“The Learning Curve of Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium.”
Hayn, M. H., A. Hussain, et al. (2010).
European Urology.
Background: Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer. Objective: We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure. Design, setting, and participants: Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009. Measurements: Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points. Results and limitations: Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5 h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients. Conclusions: RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality. © 2010 European Association of Urology.
“Surgical Margin Status After Robot Assisted Radical Cystectomy: Results From the International Robotic Cystectomy Consortium.”
Hellenthal, N. J., A. Hussain, et al. (2010).
Journal of Urology.
Purpose: Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. Materials and Methods: Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. Results: Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. Conclusions: Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy. © 2010 American Urological Association Education and Research, Inc.
“Initial experience with robotic-assisted laparoscopic partial cystectomy in urachal diseases.”
Kim, D. K., J. W. Lee, et al. (2010).
Korean J Urol 51(5): 318-322.
PURPOSE: In this study, we report our initial experience with robot-assisted laparoscopic partial cystectomy (RLPC) in urachal diseases. MATERIALS AND METHODS: Two men and two women with a mean age of 51.5+/-9.3 years underwent RLPC between June 2009 and December 2009. In each case, a single surgeon using the da Vinci-S robotic system (Intuitive Surgical, Sunnyvale, CA, USA) used a transperitoneal approach with a 0 degrees robotic camera. After careful observation of the intravesical portion of the mass, the mass was excised by use of monopolar scissors circumferentially. The bladder was closed in two layers with watertight running sutures made with 2-0 Vicryl. RESULTS: The mean operative time was 198 minutes (range, 130-260 minutes), the mean console time was 111 minutes (range, 70-150 minutes), and the mean estimated blood loss was 155 ml. The urethral catheter was removed on postoperative day 7 after a normal cystogram, and the surgical drain was removed on postoperative day 2.5 (range, 2-3 days). The mean hospital stay was 6 days (range, 4-7 days). There were no major complications. The pathology report revealed that one patient had a urachal cystadenoma, two patients had a urachal cyst, and one patient had a patent urachus. CONCLUSIONS: Our initial experience with RLPC for benign urachal disease is that it is a safe and feasible treatment modality. However, more cases are required to confirm the efficacy of RLPC.
“Robot-assisted laparoscopic management of urachal cysts in adults.”
Lee, H. E., C. W. Jeong, et al. (2010).
Journal of Robotic Surgery: 1-3.
We report two cases where a urachal cyst was managed by robot-assisted laparoscopic surgery. A 47-year-old man and a 43-year-old woman presented with gross hematuria and lower abdominal pain, respectively. Diagnosis of urachal cyst was established by computed tomography imaging. Robot-assisted laparoscopic surgery was performed transperitoneally via four ports. Both patients were diagnosed as having a urachal cyst with inflammation. Our experience suggests that robot-assisted laparoscopic excisions of urachal cysts can be performed easily and safely in adults. © 2010 Springer-Verlag London Ltd.
“Major advances in surgical technique for the treatment of genitourinary cancers.”
Patel, M. I. and M. Frydenberg (2010).
Cancer Forum 34(1): 12-15.
There have been numerous recent advances in surgical techniques for the treatment of genitourinary cancer. The advent of robotic-assisted laparoscopic radical prostatectomy is certainly a major technical development, however its superiority over the open technique has not yet been proven. Clinical trials of focal prostate therapy have begun, utilising the latest generation of ablative technologies such as cryotherapy and high intensity focused ultrasound. Small renal masses are now managed by active surveillance, nephron sparing surgery and ablative techniques with good success. Finally, extended lymphadenectomy for bladder cancer and high risk prostate cancer not only allows better pathological staging but also improved survival.
“Robotic-Assisted Laparoscopic Intracorporeal Urinary Diversion.”
Pruthi, R. S., J. Nix, et al. (2010).
European Urology.
BACKGROUND: Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy (RALRC). In most of these series, the urinary diversion has been performed in an extracorporeal fashion. There have been few case reports of an intracorporeal diversion and little description of the technique of such a procedure. OBJECTIVE: In this paper, we report our initial experience with robotic-assisted laparoscopic intracorporeal urinary diversion, describing stepwise the surgical procedure itself and evaluating perioperative and pathologic outcomes of this novel procedure. DESIGN, SETTING, AND PARTICIPANTS: We studied a single-institution case series of patients undergoing robotic-assisted cystectomy and intracorporeal urinary diversion for clinically localized urothelial carcinoma of the bladder (n=10) or for a noncompliant dysfunctional bladder refractory to more conservative management (n=2). Historical comparisons are also made to a consecutive case series of 20 patients undergoing robotic radical cystectomy and extracorporeal urinary diversion. SURGICAL PROCEDURE: RALRC and intracorporeal urinary diversion, including ileal conduit (n=9) and orthotopic ileal neobladder (n=3). MEASUREMENTS: The stepwise operative procedure is described in detail. Outcome measures evaluated in this series included operative variables, hospital recovery, and complication rate. Comparisons were made to a contemporaneous series of 20 patients who underwent a robotic cystectomy with extracorporeal diversion during this time period (from an experience of >100 robotic cystectomy patients since 2005). RESULTS AND LIMITATIONS: Twelve patients (mean age: 60.9 yr) underwent an intracorporeal diversion. Mean operating-room time of all patients was 5.3h, and mean surgical blood loss was 221ml. Mean time to flatus, bowel movement, and hospital discharge was 2.2 d, 3.2 d, and 4.5 d, respectively. Eleven of the 12 patients were discharged on or before postoperative day 5. There were six postoperative complications in five patients (42%), with one complication being Clavien grade 3 or higher. The major limitations of the study are the small sample size and the nonrandomized nature of the compared treatment groups (intracorporeal vs extracorporeal), which limits the ability to directly compare the techniques at a high level of scientific confidence. CONCLUSIONS: Our initial experience with robotic-assisted laparoscopic intracorporeal diversion appears to be favorable with acceptable operative and short-term clinical outcomes.
“Sliding-clip renorrhaphy provides superior closing tension during robot-assisted partial nephrectomy.”
Benway, B. M., J. M. Cabello, et al. (2010).
Journal of Endourology 24(4): 605-608.
Objective: Recently, our institution refined a technique for robot-assisted renorrhaphy utilizing sliding Weck Hem-O-Lock clips, which are tightened by the surgeon seated at the console and locked into place with a LapraTy clip. In addition to the relative ease of implementation, we believe that our technique also provides a superior strength of closure over other commonly used techniques. Methods: An in vivo porcine model was used to compare a sliding-clip technique against an assistant-placed LapraTy-only closure, and a surgeon-placed simple suture closure. A force gauge was used to record the maximum tension that could be applied during each closure method before the suture ripped through the renal parenchyma, thus illustrating the relative strength of each closure. Results: The simple suture closure performed relatively poorly, ripping through parenchyma at a mean force of 11.3N. The LapraTy-only method allowed a maximum applicable mean force of 16.7N. The sliding Weck clip with a LapraTy bolster provided the tightest closure, allowing for a mean force of 32.7N before ripping through parenchyma. Statistical analysis reveals that a sliding-clip technique provides a significantly tighter closure than both of the other tested methods. Conclusion: A sliding-clip technique allows for more tension to be safely applied to the closure of a partial nephrectomy defect than other commonly used methods. We believe that this is primarily attributable to the larger footprint of the Hem-O-Lock clip, which allows for the tension to be distributed over a greater surface area. The LapraTy then ensures the security of the closure by holding the Weck clip in place. Further studies are necessary to determine if this increased tension translates into appreciably better hemostasis. © Copyright 2010, Mary Ann Liebert, Inc..
“Robotic Transabdominal Kidney Transplantation in a Morbidly Obese Patient.”
Giulianotti, P., V. Gorodner, et al. (2010).
American Journal of Transplantation.
Kidney transplantation in morbidly obese patients can be technically demanding. Furthermore, morbidly obese patients experience a high rate of wound infections and related complications, which mostly result from the longer length and extent of the incision. These complications can be avoided through minimally invasive surgery; however, conventional laparoscopic instruments are unsuitable for the safe performance of a kidney transplant in morbidly obese patients. Herein, we report the first minimally invasive, total robotic kidney transplant in a morbidly obese patient. A left, deceased donor kidney was transplanted into a 29-year-old woman with a body mass index (BMI) of 41 kg/m(2) who had been on hemodialysis for 5 years. The operation was performed intraabdominally using the DaVinci Robotic Surgical System with 4 trocars and a 7 cm midline incision. The operative time was 223 min, and the blood loss was less than 50 cc. The kidney had immediate graft function. No perioperative complications were observed, and the patient was discharged on postoperative day 5 with normal kidney function. Minimally invasive access and robotic technology facilitated the safe performance of a successful kidney transplant in a morbidly obese patient.
“Robotics Applied in Laparoscopic Kidney Surgery: The Yonsei University Experience of 127 Cases.”
Lorenzo, E. I. S., W. Jeong, et al.
(2010). Urology.
Objective: We report our experience on 127 kidney surgeries with the da Vinci surgical system and show the feasibility of a robotics application in a variety of kidney surgeries by both a laparoscopically-trained and a laparoscopically-naïve surgeon. Methods: Clinical data of patients who underwent kidney surgery with the da Vinci surgical system from September 2006 to April 2009 were reviewed. Data acquired from medical records included patient demographics, operative time, estimated blood loss (EBL), incidence of intraoperative complication, duration of hospital stay, blood transfusion rate, oncological outcomes, and follow-up results. Result: One-hundred twenty-seven kidney surgeries have been conducted with the da Vinci surgical system at our institution. Three urologists-1 with formal endourology training, 1 with laparoscopic experience, and 1 laparoscopically naïve-have used it for a variety of procedures involving the kidney. The cases include 65 partial nephrectomies (RPN), 38 radical nephrectomies (RRN), and 24 nephroureterectomies with bladder cuff (RNU). Results on operative time, EBL, incidence of intraoperative injury, duration of hospital stay, and blood transfusion rate are comparable with contemporary studies. Conclusions: Robotics application in kidney surgery is a viable option for various procedures. Our experience shows it can be safely and effectively conducted by both laparoscopically-trained and laparoscopically-naïve surgeons once they are accustomed to the robotics system. © 2010 Elsevier Inc. All rights reserved.
“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.
“A review of methods for hemostasis and renorrhaphy after laparoscopic and robot-assisted laparoscopic partial nephrectomy.”
Ramanathan, R. and R. J. Leveillee (2010).
Current Urology Reports 11(3): 208-220.
The techniques for management of small renal masses (SRMs) have evolved over the past several years. Radical nephrectomy can lead to an increased risk of chronic kidney disease, and the emphasis is now shifting to nephron-conserving techniques. Partial nephrectomy is now considered a standard of care for the management of SRMs, and laparoscopic techniques are becoming popular because they are minimally invasive. The kidneys are extremely vascular organs, and renal hemorrhage is a major cause of morbidity after laparoscopic partial nephrectomies. Control of bleeding and management of calyceal injuries can be difficult and make the procedure technically challenging. This review looks at the various modalities that are available to reduce bleeding and reviews some advances in the area of hemostatic maneuvers during laparoscopic partial nephrectomies. © 2010 Springer Science+Business Media, LLC.
“Robotic extended pyelolithotomy for complete staghorn calculus.”
Sotelo, R., J. C. Astigueta, et al. (2010).
Journal of Robotic Surgery: 1-4.
Staghorn stones represent a therapeutic challenge to urologists. We present our experience with laparoscopic extended pyelolithotomy for treatment of staghorn and complex renal calculi in highly selected cases. This approach provides the principles of open surgery with the advantages of minimally invasive surgery. We describe our experience with robot-assisted extended pyelolithotomy for complex coralliform calculi. Since January 2007, robotic extended pyelolithotomy has been performed by transperitoneal approach in two patients with complete coralliform lithiasis (calculi average size 8 cm). One patient had history of percutaneous nephrolithotomy. Demographic and operative data were collected. All procedures were technically successful without need for open conversion. Mean estimated blood loss was 175 ml (range 50-300 ml), and mean operative time was 150 min (range 120-150 min). A perinephric drain was employed in one patient with duration of 5 days. Postoperative imaging confirmed complete stone clearance. Robotic extended pyelolithotomy is a feasible and reproducible procedure for removal of complete and partial staghorn calculi in selected patients with complex nephrolithiasis. This approach might limit the role of open surgery for these calculi, but further publications with more cases are necessary to further define its utility. © 2010 Springer-Verlag London Ltd.
“Impact of surgeon and hospital volume on outcomes of radical prostatectomy.”
Barocas, D. A., R. Mitchell, et al. (2010).
Urologic Oncology: Seminars and Original Investigations 28(3): 243-250.
An emerging body of literature has established a relationship between case volume and outcomes after radical prostatectomy (RP). Such findings come in the context of an already well-established association between both surgeon and hospital case volume in the field of cardiovascular surgery and for several high-risk cancer operations. The purpose of this review is to identify and summarize the seminal studies to date that investigate the impact of RP volume on patient outcomes. We performed a literature search of the English language studies available through PubMed that pertain to this topic. Thirteen original studies and a meta-analysis were found, which focus on the impact of hospital RP volume on surgical outcomes (including length of stay, perioperative complication rate, perioperative mortality, readmission rate, and several long term measures of treatment effect). Eight studies were identified that interrogated the relationship between individual surgeon case volume and outcomes. Across multiple outcome metrics, there is a pervasive association between higher hospital RP case volume and improved outcomes. Increasing individual surgeon volume may also portend better outcomes, not only perioperatively, but even with respect to long-term cancer control and urinary function. While most data arise from retrospective cohort studies, these studies, for the most part, are of sound design, show an impressive magnitude of effect, and demonstrate an impact on outcome that is proportional to surgical volume. Further research should focus on finding a means by which to translate these observations into improvements in the quality of prostate cancer care. To address differences in outcome between low volume and high volume surgeons, some have proposed and implemented subspecialization within practice groups, while others have looked toward subspecialty certification for urologic oncologists. With regard to differences in hospital volume, regionalization of care has been proposed as a solution, but is fraught with pitfalls. It may be more pragmatic and, ultimately more beneficial to patients, however, to identify processes of care that are already in place at high volume hospitals and implement them at lower volume centers. Similarly, we advocate careful studies to identify successful surgical techniques of high volume surgeons and efforts to disseminate these techniques. © 2010 Elsevier Inc. All rights reserved.
“Surgery-related complications in 1253 robot-assisted and 485 open retropubic radical prostatectomies at the Karolinska University Hospital, Sweden.”
Carlsson, S., A. E. Nilsson, et al. (2010).
Urology 75(5): 1092-1097.
OBJECTIVES: To quantify complications to surgery in patients treated with robot-assisted radical prostatectomy (RARP) and open retropubic radical prostatectomy (RRP) at our institution. Radical prostatectomy is associated with specific complications that can affect outcome results in patients. METHODS: Between January 2002 and August 2007, a series of 1738 consecutive patients underwent RARP (n = 1253) or RRP (n = 485) for clinically localized prostate cancer. Surgery-related complications were assessed using a prospective hospital-based complication registry. The baseline characteristics of all patients were documented preoperatively. RESULTS: Overall, 170 patients required blood transfusions (9.7%), 112 patients (23%) in the RRP group compared with 58 patients (4.8%) in the RARP group. Infectious complications occurred in 44 RRP patients (9%) compared with 18 (1%) in the RARP group. Bladder neck contracture was treated in 22 (4.5%) patients who had undergone RRP compared with 3 (0.2%) in the RARP group. Clavien grade IIIb-V complications were more common in RRP patients (n = 63; 12.9%) than in RARP patients (n = 46; 3.7%). CONCLUSIONS: The introduction of RARP at our institution has resulted in decreased number of patients with Clavien grade IIIb-V complications, such as bladder neck contractures, a decrease in the number of patients who require blood transfusions, and decreased numbers of patients with postoperative wound infections.
“Predictive Factors for Positive Surgical Margins and Their Locations After Robot-Assisted Laparoscopic Radical Prostatectomy.”
Coelho, R. F., S. Chauhan, et al. (2010).
European Urology.
BACKGROUND: Positive surgical margin (PSM) after radical prostatectomy (RP) has been shown to be an independent predictive factor for cancer recurrence. Several investigations have correlated clinical and histopathologic findings with surgical margin status after open RP. However, few studies have addressed the predictive factors for PSM after robot-assisted laparoscopic RP (RARP). OBJECTIVE: We sought to identify predictive factors for PSMs and their locations after RARP. DESIGN, SETTING, AND PARTICIPANTS: We prospectively analyzed 876 consecutive patients who underwent RARP from January 2008 to May 2009. INTERVENTION: All patients underwent RARP performed by a single surgeon with previous experience of >1500 cases. MEASUREMENTS: Stepwise logistic regression was used to identify potential predictive factors for PSM. Three logistic regression models were built: (1) one using preoperative variables only, (2) another using all variables (preoperative, intraoperative, and postoperative) combined, and (3) one created to identify potential predictive factors for PSM location. Preoperative variables entered into the models included age, body mass index (BMI), prostate-specific antigen, clinical stage, number of positive cores, percentage of positive cores, and American Urological Association symptom score. Intra- and postoperative variables analyzed were type of nerve sparing, presence of median lobe, percentage of tumor in the surgical specimen, gland size, histopathologic findings, pathologic stage, and pathologic Gleason grade. RESULTS AND LIMITATIONS: In the multivariable analysis including preoperative variables, clinical stage was the only independent predictive factor for PSM, with a higher PSM rate for T3 versus T1c (odds ratio [OR]: 10.7; 95% confidence interval [CI], 2.6-43.8) and for T2 versus T1c (OR: 2.9; 95% CI, 1.9-4.6). Considering pre-, intra-, and postoperative variables combined, percentage of tumor, pathologic stage, and pathologic Gleason score were associated with increased risk of PSM in the univariable analysis (p<0.001 for all variables). However, in the multivariable analysis, pathologic stage (pT2 vs pT1; OR: 2.9; 95% CI, 1.9-4.6) and percentage of tumor in the surgical specimen (OR: 8.7; 95% CI, 2.2-34.5; p=0.0022) were the only independent predictive factors for PSM. Finally, BMI was shown to be an independent predictive factor (OR: 1.1; 95% CI, 1.0-1.3; p=0.0119) for apical PSMs, with increasing BMI predicting higher incidence of apex location. Because most of our patients were referred from other centers, the biopsy technique and the number of cores were not standardized in our series. CONCLUSIONS: Clinical stage was the only preoperative variable independently associated with PSM after RARP. Pathologic stage and percentage of tumor in the surgical specimen were identified as independent predictive factors for PSMs when analyzing pre-, intra-, and postoperative variables combined. BMI was shown to be an independent predictive factor for apical PSMs.
“Early Complication Rates in a Single-Surgeon Series of 2500 Robotic-Assisted Radical Prostatectomies: Report Applying a Standardized Grading System.”
Coelho, R. F., K. J. Palmer, et al. (2010).
European Urology.
BACKGROUND: Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. OBJECTIVE: To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed. INTERVENTION: All patients underwent RARP performed by a single surgeon. MEASUREMENTS: The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeon’s experience (number of cases). RESULTS AND LIMITATIONS: Our median operative time was 90min (interquartile range [IQR]: 75-100min). The median estimated blood loss was 100ml (IQR:100-150ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p=0.0034) and in the number of anastomotic leaks (p<0.001) as the surgeon’s experience increased. CONCLUSIONS: RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon’s experience increased.
“Reply from Authors re: Manfred P. Wirth and Michael Froehner. Radical Prostatectomy-Only Centers: The Future in Genitourinary Surgery? Eur Urol 2010;57:953-4.”
Coelho, R. F., B. Rocco, et al. (2010).
European Urology 57(6): 954-955.
“Reply from Authors re: Markus Graefen. Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: A Problem Not Only in the Robotic Literature. Eur Urol 2010;57:938-40 and Vipul P. Patel. Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: What About the Evidence for Open? Eur Urol 2010;57:941-2.”
Dahm, P. and D. C. Kang (2010).
European Urology 57(6): 943-944.
“Laparoscopic radical prostatectomy: Transfer validity.”
Erdogru, T., S. Yucel, et al. (2010).
International Journal of Urology 17(5): 476-482.
Objectives: The impact of a formal fellowship training program on the independent practice of the trainees (i.e. transfer validity) has not been evaluated. We analyzed the transfer validity of a structured curriculum in an in-door as well as an out-door setting. Methods: After completing their training, two fourth generation laparoscopic surgeons who started at the same time compared operative parameters and oncological outcomes in their independent practice, prospectively analyzing the next 100 patients in each. One surgeon continued laparoscopic radical prostatectomy (LRP) in the same center of excellence (Group-In), whereas the other implemented the procedure in a separate academic center (Group-Out). Results: The demographics for both groups (Group-In vs Group-Out) were similar regarding age, prostate volume and preoperative prostate-specific antigen levels. Mean operation times (214.8 vs 224.2 min; P = 0.494) and estimated blood loss (472.4 vs 402.6 mL; P = 0.109) did not differ significantly in both groups as well as complication rate (20 vs 24%), median catheter time (8 vs 8.5 days) and continence rates at 12 months (95 vs 95.5%). According to the pathological stages, the rates of positive surgical margins were similar for pT2 (3.2 vs 4.3%) and pT3 (42.8 vs 45.2%), respectively. Conclusions: With a well designed, long-term preclinical and clinical fellowship training program, LRP techniques can be efficiently transferred from the center of excellence to other centers with no significant impact on surgical, functional and oncological outcomes. © 2010 The Japanese Urological Association.
“Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: A Problem Not Only in the Robotic Literature.”
Graefen, M. (2010).
European Urology 57(6): 938-940.
“Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: Results of a Systematic Review of the Published Literature.”
Kang, D. C., M. J. Hardee, et al. (2010).
European Urology 57(6): 930-937.
Background: Robot-assisted laparoscopic prostatectomy (RALP) is displacing radical retropubic prostatectomy as the gold standard surgical approach for clinically localised prostate cancer in the United States and is also being increasingly used in Europe and other parts of the world. This trend has occurred despite the paucity of high-quality evidence to support its relative superiority to more established treatment modalities. Objective: We performed this study to critically assess the quality of published evidence on RALP to support this major shift in practice patterns. Design, setting, and participants: We conducted a systematic review of the published literature through Medline and Embase (1966 to December 2008). All original research publications on RALP were included. Editorials, letters to the editor, and review articles were excluded. Measurements: Two reviewers independently performed the data abstraction using a standardised form derived from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Results and limitations: Seventy-five original research publications met eligibility criteria. Fifty-five (73.3%) studies were published between 2005 and 2008, and 20 studies (26.7%) were published between 2001 and 2004. Approximately three-quarters of the studies were case series (74.7%), and only two (2.7%) randomised, controlled trials (RCT) were identified. Twelve authors cowrote 72% (54 of 75) of the published studies. Reporting of STROBE criteria ranged from 100.0% (scientific rationale/background explained) to 1.3% (consideration of sample size), with no improvement over time. The study was limited to published literature in the English language. Conclusions: The published RALP literature is limited to observational studies of mostly low methodologic quality. Our findings draw into question to what extent valid conclusions about the relative superiority or equivalence of RALP to other surgical approaches can be drawn and whether published outcomes can be generalised to the broader community. There is an urgent need to raise the methodologic standards for clinical research on new urologic procedures and devices. © 2010 European Association of Urology.
“Is robotic improve laparoscopic radical prostatectomy in complex surgical cases?”
Kermarrec, I., P. Mangin, et al. (2010).
Le robot améliore-t-il la prostatectomie totale laparoscopique dans les cas complexes ?
The radical prostatectomy is the main treatment prostate cancer in young men. However in difficult cases, another therapeutic option is often suggested. Objective: Evaluation of the quality of the anastomosis in complex surgical cases by comparing laparoscopic radical prostatectomy (LRP) to robotic assisted radical prostatectomy (RLRP). Material: From March 2004 to August 2009, 397 patients underwent radical prostatectomy: 176 LRP and 221 RLRP consecutively by the same surgeon. Antecedents that might have complicated dissection were analyzed: prostatic volume over 80 cc, previous inguinal hernia repair with mesh, previous pelvic surgery, body mass index over 30 and previous trans-uretral resection of prostate. Results: In a preoperative mode, there was no significant difference between the two groups. A multivariable analysis of the quality of the anastomosis turned to the advantage of the robot (OR = 2.56 [95 %CI: 1.28-5.25]), specifically for difficult cases (Odd Ratio = 7.736 [95 %CI: 2.689-22.254]). Conclusion: The use of the robot improved the quality of the anastomosis for patients that might have raised technical issues. © 2010.
“Robot-assisted radical prostatectomy: Perioperative complications, pathological results and functional results during the learning curve.”
Laroche, J., J. Walz, et al. (2010).
La prostatectomie totale robot-assistée : complications périopératoires, résultats anatomopathologiques et fonctionnels pendant la période d’initiation.
Objective: We report our experiences regarding the peri- and postoperative complications as well as pathological and functional results of robot-assisted radical prostatectomy during the implementation phase and the learning curve of the technique. Material: All clinical, paraclinical, as well as peri- and postoperative events of the first 102 patients were filed. Postoperative complications were classified according to the Clavien classification. Regarding functional results, continence was defined as the use of 0 pads or one pad for security reasons. Erectile function was classified into absence of spontaneous erections, erections insufficient for sexual intercourse and erections sufficient for sexual intercourse. Results: Median procedure time was 240 min, blood-loss 400 mL and transfusion rate 2%. Overall, 7.8% of all patients had perioperative complications, 13.7% had minor and 4.9% had mayor post operative complications. The overall positive surgical margin rate was 16.0%. At 12 month, 87% of all patients were continent and 21.1% had spontaneous erections and 47.4% had sexual intercourse. Conclusion: Patients treated during the implementation phase of robot-assisted radical prostatectomy show rates of peri- and postoperative complications, as well as pathological and functional results comparable to the results of centers of excellence published in the literature. © 2010 Elsevier Masson SAS. All rights reserved.
“The effect of the approach to radical prostatectomy on the profitability of hospitals and surgeons.”
Lotan, Y., C. Bolenz, et al. (2010).
BJU International 105(11): 1531-1535.
Study Type – Therapy (economics analysis) Level of Evidence 2b Objective To evaluate the profit margins for radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP), and the effect on the reimbursement to the urologist, as there has been a dramatic increase in use of RALP, with the cost of the robot borne by hospitals. METHODS Data on costs and payments to hospital and surgeon from 2003 to 2008 for RRP, LRP and RALP were obtained from the hospital and urology department. We determined the profit based on the difference between payments received and total cost. Results Between 2000 and 2008, 1279 RPs were performed at our private hospital. The introduction of RALP increased total number of RPs and replaced most RRPs. RRP represents the only procedure where payments exceed total costs. For RRP there was a significantly higher profit for patients with comorbidities. The type of payer had a large effect on profit. Medicare provides a small profit for RRP but a significant loss of >US$4000 for RALP. While all insurance companies resulted in losses for LRP and RALP, there was variability of almost $600/case for LRP and >$1400/case for RALP. RALP provided the highest reimbursement for the surgeon due to additional reimbursement for the S2900 code (use of robot). Conclusions The introduction of RALP has increased the case volume at our hospital and improved profits for the surgeon. The hospital loses money on each LRP and RALP case compared with RRP, which provides a small profit. © 2009 BJU INTERNATIONAL.
“Population based time trends and socioeconomic variation in use of radiotherapy and radical surgery for prostate cancer in a UK region: Continuous survey.”
Lyratzopoulos, G., J. M. Barbiere, et al. (2010).
BMJ: British Medical Journal 340(7753): 961.
Objective: To examine variation in the management of prostate cancer in patients with different socioeconomic status. Design: Survey using UK regional cancer registry data. Setting: Regional population based cancer registry. Participants: 35 171 patients aged ≥51 with a diagnosis of prostate cancer, 1995-2006. Main outcome measures: Use of radiotherapy and radical surgery. Socioeconomic status according to fifths of small area deprivation index. Results: Over nine years of the study, information on stage at diagnosis was available for 15 916 of 27 970 patients (57%). During the study period, the proportion of patients treated with radiotherapy remained at about 25%, while use of radical surgery increased significantly (from 2.9% (212/7201) during 1995-7 to 8.4% (854/10 211) during 2004-6, P<0.001). Both treatments were more commonly used in least deprived compared with most deprived patients (28.5% v 21.0% for radiotherapy and 8.4% v 4.0% for surgery). In multivariable analysis, increasing deprivation remained strongly associated with lower odds of radiotherapy or surgery (odds ratio 0.92 (95% confidence interval 0.90 to 0.94), P<0.001, and 0.91 (0.87 to 0.94), P<0.001, respectively, per incremental deprivation group). There were consistently concordant findings with multilevel models for clustering of observations by hospital of diagnosis, with restriction of the analysis to patients with information on stage, and with sequential restriction of the analysis to different age, stage, diagnosis period, and morphology groups. Conclusions: After a diagnosis of prostate cancer, men from lower socioeconomic groups were substantially less likely to be treated with radical surgery or radiotherapy. The causes and impact on survival of such differences remain uncertain.
“Effect of prostate gland size on the learning curve for robot-assisted laparoscopic radical prostatectomy: does size matter initially?”
Martínez, C. H., V. Chalasani, et al. (2010).
Journal of endourology / Endourological Society 24(2): 261-266.
BACKGROUND AND PURPOSE: Widespread introduction of robot-assisted laparoscopic radical prostatectomy (RALRP) has led to multiple surgeons going through the learning curve (LC). One of the recommendations for surgeons on the LC for RALRP is to choose patients with smaller glands. We evaluated our LCs to determine whether prostate size influenced intraoperative outcomes and positive surgical margin rates. PATIENTS AND METHODS: Data were obtained from a prospective database for the first 154 cases of RALRP performed by a single surgeon. Patients were divided into three groups based on prostate volume (PV): <40 cc (group 1), 40 to 60 cc (group 2), or >60 cc (group 3). PV was estimated by preoperative transrectal ultrasonography (TRUS) and correlated with pathologic weight (PW). Perioperative and immediate postoperative outcomes were evaluated. RESULTS: A statistically significant difference in total operative times between the groups (206 minutes vs 201 minutes vs 233 minutes for groups 1, 2, and 3, respectively) was noted. With regard to individual intraoperative steps, the bladder neck reconstruction and anastomosis time was longer in group 3. No other statistically significant differences were noted. The Pearson correlation coefficient between PV estimation by TRUS and PW was r = 0.785, and an additional analysis based on PW supports the results of our study. CONCLUSIONS: Prostate size influenced total operative times and the bladder neck reconstruction and anastomosis time. Our data support the use of preoperative TRUS to estimate PV and recommendations for surgeons starting on their LC to choose glands less than 60 cc.
“Erectile dysfunction after robot-assisted radical prostatectomy.”
Orvieto, M. A., R. F. Coelho, et al. (2010).
Expert Review of Anticancer Therapy 10(5): 747-754.
With younger and healthier men being diagnosed and treated for localized prostate cancer, postradical prostatectomy erectile dysfunction has become an ever more important matter of debate. However, the lack of a standardized definition for potency and no consensus regarding the optimal instrument for assessing recovery of erectile function after prostatectomy makes comparison among different series extremely difficult. The potential morbidity associated with the open surgical approach has resulted in the search for less invasive surgical options. One such option is robot-assisted radical prostatectomy (RARP) performed with the da Vinci system. In this article we critically review the current outcomes on post-RALP potency rates worldwide and compare the available data with the gold standard open RRP series. A review of the literature was performed for all published manuscripts written in English, comparative and non-comparative, between 2000 and 2009 using the keywords ‘robotic radical prostatectomy, ‘robot-assisted radical prostatectomy’, ‘nerve sparing’, ‘cavernosal nerve’ and ‘potency outcomes’, using the Medline database. Manuscripts were selected according to their relevance to the current topic (i.e., original articles, number of patients in the series and prospective data collection) and incorporated into this review. To date, many large series of RARP are mature enough and have demonstrated that potency outcomes are at least comparable to if not better than open RRP. However, there is still controversy on which form of surgical approach to the neurovascular bundles provides the best results. Prospective multi-institutional studies evaluating outcomes following different techniques need to be designed and results analyzed by an independent third party. Until then, careful patient selection and wise intraoperative clinical judgment should be made when performing nerve-sparing surgery.
“Low Quality of Evidence for Robot-Assisted Laparoscopic Prostatectomy: What About the Evidence for Open?”
Patel, V. R. (2010).
European Urology.
“Major advances in surgical technique for the treatment of genitourinary cancers.”
Patel, M. I. and M. Frydenberg (2010).
Cancer Forum 34(1): 12-15.
There have been numerous recent advances in surgical techniques for the treatment of genitourinary cancer. The advent of robotic-assisted laparoscopic radical prostatectomy is certainly a major technical development, however its superiority over the open technique has not yet been proven. Clinical trials of focal prostate therapy have begun, utilising the latest generation of ablative technologies such as cryotherapy and high intensity focused ultrasound. Small renal masses are now managed by active surveillance, nephron sparing surgery and ablative techniques with good success. Finally, extended lymphadenectomy for bladder cancer and high risk prostate cancer not only allows better pathological staging but also improved survival.
“[Complications and incidences in our first 250 robotic radical prostatectomies].”
Pereira Arias, J. G., M. Gamarra Quintanilla, et al. (2010).
Actas Urologicas Espanolas 34(5): 428-439.
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 AND 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 da Vinci 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.
“Robotic-assisted radical prostatectomy in 2010.”
Singh, I. and A. K. Hemal (2010).
Expert Review of Anticancer Therapy 10(5): 671-682.
This article reviews the current status of robotic-assisted radical prostatectomy (RARP) with outcome analysis. The published English literature (PubMed) database was searched extensively for major publications and large series on RARP. The search was carried out over the preceding 3-year period. Selected series were then reviewed, summarized and analyzed for their salient features. A literature search yielded 19 major publications on RARP in the preceding 2 years. A review of the current RARP literature (2006-2009) of multi-institutional cases of RARP demonstrated a mean operating room time, blood loss, hospital stay, positive surgical margin rate and perioperative-complication rate of approximately 194 min, 196 ml, 1.43 days, 25.7% and 5.83 %, respectively (based on the analysis of data using central tendency measures [mean]). The overall potency and continence rates were 73.6 and 87.1%, respectively (based on analysis of the published and reported data). All RARP cases were performed with the use of da Vinci robotic system (Intuitive Surgical, CA, USA). It is expected that in 2010 close to 70% of radical prostatectomies in the USA will be performed with robotic assistance. The patient and surgeon appeal for RARP continues to expand exponentially. It seems pertinent to conclude that increasing experience with RARP may reduce the incidence of positive surgical margins and will improve the functional outcome, which is the challenge at this point in time. Although the early cancer control and intermediate follow-up on functional outcome with RARP appears to be convincing and favorable, the long-term ( approximately 10 years) data are still awaited.
“The quality-of-life impact of prostate cancer treatments.”
Singh, J., E. J. Trabulsi, et al. (2010).
Current Urology Reports 11(3): 139-146.
Many options exist for the treatment of localized prostate cancer. In the decision to choose a therapeutic option for localized disease, many variables need to be considered such as tumor characteristics, clinical stage, the patient’s overall health and life expectancy, and preferences of both the physician and patient. Another important consideration is the health-related quality of life (HRQOL) implications of a given treatment option. The importance of HRQOL relative to the potential side effects of prostate cancer treatments has grown over the past few years. Although our collective awareness has increased, objective data on HRQOL for prostate cancer treatment are lacking due to a paucity of prospective clinical trial data. This review defines the concept of HRQOL, discusses what is currently known about the impact of various treatments on HRQOL, and summarizes the recent literature in this area relating to the management of localized prostate cancer. © 2010 Springer Science+Business Media, LLC.
“Radical Prostatectomy-Only Centers: The Future in Genitourinary Surgery?”
Wirth, M. P. and M. Froehner (2010).
European Urology 57(6): 953-954.
“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. © Copyright 2010, Mary Ann Liebert, Inc..