“Robot-assisted laparoscopic sacrouteropexy for pelvic organ prolapse in classical bladder exstrophy.”
Benson, A. D., B. A. Kramer, et al. (2010).
Journal of Endourology 24(4): 515-519.
Classical bladder exstrophy is a rare congenital anomaly with male predominance. When occurring in women, the accompanying anatomical and functional abnormalities, including pelvic organ prolapse (POP), may cause significant problems in both pediatric and adult patients. The robotic surgical approach to POP has not been described for bladder exstrophy as it has been in otherwise normal women. We report our technique with the first robot-assisted laparoscopic sacrouteropexy for Baden-Walker grade-four POP in an 18-year-old classical bladder exstrophy patient. At 12 months of follow-up, there were no issues or symptoms/evidence of recurrence of POP. To our knowledge, this is the first reported robot-assisted laparoscopic sacrouteropexy for POP in a previously repaired bladder exstrophy case. This procedure may be a viable option in selected patients.
“The learning curve for robot-assisted radical cystectomy.”
Guru, K. A., A. E. Perlmutter, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(4): 509-514.
Objective: Robot-assisted radical cystectomy has the potential to cure patients from bladder cancer while offering the benefits of minimally invasive surgery. We sought to evaluate the learning curve for this technically demanding procedure. Materials and Methods: Robot-assisted radical cystectomy was attempted in 100 consecutive patients. An IRBapproved review of our robot-assisted radical cystectomy database was conducted. Total operative (OR) time, cystectomy time, pelvic lymph node dissection (PLND) time, estimated blood loss (EBL), margin positivity, complications, and length of hospital stay were compared among patients divided into 4 cohorts of increasing surgical experience. Scattergrams and continuous curves were plotted to develop a robotic cystectomy learning curve. Results: Overall OR time decreased from 375 minutes in cohort 1 to 352 minutes in cohort 4, with less than 1% change in OR time after case 16. Time from incision to bladder extirpation decreased from 187 minutes in cohort one to 165 minutes in cohort 4. Time for PLND increased from 44 minutes in cohort 1 to 77 minutes in cohort 4. Lymph node yield increased from 14 nodes in cohort 1 to 23 nodes in cohort 4. Positive surgical margins decreased from 4 patients in cohort 1 to 0 patient in cohort 4. The complication rate had no change from 9 patients in cohort 1 to 9 patients in cohort 4. Conclusion: Operative results and oncologic outcomes for robot-assisted radical cystectomy constantly improve as the technique evolves. © 2009 by JSLS.
“Experience With Robot Assisted Laparoscopic Surgery for Upper and Lower Benign and Malignant Ureteral Pathologies.”
Hemal, A. K., R. Nayyar, et al. (2010).
Urology.
Objectives: To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery. Methods: We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated. Results: The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range: <50-400). There were no urine leaks. Mean drain tube duration was 1.4 days (range: 1-2.5) and mean hospital stay was 2.4 days (range: 1-6). Complications included 1 case of sepsis and 1 antibiotic-induced infection. Average follow-up period was 13.5 months. Operative success as defined by symptom resolution and imaging was 100%. Conclusions: RALS is feasible, safe, and an effective option for ureteral pathologies at any level of the ureter with minimal peri-operative morbidity. However, appropriate port placement, patient positioning, and versatile experience of team is critical in handling such cases for better outcomes. © 2010 Elsevier Inc. All rights reserved.
“Robot-assisted laparoscopic cystoprostatectomy with extended pelvic lymphadenectomy, extracorporeal enterocystoplasty, and intracorporeal enterourethral anastomosis: Initial montsouris experience*.”
Kasraeian, A., E. Barret, et al. (2010).
Journal of Endourology 24(3): 409-413.
Background and Purpose: Radical cystectomy is the gold standard for management of invasive and recurrent high-grade superficial bladder cancer. We present our initial experience with robot-assisted laparoscopic cystoprostatectomy (RALCP) with extended pelvic lymphadenectomy (epLAD) and intracorporeal enterourethral anastomosis (IEUA). A video demonstrating our technique is available online at www.liebertonline.com/end. Patients and Methods: Between April 2008 and March 2009, nine patients underwent RALCP with epLAD and IEUA at our institution. Operative technique, as described in detail (with video), was assessed for feasibility. A video demonstrating this technique is available online at www.liebertonline.com/end. Preoperative patient characteristics, operative data, as well as perioperative and pathologic outcomes were analyzed. All data were collected prospectively. Results: Median total operative time was 270 minutes (range 210-330): 60 minutes, bilateral epLAD; 90 minutes, RALCP; 60 minutes, open enterocystoplasty; 60 minutes (range 45-90), IEUA. Median blood loss was 400mL (range 200-900mL). All surgical margins were negative. Median number of lymph nodes removed was 11 (range 4-21). Postoperative complications were noted in three patients and included urinoma (n=1), pyelonephritis (n=1), and hematoma (n=1). Conclusion: RALCP is feasible and can be performed safely and effectively with acceptable operative, pathologic, and short-term clinical outcomes. More experience with longer follow-up is necessary to further assess clinical and oncologic outcomes of robotic assisted laparoscopic cystectomy for treatment of bladder cancer. © 2010, Mary Ann Liebert, Inc.
“Initial experiences with robot-assisted laparoscopic radical cystectomy.”
Kwon, S. Y., B. S. Kim, et al. (2010).
Korean Journal of Urology 51(3): 178-182.
Purpose: Robot-assisted laparoscopic radical cystectomy (RLRC) is a new option for the treatment of muscle-invasive bladder cancer, and case series for RLRC have been increasing recently. We report our operative technique and initial experiences with RLRC with extracorporeal urinary diversion. Materials and Methods: Between October 2008 and November 2009, 17 consecutive patients with muscle-invasive bladder cancer underwent RLRC, pelvic lymph node dissection, and extracorporeal urinary diversion. Urinary diversion included 13 ileal conduits and 4 orthotopic neobladders (Studer method). Data were collected prospectively on patient demographics, intraoperative parameters, pathologic staging, and postoperative outcomes. Results: The mean patient age was 63.7 years. The mean body mass index was 22.6 kg/m<sup>2</sup>. No patients had a history of previous abdominal surgery. The mean operative time was 379.1 minutes, including 32.6 minutes for pelvic lymph node dissection, 185.2 minutes for RLRC, and 159.4 minutes for urinary diversion. The mean estimated blood loss was 210.5 ml. The mean hospital stay was 20.7 days and the mean time to oral intake and ambulation was 5.0 and 1.3 days, respectively. There were no major perioperative complications. The pathologic reports showed urothelial cell carcinomas in all cases. Conclusions: Our initial clinical experiences indicate that RLRC with pelvic lymph node dissection and extracorporeal urinary diversion is a safe and feasible procedure with minimal blood loss and rapid recovery. Long-term follow up in a larger patient population is needed to determine the true oncological and functional benefit of this procedure. © The Korean Urological Association, 2010.
“Robotic Cystectomy Versus Open Cystectomy: Are We There Yet?”
Palou Redorta, J., J. M. Gaya, et al. (2010).
European Urology, Supplements 9(3): 433-437.
Introduction: Open radical cystectomy (ORC) with extended pelvic lymph node dissection (PLND) represents the treatment of choice for muscle-invasive and/or high-risk non-muscle-invasive bladder cancer (BCa), especially when it does not respond to bacillus Calmette-Guérin. However, robotic cystectomy is steadily increasing as a minimally invasive option for the management of BCa. Some studies have shown the advantages of the robotic surgery over the laparoscopic approach, including a shortened learning curve, better precision, and comfort for the surgeon. Furthermore, short-term oncologic results as well as functional results appeared to be similar to those of ORC and laparoscopic radical cystectomy. Surgical technique: The patient is placed in a Trendelenburg position and the trocars placed similarly as for prostate cancer surgery. Then, an anatomic dissection of the ureter and paravesical space allows easy section with the use of LigaSure (Covidien, Boulder, CO, USA) on all the pedicles. When the seminal vesical is reached, the section of the pedicles and the plane (interfascial or extrafascial) are developed according to a nerve-sparing or non-nerve-sparing technique. After the cystectomy, we proceed to PLND. The urinary diversion (UD) is performed extracorporeally. Results: Recent reports have demonstrated surgical and perioperative results similar to or even better than the open experience. From the oncologic point of view, there is still short follow-up in robot-assisted cystectomy, but the results about margins and the number of nodes are similar to open series. The UD is done extracorporeally to improve operative time. Preservation of the neurovascular bundle during radical cystectomy (RC) has been explored by some authors in order to maximise recovery for sexual function, and the results are promising. Postoperative complications in recent published series are globally decreased in comparison to open surgery. Further studies are warranted to validate these initial results. Conclusions: Robot-assisted laparoscopic radical cystectomy with extracorporeal UD reconstruction is slowly entering the realm of the urologist because it appears to incorporate the advantages of minimally invasive surgery with the safety of the open approach. Nevertheless, future data about long-term oncologic and functional results will have to prove the real position of robot-assisted cystectomy in the management of BCa. © 2010 European Association of Urology.
“New Developments in Renal Focal Therapy.”
Autorino, R., G. P. Haber, et al. (2010).
Journal of Endourology.
Abstract Introduction: The aim of this study was to review recent advances and to provide future perspectives in renal focal therapy. Methods: Most relevant available data from current literature and reports from major urological meetings as well as clinical and experimental experience at our institution have been considered. Results: Effective treatment of incidentally detected small renal masses continues to evolve. Major recent advances have been made toward three main directions: enhancing accuracy of probe positioning, improving ablative energy efficiency, and reducing treatment-related morbidity. Conclusions: Renal focal therapy can offer the advantage of combining a nephron-sparing surgery together with a minimally invasive approach. Technical refinements will include emerging clinical data for radiofrequency and cryoablation. Single-port access renal cryotherapy has been shown to be feasible and safe. Although in its infancy, natural orifice translumenal endoscopic surgery might represent a further step toward scarless surgery. Radiosurgery is under investigation and oncological outcomes are awaited to determine its role. Stereotactic surgical navigation and robotic needle placement would facilitate and increase the accuracy of percutaneous probe placement.
“Robotic-assisted partial nephrectomy: Surgical technique using a 3-arm approach and sliding-clip renorrhaphy.”
Cabello, J. M., B. M. Benway, et al. (2009).
International Braz J Urol 35(2): 199-204.
Introduction: For the treatment of renal tumors, minimally invasive nephron-sparing surgery has become increasingly performed due to proven efficiency and excellent functional and oncological outcomes. The introduction of robotics into urologic laparoscopic surgery has allowed surgeons to perform challenging procedures in a reliable and reproducible manner. We present our surgical technique for robotic assisted partial nephrectomy (RPN) using a 3-arm approach, including a sliding-clip renorrhaphy. Materials and Methods: Our RPN technique is presented which describes the trocar positioning, hilar dissection, tumor identification using intraoperative ultrasound for margin determination, selective vascular clamping, tumor resection, and reconstruction using a sliding-clip technique. Conclusion: RPN using a sliding-clip renorrhaphy is a valid and reproducible surgical technique that reduces the challenge of the procedure by taking advantage of the enhanced visualization and control afforded by the robot. The renorrhaphy described is performed under complete control of the console surgeon, and has demonstrated a reduction in the warm ischemia times in our series.
“Straight-arm positioning and port placement for pediatric robotic-assisted laparoscopic renal surgery.”
Chandrasoma, S., P. Kokorowski, et al. (2010).
Journal of Robotic Surgery: 1-4.
Minimally invasive procedures are gaining in popularity for application in reconstructive surgeries of the kidney in children. The use of robotic assistance for these laparoscopic procedures is an emerging option. Here, we describe our straight-arm positioning technique, which serves as a simple and effective alternative to classic flank positioning in pediatric renal cases, and the associated port placement strategies for these robotic-assisted laparoscopic reconstructive renal procedures. © 2010 Springer-Verlag London Ltd.
“Reply from Authors re: Ricardo Brandina, Inderbir S. Gill. Robotic Partial Nephrectomy: New Beginnings. Eur Urol 2010;57:778-9.”
Ficarra, V., B. M. Benway, et al. (2010).
European Urology.
“Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours.”
Mottrie, A., G. De Naeyer, et al. (2010).
European Urology.
BACKGROUND: Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses. OBJECTIVE: To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN. DESIGN, SETTING, AND PARTICIPANTS: We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience. INTERVENTIONS: The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma. MEASUREMENTS: Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied. RESULTS AND LIMITATIONS: The mean pathologic tumour size was 2.8+/-1.3cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91+/-33min (range: 52-180), with a mean WIT of 20+/-7min (range: 9-40). Warm ischaemia (<20min) and console times were optimised after the first 30 (p<0.001) and 20 cases (p<0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02+/-0.38mg/dl to 1.1+/-0.7mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17+/-29 to 80.5+/-29 (millilitres per minute per 1.73m(2)) 3 mo postoperatively. CONCLUSIONS: RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT <20min, console times <100min, limited blood loss, and acceptable overall complication rates.
“Editorial Comment on: Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours.”
Nadu, A. (2010).
European Urology.
“Robot-assisted pyeloplasty: review of the current literature, technique and outcome.”
Singh, I. and A. K. Hemal (2010).
Can J Urol 17(2): 5099-5108.
AIM: To review the global select data on the current technique, perioperative outcome and literature on the robot-assisted pyeloplasty (RAP). METHODS: The published English literature (PubMed) was extensively searched using the key words; robot, robot-assisted pyeloplasty, laparoscopy, laparoscopic pyeloplasty and ureteropelvic junction obstruction. The selected studies were then reviewed, tracked and analyzed in order to determine the current role, outcome and status of robot-assisted laparoscopic pyeloplasty. RESULTS: The search yielded about 25 published series on RAP comprising about 740 cases with a mean operative time, estimated blood loss, crossing vessel prevalence, hospital stay,perioperative complication rate and follow up duration of 194 min, 50 mL, 47%, 2.3 days, 6% and 14.9 months respectively. CONCLUSION: The initial peri-operative results and intermediate follow up of cases of repair of the ureteropelvic junction obstruction with robot-assisted pyeloplasty appear to be favorable and comparable to that of open pyeloplasty, while long term outcome data is still awaited. The da Vinci surgical robotic system is a promising surgical armamentarium in the hands of the modern day urologist for the minimally invasive definitive surgical management of both primary and secondary ureteropelvic junction obstruction.
“Surgery: Robot-assisted partial nephrectomy for large renal tumors.”
Warde, N. (2010).
Nature Reviews Urology 7(3): 120.
“Novel application of da Vinci robotic system in patients of Zinners syndrome – case report and review of literature.”
Allaparthi, S. and R. D. Blute, Jr. (2010).
Can J Urol 17(2): 5109-5113.
Seminal vesicle cysts combined with ipsilateral renal agenesis, ectopic ureter and giant right ampullary cyst of vas deferens represent a rare urological anomaly, Zinners syndrome. In symptomatic patients’ seminal vesiculectomy along with enbloc excision of the ipsilateral ampullary cyst, ectopic ureter and dysplastic, renal tissue is the preferred treatment option. We report robotic assisted removal of a large seminal vesicle cyst with ipsilateral renal agenesis, ectopic ureter and a giant right ampullary cyst of vas deferens in a 34-year-old male. We reviewed the literature about this rare urological anomaly and novel usage of da Vinci surgical robotic surgical system (DSRS) (Intuitive Surgical, Sunnyvale, California) in performing this procedure.
“The Introduction of Robot-Assisted Surgery in Urologic Practice: Why Is It So Difficult?”
Mottrie, A. M. (2010).
European Urology 57(5): 747-749.
“Reply from Authors re: Alexandre M. Mottrie. The Introduction of Robot-Assisted Surgery in Urologic Practice: Why Is It So Difficult? Eur Urol 2010;57:747-9 and Manfred P. Wirth, Michael Froehner. Robot-Assisted Radical Prostatectomy: The New Gold Standard? Eur Urol 2010;57:750-1.”
Murphy, D. G. (2010).
European Urology 57(5): 752-753.
“Evolution of open versus laparoscopic/robotic surgery: 10 years of changes in urology.”
Peña González, J. A., M. Pascual Queralt, et al. (2010).
Evolución de la cirugía abierta versus laparoscópica/robótica: 10 años de cambios en Urología.
Introduction: Laparoscopic surgery has been increasingly used in urology in recent years. Laparoscopy has been performed at our center since 2001. Changes over time in the indication of open versus laparoscopic/robotic surgery, hospital stay, and learning curve are reviewed. Materials and methods: A retrospective review of our database from 1997 to the end of 2007. A total of 3622 procedures were performed during this time (endoscopic procedures were excluded): 67,75% open, 26,17% laparoscopic, 2,29% perineal, and 3,78% robotic surgeries. Of these, 83,79% were performed in males and 16,20% in females. Mean patient age was 58,8 years. Data from the study period, including mean hospital stay and changes over time in operating time as a function of the learning curve, were analyzed and compared to data for the last 12 months of the study period. Results: The percentages of all surgical procedures performed using a laparoscopic approach in the 1997-2006 versus the last 12 study months were as follows: nephrectomy, 31,8% versus 74,7%; living donor nephrectomy, 93% versus 100%; nephroureterectomy, 28,1% vs. 93,4%; partial nephrectomy, 31,3% vs 87%; and radical prostatectomy, 17,6% versus 73,5% including laparoscopic and robotic approaches. Shorter mean hospital stays and operating times were also seen. Conclusions: Use of the laparoscopic approach has greatly increased in the 10-year period studied. In renal surgery, few indications remain for open surgery. In prostate surgery, introduction of robotic surgery in 2005 and learning of laparoscopy by several of our urologists have dramatically changed the therapeutic approach. Gradual incorporation of laparoscopic surgery has led to a decreased hospital stay and to a shortening of the learning curve. © 2009 AEU.
“Risk stratification and early oncologic outcomes following robotic prostatectomy.”
Akhavan, A., A. W. Levinson, et al. (2009).
Journal of the Society of Laparoendoscopic Surgeons 13(4): 515-521.
Background and Objectives: Although the popularity of robotic-assisted laparoscopic prostatectomy is assured, little is known about the oncologic outcomes following the procedure. Methods: We performed a retrospective cohort study including consecutive patients who underwent the surgery between 2003 and 2007 with at least 6 months of follow-up (n 464). Patients were stratified into low-, in-termediate-, and high-risk groups according to D’Amico criteria. Biochemical failure was defined as a PSA 0.2 ng/mL. Results: Of study patients, 256 (55%), 171 (37%), and 37 (8%) were classified as low-, intermediate-, and high-risk, respectively. Over a mean follow-up of 14.1 months (range, 6.0 to 55.3), 7.3% experienced biochemical failure. Biochemical disease-free survival at 30 months was 94%, 79%, and 73% among patients in the low-, intermediate-, and high-risk groups, respectively, (P 0.001). Preoperative risk stratification was strongly associated with biochemical failure, with hazard ratios of 5.04 (95%: 1.52 to 16.7; P 0.001) and 7.04 (95%: 1.39 to 35.6; P 0.001) for intermediate- and high-over low-risk groups, respectively. The ability of risk stratification to predict biochemical failure had an area under the receiver operator characteristic curve of 0.74. Conclusion: Robotic prostatectomy provides excellent cancer control outcomes for clinically localized disease. © 2009 by JSLS.
“Editorial comment.”
Cabello, J. M. and S. B. Bhayani (2009).
International Braz J Urol 35(4): 423-424.
“Reply from Authors re: Manfred P. Wirth and Michael Froehner. Radical Prostatectomy-Only Centers: The Future in Genitourinary Surgery? Eur Urol. In Press. doi:10.1016/j.eururo.2010.02.001.”
Coelho, R. F., B. Rocco, et al. (2010).
European Urology.
“The use of high resolution optical coherence tomography to evaluate robotic radical prostatectomy specimens.”
Dangle, P. P., K. K. Shah, et al. (2009).
International Braz J Urol 35(3): 344-353.
Objective: Optical coherence tomography (OCT) is a unique technology, developed to provide high resolution, cross sectional images of human tissue. The objective of this study was to explore the feasibility of OCT for the evaluation of positive surgical margins and extra capsular extension in robotic prostatectomy specimens and compare it to histopathology. Materials and Methods: Radical prostatectomy was performed in 100 patients. Twenty OCT images of each specimen were taken from the base of the seminal vesicles (SV), apical and vesicle margins, peripheral and posterolateral area and any palpable nodule. Predictions were made regarding positive surgical margin, SV involvement, capsular invasion and compared with the final histopathology. Results: A total of 2000 OCT images were taken and analyzed. Out of 100 specimens, 85 had T2 disease, 15 had T3 disease with a median Gleason’s score of 7 (range 6 to 9) and 10 had positive surgical margins. We predicted 21 specimens to have positive margins based on OCT images out of which 7 were truly positive and 14 were falsely positive. Based on OCT images, 79 specimens were predicted to have negative margins out of which 76 were truly negative and 3 were falsely negative. We found the sensitivity, specificity, positive predictive value and negative predictive value to be 70%, 84%, 33% and 96% respectively. Conclusion: Our initial feasibility study established the template for the visual OCT characteristics of the prostate, SV and cancerous tissue. The negative predictive value of evaluating surgical margins was high.
“Initial experience of teaching robot-assisted radical prostatectomy to surgeons-in-training: Can training be evaluated and standardized?”
Davis, J. W., A. Kamat, et al. (2010).
BJU International 105(8): 1148-1154.
Objective To measure the time and subjective quality of individual steps of robot-assisted radical prostatectomy (RARP), as RARP performed by trainees has recently become the most common technique of RP in the USA, and although outcomes from expert surgeons are reported, limited data are available to document training experiences. Patients and Methods The patients studied were from a prospective cohort of 178 participants (124 with training data). Transperitoneal RARP was performed by one faculty surgeon and one assistant from a rotation of four urological oncology fellows and three residents. RARP was divided into 11 steps, and staff times were recorded for each step. Trainee times and quality scores were recorded for each step, the later defined as grade A equal to staff (A+, no verbal coaching); B, minor corrections; and C, major corrections. Short-term outcomes were recorded to assess the safety of the training. Results The mean (range) console time/case of trainees was 40 (10-123) min. The median console time for a complete case by faculty and by trainees (pooled group) was 128 and 231 min, respectively, an increase in 81%. Individual trainee-performed steps increased in time (compared to staff) by a median range of 50-177%, and the incidence of quality grades < A of 9-100%. Trainee quality grades for basic tissue-dissection steps were higher than for advanced tissue dissection and suturing. There was no downgrading for a major correction. Analysis of short-term outcomes suggested acceptable results in a training environment. The study is limited by no available validated training measurement tools, and a low frequency of beginner trainees advancing to more difficult steps during the rotation. ConclusionS During the initial exposure of trainees to RARP of <40 cases, we measured time and subjective quality grading of basic steps, and introduction to advanced steps. Training requires more procedure time, but does not appear to diminish expected outcomes. © 2009 BJU International.
“Oncologic, Functional, and Cost Analysis of Open, Laparoscopic, and Robotic Radical Prostatectomy.”
Djavan, B., E. Eckersberger, et al. (2010).
European Urology, Supplements 9(3): 371-378.
Context: Although open radical retropubic prostatectomy (ORRP) remains the gold standard, the past years have seen a rise in both laparoscopic radical prostatectomy (LRP) and robot-assisted radical prostatectomy (RARP), and many patients seem to prefer the so-called minimally invasive procedures despite insufficient data demonstrating superiority over the established standard (ORRP). Objective: This article seeks to review the most recent data on a variety of aspects of the different techniques for performing prostatectomies, such as cost, oncologic outcomes, continence, quality of life, and marketing and propaganda as well as the learning curve for each. Evidence acquisition: A search of the most recent literature was performed using PubMed, and data from lectures and presentations given at international conferences were used. Evidence synthesis: The review showed that, overall, LRP and RARP outcomes have not proved superior to ORRP outcomes or resulted in anticipated benefits to patients. In addition, current data seem to suggest that results of any of the procedures depend more on the surgeon’s ability than on the approach, with rates of blood loss, positive surgical margins, incontinence, and erectile dysfunction varying widely from surgeon to surgeon with all three techniques. The aggressive marketing associated with RARP has also led to significantly higher rates of dissatisfaction and regret in patients. Conclusions: Considering the evidence, ORRP remains the gold standard in radical prostatectomies. Moreover, although the differences among major outcomes are minor and associated with shorter lengths of stay, the costs associated with LRP and RARP are significantly higher than with ORRP. In the absence of solid scientific evidence, patient education, and counselling are crucial parts of the decision-making process, during which patients will opt for one treatment over another. © 2010 European Association of Urology.
“Persisting media criticism of robot-assisted laparoscopic prostatectomy.”
Jackson, C. L. (2010).
Journal of Robotic Surgery: 1.
“Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy.”
Kalmar, A. F., L. Foubert, et al. (2010).
British Journal of Anaesthesia 104(4): 433-439.
“Robot-assisted laparoscopic cystoprostatectomy with extended pelvic lymphadenectomy, extracorporeal enterocystoplasty, and intracorporeal enterourethral anastomosis: Initial montsouris experience*.”
Kasraeian, A., E. Barret, et al. (2010).
Journal of Endourology 24(3): 409-413.
Background and Purpose: Radical cystectomy is the gold standard for management of invasive and recurrent high-grade superficial bladder cancer. We present our initial experience with robot-assisted laparoscopic cystoprostatectomy (RALCP) with extended pelvic lymphadenectomy (epLAD) and intracorporeal enterourethral anastomosis (IEUA). A video demonstrating our technique is available online at www.liebertonline.com/end. Patients and Methods: Between April 2008 and March 2009, nine patients underwent RALCP with epLAD and IEUA at our institution. Operative technique, as described in detail (with video), was assessed for feasibility. A video demonstrating this technique is available online at www.liebertonline.com/end. Preoperative patient characteristics, operative data, as well as perioperative and pathologic outcomes were analyzed. All data were collected prospectively. Results: Median total operative time was 270 minutes (range 210-330): 60 minutes, bilateral epLAD; 90 minutes, RALCP; 60 minutes, open enterocystoplasty; 60 minutes (range 45-90), IEUA. Median blood loss was 400mL (range 200-900mL). All surgical margins were negative. Median number of lymph nodes removed was 11 (range 4-21). Postoperative complications were noted in three patients and included urinoma (n=1), pyelonephritis (n=1), and hematoma (n=1). Conclusion: RALCP is feasible and can be performed safely and effectively with acceptable operative, pathologic, and short-term clinical outcomes. More experience with longer follow-up is necessary to further assess clinical and oncologic outcomes of robotic assisted laparoscopic cystectomy for treatment of bladder cancer. © 2010, Mary Ann Liebert, Inc.
“A technique to relocate the robotic prostatectomy retrieval bag to the mid-line camera port.”
Khan, M. J. and O. Karim (2010).
Annals of the Royal College of Surgeons of England 92(3): 260-261.
“Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy.”
Kordan, Y., D. A. Barocas, et al. (2010).
BJU International.
“Survey of practicing urologists: robotic versus open radical prostatectomy.”
Lee, E. K., J. Baack, et al. (2010).
Can J Urol 17(2): 5094-5098.
PURPOSE: The robotic assisted radical prostatectomy (RARP) has become the most common operative choice for localized prostate cancer. At our institution, we have also seen a substantial increase in the proportion of RARP. Possible patient factors may include marketing, increased Internet usage by patients, and patient-to-patient communication. We surveyed urologists from the central United States to determine possible surgeon factors for the popularity of the RARP. MATERIALS AND METHODS: We mailed a survey to all urologists in the South Central Section of the American Urological Association. After demographic information was obtained, participants were asked to choose an operation for themselves based on two prostate cancer scenarios; low risk and high risk. RESULTS: For the low risk prostate cancer scenario, 54.3% chose RARP while 32.9% chose a radical retropubic prostatectomy (RRP). In the high risk scenario, 32.3% chose a RARP while 58.8% chose the RRP. The top reasons for choosing robotics included decreased blood loss, better pain control, and visualization of the apex. The most popular reasons for an open operation included improved lymph node dissection, better tactile sensation, and easier operation for the surgeon. The two most important factors for choosing a particular operation were cancer control and the urologist performing the operation. Also, urologists favored the operative choice in which he or she performed. CONCLUSION: Robotic assisted radical prostatectomy has become the favored operative approach for low risk prostate cancer. However, many urologists still feel an oncologic difference may exist between open and robotic surgery as evidenced by more urologists favoring an open approach for high risk prostate cancer.
“Editorial Comment.”
Lotan, Y. (2010).
Journal of Urology 183(4): 1372.
“Complications and incidences in our first 250 robotic radical prostatectomies.”
Pereira Arias, J. G., M. Gamarra Quintanilla, et al. (2010).
Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas.
Objective: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. Materials y methods: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06-March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm daVinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. Results: Demographic data recorded included: mean age, 61.5 years (47-74); mean preoperative PSA, 8.18 ng/mL (2.6-34 ng/mL); mean Gleason grade, 6.8 (2-9); and mean prostate volume 34.9 mL (12-124). Surgical variables recorded included: console setup time, 10.8 min (6-47): console operation time, 125 min (90-315); mean bleeding, 150 mL (50-1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3-35) and urinary catheter removal after 8 (5-28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. Conclusions: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results. © 2009 AEU.
“Robot-assisted extraperitoneal laparoscopic radical prostatectomy: Experience in a high-volume laparoscopy reference centre.”
Ploussard, G., E. Xylinas, et al. (2010).
BJU International 105(8): 1155-1160.
Objective To describe our current procedure of robot-assisted laparoscopic radical prostatectomy (RALP), and to assess the effect of the learning curve on perioperative data, early oncological outcomes and functional results, as RALP has increasingly become a treatment option for men with localized prostate cancer. Patients and Methods In all, 206 consecutive men had a RALP between July 2001 and November 2008 for localized prostate cancer. Among the overall cohort, the 175 men operated on by the same surgeon were distributed into five groups according to the chronological order of the procedures. The mean follow-up after RALP was 18.3 months. Patient demographics, surgical data and postoperative variables were collected into a prospective database. Data were compared by chronological groups into single-surgeon cohort. Results The median operative time and blood loss were 140 min and 350 mL, respectively. The complication rate was 8.3%. Cancers were pT3-4 in 34.5%. The mean hospital stay and duration of bladder catheterization were 4.3 and 8.2 days, respectively. The rate of positive surgical margins (PSMs) was 17.2% in pT2 cancers. The recovery rate of continence was 98% at 12 months. Intraoperative time, blood loss and length of hospital stay were significantly improved after a short learning curve. The continence recovery, the rate and the length of PSM were also improved beyond the learning curve, but difference was not statistically significant. ConclusionS RALP is a safe and reproducible procedure and offers a short learning curve for experienced laparoscopic surgeons. Beyond the learning curve, continued experience might also provide further improvements in terms of operative, pathological and functional results. © 2009 BJU International.
“Editorial: Robotic prostatectomy: Hit or myth?”
Scardino, P. T. (2010).
Nature Reviews Urology 7(3): 115.
“Robot-assisted salvage prostatectomy: Evaluation of initial patient-reported outcomes.”
Strope, S. A., M. Coelho, et al. (2010).
Journal of Endourology 24(3): 425-427.
Background and Purpose: For patients who experience a localized recurrence after definitive radiation therapy for prostate cancer, salvage prostatectomy provides a chance for cure. We sought to assess whether robot assistance would decrease the technical challenges and mitigate the considerable morbidity associated with the procedure. Patients and Methods: Using institutional data, we identified six patients who underwent robot-assisted prostatectomy after definitive radiation therapy. For all patients, preoperative and postoperative quality of life were measured using the Sexual Health Inventory for Men and the Expanded Prostate Cancer Index Composite (EPIC). Further, intraoperative and postoperative complications were assessed. Results: Functional status of patients before robot-assisted salvage prostatectomy is compromised. Three of the six patients had extremely poor sexual function before surgery (EPIC sexual domain <50), and three-quarters had significant irritative symptoms (mean EPIC urinary irritation score 60.5). Surgery was performed safely with no intraoperative complications. Postoperative complications developed in three patients, all of whom were managed conservatively. Of the six patients, four (75%) remain free of disease; however, incontinence and erectile dysfunction were evident in all, to some degree. Conclusions: Salvage robot-assisted radical prostatectomy is a safe and effective modality for salvaging patients with localized prostate cancer after radiation. Morbidity remains high, however, likely secondary to the consequences of radiation. © 2010, Mary Ann Liebert, Inc.
“Anatomical retro-apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy.”
Tewari, A. K., A. Srivastava, et al. (2010).
BJU International.
Study Type – Therapy (case series)Level of Evidence 4 OBJECTIVE To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. PATIENTS AND METHODS Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. RESULTS Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P= 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (>/=pT3a) documented on final specimen pathology (16% vs 10%, P= 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. CONCLUSION Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.
“Robot-assisted laparoscopic radical prostatectomy in patients with prostate cancer with high-risk features: Predictors of favorable pathologic outcome.”
Uberoi, J., D. Brison, et al. (2010).
Journal of Endourology 24(3): 403-407.
Introduction: Preoperative determination of pathologic outcomes in patients with high-risk prostate cancer is challenging because of limitations of existing nomograms. We aimed to assess whether certain preoperative clinical and pathologic characteristics correlate with pathologic outcome in high-risk prostate cancer patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). Methods: A retrospective evaluation of patients with high-risk disease (prostate-specific antigen [PSA] ≥10ng/dL with high volume disease or Gleason score ≥8) who underwent RALP between December 2004 and September 2008 was conducted. Patients were grouped based on favorable pathology, including organ-confined disease and negative surgical margins (group 1), and unfavorable pathology, including positive surgical margins and extracapsular extension (group 2). Preoperative PSA levels, transrectal ultrasonography findings, and biopsy reports were compared to final pathology data. Results: Of 69 high-risk patients, 37 (54%) had favorable postoperative pathology (group 1) and 32 (46%) had unfavorable pathology (group 2). Mean PSA was 10.0ng/dL (range, 4.1-20.3) (group 1) and 13.8ng/dL (range, 3.1-39.9) (group 2). Mean PSA density was 0.28 (group 1) and 0.41 (group 2). Mean positive biopsy core was 33% (group 1) and 44% (group 2). Differences in PSA levels, PSA density, and percentage of positive cores were statistically significant (p<0.05) between the groups. Bilateral disease and high-grade prostatic intraepithelial neoplasia were not statistically significant (p>0.05). Discussion: Lower PSA level and PSA density, as well as fewer positive biopsy cores, were associated with favorable postoperative pathology. Continued surveillance of these patients will serve to determine whether these findings will assist in predicting which high-risk prostate cancer patients may likely benefit from RALP. © 2010, Mary Ann Liebert, Inc.
“Robotic-assisted laparoscopic simple prostatectomy: an alternative minimal invasive approach for prostate adenoma.”
Uffort, E. E. and J. C. Jensen (2010).
Journal of Robotic Surgery: 1-4.
To substantiate robotic-assisted laparoscopic simple prostatectomy (RLSP) as an alternative minimal invasive approach for the treatment of prostatic adenoma. Retrospective chart review performed with institutional review board (IRB) approval. Demographic and clinical data were collected on 15 men between May 2007 and October 2009 who underwent RLSP for urinary retention secondary to benign prostate hypertrophy (BPH) and complicated by significant median lobe hypertrophy, bladder diverticula and/or stones. International Prostate Symptoms Score (IPSS), postvoid residual (PVR), prostate-specific antigen (PSA) and cystoscopy, urodynamics evaluation, and operative reports were reviewed and analyzed. Average age, PSA, IPSS, and PVR in the series were 65.8 years, 5.17 ng/ml, 23.85, and 265.79 ml, respectively. Eleven men (73%) had urinary retention at presentation, 93.3% had significant intravesical lobe hypertrophy, 13.3% had bladder diverticula with/without stones, and mean prostate volume was 70.85 ml. All the men complained principally of persistent lower urinary tract symptoms (LUTS) despite maximal medical treatment. Mean operative time, estimated blood loss, and adenoma weight were 128.8 min, 139.3 ml, and 46.4 g, respectively. Mean hospital stay was 2.5 days with average postoperative Foley catheter time of 4.6 days. The only significant complication in the series was a postoperative incarcerated hernia in a patient with intraoperative repair of inguinal hernia. Postoperatively, symptom score improved significantly to an average of 8.13 (P = 0.0002), and urine residual also improved to an average of 44.19 ml (P ≤ 0.0001). Significant improvement from the sequelae of BPH can be successfully achieved with RLSP. © 2010 Springer-Verlag London Ltd.
“Robot-Assisted Radical Prostatectomy: The New Gold Standard?”
Wirth, M. P. and M. Froehner (2010).
European Urology 57(5): 750-751.
“Robotic light source failure and recovery: an innovative solution to an uncommon problem.”
Wolters, J. P., B. W. Moore, et al. (2010).
Journal of Robotic Surgery: 1-3.
Since 2003 the increasing use of robotic-assisted laparoscopic prostatectomy has been accompanied by the need to be prepared for a new set of problems in the operating room. Operative complications unique to the robot and its components are rare but can lead to case conversion and procedural abandonment. We describe an innovative solution to the uncommon problem of intraoperative robotic light source failure. Surgeons carrying out such procedures should be aware of this complication and be able to substitute a comparable light source. Possession of an appropriate type of low-cost alternative light source could prevent unnecessary procedural abandonment or open conversion in the setting of mid-operative light source failure. © 2010 Springer-Verlag London Ltd.
“Intrafascial nerve-sparing radical prostatectomy with a laparoscopic robot-assisted extraperitoneal approach: early oncological and functional results.”
Xylinas, E., G. Ploussard, et al. (2010).
Journal of Endourology 24(4): 577-582.
OBJECTIVE: We investigated whether an intrafascial approach to prostatectomy would provide significantly improved outcomes compared with retropubic and laparoscopic approaches. We performed 50 radical prostatectomies with an intrafascial, nerve-sparing, laparoscopic, robot-assisted extraperitoneal approach. METHODS: From December 2007 to June 2008, 50 consecutive patients underwent nerve sparing surgery using the intrafascial technique with robotic assistance. All surgeries were performed by the same senior urologist. Patient characteristics and perioperative data were collected prospectively. Oncological outcomes were assessed by pathological examination and postoperative prostate-specific antigen levels. Functional outcomes, including continence, potency, and quality of life, were assessed from patient questionnaires. RESULTS: The mean operative time was 127 minutes (range: 80-205), the mean hospital stay was 4.2 days (range: 2-9), and the mean catheterization time was 7.8 days (range: 4-11). No perioperative complications occurred. One patient required a transfusion at the postoperative stage. The overall positive surgical margin rate was 12%; adjusted by tumor, nodes, and metastasis stage, it was 9.5% in pT2 and 17% in pT3 disease. At the 1-month follow-up, 66% of the patients were continent (no pad), 12% presented a minimal stress urinary incontinence (1 pad), and 22% required >1 pad(s) per day. Further, 60% of patients exhibited potency (erection sufficient for intercourse: 30% without the use of phosphodiesterase 5 inhibitors, 30% required a phosphodiesterase 5 inhibitor) and the remaining 40% required prostaglandin injections. CONCLUSIONS: An intrafascial approach with robotic assistance provided satisfactory early functional results with respect to postoperative continence and potency. Long-term oncological results remain to be assessed.
“Double primary tumor of the stomach and the prostate managed robotically simultaneously.”
Yoo, J., W. Jeong, et al. (2010).
Journal of Robotic Surgery: 1-3.
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.