“Extended lymphadenectomy in bladder cancer.”
Dorin, R. P. and E. C. Skinner (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: Radical cystectomy with pelvic lymph node dissection (PLND) is the preferred treatment for invasive bladder cancer. It not only results in the best disease-free term survival rates, but also provides the most accurate disease staging and most effective local symptom control. Recent investigations have demonstrated a clinical benefit to performance of an extended PLND, including all lymphatic tissue to the level of the aortic bifurcation. This review will summarize recent findings regarding the clinical benefits of radical cystectomy with extended lymphadenectomy, and will also examine the latest surgical techniques for optimizing the performance of this technically demanding procedure. RECENT FINDINGS: Recent studies have demonstrated increased recurrence-free survival and overall survival rates in patients undergoing radical cystectomy with extended PLND, even in cases of pathologically lymph node negative disease. The growing use of minimally invasive techniques has prompted interest in robotic radical cystectomy and extended PLND, and recent reports have demonstrated the feasibility of this technique. The standardization of extended PLND templates has also been a focus of contemporary research. SUMMARY: Contemporary research strongly suggests that all patients undergoing radical cystectomy for bladder cancer should undergo concomitant extended PLND. Randomized trials are still needed to confirm the benefits of extended over ‘standard’ PLND, and to clarify which patients may receive the greatest benefit from this procedure.
“Robotic-assisted Radical Cystectomy and Orthotopic Ileal Neobladder Using a Modified Pfannenstiel Incision.”
Manoharan, M., K. T. Devendar Katkoori, et al. (2010).
Urology.
OBJECTIVES: To report our technique of robotic-assisted laparoscopic radical cystectomy with a modified Pfannenstiel incision. Robotic-assisted laparoscopic radical cystectomy has been gaining in popularity. A completely intracorporeal procedure is a technically difficult and time-consuming procedure. Most surgeons perform the diversion using a small incision, typically midline, that is also used for specimen retrieval. METHODS: Radical cystectomy and pelvic lymph node dissection was performed using a da Vinci robotic platform in a standard fashion. The robot was undocked and an 8-10 cm modified Pfannenstiel incision made. A self-retaining retractor was used to expose the wound. The specimen was extracted, and an ileal neobladder was reconstructed using the incision. RESULTS: We have performed this procedure in 14 patients to date. The mean age was 58 years (range 56-61). The mean estimated blood loss was 310 +/- 220 mL, and the mean operating time was 6 +/- 0.8 hours. No intraoperative visceral injuries were noted. None of the patients had positive surgical margins. The mean number of lymph nodes removed was 12 +/- 3. The mean hospital stay was 8.5 days. CONCLUSIONS: Our initial experience with our technique of robotic-assisted laparoscopic radical cystectomy and neobladder construction using a modified Pfannenstiel incision has been favorable. The incision provides good exposure, facilitating neobladder reconstruction, can be used for specimen retrieval, and heals better with a cosmetic scar.
“Treatment of the 2 to 3 cm renal mass.”
Aron, M., I. S. Gill, et al. (2010).
Journal of Urology 184(2): 419-422.
“Concurrent Robotic Renal and Prostatic Surgery: Initial Case Series and Safety Data of a New Surgical Technique.”
Boncher, N., G. Vricella, et al. (2010).
Journal of Endourology.
Abstract Introduction: In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. Purpose: To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. Patients and Methods: From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively. Results: Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. Conclusion: Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.
“Complications in nephron-sparing renal surgery: From description to prediction.”
Boscolo-Berto, R., M. Gardi, et al. (2010).
International Journal of Urology 17(7): 683.
“Renal artery injury during robot-assisted renal surgery.”
Lee, J. W., Y. E. Yoon, et al. (2010).
Journal of Endourology 24(7): 1101-1104.
Laparoscopic partial nephrectomy (LPN) is becoming the standard of care for incidentally diagnosed, small renal tumors. With its seven degrees of freedom and three-dimensional vision, the DaVinci robotic surgical system has been used to assist in LPNs. The main disadvantage of robot-assisted surgery, however, is the lack of tactile feedback. We present a case of renal artery injury during robot-assisted renal surgery. Robot-assisted partial nephrectomy (RPN) was planned for 47-year-old man with a 3.5-cm right renal mass. After standard bowel mobilization, renal hilar dissection was performed. In the attempt to complete the dissection posteriorly, however, there was sudden profuse bleeding. The intraperitoneal pressure immediately increased to 20 mm Hg, and an additional suction device was inserted through the 5-mm liver retractor port. On inspection, there was an injury at the takeoff of the posterior segmental artery. A decision was made to convert to robot-assisted laparoscopic radical nephrectomy. The main renal artery and renal vein were controlled with Hem-o-Lok clips. The estimated blood loss was 2,000 mL. Four units of packed red blood cells were transfused intraoperatively. The post-transfusion hemoglobin level was 12.6 g/dL. There were no other perioperative complications. The surgeon should keep in mind that the robotic arms are very powerful and can easily injure major vessels because of lack of tactile feedback. A competent and experienced tableside surgeon is very important in robot-assisted surgery because the unsterile console surgeon cannot immediately react to intraoperative complications.
“A review: the application of minimally invasive surgery to pediatric urology: upper urinary tract procedures.”
Traxel, E. J., E. A. Minevich, et al. (2010).
Urology 76(1): 122-133.
This paper is one-half of a 2 part review on minimally-invasive procedures in pediatric urology. This article focuses on upper tract procedures, including complete nephrectomy, partial nephrectomy, pyeloplasty, and ureterocalicostomy. We note important articles on pure laparoscopic as well as robotic-assisted laparoscopic upper urinary tract surgeries, concentrating on their techniques and outcomes.
“Current status of robotic partial nephrectomy.”
Van Haute, W., A. Gavazzi, et al. (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: In recent years, robotic partial nephrectomy has emerged as a technique for treatment of small renal masses alongside laparoscopic and open partial nephrectomy. Since this technique is still in a phase of adoption, many technical improvements, alterations and early experiences are published. We aim to review the recent literature, focus on recent advances in techniques and give an overview of published series. RECENT FINDINGS: Recent series confirm the feasibility of robotic partial nephrectomy and demonstrate perioperative data and short-term oncological outcomes that are at least comparable to laparoscopic series. The development of better renorrhaphy techniques and optimal use of the robotic features to gain console surgeon independence seem to be the main focus. Also alternative hilar control, early unclamping and off-clamp techniques are being developed to lower the ischaemic effect on the kidney. The learning curve seems to be less steep than laparoscopic techniques. CONCLUSION: Robotic partial nephrectomy proves to be a well tolerated and efficacious minimally invasive option in the treatment of renal lesions. Main areas of interest are decreasing warm ischaemia time and modified renal closure techniques.
“Robotic right hepatectomy for giant hemangioma in a Jehovah’s Witness.”
Giulianotti, P. C., P. Addeo, et al. (2010).
Journal of Hepato-Biliary-Pancreatic Sciences: 1-7.
Background/purpose: The use of minimally invasive surgery for the resection of benign liver tumors has increased in recent years as results show decreased abdominal damage and significant cosmetic advantages. Herein, we describe the first reported application of minimally invasive surgery for the removal of a giant symptomatic hemangioma, using robotic surgery, in a Jehovah’s Witness (JW) patient. Methods: A 32-year-old JW presented with abdominal discomfort and recent episodes of acute abdominal pain due to a giant cavernous hemangioma involving segments VI and VII of the liver. Because of the location and size of the lesion, a right hepatectomy was planned. After a careful preoperative evaluation, a robotic right hepatectomy was performed using the da Vinci Surgical System. Results: The procedure was successfully completed in minimally invasive fashion with an operative time of 310 min and with an intraoperative blood loss of only 300 ml. The postoperative course was uneventful and the patient was discharged on postoperative day 10. At 30-month follow up the patient reported complete relief of symptoms and good esthetic results. Conclusions: In experienced hands, a minimally invasive robotic major hepatic resection is a viable option that can be performed with minimal blood loss in a JW patient. A careful preoperative and intraoperative strategy is required and significant experience in liver and robotic surgery is mandatory. © 2010 Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer.
“Minimally invasive sequential treatment of synchronous colorectal liver metastases by laparoscopic colectomy and robotic right hepatectomy.”
Giulianotti, P. C., A. Giacomoni, et al. (2010).
International Journal of Colorectal Disease.
PURPOSE: The ideal timing for patients with colorectal cancer to undergo surgery for resectable synchronous liver metastases remains under debate. We describe a new sequential approach using laparoscopic/robotic surgery for the treatment of synchronous liver metastases. METHODS: A 73-year-old man presented with sigmoid cancer and a single 8-cm right liver metastasis. A staged sequential minimally invasive approach was planned. A laparoscopic left colectomy was performed first, followed by a robotic right hepatectomy 10 days later. RESULTS: The left colectomy lasted 120 min with a negligible blood loss (<10 mL). The right hepatectomy was completed robotically with an operating time of 330 min and intraoperative blood loss of 300 mL. The postoperative course was uneventful and the patient was discharged at postoperative day 8 of the liver resection. Three weeks later, the patient received adjuvant chemotherapy. At 26-months follow up, the patient was alive without recurrence. CONCLUSIONS: This report suggests the technical feasibility and safety of a sequential totally minimally invasive approach for synchronous colorectal liver metastases. In selected patients, this approach can avoid the risk of a synchronous associate major liver/colonic resection using the advantages of minimally invasive surgery.
“Robotic liver surgery.”
Idrees, K. and D. L. Bartlett (2010).
Surgical Clinics of North America 90(4): 761-774.
Although minimally invasive hepatic resection surgery has shown decreased morbidity in select patients, conventional laparoscopic liver resection has inherent limitations with reduced freedom of movement within the abdominal cavity and 2-dimensional view of the operative field. Robotic liver surgery allows surgeons to perform advanced procedures with a potential for improved precision and ergonomics as well as a 3-dimensional view of the surgical site. However, use of the robot entails a steep learning curve and additional equipment. The purpose of this article is to summarize the emerging field of robotic liver surgery and include the authors’ early experience with these operations.
“Foreword: Liver Surgery: From Basics to Robotics.”
Martin, R. F. (2010).
Surgical Clinics of North America 90(4).
“Respiratory motion control for stereotactic and robotic liver interventions.”
Widmann, G., P. Schullian, et al. (2010).
Int J Med Robot.
BACKGROUND: Control of respiratory motion is an essential prerequisite for stereotactic computer-assisted and robotic interventions in the liver. METHODS: The respiratory motion control error (RMCE) of temporary disconnections of the endotracheal tube (ETT) in anaesthetized patients has been evaluated during computer tomography (CT)-guided liver punctures. Two arterial and portal phase contrast-enhanced planning CTs were obtained during one ETT disconnection. After liver puncture, a native control CT was performed during a second ETT disconnection. By image fusion, the Euclidean errors of corresponding external and internal targets were calculated as baseline measures. RMCE was obtained by subtracting the Euclidean error during one ETT disconnection from the Euclidean error during two ETT disconnections. RESULTS: In 26 patients, the overall mean RMCE showed 1.98 +/- 0.93 (range 0.44-4.02) mm for external targets and 1.41 +/- 0.75 (range 0.46-3.18) mm for the internal targets, without significant difference in means (p = 0.558). No complications were noted. CONCLUSIONS: Temporary ETT disconnections are safe and may control respiratory motion for liver interventions within 4 mm. Copyright (c) 2010 John Wiley & Sons, Ltd.
“Concurrent Robotic Renal and Prostatic Surgery: Initial Case Series and Safety Data of a New Surgical Technique.”
Boncher, N., G. Vricella, et al. (2010).
Journal of Endourology.
Abstract Introduction: In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. Purpose: To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. Patients and Methods: From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively. Results: Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. Conclusion: Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.
“Does the presence of robotic surgery affect demographics in patients choosing to undergo radical prostatectomy? A multi-center contemporary analysis.”
Cheetham, P. J., D. J. Lee, et al. (2010).
Journal of Robotic Surgery: 1-6.
We report on differences in patient demographics in those men choosing to undergo radical prostatectomy in a UK center where there is no influence of robotic surgery and in those choosing radical prostatectomy in a US center where there is a strong robotic influence. Demographic and pathologic data were prospectively recorded in parallel for 78 consecutive men undergoing robot-assisted radical prostatectomy in a tertiary care academic US center and 69 consecutive men concurrently undergoing open radical prostatectomy in a similar UK center. Although average patient age was significantly younger in the US cohort (58.8 years, range 43.1-77.6 vs. 62.2 years, range 51.7-70.5; P = 0.002), the US cohort encompassed a wider age range and older patients than the UK cohort. Average preoperative prostate-specific antigen (PSA) was significantly lower in the US group (6.0, range 2.0-6.0 vs. 8.60, range 4.6-12.6; P < 0.01). Biopsy Gleason score, clinical stage, final pathology Gleason score, pathologic staging and positive margin rate were not significantly different between the two groups. Blood loss and transfusion rate were significantly lower in the US group. 16.7% of men in the US cohort had overall positive surgical margins compared to 29% in the UK group (P = 0.07). This data confirms our belief that patient age ranges are different in a setting influenced by robotic surgery. Although pathologic parameters were similar, the age distribution of robotic surgery patients was much wider, suggesting robotics attracts men previously reluctant to undergo surgery in the open setting or to pursue active surveillance protocols. Larger studies are needed to verify this finding. © 2010 Springer-Verlag London Ltd.
“The outcome of radical prostatectomy for patients with prostate cancer and acute urinary retention.”
Fernandez, A. and S. E. Pautler (2010).
Journal of Robotic Surgery: 1-4.
Benign prostatic hyperplasia (BPH) is the fourth most commonly diagnosed medical condition in older men. As a consequence, acute urinary retention can occur in patients with preoperative prostate cancer. Robot-assisted radical prostatectomy as a treatment modality for prostate cancer was designed to decrease operative morbidity and minimize long-term morbidity such as incontinence and erectile dysfunction. Three patients with prostate cancer coexisting with a BPH-related urinary retention managed with a clean intermittent catheterization (patient #1), and an indwelling Foley catheter (patients #2 and #3), were treated with a robot-assisted radical prostatectomy. After the procedure, the patients were able to void spontaneously, with good urine flow and reasonable bladder emptying. © 2010 Springer-Verlag London Ltd.
“Intraoperative management of robotic-assisted versus open radical prostatectomy.”
Gainsburg, D. M., D. Wax, et al. (2010).
Journal of the Society of Laparoendoscopic Surgeons 14(1): 1-5.
Background and Objectives: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for several laparoscopic procedures. We sought to retrospectively compare intraoperative surgical and anesthetic parameters, postanesthetic care unit (PACU) length of stay, and hospital length of stay of patients who underwent roboticassisted laparoscopic radical prostatectomy (RAP) versus open radical retropubic prostatectomy (ORP). Methods: A retrospective investigation was performed using a urologic surgery database and an anesthesia electronic medical record. We queried information regarding 106 ORP patients from 2002 through 2007 and 575 RAP patients from 2007 through 2008. Results: Patients in the RAP group compared with ORP patients had reductions in surgical time, anesthesia time, estimated blood loss, crystalloid administration, and PACU and hospital length of stays. Compared with ORP procedures, intraoperative respiratory rates, peak inspiratory pressures, and arterial pressures in RAP procedures were higher; tidal volumes and heart rates were decreased; but end-tidal carbon dioxide concentrations were not different. In the RAP group, intraoperative complications included severe bradycardia, corneal abrasions, and 2 patients required reintubation. Surgically, no rectal perforations were noted, and no operative mortalities occurred. Conclusions: Our data demonstrate the safety and efficacy of RAP due to a combination of surgical and anesthetic factors. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.
“Pulmonary edema after da Vinci-assisted laparoscopic radical prostatectomy: a case report.”
Hong, J. Y., Y. J. Oh, et al. (2010).
Journal of Clinical Anesthesia 22(5): 370-372.
A 63 year-old man developed sudden pulmonary edema after uneventful robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer despite normal preoperative laboratory findings and appropriate anesthetic management. The pulmonary edema was attributed to prolonged (4 hrs) pneumoperitoneum with concomitant high intraabdominal pressure (15-20 mmHg).
“Editorial comment from Dr Kadono to robotic-assisted laparoscopic radical prostatectomy: learning curve of first 100 cases.”
Kadono, Y. (2010).
International Journal of Urology 17(7): 641-642.
“Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy.”
Kim, I. Y., E. A. Hwang, et al. (2010).
Yonsei Medical Journal 51(3): 427-431.
Purpose: The objective of this study is to evaluate the continence rate following reconstruction of the posterior urethral plate in robot-assisted laparoscopic radical prostatectomy (RLRP). Materials and Methods: A retrospective analysis of 50 men with clinically localized prostate cancer who underwent RLRP was carried out. Twenty-five patients underwent RLRP using the reconstruction of the posterior aspect of the rhabdosphincter (Rocco repair). Results of 25 consecutive patients who underwent RLRP prior to the implementation of the Rocco repair were used as the control. Continence was assessed at 7, 30, 90, and 180 days following foley catheter removal using the EPIC questionnaire as well as a follow-up interview with the surgeon. Results: There was no statistically significant difference between the two groups in any of the patient demographics. At 7 days, the Rocco experimental group had a continence rate of 19% vs. 38.1% in the non-Rocco control group (p = 0.306). At 30 days, the continence rate in the Rocco group was 76.2% vs. 71.4% in the non-Rocco group (p = 1). At 90 days, the values were 88% vs. 80% (p = 0.718), respectively. At 180 days, the pad-free rate was 96% in both groups. Conclusion: Rocco repair offers no significant advantage in the time to recovery of continence following RLRP when continence is defined as the use of zero pads per day. On the other hand, Rocco repair was associated with increased incidence of urinary retention requiring prolonged foley catheter placement. © Yonsei University College of Medicine 2010.
“DaVinci robotic radical prostatectomy – Our current technique and results.”
Kolombo, I., M. Toběrný, et al. (2009).
DaVinci robotická radikální prostatektomie naše současná technika a výsledky 18(1): 28-36.
daVinci robotic radical prostatectomy is the most common urologic procedure in our Centre of robotic surgery in Hospital Na Homolce Prague. We describe our current technique and evaluate our early experience with this novel robot-assisted laparoscopic technique for radical prostatectomy that has been performed in patients with prostate cancer and with intent of curative treatment. The daVinci robotic system makes it easier to move from open to laparoscopic technique. Minimally invasive robotic assisted technique enables to limit the morbidity of open radical prostatectomy with shorter convalescence and safety for patients and shorter learning curve for surgeons.
“Editorial comment from Dr Lallas to robotic-assisted laparoscopic radical prostatectomy: learning curve of first 100 cases.”
Lallas, C. (2010).
International Journal of Urology 17(7): 640-641.
“Editorial comment from Dr Lallas to robotic-assisted laparoscopic radical prostatectomy: Learning curve of first 100 cases: Editorial comment.”
Lallas, C. (2010).
International Journal of Urology 17(7): 640-641.
“Assessing the complications of laparoscopic robot-assisted surgery: the case of radical prostatectomy.”
Lebeau, T., M. Roupret, et al. (2010).
Surgical Endoscopy.
BACKGROUND: A robot-assisted laparoscopic approach for radical prostatectomy (RALRP) is being adopted increasingly worldwide for the treatment of localized prostate cancer (CaP). Complications assessment is essential to the objective evaluation of any new procedure. This study aimed to assess the perioperative complications encountered during the implementation of a robot-assisted urologic surgery program. METHODS: A prospective data collection for all men with a diagnosis of CaP who underwent RALRP between 2005 and 2009 in our department was achieved. Together with perioperative data, all the perioperative complications encountered were specifically recorded, including robot dysfunctions. The RALRP was performed with the three-arm Da Vinci system using a transperitoneal approach with six ports. To assess the perioperative complications, the validated Clavien-Dindo classification of surgical procedures was used. Two surgeons were involved in these procedures. A modified Clavien-Dindo classification also was used to account for intraoperative complications. RESULTS: According to the Clavien-Dindo classification, 16 complications (6.7% complication rate) were recorded during the first 240 procedures. Besides postoperative complications, five procedures (2.1%) were directly affected by robot malfunctions without notable consequences for the patients. Considering these five additional complications, an 8.8% complication rate was recorded using a modified Clavien-Dindo classification. The main limitation of the study was its design restricted to RALRP procedures alone. The second limitation was that the authors’ modified classification needs to be validated with a larger series and for different surgical procedures. CONCLUSIONS: The findings show that RALRP is a safe alternative to classical surgery and that the robotic approach is reliable. The authors believe that the reliability of technological devices should be systematically discussed when outcome analysis of a new procedure is performed.
“Lessons Learned from a Case of Calf Compartment Syndrome After Robot-Assisted Laparoscopic Prostatectomy.”
Rosevear, H. M., A. J. Lightfoot, et al. (2010).
Journal of Endourology.
Abstract Robot-assisted laparoscopic prostatectomy is rapidly gaining favor as a minimally invasive method to surgically address prostate cancer. The sophisticated equipment and unique positioning requirements of this technology require exceptional preparation and attention to detail to minimize the chance of surgical complications. We present the case of a 57-year-old man who developed left calf compartment syndrome after (robot-assisted laparoscopic prostatectomy) requiring fasciotomies. We use this example to highlight specific areas of risk unique to the da Vinci Surgical System((R)) using intraoperative photos to show danger areas as well as review basic positioning requirements common to all prolonged pelvic surgeries performed in Trendelenburg position.
“Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients.”
Tewari, A. K., N. D. Patel, et al. (2010).
BJU International 106(4): 528-536.
OBJECTIVE: To analyse consecutive cases of robotic-assisted laparoscopic prostatectomy (RALP), present the incidence of nerve-sparing-related positive surgical margins (SM+), include visual cues that might assist in smoothly changing to the robotic platform, and discuss the scientific rationale for ‘intersensory integration’ which might explain the ‘reverse Braille’ phenomenon, i.e. the ability to feel when vision is greatly enhanced, as the lack of tactile feedback during RALP is often cited as a disadvantage of robotic surgery, interfering with a surgeon’s ability to make intraoperative oncological decisions. PATIENTS AND METHODS: Data from 1340 consecutive patients undergoing RALP from one institution were analysed and trends for positive posterolateral SM+ (PLSM+) were correlated with oncological variables before and after RALP. A sample of patient slides were reviewed by a extramural pathologist. Multivariate regression modelling was used to compare the projected rates of PLSM+ vs the actual rate, given the effect of a conscious effort to use visual cues. Finally, video recordings of the procedure were systematically reviewed and correlated with anatomical and histopathological images in an integrated session involving the surgeon and the pathology team. RESULTS: The incidence of PLSM+ was 2.1%, which gradually declined to 1.0% in the last 100 patients. The reduction in PLSM+ occurred despite an increased rate of high-risk tumours operated on during this period. Forecasting analysis showed that the actual PLSM+ rate declined by half in the most recent 1000 patients, due to an integrated effort involving the use of visual cues during surgery. The following visual cues were considered important; appreciation of periprostatic (lateral prostatic) fascial compartments; colour and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; and a freely separating bloodless plane showing loose shiny areolar tissue. CONCLUSION: Adapting to the robotic platform is easy and there is no compromise of the oncological safety of this procedure. Experienced surgeons can use visual cues to assist during nerve-sparing RALP and achieve low PLSM+ rates.
“A comparison of the peri-operative data after open radical retropubic prostatectomy or robotic-assisted laparoscopic prostatectomy.”
Uvin, P., J. M. De Meyer, et al. (2010).
Acta Chirurgica Belgica 110(3): 313-316.
Purposes : To compare the peri-operative biochemical data, the postoperative need for help with hygiene and mobility, and the duration of bladder catheterization, hospitalization and ICU stay of patients undergoing radical retropubic prostatectomy (RRP) versus robotic-assisted laparoscopic prostatectomy (RALP) performed by an experienced open, yet inexperienced laparoscopic, surgical team, in a peripheral low-volume urological centre. Methods : Over a 4-year period (2004-2008), 22 men underwent radical prostatectomy without lymphadenectomy at the study institution. The mean age of the patients was 63.9 years and the mean PSA value at the time of diagnosis was 9.2 ng/mL. Results : Patients in the robotic-assisted laparoscopic prostatectomy group presented a significantly lower decrease in haemoglobin, haematocrit and total plasmatic protein and a significantly smaller need for help with hygiene and mobility and a shorter duration of bladder catheterization, hospitalization and ICU stay. Conclusions : The results of this study have shown that robotic-assisted laparoscopic prostatectomy is associated with lower peri-operative morbidity and a shorter hospital stay than radical retropubic prostatectomy, even when only considering the first performed robotic-assisted laparoscopic prostatectomies by a yet inexperienced robotic team in a peripheral low-volume urological centre.