Abstrakt Urologie Srpen 2009 | Česká společnost robotické chirurgie ČLS JEP

Urologie”Impact of body mass index on clinical and cost outcomes after radical cystectomy.”

Bagrodia, A., S. Grover, et al. (2009).

BJU International 104(3): 326-330.

OBJECTIVE To evaluate the effect of body mass index (BMI, kg/m2) on the cost and clinical variables after radical cystectomy (RC), as studies show that obesity might adversely affect the outcomes after RC. PATIENTS AND METHODS The charts of patients who had RC from January 2004 to March 2007 were reviewed retrospectively. Complete cost and clinical information was available for 99 patients; the patient and tumour characteristics and peri-operative outcomes were recorded. Detailed cost information (room and board, laboratory, pharmacy, radiology, operating room, surgical supply, anaesthesia, and recovery room) was obtained from hospital billing. Patients were stratified and compared in three groups of BMI, i.e. normal weight (<25), overweight (25-<30) and obese (≥30). RESULTS The mean age of the patients was 66 years; 27% were normal weight, 38% were overweight and 34% were obese. Of obese patients, 24% had an Eastern Cooperative Oncology Group performance score of 0, vs none and 2.6% in the normal and overweight groups, respectively (P = 0.001). Those of normal weight had the highest overall and major complication rates (P = 0.57 and 0.28, respectively). Obese patients had insignificantly higher transfusion rates (P = 0.28). The direct cost was higher in normal weight ($14 314) than overweight ($13 808) and obese ($13 666) patients (P = 0.47). Higher room and board cost in normal-weight patients was the only significant cost difference (P = 0.008). CONCLUSION BMI was not associated with increased costs of cystectomy. The absence of differences in cost-related and clinical outcomes might be attributable to variable comorbidity among groups and the experience of a high-volume surgeon and staff at a tertiary-care referral centre that routinely cares for obese patients. © 2009 BJU INTERNATIONAL.

“Surgery Illustrated – Surgical Atlas Robotic radical cystectomy in the male.”

Buffi, N., A. Mottrie, et al. (2009).

BJU International 104(5): 726-745.

“Lower urinary tract fistula: the minimally invasive approach.”

Dorairajan, L. N. and A. K. Hemal (2009).

Curr Opin Urol.

PURPOSE OF REVIEW: A variety of fistulas occur involving the lower urinary tract with adjacent organs namely the vagina, uterus, rectum and colon. Most of these arise out of surgical complications and contribute significantly to the morbidity of the procedures. Surgical reconstruction remains the mainstay in the management. This article reviews the use of minimal-access procedures in reconstruction of lower urinary tract fistulas focusing on the bladder. RECENT FINDINGS: Recently, numerous reports of laparoscopic and robot-assisted surgical repair of these fistulas have shown that these techniques can be used with efficacy and safety with added advantages of short hospital stay, reduced morbidity associated with surgical incision and lower blood loss. Robot-assisted surgery has the advantage of facilitating intracorporeal suturing, making laparoscopic reconstruction easier. However, the steep learning curve and the high cost of robotic surgery are limiting factors. SUMMARY: Prevention of lower urinary tract fistula requires improvement in the quality and technique of surgery and minimizing surgical errors. Minimal access procedures offer surgical treatment with low morbidity but with higher cost. Open surgical repair is being used widely for treating these fistulas at this time, worldwide.

“Ureteropelvic Junction Obstruction: Which Is the Best Treatment Today?”

Gallo, F., M. Schenone, et al. (2009).

J Laparoendosc Adv Surg Tech A.

Abstract The aim of this review is to critically compare the different procedures performed for the treatment of ureteropelvic junction obstruction (UPJO) in order to identify, currently, the best treatment that a urologist should propose to patients with this condition. Three different types of procedures were assessed: open pyeloplasty (OP), endopyelotomy, and laparoscopic pyeloplasty (LP). Regarding efficacy, success rates of 94.1, 62-83, and 95.9-97.2% were reported for OP, endopyelotomy, and LP, respectively. Concerning operative time and length of hospital stay, no extensive data are available in the literature, although endopyelotomy seems to provide shorter times with respect to those reported after OP and LP. Regarding the complication rate, it was very similar after the different techniques and due to the respective approaches. Overall, our data support the conclusion that LP provided a balance between the highly successful technique reported by OP and the quick postoperative recovery provided by the endoscopic approach. Anyway, in spite of these clear advantages, the reproducibility of LP is still strongly limited by the challenge of the learning curve. The da Vinci((R)) robot (Intuitive Surgical, Inc., Sunnyvale, CA), providing an extraordinary vision and precision of surgical movement, appears to be changing this scenario, allowing naive surgeons to achieve very good results after few procedures. In this setting, robot-assisted pyeloplasty seems to be emerging as the new standard of care in the patients with UPJO, which will further take place over the other techniques once its costs decrease.

“Re: Robot-assisted radical cystoprostatectomy in complex surgical patients: single institution report.”

Guru, K. A. (2009).

The Canadian journal of urology 16(3): 4670.

“The oncologic results of laparoscopic radical cystectomy are not (yet) equivalent to open cystectomy.”

Hautmann, R. E. (2009).

Current Opinion in Urology 19(5): 522-526.

PURPOSE OF REVIEW: To compare oncologic outcomes in a contemporary series of patients undergoing radical cystectomy (RCX) by the laparoscopic or open approach. RECENT FINDINGS: Laparoscopic RCX with extracorporeally constructed urinary diversion is a safe and effective operation for appropriate patients with bladder cancer. Perioperative and functional outcomes are comparable with open surgery. Worldwide experience continues to increase; more than 1000 surgeries have already been performed. Intermediate-term oncologic outcomes appear to be comparable to open approach. SUMMARY: When stage distribution (organ-confined versus nonorgan-confined) and survival rates of laparoscopic and open RCX are cross-checked against surrogate markers (LN+, margin+, distant failure, local recurrence rate, etc.), it becomes easily obvious that the laparoscopic RCX and open cohorts are not identical. To explain the observed discrepancy, there must be a strong selection bias. Data on overall, disease-specific and recurrence-free survival on laparoscopic RCX are still immature compared with the standard of care that must remain in open RCX. To prove the noninferiority of laparoscopic compared with open surgery regarding outcome, multicenter prospective trials are urgently needed. Until then laparoscopic RCX must be considered experimental surgery. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Modified transverse plication for bladder neck reconstruction during robotic-assisted laparoscopic prostatectomy.”

Lin, V. C., G. Coughlin, et al. (2009).

BJU Int 104(6): 878-881.

“Ureteropelvic Junction Obstruction: Which Surgical Approach?”

Nadu, A., A. Mottrie, et al. (2009).

European Urology, Supplements 8(9): 778-781.

Context: Open pyeloplasty has been considered the referral standard of treatment for ureteropelvic junction obstruction (UPJO). Minimally invasive procedures, however, have evolved and have gradually replaced open surgery, with various success and complication rates. The ideal universal treatment for UPJO is still elusive and controversial. Objectives: The current status of three surgical approaches to the treatment of UPJO are reviewed: laparoscopic pyeloplasty (LP), robotic-assisted pyeloplasty, and endopyelotomy. Evidence acquisition: The interactive discussion among the expert presenters and urologists participating at the Second Congress on Controversies in Urology in Lisbon, Portugal, is summarized. Evidence synthesis: A review of the relevant literature and the experts’ opinions seem to indicate that LP, either conventional or robotic, should be considered as the treatment of choice for UPJO, because it achieves the highest success rates (90%) while still offering the patient the advantages of minimally invasive surgery. The conventional laparoscopic approach demands a high level of surgical expertise and dedicated training that can be partially obviated by the robotic system. Evidence proving clear advantages of robotic pyeloplasty over conventional laparoscopy, however, is lacking due to short follow-up. Additionally, in its current version, the robotic system is financially prohibitive for many centers worldwide. In experienced hands, endopyelotomy performed either percutaneously or by the retrograde ureteroscopic approach can achieve long-standing satisfactory results in carefully selected patients (short strictures, minimal hydronephrosis, no crossing vessel). Additionally, endopyelotomy is the procedure of choice for failed pyeloplasty, with success rates of up to 80%. Conclusions: It can be concluded from the presented data that, given the surgical expertise, LP should be considered the current standard of care for UPJO, with high success rates comparable to the open procedure. The advantages of the robotic system for the patient remain to be proved by scientific data. Endopyelotomy is still indicated in selected cases as a primary therapeutic option and should be considered the procedure of choice for pyeloplasty failures. © 2009 European Association of Urology.

“Ureteric reconstruction and replacement.”

Peeker, R. (2009).

Curr Opin Urol.

PURPOSE OF REVIEW: To review the recent advances on ureteric reconstruction and replacement, in particular, ileal ureteric replacement and laparoscopic and robotic-assisted ureteral reconstruction. RECENT FINDINGS: Recently, the ureteric replacement with bowel has been carefully assessed by several authors, and the results are quite impressive. Also, very recent studies on laparoscopic and robotic-assisted ureteral repair have been published. Outcomes appear very promising, allowing for a faster recovery and shorter hospital stay for the patient. SUMMARY: Today, we can conclude that the field of ureteric reconstruction and replacement is still evolving. Old techniques are supported by an increasing degree of evidence, and new, more minimally invasive surgical strategies emerge. Clearly, there are some disadvantages as well as difficulties to overcome with the new techniques; however, recent studies appear to present promising results.

“Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?”

Schumacher, M. C., M. N. Jonsson, et al. (2009).

Current Opinion in Urology 19(5): 527-532.

Purpose of review: Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy. RECENT FINDINGS: Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series. SUMMARY: At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

“Radical Nephrectomy in the Setting of Metastatic Renal Cell Cancer: Proceed Judiciously.”

Aron, M. and I. S. Gill (2009).

Journal of Urology 182(3): 832-833.

“Initial Experience With Robot Assisted Partial Nephrectomy for Multiple Renal Masses.”

Boris, R., M. Proano, et al. (2009).

Journal of Urology.

Purpose: We evaluated the feasibility of performing robot assisted partial nephrectomy in patients with multiple renal masses and examined the results of our initial experiences. Materials and Methods: We reviewed the records of 10 patients with multiple renal masses who underwent attempted robot assisted partial nephrectomy within the last 2 years. Demographic information, and intraoperative, perioperative and renal function outcome data on these patients were reviewed. Results: A total of 24 tumors in 9 patients were removed with robot assistance. There was 1 open conversion with successful completion of partial nephrectomy. Of the patients 70% had a known hereditary renal cancer syndrome and the remainder had multifocal disease with unknown germline genetic alterations. Frozen section from the tumor bed evaluated in 5 of 10 cases was negative. One patient experienced urinary leak postoperatively, which resolved by postoperative day 9 without intervention. Of the 24 robotically resected masses 22 were malignant. Our most recent 3 patients underwent successful partial nephrectomy without hilar clamping, obviating the need for warm ischemia. Overall renal function was unchanged at most recent followup with a minimal decrease in operated kidney differential function. Conclusions: Robot assisted partial nephrectomy for multiple renal masses was feasible in our early experience. Patient selection is paramount for successful minimally invasive surgery. Robot assisted partial nephrectomy without hilar clamping, especially in the hereditary patient population in which repeat ipsilateral partial nephrectomy may be anticipated, appears promising but requires further evaluation. © 2009 American Urological Association.

“Camera and trocar placement for robot-assisted radical and partial nephrectomy: which configuration provides optimal visualization and instrument mobility?”

Cabello, J. M., S. B. Bhayani, et al. (2009).

Journal of Robotic Surgery: 1-5.

Proper camera and trocar placement is critical to the success of minimally invasive procedures. For robot-assisted renal surgery, two basic trocar configurations have been described. The medial approach, using a 30° downward-angled lens mimics a traditional transperitoneal laparoscopic configuration. An alternative configuration, using a 0° or 30° upward-angled lens approach locates the camera laterally, evoking a position sense similar to a retroperitoneal approach. Our objective is to compare the differences between these two standard approaches for robot-assisted renal surgery. After performing a review and analysis of available literature, our group tested both the medial and lateral camera approaches during robotic renal surgery performed in human patients. The medial approach provides a wide field of view, because of the relatively greater distance to the target structures and a horizon line closer to the patient’s midline. The lateral configuration offers significantly different visualization. The relative proximity to the target structures and a higher horizon line results in a comparatively restricted field of vision. Instrument mobility is comparable between the two approaches. Meta-analysis of the literature reveals that both approaches provide comparable overall operative times for both radical and partial nephrectomy, though there is a trend towards shorter overall operative times for partial nephrectomy performed through a medial approach. The medial trocar configuration provides a familiar working environment for both surgeon and assistant; the wide-angle view enables enhanced visualization of surrounding structures and tracking of the instruments inserted by the assistant. The lateral approach offers the potential advantage of a closer view of the kidney, but does so at the expense of a significantly restricted field of view. In our experience, a medial trocar configuration offers significant advantages over the lateral trocar configuration, and is, therefore, the standard approach at our high-volume center. © 2009 Springer-Verlag London Ltd.

“Current role of robotic assisted partial nephrectomy.”

Cestari, A., G. Guazzoni, et al. (2009).

Archivio Italiano di Urologia e Andrologia 81(2): 76-79.

The modern urologists are nowadays greatly involved in the surgical management of small renal masses, where nephron sparing surgery showed adequate oncological results, with a saving of a great amount of healthy renal tissue. Among the various minimally invasive surgical options, laparoscopic partial nephrectomy duplicates the open technique considered the standard of referral. Robotic assisted partial nephrectomy, aims to add to laparoscopy all the well known advantages offered by the Da Vinci system, such as the 3-Dvision and 7 degree of freedom of surgical instruments. We reviewed the current English literature on robotic partial nephrectomy published in 2008-2009 with at least 20 cases, adding our experience of 26 cases. Although the retroperitoneoscopic approach showed to be feasible in selected cases, all the procedures reported were performed with a transperitoneal approach. Among the 106 robotic assisted partial nephrectomy procedures selected, the mean tumor diameter was 2.8 cm; the mean operative time was 148.7 min with a mean warm ischemia time of 23.8 min and the positive surgical margins rate was 1.8%, reflecting the learning curve of the procedure. Overall complications rate was 15%, although the majority were minor and conservatively treated. Altough robotic partial nephrectomy is still in its infancy, it showed adequate overall results when compared to laparoscopic partial nephrectomy with similar results but with a reduced learning curve. Actually robotic partial nephrectomy should be considered a viable option for nephron sparing surgery both in experienced laparoscopy centers for larger lesions in robotic naïve centers where it may become the standard option for the treatment of small renal masses.

“Pediatric laparoscopic pyeloplasty: Lessons learned from the first 52 cases.”

Chacko, J. K., L. A. Piaggio, et al. (2009).

Journal of Endourology 23(8): 1307-1311.

Background and Purpose: The use of laparoscopy for pediatric pyeloplasty is increasing. We review our experience with our first 50 cases and describe the main technical points learned during this experience. Patients and Methods: We retrospectively reviewed the charts of all patients who underwent laparoscopic pyeloplasties (LP) over a 4-year period (January 2004 to January 2008) at our institution. Patient demographics, operative details, hospital stay, outcomes, and complications were examined. Results: Fifty-two patients underwent LP from for primary repair of ureteropelvic junction obstruction (UPJO). Thirty-six male and 16 female were operated on at an average age and weight (range) of 51.8 months (3 weeks to 216 months) and 20kg (3.9-74.2kg), respectively. Intraoperatively, 47/52 (90%) underwent retrograde ureteropyelography (RUPG), and 51/52 (98%) had a ureteral stent placed during surgery. Nine crossing vessels (17%) were identified at the time of surgery. The anastomoses were performed with a running absorbable suture. Operative time was 248min (range 120-693min). The average hospital stay was 3 days (range 1-7). A bladder catheter usually remained indwelling for 2 days and a perirenal drain for 3 days; they were removed before hospital discharge. The stent remained in place on average 39 days (range 11-127d) and was removed with the patient under a brief general anesthetic. Anastomotic patency was seen in 51/52 (98%) patients determined by improvement on postoperative renal ultrasonography and/or resolution of symptoms. Mean follow-up was 20 months (range 3-50 mos). Complications included recurrence of UPJO necessitating redo LP (1), dislodgement of a nephrostomy (1), stent replacement (1), ileus (2), and vascular injuries treated laparoscopically (2). No patients needed conversion to open surgery. Conclusion: LP has supplanted open pyeloplasty at our institution. We have noted improved success by performing RUPG to define the anatomy and stent placement at the beginning of the case, using purple 5-0 or 6-0 poliglecaprone suture for the anastomosis and a 5-mm wide-angle lens for visualization. We found no disadvantages for the transperitoneal approach, although we find it necessary to leave a drain. With the increased use of LP in pediatric urology, we hope these observations from our experience will help improve the learning curve for others making this transition. © Copyright 2009, Mary Ann Liebert, Inc. 2009.

“Optimal management of localized renal cell carcinoma: Surgery, ablation, or active surveillance.” Chen, D. Y. T. and R. G. Uzzo (2009).

JNCCN Journal of the National Comprehensive Cancer Network 7(6): 635-643.

Radical nephrectomy is historically accepted as standard treatment for localized renal cell carcinoma (RCC). However, the presentation of RCC has changed dramatically over the past 3 decades. Newer alternative interventions aim to reduce the negative impact of open radical nephrectomy, with the natural history of RCC now better understood. This article discusses current surgical and management options for localized kidney cancer. © Journal of the National Comprehensive Cancer Network 2009.

“Promising functional outcomes obtained with robot-assisted laparoscopic pyeloplasty: A single-center experience.”

Ferhi, K., M. Rouprêt, et al. (2009).

Journal of Endourology 23(6): 959-963.

Purpose: To assess the effectiveness of robot-assisted pyeloplasty in patients with clinically symptomatic ureteropelvic junction obstruction (UPJO). Patients and Methods: We retrospectively reviewed our database for all patients who were treated for UPJO by a single surgeon using a robot-assisted procedure between 2005 and 2007. We collected the following: Patient age, clinical presentation, perioperative data, complications, length of hospital stay, and outcome. Preoperative evaluation of UPJO always included an injected renal CT scan and furosemide-mercaptoacetyltriglycine (MAG-3) renal scintigraphy. Patients were seen at 3 and 6 months after surgery and once a year thereafter. Postoperative success was defined as symptomatic response and radiographic evidence of no further obstruction. Results: Twenty patients with a mean age of 36.8 ± 16 years (range 15-69 yr) were included. Six (30%) patients had previously undergone endoscopic treatment.The mean operative time was 150.3 ± 36.22 minutes (range 150-240 min). The mean follow-up was 19.9 ± 10.03 months (range 3-37 mos). Two (10%) procedures necessitated conversion to laparoscopic procedures, and there was no conversion to laparotomy. Four (20%) patients experienced minor complications: Two urinary tract infections and two urinomas. Repeated early surgery was needed in one patient for temporary (ie, 8 days) stent placement in the case of urinoma. There was no recurrence of the UPJO, and no repeated surgery was deemed necessary during the follow-up period. The success rate was estimated to be 95%. Conclusions: Functional outcomes after robot-assisted procedures for alleviation of UPJO are very promising. Our data showed that the robot-assisted procedure was safe and featured negligible morbidity. Therefore, we conclude that our approach is a viable alternative to open surgery. © Mary Ann Liebert, Inc. 2009.

“Transmesocolic robot-assisted pyeloplasty: Single center experience.”

Gupta, N. P., S. Mukherjee, et al. (2009).

Journal of Endourology 23(6): 945-948.

Purpose: To demonstrate the technical feasibility of the transmesocolic approach of robotic pyeloplasty for left ureteropelvic junction obstruction (UPJO). Patients and Methods: Between July 2006 and December 2007, 60 patients underwent robot-assisted pyeloplasty that included 33 cases on the right side and 27 cases on the left side. Of the 27 left-side cases, 24 were performed using a transmesocolic approach. Three left-side surgeries were performed by mobilizing the colon because of associated accessory vessel and renal calculi. A pure robot-assisted dismembered reduction pyeloplasty with excision of the ureteropelvic junction was performed in all cases. Results: The mean operative time was 125.33 minutes. The time to perform the anastomosis was 43.58 minutes, and mean blood loss 38.7 mL. Average hospital stay was 2.5 days, and the drain was removed within 48 hours. One patient had prolonged drainage with fever because of a misplaced ureteral stent. Of the 24 patients, 23 were followed for 1 year and 1 was lost to follow-up. No patient demonstrated clinical or radiographic evidence of repeated obstruction. Conclusion: In the transmesocolic approach, mobilization of the colon is not necessary, and the UPJO can be approached directly after incising the mesocolon. This approach is safe and feasible in patients with a thin mesentry and when extensive mobilization of the kidney is not needed for any associated problems. The technique is highly effective with durable success rates similar to those of open surgery. © Mary Ann Liebert, Inc. 2009.

“Parenchymal-Sparing Surgery for Renal Lesions: Open versus Laparoscopic/Robotic Surgery.”

Halachmi, S., A. Finelli, et al. (2009).

European Urology, Supplements 8(9): 753-757.

Open parenchymal-sparing surgery (PSS) is still considered standard surgical treatment for renal masses. Laparoscopic and robotic PSS should be performed in specialised centres. Robotic surgery is an emerging technology with the potential to be the preferred endoscopic approach for PSS. © 2009 European Association of Urology.

“14-Gauge Angiocatheter: The Assist Port.”

Hotaling, J. M., S. Shear, et al. (2009).

J Laparoendosc Adv Surg Tech A.

Abstract Introduction: Minimally invasive techniques have emerged as the standard of care for some procedures in pediatric urology. In an effort to minimize required ports for robotic-assisted laparoscopic (RAL) surgeries in children, we describe in this article a novel technique for using a 14-gauge (G) angiocatheter as an assist port in concert with various readily available cystoscopic equipment. Materials and Methods: After the insertion of robotic ports and docking, the da Vinci((R)) Surgical System (Intuitive Surgical, Sunnyvale, CA), using a 14-G angiocatheter, was placed through the abdominal wall under direct vision. The 14-G angiocatheter was then used to facilitate stent placement, provide a port for semiflexible cystoscopic graspers, and to evacuate cautery smoke. At the end of each case, the 14-G angiocatheter was removed under direct vision prior to undocking the robot. Results: A 14-G angiocatheter was used as an assist port in 17 RAL urologic procedures (16 RAL dismembered pyeloplasties and 1 robotic orchiopexy). No complications occurred and the angiocatheter’s use avoided the placement of 3- or 5-mm additional assist ports. Conclusions: The 14-G angiocath technique uses existing equipment, requires no closure, and can be placed anywhere on the abdominal wall. It allows the RAL dismembered pyeloplasty to be performed with only two instrument ports and no additional trocar for assistance. This is the first described method in the urologic literature of using a 14-G angiocatheter to maximize operative assistance while minimizing port placement in pediatric RAL surgery.

“Robot-Assisted Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy: Comparison of Outcomes.”

Kural, A. R., F. Atug, et al. (2009).

J Endourol.

Abstract Purpose: We report our initial experience with laparoscopy- and robot-assisted partial nephrectomy (RAPN) operations. Materials and Methods: Between November 2003 and April 2009, laparoscopic partial nephrectomy (LPN) was performed in 20 patients (hand-assisted procedure in one patient) and RAPN in 11 patients. Transperitoneal approach was used in both groups. Results: The patient demographics were similar in both groups. The groups were statistically comparable for body mass index (BMI), gender, and American Society of Auesthesiologists (ASA) scores. The mean tumor size was 32.1 mm (range 20-41 mm) in the RAPN group and 31.45 mm (range 15-70 mm) in the LPN group. The operative time was 226 minutes (range 120-420) in the LPN group and 185 minutes (range 120-270) in the RAPN group; the difference was not statistically significant (p = 0.07). The mean warm ischemia time was significantly shorter in the RAPN group (27.3 minutes for the RAPN group and 35.8 for the LPN group) (p = 0.02). The mean estimated blood loss was 286.4 mL in the RAPN group and 387.5 mL in the LPN group (p = 0.3). One patient (5%) had focal positive margin in the LPN group. No patient had positive surgical margins in the RAPN group. Conclusions: In this pilot study, we found that RAPN and LPN are feasible and safe operations in T1 renal tumors. The advantages for RAPN are excision of the tumor under three-dimensional vision and easy suturing with the articulated instruments of the robotic system. The cost and the need for two experienced laparoscopic surgeons are the disadvantages of robotic surgery. Larger randomized studies are needed to evaluate whether RAPN has any advantages over LPN.

“Temporary Segmental Renal Artery Occlusion Using Reverse Phase Polymer for Bloodless Robotic Partial Nephrectomy.”

Moinzadeh, A., S. Flacke, et al. (2009).

Journal of Urology.

Purpose: Renal vascular clamping with ensuing warm ischemia is typically needed during robotic or laparoscopic partial nephrectomy. We developed a technique for angiographic delivery of the novel intra-arterial reverse thermoplastic polymer LeGoo-XL^TM that allows temporary selective vascular occlusion with normal perfusion of the remaining kidney. Materials and Methods: Eight pigs underwent a total of 16 selective angiographic occlusions of the lower pole segmental artery using gel polymer. The technical feasibility of 2 hemostatic techniques, perfusion hemostasis and local plug formation, was assessed in 4 pigs each. Selective ischemia time was recorded and the vascular occlusion site was noted radiographically and laparoscopically. The feasibility of reversing the polymer from solid back to liquid state to allow reperfusion was determined. Pathological analysis of the kidney was completed in these acute model pigs. In the last 2 cases lower pole robotic partial nephrectomy was done using the da Vinci® surgical system. Results: Selective lower pole ischemia was achieved in all 8 cases. Perfusion hemostasis yielded an inconsistent duration of occlusion (zero to greater than 60 minutes). Vascular occlusion time using local plug formation was more reliable (17 to 30 minutes) with consistent ability to reverse the plug to liquid state by cold saline flush. Two lower pole robotic partial nephrectomies were completed with minimal blood loss. Conclusions: We developed a reliable technique of angiographic delivery of gel polymer for temporary vascular occlusion of selective renal artery branches using local plug formation. Ongoing studies are under way to assess technique consistency and the long-term effects of the polymer. © 2009 American Urological Association.

“Robotic management of complicated ureteropelvic junction obstruction.”

Nayyar, R., N. P. Gupta, et al. (2009).

World J Urol.

PURPOSE: To assess the feasibility and outcomes of robotic pyeloplasty for complicated cases of ureteropelvic junction obstruction (UPJO). METHODS: Complicated UPJO cases included patients with the following: concomitant multiple or calyceal stones, secondary UPJO (post-ureteroscopy, open or percutaneous surgery), malrotated kidney, horseshoe kidney, ectopic kidney, giant hydronephrosis, poorly functioning kidney (glomerular filtration rate <20 ml/min), non-redundant renal calyces (requiring nephroplication), ptosis of the kidney (requiring nephropexy), long stricture (>2 cm), age <5 or >60 years and duplex pelvis. All cases underwent dismembered robotic pyeloplasty. Data were collected for operative time, blood loss, stone clearance, analgesic usage and time to recovery. Follow-up was done with intravenous urography and dynamic renal scan. RESULTS: A total of 29 cases underwent dismembered robotic pyeloplasty with an average operative time and blood loss of 130 min and 50 ml. Stone clearance could be achieved in 8 out of 10. The average follow-up period was 15 months with a symptomatic and objective success rate of 96.6% (28/29). No perioperative complications were noted. CONCLUSIONS: Robotic pyeloplasty for complicated cases of UPJO is feasible, safe and effective, and has a durable success rate.

“Laparoendoscopic single-site surgery of the kidney with no accessory trocars: An initial experience.” Rais-Bahrami, S., S. Montag, et al. (2009).

Journal of Endourology 23(8): 1319-1324.

Background and Purpose: As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS. Patients and Methods: A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments. Results: Six of the patients were men. The mean operative time was 162.4±38.5 minutes. The mean estimated blood loss was 104.5±41.6mL, with a mean length of hospitalization of 2.4±0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8±46.7mg (range 7-158mg) of morphine equivalents with three patients receiving intravenous ketorolac. Conclusion: Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards. © Copyright 2009, Mary Ann Liebert, Inc. 2009.

“Laparoendoscopic single-site surgery: Early experience with tumor nephrectomy.”

Stolzenburg, J. U., G. Hellawell, et al. (2009).

Journal of Endourology 23(8): 1287-1292.

Background and Purpose: Laparoendoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. We performed LESS for renal tumor nephrectomy in eight patients to assess feasibility and perioperative outcome. Patients and Methods: Eight patients with a body mass index (BMI) ≤30 underwent single-port nephrectomy for renal tumor by an experienced laparoscopic surgeon. Tri-Ports were used through a transumbilical incision in all cases. A flexible grasper and a 5-mm 30-degree high-definition camera were used in addition to standard laparoscopic equipment. Patient demographics; operative details, including procedure duration, blood loss, and complications; and final pathology results were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. Results: All LESS nephrectomy operations were successfully accomplished without the need to convert to conventional laparoscopy. The median patient age was 60.75 years (range 22-76 years) and median BMI was 22.95 (range 18.2-26.1). The median operative duration was 141 minutes (range 120-180min), and the median blood loss was 103mL (range 50-150mL). Histologic evaluation confirmed complete excision of an intact specimen. All cases revealed organ-confined T1 renal-cell carcinoma (two right-sided and six left-sided, tumor diameter range 4-8cm). A tumor with an adjacent simple renal cyst was excised in one patient. No intraoperative or postoperative complications occurred. Conclusions: LESS was a feasible and safe approach in a selected group of patients (low BMI and stage tumor). LESS nephrectomy was made possible with the use of multi-instrument port and flexible instruments. The oncologic outcome was not compromised. Further evaluation of LESS surgery needs prospective, randomized studies. © Copyright 2009, Mary Ann Liebert, Inc. 2009.

“Urology training in India: Balancing national needs with global perspectives.”

Aron, M. (2009).

Indian Journal of Urology 25(2): 254-256.

“Everything we always wanted to know about nephron-sparing surgery, but were afraid to ask.”

Carini, M. and A. Minervini (2009).

Archivio Italiano di Urologia e Andrologia 81(2): 59-60.

“Transrectal high-intensity focused ultrasound for local treatment of prostate cancer : 2009 update.”Chaussy, C. G. and S. Thüroff (2009).

Hoch intensiver fokussierter transrektaler Ultraschall (rHIFU) zur lokalen Therapie des prostatakarzinoms : update 2009 48(7): 710-718.

Pulsed robotic high-intensity focused ultrasound (rHIFU) is an interesting therapeutic option mainly due to its noninvasive character. In urologic oncology, rHIFU is used for the transrectal therapy of prostate cancer. While percutaneous therapy of renal cancer using rHIFU is still being tested in experimental studies, transrectal therapy with rHIFU for prostate cancer is already established in more than 230 urologic departments worldwide. The results of prostate cancer therapy with rHIFU are mainly based on different clinical studies. In 2007 a clinical study comparing rHIFU and cryotherapy for the treatment of prostate cancer was initiated in the USA in order to gain clinical approval by the FDA. The most recent publications concluded that the use of rHIFU is an effective standard treatment for prostate cancer with a broad range of indications in all tumor stages: (1) in the primary treatment of local prostate cancer, (2) in patients with local recurrence after failure of any primary treatment, and (3) as an adjuvant therapy in the palliation of systemic prostate cancer. © 2009 Springer Medizin Verlag.

“Radical CyberKnife radiosurgery with tumor tracking: An effective treatment for inoperable small peripheral stage i non-small cell lung cancer.”

Collins, B. T., S. Vahdat, et al. (2009).

Journal of Hematology and Oncology 2.

Objective: Curative surgery is not an option for many patients with clinical stage I non-small-cell lung carcinoma (NSCLC), but radical radiosurgery may be effective. Methods: Inoperable patients with small peripheral clinical stage I NSCLC were enrolled in this study. Three-to-five fiducial markers were implanted in or near tumors under CT guidance. Gross tumor volumes (GTVs) were contoured using lung windows. The GTV margin was expanded by 5 mm to establish the planning treatment volume (PTV). A dose of 42-60 Gy was delivered to the PTV in 3 equal fractions in less than 2 weeks using the CyberKnife radiosurgery system. The 30-Gy isodose contour extended at least 1 cm from the GTV. Physical examination, CT imaging and pulmonary function testing were completed at 6 months intervals for three years following treatment. Results: Twenty patients with an average maximum tumor diameter of 2.2 cm (range, 1.1-3.5 cm) and a mean FEV1 of 1.08 liters (range, 0.53-1.71 L) were treated. Pneumothorax requiring tube thoracostomy occurred following CT-guided fiducial placement in 25% of the patients. All patients completed treatment with few acute side effects and no procedure-related mortality. Transient chest wall discomfort developed in 8 of the 12 patients with lesions within 5 mm of the pleura. The mean percentage of the total lung volume receiving a minimum of 15 Gy was 7.3% (range, 2.4% to 11.3%). One patient who received concurrent gefitinib developed short-lived, grade III radiation pneumonitis. The mean percent predicted DLCO decreased by 9% and 11% at 6 and 12 months, respectively. There were no local failures, regional lymph node recurrences or distant metastases. With a median follow-up of 25 months for the surviving patients, Kaplan-Meier overall survival estimate at 2 years was 87%, with deaths due to COPD progression. Conclusion: Radical CyberKnife radiosurgery is a well-tolerated treatment option for inoperable patients with small, peripheral stage I NSCLC. Effective doses and adequate margins are likely to have contributed to the optimal early local control seen in this study. © 2009 Collins et al; licensee BioMed Central Ltd.

“Current status of robot-assisted surgery in urology: a multi-national survey of 297 urologic surgeons.”Guru, K. A., A. Hussain, et al. (2009).

Can J Urol 16(4): 4736-4741; discussion 4741.

PURPOSE: The surgical robot is becoming an important tool for performance of minimally invasive surgical procedures around the world. We surveyed opinions about and utilization of robot-assisted surgery among urologic surgeons from 44 countries. MATERIAL AND METHODS: A total of 297 surveys were completed from September to November 2008 by participating urologic surgeons polled at various national and international urologic meetings. The survey evaluated surgeon background, personal experience with minimally invasive surgery, institutional status regarding robotic surgery surgeons’ attitudes towards robot-assisted surgery, in general, and prostate, bladder and kidney oncologic procedures, specifically. RESULTS: Two hundred ninety-seven participants completed the survey of which 35% were in training for and 54% in practice of urology. Although 57% of these participants were older than 40, 62% had never sat on a robotic surgical console but 61% believed they would perform robot-assisted surgery. Seventy-eight percent of respondents felt it was required or beneficial to have training in robot-assisted surgery. Only 21% of respondents were currently performing robot-assisted radical prostatectomy. Sixty-one percent of respondents felt robot-assisted radical prostatectomy was the current gold standard or as good as laparoscopic prostatectomy. Only 10% had performed robot-assisted radical cystectomy and 70% of these surgeons have transferred skills from robot-assisted radical prostectomy. Ten percent were performing robot-assisted radical nephrectomies and 30% had transferred skills for laparoscopic partial nephrectomy to robot-assisted partial nephrectomy. CONCLUSION: Robot-assisted surgery has begun to integrate into the minimally invasive armamentarium for urologic surgery and is applied for more procedures as experience is gained.

“Pediatric robot-assisted laparoscopic varicocelectomy.”

Hidalgo-Tamola, J., M. D. Sorensen, et al. (2009).

Journal of Endourology 23(8): 1297-1300.

Purpose: We determined the feasibility and safety of robot-assisted laparoscopic varicocelectomy (RALV) in the pediatric population compared with laparoscopic varicocelectomy (LV). Patients and Methods: We identified all patients who underwent RALV since April of 2006. For each case, we selected two age-matched controls who underwent LV and compared the groups in terms of operative times, postoperative complications, and hospital charges. Statistics were determined using the Student t test and the Fisher exact test. Results: Four patients underwent RALV with a mean age of 15.3 years (standard deviation 1.3). All varicoceles were left-sided. Two patients had testicular size discrepancy at presentation (mean 24%). Mean operative times were 112 minutes for RALV vs 73 minutes for LV (P=0.02). No intraoperative or postoperative complications were experienced in the RALV group. The mean total hospital charge-including facility, equipment, anesthesiology, and recovery room fees, but excluding surgeon’s professional fees-was significantly higher for the robot-assisted group ($15,800 vs $8,600, P=0.0005). Conclusion: We report the first RALV in a pediatric patient population. We demonstrate that it is technically feasible with no intraoperative complications. It remains to be seen whether RALV is cost effective over LV. © Copyright 2009, Mary Ann Liebert, Inc. 2009.

“Open, laparoscopic and robotic radical prostatectomy: Optimizing the surgical approach.”

Bivalacqua, T. J., P. M. Pierorazio, et al. (2009).

Surgical Oncology 18(3): 233-241.

As advances in the understanding of prostatic anatomy led to improvements in functional and oncologic outcomes after prostatectomy of the past few decades, advances in technology and surgical technique have made minimally-invasive prostate surgery a reality. Today patients diagnosed with clinically localized prostate cancer have more surgical treatment options than in the past including open, laparoscopic and robot-assisted laparoscopic radical prostatectomy. Advantages and disadvantages exist for each modality and lead to subtle differences in the technical execution of the procedure. Evidence from centers of excellence and from experienced surgeons demonstrates that both laparoscopic and robotic-assisted laparoscopic radical prostatectomy appear to be comparable to outcomes achieved with open radical retropubic prostatectomy series. Individual surgeon skill, experience and clinical judgment are likely the stronger predictors of outcome rather than the technique chosen. However, learning curves, oncologic outcomes and cost-efficacy remain important considerations in the dissemination of minimally-invasive prostate surgery. A greater appreciation of the periprostatic anatomy and further modification of surgical technique will result in continued improvement in functional outcomes and oncological control for patients undergoing radical prostatectomy, whether by open or minimally-invasive surgery. © 2009 Elsevier Ltd. All rights reserved.

“Camera and trocar placement for robot-assisted radical and partial nephrectomy: which configuration provides optimal visualization and instrument mobility?”

Cabello, J. M., S. B. Bhayani, et al. (2009).

Journal of Robotic Surgery: 1-5.

“A Prospective Study of Symptom Distress and Return to Baseline Function After Open Versus Laparoscopic Radical Prostatectomy.”

Dahl, D. M., M. J. Barry, et al. (2009).

Journal of Urology 182(3): 956-966.

Purpose: We assessed and compared outcomes following open and laparoscopic radical prostatectomy. Materials and Methods: Patients who were scheduled to undergo open or laparoscopic radical prostatectomy were enrolled in the study and followed prospectively. Before surgery the patients were administered a multi-item validated questionnaire, and were followed by telephone and with mail questionnaires periodically for 12 months. Complications were recorded from chart review and compared. Symptom distress and return to baseline for various parameters were compared between the 2 groups. Results: Of the patients 102 who underwent open prostatectomy and 104 treated with laparoscopic prostatectomy were enrolled in the study. At 1 year 90% in the open and 91% in the laparoscopic group returned the questionnaire. Symptom distress between the 2 groups did not differ at any time during followup. There was no significant difference in return to baseline at 1 year for continence, erectile function or physical function. Of the patients 95% had a return to baseline physical function, approximately 90% do not wear a pad and approximately 50% returned to baseline erectile function with or without phosphodiesterase type 5 inhibitors at 1 year. Although complications were few there was a significant difference in the number for laparoscopic vs open prostatectomy with a slightly higher rate of hematuria and lymphocele formation in the laparoscopic group. Cancer control at 1 year was excellent in both groups. Conclusions: Radical prostatectomy is an effective form of therapy for patients with clinically localized cancer of the prostate. The open and laparoscopic techniques have similar functional outcomes, and these data provide patients a realistic view of what to expect following these 2 methods of radical prostatectomy. © 2009 American Urological Association.

“Hypothermic Robotic Radical Prostatectomy: Impact on Continence.”

Finley, D. S., K. Osann, et al. (2009).

J Endourol.

Abstract Introduction: Radical prostatectomy undoubtedly causes inflammatory damage to surrounding neuromuscular tissues (i.e., bladder, urethra, and nerves) that may contribute to urinary incontinence. We report the use of local hypothermia during robot-assisted laparoscopic prostatectomy to attenuate this injury. Methods: Regional pelvic cooling was achieved using cold intracorporeal irrigation and an endorectal cooling balloon (ECB). In all, 115 men undergoing hypothermic robot-assisted laparoscopic radical prostatectomy (hRLP) (case #667-782) were prospectively compared with a historical cohort (case #1-666). Intracorporeal rectal and neurovascular bundle temperatures (T) and intrarectal temperatures were measured. Continence was defined as zero urinary pads. Kaplan-Meier analysis of time to zero pads and multivariate Cox proportional hazards regression was used. Results: Hypothermia was achieved in 112/115 patients; 6 were excluded (3 ECB malfunction, 2 prior radiation, and 1 completion prostatectomy). Median endorectal T = 18.7 degrees C (range 9.1-29.5 degrees C). Mean intracorporeal T = 25.58 degrees C (ECB + irrigation, range 19.4-34.0 degrees C). Three and 12-month hRLP zero pad rates were 81% to 89% and 100% for initial and extended cooling groups versus 65% and 89% for controls. Return to continence was significantly faster for hRLP versus controls: median time to zero pad use was 39 days for hRLP versus 62 days for controls. Multivariate analysis adjusting for American Urological Association (AUA) symptom score, nerve-sparing surgery, learning curve, international index of erectile function-5, age, and prostate weight demonstrated a significantly faster return to continence (hazard ratio = 1.526; 95% CI 1.11, 2.09). Trends toward improved continence were observed with colder temperatures and older patients. Conclusions: Local hypothermia during prostatectomy resulted in a significant improvement in early postoperative zero pad continence rates. Longer and deeper cooling appears to be associated with improved continence, particularly among older patients.

“Editorial comment. Pelvic lymphadenectomy during robot-assisted radical prostatectomy: assessing nodal yield, perioperative outcomes, and complications.”

Ghavamian, R. (2009).

Urology 74(2).

“Robot-assisted radical prostatectomy in men aged >/=70 years.”

Greco, K. A., J. J. Meeks, et al. (2009).

BJU Int.

OBJECTIVES To assess the outcomes of elderly men with prostate cancer treated with robot-assisted radical prostatectomy (RARP), because more healthy elderly men will present with localized prostate cancer and many will seek surgical treatment as the population ages. PATIENTS AND METHODS Between 2005 and 2008, 203 men had RARP performed by one surgeon; patients were categorized into two groups based on their age (>/=70 vs <70 years). All data were recorded prospectively in an institutional approved database. RESULTS Of the 203 men, 23 (11%) were aged >/=70 years; the older men had similar baseline characteristics as younger men, and had characteristics during and after surgery comparable to those in younger men. The pathological RARP Gleason grade was significantly greater in older men. Surgical complications were not significantly different between the groups. Continence rates were significantly lower in older men at 6 months after surgery, but returned to levels equivalent to those in younger men within 12 months after surgery. Older patients took significantly longer to be capable of driving after surgery. CONCLUSIONS The outcomes of RARP in elderly men are largely comparable to those in younger men, with the exception of higher pathological Gleason grade, a transient delay in return of continence, and taking longer to return to driving after surgery. Advanced chronological age should not be a contraindication for RARP in patients with clinically localized prostate cancer, but expectations should be managed preoperatively.

“Effect of bony pelvic dimensions measured by preoperative magnetic resonance imaging on performing robot-assisted laparoscopic prostatectomy.”

Hong, S. K., S. T. Lee, et al. (2009).

BJU International 104(5): 664-668.

Objective To evaluate the effect of bony pelvic dimensions measured by preoperative magnetic resonance imaging (MRI) on performing robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND Methods In this exploratory study, we analysed the data of 141 patients who underwent RALP for clinically localized prostate cancer after undergoing MRI at our institution. Associations of various clinicopathological factors were analysed, including pelvic dimensions measured by preoperative MRI, with operative duration, estimated blood loss (EBL), surgical margin status, and postoperative urinary continence and erectile function. Results For operative duration, no pelvic dimension had a significant association on univariate analysis, with only the newly developed variable of pelvic cavity index approaching significance (P = 0.071). Only prostate volume had a significant association with operative duration on multivariate analysis (P = 0.015). For EBL, no bony pelvic dimension had a significant association on univariate analysis, with only intertuberous distance and interspinous distance approaching significance (P = 0.087 and P = 0.072, respectively). Again, only prostate volume was significantly associated with EBL on univariate analysis (P = 0.045). No pelvic dimension had any significant effect on surgical margin status, recovery of urinary continence or erectile function at 6 months after RALP. Conclusion Bony pelvic dimensions may not be a significant factor contributing to the technical difficulty of RALP among Korean patients compared with other patient-related factors such as prostate volume. © 2009 BJU International.

“Posterior reconstruction and anterior suspension with single anastomotic suture in robot-assisted laparoscopic radical prostatectomy: a simple method to improve early return of continence.”

Kalisvaart, J. F., K. E. Osann, et al. (2009).

Journal of Robotic Surgery: 1-5.

Post-prostatectomy urinary incontinence is a major cause of morbidity from radical prostatectomy. Efforts have been made to develop techniques to hasten return of urinary control. Several authors have demonstrated improved early continence with anterior, posterior, or combined reconstruction of the urethral-pelvic attachments. In this study, we compare three-month urinary function and continence data for patients who underwent RALP with posterior reconstruction and anterior suspension with single anastomotic suture (PRASS). A prospective cohort of 50 patients underwent RALP with PRASS reconstruction and were compared to 50 control patients who underwent standard RALP. Continence was defined as use of 0-1 urinary pads and was evaluated at each follow-up visit using the EPIC-26 questionnaire. A weighted summary score was created and group differences were compared using a repeated measures analysis of variance model. After adjusting for age, baseline AUA symptom score, and SHIM scores, which were found to correlate with continence, patients who underwent the PRASS reconstruction had significantly improved urinary control at three months compared with the control group; 90.9% of the patients in the PRASS group wore 0-1 pads per day versus 48.2% in the control group (P = 0.014). Of the patients undergoing the standard prostatectomy 20.6% were totally pad-free compared with 42% of the patients undergoing the PRASS procedure (P = 0.042). In conclusion, the PRASS technique resulted in statistically significant improvement in urinary control three months post-operation. The PRASS reconstruction is technically straightforward, requires no additional sutures, and is a simple technique that is easily learned and adaptable to other robotic surgery. © 2009 The Author(s).

“Prostate cancer: Medicoeconomic aspects.”

Kanso, C., J. Etner, et al. (2009).

Cancer de la prostate : aspects médicoéconomiques.

Prostate cancer is the first cancer in men. Its incidence is constantly increasing. The significant evolution of diagnostic and therapeutic means during the two last decades contrasts with the scarcity of medicoeconomic studies. The aim of this review is to present a synthesis of the different studies published and to respond to questions about the economic aspects of this disease, with the evaluation of its direct and indirect costs. The cost-effectiveness and the benefits of the prevention and the screening are still being studied. The costs of the surgery and the radiotherapy are roughly similar. The new surgical techniques, especially the laparoscopic and the robotic surgeries, are not necessarily associated with higher costs, in condition of a high-volume laparoscopic surgery program and a faster discharge. The indirect costs of prostate cancer concern the loss of economic production associated with the disease and death and are more difficult to determine. © 2009 Elsevier Masson SAS. All rights reserved.

“Impact of percutaneous suprapubic tube drainage on patient discomfort after radical prostatectomy.”

Krane, L. S., M. Bhandari, et al. (2009).

Eur Urol 56(2): 325-330.

BACKGROUND: Patients undergoing radical prostatectomy (RP) traditionally require urethral catheterization for adequate bladder drainage in the postoperative period. However, many patients have significant discomfort from the urethral catheter. OBJECTIVE: To describe a technique of percutaneous suprapubic tube (PST) bladder drainage after robotic-assisted laparoscopic radical prostatectomy (RALP) and to evaluate patient discomfort, complications, continence, and stricture rate after this procedure. DESIGN, SETTING, AND PARTICIPANTS: Two hundred two patients undergoing RALP were drained with a 14F PST instead of a urethral catheter. The PST was placed robotically at the conclusion of the urethrovesical anastomosis and secured to the skin over a plastic button. Beginning on postoperative day 5, patients clamped the PST, urinated per urethra, and measured the postvoid residual (PVR) drained by PST. The PST was removed when residuals were <30 cm(3) per void. The control group consisted of 50 consecutive patients undergoing RALP with urethral catheter drainage. MEASUREMENTS: The primary end point was catheter-associated discomfort as measured with the Faces Pain Score-Revised (FPS-R). Secondary end points included use of anticholinergics, complications related to the PST, urinary continence, and urethral stricture. RESULTS AND LIMITATIONS: When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on postoperative days 2 and 6 (p<0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p<0.001). Ten patients required urethral catheterization for PST dislodgement (n=5) or urinary retention (n=5). No patient has developed a urethral stricture at a mean follow-up of 7 mo. CONCLUSIONS: PST provides adequate urinary drainage following RALP with less patient discomfort and no increased risk of urethral stricture.

“Modified transverse plication for bladder neck reconstruction during robotic-assisted laparoscopic prostatectomy.”

Lin, V. C., G. Coughlin, et al. (2009).

BJU Int 104(6): 878-881.

“Erosion of hem-o-lok clips at the bladder neck after robot-assisted radical prostatectomy.”

Moser, R. L. and N. Narepalem (2009).

Journal of Endourology 23(6): 949-951.

The use of Hem-o-Lok clips is well described for control of the lateral pedicles in robot-assisted laparoscopic prostatectomy. We report two cases of urethral erosion of Hem-o-Lok clips after robot-assisted laparoscopic prostatectomy in patients who presented with symptoms of bladder neck contracture. We describe the presentation, treatment, and possible methods to avoid this complication. © Mary Ann Liebert, Inc. 2009.

“The effect of pneumoperitoneum in the steep Trendelenburg position on cerebral oxygenation.”

Park, E. Y., B. N. Koo, et al. (2009).

Acta Anaesthesiologica Scandinavica 53(7): 895-899.

Background: daVinci® robot-assisted laparoscopic radical prostatectomy (RALP) requires pneumoperitoneum in the steep Trendelenburg position, which results in increased intracranial pressure and cerebral blood flow. The aim of this study was to evaluate the effect of pneumoperitoneum in a 30° Trendelenburg position on cerebral oxygenation using regional cerebral oxygen saturation (rSO2). Methods: Thirty-two male patients of ASA I and II physical status without previous episodes of cerebral ischemia or hemorrhage undergoing daVinci® RALP were enrolled. The rSO 2 was continuously monitored with near-infrared spectroscopy (INVOS® 5100^TM) during the study period. Measurements were obtained immediately after anesthesia induction (T0; baseline), 5 min after a 30° Trendelenburg position (T1), 5 min after 15 mmHg pneumoperitoneum in a supine position (T2), 30, 60 and 120 min after the pneumoperitoneum in a Trendelenburg position (T3, T4 and T5, respectively) and after desufflation in a supine position (T6). Results: The change in the left and right rSO2 was statistically significant (Left P=0.004 and Right P=0.023). Both the right and the left rSO2 increased significantly during pneumoperitoneum in a Trendelenburg position (from T3 to T5) and at T6 compared with the baseline value at T0. The partial pressure of carbon dioxide (PaCO2) was increased significantly at T2, T3, T5 and T6 compared with the baseline value at T0. Conclusions: During daVinci® RALP, cerebral oxygenation, as assessed by rSO2, increased slightly, which suggests that the procedure did not induce cerebral ischemia. The PaCO 2 should be maintained within the normal limit during pneumoperitoneum in a Trendelenburg position in patients undergoing daVinci ® RALP because the rSO2 increased in conjunctions with the increase in PaCO2. © 2009 The Acta Anaesthesiologica Scandinavica Foundation.

“Prostate cancer and urinary incontinence.”

Parsons, B. A., S. Evans, et al. (2009).

Maturitas 63(4): 323-328.

Prostate cancer is the third most common cancer worldwide and an increasing proportion of men are being diagnosed with localised disease. Urinary incontinence is uncommon in healthy men, but may develop as a result of curative treatment for prostate cancer. The optimal therapy remains undefined so the treatment associated morbidity is an important determinant in patient choice. Urinary incontinence may also develop from tumour progression during deferred treatment, sphincter involvement in advanced disease or surgery for symptomatic malignant bladder outlet obstruction. As urinary incontinence is known to have a significant impact on health related quality of life, we have reviewed the literature on incontinence related to prostate cancer and its treatment. © 2009 Elsevier Ireland Ltd. All rights reserved.

“Prostate Size is Associated With Surgical Difficulty but Not Functional Outcome at 1 Year After Radical Prostatectomy.”

Pettus, J. A., T. Masterson, et al. (2009).

Journal of Urology 182(3): 949-955.

Purpose: We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture. Materials and Methods: From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach. Results: With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22). Conclusions: Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands. © 2009 American Urological Association.

“Is robot assistance affecting operating room time compared with pure retroperitoneal laparoscopic radical prostatectomy?”

Ploussard, G., E. Xylinas, et al. (2009).

Journal of Endourology 23(6): 939-943.

Purpose: To compare operating room times between retroperitoneal robot-assisted laparoscopic radical prostatectomy (RALRP) and pure retroperitoneal laparoscopic radical prostatectomy (LRP). Patients and Methods: From March 2007 to April 2008, 288 patients underwent an extraperitoneal LRP in our institution. Eighty-three LRPs were performed with robot assistance using the da Vinci® Surgical System (RALRP) whereas 205 pure LRPs were performed. Operating room times were compared between the two groups. Results: Both groups were statistically equal concerning age (P =0.95), body mass index (P =0.52), prostate-specific antigen level (P = 0.40), prostate volume (P = 0.49), clinical stage (P = 0.11), and Gleason score on biopsy (P = 0.57). Total operating room time was not significantly different between the two groups (223.6 vs 215.7 minutes in LRP and RALRP groups, respectively; P = 0.23). Mean patient installation was longer in the RALRP group (33.2 vs 24.0 minutes, P < 0.01). Mean operative time was significantly shorter by about 20 minutes in the RALRP group (145.6 vs 164.7 minutes, P < 0.01). Mean estimated blood loss was significantly lower in the RALRP group (469 mL vs 889 mL in the LRP group, P< 0.01). No statistical differences were observed regarding hospital stay, bladder catheterization, and complication rate between the two groups. Conclusion: Occupation times of the operating room are equivalent during pure retroperitoneal LRP and RALRP. For a trained team performing four procedures per week, the use of the robot for LRP with no lymph node dissection decreases actual operative time at the expense of an increase in installation time, compared with pure laparoscopy. © Mary Ann Liebert, Inc. 2009.

“Comparison of open and robot-assisted pelvic lymphadenectomy for prostate cancer.”

Polcari, A. J., C. M. Hugen, et al. (2009).

Journal of Endourology 23(8): 1313-1317.

Purpose: We evaluated whether there were differences in the lymph node yield and incidence of nodal metastasis among patients undergoing robot-assisted radical prostatectomy with pelvic lymphadenectomy (LAD) and open radical retropubic prostatectomy with either a standard or extended node dissection. Patients and Methods: Data were collected retrospectively on all patients undergoing radical prostatectomy with pelvic LAD at our institution between January 2006 and December 2008. Patients in group 1 (n=60) underwent robot-assisted standard LAD, those in group 2 (n=64) had open standard LAD, and group 3 patients (n=43) were treated with open extended LAD. Statistical comparison was then made between the three groups stratified by histologic grade and pathologic stage. Results: The mean lymph node yield was 8.2 for group 1, 7.6 for group 2, and 14.8 for group 3. The overall incidence of positive nodes in each group was 3.3%, 1.6%, and 18.6%, respectively. There were no differences between the node counts (P=0.84) and probability of finding positive nodes between the robot-assisted and open standard dissections. The extended LAD identified patients with positive nodes at a greater frequency, although those patients were more likely to have adverse pathologic features. Complications related to the lymphadenectomy were not different between the groups. Conclusion: The lymph node yield obtained during robot-assisted pelvic lymphadenectomy for prostate cancer is comparable to an open approach using a similar template. An open extended node dissection yields more nodes and identifies a greater number of patients with lymph node involvement. © Copyright 2009, Mary Ann Liebert, Inc. 2009.

“Functional and Oncologic Outcomes Comparing Interfascial and Intrafascial Nerve Sparing in Robot-Assisted Laparoscopic Radical Prostatectomies.”

Potdevin, L., M. Ercolani, et al. (2009).

J Endourol.

Abstract Introduction: The impact of intrafascial versus interfascial nerve sparing during radical prostatectomy on oncologic and postoperative outcome is still controversial. This manuscript compares the outcomes of intrafascial versus interfascial techniques of nerve sparing used during robot-assisted laparoscopic radical prostatectomy (RALRP) at our institution. Materials and Methods: Of the 171 patients who underwent RALRP at our institution from January 2006 through December 2007, the charts of 147 patients who underwent bilateral nerve sparing procedure were reviewed retrospectively. During the study period, the preferred technique of nerve sparing at our institution changed from the conventional interfascial approach to athermal intrafascial robotic (AIR) approach. The rates of positive surgical margins (+SMs), continence, and potency were measured. Results: Perioperative characteristics and complication rates were similar between the two groups. Continence rates at 1, 3, and 6 months increased from 27.3%, 68.8%, and 93.5%, respectively, after the interfascial procedure to 68.6%, 84.3%, and 92.9% after the AIR procedure. Potency rates at 3, 6, and 9 months in the interfascial group were 16.7%, 43.8%, and 66.7%, respectively, whereas in the AIR group they improved to 24.2%, 81.8%, and 90.9%. The rates of +SMs in pT2 disease were 5.88% in the interfascial group and 7.55% in the AIR group (not significant), whereas in pT3, +SMs were 22.2% in the interfascial group and 41.18% in the AIR group (p < 0.05). Conclusion: AIR technique greatly improved potency rate and shortened the time to return of continence following RALRP. This improved outcome, though, was achieved at the price of higher +SM rates in patients with pT3 disease.

“History of prostate cancer treatment.”

Sriprasad, S., M. R. Feneley, et al. (2009).

Surgical Oncology 18(3): 185-191.

The last two decades have seen great advancements in our understanding of the prostate anatomy and approach including laparoscopic and robotic techniques. One should not however, forget that the techniques evolved with time. The history of developments in prostate cancer surgery, radiotherapy and hormonal therapy is fascinating and urologists through the ages had the quest to find an ideal treatment for prostate cancer in spite of their limitations of resources and understanding. Surgeons have now practiced radical prostatectomy for prostate cancer for over 100 years. Initially feared because of its complications and difficulty, the operation can now be carried out safely owing principally to advances in our knowledge of the surgical anatomy. Refinements in surgical technique based on anatomical understanding have enabled morbidity to be progressively reduced to a widely acceptable level. Within the past 10 years, the same principles have been applied successfully in laparoscopic and robotic techniques of prostatectomy. There are constant improvements in the field of radiotherapy, evolution of cryotherapy and changes in the role of hormones. To the future, the matching of patients to the treatment modality most appropriate to their tumour, and quality of life outcomes are likely to become increasingly important in determining future practice. It is worth while to look at the evolution to plan for the future. © 2009 Elsevier Ltd. All rights reserved.

“Editorial comment.”

Tewari, A. (2009).

BJU International 103(10): 1408-1409.

“Integrated navigation and control software system for MRI-guided robotic prostate interventions.” Tokuda, J., G. S. Fischer, et al. (2009).

Comput Med Imaging Graph.

A software system to provide intuitive navigation for MRI-guided robotic transperineal prostate therapy is presented. In the system, the robot control unit, the MRI scanner, and the open-source navigation software are connected together via Ethernet to exchange commands, coordinates, and images using an open network communication protocol, OpenIGTLink. The system has six states called “workphases” that provide the necessary synchronization of all components during each stage of the clinical workflow, and the user interface guides the operator linearly through these workphases. On top of this framework, the software provides the following features for needle guidance: interactive target planning; 3D image visualization with current needle position; treatment monitoring through real-time MR images of needle trajectories in the prostate. These features are supported by calibration of robot and image coordinates by fiducial-based registration. Performance tests show that the registration error of the system was 2.6mm within the prostate volume. Registered real-time 2D images were displayed 1.97s after the image location is specified.

“Tertiary Gleason Patterns and Biochemical Recurrence After Prostatectomy: Proposal for a Modified Gleason Scoring System.”

Trock, B. J., C. C. Guo, et al. (2009).

Journal of Urology.

Purpose: We investigated the relationship between the tertiary Gleason component in radical prostatectomy specimens and biochemical recurrence in what is to our knowledge the largest single institution cohort to date. Materials and Methods: We evaluated data on 3,230 men who underwent radical prostatectomy at our institution from 2000 to 2005. Tertiary Gleason component was defined as Gleason grade pattern 4 or greater for Gleason score 6 and Gleason grade pattern 5 for Gleason score 7 or 8. Results: Biochemical recurrence curves for cancer with tertiary Gleason component were intermediate between those of cancer without a tertiary Gleason component in the same Gleason score category and cancer in the next higher Gleason score category. The only exception was that Gleason score 4 + 3 = 7 with a tertiary Gleason component behaved like Gleason score 8. The tertiary Gleason component independently predicted recurrence when factoring in radical prostatectomy Gleason score, radical prostatectomy stage and prostate specific antigen (HR 1.45, p = 0.029). Furthermore, the magnitude of the tertiary Gleason component effect on recurrence did not differ by Gleason score category (p = 0.593). Conclusions: Although the tertiary Gleason component is frequently included in pathology reports, it is routinely omitted in other situations, such as predictive nomograms, research studies and patient counseling. The current study adds to a growing body of evidence highlighting the importance of the tertiary Gleason component in radical prostatectomy specimens. Accordingly consideration should be given to a modified radical prostatectomy Gleason scoring system that incorporates tertiary Gleason component in intuitive fashion, including Gleason score 6, 6.5 (Gleason score 6 with tertiary Gleason component), 7 (Gleason score 3 + 4 = 7), 7.25 (Gleason score 3 + 4 = 7 with tertiary Gleason component), 7.5 (Gleason score 4 + 3), 8 (Gleason score 4 + 3 with tertiary Gleason component or Gleason score 8), 8.5 (Gleason score 8 with tertiary Gleason component), 9 (Gleason score 4 + 5 or 5 + 4) and 10. © 2009 American Urological Association.

“The science behind haptics in robotic urological surgery.”

Vivekananda, U., A. Henderson, et al. (2009).

BJU Int 104(4): 433-434.

“Interposition nerve grafting during radical prostatectomy: cumulative review and critical appraisal of literature.”

White, W. M. and E. D. Kim (2009).

Urology 74(2): 245-250.

In 1997, the first report of sural nerve interposition grafting during radical prostatectomy was published in Urology. The favorable findings in this initial pilot study generated numerous follow-up reports that have demonstrated conflicting and contradictory outcomes. Certainly, controversy exists regarding the true benefit of nerve grafting. This review will objectively and critically summarize the salient literature, discuss evolving techniques, and offer insight into the future of interposition grafting in the current era of clinically localized prostate cancer and robotic prostatectomy.