients remain so with or without PDE5 inhibitor. CONCLUSION: Six months of training (52 cases, 28 as surgeon for part or all) did not alleviate the LRP learning curve.

“Outcomes of robotic assisted radical prostatectomy.”

Dasgupta, P. and R. S. Kirby (2009).

Int J Urol 16(3): 244-8.

Robot-assisted radical prostatectomy (RARP) is a rapidly evolving technique for the treatment of localized prostate cancer. However, cynics point to the increasing role of market forces in the robotic revolution. As yet, Europe has not taken up RARP in large numbers and this may in part relate to the high level of expertise in laparoscopy previously gained. Furthermore, setting up a robotic program is a major undertaking for many surgical units. This article reviews the current literature on RARP with regard to oncologic, continence and potency outcomes – the so called ‘trifecta’. Preliminary data appears to show an advantage of RARP over open prostatectomy with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most intra-institutional studies demonstrate good postoperative continence and potency with RARP; however this needs to be viewed in the context of a paucity of randomized data available in the literature. There is no definitive data to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging.

“[Oncologic and functional outcomes after robot-assisted laparoscopic radical prostatectomy.].”

Drouin, S. J., C. Vaessen, et al. (2009).

Prog Urol 19(3): 158-64.

The current gold standard treatment for localized prostate cancer remains open radical prostatectomy. From 1992, several teams have tried to explore less invasive surgical access. The first robotically assisted laparoscopic prostatectomy (RALP) case was reported in 2000. Enhancement of the ergonomics and optimization of the surgical vision provided by the robotic interface, are some reasons that explain the worldwide widespread of RALP. Although this procedure accounted for the vast majority of radical prostatectomies performed in United States, its diffusion is still limited in Europe. The cost for robot purchase and maintenance are obvious limiting factors for its expansion. According to the literature, the operating time and the blood loss are, once the learning curve is completed, similar to those of open or laparoscopic procedures. Hospital stay and time before bladder catheter removal are shorter compared to other approaches. Intermediate oncological and functional outcomes do not show difference with the open or laparoscopic results. Given that these data are encouraging, the limited follow-up with RALP do not allow to draw any definitive statement in comparison with conventional techniques.

“Robotic-Assisted Laparoscopic Extended Pelvic Lymph Node Dissection for Prostate Cancer: Surgical Technique and Experience with the First 99 Cases.”

Feicke, A., M. Baumgartner, et al. (2009).

European Urology 55(4): 876-884.

Background: To date, there is still a paucity of data in the literature on robotic-assisted laparoscopic extended pelvic lymph node dissection (RALEPLND) in patients with prostate cancer. Objective: To assess the technical feasibility of RALEPLND and to present our surgical technique. Design, setting, and participants: From April 2006 to March 2008, we performed RALEPLND in 99 patients prior to robotic-assisted laparoscopic radical prostatectomy. Indications for RALEPLND were a prostate-specific antigen (PSA) ?10 ng/ml or a preoperative Gleason score ?7. The data were evaluated retrospectively. Surgical procedure: The transperitoneal approach was used in all cases. In order to gain optimal access to the common iliac bifurcation, the five trocars were placed in a more cephalad position than in patients undergoing radical prostatectomy without RALEPLND. After identification of important landmarks, the lymphatics covering the external iliac vein, the obturator lymphatic packet, and the lymphatics overlying the internal iliac artery were removed on both sides. Measurements: The total lymph node yield, the frequency of lymph node metastases, and the complication rate. Results and limitations: The median patient age was 64 yr (range: 45-78). The median preoperative PSA level was 7.7 ng/ml (range: 1.5-84.6). The median number of lymph nodes harvested was 19 (range: 8-53). In 16 patients (16%), we found lymph node metastasis. Complications occurred in seven patients (7%). Conclusions: RALEPLND is feasible, and its lymph node yield is well in the range of open series. The robotic-assisted laparoscopic approach in itself does not seem to limit a surgeon’s ability to perform a complete extended pelvic lymph node dissection. © 2008 European Association of Urology.

“Hypothermic Nerve-sparing Radical Prostatectomy: Rationale, Feasibility, and Effect on Early Continence.”

Finley, D. S., K. Osann, et al.

Urology.

Objectives: To report the first application of preemptive local hypothermia during robotic-assisted laparoscopic prostatectomy (hRLP) to attenuate inflammation. Surgical excision of the prostate during radical prostatectomy causes inflammatory damage to the surrounding neuromuscular tissues that could affect urinary continence. Methods: Of 50 consecutive patients undergoing nerve-sparing hRLP (case numbers 668-717; 3 were excluded-2 underwent radiotherapy and 1 was withdrawn because of balloon failure), 47 were prospectively compared with a standard RLP cohort (case numbers 1-667). Pelvic cooling was achieved using cold irrigation and an endorectal cooling balloon cycled with 4°C saline. The intracorporeal temperatures were measured. Continence was defined as 0 urinary pads. The Kaplan-Meier analysis of the time to 0 pads and multivariate Cox proportional hazards regression analysis was used to examine the group differences in continence after adjusting for the baseline characteristics. Results: The median temperature was 29.0°C (endorectal cooling balloon only, range 24.4°-35.9°C) and 25.5°C (endorectal cooling balloon plus irrigation, range 19.4°-34.0°C). The time to 0-pad status was determined in 590 of 667 controls (88%). The 3-month hRLP 0-pad rate was 86.8% ± 5.8% and was 68.6% ± 2.0% for the controls. The return to continence was faster for hRLP vs controls: median 39 days (range 0-110) vs 59 days (range 1-720), respectively (P = .002, log-rank test). A multivariate analysis adjusting for factors, including age, American Urological Association symptom score, abbreviated International Index of Erectile Function-5, body mass index, prostate weight, stage, nerve-sparing, and learning curve demonstrated a faster return to continence for the hRLP group relative to the control group (hazard ratio 1.66, 95% confidence interval 1.11-2.49, P = .014). Conclusions: This study represents the initial application of local hypothermia to reduce the traumatic inflammatory sequela of RLP. Hypothermia was easily induced and safe and resulted in a statistically significant improvement in early postoperative continence. © 2009 Elsevier Inc. All rights reserved.

“The dimensions and symmetry of the seminal vesicles.”

Gofrit, O. N., K. C. Zorn, et al. (2009).

Journal of Robotic Surgery: 1-5.

The traditional anatomical description of the seminal vesicles is based on autopsy and imaging studies. Trans-peritoneal robotic-assisted laproscopic surgery, with its three-dimensional magnified view and miniature articulated working instruments, provides an opportunity to perform accurate dissections of the seminal vesicles even when extremely long and tortuous. We used specimens obtained by robotic-assisted laparoscopic radical prostatectomy (RLRP) for accurate anatomic assessment of the dimensions of the seminal vesicles. Digital photos of 78 specimens from men (mean age 59 ± 6.1 years) who underwent RLRP were analyzed using the Image Pro Plus software. Seminal vesicle dimensions were correlated with patients’ age, weight, height, prostate weight, sexual function profile (SHIM) and symptom severity score of the lower urinary tract symptoms (IPSS). We found that the length of the seminal vesicles is highly variable (range of 8.5-94.6 mm). The average seminal vesicle length was 31 ± 10.3 mm and its average volume 7.1 ± 5.2 ml. The right seminal vesicle was significantly larger than the left in length, width and volume (P < 0.003). The seminal vesicles were found to be highly asymmetric with a mean difference of 17.8% in length and 24.9% in width between the sides. No correlation between seminal vesicle dimensions and any of the parameters tested was found. We concluded that the normal human seminal vesicles are characterized by marked (11-fold) variation in length and are asymmetric in most patients. The right seminal vesicle is significantly larger than the left. Seminal vesicle dimensions cannot be predicted from other morphometric or physiologic parameters. © 2009 Springer-Verlag London Ltd.

“Editorial Comment on: Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy.”

Hakenberg, O. W. (2009).

European Urology 55(4): 901.

“Port site hernias following robot-assisted laparoscopic prostatectomy.”

Hotston, M. R., J. D. Beatty, et al. (2009).

Journal of Robotic Surgery: 1-3.

Port site herniation is a rare but potentially major complication of laparoscopic surgery, but its importance within the context of robot-assisted laparoscopic prostatectomy (RALP) is less understood. We describe two cases that developed port site hernias following RALP, within a single surgeon case series of over 500 cases. Both patients re-presented with vague abdominal symptoms early following surgery, with a subsequent Computer tomography scan demonstrating small bowel herniation through the abdominal wall defect at the right lateral assistant 12 mm port site. Both required surgical exploration and successful repair. Following review of these cases and the current literature, we have since adapted our surgical approach. We recommend the routine use of a ‘nonbladed’ trocar for all 12 mm ports, which should also be formally closed incorporating all fascial layers. Early post-operative abdominal signs should alert the surgeon to its presence, and management should include immediate abdominal CT scanning and surgical re-exploration. © 2009 Springer-Verlag London Ltd.

“Does robot-assisted laparoscopic radical prostatectomy enable to obtain adequate oncological and functional outcomes during the learning curve? From the Korean experience.”

Ko, Y. H., J. H. Ban, et al. (2009).

Asian J Androl 11(2): 167-75.

To estimate the short-term results of robot-assisted laparoscopic radical prostatectomy (RALRP) during the learning curve, in terms of surgical, oncological and functional outcomes, we conducted a prospective survey on RALRP. From July 2007, a single surgeon performed 63 robotic prostatectomies using the same operative technique. Perioperative data, including pathological and early functional results of the patient, were collected prospectively and analyzed. Along with the accumulation of the cases, the total operative time, setup time, console time and blood loss were significantly decreased. No major complication was present in any patient. Transfusion was needed in six patients; all of them were within the initial 15 cases. The positive surgical margin rate was 9.8% (5/51) in pT2 disease. The most frequent location of positive margin in this stage was the lateral aspect (60%), but in pT3 disease multiple margins were the most frequent (41.7%). Overall, 53 (84.1%) patients had totally continent status and the median time to continence was 6.56 weeks. Among 17 patients who maintained preoperative sexual activity (Sexual Health Inventory for Men >/= 17), stage below pT2, followed up for > 6 months with minimally one side of neurovascular bundle preservation procedure, 12 (70.6%) were capable of intercourse postoperatively, and the mean time for sexual intercourse after operation was 5.7 months. In this series, robotic prostatectomy was a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, satisfactory results were obtained with regard to functional and oncological outcome.Asian Journal of Andrology (2009) 11: 167-175. doi: 10.1038/aja.2008.52; published online 19 January 2009.

“Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: Results of a 2 group parallel randomized controlled trial – Commentary.”

Lee, D. I. (2009).

Journal of Endourology 23(2): 220.

“Catheter-less robotic radical prostatectomy using a custommade synchronous anastomotic splint and vesical urinary diversion device: Report of the initial series and perioperative outcomes – Commentary.”

Lee, D. I. (2009).

Journal of Endourology 23(2): 219-220.

“Training of urologic oncology fellows does not adversely impact outcomes of robot-assisted laparoscopic prostatectomy.”

Link, B. A., R. Nelson, et al. (2009).

Journal of Endourology 23(2): 301-305.

Purpose: Robot-assisted laparoscopic prostatectomy (RALP) is an increasingly popular treatment choice among men with clinically localized prostate cancer and has resulted in the need to adequately train urologists to perform the procedure. We reviewed the City of Hope experience to determine if the extent of fellow involvement in the procedure has an adverse effect on surgical outcomes. Patients and Methods: We reviewed the charts of 1833 patients who underwent RALP at the City of Hope from January 2004 to September 2007. During the academic year, each fellow has participated in 300 or more RALP with a systematic stepwise approach to learning the operation. The procedure is divided into six segments arranged by the sequence of learning. We examined intraoperative and perioperative outcomes stratified by quartiles of the academic year corresponding to the fellows’ progress through the different segments of the operation. Results: No differences were found across quartiles of the academic year for intraoperative or perioperative complications, length of hospital stay, continence rates at 1 year, time to continence, and prostate-specific antigen-free recurrence rates. In the 1st and 3rd quarters of the academic year, from July to September and January to March, there were slightly longer operative times with a mean of 2.9 hours compared with the 2nd and 4th quarter mean of 2.8 hours (P = 0.01). The 3rd quarter also demonstrated slightly higher estimated blood loss of 280 mL compared with the overall mean of 262 mL (P = 0.02). During the 3rd quarter of the year, the fellows are reliably performing bladder neck division, urethral anastomosis, and beginning to learn the dissection of the neurovascular bundles. Conclusions: We found that in a high-volume center for RALP, urologic oncology fellows can be trained to perform the procedure with no significant adverse impact on patient clinical outcomes. © Mary Ann Liebert, Inc. 2009.

“Editorial Comment on: Robotic-Assisted Laparoscopic Extended Pelvic Lymph Node Dissection for Prostate Cancer: Surgical Technique and Experience with the First 99 Cases.”

Mottrie, A. (2009).

European Urology 55(4): 883-884.

“Quality of life outcomes following treatment for localized prostate cancer: is there a clear winner?”

Parker, W. R., J. S. Montgomery, et al. (2009).

Curr Opin Urol.

PURPOSE OF REVIEW: The majority of men treated for localized prostate cancer are cured of their disease. As a result, it is important to discuss long-term quality of life (QoL) expectations when counseling patients regarding treatment options. The varying QoL outcomes for radical prostatectomy, external beam radiotherapy, brachytherapy, and cryotherapy will be reviewed. RECENT FINDINGS: Robotic and radical prostatectomy has similar outcomes with significant initial worsening of urinary continence and sexual function. External beam radiation has less impact on continence and sexual function but noteworthy bowel toxicity. Brachytherapy results in the most irritative urinary symptoms, with decreased sexual and bowel QoL as well. Cryotherapy greatly reduces sexual function. SUMMARY: Every patient has unique pretreatment variables, priorities, and preferences. It is crucial to fully explain the range of oncologic and QoL implications when counseling patients regarding treatment for localized prostate cancer.

“Editorial Comment on: Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy.”

Reynolds, W. S. and S. E. Eggener (2009).

European Urology 55(4): 900-901.

“Re: Assessment of Early Continence After Reconstruction of the Periprostatic Tissues in Patients Undergoing Computer Assisted (Robotic) Prostatectomy: Results of a 2 Group Parallel Randomized Controlled Trial. M. Menon, F. Muhletaler, M. Campos and J. O. Peabody J Urol 2008; 180: 1018-1023.”

Rocco, B. and F. Rocco (2009).

Journal of Urology 181(3): 1500-1501.

“Editorial Comment on: Robotic-Assisted Laparoscopic Extended Pelvic Lymph Node Dissection for Prostate Cancer: Surgical Technique and Experience with the First 99 Cases.”

Touijer, K. (2009).

European Urology 55(4): 884.

“Preservation of Lateral Prostatic Fascia is Associated with Urine Continence after Robotic-Assisted Prostatectomy.”

van der Poel, H. G., W. de Blok, et al. (2009).

European Urology 55(4): 892-901.

Background: Among several clinical factors, nerve or prostatic fascia preservation is associated with an improved continence outcome in several studies. Objective: We study the clinical aspects associated with urine continence after prostatectomy, paying special attention to the extent and location of fascia preservation. Design, setting, and participants: European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life – Core 30 (QLQ-C30) and Prostate Cancer Module (PR25) questionnaires were used to evaluate quality-of-life (QoL) parameters prior to and at 6 and 12 mo after surgery for 151 men treated with robot-assisted laparoscopic prostatectomy (RALP) for localised prostate cancer. Fascia preservation was scored at 12 locations around the circumference of the prostate. Any involuntary urine loss showed a strong correlation with several domains of the EORTC QLQ-C30 and was therefore chosen as the definition of urine incontinence. Intervention: Robot-assisted laparoscopic prostatectomy (RALP). Measurements: Any urine incontinence. Results and limitations: Of the preoperative and intraoperative characteristics, a low fascia preservation (FP) score and a higher score for preoperative voiding complaints (EORTC QLQ-P25 domain 1) were associated with an increased risk of urine incontinence and pad use at 6 and 12 mo postoperatively. In the multivariate binary logistic regression analysis, the extent of fascia preservation at the lateral aspects of the prostate as assessed by the FP score was the best predictor of urine continence at 6 and 12 mo postoperatively. The odds ratio for urine incontinence in men with preservation of the lateral prostatic fascia was 0.378 (95% CI, 0.121-0.624) and 0.289 (95% CI, 0.201-0.524) for preservation at the right and left aspects, respectively. This is a retrospective analysis not containing pad-test data. Conclusions: Fascia preservation at the lateral aspect of the prostate was the best predictor of urine continence after RALP. These data suggest that preservation of fascial support lateral rather than dorsolateral to the urethra and prostate may protect neurovascular structures important to improving postprostatectomy urine continence. © 2009 European Association of Urology.

“Patient outcomes in the acute recovery phase following robotic-assisted prostate surgery: a prospective study.”

Watts, R., M. Botti, et al. (2009).

Int J Nurs Stud 46(4): 442-9.

BACKGROUND: Robotic-assisted minimally invasive urologic surgery was developed to minimise surgical trauma resulting in quicker recovery. It has many potential benefits for patients with localised prostate cancer over traditional surgical techniques without taking a risk with the oncological result. OBJECTIVES: To report the specific surgical outcomes for the first Australian cohort of patients with localised prostate cancer that had undergone robotic-assisted radical prostatectomy (RARP) surgery. The outcomes represent the acute (in-hospital) recovery phase and include pain, length of stay (LOS), urinary catheter management and wound management. METHODS: Prospective descriptive survey of 214 consecutive patients admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. Patients had undergone RARP surgery for localised prostate cancer. Data were collected from the medical records and through interview at the time of discharge. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency. RESULTS: The findings from this study are highly encouraging when compared to outcomes associated with traditional surgical techniques. Transurethral catheter duration (median 7 days (IQ range 2)) and LOS (median 3 days (IQ range 2)) were considerably reduced. While operation time (median 3.30 h (IQ range 1.07)) was marginally reduced we would expect a further reduction as the surgical team becomes more skilled. CONCLUSION: The findings from this study contribute to building a comprehensive picture of patient outcomes in the acute (in-hospital) recovery phase for a cohort of Australian patients who have undergone RARP surgery for localised prostate cancer. As such, these findings will provide valuable information with which to plan care for patients’ who undergo robotic-assisted surgery.

“Comparative Analysis of Surgical Margins Between Radical Retropubic Prostatectomy and RALP: Are Patients Sacrificed During Initiation of Robotics Program?”

White, M. A., A. P. De Haan, et al. (2009).

Urology 73(3): 567-571.

Objectives: To compare the incidence of positive surgical margins obtained with robotic-assisted laparoscopic prostatectomy (RALP), during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy (RRP) cases as performed by a single surgeon. Methods: From December 2005 to March 2008, 63 patients underwent RRP and another 50 underwent RALP by a single urologist. The records were retrospectively reviewed, and 50 RRP patients were selected from the RRP group whose records were similar to the records of the 50 patients who had undergone RALP. We compared the incidence of positive surgical margins and the location of positive margins among the 2 groups. Additional variables evaluated included the preoperative prostate-specific antigen level, preoperative Gleason score, clinical stage, postoperative Gleason score, tumor volume, and pathologic stage. Results: The positive margin rate for the RRP group was 36% compared with 22% for the RALP group (P = .007). The incidence of positive margins for pathologic Stage pT2c disease in the RALP group was 22.8% compared with 42.8% in the RRP group, a statistically significant difference (P = .006). Fewer positive margins were found in the RALP Gleason score 7 group than in the RRP group, 29% vs 60%, again a statistically significant difference (P = .003). Conclusions: We present our series comparing a single urologist’s positive margin rates during the learning curve of a robotics program with his experience of a similarly matched cohort of RRP patients. A statistically significant lower positive margin rate can be achieved in RALP patients even during the learning period. © 2009 Elsevier Inc. All rights reserved.