“Bladder cancer: Fewer complications after robotic cystectomy?”
Drake, R. (2010).
Nat Rev Urol 7(6): 302.
“Oncologic outcomes for complete robot-assisted laparoscopic management of upper-tract transitional cell carcinoma.”
Eandi, J. A., R. A. Nelson, et al. (2010).
Journal of Endourology 24(6): 969-975.
Background and Purpose: The gold standard for treatment of upper-tract transitional cell carcinoma (TCC) is nephroureterectomy. For distal ureteral TCC, distal ureterectomy with ureteral reimplantation represents a treatment option. Multiple minimally invasive techniques have been introduced with the goal of replicating these open procedures. Currently, there is a paucity of literature for the use of robot-assisted laparoscopic (RAL) management of upper-tract TCC. We evaluated our experience with RAL management of upper-tract TCC. Patients and Methods: A retrospective chart review was performed on all patients who underwent complete RAL nephroureterectomy or distal ureterectomy with ureteral reimplantation at our institution. Results: Eleven patients with a mean age of 67.4 years underwent RAL nephroureterectomy. Mean operative time was 326 minutes (range 243-470 minutes), estimated blood loss 200mL (range 100-400mL), and mean length of hospital stay was 4.7 days. With a mean follow-up of 15.2 months (range 2-31 months), four patients experienced recurrence, and two ultimately died from metastatic disease. Four patients with a mean age of 73.5 years underwent RAL distal ureterectomy with ureteral reimplantation for distal ureteral TCC. Mean operative time was 311 minutes (range 225-446 minutes), estimated blood loss 200mL (range 100-350mL), and mean length of hospital stay was 4.7 days. With a mean follow-up of 30.5 months (range 12-48 months), only one patient, whose pathology exhibited carcinoma in situ within periureteral tissue, required adjuvant treatment for recurrent disease. Conclusions: RAL nephroureterectomy and distal ureterectomy with ureteral reimplantation are feasible options for patients with upper-tract TCC with promising short-term oncologic outcomes. © Mary Ann Liebert, Inc. 2010.
“Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.”
Hellenthal, N. J., A. Hussain, et al. (2010).
BJU International.
OBJECTIVE To evaluate the incidence of, and predictors for, lymphadenectomy in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer. PATIENTS AND METHODS Utilizing the International Robotic Cystectomy Consortium (IRCC) database, 527 patients were identified who underwent RARC at 15 institutions from 2003 to 2009. After stratification by age group, sex, pathological T stage, nodal status, sequential case number, institutional volume and surgeon volume, logistic regression was used to correlate variables to the likelihood of undergoing lymphadenectomy (defined as >/=10 nodes removed). RESULTS Of the 527 patients, 437 (82.9%) underwent lymphadenectomy. A mean of 17.8 (range 0-68) lymph nodes were examined. Tumour stage, sequential case number, institution volume and surgeon volume were significantly associated with the likelihood of undergoing lymphadenectomy. Surgeon volume was most significantly associated with lymphadenectomy on multivariate analysis. High-volume surgeons (>20 cases) were almost three times more likely to perform lymphadenectomy than lower-volume surgeons, all other variables being constant [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.39-4.05; P= 0.002]. CONCLUSION The rates of lymphadenectomy at RARC for advanced bladder cancer are similar to those of open cystectomy series using a large, multi-institutional cohort. There does, however, appear to be a learning curve associated with the performance of lymphadenectomy at RARC.
“Robot-assisted radical cystectomy: Intermediate survival results at a mean follow-up of 25 months.” Martin, A. D., R. N. Nunez, et al. (2010).
BJU International 105(12): 1706-1709.
Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To assess the overall and disease-specific survival rates of patients undergoing robot-assisted radical cystectomy (RARC) compared with historical open cystectomy. Patients and Methods Survival, pathological and demographic data were collected on all patients undergoing RARC for bladder cancer from both Tulane University Medical Center and Mayo Clinic Arizona. Of a total of 80 RARCs we only included those with a follow-up of ≥6 months from surgery. Survival curves were compared with those from historical series of open cystectomy. Results Of the 80 patients 59 were identified as having a follow-up of ≥6 months from the date of surgery. The mean (range) follow-up was 25 (6-49) months. Overall survival rates at 12 and 36 months were 82% and 69%, respectively, and disease-specific survival rates were 82% and 72% at 12 and 36 months, respectively. These results are comparable to survival rates from open cystectomy. As expected, patients with lymph node-positive disease fared worse than those with lymph node-negative disease. Patients with extravesical lymph node-negative disease (pT3, pT4) fared worse than patients with organ-confined lymph node-negative disease. Also, patients with lymph node-positive disease fared worse than those with extravesical lymph node-negative disease, which is consistent with historical results of open cystectomy. Conclusions RARC has a comparable survival rate to open cystectomy in the intermediate follow-up. Further study with a longer follow-up and more patients is necessary to determine any long-term survival benefits. © 2009 BJU INTERNATIONAL.
“Robotic-assisted laparoscopic intracorporeal urinary diversion.”
Pruthi, R. X., J. Nix, et al. (2010).
Journal of Endourology 24(6): 894-895.
“Robot-assisted Pelvic Lymphadenectomy for Bladder Cancer-Where Have We Reached By 2009.” Singh, I. (2010).
Urology 75(6): 1269-1274.
Objectives: To review the current status and role of robot-assisted laparoscopic pelvic lymphadenectomy. To review the need, extent, lymph node yield, oncological feasibility, and outcome of robot-assisted pelvic lymphadenectomy for invasive bladder cancer in patients undergoing a robot-assisted laparoscopic radical cystectomy. Methods: The National Library of Medicine and the Pub Med were extensively searched for the cases of robot-assisted laparoscopic pelvic lymphadenectomy performed in conjunction with robot-assisted laparoscopic radical cystectomy for bladder cancer using the following keywords: bladder cancer, pelvic lymphadenectomy, cystectomy, laparoscopy, robot, and robot-assisted radical cystectomy. These were reviewed and analyzed (using certain tabulated parameters) to determine the current status of robot-assisted pelvic lymphadenectomy. Results: The search yielded about 12 major published series (278 cases) of “robot-assisted radical cystectomy with pelvic lymphadenectomy,” with an overall acceptable mean operating time(s), complication rate, blood loss, and hospital stay. Conclusions: Robot-assisted laparoscopic pelvic lymphadenectomy in conjunction with robot-assisted laparoscopic radical cystectomy is an oncologically feasible and technically safe procedure with acceptable early operative outcomes that appear to be comparable to those achieved with open/laparoscopic surgery. © 2010 Elsevier Inc. All rights reserved.
“Robot-assisted laparoscopic transperitoneal pelvic lymphadenectomy and metastasectomy for melanoma: initial report of two cases.”
Sohn, W., D. S. Finley, et al. (2010).
Journal of Robotic Surgery: 1-4.
Robotic pelvic lymphadenectomy is a well established procedure in the urologic and gynecologic literature. To our knowledge robotic pelvic lymphadectomy for metastatic melanoma has yet to be described. Herein we present the first report of robot-assisted pelvic lymphadenectomy in malignant melanoma. After placement of six laparoscopic ports (12 mm camera, three 8-mm robotic ports, 12-mm and 5-mm assistant ports) the DaVinci S robot (Intuitive Surgical, CA, USA) was docked in standard fashion with the patient in low lithotomy. In both cases the patients had enlarged pelvic lymph nodes on computed tomography and complete excision of these masses was accomplished along with complete lymphadenectomy extending from Cooper’s ligament to just below the hypogastric artery in case 1 and to level of the bifurcation of aorta in case 2. A PK Maryland Dissector and monopolar scissors were used for dissection. Both patients were discharged on postoperative day #1. Robotic pelvic lymphadenectomy can be safely used for management of patients with metastatic melanoma involving the pelvic lymph nodes. Compared with the standard open procedure, pelvic lymphadenectomy with robotic assistance is associated with excellent vision and minimum morbidity. © 2010 The Author(s).
“Comparison of laparoscopic versus robotic assisted partial nephrectomy: one surgeon’s initial experience.”
DeLong, J. M., O. Shapiro, et al. (2010).
Can J Urol 17(3): 5207-5212.
INTRODUCTION/OBJECTIVE: Partial nephrectomy is an effective surgical treatment for small renal masses. We compare a single surgeon’s experience with consecutive laparoscopic and robotic partial nephrectomy to assess potential perioperative outcomes. A review of the literature is provided. MATERIALS AND METHODS: A retrospective review was performed comparing 15 consecutive patients undergoing laparoscopic partial nephrectomy to the subsequent consecutive 13 patients undergoing robotic assisted partial nephrectomy for small renal tumors. All patients had normal contralateral kidney appearance on cross sectional imaging. A similar transperitoneal technique was employed for both cohorts. A 4-arm technique was used for the robotic cases using the da Vinci (Intuitive Surgical, Sunnyvale, USA) surgical system. Patient demographics, tumor characteristics, intraoperative, and postoperative data including tumor size, warm ischemia time, and estimated blood loss (EBL) were compared using Student t-test, Wilcoxon rank-sum, or Chi square test as appropriate. RESULTS: All cases were completed laparoscopically or with robotic assistance without conversion to open surgery. Demographic data were not statistically different between the two groups. Warm ischemia time (WIT) was shorter in the robotic group: 29.7 minutes versus 39.9 minutes for the laparoscopic group (p < 0.0001). Operative time was longer in the robotic group: 253 versus 352 minutes (p < 0.0001). Mean hospital stay and postoperative complication rates were not statistically different. Two (13%) of patients in the laparoscopic group required conversion of partial nephrectomy to radical nephrectomy while none did in the robotic group. Final pathology revealed negative margins in all cases. CONCLUSIONS: Robotic partial nephrectomy resulted in decreased WIT as compared to the conventional laparoscopic approach. Total operating time was increased in the robotic group.
“Robotic Versus Laparoscopic Partial Nephrectomy: Single-surgeon Matched Cohort Study of 150 Patients.”
Pascal Haber, G., W. M. White, et al. (2010).
Urology.
Objectives: To present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or laparoscopic partial nephrectomy (LPN) by a single surgeon at a single institution. Methods: Between March 2002 and August 2009, a retrospective review of 261 consecutive patients who underwent LPN (n = 186) or RPN (n = 75) by a single surgeon was performed. Patients were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and tumor size, side, and location. Perioperative outcomes were compared. Results: A matched cohort of 150 patients who underwent RPN (n = 75) or LPN (n = 75) were compared. There was no significant difference between the 2 cohorts with respect to patient age (P = .17), BMI (P = .68), ASA score (P = .96), preoperative estimated glomerulofiltration rate (eGFR; P = .54), or tumor size (P = .17). Mean operative time for RPN was 200 vs 197 minutes for LPN (P = .75). Mean estimated blood loss (EBL) was higher in the RPN cohort (323 vs 222 mL, P = .01). There was no significant difference with respect to warm ischemia time (18.2 minutes vs 20.3 minutes, P = .27), length of hospitalization (P = .84), percent change in eGFR (P = .80), or adverse events (P = .52). All surgical margins were negative. Conclusions: Although initial surgical experience with RPN was included in this study and compared with a vast experience in LPN by the same surgeon, RPN offers at least comparable outcomes to LPN. © 2010 Elsevier Inc. All rights reserved.
“Robot-assisted partial nephrectomy: a large single-institutional experience.”
Scoll, B. J., R. G. Uzzo, et al. (2010).
Urology 75(6): 1328-1334.
OBJECTIVES: To report experience with 100 robot-assisted partial nephrectomy (RAPN) operations performed at our institution. Nephron-sparing surgery is an established treatment for patients with small renal masses. The laparoscopic approach has emerged as an alternative to open nephron-sparing surgery, but it is recognized to be technically challenging. The robotic surgical system may enable faster and greater technical proficiency, facilitating a minimally invasive approach to more difficult lesions while reducing ischemia time. METHODS: A total of 100 RAPN operations were performed for suspicious solid renal lesions during a 21-month period. Clinicopathologic variables, nephrometry scores, operative parameters, and renal functional outcomes were prospectively recorded and analyzed. RESULTS: Median tumor size was 2.8 cm (range, 1.0-8). Nephrometry scores of resected lesions were low in 47.9% of patients, medium in 45.7%, and high in 6.4% of patients. Forty-seven percent of patients had tumors>50% intraparenchymal, and 61.7% had tumors located less than 7 mm away from the renal sinus or collecting system. In 17% of patients, the tumors were touching a first-order vessel in the renal hilum. Mean warm ischemia time was 25.5 minutes (range, 0-53). Mean change in postoperative glomerular filtration rate improved 6.32 mL/min/1.73 m2 (range, -41.9 to 68.9). Histology was renal cell carcinoma in 81% (87/107) of tumors. There were 5 microscopically positive margins on final pathology (5.7%). Major and minor complication rates were 6% and 5%, respectively. There were 2 conversions to open surgery. CONCLUSIONS: RAPN seems to be a safe and technically feasible minimally invasive approach to nephron-sparing surgery even in more complex cases, with acceptable pathologic and renal function outcomes.
“Selective Renal Parenchymal Clamping in Robotic Partial Nephrectomy: Initial Experience.”
Viprakasit, D. P., H. O. Altamar, et al. (2010).
Urology.
OBJECTIVES: To describe our early experience using a laparoscopic clamp to induce selective regional ischemia during robotic-assisted partial nephrectomy without hilar occlusion. The creation of a bloodless field during minimally invasive approaches to nephron-sparing surgery often requires complete warm ischemia with renal hilar clamping that can potentially result in subsequent renal damage. METHODS: After transperitoneal renal mobilization and delineation of the renal tumor margin using laparoscopic ultrasound, the laparoscopic clamp is placed across the renal parenchyma 2-3 cm proximal to the resection line. After tumor excision, the renal defect is repaired robotically and hemostatic agents are used to aid in achieving compressive hemostasis. RESULTS: Three patients with predominantly exophytic renal masses underwent this procedure for elective indications. Mean tumor diameter was 4.9 cm (range 1.2-7.0). Mean selective clamp time was 37 minutes (range 20-52). Estimated blood loss was minimal and no patients required renal hilar clamping. There were no perioperative complications. Mean change in preoperative and postoperative creatinine was 0.1 (+/-0.09). Final pathology revealed clear cell and papillary renal carcinomas with no positive margins on frozen or final evaluation. CONCLUSIONS: Regional renal parenchymal clamping during robotic partial nephrectomy can be safely and effectively used to create a bloodless operative field in select patients with optimally located renal tumors. Our early experience with this technique allows for frozen pathologic evaluation of the tumor and margin status without concern for warm ischemia and represents another tool for surgeons performing minimally invasive nephron-sparing surgery.
“Robot-assisted surgery: Applications in urology.”
Raynor, M. C. and R. S. Pruthi (2010).
Open Access Journal of Urology 2: 85-89.
The past decade has seen a dramatic shift in the surgical management of certain urologic conditions with the advent of a robotic surgical platform. In fact, the surgical management of prostate cancer has seen the most dramatic shift, with the majority of cases now being performed robotically. Technical refinements over the years have led to improved outcomes regarding oncologic and functional results. Recently, robotic surgery has also been utilized for the surgical management of bladder cancer, renal cancer, and other benign conditions. As further experience is gained and longer-term outcomes are realized, robotic surgery will likely play an increasing role in the surgical management of many urologic conditions. © 2010 Raynor and Pruthi, publisher and licensee Dove Medical Press Ltd.
“Robotics in urologic surgery.”
Shiroki, R. (2010).
Japanese Journal of Clinical Urology 64(6): 367-376.
“Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: Comparison of short-term biochemical recurrencefree survival.”
Barocas, D. A., S. Salem, et al. (2010).
Journal of Endourology 24(6): 893-894.
“Critic analysis of a comparative meta-analysis on the morbidity, functional and carcinologic results after radical prostatectomy according to surgical approach. Work of cancerology committee of the french urological association.”
Bastide, C., F. Rozet, et al. (2010).
Analyse critique d’une méta-analyse comparative sur la morbidité, les résultats fonctionnels et carcinologiques de la prostatectomie totale en fonction de la voie d’abord utilisée. Travail du comité de cancérologie de l’AFU.
Surgical approach for radical prostatectomy is even today a subject of debate in the urologic community. Many comparative studies between retropubic and laparoscopic approach (robotic assisted or not) were reported since 10 years without being able to decide between the supporters of retropubic or laparoscopic approach. The committee of cancer research of the French urological association took hold this question after a recent meta-analysis publication on this subject. Although imperfect, this meta-analysis exists and permits to conclude partially on the advantages and the inconveniences supposed for each surgical approach. Regarding morbidity after radical prostatectomy, the only significant difference reported concerns the hemorrhagic risk in favour of the laparoscopic approach. Regarding oncologic results, the only exploitable data concern positive surgical margins rate, which is identical whatever surgical approach. Concerning the functional results, no difference was reported in the literature between different surgical approaches. © 2010 Elsevier Masson SAS. All rights reserved.
“The displacement of the tracheal tube during robot-assisted radical prostatectomy.”
Chang, C. H., H. K. Lee, et al. (2010).
European Journal of Anaesthesiology 27(5): 478-480.
Background and objective Robot-assisted prostatectomy requires pneumoperitoneum in a steep Trendelenburg position, which may induce endobronchial intubation or accidental extubation. The aim of the study was to evaluate the effect of pneumoperitoneum in 308 Trendelenburg position on the displacement of the tracheal tube and to measure the changes in trachea length using fiberoptic bronchoscope. Methods Thirty male patients scheduled for robot-assisted radical prostatectomy were enrolled. After induction of general anaesthesia, the distance between the vocal cords and the tracheal tube tip (DVE), between the tracheal tube tip and the carina (DEC) and between the vocal cords and thecarina (DVC) was measured using a fiberoptic bronchoscope before and 10 min after pneumoperitoneum in neutral position (T1 and T2, respectively), and 2 h after pneumoperitoneum in 308 Trendelenburg position (T3). Results The DVC and DEC decreased significantly 10 min after pneumoperitoneum in neutral position (T2) and 2 h after pneumoperitoneum in Trendelenburg position (T3) compared with those before pneumoperitoneum in neutral position (T1) (all P<0.001). The changes in DVE were not statistically significant. Conclusion The confirmation of the tracheal tube position is recommended after pneumoperitoneum in steep Trendelenburg position during robot-assisted prostatectomy because the displacement of the tracheal tube may result in endobronchial intubation due to shortening of the carina-to-tube tip distance. © 2010 Copyright European Society of Anaesthesiology.
“Robot-assisted high-intensity focused ultrasound in focal therapy of prostate cancer.”
Chaussy, C. G. and S. Thüroff (2010).
Journal of Endourology 24(5): 843-847.
In one-third of patients, prostate cancer (PCa) is monofocal. These patients can undergo focal high-intensity focused ultrasound (HIFU) therapy of the tumor without damage to surrounding structures and not compromising uro-oncologic safety. Robot-assisted HIFU coagulates the entire targeted volume within the prostate transrectally, in one session, without direct tumor contact and without adjuvant endourologic therapy. It is performed with the patient receiving spinal anesthesia and without blood loss; negative immunologic influence can be excluded. Heat-destroyed cancer cells that act as tumor vaccination are discussed. Right now, the limitation of focal therapy is caused by the lack of diagnostic accuracy to determine multifocal stages of PCa reliably. Discussions of tumor development, triggering primary lesion monotherapy, do not overcome skepticism about leaving invisible tumor foci untreated. This explains why PCa therapy today treats always the entire gland. Furthermore, the thought that the problem could be solved “radically, once forever,” ignores the fact that in all PCa therapies, local recurrence rates are between 10% and 50%. Considering the longer survival of men in industrialized countries, a structured multimodal therapy concept should be created and evaluated in studies and should replace the competition between classic therapies. Focal therapy in most cases should be the first approach in cancer therapy because it is noninvasive, has low side effects, and is a single-session therapy. It does not exclude but may delay other, more invasive therapies in cases of cancer recurrence. Focal therapy should not be misunderstood as substitution for existing classic therapies but as a therapeutic first choice in monofocal, low-aggressive PCa cases. © Copyright 2010, Mary Ann Liebert, Inc.
“Use of a Flexible Carbon Dioxide Laser Fiber for Precise Dissection of the Neurovascular Bundle During Robot-Assisted Laparoscopic Prostatectomy.”
Cheetham, P. J., M. D. Truesdale, et al. (2010).
Journal of Endourology.
Abstract Introduction: Carbon dioxide (CO(2)) lasers deliver energy with minimal thermal spread to tissues during dissection. Excess thermal spread during dissection of the neurovascular bundle (NVB) can affect potency in men after robot-assisted radical prostatectomy (RARP). We report on a novel delivery mechanism for CO(2) laser energy through a flexible fiber to enhance accuracy of NVB dissection during RARP. Materials: A feasibility study of the OmniGuide((R)) BeamPath() URO-LG CO(2) laser fiber for NVB dissection was performed on 10 patients with primary Gleason 3 T1c prostate cancer during RARP. Bilateral lateral fascial antegrade nerve sparing was performed. We evaluated fiber performance, safety, and efficacy. Results: The fiber was inserted through the 12-mm assistant’s port and easily manipulated by robotic instruments. Once pedicles were clipped and dissected, the laser fiber was effective in establishing planes of dissection between prostatic capsule and NVB. The endoscopically discernable thermal laser footprint was small, with minimal thermal spread during nerve sparing, meticulous dissection of NVB, and fascial layer identification. Although the laser did provide extremely accurate dissection, it was unable to serve as an adequate means of larger vessel coagulation. Conclusions: The flexible CO(2) laser fiber was easily manipulated. Identification of fascial layers during nerve sparing was facilitated with the fiber. Long-term follow-up is necessary to determine efficacy of this technology versus conventional techniques on the NVB. Larger studies are currently in progress to determine if use of the flexible CO(2) laser fiber results in improvements in functional outcomes with regard to return of sexual potency after RARP.
“Insight into current surgical techniques and practice patterns associated with robotic-assisted radical prostatectomy: a national survey of urologists within the USA.”
Dyche, D. J., M. Coffey, et al. (2010).
Journal of Robotic Surgery: 1-6.
Robotic-assisted radical prostatectomy (RARP) has been rapidly adopted throughout the USA. The purpose of this study is to describe the prevailing RARP operative techniques and perceptions within the USA. An anonymous web-based survey was sent electronically to a list of 920 robotic urological surgeons. The survey assessed surgeon demographics, surgical technique, and postoperative care related to RARP. The study was comprised of urologists from community hospitals (76%) and university hospitals/specialty centers (24%). All geographic sections of the American Urological Association were represented. The most common neurovascular preservation techniques were ante/retrograde approach (48%), athermal (22%), and preservation of lateral pelvic fascia (17%). Surgeon choice of neurovascular preservation technique varied with the average number of procedures performed per year (P = 0.0065). High-volume surgeons tended to require a higher number of robotic cases in order to go through the learning curve of the “comfortable” (P = 0.001) and “expert” levels (P < 0.0001). The majority of surgeons reported that RARP (as compared with open surgery) improved urinary continence (77.2%), sexual function (65.6%), and surgical margin rates (53.8%). RARP is an evolving surgical procedure with significant variability in practice patterns among US surgeons. Further studies are necessary to compare the various techniques in order to improve surgical outcomes. © 2010 Springer-Verlag London Ltd.
“Surgical treatment of prostate cancer: what to do?”
Eckrich, P. (2010).
South Dakota medicine : the journal of the South Dakota State Medical Association Spec No: 46-48.
Although there is a paucity of prospective studies comparing surgical treatment of prostate cancer to other treatments, surgical treatment is usually recommended for men with a good chance for cure who have ten or more years life expectancy. Proper selection of men undergoing surgery is critical to achieve cures and minimize side effects. Laparoscopic and robotic prostatectomy have become the predominant approach for surgery despite a very slow learning curve, greater expense, and higher dissatisfaction rates compared to more traditional approaches. Outcomes using a laparoscopic or robotic approach are equivalent to open methods only after 250 to 1000 procedures. In this era of increasing medical costs, utilization of robotic and laparoscopic approaches to prostatic cancer surgery needs to be critically examined.
“A New Anatomic Approach for Robot-Assisted Laparoscopic Prostatectomy: A Feasibility Study for Completely Intrafascial Surgery{black small square}.”
Galfano, A., A. Ascione, et al. (2010).
European Urology.
Robot-assisted laparoscopic prostatectomy (RALP) has been disseminated widely, changing the knowledge of surgical anatomy of the prostate. The aim of our study is to demonstrate the feasibility of a new, purely intrafascial approach. The Bocciardi approach for RALP passes through the Douglas space, following a completely intrafascial plane without any dissection of the anterior compartment, which contains neurovascular bundles, Aphrodite’s veil, endopelvic fascia, the Santorini plexus, pubourethral ligaments, and all of the structures thought to play a role in maintenance of continence and potency. In this case series, we present our first five patients undergoing the Bocciardi approach for RALP. We report the results of our technique in three patients following two unsuccessful attempts. No perioperative major complication was recorded. Pathologic stage was pT2c in two patients and pT2a in one patient, with no positive surgical margin. The day after removing the catheter, two of the three patients reported use of a single, small safety pad, and one patient was discharged without any pad. One patient reported an erection the day after removing the catheter. The anatomic rationale for better results compared with traditional RALP is strong, but well-designed studies are needed to evaluate the advantages of our technique. © 2010 European Association of Urology.
“Posterior Rhabdosphincter Reconstruction During Robot-assisted Radical Prostatectomy: Critical Analysis of Techniques and Outcomes.”
Gautam, G., B. Rocco, et al. (2010).
Urology.
Many centers have recently implemented posterior rhabdosphincter reconstruction (PRR) into robot-assisted radical prostatectomy (RARP) with the objective of earlier continence recovery. We comprehensively review the anatomic and functional changes occurring post prostatectomy along with the reconstructive techniques and published outcomes of PRR. Several case control studies show a better continence rate within the first 3 months, whereas the only randomized control trial presents a conflicting conclusion. Unfortunately, all reported studies lack uniform surgical technique, continence definition, and measures, making comparison difficult. Although initial results appear favorable, the true continence benefit of PRR remains debatable and requires further research. © 2010.
“Robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal continent urinary diversion: highlight of surgical techniques and outcomes.”
Josephson, D. Y., J. A. Chen, et al. (2010).
Int J Med Robot.
BACKGROUND: We report our technique for robotic-assisted laparoscopic radical cystoprostatectomy (RARCP) and extracorporeal urinary diversion and present their clinical outcomes. METHODS: Between October 2003 and December 2008 we performed 58 RARCPs with extracorporeal continent urinary diversion. Preoperative, operative and postoperative data was evaluated. RESULTS: Mean patient age was 68 (range 46-89) years, with an average American Society of Anesthesiologists classification of 2.9. Mean operative time was 8 (range 5-11) h. Median blood loss was 450 ml. Thirteen patients received intra-operative blood transfusions and 22 patients received peri-operative blood transfusions. Continent urinary diversions were performed by means of the Studer technique (n = 42) or Indiana pouch (n = 16). Mean number of lymph nodes examined on lymphadenectomy was 27 (range 0-52). CONCLUSIONS: Our RARCP and continent diversion technique is a safe and feasible option for primary urothelial carcinoma of the bladder. Oncological and surgical outcomes are comparable to open cystectomy series. Copyright (c) 2010 John Wiley & Sons, Ltd.
“Impact of Posterior Musculofascial Reconstruction on Early Continence After Robot-Assisted Laparoscopic Radical Prostatectomy: Results of a Prospective Parallel Group Trial.”
Joshi, N., W. de Blok, et al. (2010).
European Urology 58(1): 84-89.
Background: A significant proportion of patients develop urinary incontinence early after radical prostatectomy. Posterior reconstruction of supporting tissues has been found to reduce incontinence in open and conventional laparoscopic prostatectomy series. Objective: To investigate whether our version of a posterior musculofascial reconstruction will reduce early incontinence and have a beneficial effect on patients’ quality of life (QoL). Design, setting, and participants: One hundred seven consecutive patients undergoing primary robot-assisted radical laparoscopic prostatectomy (RALP) performed by a single surgeon at one tertiary referral oncology institution were alternately assigned (not randomised) to intervention (n = 53) or control groups (n = 54). Surgical procedure: RALP with median fibrous raphe reconstruction (MFRR) followed by formation of the urethrovesical anastomosis (intervention group) versus standard anastomosis without posterior reconstruction (control group). Measurements: Measurements included incontinence at baseline and 3-mo intervals; QoL as measured by a simple questionnaire, the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life-Core 30 (QLQ-C30), and Prostate Cancer Module (PR25) questionnaires preoperatively and at 6 mo postprocedure; tumour characteristics; operative time; fascial preservation score; duration of catheterisation; and anastomotic leakage on cystogram. Results and limitations: For intervention and control groups respectively, mean catheter duration was 11.74 d and 12.74 d (p = 0.451); leakage on cystogram was present in six and eight cases (p = 0.28); and incontinence (any involuntary urine loss) at 3 mo was 75% and 69% (p = 0.391) and at 6 mo was 51% and 43% (p = 0.686). Urinary retention occurred only in one case (control group). The percentage of cases returning to baseline in all QoL domains (except insomnia) was similar at 6 mo between the two groups. Short follow-up, lack of blinding, and probable small differences in our method of MFRR performed compared with other studies were identified as significant limitations. Conclusions: No significant difference in any of the analysed outcome measures was observed. Posterior reconstruction of the musculofascial complex does not appear to improve early urinary incontinence after RALP. © 2010 European Association of Urology.
“The current state of robot assisted radical prostatectomy.”
Khatlani, K., S. Sharma, et al. (2010).
Minerva Urologica e Nefrologica 62(2): 193-201.
AIM: The introduction of robotics in the operating room made its first major impact in the arena of prostate cancer. Robot assisted radical prostatectomy (RARP) is the most commonly performed surgery for prostate cancer in the United States. METHODS: In this review article, we discuss the history of robotic prostatectomy as well as the benefits and drawbacks of the robotic surgical platform. Our University of Pennsylvania technique is described. Patient selection, peri-operative factors, oncological data, and functional outcomes specific to RARP are addressed. RESULTS: While cost remains a valid criticism to the robotic technique, some of the additional expenditure is offset by improved convalescence, fewer medical complications, and decreased morbidity. Data with follow up approaching 10 years demonstrates equal if not superior outcomes with respect to continence, sexual and oncological factors. CONCLUSION: The diligent efforts of many have led to the rapid evolution of robot assisted radical prostatectomy. There is a renewed interest in the anatomy, oncological outcomes, and functional consequences of prostatectomy. With technological advances occurring at an accelerating rate, the advances in surgery should be very exciting indeed.
“Predictors of early urinary continence after robotic prostatectomy.”
Lee, D. J., P. Cheetham, et al. (2010).
Can J Urol 17(3): 5200-5205.
OBJECTIVE: We sought to identify predictors of early urinary continence after robot-assisted prostatectomy (RARP) in men who underwent a posterior rhabdosphincter reconstruction. MATERIALS AND METHODS: A prospective analysis was performed in 107 consecutive men who underwent RARP by a single surgeon in an academic center. Men were excluded if they received adjuvant radiation therapy (7 men), were lost to follow up (4), or did not have a posterior rhabdosphincter reconstruction (8 men). Eighty-eight men received a posterior rhabdosphincter reconstruction and were followed in this study. Patient demographic and postoperative urinary control was recorded at interval follow up visits by the physician and research staff. Level of comorbidity was measured with the Charlson Comorbidity Index (CACI). Preoperative urinary function was measured using the International Prostate Symptom Score (IPSS). Continence was defined as men using zero pads per day. RESULTS: Eighty-eight men with a mean age of 59.2 years (43.1-77.6) were followed for a median of 7.6 (range 1.5-16.7) months. The median preoperative PSA and IPSS was 5.0 ng/mL (range 0.95 ng/mL-23 ng/mL) and 8 (range 0-30), respectively. Overall, 91% of the men achieved continence with a median time to continence of 2.3 months. Of those, 50% achieved continence by 6 weeks. Men continent at 6 weeks were significantly younger, had lower IPSS scores, and less comorbidities (p = 0.01). Age (OR = 0.91, p < 0.01) and higher IPSS scores (OR = 0.28, p = 0.03) were associated with decreased odds of achieving continence at 6 weeks. The presence of coexisting disease was not predictive of continence return. After adjusting for comorbidity, body mass index (BMI), nerve sparing, and IPSS score, only age remained as an independent predictor of early continence (OR = 0.90, p = 0.04). CONCLUSIONS: In conclusion, we found that increased age and increased lower urinary tract symptom (LUTS) severity are associated with decreased odds of achieving continence 6 weeks after RARP. Patient age remains the strongest predictor of early return of continence in a multivariate model. These factors should be used in counseling prior to surgery to meet realistic patient expectations.
“Australian mens long term experiences following prostatectomy: A qualitative descriptive study.”
O’Shaughnessy, P. K. and T. A. Laws (2009).
Contemporary Nurse 34(1): 98-109.
The experiences of men in the immediate postoperative period following surgery for primary prostate cancer are well reported in the literature. Recognition of the unresolved morbidity encountered by men in the medium term suggests that a more complete understanding of how men cope in the long term is needed. Health professionals are deserving of a more complete literature for the purpose of providing holistic care for this group of men, providing informed advocacy and better support for men living with the diagnosis of prostate cancer. Emerging literature reveals that men’s knowledge of the long term problems associated with prostatectomy was inadequate at the time they consented to treatment; the likely outcomes at all phases of recovery should be taken into account when deciding on choice of treatment or no treatment. This qualitative study aims to describe men’s long term recovery following prostatectomy for the purpose identifying the effects of unresolved post surgical morbidity. The content analysis of focus group interviews revealed that incontinence and impotence were a major source of emotional tension affecting the men’s social interactions and sense of self-worth. The men expressed great regret over the lack of information accessible to them for evaluating the risk and nature of long term problems. The thick description provided in this study identifies the need for empathetic assessment of men with ongoing post surgical issues and alerts the reader to the inadequacies of information provided prior to consent to prostatectomy. © eContent Management Pty Ltd.
“Robotic-assisted laparoscopic radical prostatectomy: Learning curve of first 100 cases.”
Ou, Y. C., C. R. Yang, et al. (2010).
International Journal of Urology 17(7): 635-640.
Objective: Robotic-assisted laparoscopic radical prostatectomy (RALP) is gaining popularity for treating localized prostate cancer. We aimed to analyze the learning curve of a single surgeon using RALP in Taiwan. Methods: Medical records of 100 consecutive patients who underwent RALP were retrospectively reviewed. Preoperative, perioperative and postoperative parameters between patients in the first 30 cases (Group I), the second 30 cases (Group II) and cases 61-100 (Group III) undergoing RALP were analyzed. Results: Console time was shorter and blood loss was reduced in Groups II and III compared with Group I. Significant differences were found in vesicourethral anastomosis time (46.38 min for Group I vs 31.0 min for Group II vs 27 min for Group III, P < 0.01). Postoperative stay became statistically significantly shorter, from 7.33 days for Group I to 3.93 days for Group II to 3.0 days for Group III. Positive surgical margin of pT2 was reduced (13.3% for Group I, 7.1% for Group II and 0% for Group III) but not of pT3 (86.7% for Group I, 75% for Group II and 62.9% for Group III). Continence rate at 3 months was higher in Groups II (95%) and III (96.6%) than in Group 1 (76.7%, P < 0.05). Conclusions: For every 30 cases of RALP, vesicourethral anastomosis time and postoperative stay were significantly shorter. However, the incidence of surgical margin in pT3 prostate cancer was not significantly reduced. A learning curve of more than 100 cases is required to decrease the positive surgical margin in pT3 tumors. © 2010 The Japanese Urological Association.
“Erectile dysfunction in patients with prostate cancer who have undergone surgery: Systematic review of literature.”
Ruiz-Aragón, J., S. Márquez-Peláez, et al. (2010).
Disfunción eréctil en pacientes intervenidos de cáncer de próstata. Revisión sistemática de la literatura médica.
Objective: To assess erectile dysfunction in patients with prostate cancer undergoing surgery by radical prostatectomy, laparoscopic prostatectomy or robotic prostatectomy. Material and methods: Systematic Review of literature based on a search strategy (2000-10) in MedLine, Embase, Cochrane Library, CRD, ECRI, and Hayes. Mesh terms used were “Prostatectomy”, “Prostatic Neoplasm”, “Transuretral Resection Prostate”, “Impotence” and as free terms “erectile dysfunction” and “prostatectomy”. Studies included patients with prostate cancer underwent by prostatectomy radical with open surgery (retropubic), laparoscopic or robotic surgery. Results: Ten observational studies with moderate quality and 29 case series with low quality were selected. Observational studies showed lower percentages of erectile dysfunction after intervention in the patients underwent robotic surgery (3-51%). Radical surgery (36-91%) and laparoscopic surgery showed higher values of impotence. In the studies that compared surgery versus radiotherapy, the results were better for radiotherapy (3-72% erectile dysfunction). In the case series, lower percentages of erectile dysfunction were shown in patients underwent to robotic surgery (22%), the following was for laparoscopic surgery (40%) and open radical prostatectomy (41.4%). Conclusions: This result should be considered with caution because of the low methodological quality of the studies included. However, the different surgical techniques assessed showed similar effects in the two types of studies included and we found that robotic surgery presented lower percentages of sexual impotence. © 2010 AEU.
“Preemptive Multimodal Pain Regimen Reduces Opioid Analgesia for Patients Undergoing Robotic-Assisted Laparoscopic Radical Prostatectomy.”
Trabulsi, E. J., J. Patel, et al. (2010).
Urology.
Objectives: Minimally invasive surgical techniques have many benefits, including reduced postoperative pain. Despite this, most patients require opioid analgesia, which can have significant side effects and toxicity. We report the first urologic study using multimodal analgesia with pregabalin, a gabapentinoid. Methods: The present retrospective study included 60 patients who underwent robotic-assisted laparoscopic radical prostatectomy. Of the 60 patients, 30 received multimodal treatment with pregabalin 150 mg, acetaminophen 975 mg, and celecoxib 400 mg orally 2 hours before the start of the procedure and continued postoperatively. These patients were compared with 30 consecutive previous patients, who had received a standard postoperative analgesic regimen with intravenous ketorolac 15 mg every 6 hours with oxycodone 5 mg and acetaminophen 325 mg, 1 to 2 tablets, every 4 hours as needed for pain. Results: The patients in the multimodal treatment group had a significantly reduced intraoperative opioid requirement, as measured by the mean morphine equivalent dose administered (38.4 ± 2.73 mg vs 49.1 ± 2.65 mg; P < .01). The mean postoperative opioid use was also significantly reduced (10.7 ± 2.82 mg vs 26.2 ± 6.56 mg; P = .034), as was the mean total morphine equivalent dose administered (49.1 ± 2.7 mg vs 75.3 ± 4.6 mg; P < .001). The operative time, estimated operative blood loss, antiemetic use, postoperative creatinine and hemoglobin levels, and length of stay were similar in the 2 groups. No operative or treatment complications occurred in either group. Conclusions: The present retrospective review has indicated that a multimodal analgesic approach with pregabalin and celecoxib administered preoperatively decreases intraoperative and postoperative opioid use in patients undergoing robotic-assisted laparoscopic radical prostatectomy. © 2010 Elsevier Inc. All rights reserved.
“Double primary tumor of the stomach and the prostate managed robotically simultaneously.”
Yoo, J., W. Jeong, et al. (2010).
Journal of Robotic Surgery 4(1): 53-55.
The occurrence of multiple primary tumors is rare. Here we present a case of a 65-year-old male with a longstanding cardiac condition who presented with synchronous adenocarinoma of the stomach and prostate. Both cancers were managed simultaneously using robot-assisted laparoscopy techniques. Subtotal gastrectomy with gastro-jejunostomy and nerve-sparing radical prostatectomy were performed successfully. Post-operative course was likewise uneventful. Operative and oncologic outcomes were excellent with the patient cancer-free after one year of follow up. We believe the robotic system enabled us to manage this case simultaneously with excellent results. © 2010 Springer-Verlag London Ltd.
“Editorial comment re: Predictors of early urinary continence after robotic prostatectomy.”
Zorn, K. C. (2010).
Can J Urol 17(3): 5205-5206.