Abstrakt Urologie Duben 2012 | Česká společnost robotické chirurgie ČLS JEP

Uro_Bladder (10)

Frohneberg, D. (2012). “[Comments on radical cystectomy - laparoscopic versus robotic.].” Urologe. Ausgabe A.

Kamradt, J., M. Saar, et al. (2012). “Radical cystectomy – pro robotic.” Radikale Zystektomie – pro robotisch: 1-3.

The standard therapy for muscle invasive bladder cancer is radical cystectomy and urinary diversion. For open surgery this procedure has notable perioperative morbidity. Performing laparoscopic cystectomy can reduce this morbidity. So far it remains unclear, whether the oncologic outcome of the laparoscopic approach is comparable to open surgery or not due to a lack of long-term follow-up data. Important surgical steps, such as extended lymphadenectomy, sparing of the neurovascular bundle for preservation of potency, preparation of the urethra for orthotopic neobladder and intracorporeal construction of a urinary diversion can be achieved much more easily with a robot-assisted approach than with conventional laparoscopy. Furthermore, the learning curve for robot-assisted cystectomy is much steeper. Therefore, if a laparoscopic cystectomy is performed, it should be performed using a robot-assisted approach. © 2012 Springer-Verlag.

Kang, S. G., Y. H. Ko, et al. (2012). “Initial Experience of Robot-Assisted Radical Cystectomy with Total Intracorporeal Urinary Diversion: Comparison with Extracorporeal Method.” Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A.

Abstract Purpose: To report our surgical technique and initial experience with robot-assisted laparoscopic radical cystectomy (RARC) with total intracorporeal urinary diversion compared with an extracorporeal method. Subjects and Methods: In total, 42 patients underwent RARC by a single surgeon at our institute for clinically localized bladder cancer. Among these, 4 patients underwent RARC with complete intracorporeal urinary diversion. An ileal conduit was achieved in 3 patients, and an orthotopic neobladder was created in 1 patient. Our surgical technique is presented in detail, and the intracorporeal cases were compared with 38 previous extracorporeal diversion cases for perioperative outcome, postoperative oncologic outcome, and complications. Results: Three men and 1 woman underwent complete intracorporeal urinary diversion. In patients receiving ileal conduits the mean total operative time was 510 minutes, and the estimated blood loss was 400 mL. In the patient receiving an ileal neobladder the total operative time was 585 minutes, and the estimated blood loss was 500 mL. Mean time to flatus was 60 hours, and no intraoperative or postoperative major complications occurred. Surgical margins were negative with no positive lymph nodes. Compared with extracorporeal cases, the mean total operative time for RARC was significantly longer, but perioperative outcomes of estimated blood loss, time to flatus, and postoperative oncologic outcomes were not significantly different. Conclusions: Our initial experience showed that RARC with complete intracorporeal urinary diversion is feasible based on perioperative data and oncologic features. However, in this small case series, we observed no definite benefits associated with intracorporeal urinary diversion over extracorporeal urinary diversion except for better cosmesis. Long-term, large-scale, prospective comparative studies will be needed to demonstrate the benefit of intracorporeal urinary diversion.

Khan, M. S., B. Challacombe, et al. (2012). “A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy.” International Journal of Clinical Practice.

Introduction: The role of minimally invasive radical cystectomy as opposed to open surgery for bladder cancer is not yet established. We present comparative outcomes of open, laparoscopic and robotic-assisted radical cystectomy Material and Methods: Prospective cohort comparison of 158 patients from 2003-2008 undergoing open radical cystectomy (ORC) (n=52), laparoscopic radical cystectomy (LRC) (n=58) or robotic-assisted radical cystectomy (RARC) (n=48) performed by a team of three surgeons at two hospitals. Peri-operative data, complication rates, length of hospital stay, oncological outcome (including lymph node status) and survival were recorded. Statistical analyses were adjusted to account for potential confounding factors such as ASA grade, gender, age, diversion type and final histology. Results: RARC took longer than LRC and ORC. Patients were about 30 times more likely to have a transfusion if they had ORC than if they had RARC (p<0.0001) and about eight times more likely to have a transfusion if they had LRC compared with RARC (p<0.006). Patients were four times more likely to have a transfusion if they had ORC as compared with LRC (p<0.007). Patients were four times more likely to have complications if they had ORC than RARC (p=0.006) and about three times more likely to have complications with LRC than with RARC (p=0.02). Hospital stay was mean 19days after ORC, 16days after LRC and 10days after RARC. Conclusions: Despite study limitations, RARC had the lowest transfusion and complication rates and the shortest length of stay, although taking the longest to perform. © 2012 Blackwell Publishing Ltd.

Ma, L. L., H. Bi, et al. (2012). “Laparoendoscopic single-site radical cystectomy and urinary diversion: Initial experience in China using a homemade single-port device.” Journal of Endourology 26(4): 355-359.

Purpose: We report our initial experience with the first series of laparoendoscopic single-site (LESS) radical cystectomy and urinary diversion performed by a single surgeon using a homemade single-port device at a single institution in China. Patients and Methods: Between December 2010 and February 2011, we performed five LESS radical cystectomis using a homemade single-port device composed of an inverted cone device of polycarbonate and a powder-free surgical glove. The port was placed into a 5-cm periumbilical incision. The conventional laparoscope and laparoscopic instruments were inserted through the single-port. No additional ports were needed for radical cystoprostatectomy and bilateral standard pelvic lymphadenectomy. Cutaneous ureterostomy and ileal conduit urinary diversion were used for our patients, respectively. Perioperatively, oncologic data and complications were collected and analyzed. Results: All the procedures were completed successfully. The mean extirpative operative time was 208.2 (168-280) minutes, estimated blood loss was 270 (100-500) mL, bowel recovering time was 9.75 (6-12) days, and postoperative hospital stay was 19.5 (14-28) days. One patient needed a transfusion of 400 mL of red blood cells. The pathologic evaluation revealed negative margins and negative lymph node involvement. After the operations, one patient had a bowel obstruction, while another patient died from cardiac disease. Mean follow-up time was 143 (110-173) days. Conclusions: In our experience, LESS radical cystectomy is clinically feasible and safe for selected patients, but requires a learning curve. Our homemade single-port device is a cost-effective and convenient device. Although the initial outcomes have been promising, the long-term oncologic evaluation of these patients awaits. © Copyright 2012, Mary Ann Liebert, Inc.

Mmeje, C. O., R. Nunez-Nateras, et al. (2012). “Oncologic outcomes for lymph node-positive urothelial carcinoma patients treated with robot assisted radical cystectomy: With mean follow-up of 3.5 years.” Urologic Oncology: Seminars and Original Investigations.

Purpose: Previous studies have shown robot assisted radical cystectomy (RARC) to have comparable perioperative outcomes to open radical cystectomy. There are few reports that have examined the oncologic results of RARC, specifically with respect to lymph node-positive patients. We report the outcomes of pathologic node-positive patients who have undergone RARC with medium-term follow-up. Materials and methods: A total of 275 patients underwent RARC at 2 institutions for invasive bladder cancer between April 2005 and June 2009. We examined the 50 patients with lymph node-positive disease. Oncologic outcomes, overall, and recurrence-free survival were analyzed and compared with the open literature. Results: Mean (median) clinical follow-up in this cohort was 42 (39.5) months (range 16-75 months). The mean (median) number of lymph nodes (LN) removed was 18 (17.5) (range 5-35), and mean (median) number of positive LN was 3 (2) (range 1-12). Mean lymph node density was 18%. Seventeen (34%) patients had ≤ pT 2 disease and 33 (66%) pT 3/T 4 disease. At this follow-up, 29 patients have recurred, and 22 patients have died of disease. Mean (median) time to recurrence was 10 (9) months. The estimated overall survival at 36 and 60 months was 55%, and 45%, respectively. The recurrence-free survival at 36 and 60 months was 43%, and 39%, respectively. Thirty-three (66%) patients had an LN density <20%. The estimated overall survival at 36 months of patients with a lymph node density of <20% was higher than those with a lymph node density >20%, though the difference was not statistically significant. A total of 58% of patients received chemotherapy in this cohort. The use of chemotherapy was associated with a statistically significant (P = 0.033) improvement in overall survival, with an overall survival of 68% at 36 months compared with 36% for the patients who did not receive any chemotherapy. Conclusions: The oncologic outcomes of patients with lymph node-positive bladder cancer treated with robot assisted radical cystectomy (RARC) compare favorably to previous published studies of open radical cystectomy at medium-term (mean follow-up of 42 months). As our follow-up increases, we expect to continue to accurately define the long-term clinical suitability and oncologic success of this procedure in this high-risk population. © 2012.

Phillips, E. A. and D. S. Wang (2012). “Current Status of Robot-Assisted Laparoscopic Ureteral Reimplantation and Reconstruction.” Current Urology Reports: 1-5.

We reviewed the literature on robot-assisted laparoscopic ureteral reimplantation and provide general considerations for indications, perioperative management, and steps of the case. Robot-associated laparoscopic procedures are becoming more common in urologic surgery. The uses of the da Vinci robot (Intuitive Surgical, Sunnyvale, CA) are expanding as well. We examine the use of the robot in distal ureteral reconstruction. A PubMed search was performed using keywords “robot” and “ureter,” “distal ureter,” “ureteral reimplant,” “psoas,” and “Boari.” Papers that discussed proximal ureteral reconstruction and nephroureterectomy were excluded. A total of nine papers were relevant. Personal experience was also drawn upon. Distal ureteral reconstruction using the robotic technique is feasible, safe, and becoming more and more prevalent as surgeon comfort with the robot increases. © 2012 Springer Science+Business Media, LLC.

Stegemann, A., S. Rehman, et al. (2012). “Short-term Patient-reported Quality of Life After Robot-assisted Radical Cystectomy Using the Convalescence and Recovery Evaluation.” Urology.

OBJECTIVE: To determine the short-term health status of patients after robot-assisted radical cystectomy using the Convalescence and Recovery Evaluation (CARE). Radical cystectomy and urinary diversion in patients with invasive bladder cancer can have a significant effect on patients’ quality of life. METHODS: A total of 91 patients completed the CARE preoperatively and postoperatively. The CARE scores were calculated from postoperative day 7 to 90. Outcome measures were calculated using the CARE difference index (CDI), defined as the difference between the baseline CARE and postoperative day 7 CARE scores. The primary outcome was the time taken to recover 90% of the CDI. RESULTS: The mean age at robot-assisted radical cystectomy was 69 years (range 42-86). Of the 91 patients, 68 (74%) were men, 38 underwent extracorporeal urinary diversion, 52 underwent intracorporeal urinary diversion, and 1 underwent no diversion. A comparison of the preoperative and postoperative day 7 scores demonstrated a 48% decline in the total CARE score. The decline in specific CARE domains was 14%, 34%, 56%, and 66% against baseline for the cognition, pain, gastrointestinal, and activity domains, respectively. The mean time to recover 90% of the CDI for the total CARE score was 63 days. The mean time to recover 90% of the CDI for the pain, cognition, and activity domains was 33, 57, and 82 days, respectively. Patients did not recover 90% of the CDI for the gastrointestinal domain within the 90-day follow-up period. CONCLUSION: Patients who underwent robot-assisted radical cystectomy approached preoperative baseline levels within 90 days using the CARE in the total CARE, pain, cognition, and activity domains but not in the gastrointestinal domain.

Styn, N. R., J. S. Montgomery, et al. (2012). “Matched Comparison of Robotic-assisted and Open Radical Cystectomy.” Urology.

Objective: To evaluate our initial robotic-assisted radical cystectomy (RARC) experience compared with a robust open radical cystectomy (ORC) series performed at a single institution using a matched-pair analysis. Although early results suggest that RARC is safe, with favorable perioperative and early oncologic outcomes, limited data exist comparing ORC and RARC. Methods: RARC and ORC patients were identified through a prospectively maintained institutional review board-approved bladder cancer database. RARC and ORC cases performed from September 2007 to November 2010 were matched 1:2 by age, sex, urinary diversion, and clinical stage. The perioperative, complication, and pathologic outcomes were compared. Results: A total of 50 RARC and 100 ORC cases were reviewed, with a median follow-up of 8 and 13.5 months, respectively. No differences in the demographic parameters were present between the 2 groups. RARC was associated with a significantly decreased median estimated blood loss (350 vs 475 mL) and 30-day transfusion rate (2% vs 24%) but with longer operative times (454.9 vs 349.1 minutes). No difference was found in the rate of 30-day minor or major Clavien complications, length of stay, or 30-day readmissions between groups. The 90-day mortality rate was 3% versus 0% for ORC and RARC, respectively. No difference in the final pathologic findings, number of lymph nodes removed, or margin status was identified. Conclusion: Early experience with RARC compared with a robust ORC experience demonstrated similar perioperative and pathologic outcomes. Continued experience with RARC has the potential to bring improved perioperative results. © 2012 Elsevier Inc. All rights reserved.

Yu, H. y., N. D. Hevelone, et al. (2012). “Comparative Analysis of Outcomes and Costs Following Open Radical Cystectomy Versus Robot-Assisted Laparoscopic Radical Cystectomy: Results From the US Nationwide Inpatient Sample.” European Urology.

Background: Although robot-assisted laparoscopic radical cystectomy (RARC) was first reported in 2003 and has gained popularity, comparisons with open radical cystectomy (ORC) are limited to reports from high-volume referral centers. Objective: To compare population-based perioperative outcomes and costs of ORC and RARC. Design, setting, and participants: A retrospective observational cohort study using the US Nationwide Inpatient Sample to characterize 2009 RARC compared with ORC use and outcomes. Outcome measurements and statistical analysis: Propensity score methods were used to compare inpatient morbidity and mortality, lengths of stay, and costs. Results and limitations: We identified 1444 ORCs and 224 RARCs. Women were less likely to undergo RARC than ORC (9.8% compared with 15.5%, p = 0.048), and 95.7% of RARCs and 73.9% of ORCs were performed at teaching hospitals (p < 0.001). In adjusted analyses, subjects undergoing RARC compared with ORC experienced fewer inpatient complications (49.1% and 63.8%, p = 0.035) and fewer deaths (0% and 2.5%, p < 0.001). RARC compared with ORC was associated with lower parenteral nutrition use (6.4% and 13.3%, p = 0.046); however, there was no difference in length of stay. RARC compared with ORC was $3797 more costly (p = 0.023). Limitations include retrospective design, absence of tumor characteristics, and lack of outcomes beyond hospital discharge. Conclusions: RARC is associated with lower parenteral nutrition use and fewer inpatient complications and deaths. However, lengths of stay are similar, and the robotic approach is significantly more costly. © 2012 European Association of Urology.

Khan, M. S., B. Challacombe, et al. (2012). “A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy.” International Journal of Clinical Practice.

Styn, N. R., J. S. Montgomery, et al. (2012). “Matched Comparison of Robotic-assisted and Open Radical Cystectomy.” Urology.

Uro_Kidney (23)

Akçetin, Z. and S. Siemer (2012). “Pyeloplasty – pro robotic-assisted.” Nierenbeckenplastik – pro robotisch: 1-4.

Open pyeloplasty is still the gold standard in the treatment of ureteropelvic junction (UPJ) obstructions in many clinics. Similar functional results could be shown in diverse publications using conventional laparoscopic pyeloplasty (CLPP). The reconstruction of the UPJ is the main step during this type of surgery and constitutes a major challenge to surgeons working with minimally invasive techniques. The more complex the surgery the more obvious the benefits of robotic assistance (seven grades of freedom, 3D view etc.) in comparison to conventional laparoscopy. Thus robotic assistance is optimally suitable for pyeloplasty. The robotic-assisted laparoscopic pyeloplasty (RLPP) facilitates intracorporeal suturing and shortens the learning curve. Residents benefit from this shortened learning curve. Disorders caused by the non-physiological position during conventional laparoscopy are avoided during RLPP, which is an additionally benefit. Robotics also seem to be the optimum platform for the future of reconstructive LESS. The RLPP rather than the CLPP technique has therefore the potential to replace open pyeloplasty as the gold standard in treatment of UPJ. © 2012 Springer-Verlag.

Altunrende, F., H. Laydner, et al. (2012). “Correlation of the RENAL nephrometry score with warm ischemia time after robotic partial nephrectomy.” World Journal of Urology: 1-5.

Purpose: The RENAL nephrometry score (RNS) was developed to quantify complexity of renal tumors in a reproducible manner. We aim to determine whether individual categories of the RNS have different impact on the warm ischemia time (WIT) for patients undergoing robotic partial nephrectomy (RPN). Methods: In a retrospective analysis of a prospectively maintained database, we identified 251 consecutive patients who underwent RPN between January 2007 and June 2010. RNS was determined in 187 with available imaging. Univariable analysis and multivariable linear regression analysis were performed to identify which factors were more significantly associated with WIT. Results: Overall RNS was of low (4-6), moderate (7-9), and high complexity (10-12) in 84 (45 %), 80 (43 %), and 23 (12 %) patients, respectively. There was no association between gender (p = 0.6), BMI (p = 0.3), or anterior/posterior location (A) (p = 0.8), and WIT. On univariable analysis, longer WIT was associated with size (R) >4 cm (p < 0.0001), entirely endophytic properties (E) (p = 0.005), tumor <4 mm from the collecting system/sinus (N) (p < 0.0001), and location between the polar lines (L) (p = 0.004). Total RNS and WIT were highly correlated (Spearman correlation coefficient = 0.54, p < 0.0001). There was a significant trend of higher WIT with increased tumor complexity (p for trend <0.0001). After multivariable analysis, only R (p = 0.0003), E (p = 0.003), and N (p = 0.00002) components of the RNS were significantly associated with WIT. Conclusions: The A and L subcategories of the RNS have no significant impact on the WIT of patients undergoing RPN. WIT is significantly dependent upon the other subcategories, as well as the overall RNS. These findings can be used to preoperatively predict which tumor characteristics will likely affect WIT and may be useful in preoperative counseling as well as planning of approach. © 2012 Springer-Verlag.

Buse, S. (2012). “Nephrectomy – pro robotic.” Nephrektomie – pro robotisch: 1-3.

The last two decades have witnessed the rapid dissemination of robot-assisted laparoscopic urological surgery related to the technical advantages of this new laparoscopic tool. Master-slave systems ease intracorporeal anastomosis and the performance of technically highly demanding procedures, as reflected by a steep learning curve. Robot-assistance is particularly useful for partial nephrectomy, live-donor kidney transplantation, extended procedures, e.g. upper and lower urogenital tract resection and difficult anatomy as encountered in obese patients or patient with a history of multiple intraperitoneal procedures. © 2012 Springer-Verlag.

Cestari, A., N. M. Buffi, et al. (2012). “Feasibility and Preliminary Clinical Outcomes of Robotic Laparoendoscopic Single-Site (R-LESS) Pyeloplasty Using a New Single-Port Platform.” European Urology.

This study tested the technical feasibility and short-term perioperative outcomes of the novel da Vinci Single-Site Instrumentation platform for the treatment of upper ureteropelvic junction obstruction (UPJO) in a selected group of patients. Nine patients underwent robotic laparoendoscopic single-site (R-LESS) pyeloplasty using a new single-site platform for UPJO at our department of urology. All the procedures were completed without the need for traditional robotic surgery or laparoscopic/open conversion, although in one patient with congenital hepatomegaly it was necessary to use an auxiliary 3-mm trocar to retract the liver properly and expose the surgical field. Mean operative time was 166min, and no intraoperative complications were recorded. The indwelling catheter was removed on postoperative day 2 in five patients and on postoperative day 3 in four patients. Patients were discharged the day after drain removal. One patient experienced transient hyperpyrexia, treated with antibiotics. No other complications were observed. All patients had the DJ stent removed 4 wk after surgery, following a negative urine culture and abdominal ultrasound evaluation. The five patients who reached a 3-mo follow-up had a clinical resolution of preoperative symptoms and hydronephrosis at the abdominal ultrasound. The same results were maintained in the two patients with 6-mo follow-up evaluations. In selected patients, R-LESS pyeloplasty using the new single-port platform appears to be a technically feasible and reproducible surgical procedure for the minimally invasive treatment of UPJO. Prolonged follow-up and larger series are required to confirm its potential role as a valid alternative to standard robotic pyeloplasty.

Dogra, P. N., N. Abrol, et al. (2012). “Outcomes following Robotic Radical Nephrectomy: A Single-Center Experience.” Urologia Internationalis.

Objectives: Advancement in technology has led to a decrease in invasiveness for surgical management of malignant renal neoplasms. Laparoscopic radical nephrectomy is an established treatment for renal tumors. Since the introduction of robotic surgery in the realm of urology, many procedures have been done robotically. We evaluated the feasibility, safety, and oncological outcomes of robotic radical nephrectomy (RRN). Methods: We retrospectively reviewed the records of patients who underwent RRN for renal tumors at our institute from September 2007 to March 2011. Patients with standard indications for a radical nephrectomy were offered a robot-assisted procedure. Intraoperative parameters (operative time, blood loss, transfusion of blood products), postoperative parameters and complications were recorded. Results: Twenty-three patients who underwent RRN were included. Mean operative time was 132.7 min and mean blood loss 270 ml. The majority of patients were able to tolerate liquid diet, were free from drain, and were fit for discharge by postoperative day (POD) 1, POD 2 and POD 3, respectively. After the mean follow-up of 29.4 months, no patient had residual tumor, local recurrence or metastasis. Conclusion: We conclude that RRN is a feasible and safe procedure with good oncological outcome on short-term follow-up.

Fisch, M. (2012). “[Comments on pyeloplasty - laparoscopic versus robotic.].” Urologe. Ausgabe A.

Janetschek, G. (2012). “[Partial nephrectomy - pro laparoscopy.].” Urologe. Ausgabe A.

Partial nephrectomy has become the most frequently used surgical procedure in the treatment of renal cell cancer. The current role of laparoscopy for this indication has to be defined.The technique of laparoscopic partial nephrectomy has undergone a continuous development to become mature. Once the learning curve of the individual surgeon has been overcome the results are comparable to those of open surgery. This is true for ischemia time, complication rate and oncologic outcome. In addition there is the advantage of the minimally invasive approach in laparoscopy sparing a painful flank incision. Laparoscopic partial nephrectomy is not yet a standard of care but yields excellent results in the hands of experts. There are no conclusive studies comparing standard and da Vinci(R)-assisted laparoscopy. No clear advantages become obvious, but the costs of the robot are substantial.

Lane, B. R. and C. M. Whelan (2012). “The Influence of Surgical Approach to the Renal Mass on Renal Function.” Urologic Clinics of North America 39(2): 191-198.

The National Kidney Foundation estimates that 26 million Americans are living with chronic kidney disease (CKD). The high prevalence of obesity, heart disease, hypertension, and diabetes places millions more at risk for developing CKD. Although long-term sufficient renal function is routine in screened kidney donors, CKD is present in more than 30% of patients with a newly diagnosed renal mass and develops in most patients who undergo radical nephrectomy and a portion of those who undergo nephron-sparing approaches. Herein, the authors review the effect of the surgical approach on renal function for patients presenting with a renal mass. © 2012 Elsevier Inc.

Long, J. A., R. Yakoubi, et al. (2012). “Robotic Versus Laparoscopic Partial Nephrectomy for Complex Tumors: Comparison of Perioperative Outcomes.” European Urology.

Background: Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors. Objective: To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity. Design, setting, and participants: A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. Intervention: LPN or RPN. Outcome measurements and statistical analysis: Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. Results and limitations: There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m 2 compared with 30.7 kg/m 2, p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m 2, p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p < 0.001) and a higher decrease in percentage of eGFR (-16.0% compared with -12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study. Conclusions: RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings. © 2012 European Association of Urology.

Nepple, K. G., G. S. Sandhu, et al. (2012). “Description of a multicenter safety checklist for intraoperative hemorrhage control while clamped during robotic partial nephrectomy.” Patient Safety in Surgery 6(1): 8.

ABSTRACT: BACKGROUND: The adoption of robotic assistance has contributed to the increased utilization of partial nephrectomy for the management of renal tumors. However, partial nephrectomy can be technically challenging because of intraoperative hemorrhage, which limits the ability to identify the tumor margin and may necessitate the conversion to open surgery or radical nephrectomy. To our knowledge, a comprehensive safety checklist does not exist to guide surgeons on the management of hemorrhage during robotic partial nephrectomy. We developed such an safety checklist based on the cumulative experiences of high volume robotic surgeons. METHODS: A treatment safety checklist for the management of hemorrhage during robotic partial nephrectomy was collaboratively developed based on prior experiences with intraoperative hemorrhage during robotic partial nephrectomy. RESULTS: Reducing the risk of hemorrhage during robotic partial nephrectomy begins with reviewing the preoperative imaging for renal vasculature and tumor anatomy, with a focus on accessory vessels and renal tumor proximity to the renal hilum. During hilar exposure, an attempt is made to identify additional accessory renal arteries. The decision is then made on whether to clamp the hilum (artery +/- vein). If bleeding is encountered during resection, management is based on whether the bleeding is suspected to be arterial or from venous backbleeding. Operative maneuvers that may increase the chance of success are highlighted in safety checklists for arterial and venous bleeding. CONCLUSIONS: Safely performing robotic partial nephrectomy is dependent on attention to prevention of hemorrhage and rapid response to the challenge of intraoperative bleeding. Preparation is essential for maximizing the chance of success during robotic partial nephrectomy.

Novak, R., D. Mulligan, et al. (2012). “Robotic Partial Nephrectomy Without Renal Ischemia.” Urology.

Objective: To evaluate our outcomes of robotic partial nephrectomy (RPN) without renal artery clamping (off-clamp), in order to avoid ischemic renal injury, using cold-scissor tumor excision and sutured reconstruction without ablation or other regional hypoperfusion. Materials and Methods: Between September 2009 and October 2010, patients who underwent off-clamp RPN for ≥1 tumors were reviewed from a prospective database. All procedures were performed by a single surgeon experienced in RPN. Indications included solitary kidney, multiple tumors in the same kidney, or electively when they it was possible. Results: Twenty-eight off-clamp RPNs were performed in 22 patients. Mean age and body mass index were 55 years (range 24-73) and 31 kg/m 2. Mean operative time was 183 minutes with mean blood loss of 274 mL. One patient required transfusion and was the only patient with Clavien grade II or higher complications (4.5%). Mean ± SD off-clamp tumor size on final pathology was 2.1 ± 1.1 cm (range 0.8-4.9) with mean RENAL nephrometry score of 6.25 (4a-9ph). For patients with additional tumors undergoing RPN with clamping, mean warm ischemia time was 12.1 minutes (range 7-19.3) for tumors of 4.6-10.5 cm. Twenty patients (91%) were discharged on postoperative day 1. All had negative margins. Mean preoperative, immediate postoperative, and 6-month postoperative estimated glomerular filtration rate were 89.8, 77.5, and 86.5 mL/min, respectively. Conclusion: For selected patients and tumors, RPN without ischemia is feasible without ablation, energy resection, or regional hypoperfusion. Further experience is necessary to determine which patients are ideally suited. © 2012 Elsevier Inc. All rights reserved.

Padevit, C. and H. John (2012). “Partial nephrectomy: Minimally invasive or open surgery?” Nierenteilresektion: Minimal-invasiv oder offen? 19(1): 12-13.

Patel, T. H., S. J. Sirintrapun, et al. (2012). “Surgeon-controlled robotic partial nephrectomy for a rare renal epithelioid angiomyolipoma using near-infrared fluorescence imaging using indocyanine green dye: A case report and literature review.” Canadian Urological Association Journal 6(2): E91-94.

Renal epithelioid angiomyolipoma (E-AML) is a rare variant of angiomyolipoma (AML). It is a mesenchymal tumour believed to originate from the perivascular epithelioid cell (PEC). Unlike conventional AML which are benign, E-AML has a rare aggressive behaviour. Conventional AML is typically triphasic containing adipose tissue, smooth muscle and dystrophic vessels in variable proportions, while E-AML are generally composed of plump spindled and polygonal-shaped “epithelioid cells” showing clear or eosinophilic cytoplasm and occasional pleomorphic multinucleated giant cells. E-AML can be misdiagnosed as renal cell carcinoma (RCC) when these “epithelioid cells” show clearing. Only a small number of cases of E-AML have been reported with the standard treatment being radical or partial nephrectomy. We report the first case report of a surgeon-controlled robotic partial nephrectomy using a near-infrared fluorescence imaging using indocyanine green dye on a 25-year-old woman with a T1B (6.6 cm) right renal mass. The final pathology revealed the diagnosis of E-AML. There was no recurrence and metastases after the 6-month follow-up.

Richstone, L. (2012). “Editorial Comment on END-2011-0573-TE.R1.” Journal of Endourology.

Editorial comment on Robotic-Assisted Laparoendoscopic Single-Site Pyeloplasty: Technique Using the da Vinci Si Robotic Platform.

Riedmiller, H. (2012). “[Comments on nephrectomy - laparoscopic versus robotic.].” Urologe. Ausgabe A.

Rodriguez, A. R., M. A. Rich, et al. (2012). “Stentless pediatric robotic pyeloplasty.” Therapeutic Advances in Urology 4(2): 57-60.

Objectives: Open dismembered pyeloplasty remains the standard of care for the correction of ureteropelvic junction obstruction in children. We describe our experience with a tubeless, stentless pediatric robotic pyeloplasty technique.Methods: Between October 2008 and September 2009, 12 consecutive children underwent robotic dismembered pyeloplasty. Ureteral stents or nephrostomy tubes were not used. Operative time, hospital stay, days of Jackson-Pratt drainage, and complications were analyzed. Postoperative renal ultrasonography was obtained at 4-6 weeks after surgery.Results: The mean patient age was 9.1 years (3.5-16). The mean operative and console times were 178 (122-250) and 129 (96-193) minutes, respectively. The Jackson-Pratt drain was removed after a mean of 1.8 days (1-4). The mean hospital stay was 2.4 days (1-4.5). There were no complications. Mean follow up was 16 months (12-24 months). All patients had complete resolution of symptoms. Hydronephrosis either completely resolved or significantly decreased in all cases. In cases without complete resolution of hydronephrosis, 99m Tc-MAG-3 diuretic renography showed preservation of renal function without obstruction.Conclusions: Robot-assisted laparoscopic pyeloplasty can be safely performed without internal indwelling stent drainage. In children, this avoids the need for additional anesthesia and stent-related morbidity. © The Author(s), 2012.

Seideman, C. A., J. P. Sleeper, et al. (2012). “COST COMPARISON OF ROBOTIC-ASSISTED AND LAPAROSCOPIC PYELOPLASTY.” Journal of Endourology.

Abstract Introduction and Objective: Laparoscopic repair of ureteropelvic junction obstruction is now the standard of care at many institutions. The objective of this study is to compare costs associated with robotic-assisted (RP) versus laparoscopic pyeloplasty (LP). Methods: A decision analysis model was developed to compare costs of each procedure based on hospital related cost centers. A literature search was performed to identify non-overlapping studies with outcomes for RP and LP. Weighted means were calculated for operative time and length of stay. Cost data was obtained from our institution. One- and two-way sensitivity analyses were performed to evaluate the effect of changing variables on the cost-effectiveness of RP. Results: 8 studies were identified with 181 and 145 patients undergoing RP or LP respectively. Operative times were 211 minutes for RP and 224 minutes for LP. Hospital stays were shorter for RP at 1.54 days compared to 1.98 days for LP. Mean direct costs were higher for RP at $10,635 versus $9,065 for LP. The largest difference was in fixed surgical supply costs per case at $1357 for RP and $406 for LP. One way sensitivity analysis showed that a RP would be cost effective if performed in less than 96 minutes. However, even if RP was performed on an outpatient basis or more than 1000 cases/year, LP would still be cost superior. Two way analyses showed areas where RP could be more cost-effective than LP. Conclusions: RP is associated with higher cost compared to LP, predominately due to the cost of the robot and surgical supply costs. Decreasing operative time and equipment costs may result in RP being more cost-effective than LP. However, shorter hospital stay alone is insufficient to allow RP to be cost-effective. One would need to demonstrate tangible advantages to the robot to justify the added costs.

Simhan, J., M. C. Smaldone, et al. (2012). “Perioperative Outcomes of Robotic and Open Partial Nephrectomy for Moderately and Highly Complex Renal Lesions.” Journal of Urology.

PURPOSE: We compared outcomes in patients undergoing robotic vs open partial nephrectomy stratified by moderately and highly complex tumor nephrometry scores. MATERIALS AND METHODS: Patients treated with partial nephrectomy from 2007 to 2010 were grouped by tumor characteristics into low-nephrotomy score 4 to 6, moderate-7 to 9 and high-10 to 12 anatomical complexity cohorts. Lesions with low complexity were excluded from study. Demographic, surgical and pathological outcomes were compared between patients undergoing robotic vs open partial nephrectomy in the moderately and highly complex cohorts. RESULTS: A total of 281 patients, of whom 63.3% were male, with a mean +/- SD age of 58.1 +/- 11.7 years and a mean followup of 21.3 +/- 16.3 months underwent partial nephrectomy. Moderately complex lesions were noted in 81 robotic and 136 open partial nephrectomy cases with a mean tumor size of 3.8 +/- 2.2 cm. Highly complex lesions were noted in 10 robotic and 54 open partial nephrectomy cases with a mean tumor size of 4.8 +/- 3.0 cm. There were no differences between the groups in patient age, race, gender, body mass index or American Society of Anesthesiologists classification. Cases treated with open partial nephrectomy for moderately or highly complex lesions were of higher pathological stage (p = 0.02 and 0.01, respectively). The percent change in creatinine and the glomerular filtration rate were similar for robotic and open partial nephrectomy in the moderately and highly complex tumor groups. In patients undergoing robotic vs open partial nephrectomy for moderately complex lesions we noted differences in pathological tumor size (mean 3.2 +/- 1.8 vs 4.1 +/- 2.3 cm, p <0.0001) and operative time (205.9 +/- 52.5 vs 189.5 +/- 52.0 minutes, p <0.01) while decreased estimated blood loss (131.3 +/- 127.8 vs 256.5 +/- 291.3 ml) and hospital length of stay (3.7 +/- 1.6 vs 5.6 +/- 3.9 days, each p <0.001) were observed in the robotic group. Comparison of highly complex lesions revealed decreased hospital length of stay (2.9 +/- 1.4 vs 6.1 +/- 4.1days, p <0.0001) in the robotic partial nephrectomy group. CONCLUSIONS: In our large institutional series of patients with moderate and highly complex solid renal tumors classified by the nephrometry score robotic partial nephrectomy offered comparable perioperative and functional outcomes with the added benefit of decreased hospital length of stay.

Tanagho, Y. S., S. Bhayani, et al. (2012). “Off-Clamp Robot-Assisted Partial Nephrectomy: Initial Washington University Experience.” Journal of Endourology.

Background and Purpose: Due to the impact warm ischemia time may have on renal function, various surgical techniques have been proposed in order to minimize or eliminate warm ischemia. The purpose of this study is to evaluate our initial renal functional outcomes of off-clamp robot-assisted partial nephrectomy (RAPN), while assessing the safety profile of this unconventional surgical approach. Materials and Methods: We performed a retrospective review of our off-clamp RAPN experience between August 2007 and January 2012. All patients with baseline and postoperative serum creatinine were included. Patient demographics, operative information, perioperative outcomes, and renal functional outcomes were evaluated for this cohort. Results: Forty-two patients with a mean age of 59.9 years (SD=12) had a median follow-up of 100 days (range 1-1007). In all cases, warm ischemia time was 0 minutes. Mean operative time was 143 minutes (SD=59), and median estimated blood loss was 138 mL (range 50-1500). No intraoperative complications were encountered, and all surgical margins were negative. Our postoperative complication rate was 14.3%. At most recent follow-up, mean estimated glomerular filtration rate (eGFR) was 76.2 mL/min/1.73m2 (SD=27.6), compared to 78.5 mL/min/1.73m2 (SD=28.9) preoperatively (p=0.11). Therefore, the mean eGFR decline of 2.3 ml/min/1.73m2 (SD=9.1) was not significant. Conclusions: Off-clamp RAPN is associated with minimal morbidity and minimal decline in renal function on short-term follow-up. Further studies and continued monitoring of renal function are needed to determine if off-clamp RAPN provides any advantage in renal functional preservation relative to the traditional RAPN with vascular clamping.

Tanagho, Y. S., R. S. Figenshau, et al. (2012). “Is There a Financial Disincentive to Perform Partial Nephrectomy?” Journal of Urology.

PURPOSE: Despite the explicit endorsement of the American Urological Association guidelines of partial nephrectomy as the treatment of choice for T1a renal cell carcinoma, a considerable underuse of nephron sparing surgery characterizes general practice patterns in the United States. We explored possible financial disincentives associated with partial nephrectomy that may contribute to this important quality of care deficit. MATERIALS AND METHODS: A PubMed(R) query on perioperative outcomes identified 10 series on open or laparoscopic radical nephrectomy and 16 on open, laparoscopic or robot-assisted partial nephrectomy. Mean operative time and hospital length of stay were calculated for each group. Using these data in conjunction with Health Care Financing Administration data on physician work time, which guides the current Resource-Based Relative Value Scale Medicare fee schedule, we calculated global physician time expenditure and hourly Medicare reimbursement rates for each of these 5 surgical services. RESULTS: Mean +/- SD operative time for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 180.7 +/- 24.7 minutes (95% CI 119.3-242.0) in 3 studies, 178.8 +/- 16.5 (95% CI 163.5-194.1) in 7, 226.0 +/- 36.9 (95% CI 187.2-264.8) in 6, 227.9 +/- 40.2 (95% CI 185.8-270.1) in 6 and 227.9 +/- 37.8 (95% CI 167.7-288.1) in 4, respectively (p = 0.028). Mean length of stay (days) after open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy was 5.8 +/- 0.7 days (95% CI 4.0-7.7) in 3 studies, 2.5 +/- 1.1 (95% CI 1.4-3.6) in 6, 5.8 +/- 0.4 (95% CI 5.3-6.2) in 5, 2.9 +/- 0.3 (95% CI 2.6-3.3) in 6 and 2.8 +/- 1.0 (95% CI 1.2-4.4) in 4, respectively (p <0.001). The hourly reimbursement rate was calculated at $200.61, $242.03, $185.66, $231.27 and $231.97 for open and laparoscopic radical nephrectomy, and open, laparoscopic and robot-assisted partial nephrectomy, respectively. Hence, open partial nephrectomy emerged as the lowest paying of these procedures. CONCLUSIONS: Inferior compensation for open partial nephrectomy relative to that of laparoscopic or open radical nephrectomy may impede the dissemination of nephron sparing surgery for small renal masses. This may occur particularly in a general practice setting, where the expertise required for laparoscopic or robot-assisted partial nephrectomy may be lacking. We propose rectifying this inequity to facilitate wider use of nephron sparing surgery in the clinically appropriate setting.

Thuroff, J. W. (2012). “[Comments on partial nephrectomy - laparoscopic versus robotic.].” Urologe. Ausgabe A.

Tobis, S., J. K. Knopf, et al. (2012). “Near infrared fluorescence imaging after intravenous indocyanine green: Initial clinical experience with open partial nephrectomy for renal cortical tumors.” Urology 79(4): 958-964.

Objective: To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. Methods: Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. Results: A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. Conclusion: The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy. © 2012 Elsevier Inc. All Rights Reserved.

Yuh, B., S. Muldrew, et al. (2012). “Integrating robotic partial nephrectomy to an existing robotic surgery program.” Can J Urol 19(2): 6193-6200.

INTRODUCTION: As more centers develop robotic proficiency, progressing to a successful robot-assisted partial nephrectomy (RAPN) program depends on a number of factors. We describe our technique, results, and analysis of program setup for RAPN. MATERIALS AND METHODS: Between 2005 and 2011, 92 RAPNs were performed following maturation of a robotic prostatectomy program. Operating rooms and supply rooms were outfitted for efficient robotic throughput. Tilepro and intraoperative ultrasound were used for all cases. Training and experiential learning for surgeons, anesthesia and nursing staff was a high priority. An onsite robotic technician helped troubleshoot, prepare the room and staff prior to starting surgery, and provide assistance with different robotic models. RESULTS: Average operative time decreased over time from 235 min to 199 min (p = .03). Warm ischemia time decreased from 26 minutes to 23 minutes (p = .02) despite an increased complexity of tumors and operations on multiple tumors. Median estimated blood loss was 150 mL. Average length of hospital stay was 3 days (range 1-9). Average size of lesions was 2.7 cm (range 0.7-8.6). Final pathology demonstrated 71 (77%) malignant lesions and 21 (23%) benign lesions. CONCLUSIONS: The addition of a robot-assisted partial nephrectomy program to an institutional robotic program can be coordinated with several key steps. Outcomes from an operational, oncologic, and renal functional standpoint are acceptable. Despite increased complexity of tumors and treatment of multiple lesions, operative and warm ischemia times showed a decrease over time. An organizational model that involves the surgeons, anesthesia, nursing staff, and possibly a robotic technical specialist helps to overcome the learning curve.

Long, J. A., R. Yakoubi, et al. (2012). “Robotic Versus Laparoscopic Partial Nephrectomy for Complex Tumors: Comparison of Perioperative Outcomes.” European Urology.

Seideman, C. A., J. P. Sleeper, et al. (2012). “COST COMPARISON OF ROBOTIC-ASSISTED AND LAPAROSCOPIC PYELOPLASTY.” Journal of Endourology.

Simhan, J., M. C. Smaldone, et al. (2012). “Perioperative Outcomes of Robotic and Open Partial Nephrectomy for Moderately and Highly Complex Renal Lesions.” Journal of Urology.

Tanagho, Y. S., R. S. Figenshau, et al. (2012). “Is There a Financial Disincentive to Perform Partial Nephrectomy?” Journal of Urology.

Uro_Other (6)

Alkhudair, W. K., R. Seyam, et al. (2012). “Robotic uretero-ureterostomy of the retrocaval ureter without excision of the retrocaval segment.” Journal of the Canadian Urological Association 6(2): e38-e41.

Robotic reconstruction of the retrocaval ureter is gaining momentum as the method of choice for surgically treating this rare condition. Maintaining the retrocaval ureteric segment further facilitates the procedure. We report a case of a 23-year-old man who underwent intraperitoneal robotic resection anastomosis and repositioning of the retrocaval ureter. We also discuss the advantages of this technique. © 2012 Canadian Urological Association.

Chen, C. C., Y. C. Ou, et al. (2012). “Malfunction of the da Vinci robotic system in urology.” International Journal of Urology.

Objectives: To analyze the incidence of malfunction of the da Vinci robotic system in a single center and to provide potential solutions. Methods: A total of 400 patients underwent da Vinci robotic urological surgery at Taichung Veterans General Hospital in Taichung, Taiwan, from December 2005 to April 2011. Episodes of malfunction of the robotic system were analyzed by period of operation, type of procedure, type of malfunction and management of the event. Results: Overall, 14 cases of malfunction occurred (3.5% of the entire series). Among them, five (1.25%) occurred before the surgery and nine (2.25%) intraoperatively. Operative procedures included radical prostatectomy, bilateral pelvic lymph node dissection, dismembered pyeloplasty, partial nephrectomy, nephroureterectomy, and radical and partial cystectomies. Areas of malfunctions included the robotic arm system and joint (11/14), optical system (1/14), power system and connector (1/14), endoscopic instrument (1/14), and software (1/14). In 10 cases, the failure was recoverable, whereas in four cases there was a critical failure, requiring a conversion to standard laparoscopy in three of them, and the rescheduling of the surgery in one case. Conclusions: The da Vinci robotic system is extremely reliable for use in urology. Malfunction is rare and the risk of critical failure is very low. Managing mechanical failure before or during the surgery is the key to maintaining the safety of patients undergoing robotic surgical procedures. © 2012 The Japanese Urological Association.

Grimm, M. O., S. Voigt, et al. (2012). “Robot-assisted laparoscopic operations in urology.” Roboterassistierte laparoskopische Operationen in der Urologie: 1-4.

Robotic laparoscopic surgery has increased rapidly in recent years. In the USA more than 80% of radical prostatectomies and an increasing number of hysterectomies are performed using the da Vinci system and a similar trend, although with some delay, can be observed in Europe. Recently, the Canadian Agency for Drugs and Technologies in Health (CADTH) systematically evaluated robot-assisted surgery including a meta-analysis. Statistically significant differences favoring robotic surgery were identified for several outcomes but there was uncertainty about its clinical relevance. Regarding hysterectomy a shorter length of hospital stay (LOS), less complications and a lower blood loss were observed. For partial nephrectomy a shorter warm ischemia time compared to conventional laparoscopy was noted. For robotic-assisted laparoscopic prostatectomy two prospective randomized trials apart from the CADTH report have been reported recently. Overall, these data suggest that in addition to the general advantages of laparoscopic surgery (shorter LOS, lower blood loss/transfusion rate) improvements with regard to positive surgical margin rate (at least for organ confined tumors), recurrence-free survival as well as continence and potency can be obtained. However, the higher costs not reimbursed according to the diagnosis-related groups (DRG) system remain a concern. © 2012 Springer-Verlag.

Hillyer, S., G. Spana, et al. (2012). “Novel robotic renorrhaphy technique for hilar tumours: ‘V’ hilar suture (VHS).” BJU International 109(10): 1572-1577.

Piechaud, P. (2011). “State of the art: urologic surgery.” J Visc Surg 148(5 Suppl): e27-29.

Thuroff, J. W. (2012). “[Laparoscopic vs. robotic operations in urology.].” Urologe. Ausgabe A.

Grimm, M. O., S. Voigt, et al. (2012). “Robot-assisted laparoscopic operations in urology.” Roboterassistierte laparoskopische Operationen in der Urologie: 1-4.

Thuroff, J. W. (2012). “[Laparoscopic vs. robotic operations in urology.].” Urologe. Ausgabe A.

Uro_Prostate (27)

Adding, C., A. Nilsson, et al. (2012). “[Radical prostatectomy--the optimal surgical treatment].” Lakartidningen 109(8): 407-411.

Barbaro, S., A. Paudice, et al. (2012). “Robot-assisted radical prostatectomy: A minihealth technology assessment in a teaching hospital.” HealthMED 6(3): 724-730.

Objectives: The aim of this study is to perform a comparative costs analysis of radical retropubic prostatectomy (RRP) and robotic-assisted laparoscopic prostatectomy (RAP) for clinically localized prostate cancer and to determine whether to expand the use of RAP or to continue with conventional RRP in Teaching Hospital San Giovanni Battista Turin Italy. Methods: A cohort study was carried out comprising consecutive patients undergoing radical prostatectomy. The decision of which surgical approach to use was by patient choice after a discussion of the perceived pros and cons of each alternative. No other selection criteria were routinely used. All patients were followed on a common care pathway. Included in the assessment model were the following domains (EUnetHTA): Safety, Clinical effectiveness, Organizational aspects, Cost and economic evaluation. Data were collected from the patient’s medical health record and the operating room report and data were obtained from the hospital accounting office. Two-way sensitivity analysis of RAP was performed. Results: In agreement with other observations our results showed that the mean LOS for RAPtreated patients was shorter and that LOS in the ICU was longer as well as the operating time. RAP is more expensive than RRP. Conclusion: In the current circumstances, increasing the use of RAP at the San Giovanni Battista Hospital does not appear expedient. This conclusion is corroborated by the sensitivity analysis which showed that RAP carries higher costs than RRP.

Boylu, U., C. Başataç, et al. (2012). “Robot-assisted radical prostatectomy: Surgical, oncological, and functional outcomes.” Robot yardi{dotless}mli{dotless} radikal prostatektomi: Cerrahi, onkolojik ve fonksiyonel sonuçlar 38(1): 8-13.

Objective: To evaluate the surgical, oncological, and functional outcomes of robot-assisted radical prostatectomy. Materials and Methods: Between 2008 and 2011, a total of 203 patients with localized prostate cancer underwent robot-assisted radical prostatectomy. Of these patients, 150 were included into the study and were followed for a minimum of 1 year. Body mass index, IIEF-5 score, positive surgical margin rates, operative times, estimated blood loss, transfusion rates, biochemical recurrence rates, and length of hospital stay were noted. The continence and potency rates were evaluated at 3, 6, 9, and 12 months. Results: The mean operative time was 156 min. The mean blood loss was 220 mL. Bilateral nerve sparing was performed in 112, whereas a unilateral nerve sparing technique was used in 12 patients. A conversion to open surgery occurred in 1 patient due to excessive bleeding. The drain was removed after a mean duration of 2 days. The mean length of stay was 3.9 days. The urethral catheter was removed in a mean of 8.5 days. There were 20 grade 2, 5 grade 3, 2 grade 4 and 1 grade 5 complications (a total of 28 complications). Conclusion: Robot-assisted radical prostatectomy is an effective and safe minimally invasive approach in the treatment of localized prostate cancer. It is a strong alternative to conventional techniques with respect to its surgical, oncological, and functional outcomes. © 2012 by Turkish Association of Urology.

Cooperberg, M. R., A. Y. Odisho, et al. (2012). “Outcomes for radical prostatectomy: is it the singer, the song, or both?” Journal of Clinical Oncology 30(5): 476-478.

Gillitzer, R. (2012). “Radical prostatectomy – pro robotic.” Radikale Prostatektomie – pro robotisch: 1-5.

Anatomical radical prostatectomy was introduced in the early 1980s by Walsh and Donker. Elucidation of key anatomical structures led to a significant reduction in the morbidity of this procedure. The strive to achieve similar oncological and functional results to this gold standard open procedure but with further reduction of morbidity through a minimally invasive access led to the establishment of laparoscopic prostatectomy. However, this procedure is complex and difficult and is associated with a long learning curve. The technical advantages of robotically assisted surgery coupled with the intuitive handling of the device led to increased precision and shortening of the learning curve. These main advantages, together with a massive internet presence and aggressive marketing, have resulted in a rapid dissemination of robotic radical prostatectomy and an increasing patient demand. However, superiority of robotic radical prostatectomy in comparison to the other surgical therapeutic options has not yet been proven on a scientific basis. Currently robotic-assisted surgery is an established technique and future technical improvements will certainly further define its role in urological surgery. In the end this technical innovation will have to be balanced against the very high purchase and running costs, which remain the main limitation of this technology. © 2012 Springer-Verlag.

Gondo, T., K. Yoshioka, et al. (2012). “The powerful impact of double-layered posterior rhabdosphincter reconstruction on early recovery of urinary continence after robot-assisted radical prostatectomy.” Journal of Endourology.

Background and Purpose: The usefulness of posterior rhabdosphincter reconstruction (PR) during robot-assisted radical prostatectomy (RARP) has still been controversial. We investigated the association of several factors, including Rocco’s original double-layered PR, with early recovery of urinary continence after RARP. Methods: Between August 2006 and April 2011, 206 RARPs were performed by a single surgeon at Tokyo Medical University Hospital. Of these 206 patients, 199 eligible patients were enrolled in this study. We retrospectively analyzed the correlation of several perioperative factors, including surgical techniques, with early recovery of urinary continence 1 month after catheter removal. Continence was defined as no use or the use of only 1 safety pad. Results: Univariate analysis showed that surgeon experience, lateral approach of bladder neck preservation, bladder neck reconstruction, anterior reconstruction, and Rocco’s double-layered PR were significantly associated with early recovery of urinary continence 1 month after catheter removal. However, preoperative prostate-specific antigen level, body mass index, and attempted nerve-sparing (NS) procedures were not significantly associated with early recovery of urinary continence. Multivariate logistic regression analysis showed that Rocco’s PR and attempted NS were the only independent predictive factors of urinary continence recovery 1 month after catheter removal (odds ratio [OR], 15.01; 95% confidence interval [CI], 3.41366.67; P = 0.0003 and OR, 2.248; 95% CI, 1.0484.975; P = 0.0402, respectively). When we applied NS as well as Rocco’s PR the recovery rates of continence at 1 month after catheter removal was 85.3%. Conclusions: Rocco’s double-layered PR and attempted NS and not surgeon experience were the significant independent predictive factors of early recovery of urinary continence after RARP. NS procedures positively influenced early recovery of urinary continence only when they were applied with the PR technique.

Gondo, T., K. Yoshioka, et al. (2012). “Perioperative care of patient undergoing robotic-assisted radical prostatectomy.” Japanese Journal of Clinical Urology 66(4): 387-393.

Heer, R., I. Raymond, et al. (2011). “A critical systematic review of recent clinical trials comparing open retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy.” Rev Recent Clin Trials 6(3): 241-249.

The surgical treatment of prostate cancer has evolved rapidly, driven by technological advances that have made minimally-invasive prostatectomy feasible. The contemporary surgical approaches are laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP). These are now considered standard modalities of treatment in urology departments across North America, Europe and centres of excellence world-wide. However, despite the widespread adoption of minimally-invasive approaches there are only a handful of robust studies directly comparing the results of these techniques with the gold standard approach of open radical prostatectomy (ORP). Of note, uncertainty remains over exactly which men with localised prostate cancer will benefit from radical treatment and the reduction of surgical side-effects is paramount in optimising outcomes. This systematic review examines the current status of minimally- invasive prostatectomy focussing on peri-operative, oncological and urogenital functional outcomes.

Hung, A. J., A. L. D. C. Abreu, et al. (2012). “Robotic Transrectal Ultrasonography During Robot-Assisted Radical Prostatectomy{black small square}.” European Urology.

We evaluate the use of robotically manipulated transrectal ultrasound (TRUS) for real-time monitoring of prostate and periprostatic anatomy during robot-assisted prostatectomy (RAP). Ten patients with clinically organ-confined prostate cancer undergoing RAP underwent preoperative and real-time intraoperative biplanar TRUS evaluation using a robotically manipulated TRUS device (ViKY System; EndoControl Medical, Grenoble, France). Median patient age was 66 yr (range: 54-88), baseline prostate-specific antigen (PSA) was 5.3 (range: 1.3-17.9), and four patients (40%) had clinical high-grade and high-stage disease. Bilateral or unilateral nerve sparing was performed in nine patients (90%). Median time for ViKY System setup to insertion of the TRUS probe was 7 min (range: 4-12). Complete robotic TRUS evaluation was successful in all patients. Five patients (50%) had TRUS-visible hypoechoic lesions, confirmed cancerous on preoperative biopsy. Relevant intraoperative TRUS findings were relayed in real time to the robotic surgeon, particularly during dissection of the bladder neck and prostatic apex, during neurovascular bundle preservation, and when hypoechoic prostate lesions approximated nerve-preserving dissection. Negative margins were achieved in nine patients (90%), including cases where significant intraprostatic lesions abutted or extended through the prostate capsule. No complications occurred. We concluded that real-time robotic TRUS guidance during RAP is feasible and safe. Robotic TRUS can provide the console surgeon with valuable anatomic information, thus maximizing functional preservation and oncologic success. © 2012 European Association of Urology.

Koc, G., N. N. Tazeh, et al. (2012). “Lower Extremity Neuropathies After Robot-Assisted Laparoscopic Prostatectomy on a Split-Leg Table.” Journal of Endourology.

Background: Lower extremity neuropathies from prolonged lithotomy positioning have been well documented. When we initiated our robot-assisted laparoscopic prostatectomy (RALP) program in December 2002, we chose to use the split-leg table that allows patient support in a more anatomic position, hypothesizing that this would reduce risk of neurological compression injuries. We report our incidence of lower extremity neuropathies associated with RALP using split-leg positioning, and review patient and surgical variables associated with this complication. Methods: We retrospectively reviewed records of 377 patients who underwent RALP using a split-leg table. Patient data including height, weight, BMI, age, and smoking status as well as surgical variables such as surgeon operative experience and intraoperative times were also assessed. Intraoperative time was defined as anesthesia induction to anesthesia emergence to more accurately measure total time patients spent in split-leg position. Results: Of 377 patients, 5 (1.3%) developed lower extremity neuropathies in the immediate postoperative period. Of all variables examined, only increased intraoperative time was identified as a potential risk factor for the development of this complication(496.2 +/- 34.8 min vs. 366.3 +/- 96.1 min, p < 0.001). Overall mean operative time for all patients was 368.0 +/- 96.6 min. 3 of the 5 patients had sympoms suggestive of a femoral mononeuropathy. Conclusions: Intraoperative time as defined in our study is a significant risk factor for developing postoperative neuropathy. We also found that split-leg positioning appears to put the femoral nerve at risk for injury, instead of the common peroneal nerve as has been previously reported from prolonged lithotomy positioning.

Lipsky, M., P. Motamedinia, et al. (2012). “Is there a Difference in Laterality during Robot Assisted Radical Prostatectomy? Assessment of Lymph Node Yield and Neurovascular Bundle Dissection.” Journal of Endourology.

Purpose: The da Vinci surgical system (dVSS) has been reported to eliminate innate hand dominance of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its own inherent ‘handedness’ resulting from the fixed left-right preference of specific instrument docking and assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB) dissections as well as positive surgical margin rates as procedure points during robot assisted radical prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency. Materials and Methods: Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010 were identified. Surgeon instrument preference and port placement were consistent across all cases. Pathological LN yield was stratified by the intended limits of dissection (limited or extended) and laterality. Additionally, fascial widths (FW) were prospectively measured for 93 consecutive patients; a narrower FW indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections. Results: A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right compared to left (3.26 vs. 2.76, p = 0.010). This difference was not seen in the extended LN dissection (p=0.96). Average FW was narrower on the right surgical margin compared to the left (1.99 vs. 2.64mm, p<0.001). Conclusions: Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved on the right compared to the left using the dVSS during RARP. This can be attributed to surgeon handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these potential differences is important for the pre-operative planning prior to RARP.

Lowrance, W. T., J. A. Eastham, et al. (2012). “Contemporary Open and Robotic Radical Prostatectomy Practice Patterns Among Urologists in the United States.” Journal of Urology.

Purpose: We describe current trends in robotic and open radical prostatectomy in the United States after examining case logs for American Board of Urology certification. Materials and Methods: American urologists submit case logs for initial board certification and recertification. We analyzed logs from 2004 to 2010 for trends and used logistic regression to assess the impact of urologist age on robotic radical prostatectomy use. Results: A total of 4,709 urologists submitted case logs for certification between 2004 and 2010. Of these logs 3,374 included 1 or more radical prostatectomy cases. Of the urologists 2,413 (72%) reported performing open radical prostatectomy only while 961 (28%) reported 1 or more robotic radical prostatectomies and 308 (9%) reported robotic radical prostatectomy only. During this 7-year period we observed a large increase in the number of urologists who performed robotic radical prostatectomy and a smaller corresponding decrease in those who performed open radical prostatectomy. Only 8% of patients were treated with robotic radical prostatectomy by urologists who were certified in 2004 while 67% underwent that procedure in 2010. Median age of urologists who exclusively performed open radical prostatectomy was 43 years (IQR 38-51) vs 41 (IQR 35-46) for those who performed only robotic radical prostatectomy. Conclusions: While the rate was not as high as the greater than 85% industry estimate, 67% of radical prostatectomies were done robotically among urologists who underwent board certification or recertification in 2010. Total radical prostatectomy volume almost doubled during the study period. These data provide nonindustry based estimates of current radical prostatectomy practice patterns and further our understanding of the evolving surgical treatment of prostate cancer. © 2012 American Urological Association Education and Research, Inc.

Martinschek, A., K. Heinzelmann, et al. (2012). “Radical prostatectomy after previous transurethral resection of the prostate: robotic-assisted laparoscopic vs. open radical prostatectomy in a matched-pair analysis.” Journal of Endourology.

Objective: To determine whether or not previous transurethral resection (TURP) of the prostate compromise the surgical outcome and pathological findings in patient who underwent either robotic-assisted laparoscopic radical prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, as transurethral resection of the prostate is reported to complicate radical prostatectomy and there are conflicting data. Patients and Methods: From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 patients (5.3%) had undergone previous TUR-P. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen (PSA), the biopsy Gleason-score, the American Society of Anaesthesiologists (ASA) classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons. Results: Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217+/-51.9 minutes for RALP and 174+/-57.7 minutes for RRP (p<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT2 tumours: 10.5% for RALP and 5.3% for RRP; p=1.0). Mean estimated blood loss was 333+/-144mL in RALP patients and 1103+/-636mL in RRP patients (p<0.001). The difference between preoperative and postoperative haemoglobin levels was 3.22+/-0.98g/dL for RALP and 5.85+/-1.95g/dL for RRP (p=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58+/-1.17 versus 11.74+/-5.22days; p=0.0037), duration of catheterisation (7.95+/-5.69 versus 11.78+/-6.97days; p=0.0016), postoperative complications according to the Clavien-classification system (6 versus 15 patients; p=0.0027), and transfusion rate (0% versus 10.5%; p<0.001). Conclusion: RALP offers advantages over open radical prostatectomy after prior surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.

Mirkin, J. N., W. T. Lowrance, et al. (2012). “Direct-to-consumer internet promotion of robotic prostatectomy exhibits varying quality of information.” Health Affairs 31(4): 760-769.

Robotic surgery to remove a cancerous prostate has become a popular treatment. Internet marketing of this surgery provides an intriguing case study of direct-to-consumer promotions of medical devices, which are more loosely regulated than pharmaceutical promotions. We investigated whether the claims made in online promotions of robotic prostatectomy were consistent with evidence from comparative effectiveness studies. After performing a search and cross-sectional analysis of websites that mentioned the procedure, we found that many sites claimed benefits that were unsupported by evidence and that 42 percent of the sites failed to mention risks. Most sites were published by hospitals and physicians, which the public may regard as more objective than pages published by manufacturers. Unbalanced information may inappropriately raise patients’ expectations. Increasing enforcement and regulation of online promotions may be beyond the capabilities of federal authorities. Thus, the most feasible solution may be for the government and medical societies to promote the production of balanced educational material.

Ouzaid, I., E. Xylinas, et al. (2012). “Anastomotic stricture after mini-invasive radical prostatectomy: What should be expected from the Van Velthoven single knot running suture?” Journal of Endourology.

Objective: Patients with localized prostate cancer (PCa) treated by radical prostatectomy (RP) have a good overall survival rate. However, their quality of life can be deteriorated due to the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single knot running suture also known as the Van Velthoven Technique (VVT). Patients and Methods: From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal or robotic assisted radical prostatectomy for localized PCa. A single knot running suture according to the Van Velthoven technique was performed for the vesico-urethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. Bladder neck contracture was defined by a reduction of the lumen that does not allow the passage of an 18 French fibroscope. Results: Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241 and 532 had extra peritoneal, transperitoneal and robotic assisted prostatectomy respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% were diagnosed within the first year of follow-up. Prior TURP and external beam radiotherapy were independent risk factors of BNC. Conclusions: BNC incidence after MIRP using the single knot running suture for the vesico-urethral anastomosis is low. Prior TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classical laparoscopic or robotic approach.

Sabbagh, R., S. Chatterjee, et al. (2012). “Transfer of laparoscopic radical prostatectomy skills from bench model to animal model: A prospective, single-blind, randomized, controlled study.” Journal of Urology 187(5): 1861-1866.

Purpose: Learning laparoscopic urethrovesical anastomosis is a crucial step in laparoscopic radical prostatectomy. Previously we noted that practice on a low fidelity urethrovesical model was more effective for trainees than basic suturing drills on a foam pad when learning laparoscopic urethrovesical anastomosis skills. We evaluated learner transfer of skills, specifically whether skills learned on the urethrovesical model would transfer to a high fidelity, live animal model. Materials and Methods: A total of 28 senior residents, fellows and staff surgeons in urology, general surgery and gynecology were randomized to 2 hours of laparoscopic urethrovesical anastomosis training on a urethrovesical model (group 1) or to basic laparoscopic suturing and knot tying on foam pads (group 2). All participants then performed timed laparoscopic urethrovesical anastomosis on anesthetized female pigs. A blinded urologist scored subject videotaped performance using checklist, global rating scale and end product rating scores. Results: Group 1 was significantly more adept than group 2 at the laparoscopic urethrovesical anastomosis pig task when measured by the checklist, global rating scale and end product rating (each p <0.05). Time to completion was similar in the 2 groups. No statistically significant difference was noted in global rating scale and checklist scores for laparoscopic urethrovesical anastomosis performed on the urethrovesical model vs the pig. Conclusions: Training on a urethrovesical model is superior to training with basic laparoscopic suturing on a foam pad for performing laparoscopic urethrovesical anastomosis skills on an anesthetized female pig. Skills learned on a urethrovesical model transfer to a high fidelity, live animal model. © 2012 American Urological Association Education and Research, Inc.

Shih, Y. C. T., J. F. Ward, et al. (2012). “Comparative effectiveness, cost, and utilization of radical prostatectomy among young men within managed care insurance plans.” Value in Health 15(2): 367-375.

Background: Costs and benefits of emerging prostate cancer treatments for young men (age < 65 years) in the United States are not well understood. We compared utilization, clinical outcomes, and costs between two types of radical prostatectomy (RP) – minimally invasive prostatectomy (MIRP) and retropubic prostatectomy (RRP) – among young patients. Methods: We extracted from LifeLink Health Plan Claims Database, a commercial claims database, information on 10,669 patients receiving either MIRP or RRP between 2003 and 2007. In unadjusted analyses, we used chi-square tests to compare clinical outcomes and nonparametric bootstrapping method to compare costs between the MIRP and RRP groups. We applied logistic, Cox proportional hazard, and extended estimation equation methods to examine the association between surgical modality and perioperative complications, anastomotic stricture, and costs while controlling for age, comorbidity, and health plan characteristics. Results: The percentage of prostatectomies performed as MIRP increased from 5.7% in 2003 to 50.3% in 2007. Patients with more comorbidity were more likely to undergo RRP than MIRP. Compared with the RRP group, the MIRP group had a significantly lower rate of perioperative complications (23.0% vs. 30.4%; P < 0.001) and a lesser tendency for anastomotic strictures (hazard ratio 0.42; 95% CI 0.35-0.50) within the first postoperative year but had higher hospitalization costs ($19,998 vs. $18,424; P < 0.001) despite shorter hospitalizations (1.7 days vs. 3.1 days; P < 0.001). Similar findings were reported in the subgroup analysis of patients with comorbidity score 0. Conclusion: MIRP among nonelderly patients increased substantially over time. MIRP was found to have fewer complications. Lower costs of complications appeared to have offset higher hospitalization costs of MIRP. Copyright © 2012, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.

Sooriakumaran, P., A. Calaway, et al. (2012). “The impact of multiple biopsies on outcomes of nerve-sparing robotic-assisted radical prostatectomy.” International Journal of Impotence Research.

Active surveillance of prostate cancer patients involves subjecting them to multiple prostate biopsies, and we sought to investigate the effects of this on functional outcomes after robotic-assisted radical prostatectomy (RARP). Between May 2009 and December 2009, 367 patients who consecutively underwent RARP by a single surgeon were divided into two groups, one that had single prostate biopsy and another multiple biopsies before RARP. The groups were matched for significant clinicopathologic preoperative variables, and only premorbidly potent low-risk cases that underwent nerve sparing were included. This left 50 and 23 patients for analysis in the single and multiple biopsy groups, respectively. The primary endpoint was potency and continence at 3 and 6 months after surgery. We found continence rates of 84% (83%) and 94% (96%) for single (multiple) biopsy groups at 3 and 6 months, respectively (P=0.88, P=0.77). Multiple biopsy patients had worse postoperative erectile function at 6 months (57% versus 80%, P=0.03). Men subject to multiple preoperative biopsies are more likely to become impotent postoperatively than those who undergo surgery after a single biopsy. This should be borne in mind when counseling men regarding repeat biopsy as part of an active surveillance strategy.International Journal of Impotence Research advance online publication, 26 April 2012; doi:10.1038/ijir.2012.9.

Stensvold, A., A. A. Dahl, et al. (2012). “Methods for prospective studies of adverse effects as applied to prostate cancer patients treated with surgery or radiotherapy without hormones.” Prostate 72(6): 668-676.

BACKGROUND Recently two new methods for prospective studies of adverse effects after treatment have been developed: Proportions of patients regaining 90% of baseline function score (PBS-90) and Generalized Estimating Equation (GEE). We compared these methods to examine changes of sexual, urinary, and bowel functions after robot-assisted prostatectomy (RALP) and conformal external beam radiotherapy (EBRT) in patients without androgen deprivation therapy (ADT). METHODS The post-treatment functional course was studied prospectively in 254 patients (N=150RALP and N=104EBRT) with PBS-90 and GEE. The time points at which functions reached stability and significant associations with function at 24 months were examined with PBS-90, and predictors were identified with GEE. The patients filled in the UCLA-PCI questionnaire at baseline and at 3, 6, 12, and 24-month post-treatment. RESULTS The proportions reaching PBS-90 at 24 months were 69% EBRT and 34% RALP patients for urinary function, 70% of EBRT and 7% of RALP patients for sexual function, and 70% of EBRT and 86% of RALP patients for bowel function. GEE showed that the function scores at 6 months were significantly associated with the functions at 24 months. PBS-90 found that stability of function was reached at 3 months for urinary and 6 months for sexual and bowel functions. CONCLUSIONS In outcome assessment PBS-90 mainly demonstrates when post-treatment level become stabilized and GEE shows the time points at which final outcome can be predicted. The two methods therefore supplement each other. Changes of functions corresponded to those reported in samples including patients having ADT. Copyright © 2011 Wiley Periodicals, Inc.

Trinh, Q. D., K. R. Ghani, et al. (2012). “Robot-assisted Radical Prostatectomy: Ready To Be Counted?” European Urology.

Trinh, Q. D., J. Sammon, et al. (2012). “Variations in the quality of care at radical prostatectomy.” Therapeutic Advances in Urology 4(2): 61-75.

Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority. © The Author(s), 2012.

Trinh, Q. D., J. Schmitges, et al. (2012). “Improvement of racial disparities with respect to the utilization of minimally invasive radical prostatectomy in the United States.” Cancer 118(7): 1894-1900.

BACKGROUND: Race represents an established barrier to health care access in the United States and elsewhere. We examined whether race affects the utilization rate of minimally invasive radical prostatectomy (MIRP) in a populationbased sample of individuals from the United States. METHODS: Within the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients in whom MIRP and open radical prostatectomy (ORP) were performed between 2001 and 2007. We assessed the proportions and temporal trends in race distributions between MIRP and ORP. Multivariable logistic regression analyses further adjusted for age, year of surgery, baseline Charlson Comorbidity Index, annual hospital caseload tertiles, hospital region, insurance status, and median zip code income. RESULTS: Of 65,148 radical prostatectomies, 3581 (5.5%) were MIRPs. African Americans accounted for 11.4% of patients versus 78.8% for Caucasians versus 9.9% for others. Between 2001 and 2007, the annual proportions of Caucasian patients treated with MIRP were 2.2%, 0.9%, 2.6%, 7.2%, 4.7%, 9.3%, and 11.6%, respectively (chi-square trend p<0.001). For the same years in African American patients, the proportions were 0.8, 0.3, 1.4, 4.4, 3.5, 9.0 and 8.4% (chi-square trend P < .001). In multivariable analyses relative to Caucasian patients, African American patients were 14% less likely to undergo MIRP (P = .01). After period stratification between years 2001-2005 versus 2006- 2007, African Americans were 22% less likely to undergo a MIRP in the early period (P = .007) versus 11% less likely to have a MIRP in the contemporary period (P = .1). CONCLUSIONS: The racial discrepancies in MIRP utilization rates are gradually improving. © 2011 American Cancer Society.

Turney, B. W. and A. Jones (2012). “A technique to elevate the seminal vesicles during robotic prostatectomy.” Annals of the Royal College of Surgeons of England 94(2): 133-134.

van der Poel, H., C. Tillier, et al. (2012). “Extended nodal dissection reduces sexual function recovery after robot assisted laparoscopic prostatectomy.” Journal of Endourology.

Objective: Considering the anatomical proximity of the internal iliac lymph nodes and the pelvic plexus it may be expected that more extensive pelvic nodal dissection is associated with an increased risk of damage to the small pelvis neural and vascular structures. Here we evaluate whether nodal dissection is associated with functional outcome after robot assisted radical prostatectomy (RARP). Patients and Method: In a series of 798 RARP procedures, 325 (40.7%) patients underwent a lymph node dissection. Continence, sexual function, and LUTS were assessed using the ICIQ-SF, IIEF-15, and EORTC-QLQ-PR25 questionnaires prior to and at 6 months intervals after RARP. Results: Preoperative ICIQ-SF, IIEF-15, and PR25-LUTS scores were similar for men with and without nodal dissection. Normal postoperative erectile function (IIEF-EF>24) at 6 months was reported by 1,7%, 9,1%, and 50,4% of men with no, unilateral, and bilateral nerve preservation and normal preoperative erectile function. All domains of the IIEF-15 score showed a negative correlation with the number of removed lymph nodes. In 70 of 325 (21%) cases with nodal dissection more than 10 nodes were removed. Men with more than 10 nodes removed had lower IIEF-15 domain scores compared to men with 1-10 removed lymph nodes. The postoperative ICIQ-SF and PR25-LUTS scores were not associated with extent of nodal dissection. Nodal metastases were found in 5.9% and 15.7% of men with <=10 nodes and > 10 nodes removed (p=0.005). In a multivariate analysis, extent of fascia preservation (FP-score), preoperative IIEF-EF and number of removed nodes were the strongest independent predictors of postoperative erectile function recovery. Conclusion: More extensive nodal dissection was associated with impaired postoperative sexual function recovery but not continence and voiding function after RARP, independent of preoperative function and nerve preservation.

Wehrberger, C., I. Berger, et al. (2012). “Radical prostatectomy in Austria from 1992 to 2009: An updated nationwide analysis of 33,580 cases.” Journal of Urology 187(5): 1626-1631.

Purpose: We analyzed the demographics and outcome of radical prostatectomy in Austria in a nationwide series. Materials and Methods: We analyzed the records of all 33,580 patients who underwent radical prostatectomy at a public hospital, including 95% of all surgical procedures, in Austria between 1992 and 2009. Patient demographics, perioperative mortality, interventions for anastomotic strictures and urinary incontinence, and overall survival were determined. Data were provided by the Austrian Health Institute. Results: The annual number of radical prostatectomies increased 688% from 396 in 1992 to 3,123 in 2007 and gradually decreased to 2,612 in 2009. Mean ± SD patient age at surgery decreased slightly from 64.4 ± 6.3 years in 1992 to 62.0 ± 6.7 years in 2003. Age has remained at that level since then. Endourological intervention for anastomotic stricture and urinary incontinence was done in 7.5% and 2.8% of cases, respectively. The risk of each intervention increased with patient age and decreased in patients treated within the last 10 years compared to those treated before 2000. The 30-day mortality rate was 0.1%, which increased threefold from the youngest to the oldest age group. Ten-year overall survival decreased from 93% in patients 45 to 49 years old to 63% in those 70 years old or older at surgery. Conclusions: This nationwide analysis of a country that has had a public, equal access health care system for decades describes some current radical prostatectomy trends. Since 2007, the absolute number of radical prostatectomies has decreased. Data on morbidity, perioperative mortality and overall survival raise caution about performing radical prostatectomy in elderly men, eg those 70 years old or older. © 2012 American Urological Association Education and Research, Inc.

Yoshino, Y. (2012). “Editorial Comment to Novel posterior reconstruction technique during robot-assisted laparoscopic prostatectomy: Description and comparative outcomes.” International Journal of Urology.

Yuh, B. E., N. H. Ruel, et al. (2012). “Robotic extended pelvic lymphadenectomy for intermediate- and high-risk prostate cancer.” European Urology 61(5): 1004-1010.

Background: Accurate staging of prostate cancer is enhanced by a thorough evaluation of the pelvic lymph nodes. Limited data are available regarding robotic extended pelvic lymphadenectomy (PLA) in this setting. Objective: Analyze our experience performing robotic extended PLA. Design, setting, and participants: A total of 143 consecutive men with intermediate- or high-risk clinically localized adenocarcinoma of the prostate underwent robotic extended PLA and radical prostatectomy between September 2010 and November 2011 by a single surgeon. Surgical procedure: Lymph node packets were sent separately from bilateral common, external, and internal iliacs, obturators, node of Cloquet, and anterior prostatic fat. Measurements: Descriptive statistics were used to summarize lymph node yields and positive nodes. Clinical variables were examined in logistic regression models to predict lymph node positivity. Results and limitations: Median lymph node yield was 20 (range: 9-65, interquartile range: 15-25). Eighteen patients (13%) were found to have metastatic prostate cancer in the lymph nodes. The mean number of positive nodes found was 2.9 (range: 1-11). In 14 of 18 node-positive patients (78%), the extent of nodal invasion was outside the boundaries of a limited PLA. For four patients with positive nodes (22%), prostate biopsy predicted unilateral disease but PLA revealed contralateral positive lymph nodes. A total of 82% of patients experienced no complications, and most Clavien grade 1-2 complications consisted of anastomotic leakage, urinary retention, ileus, and lymphocele. Only 4% of patients experienced a grade 3 complication. Under multivariate regression analysis, prostate-specific antigen (PSA), clinical stage, and maximum biopsy core tumor volume were identified as significant predictors of finding positive pelvic lymph nodes (area under the curve: 91%). The main limitations include short follow-up and lack of randomization. Conclusions: Robotic extended bilateral PLA for prostate cancer up to the common iliac bifurcation increases nodal yield and positive nodal rate and can be performed safely. PSA, clinical stage, and maximum biopsy core volume are predictors for lymph node invasion. Long-term follow-up is needed to evaluate for therapeutic benefit. © 2012 European Association of Urology.

Barbaro, S., A. Paudice, et al. (2012). “Robot-assisted radical prostatectomy: A minihealth technology assessment in a teaching hospital.” HealthMED 6(3): 724-730.

Lowrance, W. T., J. A. Eastham, et al. (2012). “Contemporary Open and Robotic Radical Prostatectomy Practice Patterns Among Urologists in the United States.” Journal of Urology.