Abstrakt Urologie Leden 2009

“Robotic and laparoscopic radical cystectomy in the management of bladder cancer.”

Hemal (2009).

Current Urology Reports 10(1): 45-54.

To review the current status of robot-assisted and laparoscopic radical cystectomy (RARC and LRC) in the management of bladder cancer, published English literature was searched using the National Library of Medicine database. The experience with RARC is rapidly growing, and this minimally invasive option and has relatively better results than LRC. Both techniques allow an appropriate lymph node dissection in the hands of experienced and skilled surgeons at high-volume centers. The early and intermediate oncological outcomes of RARC and LRC compare favorably with open radical cystectomy (ORC). Extracorporeal urinary diversions are performed via a mini-incision in most cases and have better outcome than pure intracorporeal urinary diversions. RARC has taken over LRC at most of the centers where robot is available. The future of RARC with extracorporeal urinary diversion looks optimistic and has potential to supplant ORC, but with greater cost. © 2009 Springer Science+Business Media, LLC.

“Role of robot-assisted surgery for bladder cancer.”

Hemal (2009).

Current Opinion in Urology 19(1): 69-75.

Purpose of review: To review the developments and current status of robot-assisted radical cystectomy (RARC) with pelvic lymphadenectomy (PLND) and urinary diversion for the treatment of bladder cancer. Recent findings: RARC is growing steadily in 2008, and it is superseding pure laparoscopic radical cystectomy (LRC) at centers, where robot is available and increasingly becoming an option at major tertiary referral centers. RARC with PLND can be performed with tolerance and effectiveness. Urinary diversions with RARC are performed extracorporeally via a small incision as intracorporeal diversion takes a long operative time with associated morbidity and complications. Short-term oncologic follow-up data is satisfactory. Advantages of RARC are minimal blood loss, shorter hospital stay, quicker recovery, and possibly more precise and rapid removal of the bladder with PLND, though depends on the experience and skills of the surgeon. Summary: The future of RARC with extracorporeal reconstruction of urinary diversion (ECUD) looks optimistic as favored by the patients and surgeons alike and emerging as an alternate technique. Lack of uniform PLND, devoid of long-term oncological and functional outcome data are still issues to be answered. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Robotic-assisted partial cystectomy for recurrent extra-adrenal pheochromocytoma.”

Jayram (2009).

Journal of Robotic Surgery: 1-3.

A 27-year-old male experienced a bladder metastasis of a malignant extra-adrenal retroperitoneal pheochromocytoma 10 months after surgical resection of the primary tumor. This recurrence was managed successfully utilizing a robotic-assisted partial cystectomy with minimal morbidity and negative surgical margins. This is the first published report of robotic-assisted management of bladder pheochromocytoma. © 2009 Springer-Verlag London Ltd.

“Role of robotics for ureteral pelvic junction obstruction and ureteral pathology.”

Leveillee (2009).

Current Opinion in Urology 19(1): 81-88.

Purpose of review: To review the role of robotics for the management of ureteral pathology, in particular, ureteropelvic junction obstruction and ureteric stricture disease. Recent findings: Minimally invasive surgery has an expanding role in the management of ureteric pathology. Minimally invasive surgery modalities are associated with decreased morbidity when compared with open reconstructive techniques. Robotics solves many of the technical complexities that may be prohibitive with standard laparoscopic surgery such as intracorporeal suturing. Several studies have demonstrated equivalent or superior short-term outcomes in comparison to traditional open techniques. Encouraging long-term data are now emerging for robotic pyeloplasty. Summary: In 2008, robotic surgery appears to be a feasible and effective alternative to laparoscopy for reconstructive procedures of the ureter and may represent a potential solution to some of the drawbacks associated with ureteric reconstruction. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Pediatric Robotic-Assisted Laparoscopic Diverticulectomy.”

Meeks (2009).

Urology 73(2): 299-301.

Congenital bladder diverticula are rare anomalies of the bladder. Patients present with infection, hematuria, and/or urinary obstruction. We report on the case of a 12-year-old boy who developed gross hematuria and recurrent infection owing to a 12-cm bladder diverticulum. Robotic-assisted laparoscopic diverticulectomy was performed. We describe the first reported robotic-assisted laparoscopic diverticulectomy in a pediatric patient. © 2009 Elsevier Inc. All rights reserved.

“Robotic-assisted laparoscopic radical cystectomy: Where do we stand?”

Novara (2009).

International Journal of Clinical Practice 63(2): 185-188.

“Re: Georges-Pascal Haber, Sebastien Crouzet, Inderbir S. Gill. Laparoscopic and Robotic-Assisted Radical Cystectomy for Bladder Cancer: A Critical Analysis. Eur Urol 2008;54:54-64.”

Simonato (2009).

European Urology 55(1).

“Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes{black small square}.”

Benway (2009).

European Urology.

Background: Robotic partial nephrectomy (RPN) is emerging as an alternative to traditional laparoscopic partial nephrectomy (LPN). Despite the potential advantages of the robotic approach, renorrhaphy remains a challenging portion of the procedure. Objective: To present our technique and outcomes for RPN, including sliding-clip renorrhaphy. Design, setting, and participants: Between 2007 and 2008, 50 patients underwent RPN performed by a single attending surgeon. Surgical procedure: In this paper, we describe our technique for RPN, including a sliding-clip renorrhaphy, which is distinguished by the use of Weck Hem-O-Lock clips that are slid into place under complete control of the surgeon seated at the console and secured with a LapraTy clip. For the first 13 procedures, traditional tied-suture or assistant-placed clip closures were performed; sliding-clip renorrhaphy was performed in the remaining 37 cases. Results and limitations: Mean tumor size was 2.5 cm. Mean operative time was 145.3 min, and mean overall warm ischemia time was 17.8 min. Mean estimated blood loss was 140.3 ml. The learning curve for overall operative time was 19 cases; the learning curve for portions of the case performed under warm ischemia (including tumor resection and renorrhaphy) was 26 cases. The introduction of a sliding-clip renorrhaphy produced significant reductions in overall operative time and warm ischemia time, while blood loss and hospital stay remained stable over our experience. Limitations of RPN include cost and increased reliance on the bedside assistant. Conclusions: Sliding-clip renorrhaphy provides an efficient and effective repair that is under nearly complete control of the surgeon. This technique appears to contribute to significantly shorter overall operative times and, perhaps most critically, to shorter warm ischemia times. The learning curve for RPN using this technique appears to be foreshortened compared with LPN. © 2008 European Association of Urology.

“Robotic pyeloplasty in the pediatric population.”

Casale (2009).

Current Opinion in Urology 19(1): 97-101.

Purpose of review: Robotic technology is changing the way surgery is performed. It allows in-situ surgery as well as increased magnification and dexterity for minimally invasive surgery. The development and application of pediatric robotic urology are currently manifesting themselves with a rapid growth. Recent findings: The procedure most performed with the da Vinci system in pediatric urology is pyeloplasty for ureteropelvic junction obstruction. As with laparoscopic pyeloplasty, robotic-assisted pyeloplasty can be performed by a trans or retroperitoneal approach. Suturing is done with a 6-0 monofilament absorbable suture, but one can utilize any 5-0 or 6-0 suture depending on the size of the patient. Currently, it appears that nothing larger than 6-0 for small children and infants is recommended. Robotic-assisted pyeloplasty in children has been demonstrated to be feasible and to have satisfactory results. Summary: Although there are only a few published series on the long-term outcome to date, the short-term data suggest that outcomes are similar to those of open pyeloplasty in children, and it appears to be more than promising. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Robotic pyeloplasty in the pediatric population.”

Casale (2009).

Current Urology Reports 10(1): 55-59.

The procedure most performed with the da Vinci system (Intuitive Surgical, Sunnyvale, CA) in pediatric urology is pyeloplasty for ureteropelvic junction obstruction. As with laparoscopic pyeloplasty, robotic-assisted pyeloplasty (RAP) can be performed by a trans- or retroperitoneal approach. Suturing is done with a 6-0 monofilament absorbable suture, but any 5-0 or 6-0 suture can be used depending on the size of the patient. Currently, it appears that nothing larger than 6-0 is recommended for small children and infants. RAP in children has been demonstrated to be feasible and to have satisfactory results. Although there are only a few published series on the long-term outcome to date, the short-term data suggest that outcomes are similar to those of open pyeloplasty in children, and it appears to be more than promising. © 2009 Springer Science+Business Media, LLC.

“A prospective comparison of laparoscopic and robotic radical nephrectomy for T1-2N0M0 renal cell carcinoma.”

Hemal (2009).

World J Urol 27(1): 89-94.

OBJECTIVES: We prospectively evaluated the safety, feasibility, and efficiency of robotic radical nephrectomy (RRN) for localized renal tumors (T1-2N0M0) and compared this with laparoscopic radical nephrectomy (LRN). MATERIALS AND METHODS: Between October 2006 to August 2007, a prospective data analysis of 15 cases of renal cell carcinoma (RCC) stage T1-2N0M0, undergoing RRN was done. These patients were compared with a contemporary cohort of 15 patients of RCC with clinical stage T1-2N0M0, undergoing LRN. To keep comparison robust, all cases were performed by a single surgeon. Demographic, intra-operative, post-operative outcomes, pathological characteristics and follow-up data of the two groups were recorded and analyzed statistically. RESULTS: Patients in group A (RRN) experienced significantly (P = 0.001) long operating time than group B (LRN). However, mean estimated blood loss, intra-operative and post-operative complications, blood transfusion rate, analgesic requirement, hospital stay and convalescence were comparable in two groups (P < 0.05). There was one conversion to open surgery in group A, and none in group B. The mean follow-up was comparable in two groups (8.3 and 9.1 months, respectively, in group A and B, P = 0.09). There were no local, port-site or distal recurrences in either group. CONCLUSIONS: Robotic radical nephrectomy is a safe, feasible and effective for performing radical nephrectomy for localized RCC. Both groups (RRN and LRN) had comparable intra-operative, peri-operative, post-operative and oncological outcomes except for longer operating time with increased cost for RRN. In this comparative study, there were no outstanding benefits of RRN observed over LRN for localized RCC.

“Single-Port Laparoscopic and Robotic Partial Nephrectomy.”

Kaouk (2009).

European Urology.

Background: Partial nephrectomy (PN) for small renal masses provides effective oncologic outcomes. Single-port laparoscopic (SPL) and robotic surgeries are evolving approaches to advance minimally invasive surgery. Objective: To determine the feasibility of laparoscopic and robotic single-port PN. Design, setting, and participants: Since 2007, evaluation of patients undergoing SPL and single-port robotic (SPR) PN at a primary referral center was performed. Patients with small, solitary, exophytic-enhancing renal masses were selected. Patients with a solitary kidney, endophytic or hilar tumors, and previous abdominal and/or kidney surgery were excluded. Perioperative and pathologic data were entered prospectively into an institutional review board (IRB)-approved database. Interventions: Tumor location determined either an open Hasson transperitoneal or retroperitoneal approach. A single multichannel port or Triport provided intra-abdominal access. The Harmonic Scalpel was used for tumor excision under normal renal perfusion. The da Vinci surgical robot was used for SPR cases. Measurements: Patient demographics, perioperative, hematologic, and pathologic data as well as pain assessment using the Visual Analog Pain Scale (VAPS) were assessed. Results and limitations: A total of seven patients underwent single-port PN (SPL = 5, SPR = 2). One patient with a right anterior upper-pole mass required conversion from SPL to standard laparoscopy following tumor excision because of intraoperative bleeding. Pathology revealed six lesions compatible with renal cell carcinoma (RCC) and one benign cyst. One negative frozen section came back focally positive on final histopathology. All other surgical margins were negative. A mean difference of 3.0 ± 2.0 g/dl in hemoglobin was noted in all patients. Minimal pain was noted at discharge following both laparoscopic and robotic single-port surgery (VAPS = 1.7 ± 1.2 vs 1 ± 0.5/10). Conclusions: SPL and SPR PN is feasible for select exophytic tumors. Robotics may improve surgical capabilities during single-port surgery. © 2009 European Association of Urology.

“Robot Assisted Laparoscopic Partial Nephrectomy: A Viable and Safe Option in Children.”

Lee (2009).

Journal of Urology 181(2): 823-829.

Purpose: The safety, benefits and usefulness of laparoscopic partial nephrectomy have been demonstrated in the pediatric population. We describe our technique, and determine the safety and feasibility of robot assisted laparoscopic partial nephrectomy based on our initial experience. Materials and Methods: We retrospectively reviewed robot assisted laparoscopic partial nephrectomy performed at our institution between 2002 and 2005. The technique was conducted via a transperitoneal approach with the da Vinci® Surgical System using standard laparoscopic procedural steps. Clinical indicators of outcomes included estimated blood loss, complications, in hospital narcotic use and length of stay. Results: Robot assisted laparoscopic partial nephrectomy was completed successfully in 9 cases. Mean patient age was 7.2 years and mean followup was 6 months. Mean operative time was 275 minutes and mean estimated blood loss was 49 ml. Operative times improved significantly with experience. Overall patients had a mean hospitalization of 2.9 days and required 1.3 mg morphine per kg. All patients had a normal remaining renal moiety confirmed on Doppler ultrasound. The only complication was an asymptomatic urinoma discovered on ultrasound, which was treated with percutaneous drainage and ultimately resolved. Conclusions: Our initial experience shows the safety and feasibility of robot assisted laparoscopic partial nephrectomy in children. Operative time decreases with experience. The enhanced visualization and dexterity of a robotic system potentially offer improved efficiency and safety over standard laparoscopy. Robot assisted laparoscopy is an option for partial nephrectomy and may become the minimally invasive treatment of choice. © 2009 American Urological Association.

“Robotic-assisted Laparoscopic Partial Nephrectomy: Initial Clinical Experience.”

Michli (2009).

Urology 73(2): 302-305.

Objectives: To report on our initial experience with robotic-assisted partial nephrectomy. Laparoscopic partial nephrectomy requires experience and a lengthy learning curve to successfully accomplish tumor excision and renal reconstruction, which may adversely prolong the ischemia time. The advent of robotic-assisted laparoscopic surgery has proved successful in prostate cancer surgery, encouraging a growing number of centers to apply this technology to complex renal surgery. Methods: A total of 20 consecutive patients underwent robotic-assisted partial nephrectomy from September 2007 to April 2008. The surgical technique we used followed the standard 4-port laparoscopic partial nephrectomy technique. Renal hilum clamping was used in 12 cases. The demographic data and perioperative outcomes were retrospectively reviewed. Results: The mean patient age and body mass index was 66 years and 29 kg/m2, respectively. The mean tumor size was 2.7 cm. The mean operative and warm ischemia time was 142 and 28 minutes, respectively. The mean estimated blood loss was 263 mL, and 3 patients required a blood transfusion. One intraoperative complication required open conversion. Two postoperative complications were observed; 1 patient developed a pulmonary embolism and 1 developed an abscess at the resection site. The average hospital stay was 2.8 days. Pathologic examination of the lesions revealed 14 cases of renal cell carcinoma and 6 of benign lesions. All resection margins were free of tumor. Conclusions: The results of our study have shown that robotic partial nephrectomy is safe and practical for patients with small renal tumors considered candidates for open partial nephrectomy. In our experience, the procedure can be performed with safe ischemia time and offers all the advantages of a minimally invasive procedure. © 2009 Elsevier Inc. All rights reserved.

“Maximizing Console Surgeon Independence during Robot-Assisted Renal Surgery by Using the Fourth Arm and TileProtrade mark.”

Rogers (2009).

J Endourol 23(1): 115-22.

Purpose: We describe multiple uses of the fourth robotic arm and TileProtrade mark on the da Vinci((R)) S surgical system to maximize console surgeon independence from the assistant during robot-assisted renal surgery. Materials and Methods: We prospectively evaluated the use of the fourth robotic arm and TilePro on the da Vinci S during robot-assisted radical nephrectomy (RRN) and robot-assisted partial nephrectomy (RPN). The fourth robotic arm was used to provide kidney retraction, place the renal hilum on stretch, control vascular structures, apply and remove bulldog clamps during partial nephrectomy, and secure renal capsular stitches. TilePro was used to project intraoperative ultrasonography and preoperative CT images onto the console screen. Results: From January 2006 to June 2008, 90 robot-assisted kidney procedures were performed, of which the fourth robotic arm was used in 46 cases (RRN, 18; RPN, 24; nephroureterectomy, 4). The fourth robotic arm facilitated consistent kidney retraction for dissection of the renal hilum and mobilization of the kidney. The robotic Hem-o-Lok clip applier effectively controlled renal hilar vessels during eight RPN cases and secured renal capsular stitches during two RPN cases. Bulldog clamps were successfully applied to the renal artery during RPN using the fourth arm in two cases. TilePro was used during 22 RPN cases to project intraoperative ultrasonographic images and preoperative CT images onto the console screen as a picture-on-picture image to guide tumor resection. Conclusions: Robotic instruments used with the fourth robotic arm may give the console surgeon greater independence from the assistant during robot-assisted kidney surgery by facilitating steps such as kidney retraction, hilar dissection, and vascular control. The TilePro feature of the da Vinci S can be used to project intraoperative ultrasonography and preoperative imaging onto the console screen, potentially guiding tumor localization and resection during RPN without the need to leave the console to view external images.

“Editorial Comment on: Single-Port Laparoscopic and Robotic Partial Nephrectomy.”

Schips (2009).

European Urology.

“The role of nephron-sparing robotic surgery in the management of renal malignancy.”

Shapiro (2009).

Current Opinion in Urology 19(1): 76-80.

Purpose of review: Robotic-assisted partial nephrectomy is an emerging technique for the treatment of renal malignancy. Our aim is to review the initial reported experience with robotic partial nephrectomy, evaluating techniques, early outcomes, and potential advantages of the robotic approach over the traditional laparoscopic approach. Recent findings: Early experience with robotic partial nephrectomy demonstrates good oncologic outcomes. Other parameters, such as operative time, blood loss, postoperative renal function, and hospital stay, appear to be at least equivalent to laparoscopic partial nephrectomy. New techniques, including refined methods for Tenorrhaphy, have also been introduced which aim to simplify critical portions of the procedure, although vascular clamping still remains a challenging aspect of the procedure. The learning curve appears to be slight, even for surgeons without extensive laparoscopic experience. Summary: Although long-term outcome data is presently lacking, the early experience with robotic partial nephrectomy shows promise. The technique should continue to evolve as it gains acceptance as an alternative to the traditional laparoscopic approach. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Robotic Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma: Single-Surgeon Analysis of >100 Consecutive Procedures.”

Wang (2009).

Urology 73(2): 306-310.

Objectives: To compare a single-surgeon experience of laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN) in 102 consecutive patients. Methods: The clinical, pathologic, and follow-up information from 102 consecutive procedures (40 RPNs and 62 LPNs) was reviewed. Results: No statistically significant differences were found between the groups with regard to age, body mass index, or American Society of Anesthesiologists score. No significant difference was found between the estimated blood loss (136 vs 173 mL), tumor size (2.5 vs 2.4 cm), need for pelvicaliceal repair (56% for both), and positive margin rate (1 vs 1 patient) between RPN and LPN, respectively. The mean total number of trocars in the robotic group was greater than the laparoscopic group (4.6 vs 3.2, P = .01). The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively. Conclusions: RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed. © 2009 Elsevier Inc. All rights reserved.

“Patient perception of robotic urology.”

Bultitude (2009).

BJU International 103(3): 285-286.

“Robotic-assisted Endoscopic Inguinal Lymphadenectomy.”

Edgerton (2009).

Urology 73(1): 167-170.

Introduction: Open inguinal lymphadenectomy is a well-established therapeutic and diagnostic option for patients with invasive penile squamous cell carcinoma who are at risk of regional and distant metastases. We report the use of endoscopic robotic-assisted bilateral inguinal lymph node dissections in a patient with palpable inguinal nodes despite oral antibiotics. Technique: A 2-cm mid-thigh incision was made to develop a plane just deep to Camper’s (fatty) fascia. Once a sufficient working space was created to place 3 robotic ports and 1 assistant port, subcutaneous gas was instilled, and the robotic device was docked and used to perform the dissection. The surgical approach replicated the principles of open techniques such that the contents of the femoral canal were dissected to the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially to include both superficial and deep lymph nodes in the dissection template. Conclusions: To our knowledge, this is the first report of an endoscopic robotic-assisted inguinal lymph node dissection. A minimally invasive approach circumventing the need for thick skin flaps, the improved flexibility afforded by robotic instruments, and the improved magnification could decrease the morbidity associated with inguinal lymphadenectomy while maintaining oncologic principles. © 2009.

“Robotic single-port transumbilical surgery in humans: Initial report.”

Kaouk (2009).

BJU International 103(3): 366-369.

OBJECTIVE: To describe our initial clinical experience of robotic single-port (RSP) surgery. PATIENTS AND METHODS: The da Vinci® S robot (Intuitive, Sunnyvale, CA, USA) was used to perform radical prostatectomy (RP), dismembered pyeloplasty, and radical nephrectomy. A robot 12-mm scope and 5-mm robotic grasper were introduced through a multichannel single port (R-port, Advanced Surgical Concepts, Dublin, Ireland). An additional 5-mm or 8-mm robotic port was introduced through the same umbilical incision (2 cm) alongside the multichannel port and used to introduce robotic instruments. Vesico-urethral anastomosis and pelvi-ureteric anastomosis were successfully performed robotically using running intracorporeal suturing. RESULTS: All three RSP surgeries were performed through the single incision without adding extra umbilical ports or 2-mm instruments. For RP, the operative duration was 5 h and the estimated blood loss was 250 mL. The hospital stay was 36 h and the margins of resection were negative. For pyeloplasty, the operative duration was 4.5 h, and the hospital stay was 50 h. Right radical nephrectomy for a 5.5-cm renal cell carcinoma was performed in 2.5 h and the hospital stay was 48 h. The specimen was extracted intact within an entrapment bag through the umbilical incision. There were no intraoperative or postoperative complications. At 1 week after surgery, all patients had minimal pain with a visual analogue score of 0/10. CONCLUSIONS: Technical challenges of single-port surgery that may limit its widespread acceptance can be addressed by using robotic technology. Articulation of robotic instruments may render obsolete the long-held laparoscopic principles of triangulation especially for intracorporeal suturing. We report the initial series of robotic surgery through a single transumbilical incision. © 2008 The Authors.

“Urologic robots and future directions.”

Mozer (2009).

Current Opinion in Urology 19(1): 114-119.

Purpose of review: Robot-assisted laparoscopic surgery in urology has gained immense popularity with the daVinci system, but a lot of research teams are working on new robots. The purpose of this study is to review current urologic robots and present future development directions. Recent findings: Future systems are expected to advance in two directions: improvements of remote manipulation robots and developments of image-guided robots. Summary: The final goal of robots is to allow safer and more homogeneous outcomes with less variability of surgeon performance, as well as new tools to perform tasks on the basis of medical transcutaneous imaging, in a less invasive way, at lower costs. It is expected that improvements for a remote system could be augmented in reality, with haptic feedback, size reduction, and development of new tools for natural orifice translumenal endoscopic surgery. The paradigm of image-guided robots is close to clinical availability and the most advanced robots are presented with end-user technical assessments. It is also notable that the potential of robots lies much further ahead than the accomplishments of the daVinci system. The integration of imaging with robotics holds a substantial promise, because this can accomplish tasks otherwise impossible. Image-guided robots have the potential to offer a paradigm shift. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Surgical management of urological malignancy: Anaesthetic and critical care considerations.”

Shenoy (2009).

Current Anaesthesia and Critical Care 20(1): 22-27.

Surgical resection of urological malignancy is increasingly performed due to advances in minimal access surgery and the capability to operate on patients with greater comorbidities. The ageing population implies that these procedures may feature even more frequently in the anaesthetic workload in the future. Here we describe the major pre-operative considerations for renal, bladder, prostate and testicular tumours. An overview of each of the specific procedures involved is provided, detailing operative parameters such as monitoring and patient positioning as well as common complications. Analgesia and fluid management in the post-operative period are addressed. We also summarise adjunctive radiotherapy and chemotherapy, and comment on their implications for peri-operative management. © 2008 Elsevier Ltd. All rights reserved.

“Role of robotics in modern urologic practice.”

Su (2009).

Current Opinion in Urology 19(1): 63-64.

“Robotic and imaging in urological surgery.”

Teber (2009).

Current Opinion in Urology 19(1): 108-113.

Purpose of review: New imaging modalities and tissue navigation systems, which are adoptable to minimally invasive robotic urological surgical systems and prone to make the procedures more precise and easy, are reviewed. Recent findings: Image-guided surgery as the general name of combining information of imaging modalities with real-time surgery has already found a place in open and minimally invasive procedures. Soft tissue navigation is a complex type of computer-assisted surgery for soft tissue interventions. Robotic surgery has advantages of superior degrees of freedom and three-dimensional stereotactic user interface. A combination of surgical robotics with image-assisted surgery and soft tissue navigation may offer advantages of more precise anatomical target localization and dissection with minimal damage to the tissue. Solving the problem of organ shift and as a result, unpredictable changing of intraoperative anatomy soft tissue navigation has the potential to increase the precision of minimally invasive robotic surgery. Summary: Apart from less invasiveness, the concomitant use of minimal invasive robotic systems with soft tissue navigation enhances surgical precision. However, at present, abdominal navigation systems are in experimental use and not perfect enough for daily surgical routine. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Fiberoptic imaging for urologic surgery.”

Tuttle (2009).

Current Urology Reports 10(1): 60-64.

Laparoscopic and robot-assisted surgery is likely to be improved with the development of real-time, intraoperative imaging for diagnosis, margin determination, and anatomical definition. A significant goal of much of this effort has been focused upon providing better outcomes after radical prostatectomy. The feasibility of fluorescent imaging of labeled cavernosal nerves in the operative field has been demonstrated in vivo in animals. Other applications of the technology and capability will certainly be developed over time. This article reviews and assesses the potential and capabilities of the different imaging modes currently in use or development. © 2009 Springer Science+Business Media, LLC.

“The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference.”

Wexner (2009).

Surg Endosc 23(2): 438-43.

BACKGROUND: Despite the significant benefits of laparoscopic surgery, limitations still exist. One of these limitations is the loss of several degrees of freedom. Robotic surgery has allowed surgeons to regain the two lost degrees of freedom by introducing wristed laparoscopic instruments. METHODS: At the first Pelvic Surgery Meeting held in Brescia in June 2007, the participants focused on the role of robotic surgery in pelvic operations surgery for malignancy including prostate, rectal, uterine, and cervical carcinoma. All members of the interdisciplinary panel were asked to define the role of robotic surgery in prostate, rectal, and uterine carcinoma. All key statements were reformulated until a consensus within the group was achieved (Murphy et al., Health Technol Assess 2(i-v):1-88, 1998). For the systematic review, a comprehensive literature search was performed in Medline and the Cochrane Library from January 1997 to June 2007. The keywords used were Da Vinci, telemonitoring, laparoscopy, neoplasms for urology, colorectal, gynecology, visceral surgery, and minimally invasive surgery. The pelvic surgery meeting was supported by Olympus Medical Systems Europa. RESULTS: As of December 31, 2007, there were 795 unit shipments worldwide of the Da Vinci((R)): 595 in North America, 136 in Europe, and 64 in the rest of the world (http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359&p=irol-faq#22324 ). It was estimated that, during 2007, approximately 50,000 radical prostatectomies were performed with the Da Vinci robot system in the USA, reflecting market penetration of 60% of radical prostatectomies in the USA. This utilization represents 50% growth as in 2006 only 42% of all radical prostatectomies performed in the USA employed robotics. CONCLUSION: While robotic prostatectomy has become the most widely accepted method of prostatectomy, robotic hysterectomy and proctectomy remain far less widely accepted. The theoretical benefits of the increased degrees of freedom and three-dimensional visualization may be outweighed in these areas by the loss of haptic feedback, increased operative times, and increased cost.

“Editorial Comment on: Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up.”

Cestari (2009).

European UroProstate.

“Short- and long-term complications of open radical prostatectomy according to the Clavien classification system.”

Constantinides (2009).

BJU International 103(3): 336-340.

OBJECTIVE: To assess the use of the Clavien classification system in documenting the complications related to open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS: The medical records of 995 patients, who had open RRP during a period of 7 years, were reviewed retrospectively. Short- and long-term complications were classified according to the recently revised Clavien classification system. We also compared the results with a recently reported series of laparoscopic and robotic RRP. RESULTS: The overall complication rate was 26.9%; Grade I, Id, II, IIIa, IIIb and V complications were recorded in 3.4%, 3.9%, 12.8%, 2.6%, 3.8% and 0.3% of cases, respectively. Rectal injuries (10) and postoperative wound infections (24) were included in the Grade I category. Anastomotic leakage was recorded in 39 patients and rated as Grade Id. Grade II included cases of deep vein thrombosis (11), urinary tract infections (42), lymphorrhoeas (22) and haemorrhage requiring transfusion (53). Anastomotic strictures (26) and incisional hernias (38) were included in Grade IIIa and IIIb, respectively. Pulmonary embolism was fatal for three patients (0.3%) of Grade IV and V. CONCLUSIONS: To avoid incoherence in reporting morbidity data, a reproducible and practical classification system is necessary. The Clavien system could provide, after refinement and validation, a common language among urologists. © 2008 The Authors.

“Long-Term Impact of a Robot Assisted Laparoscopic Prostatectomy Mini Fellowship Training Program on Postgraduate Urological Practice Patterns.”

Gamboa (2009).

Journal of UroProstate 181(2): 778-782.

Purpose: Robot assisted laparoscopic prostatectomy has stimulated a great deal of interest among urologists. We evaluated whether a mini fellowship for robot assisted laparoscopic prostatectomy would enable postgraduate urologists to incorporate this new procedure into clinical practice. Materials and Methods: From July 2003 to July 2006, 47 urologists participated in the robot assisted laparoscopic prostatectomy mini fellowship program. The 5-day course had a 1:2 faculty-to-attendee ratio. The curriculum included lectures, tutorials, surgical case observation, and inanimate, animate and cadaveric robotic skill training. Questionnaires assessing practice patterns 1, 2 and 3 years after the mini fellowship program were analyzed. Results: One, 2 and 3 years after the program the response rate to the questionnaires was 89% (42 of 47 participants), 91% (32 of 35) and 88% (21 of 24), respectively. The percent of participants performing robot assisted laparoscopic prostatectomy in years 1 to 3 after the mini fellowship was 78% (33 of 42), 78% (25 of 32) and 86% (18 of 21), respectively. Among the surgeons performing the procedure there was a progressive increase in the number of cases each year with increasing time since the mini fellowship training. In the 3 attendees not performing the procedure 3 years after the mini fellowship training the reasons were lack of a robot, other partners performing it and a feeling of insufficient training to incorporate the procedure into clinical practice in 1 each. One, 2 and 3 years following the mini fellowship training program 83%, 84% and 90% of partnered attendees were performing robot assisted laparoscopic prostatectomy, while only 67%, 56% and 78% of solo attendees, respectively, were performing it at the same followup years. Conclusions: An intensive, dedicated 5-day educational course focused on learning robot assisted laparoscopic prostatectomy enabled most participants to successfully incorporate and maintain this procedure in clinical practice in the short term and long term. © 2009 American Urological Association.

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

Hakenberg (2009).

European UroProstate.

“Direct Comparison of Surgical and Functional Outcomes of Robotic-Assisted Versus Pure Laparoscopic Radical Prostatectomy: Single-Surgeon Experience.”

Hakimi (2009).

UroProstate 73(1): 119-123.

Objectives: To compare the perioperative and functional outcomes of laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic prostatectomy (RALP) in a single-surgeon series. Robotic assistance aids the laparoscopically naive surgeon in performing minimally invasive prostate surgery by offering superior visualization and dexterity. Methods: The initial 75 patients with ?12 months of functional data who had undergone RALP by a single surgeon were selected. These were compared with 75 patients who had undergone LRP from a confidential database of the same surgeon experienced in LRP toward the end of his experience with this modality (>300 cases). Results: The patients in both groups were similar with respect to age, preoperative prostate-specific antigen level, biopsy Gleason score, pathologic stage, and positive margin rate. Statistically significant differences were noted in favor of RALP vs LRP with regard to operative time (199 vs 232 minutes, P < .001), intraoperative blood loss (230 vs 311 mL, P = .004), and length of stay (1.95 vs 3.4 days, P < .0001). The 12-month continence rate was 89% after LRP and 93.3% after RALP (P = .56). The potency rate was 71.1% and 76.5% at 12 months after LRP and RALP (P = .64) for a bilateral nerve-sparing procedure, respectively. Conclusions: Our initial experience has revealed that RALP is an equivalent, if not a superior, minimally invasive surgical option for localized prostate cancer with less blood loss and a shorter operative time and length of stay. Although the potency and continence rates were comparable, a trend was noted toward a faster return of functional outcomes in our early RALP experience. © 2009.

“Malfunction of da Vinci Robotic System-Disassembled Surgeon’s Console Hand Piece: Case Report and Review of the Literature.”

Ham (2009).

UroProstate 73(1).

Recently, increasing numbers of robotic-assisted laparoscopic radical prostatectomy have been performed at many centers. Although uncommon, malfunction of the da Vinci Surgical system represents a new and unique problem in urologic surgery. In this study, we report a rare case of a disassembled surgeon’s console hand piece because of a loose screw during robotic-assisted laparoscopic radical prostatectomy. © 2009 Elsevier Inc. All rights reserved.

“Robot-Assisted Laparoscopic Prostatectomy: A Single-Institutions Learning Curve.”

Jaffe (2009).

UroProstate 73(1): 127-133.

Objectives: To evaluate the results of robot-assisted laparoscopic prostatectomy (RALP) at a high-volume conventional laparoscopic radical prostatectomy (LRP) center, to determine whether a learning curve still exists. Material and Methods: A total of 293 consecutive men underwent RALP between May 2000 and November 2006. We prospectively collected and reviewed patient data including the preoperative prostate-specific antigen (PSA) and Gleason score, operative duration, and blood loss, duration of hospitalization, and pathologic Gleason score and margin status. Results: Mean operative duration for the entire group was 158 ± 50 minutes, blood loss was 533 ± 416 mL, hospital duration was 5 days, and mean age was 61 years. Operative time showed a statistically significant decline at 2 different breakpoints: after the first 12 cases, and after 189 cases, dividing the patients into 3 groups. Operative times were 242 ± 64, 165 ± 43, and 134 ± 45 minutes, respectively, for each group. We also evaluated margin status in the 3 groups. The positive margin rate in each group was 7/12 (58%), 41/180 (23%), and 10/89 (9%), which was statistically significant. Foley catheter duration was also statistically significant among groups. Age, preoperative Gleason score, and PSA were statistically significant between the second and third groups. There was no statistical significance demonstrated in blood loss, postoperative Gleason score, and length of hospital stay. Conclusions: Urologists who are proficient in laparoscopic radical prostatectomy will still have a learning curve when first performing an RALP. Experienced laparoscopic surgeons demonstrated continued improvement in operative and pathologic parameters with regard to operative duration and positive margin rate as their experience grew. © 2009.

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

Ko (2009).

Asian J Androl.

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

“Role of robotics for prostate cancer.”

McCullough (2009).

Current Opinion in UroProstate 19(1): 65-68.

Purpose of review: To describe how robotics became involved in prostate cancer as well as to highlight the most important developments in robotic prostate cancer treatment during the last year. Recent findings: Refinements in technique during robotic-assisted laparoscopic prostatectomy have improved the early return of continence postoperatively. Mean positive surgical margin rates were lowest for robotic-assisted laparoscopic prostatectomy as compared to pure laparoscopic or open radical prostatectomy series. Sexual potency rates were similar among all surgical treatments of prostate cancer. Summary: As the implementation of robotic technologies to treat prostate cancer continues to grow, randomized controlled trials will eventually provide a better comparison of results. The role of robotics in prostate cancer treatment is established, and continued technical advancements will ultimately improve patient outcomes. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Impact of Prostate Median Lobe Anatomy on Robotic-assisted Laparoscopic Prostatectomy.”

Meeks (2009).

UroProstate 73(2): 323-327.

Objectives: Robotic-assisted laparoscopic prostatectomy (RALP) is becoming widely used for the management of prostate cancer. Although prostate size does not affect operative times for RALP, the effect of a large median prostate lobe has not been described. Methods: One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. Patients were categorized into 2 groups based on the presence or absence of a large median prostate lobe identified during RALP. The RALP was divided into sections from bladder mobilization to vesicourethral anastomosis. Operative times and outcomes were recorded prospectively. Results: Of the 154 patients, 29 (18%) of the men had large median prostate lobes. Men with large median lobes were slightly older, but had similar prostate-specific antigen, body mass index, clinical and pathologic stage, biopsy and prostatectomy Gleason grade, tumor volumes, and surgical margin rate compared with men without median lobes. Yet, prostate weight, estimated blood loss, and hospital stay was significantly greater in men with large median lobes. The overall operative time for the RALP was greater in men with a large median lobe caused by an increased time required for posterior bladder neck and seminal vesicle dissection. There was no difference in complications such as urine leaks, bladder neck contractures, and migration of Hem-o-lok clips into the bladder. Continence at 3 and 6 months after RALP were not significantly different in men with large median lobes. Conclusions: Despite equivalent oncological outcomes, we demonstrate a significant increase in operative times among men with large median lobes.

“Re: James A. Eastham, Robotic-Assisted Prostatectomy: Is There Truth in Advertising? Eur Urol 2008;54:720-2.”

Menon (2009).

European UroProstate 55(1).

“Post-radical prostatectomy management options for positive surgical margins: Argument for observation.”

Moul (2009).

Urologic Oncology: Seminars and Original Investigations 27(1): 92-96.

The screening zeal for prostate cancer in the PSA era resulted in and continues to produce an unprecedented number of men who have clinically localized prostate cancer seeking radical prostatectomy. Even before the advent of robotic laparoscopic-assisted radical prostatectomy (RALP), the topic of positive margins was hot. However, now it is even more contested in the era of the “RALP learning curve”, the era of “The role of the experienced surgeon,” and the era of the “well-informed Internet-savvy patient.” The typical modern-era man with localized prostate cancer has very high expectations. He may be a younger Baby-Boomer who has been used to getting things his way and has been raised in a consumer-driven society. He is diagnosed with prostate cancer and his knowledge-seeking behavior then may be analogous to “finding religion.” He, and/or his family, seeks “the best” surgeon and “the best” method of surgery, and he is expecting the trifecta outcome of cure, continence, and potency. The first episode to potentially deflate his sails is when the surgical pathology report returns and shows a positive margin. © 2009 Elsevier Inc. All rights reserved.

“Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up{black small square}.”

Murphy (2009).

European UroProstate.

Background: Robotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer. Objective: We report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit. Design, setting and participants: From December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases. Surgical procedure: A six port transperitoneal approach using a 4-arm da Vinci® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up. Measurements: Perioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ?0.2 ng/mL) is used as a surrogate for cancer control. Results and limitations: The mean age ± standard deviation (SD) was 60.2 ± 6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3-9.6) ng/mL. The mean operating time ± SD was 186 ± 49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively. The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR = 15-30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ?21) who underwent nerve-sparing RALP, 62% were potent at 12 months. Conclusions: The safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes. © 2008 European Association of UroProstate.

“Outcomes after robot-assisted laparoscopic radical prostatectomy.”

Murphy (2009).

Asian J Androl 11(1): 94-9.

Robot-assisted laparoscopic radical prostatectomy (RALRP) using the da Vinci surgical system is now in widespread use in many countries where economic conditions allow the installation of this expensive technology. Controversy has surrounded the procedure since it was first performed in 2000, with many critics highlighting the lack of evidence to support its use. However, despite the lack of level I evidence, many large studies of patients have confirmed that the procedure is feasible and safe, with low morbidity. Available longer-term oncological data seem to show that outcomes from the robotic approach at least match those of traditional open radical prostatectomy. Functional outcomes also seem satisfactory, although randomized controlled trials are lacking. This paper reviews the current status of RALRP with respect to perioperative data and complications and oncologic and functional outcomes.Asian Journal of Andrology (2009) 11: 94-99. doi: 10.1038/aja.2008.10; published online 1 December 2008.

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

Poel, v. d. (2009).

European UroProstate.

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

“Does 3-Dimensional (3-D) visualization improve the quality of assistance during robotic radical prostatectomy?”

Ramanathan (2009).

World J Urol 27(1): 95-9.

OBJECTIVE: 3-Dimensional (3-D) visualization by the surgeon is considered to be one of the major advantages of robotic prostatectomy. We undertook this study to see if passing on this technology to the surgical assistants would improve the efficiency of their assistance. MATERIALS AND METHODS: The study was conducted in consecutive patients undergoing robotic radical prostatectomy by the same team, in one month at our center. A 3-D head mounted device (HMD) was used by the left and/or right assistant. Video recording from these patients were studied by a blinded observer with prior training in laparoscopic surgery for the efficiency of laparoscopic moves by the two assistants. These moves were scored on a point scoring system from 0 to 100 with 100 signifying the best possible performance. RESULTS: After exclusions, 26 videos were available for review. Each patient had a right and left-sided assistant. The right-sided assistant had prior experience in Laparoscopic UroProstate, and the left-sided assistant had a relatively limited laparoscopic experience. The mean scores for the left assistant improved from 76.3 to 84.6 with the use of 3-D visualization (p < 0.002), while the improvement for the right assistant was from 84.1 to 86.9 (NS). CONCLUSIONS: The use of 3-D visualization possibly improves the efficiency of assistance during robotic radical prostatectomies, for the assistant with limited experience in laparoscopic surgery. Because of the high-quality 3-D vision provided, these HMDs have the potential to be used as teaching aids in the robotic lab.

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

Reynolds (2009).

European UroProstate.

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

Rocco (2009).

Journal of UroProstate.

“Single Institution 2-Year Patient Reported Validated Sexual Function Outcomes After Nerve Sparing Robot Assisted Radical Prostatectomy.”

Rodriguez (2009).

Journal of UroProstate 181(1): 259-263.

Purpose: To identify surgeon specific factors for preserving sexual function (and minimize patient related factors) we report 2-year potency outcomes in men 65 years or younger with normal preoperative sexual function undergoing nerve sparing robot assisted laparoscopic radical prostatectomy. Materials and Methods: Between July 2004 and February 2006, 200 consecutive patients underwent robot assisted laparoscopic radical prostatectomy by 1 surgeon. Inclusion criteria were age 65 years or younger with normal baseline 5-item International Index of Erectile Function score of 22 to 25 and complete 2-year followup. Postoperatively potency was defined by a yes to “erections adequate for vaginal penetration” and “satisfactory erections” on prospective self-administered validated questionnaires with or without phosphodiesterase type 5 medications. Men also reported 5-item International Index of Erectile Function scores and erectile fullness of 0% to 10%, 25%, 50%, 75% or 100% compared to before surgery. Results: A total of 62 patients met the inclusion criteria, and of these 3 were lost to followup and 1 was excluded from study due to receiving hormonal therapy. At 3 months 32.1% reported potency. At 24 months potency was 89.7% (52 of 58) overall, 93.0% (40 of 43) for bilateral and 80.0% (12 of 15) for unilateral nerve sparing. For potent men the mean 5-item International Index of Erectile Function score was 20.4 at 3 months vs 21.3 at 24 months. Mean erectile firmness at 24 months was 91% compared to preoperative baseline, with 34 of 52 (65%) reporting 100% of preoperative fullness. The 5-item International Index of Erectile Function score and fullness at 24 months were equivalent for unilateral nerve sparing and bilateral nerve sparing. Conclusions: Overall 90% of men reported return of potency at 24 months, and 46% returned to baseline with normal 5-item International Index of Erectile Function scores and 100% firmness. Remarkably there was no difference in 5-item International Index of Erectile Function scores or fullness between unilateral nerve sparing and bilateral nerve sparing. © 2009 American Urological Association.

“The “halo effect” in Korea: change in practice patterns since the introduction of robot-assisted laparoscopic radical prostatectomy.”

Sung (2009).

Journal of Robotic Surgery: 1-4.

Acquisition of the da Vinci surgical system (Intuitive Surgical, Mountain View, USA) has enabled robot-assisted surgery to become an acceptable alternative to open radical prostatectomy (ORP). Implementation of robotics at a single institution in Korea induced a gradual increase in the number of performances of robot-assisted laparoscopic radical prostatectomy (RALP) to surgically treat localized prostate cancer. We analyzed the impact of robotic instrumentation on practice patterns among urologists and explain the change in value in ORP and RALP-the standard treatment and the new approach or innovation of robotic technology. The overall number of prostatectomies has increased over time because the number of RALPs has grown drastically whereas the number of OPRs did not decrease during the period of evaluation. Our experience emphasizes the potential of RALP to become the gold standard in the treatment of localized prostate cancer in various parts of the world. © 2009 Springer-Verlag London Ltd.

“Minimal access surgery for cancer.”

Tewari (2009).

Journal of Surgical Oncology 99(1): 5-6.

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

Watts (2009).

International Journal of Nursing Studies.

Background: Robotic-assisted minimally invasive urologic surgery was developed to minimise surgical trauma resulting in quicker recovery. It has many potential benefits for patients with localised prostate cancer over traditional surgical techniques without taking a risk with the oncological result. Objectives: To report the specific surgical outcomes for the first Australian cohort of patients with localised prostate cancer that had undergone robotic-assisted radical prostatectomy (RARP) surgery. The outcomes represent the acute (in-hospital) recovery phase and include pain, length of stay (LOS), urinary catheter management and wound management. Methods: Prospective descriptive survey of 214 consecutive patients admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. Patients had undergone RARP surgery for localised prostate cancer. Data were collected from the medical records and through interview at the time of discharge. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency. Results: The findings from this study are highly encouraging when compared to outcomes associated with traditional surgical techniques. Transurethral catheter duration (median 7 days (IQ range 2)) and LOS (median 3 days (IQ range 2)) were considerably reduced. While operation time (median 3.30 h (IQ range 1.07)) was marginally reduced we would expect a further reduction as the surgical team becomes more skilled. Conclusion: The findings from this study contribute to building a comprehensive picture of patient outcomes in the acute (in-hospital) recovery phase for a cohort of Australian patients who have undergone RARP surgery for localised prostate cancer. As such, these findings will provide valuable information with which to plan care for patients’ who undergo robotic-assisted surgery. © 2007 Elsevier Ltd. All rights reserved.

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

White, M. A. (2009).

UroProstate.

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

“Robotic Radical Prostatectomy in Overweight and Obese Patients: Oncological and Validated-Functional Outcomes.”

Wiltz (2009).

UroProstate 73(2): 316-322.

Objectives: To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. Methods: Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal weight (BMI < 25 kg/m2), overweight (BMI = 25 to < 30 kg/m2) and obese (BMI ? 30 kg/m2) for outcomes analysis. Results: Preoperatively, obese men had a significantly greater percentage of medical comorbidities (P < .01) as well as a baseline erectile dysfunction (lower mean baseline Sexual Health Inventory for Men score [P = .01] and UCLA-PCI-SF36v2 sexual function domain scores [P = .01]). Mean operative time was significantly longer in obese patients when compared with normal and overweight men (234 minutes vs 217 minutes vs 214 minutes; P = .0003). Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all P < .05). Conclusions: In this series, obese men experienced a longer operative time, particularly during the initial robotic experience. As such, surgeons early in their RLRP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counseling. © 2009 Elsevier Inc. All rights reserved.