Abstrakt Urologie Bžezen 2011

“Feasibility and Outcomes of Robotic-assisted Laparoscopic Radical Cystectomy for Bladder Cancer in Older Patients.”

Coward, R. M., A. Smith, et al. (2011).



Objectives: To report our maturing experience with robotic radical cystectomy as applied to an older patient population with regard to perioperative measures and pathologic outcomes. A robotic approach to radical cystectomy for bladder cancer have recently been described, but its application in an older patient population, which is often the case in bladder cancer and cystectomy, has not yet been assessed. Methods: A total of 119 patients underwent robotic cystectomy and extracorporeal urinary diversion at our institution from January 2006 through October 2009 for clinically localized bladder cancer. Owing to the patient selection early in the present series, the first 20 cases were excluded. The clinical characteristics, operative outcomes, and pathologic results of the consecutive cases were categorized by age (younger, <70 years vs older, age ≥70 years). Results: The outcomes of the 61 younger and 38 older patients, including 7 patients >80 years old, were assessed. The younger versus older patients had a lower American Society of Anesthesiologists score (2.6 vs 3.0; P < .001), greater body mass index (28.2 vs 26.1; P = .008), and longer operating room time (4.8 vs 4.4 hours; P = .015). No differences were observed between the 2 groups in blood loss, time to discharge, or complication rate. Also, no significant differences were found in the surgical pathologic findings, including the organ-confined rate (62% vs 71%) and lymph node yield (19.5 vs 18.1). Conclusions: Older patients do not appear to have any significant differences or compromises with regard to the perioperative and pathologic outcomes after robotic radical cystectomy. Thus, robotic radical cystectomy appears to be an appropriate surgical option for older patients. © 2011 Elsevier Inc. All rights reserved.




“Robot-assisted tapered ureteral reimplantation for congenital megaureter.”

Goh, A. C. and R. E. Link (2011).

Urology 77(3): 742-745.


Objective To discuss the clinical implications of primary obstructed congenital megaureter in the adult and illustrate a minimally-invasive approach for surgical intervention. Methods We present the case of a 51-year-old man with a longstanding history of symptomatic congenital megaureter, illustrating an approach for robot-assisted tapered ureteral reimplantation. Ureteral dissection, tapering, and nonrefluxing ureteroneocystostomy were all completed using a robot-assisted laparoscopic technique. Results The total operative time was 262 minutes, with an estimated blood loss of 150 mL. The patient’s hospital course was uneventful, with discharge on postoperative day 4 without a Foley catheter or drain. A diuretic renal scan was performed at 5 months that showed good preservation of renal function with rapid clearance of tracer on the reconstructed side. The patient was pain free at his last follow-up visit without any symptoms. Conclusions We have demonstrated a technique for robot-assisted tapered nonrefluxing ureteral reimplantation for congenital megaureter. Robotic assistance provided a safe and effective approach for complex ureteral reconstruction while minimizing morbidity. © 2011 Elsevier Inc.




“Lower extremity neuropathy after robot assisted laparoscopic radical prostatectomy and radical cystectomy.”

Manny, T. B., I. Gorbachinsky, et al. (2010).

The Canadian journal of urology 17(5): 5390-5393.


To describe the incidence and outcomes of lower extremity neuropathies in a series of robot assisted laparoscopic radical prostatectomy (RALRP) and robot assisted laparoscopic radical cystectomy (RALRC) patients with 9 months follow up. Additionally, we compare this cohort to other published series of lithotomy based surgery and describe strategies for minimizing risk. We performed a retrospective analysis of 179 consecutive patients who underwent either RALRP or RALRC at a single institution during a 17 month period. We included all patients who experienced bothersome lower extremity pain, weakness, or numbness at any time during their postoperative course. We further defined postoperative neuropathy as de-novo symptoms presenting in the first week postoperatively. Chart review and telephone survey were used to further characterize these patients. Six out of 179 patients complained of lower extremity neuropathic symptoms by 9 months of follow up. Probable injuries to the common peroneal, lateral femoral cutaneous, and obturator nerves were found. Three patients met our criteria for postop neuropathy making the incidence 1.68%. All patients remained ambulatory throughout their course. At 9 months follow up, only one patient, a man with metastatic bladder cancer, had activity limiting neuropathic symptoms. With routine use of common risk minimizing strategies, RALRP or RALRC may result in lower extremity europathy at rates similar to other lithotomy based procedures described in the literature.




“Robotic Assisted Laparoscopic Ureteral Reimplantation in Children: Case Matched Comparative Study With Open Surgical Approach.”

Marchini, G. S., Y. K. Hong, et al. (2011).

Journal of Urology.


PURPOSE: Surgical treatment may be required in some patients with vesicoureteral reflux. With the recent development of robotic assistance, laparoscopic treatment of vesicoureteral reflux has gained popularity. We sought to evaluate our initial experience with pediatric robotic assisted laparoscopic intravesical and extravesical ureteral reimplantation, and to compare outcomes with the open technique. MATERIALS AND METHODS: A retrospective chart review was performed on all patients who underwent robotic assisted laparoscopic ureteral reimplantation between 2007 and 2010. Comparisons were made with a case matched cohort of patients who underwent the open technique. The groups were compared using t tests for numerical variables and chi-square comparisons or Fisher’s exact test for categorical variables. A Kaplan-Meier model was used to compare success rates. RESULTS: A total of 19 patients underwent intravesical and 20 underwent extravesical robotic assisted laparoscopic ureteral reimplantation during the study period. They were compared to 22 patients undergoing intravesical and 17 undergoing extravesical open ureteral reimplantation. Although the robotic assisted approach was associated with a longer operative time (p <0.001), children undergoing intravesical robotic assisted reimplantation had a shorter duration of urinary catheter drainage, fewer bladder spasms and a shorter hospital stay compared to those undergoing the intravesical open technique (p <0.01). There were no significant differences in these parameters when comparing extravesical robotic assisted reimplantation to the extravesical open technique. Overall success rates were similar among patients who underwent robotic assisted laparoscopic ureteral reimplantation and open reimplantation (p >0.5). CONCLUSIONS: Robotic assisted laparoscopic ureteral reimplantation offers similar success rates to the gold standard, open ureteral reimplantation. Future large scale studies will be required to define further the costs and benefits of robotic assisted laparoscopic ureteral reimplantation in the surgical treatment of vesicoureteral reflux.




“Robot-assisted radical cystectomy versus open radical cystectomy: A complete cost analysis.”

Martin, A. D., R. N. Nunez, et al. (2011).

Urology 77(3): 621-625.


Objectives To perform a complete cost analysis comparing robot assisted radical cystectomy (RARC) versus open radical cystectomy (ORC). Material and Methods After institutional review board approval for data collection, we prospectively recorded perioperative outcomes and costs, such as hospital stay, transfusion rate, readmission rate, and medications for consecutive patients undergoing RARC or ORC. Using actual cost data, we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC. Multivariate sensitivity analysis was performed to elucidate which variables had the greatest impact on overall cost. Breakeven points with ORC were calculated using our model to better evaluate variable influence. In addition to the above modeled analysis, actual patient costs, including complications 30 days from surgery, were also compared for each procedure. Results Our model analysis showed that operative time and length of stay had the greatest impact on perioperative costs. Robotic cystectomy became more expensive than open cystectomy at the following break-even points: operating room (OR) time greater than 361 minutes, length of stay greater than 6.6 days, or robotic OR supply cost exceeding $5853. RARC was 16% more expensive when only comparing direct operative costs. Interestingly, actual total patient costs revealed a 38% cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort. Conclusions RARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants. Higher complication rates with ORC make total actual costs much higher than RARC. © 2011 Elsevier Inc.




“[Robotic Laparoscopic Cystectomy: On the Way to a Standard Procedure?].”

Schwentner, C., T. Todenhofer, et al. (2011).

Aktuelle Urol 42(2): 103-108.


INTRODUCTION: Radical cystectomy is considered the standard treatment for muscle-invasive bladder cancer. Minimally invasive techniques – especially robot-assisted techniques (RARC) – are being increasingly employed for this indication. Herein, we evaluate the current status of RARC and its acceptance in the urological community. RESULTS: The field of RARC is steadily increasing particularly due to an extremely short learning curve for surgeons with previous experience in robot-assisted radical prostatectomy. Lymph node yield has been shown to be adequate in several independent studies, being comparable to that of the open approach. Urinary diversion is most frequently done extracorporeally while several groups have commited themselves to intracorporeal techniques and have already shown excellent results. The perioperative outcome data compare favourably to those of open cystectomy. Short-term and interim oncological data are promising while a final long-term assessment is still lacking. CONCLUSIONS: RARC completed by appropriate urinary diversion is gaining relevance in academic institutions worldwide. The relatively wide availability of the robotic system will further add to this development. Secondary to the final assessment of its oncological efficacy RARC has the potential to become a standard treatment of muscle-invasive bladder cancer since its perioperative efficacy is excellent.




“Robotic-Assisted Laparoscopic Radical Cystectomy: Evaluation of Functional and Oncological Results.”

Treiyer, A., M. Saar, et al. (2010).

Cistectomía radical laparoscópica asistida por robot: evaluación de los resultados funcionales y oncológicos.


Purpose: radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 84 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications. Materials and methods: a total of 84 consecutive patients (70 male and 14 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2007 to August 2010 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate. Results: mean age of this cohort was 65.5 years (range 28 to 82). Of the patients 62 underwent ileal conduit diversion, 22 received a neobladder. Mean operating room time for all patients was 261 min. (range: 243-618 min.) and mean surgical blood loss was 298 ml (range: 50-2000 ml). 29% of the cases were pT1 or less disease, 38% were pT2, 26% and 7% were pT3 and T4 disease respectively, 15% were node positive. Mean number of lymph nodes removed was 15 (range 1 to 33). In 2 cases (2.4%) there was a positive surgical margin. Mean days to flatus were 2.12, bowel movement 2.87 and discharge home 17.7 (range: 10-33). There were 45 postoperative complications with 11.9% having a major complication (Clavien grade 3 or higher). At a mean followup of 16.7 months 10 patients (11%) had disease recurrence and 2 died of disease. Conclusions: our experience with robotic radical cystectomy for the treatment of bladder cancer suggests that in proper hands this procedure provides acceptable surgical and pathological outcomes. © 2010 AEU.





“Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy.”

Abaza, R. (2011).

European Urology 59(4): 652-656.


Laparoscopy has become a standard modality for most renal tumors but not as yet for renal cell carcinoma (RCC) involving the inferior vena cava (IVC). Robotic technology may facilitate such complex procedures. We report the first series of robotic nephrectomy with IVC tumor thrombectomy including the first cases requiring cross-clamping of the IVC in a minimally invasive fashion. Five patients underwent robotic nephrectomy with IVC tumor thrombectomy including one patient having two renal veins, each with an IVC thrombus, for a total of six IVC thrombi. The IVC was opened in all patients, and tumor thrombi were delivered intact, followed by sutured closure. The mean patient age was 64 yr (53-70 yr) with a mean body mass index of 36.6 kg/m2 (22-43 kg/m 2). Thrombi protruded 1 cm, 2 cm, 4 cm, and 5 cm into the IVC in five patients and 3 cm and 2 cm in the patient with two thrombi. The mean estimated blood loss was 170 ml (50-400 ml). Mean operative time was 327 min (240-411 min). Mean length of stay was 1.2 d. There were no complications, transfusions, or readmissions. This early series represents a limited experience by a single surgeon with a new procedure and may not be reproducible in larger numbers or by all surgeons. Further experience is necessary to validate this application. © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.




“Robotic surgery and minimally invasive management of renal tumors with vena caval extension.”

Abaza, R. (2011).

Current Opinion in Urology 21(2): 104-109.


Purpose of Review: Although laparoscopic nephrectomy for renal cell carcinoma (RCC) has become a widely accepted option for most renal tumors, open surgery remains the standard in managing tumors with extension into the inferior vena cava (IVC). Robotic technology has been applied to increasingly complex laparoscopic procedures and may facilitate minimally invasive procedures previously felt unfeasible with standard laparoscopy. The evolution to completely intracorporeal techniques for IVC tumor thrombectomy from incremental advancements in laparoscopic and hybrid techniques is reviewed. Recent Findings: Laparoscopic management of IVC tumor thrombi has been demonstrated in animal models and more recently in the form of individual case reports. Hybrid laparoscopic techniques have been developed to allow hand-assisted thrombus retraction out of the IVC or open incisions for IVC management after laparoscopic dissection. Robotic surgery only recently has been described to allow a completely minimally invasive technique for tumor thrombectomy even when cross-clamping of the cava is required. Such techniques have yet to gain popular acceptance but have been reproduced to a limited degree by other investigators. Summary: Robotic technology applied to complex laparoscopic procedures may extend the limits of what can be performed successfully in minimally invasive fashion. The early reported experiences of robotic nephrectomy with IVC tumor thrombectomy, thus far, demonstrate feasibility but require further investigation. Discrimination of ideal candidates and reproducibility by other surgeons will be necessary before widespread adoption and acceptance. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.




“Comparison of robot-assisted versus conventional laparoscopic transperitoneal pyeloplasty for patients with ureteropelvic junction obstruction: A single-center study.”

Bird, V. G., R. J. Leveillee, et al. (2011).

Urology 77(3): 730-734.


Objectives To compare conventional laparoscopic pyeloplasty (C-LPP) and robotic-assisted laparoscopic pyeloplasty (RA-LPP), which are both used for correction of ureteropelvic junction obstruction. Robotic assistance may further expedite dissection and reconstruction; however it is unclear whether this has an impact on results. Methods Between 1999 and 2009, 172 conventional or robotic-assisted transperitoneal laparoscopic pyeloplasties were performed by 2 surgeons. Data were obtained from our prospective database, patient charts, and radiographic reports. Statistical analysis was performed for the groups. Results A total of 98 patients underwent R-LPP, and 74 underwent C-LPP. Mean age, body mass index, and gender distribution were similar for the groups. Of the patients, 22 (12.8%) had secondary ureteropelvic junction obstruction. Operative time in minutes was 189.3 ± 62 for RA-LPP, and 186.6 ± 69 for C-LPP (P = .69) respectively. Intraoperative and postoperative complication rates for RA-LPP and C-LPP were 1%, 5.1% and 0, 2.7% (P = .83 and .85) respectively. There was no significant difference in mean suturing time: 48.3 ± 30 and 60 ± 46 (P = .30) for RA-LPP and C-LPP, respectively. Long-term follow up (minimum 6 months; available for 136 patients) showed 93.4% and 95% radiographic success rate based upon diuretic scintirenography for RA-LPP and C-LPP respectively. Conclusions Operative time, perioperative outcome and success rates are similar for C-LPP and RA-LPP. Mean suturing time for RA-LPP was shorter; however, there was no significant time difference in total operative time. Complications for both procedures are infrequent. Success rates, as measured by diuretic scintirenography, are high for the 2 procedures. © 2011 Elsevier Inc.




“Comparison of robot-assisted nephrectomy with laparoscopic and hand-assisted laparoscopic nephrectomy.”

Boger, M., S. M. Lucas, et al. (2010).

Journal of the Society of Laparoendoscopic Surgeons 14(3): 374-380.


Objective: To compare the initial perioperative outcomes of our robot-assisted laparoscopic nephrectomies with laparoscopic and hand-assisted nephrectomies performed by 2 experienced laparoscopic surgeons. Patients and Methods: We retrospectively evaluated all patients who underwent laparoscopic (LN), hand-assisted (HALN), and robot-assisted laparoscopic nephrectomy (RALN) for benign and malignant diseases between August 2006 and December 2008. Data collected included patient age, body mass index, operative times, estimated blood loss, complications, and hospital stay. Radical nephrectomy was performed for renal neoplasms, and simple nephrectomy was performed for suspected benign diseases. In addition, average direct costs and total costs were calculated for each laparoscopic approach. Results: Forty-six patients underwent LN, 20 underwent HALN, and 13 underwent RALN. The median operative time was 171, 210, and 168 minutes, respectively. LN, HALN, and RALN groups had similar median EBL [(100mL (IQR=113mL), 100mL (IQR=150mL), and 100mL (IQR= 125mL); P=0.695], length of hospital stay [2.0d (IQR= 1.0d), 3.0d (IQR=2.0d), and 2.0d (IQR=3.0d); P=0.233], and postoperative morphine equivalent analgesic requirements [33mg (IQR=43mg), 45mg (IQR=50mg), and 30mg (IQR=16mg); P=0.766]. Three patients (6%) in the LN group had complications, 2 (10%) in the HALN group had complications, and 4 (30%) in the RALN group had complications. The average total direct operating room costs were $5,500, $6,979, and $6,869 for the LN, HALN, and RALN groups, respectively. Conclusions: Early experience with robotic assistance for radical and simple nephrectomy offers no significant advantage over traditional laparoscopic or hand-assisted approaches. It was also more costly. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.




“Robot-assisted versus standard laparoscopic partial nephrectomy: Comparison of perioperative outcomes from a single institution.”

Cho, C. L., K. L. Ho, et al. (2011).

Hong Kong Medical Journal 17(1): 33-38.


Objective: To evaluate the perioperative outcomes of robot-assisted laparoscopic partial nephrectomy and standard laparoscopic partial nephrectomy in a teaching hospital. Design: Retrospective study. Setting: Division of Urology, Department of Surgery, Queen Mary and Tung Wah hospitals, Hong Kong. Patients: The first 10 consecutive patients who had robot-assisted laparoscopic partial nephrectomy for renal tumours between January 2008 and September 2009 with prospective data collection were evaluated. Their outcomes were compared with the last 10 consecutive patients in our database, who had standard laparoscopic partial nephrectomy between November 2004 and October 2007. Main outcome measures: Demographics, tumour characteristics, perioperative outcomes, renal function, and pathological outcomes. Results: There were no differences between the groups with regard to age (63 vs 56 years; P=0.313) and tumour size (2.7 vs 2.8 cm; P=0.895). No significant difference was found between the two groups with respect to the operating room time (376 vs 361 min; P=0.722), estimated blood loss (329 vs 328 mL; P=0.994), and length of hospital stay (7 vs 14 days; P=0.213). A statistically significant shorter mean warm ischaemic time for the robotassisted group was noted (31 vs 40 minutes; P=0.032). Respective renal functional outcomes as shown by the difference between day 0 and day 60 serum creatinine levels were comparable (+10 vs +7 mmol/L; P=0.605). In both groups, there were no intra-operative complications or instances of surgical margin tumour involvement. Three patients endured postoperative complications in the standard laparoscopic group (a perinephric haematoma, urine leakage, and lymph leakage) compared with one in the robot-assisted group (a perinephric haematoma). These complications all resolved with conservative treatment. Conclusions: Robot-assisted laparoscopic partial nephrectomy is a technically feasible alternative to standard laparoscopic partial nephrectomy, and provides comparable results. Robot-assisted laparoscopic partial nephrectomy appears to offer the advantage of decreased warm ischaemic time. Longer follow-up is required to assess renal function and oncological outcomes. Further experience and randomised trials are necessary to compare robot-assisted with standard laparoscopic partial nephrectomy.




“Robotic nephroureterectomy with partial duodenectomy for invasive ureteral tumor.”

Dangle, P. P., S. Moore, et al. (2010).

Journal of the Society of Laparoendoscopic Surgeons 14(3): 442-446.


Robotic surgery is gaining acceptance in the management of diverse urological disorders. Any minimally invasive procedure carries a risk of open conversion either for complications or unexpected intraoperative findings, but the additional dexterity of robotic instrumentation may allow even complex situations to be managed laparoscopically. We report the case of an upper tract transitional cell carcinoma discovered at the time of robotic nephroureterectomy to be invading the duodenum that was successfully excised robotically. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.




“Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases.”

Dulabon, L. M., J. H. Kaouk, et al. (2011).

European Urology 59(3): 325-330.


BACKGROUND: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. OBJECTIVE: We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. MEASUREMENTS: Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. RESULTS AND LIMITATIONS: Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2cm vs 2.6cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3+/-7.4min vs 19.6+/-10.0min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience. CONCLUSIONS: The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.




“Innovations in laparoscopic and robotic partial nephrectomy: A novel ‘zero ischemia’ technique.”

Eisenberg, M. S., M. B. Patil, et al. (2011).

Current Opinion in Urology 21(2): 93-98.


Purpose of Review: To describe a novel ‘zero ischemia’ technique for laparoscopic and robotic partial nephrectomy. Recent Findings: Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. Summary: Initial results with our ‘zero ischemia’ technique have been encouraging. Evaluation of long-term outcomes is ongoing. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.




“Robot-assisted laparoendoscopic single-site surgery: Partial nephrectomy for renal malignancy.”

Han, W. K., D. S. Kim, et al. (2011).

Urology 77(3): 612-616.


Objectives To describe our experience with robot-assisted laparoendoscopic single-site surgery (LESS) to perform partial nephrectomy and evaluate a hybrid homemade port system as an effective access technique. Methods From December 2008 to September 2009, robot-assisted LESS to perform partial nephrectomy through a hybrid homemade port was performed to treat 14 cases of renal cell carcinoma. The data, including patient characteristics, operative records, complications, and pathologic results, were analyzed. Results The mean tumor size was 3.2 cm, the mean ischemic time was 30 minutes, and the mean operative time was 233 minutes. We used the hybrid homemade port technique in 10 cases. All surgical margins after partial nephrectomy were negative for malignancy. No port-related complications were reported. Two cases required conversion to mini-incisional partial nephrectomy. Conclusions Robot-assisted LESS for performing partial nephrectomy using a hybrid homemade port system is a safe and feasible treatment technique. It provided access for meticulous suturing on the renal parenchyma using articulating robot arms and ready access to the surgical field for the assistant. © 2011 Elsevier Inc.




“Robot-assisted partial nephrectomy in obese patients.”

Naeem, N., F. Petros, et al. (2011).

Journal of Endourology 25(1): 101-105.


Purpose: To report our experience with robot-assisted partial nephrectomy (RAPN) in obese patients compared with a contemporary cohort of nonobese patients. Patients and Methods: We defined obesity as a body mass index (BMI) ≥30 kg=m2. From June 2004 to September 2009, 97 patients underwent RAPN at our institution, of whom 49 were obese (group 1) and 48 were nonobese (group 2, BMI &lt;30 kg=m2). We compared demographics, operative data, complications, and pathological outcomes between these two groups. Results: The average BMI for the obese group was 36.2 kg=m2 (range 30.3-49) compared with 25.7 kg=m2 (range 20.5-29.7) for the nonobese group. Median tumor size was 2.5 versus 2.3 cm for obese and nonobese groups, respectively. Obese patients had a larger median estimated blood loss (150 vs.100mL, p=0.027) and a trend toward a longer median operative time (265 vs. 242.5 minutes, p=0.085) and median warm ischemia time (26.5 vs. 22.5 minutes, p=0.074), but this did not achieve statistical significance. An intraoperative complication occurred in one patient in each group. The postoperative complication rate was not statistically significant between the two groups (8.3% vs. 4.3%, p=0.377). The median hospital stay was 2 days for both groups. Conclusions: RAPN is safe and feasible in obese patients. Obese patients had a higher estimated blood loss and a trend toward greater operative time and warm ischemia time, which did not achieve statistical significance. Copyright © Mary Ann Liebert, Inc.




“Barbed suture for renorrhaphy during robot-assisted partial nephrectomy.”

Sammon, J., F. Petros, et al. (2011).

Journal of Endourology 25(3): 529-533.


Abstract Background and Purpose: Robot-assisted partial nephrectomy (RAPN) is an emerging technique for minimally invasive nephron-sparing surgery that may facilitate the technical challenges of sutured renorrhaphy. Barbed suture allows for knotless wound closure and improves suturing efficiency. We present the first clinical study of barbed suture for renorrhaphy during RAPN in human patients and compare perioperative outcomes to RAPN with polyglactin suture. Patients and Methods: Thirty consecutive patients underwent RAPN by a single surgeon; 15 using polyglactin suture for renorrhaphy followed by 15 using the V-Loc 180 wound closure device. Renorrhaphy was performed in two layers, with a continuous running closure of deep vessels and the collecting system, followed by a running closure of the renal capsule, using the sliding Hem-o-lok clip technique. Operative characteristics and complications were compared between groups. Results: Renorrhaphy was successfully completed in all 30 consecutive RAPN procedures. V-Loc and conventional groups were equivalent in demographic and tumor characteristics. Mean operative and console time were equivalent; warm ischemia time was significantly shorter in the V-Loc group (18.5 vs 24.7 min, P = 0.008). There were no instances of suture slippage or tearing in the barbed suture group. The barbs held the sliding clip renorrhaphy intact without the need for redundant clips to prevent backsliding. Conclusion: Use of barbed suture simplifies the renorrhaphy technique during RAPN and improves efficiency, allowing for reduced warm ischemia times. We demonstrate feasibility and safety of this suture technique in human patients undergoing minimally invasive partial nephrectomy.




“Robot-assisted partial nephrectomy: Early unclamping technique.”

San Francisco, I. F., M. C. Sweeney, et al. (2011).

Journal of Endourology 25(2): 305-308.


Robot-assisted partial nephrectomy (RAPN) is emerging as a viable minimally invasive surgical technique for small renal tumors. The warm ischemia time (WIT) during laparoscopic partial nephrectomy has been reduced using an early unclamping (EU) technique. We present our technique of EU technique in RAPN. From November 2009 to June 2010, 12 consecutive RAPNs were performed by a single surgeon (A.W.) using EU technique. The median operative time was 227 minutes (176-315); median WIT, 16 minutes (11-25). Median estimated blood loss was 150 mL (50-500) and length of stay 2 days. There were no intraoperative or postoperative complications. RAPN using EU technique is a safe and feasible option in experienced hands, allowing for a shorter WIT without increasing blood loss. This approach requires a highly skilled bedside assistant who is imminently familiar with the robotic system and advanced laparoscopic techniques. Copyright 2011, Mary Ann Liebert, Inc.




“Robot-assisted partial nephrectomy.”

Sukumar, S. and C. G. Rogers (2011).

Journal of Endourology 25(2): 151-157.


Robot-assisted partial nephrectomy (RAPN) is a viable option for patients and surgeons who desire a minimally invasive alternative for the performance of nephron-sparing surgery (NSS). NSS has become the norm for the management of small renal masses. Numerous series have shown favorable outcomes for RAPN. RAPN has a shortened learning curve and eases the transition to minimally invasive NSS. We describe the indications, preparation, instrumentation, setup, technique, and complications for transperitoneal RAPN using a two- or three-arm approach. We also suggest strategies and tips so that surgeons early in the learning curve can effectively anticipate, avoid, and, if inevitable, manage complications. Copyright 2011, Mary Ann Liebert, Inc.




“Robot-Assisted Retroperitoneal Partial Nephrectomy: Technique and Perioperative Results( * ).” Weizer, A. Z., G. V. Palella, et al. (2011).

Journal of Endourology.


Abstract Growing evidence supports the use of nephron-sparing techniques for the management of appropriately selected renal masses up to 7 cm. Compared with the surgical standard of open partial nephrectomy, minimally invasive approaches have demonstrated equivalent cancer control with reduced patient morbidity. Robot assistance has the potential to provide patients and physicians greater access to minimally invasive nephron-sparing surgery. We describe a robot-assisted retroperitoneal approach for the management of posterior renal masses. Our early results suggest reduced perioperative morbidity with the ability to manage more complex tumors.




“Robotic Laparoendoscopic Single-Site Radical Nephrectomy: Surgical Technique and Comparative Outcomes.”

White, M. A., R. Autorino, et al. (2011).

European Urology.


Background: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. Objective: To report our early experience with R-LESS radical nephrectomy (RN). Design, setting, and participants: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. Surgical procedure: R-LESS RN was performed using methods outlined in the manuscript and . All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. Measurements: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results and limitations: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2 kg/m2. There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p = 0.049) and a shorter length of stay (2.5 d vs 3.0 d; p = 0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. Conclusions: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery. © 2011 European Association of Urology.





“Framework for incorporating simulation into urology training.”

Arora, S., B. Lamb, et al. (2011).

BJU International 107(5): 806-810.


Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Simulation-based training can provide urology trainees with the opportunity to develop their technical and non-technical skills in a safe and structured environment. Despite its promised benefits, incorporation of simulation into current curricula remains minimal. This paper provides a comprehensive review of the current status of simulation for both technical and non-technical skills training as it pertains to urology. It provides a novel framework with contextualised examples of how simulation could be incorporated into a stage-specific curriculum for trainees through to experienced urologists, thus aiding its integration into current training programmes. OBJECTIVES Changes to working hours, new technologies and increased accountability have rendered the need for alternative training environments for urologists. Simulation offers a promising arena for learning to take place in a safe, realistic setting. Despite its benefits, the incorporation of simulation into urological training programmes remains minimal. The current status and future directions of simulation for training in technical and non-technical skills are reviewed as they pertain to urology. A framework is presented for how simulation-based training could be incorporated into the entire urological curriculum. MATERIALS AND METHODS The literature on simulation in technical and non-technical skills training is reviewed, with a specific focus upon urology. RESULTS To fully integrate simulation into a training curriculum, its possibilities for addressing all the competencies required by a urologist must be realized. At an early stage of training, simulation has been used to develop basic technical skills and cognitive skills, such as decision-making and communication. At an intermediate stage, the studies focus upon more advanced technical skills learnt with virtual reality simulators. Non-technical skills training would include leadership and could be delivered with in situ models. At the final stage, experienced trainees can practise technical and non-technical skills in full crisis simulations situated within a fully-simulated operating rooms. CONCLUSIONS Simulation can provide training in the technical and non-technical skills required to be a competent urologist. The framework presented may guide how best to incorporate simulation into training curricula. Future work should determine whether acquired skills transfer to clinical practice and improve patient care. © 2010 BJU International.




“Robotic enterocystoplasty: Technique and early outcomes.”

Gould, J. J. and J. T. Stoffel (2011).

Journal of Endourology 25(1): 91-95.


Objective: Enterocystoplasty is an established treatment for patients with refractory neurogenic bladder symptoms. We assessed the feasibility, safety, and efficacy of a robot-assisted enterocystoplasty in this population. Materials and Methods: Five neurogenic bladder patients, median age of 43.8 years, underwent the procedure. Using a five-port technique, intraperitoneal robotic enterocystoplasty was performed through the following steps: (1) creation of a U-shaped full-thickness detrusor cystotomy, (2) intracorporeal harvesting of 30 cm of ileum, (3) intracorporeal construction of a detubularized ileal patch, and (4) anastomosis of the ileal patch to the cystotomy. An extracorporeal side-to-side bowel anastomosis re-established bowel continuity. After surgery, urinary continence, bladder capacity, upper tract protection, and complications were assessed. Results: Mean operative time was 6.4 hours, estimated blood loss was 180 mL, and length of stay was 7 days. Postoperatively, all patients had a functioning enterocystoplasty, urethral continence, and normal upper tract imaging. One patient was rehospitalized for an ileus=urinoma, which resolved with conservative treatment. Conclusions: Robot-assisted enterocystoplasty can be effectively and safely performed with minimal morbidity. Copyright © Mary Ann Liebert, Inc.




“Paediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy (RALIMA): feasibility of and initial experience with the University of Chicago technique.”

Gundeti, M. S., S. S. Acharya, et al. (2011).

BJU International 107(6): 962-969.


Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? There is no information on robotic laparoscopic approach for reconstruction of the bladder and this is the first study to find out the feasibility and technique with this approach and see if there are any outcome differences. In the short term we have seen the advantages of early recuperation and less need of analgesic medication. OBJECTIVE: * To present the first series of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendico-vesicostomy (RALIMA) in a paediatric population. PATIENTS AND METHODS: * From February to November 2008, six patients with neurogenic bladder secondary to spina bifida (status post corrective spine surgery) were selected to undergo RALIMA by a single surgeon (MSG) at the University of Chicago Medical Center. * Patients had constipation, day and night-time incontinence, with recurrent urinary tract infection (UTI), and failed attempts at anticholinergic therapy and clean intermittent catheterization. All had low-capacity bladders with poor compliance and high leak point pressures. * Preoperative bowel preparation was not performed. Mean follow-up is 18 months. RESULTS: * One patient required conversion to open ileal augmentation because of failure to progress and another underwent augmentation ileocystoplasty without appendico-vesicostomy. The average age of patients was 9.75 years (range 8-11 years). * Average operative time was 8.4 h (range 6-11 h). There were no intraoperative complications. One patient had a postoperative wound infection, one had a lower extremity venous thrombus, and another had temporary unilateral lower extremity paresthesia that has resolved. Three patients required revision of their stoma at the skin-level. * Perioperatively, patients only required oral analgesia for 24-36 h (excluding one patient with paralytic ileus), started on liquid diet after 7.5 hours (range 6-10 h), on regular diet after 24 h (range 12-36 h) and were discharged home within 7 days. * Postoperatively, patients demonstrated no leak on follow-up cystogram, and were catheterizing per apendico-vesicostomy (three patients by 6 weeks) or urethra (1 patient at 4 weeks). * All patients now have day and night-time continence with no UTIs, and bladder capacity of 250-450 mL. CONCLUSION: * While longer follow-up will be necessary to see if these results are durable, this series demonstrates that RALIMA is a safe, feasible and effective procedure in the short term, with the possible added benefits of reduced analgesia, shorter recovery time and improved aesthetic appearance.




“Double spinofixation laparoscopic versus laparoscopic robot-assisted: Morbidity, anatomical and functional short-term results.”

Larue, S., G. Meurette, et al. (2011).

Double promontofixation laparoscopique versus laparoscopique robot-assistée : morbidité, résultats anatomiques et fonctionnels à court terme.


Objective: The purpose of our study was to compare the morbidity and the short-term anatomical and functional outcome of the double promontofixation according to the surgical access laparoscopic versus laparoscopic robot-assisted. Methods: Forty-six patients were operated for anterior and posterior promontofixation with two mesh between March 2008 and February 2010, 19 were robot-assisted (PR) and 27 laparoscopic (PL). All the patients were contacted again by telephone to answer a questionnaire estimating the functional results. Results: Both groups (PR vs PL) were comparable in terms of age, score ASA and of surgical histories. There was no difference in terms of hospital stay nor per- and postoperative complications. The mean operating time was significantly more important in the group PR (P = 0.049). With a mean follow-up of 10,7 ± 7,8 months (PL) versus 8,8 ± 5,9 months (PR), the anatomical result was good without recurrence in 93,5% of the cases. The rate of recurrence was similar in both groups with three patients who had a cystocele grade 2, two in the group PR and one in the group PL (P = 0.411). The urinary and sexual functional results were comparable between both groups with an improvement of the rate of dyspareunia and dysuria. However we observed more postoperative constipation in the group PR (10/19 vs 6/27, P = 0.033). Conclusion: The robot-assisted laparoscopic promontofixation is a reproducible technique with a morbidity and anatomical and functional results comparable to the laparoscopic way. © 2011 Elsevier Masson SAS. All rights reserved.




“Management of the ventriculo-peritoneal shunt in pediatric patients during robot-assisted laparoscopic urologic procedures.”

Marchetti, P., A. Razmaria, et al. (2011).

Journal of Endourology 25(2): 225-229.


Introduction: Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures. Materials and Methods: After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications. Results: We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen. Conclusions: In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results. Copyright 2011, Mary Ann Liebert, Inc.




“Robotic-assisted laparoscopic surgery for restorative proctocolectomy with ileal J pouch-anal anastomosis.”

Pedraza, R., C. B. Patel, et al. (2011).

Minim Invasive Ther Allied Technol.


Abstract Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice for chronic ulcerative colitis (CUC). Robotic-assisted laparoscopic surgery (RALS) has been shown to have its greatest merits in colorectal procedures involving the pelvis. The aim of this study was to evaluate the safety and feasibility of RP with IPAA using an innovative robotic technique. A total of five consecutive patients underwent RALS RP with IPAA between August 2008 and February 2010. Patient demographics, intraoperative parameters, and postoperative outcomes were tabulated and assessed. Surgery was indicated for medically intractable CUC in three patients (60%), CUC-related dysplasia in one patient (20%) and CUC-related adenocarcinoma in one patient (20%). An ileal pouch-anal anastomosis was successful in all five cases. The mean operative time was 330 min and estimated blood loss was 200 cc. There were no intraoperative complications or conversions. The mean length of hospital stay was 5.6 days and no patients developed major postoperative complications. RALS is an innovative technique offering technical and visual advantages to the colorectal surgeon and can be offered for those who are seeking restorative proctolectomy for chronic ulcerative colitis.




“Content validation of a novel robotic surgical simulator.”

Seixas-Mikelus, S. A., A. P. Stegemann, et al. (2011).

BJU International 107(7): 1130-1135.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE: * To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System. PATIENTS AND METHODS: * Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool. RESULTS: * Forty-two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. * Eighty per cent of the entire cohort had an average of 4 years of experience with robot-assisted surgery. * Eleven (26%) novices lacked independent robot-assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160-2200) robot-assisted cases. Experts rated the ‘clutch control’ virtual simulation task as a good (71%) or excellent (29%) teaching tool. * Seventy-eight per cent rated the ‘ball place’ task as good or excellent but 22% rated it as poor. * Twenty-seven per cent rated the ‘needle removal’ task as an excellent teaching tool, 60% rated it good and 13% rated it poor. * Ninety-one per cent rated the ‘fourth arm tissue removal’ task as good or excellent. * Ninety-four per cent responded that RoSS would be useful for training purposes. * Eighty-eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. * Seventy-nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery. CONCLUSION: * Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity.




“Continence Outcomes in Patients Undergoing Robotic Assisted Laparoscopic Mitrofanoff Appendicovesicostomy.”

Wille, M. A., G. P. Zagaja, et al. (2011).

Journal of Urology.


Purpose: Continent catheterizable channels for emptying the bladder are typically performed via an open surgical approach. We present our surgical approach and initial outcomes with specific attention to continence for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy formation. Materials and Methods: Between February 2008 and April 2010, 13 patients were considered for robotic assisted laparoscopic Mitrofanoff appendicovesicostomy and 11 underwent the procedure (2 open conversions). Five patients underwent enterocystoplasty with appendicovesicostomy and 6 underwent isolated appendicovesicostomy. The appendicovesicostomy anastomosis was performed on the anterior (without augmentation) or posterior (with augmentation) bladder wall and the stoma was brought to the umbilical site or right lower quadrant. Detrusor backing (4 cm) was ensured except in 1 patient (number 5). Results: Mean patient age at surgery was 10.4 years (range 5 to 14). Mean estimated blood loss was 61.8 cc. Mean operative time for isolated appendicovesicostomy was 347 minutes and there were no intraoperative complications. Incontinence through the stoma developed in 1 patient with inadequate detrusor backing (less than 4 cm), which resolved with dextranomer/hyaluronic acid injection into the appendicovesicostomy anastomosis. This patient had resolution of incontinence with an increase in bladder capacity to 300 cc. Three patients required skin flap revision for cutaneous scarring. To date all patients are catheterizing without difficulty and are continent. Median followup was 20 months (range 3 to 29). Conclusions: We are encouraged by our preliminary experience with the robotic assisted laparoscopic Mitrofanoff appendicovesicostomy continent urinary diversion with or without ileocystoplasty. Early in the experience we emphasize the importance of 4 cm of detrusor backing to maintain stomal continence. © 2011 American Urological Association Education and Research, Inc.




“Initial Series of Robot-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer.”

Williams, S. B., C. S. Lau, et al. (2011).

European Urology.


Robotic technology has enabled urologists to perform a variety of laparoscopic surgeries. Robotic surgery offers enhanced optical magnification and visualization with precise surgical movements. We report the first case series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular cancer in three consecutive patients. All procedures were performed using a modified template nerve-sparing approach. The mean patient age was 31 yr. Estimated blood loss was 150-200ml; operative time was 150-240min. Length of stay was 2 d, and there were no perioperative complications. This early series in carefully selected and well-informed patients represented a limited experience. These results may not be applicable to all surgeons. Further long-term follow-up with a larger number of patients are warranted to validate these preliminary findings.




“Reply from Authors re: Michael Marberger. Is Robot-Assisted Radical Prostatectomy Safer Than Other Radical Prostatectomy Techniques? Eur Urol 2011;59:699-700.”

Agarwal, P. K. and M. Menon (2011).

European Urology.





Barocas, D. A. (2011).

BJU International 107(5): 854.




“Posterior reconstruction before vesicourethral anastomosis in patients undergoing robot-assisted laparoscopic prostatectomy leads to earlier return to baseline continence.”

Brien, J. C., B. Barone, et al. (2011).

Journal of Endourology 25(3): 441-445.


Abstract Introduction: Reapproximation of Denonvilliers’ fascia adjacent to bladder neck to the rectourethralis, or posterior reconstruction (PR), has been suggested to improve continence in postprostatectomy patients. We examined the impact of the PR on postoperative urinary and other quality-of-life (QoL) outcomes in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). Methods: We identified 89 patients who underwent RALP for prostate cancer between 2006 and 2009 by a single surgeon (R.G.), consented to participate in our prospective QoL study, which collects RAND-UCLA QoL and AUA symptom scores for all patients undergoing treatment for prostate cancer, and completed a baseline and a 3- or 6-month questionnaire. Of these, 31 patients had PR before vesicourethral anastomosis. We compared return to baseline function percentage at 3 and 6 months by PR group. Differences found in univariate analysis were further investigated using multiple linear regression models adjusting for demographics, clinical variables, and nerve-sparing status. Results: While most patients had both 3- and 6-month follow-up (n = 74, 83%), sample size at 3 months was n = 86 and at 6 months was n = 77. Groups were comparable by preoperative characteristics, pathologic stage, nerve-sparing status, and baseline QoL/AUA symptom scores. At 3-months, there was a statistically significant improvement comparing PR to non-PR groups in return to baseline score for urinary bother (72% vs. 53%; p = 0.008) and urinary function (64% vs. 50%; p = 0.05), as well as change in absolute AUA symptom score (+0.2 vs. +3.8; p = 0.005). Differences in urinary bother (+20%; 95% confidence interval 5%, 34%) and AUA symptom score (-2.8; 95% confidence interval, -5.4, -0.2) persisted after multivariate adjustment. Groups had similar scores for all parameters by 6 months postprostatectomy. Conclusions: PR in patients undergoing RALP has a significant impact on early return to baseline parameters relating to urinary bother, urinary function, and AUA symptom score.




“Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy.”

Carmignani, L., M. Pavesi, et al. (2011).

BJU International 107(5): 853-854.




“Early oncological outcomes of robot-assisted radical prostatectomy for high-grade prostate cancer.”

Cathcart, P., S. Connolly, et al. (2011).

BJU International 107(6): 1009.




“Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy.”

Choi, E. M., S. Na, et al. (2011).

Journal of Clinical Anesthesia.


STUDY OBJECTIVE: To compare the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on respiratory mechanics and hemodynamics in steep Trendelenburg position. DESIGN: Prospective, randomized clinical trial. SETTING: University hospital. PATIENTS: 34 ASA physical status 1 and 2 patients undergoing RLRP. INTERVENTIONS: Patients were randomly allocated to either the VCV (n = 17) or the PCV group (n = 17). After induction of anesthesia, each patient’s lungs were ventilated in constant-flow VCV mode with 50% O(2) and tidal volume of 8 mL/kg; a pulmonary artery catheter was then inserted. After establishment of 30 degrees Trendelenburg position and pneumoperitoneum, VCV mode was switched to PCV mode in the PCV group. MEASUREMENTS: Respiratory and hemodynamic variables were measured at baseline supine position (T1), post-Trendelenburg and pneumoperitoneum 60 minutes (T2) and 120 minutes (T3), and return to baseline after skin closure (T4). MAIN RESULTS: The PCV group had lower peak airway pressure (AP(peak)) and greater dynamic compliance (C(dyn)) than the VCV group at T2 and T3 (P < 0.05). However, no other variables differed between the groups. Pulmonary arterial pressure and central venous pressure increased at T2 and T3 (P < 0.05). Cardiac output and right ventricular ejection fraction were unchanged in both groups. CONCLUSIONS: PCV offered greater C(dyn) and lower AP(peak) than VCV, but no advantages over VCV in respiratory mechanics or hemodynamics.




“‘Mohs surgery of the prostate’: the utility of in situ frozen section analysis during robotic prostatectomy.”

Dasgupta, P. (2011).

BJU International 107(6): 979.




“Quality of Evidence to Compare Outcomes of Open and Robot-Assisted Laparoscopic Prostatectomy.”

Duffey, B., B. Varda, et al. (2011).

Current Urology Reports: 1-8.


Robot-assisted laparoscopic radical prostatectomy (RALP) has gained widespread acceptance in the treatment of prostate cancer. While it increasingly is becoming the surgical approach of choice in many centers, limited data exist directly comparing it to radical retropubic prostatectomy (RRP). This review examines the evidence comparing RALP to RRP. The outcomes evaluated are arranged into perioperative, oncologic, and functional outcomes. Of the 21 publications meeting our selection criteria, Level II, III, and IV evidence were found in 9, 1, and 11 articles, respectively. Overall, RALP was associated with lower blood loss, transfusion rates, length of stay, and higher cost when compared to RRP. Definitive conclusions regarding complications and oncologic and functional outcomes are not yet possible, and will require longer-term follow-up and well-designed randomized controlled trials. © 2011 Springer Science+Business Media, LLC.




“Changes in penile length after robot-assisted laparoscopic radical prostatectomy.”

Engel, J. D., D. E. Sutherland, et al. (2011).

Journal of Endourology 25(1): 65-69.


Background and Purpose: Radical prostatectomy is commonly performed for the treatment of patients with prostate cancer. Several studies have demonstrated a reduction in penile size after open radical retropubic prostatectomy. The objective of this study is to describe changes in penile length after after robot-assisted laparoscopic radical prostatectomy (RALRP). Patients and Methods: We performed a randomized, open label, multicenter study in men with normal erectile function who underwent bilateral nerve-sparing radical prostatectomy. We evaluated changes in measured stretched penile length (SPL), a secondary end point of the study, in a subset of men from a single site who underwent RALRP by one surgeon. They were randomized to either intraurethral alprostadil 125 to 250 mg daily or oral sildenafil citrate 50mg daily for 9 months. SPL was measured from pubic bone to coronal sulcus using a semirigid ruler before surgery and at 1, 3, 6, 9, 10, and 11 months. Results: A total of 127 patients were enrolled and 94 completed the 11-month follow-up. The mean patient age was 56.5 years. Baseline mean SPL (cm) before surgery was 11.77 and decreased to 11.13 at 1 month (P<0.0001). A trend toward recovery of SPL was seen at 3 and 6 months. Mean SPL was not significantly different from baseline at 9, 10, and 11 months. Conclusions: This report describes changes in SPL over time after RALRP for prostate cancer. The expected decrease in length was observed shortly after surgery, but, by 9 months, penile length had returned to the preoperative measurement. Copyright © Mary Ann Liebert, Inc.




“Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate.”

Gupta, N. P., P. Singh, et al. (2011).

BJU International.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVES: * To critically analyze and compare surgical, oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without previous transurethral resection of prostate (TURP). PATIENTS AND METHODS: * The study comprised 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). * Surgical, oncological and functional (short- and intermediate-term) outcomes of Group A were compared with 132 cases without previous TURP (Group B). RESULTS: * Post TURP patients were found to have significantly greater blood loss (494 vs 324 mL) and a need for bladder neck reconstruction (26.7% vs 9.7%) compared to the non-TURP group. * Surgical time (189 vs 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. * Incontinence rates were higher both at 6 (14% vs 11.8%) and 12 (25% vs 8%) months follow-up. CONCLUSIONS: * RARP is feasible but challenging after TURP. It entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. * These cases should be handled by an experienced robotic surgeon with the appropriate expertise.




“Prostate cancer: Postprostatectomy inguinal hernia: Does surgical method matter?”

Hakimi, A. A. and F. Rabbani (2011).

Nature Reviews Urology 8(1): 11-13.




“The impact of prostate size, median lobe, and prior benign prostatic hyperplasia intervention on robot-assisted laparoscopic prostatectomy: Technique and outcomes.”

Huang, A. C., K. J. Kowalczyk, et al. (2011).

European Urology 59(4): 595-603.


Background: Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP). Objective: To describe technical modifications to overcome BPH sequelae and associated outcomes. Design, settings, and participants: A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention (n = 59), and median lobes >1 cm (n = 42). Surgical procedure: RALP. Measurements: Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured. Results and limitations: In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5 ml; p < 0.001 and 236.4 vs 193.3 ml; p = 0.002), and larger prostates were associated with more transfusions (4 vs 1; p = 0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1 min; p = 0.002), median lobes (185.8 vs 155.0 min; p = 0.004), and prior BPH surgical interventions (170.2 vs 155.4 min; p = 0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p = 0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL (p = 0.006) and operative times (p < 0.001), while prior BPH interventions also prolonged operative times (p = 0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function. Conclusions: Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function. © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.




“Comparison of the rate, location and size of positive surgical margins after laparoscopic and robot-assisted laparoscopic radical prostatectomy.”

Kasraeian, A., E. Barret, et al. (2011).

BJU International.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE: * To review and compare the rate, location and size of positive surgical margins (PSMs) after pure laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP). PATIENTS AND METHODS: * The study comprised 200 patients who underwent RALP and 200 patients who underwent LRP up to January 2008. * We compared patient age, body mass index, preoperative prostate-specific antigen (PSA), preoperative stage and grade, prostate size, pathological stage and grade and neurovascular bundle preservation, as well as PSM rate, size and location. * Continuous and categorical data were compared using Student’s t-test and Pearson’s chi-squared test. * Multivariate regression analyses were used to identify preoperative and intraoperative predictors of PSMs. RESULTS: * Although the PSM rate was similar between the two groups (LRP: 12% vs RALP: 13.5%; P= 0.76), location and size were not. PSMs after LRP were mostly at the apex (58.3%; P= 0.038), while most PSMs after RALP were posterolateral ([PL] 48%; P= 0.046). * In addition, the median margin size after RALP was significantly smaller than after LRP (RALP: 2 mm vs LRP: 3.5 mm; P= 0.041). * In univariate and multivariate analyses, tumour-node-metastasis (TNM) stage and preoperative PSA were the only independent preoperative predictors of PSMs (P= 0.044 and P= 0.01, respectively). CONCLUSION: * The PSM risk is dependent on TNM stage and preoperative PSA and not the surgical technique, when comparing LRP with RALP.




“Impacting Factors for Recovery of Erectile Function Within 1 Year Following Robotic-Assisted Laparoscopic Radical Prostatectomy.”

Ko, W. J., M. D. Truesdale, et al. (2011).

Journal of Sexual Medicine.


Introduction. Neurovascular bundle preservation generally results in good postoperative sexual function after radical prostatectomy. However, erectile function (EF) after radical prostatectomy is still a significant concern. The same surgical technique often results in different EF outcomes. Aim. We evaluated factors that correlate with recovery of EF within 1 year after robotic-assisted laparoscopic radical prostatectomy (RALP). Methods. From January 2008 to May 2009, 145 consecutive patients underwent RALP by one surgeon. Patients were followed postoperatively at 3-month intervals and assessed for EF recovery, defined as an erection sufficient for penetrative intercourse with satisfaction. Baseline demographics, medical comorbidities, degree of nerve sparing, and perioperative and postoperative variables were recorded. Univariate and multivariate analyses were used to determine factors associated with EF recovery. Main Outcome Measures. Postoperative sexual outcomes were attained prospectively via our erectile state questionnaire. Results. Complete follow-up EF data were available on 89 men. Within 1-year follow-up, 56 men (62.9%) recovered EF and 33 men (37.1%) did not. In univariate logistic regression analysis, race (black), diabetes mellitus, hyperlipidemia, and clinical T2 carcinoma of the prostate were associated with diminished EF. Higher-preoperative Sexual Health Inventory for Men score and incremental nerve sparing (enhanced lateral prostatic fascia sparing) were associated with higher odds of recovering potency. In multivariate analysis, hyperlipidemia was primary comorbidity associated with diminished EF, and bilateral nerve sparing with a minimum unilateral-enhanced status was the impacting factor for EF recovery within 1 year after surgery. Conclusions. Bilateral nerve preservation with a minimum unilateral-enhanced status is associated with improved recovery of EF, and hyperlipidemia is a significant negative predictive factor of postoperative EF recovery within 1 year following RALP. Therefore, it is important to control hyperlipidemia as well as to use the proper surgical technique in maximizing EF recovery within 1 year after radical prostatectomy. Ko WJ, Truesdale MD, Hruby GW, Landman J, and Badani KK. Impacting factors for recovery of erectile function within 1 year following robotic-assisted laparoscopic radical prostatectomy. J Sex Med **;**:**-**.




“Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy.”

Kowalczyk, K. J., H. y. Yu, et al. (2011).

World Journal of Urology: 1-5.


Objectives: To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP). Methods: A review of the peer reviewed literature was performed for reported series of RRP, LRP, and RALP using Pubmed and MEDLINE with emphasis on comparing perioperative, functional, and oncologic outcomes. Common methods used for outcomes assessment were categorized and compared, highlighting the pros and cons of each approach. Results: The majority of the literature comparing RRP, LRP, and RALP comes in the form of observational data or administrative data from secondary datasets. While randomized controlled trials are ideal for outcomes assessment, only one such study was identified and was limited. Non-randomized observational studies contribute to the majority of data, however are limited due to retrospective study design, lack of consistent endpoints, and limited application to the general community. Administrative data provide accurate assessment of operative outcomes in both academic and community settings, however has limited ability to convey accurate functional outcomes. Conclusions: Non-randomized observational studies and secondary data are useful resources for assessment of outcomes; however, limitations exist for both. Neither is without flaws, and conclusions drawn from either should be viewed with caution. Until standardized prospective comparative analyses of RRP, LRP, and RALP are established, comparative outcomes data will remain imperfect. Urologic researchers must strive to provide the best available outcomes data through accurate prospective data collection and consistent outcomes reporting. © 2011 Springer-Verlag.




“Nerve-sparing procedure in radical prostatectomy: A risk factor for hernia repair following open retropubic, pure laparoscopic and robot-assisted laparoscopic procedures.”

Ku, J. H., C. W. Jeong, et al. (2011).

Scandinavian Journal of Urology and Nephrology 45(3): 164-170.


Abstract Objective. To identify risk factors for hernia repair following open retropubic, pure laparoscopic and robot-assisted laparoscopic radical prostatectomy. Material and methods. The medical records of 632 patients who had undergone radical prostatectomy (open retropubic n = 430, pure laparoscopic n = 49, and robot-assisted laparoscopic n = 202) were reviewed retrospectively. Patients with postprostatectomy inguinal hernia were defined as those who had undergone subsequent hernia repair. The mean period of follow-up was 19.5 months (median 19, range 1 to 42). Results. Hernia repairs were performed in 27 of the 632 patients (4.3%). The site of the repair was right in 15 patients (55.6%), left in 9 patients (33.3%), and bilateral in 3 patients (11.1%). The timing of the hernia repair ranged from 4 to 35 months (mean 13.1) following radical prostatectomy. No difference in hernia-repair-free rates was observed between the extraperitoneal open and transperitoneal pure or robot-assisted laparoscopic radical prostatectomy procedures (p = 0.225, log-rank test). The log-rank test revealed that the nerve sparing procedure (p = 0.019) and the absence of diabetes (p = 0.017) were significant risk factors for postprostatectomy hernia repair. In the multivariate Cox proportional hazards model, neurovascular bundle saving was the only significant risk factor for postprostatectomy inguinal hernia repair (Hazard ratio, 2.64, 95% confidence interval 1.09 to 6.41, p = 0.032). Conclusions. These findings suggest that the nerve sparing procedure may increase the risk of hernia repair. Prospective studies are warranted to investigate the possible adverse effects of the nerve sparing technique.




“Robotic prostatectomy in a patient with hemophilia.”

Lavery, H. J., P. Senaratne, et al. (2010).

Journal of the Society of Laparoendoscopic Surgeons 14(3): 439-441.


Given the rich blood supply to the prostate and the adjacent Santorini’s plexus, radical prostatectomy is associated with significant blood loss even in patients with normal coagulation profiles. In patients with hemophilia, any surgical procedure carries a risk of significant hemorrhage due to a deficiency of factors in the coagulation cascade. For these reasons, hemophiliac patients have often been encouraged to undergo radiation or other forms of nonsurgical treatment for clinically localized prostate cancer. However, the decreased blood loss associated with a laparoscopic/robotic approach and appropriate perioperative factor transfusions can minimize the risk of hemorrhage during robotic-assisted radical prostatectomy. We present the case report of a successful robotic-assisted laparoscopic prostatectomy in a patient with mild hemophilia A, with an estimated blood loss for the procedure of 20mL. We will focus on the perioperative management of the patient’s factor replacement. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.




“‘Mohs surgery of the prostate’: the utility of in situ frozen section analysis during robotic prostatectomy.”

Lavery, H. J., G. Q. Xiao, et al. (2011).

BJU International 107(6): 975-979.


Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Interim result of this study had shown promising efficacy, with response rate of 14.7% and median PFS of 7.4 months, and good tolerability in previously-treated Japanese metastatic RCC patients. The final result of the study adds: 1 The median overall survival in Japanese metastatic RCC patients was 25.3 months, which is longer than that in the Treatment Approaches in Renal Cancer Global Evaluation Trial (TARGET). 2 The response rate elevated from 14.7% to 19.4% because of 6 late responders achieved after 9.2 months or longer of SD period. 3 Neither unknown adverse events nor cumulative toxicity was observed in the long-term use of sorafenib. OBJECTIVE * To evaluate a novel technique to lower positive surgical margin rates while preserving as much of the neurovascular bundles as possible during nerve-sparing robotic prostatectomy. MATERIALS AND METHODS * In situ intraoperative frozen section (IFS) was performed during robotic-assisted laparoscopic prostatectomy (RALP) when there was macroscopic concern for a positive margin or residual prostate tissue. * When IFS was positive, additional sections were taken from the same area until the IFS was negative, similar to the procedure of Mohs micrographic surgery. * Positive surgical margin and biochemical recurrence rates were compared between the patients who underwent IFS and those who did not. RESULTS * Of 970 patients consecutively undergoing RALP at a single institution, IFS was performed on 177 (18%). * Eleven patients (6%) had IFS positive for carcinoma, whereas another 25 (14%) had benign prostatic tissue in the IFS specimen. * IFS and non-IFS patients had similar pathological and nerve-sparing characteristics. * The IFS group had significantly lower rates of positive surgical margins, 7% vs 18% (P= 0.001) but similar rates of biochemical recurrence (5%) at a median follow-up of 11 months. CONCLUSIONS * In situ IFS is an effective way of reducing positive margins during RALP. * Twenty percent of patients who underwent IFS, representing 4% of the overall RALP population, had either malignant or benign prostate tissue removed from their prostatic fossa. * Although a reduction of biochemical recurrence was not demonstrated, the follow-up is short and a difference may become apparent as the data mature.




“Trends in treatment for localized prostate cancer after emergence of robotic-assisted laparoscopic radical prostatectomy in Taiwan.”

Liu, C. L., C. C. Li, et al. (2011).

Journal of the Chinese Medical Association.


Background: Radical retropubic prostatectomy remains the gold standard treatment for localized prostate cancer. However, new minimally invasive techniques have emerged, providing a less invasive approach. Robotic-assisted laparoscopic radical prostatectomy is the ideal technique, providing good oncologic and functional outcomes. We analyzed the impact of robotic surgical systems on practice patterns among urologists to explain changes in the value of radical retropubic prostatectomy, laparoscopic radical prostatectomy and robotic-assisted laparoscopic radical prostatectomy in a single institution in Taiwan. Methods: We retrospectively reviewed the records of patients who received prostatectomy by one of the above procedures between January 2004 and November 2009. Decisions to perform these procedures were made by patient preference. Patients who received prostate biopsies at other hospitals were transferred to our hospital specifically for robotic-assisted prostatectomy. Results: A total of 434 radical prostatectomies were performed, of which 141 (32.49%) were radical retropubic prostatectomies, 59 (13.59%) were laparoscopic radical prostatectomies and 234 (53.92%) were robotic-assisted laparoscopic prostatectomies. The overall number of prostatectomies has increased over time because of an increase in robotic-assisted procedures. No decreases were seen in the number of radical retropubic prostatectomies during the evaluation period. Changes in the ratio of robotic-assisted prostatectomies compared to radical retropubic and laparoscopic radical prostatectomies demonstrated a trend toward robotic-assisted procedures. The percentage of cases transferred from other hospitals also increased over time from 28.57% to 68.60%. Conclusion: Our experience emphasizes the potential of robotic-assisted prostatectomy to become the mainstream treatment for localized prostate cancer in Taiwan. © 2011.




“Iliac vein injury due to a damaged Hot Shears tip cover during robot assisted radical prostatectomy.”

Lorenzo, E. I., W. Jeong, et al. (2011).

Yonsei Medical Journal 52(2): 365-368.


We report a rare case of vascular injury secondary to a damaged Hot Shears tip cover. Two 1 mm holes in the tip cover resulted in perforations in the obturator and external iliac veins during pelvic node dissection. Bleeding was controlled with bipolar coagulation and a 5 mm metal clip in the obturator and iliac vein, respectively. The rest of the procedure was completed uneventfully. Frequent integrity assessment of this accessory is necessary. Its function is important in order to carry out safe dissection in proximity to delicate structures. When injuries arise from areas not directly involved in the dissection, immediate inspection of the instruments should be mandatory.




“The Impact of Robotics on Treatment of Localized Prostate Cancer and Resident Education in Rochester, New York.”

Madeb, R., D. Golijanin, et al. (2011).

Journal of Endourology.


Abstract Background and Purpose: Robot-assisted radical prostatectomy (RARP) has been performed in Rochester, NY, since 2003. Currently, 10 area urologists perform RARP, and robotic training has become an important component of the residency. We present data describing the timeline for adoption, both in clinical practice and in the residency program. Materials and Methods: We reviewed the operating logs for all surgeons who were performing prostatectomies in all hospitals in Rochester, NY, from 2003 to 2007. We examined the influence RARP had on other treatments, including brachytherapy and cryotherapy. Surgical logs of graduating chief residents were also reviewed. Results: Eleven surgeons in Rochester regularly perform radical prostatectomy (10 perform primarily RARP, one performs only open prostatectomy). Three of the city’s four hospitals have robotic systems. In 2003-2004, there were 30 open prostatectomies performed monthly and fewer than 10 performed robotically. By 2006, the trend was reversed, with 50 robot-assisted prostatectomies performed each month and fewer than 10 open prostatectomies (P<0.05). The rate of brachytherapy fluctuated, increasing in centers without a robot. The number of open prostatectomies in centers without a robot dropped significantly to fewer than 10 cases per year. There was also a significant decrease in the number of open prostatectomies performed by chief residents. Conclusions: Since the introduction of surgical robotics, significant changes have been seen. The volume of radical prostatectomies performed by surgeons at institutions with robotics has increased; the volume at robot-free institutions has become nominal. There is a trend toward increased radiation therapy at robot-free institutions. While radical prostatectomies logged by graduating chief residents have increased, open prostatectomy experience is now minimal.




“Lower extremity neuropathy after robot assisted laparoscopic radical prostatectomy and radical cystectomy.”

Manny, T. B., I. Gorbachinsky, et al. (2010).

The Canadian journal of urology 17(5): 5390-5393.


To describe the incidence and outcomes of lower extremity neuropathies in a series of robot assisted laparoscopic radical prostatectomy (RALRP) and robot assisted laparoscopic radical cystectomy (RALRC) patients with 9 months follow up. Additionally, we compare this cohort to other published series of lithotomy based surgery and describe strategies for minimizing risk. We performed a retrospective analysis of 179 consecutive patients who underwent either RALRP or RALRC at a single institution during a 17 month period. We included all patients who experienced bothersome lower extremity pain, weakness, or numbness at any time during their postoperative course. We further defined postoperative neuropathy as de-novo symptoms presenting in the first week postoperatively. Chart review and telephone survey were used to further characterize these patients. Six out of 179 patients complained of lower extremity neuropathic symptoms by 9 months of follow up. Probable injuries to the common peroneal, lateral femoral cutaneous, and obturator nerves were found. Three patients met our criteria for postop neuropathy making the incidence 1.68%. All patients remained ambulatory throughout their course. At 9 months follow up, only one patient, a man with metastatic bladder cancer, had activity limiting neuropathic symptoms. With routine use of common risk minimizing strategies, RALRP or RALRC may result in lower extremity europathy at rates similar to other lithotomy based procedures described in the literature.




“Impact of prostate weight on probability of positive surgical margins in patients with low-risk prostate cancer after robotic-assisted laparoscopic radical prostatectomy.”

Marchetti, P. E., S. Shikanov, et al. (2011).

Urology 77(3): 677-681.


Objective To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. Methods The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. Results A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. Conclusions Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing. © 2011 Elsevier Inc.




“Pelvic anatomy on preoperative magnetic resonance imaging can predict early continence after robot-assisted radical prostatectomy.”

Mendoza, P. J., J. M. Stern, et al. (2011).

Journal of Endourology 25(1): 51-55.


Background and Purpose: Postoperative incontinence is multifactorial after radical prostatectomy. Using endorectal coil MRI, we examined features of the male urethra and accompanying muscular sphincter to predict continence after robot-assisted radical prostatectomy (RARP). Patients and Methods: 80 patients underwent preoperative 1.5 Tesla endorectal coil MRI. Urethral length was measured in the coronal plane. All patients underwent RARP. Questionnaires were completed by patients at monthly intervals. The primary end point was time to continence defined as necessitating 0 to 1 pad per day (PPD). Statistical analysis was performed using Cox regression models to create both univariate and multivariate survival models. Results: Mean age was 59.7 (standard deviation [SD] 7.1); 98% had bilateral nerve sparing. Mean urethral length was 17.1mm (SD 4.5mm). Mean prostate size was 34.7 g (SD 17.8). By 3 months, 60 patients achieved 1 PPD (mean 8.1 weeks, SD 9.4) and 34 patients achieved 0 PPD (mean 10.5 weeks, SD 8.0). Time to social continence was significantly related to prostate size both as a continuous variable (P=0.01), and as a dichotomized variable of ≥50 vs<50 g (P=0.02). Increased urethral length was related to decreased time to continence both as a continuous variable (P=0.06), and when dichotomized to ≥20 vs<20mm (P=0.08). In addition to larger prostate size (hazard ratio [HR] 0.97, P<0.04), older age (0.95 P<0.025) was also associated with a longer time to achieve 0 PPD. Multivariate analysis revealed that longer urethral length was associated with a faster recovery of continence (HR 1.11, P<0.01). After controlling for age and urethral length, patients with a prostate size ≥50 g had 75% lower likelihood of achieving continence at all time points when compared with patients with prostate size <50 g (HR 0.25; 95% confidence interval: 0.06, 1.06; P=0.06). Conclusions: Longer urethral length increased the likelihood of achieving continence at all time points postoperatively. Advanced age and larger prostate size were negatively associated with continence outcomes. Copyright © Mary Ann Liebert, Inc.




“Robotic radical prostatectomy: a critical analysis of the impact on cancer control.”

Mottrie, A., G. De Naeyer, et al. (2011).

Current Opinion in Urology.


PURPOSE OF REVIEW: Robot-assisted laparoscopic prostatectomy (RALP) has become the most used surgical procedure to treat clinically localized prostate cancer. Considering its curative intent, the evaluation of the oncologic outcomes must be considered with careful attention. In this review, we summarized and critically discussed the most relevant oncologic data available in the literature about RALP. RECENT FINDINGS: Currently, the oncologic effectiveness of RALP procedure can be evaluated looking at surrogate end-points such as positive surgical margins rate, percentage of additional salvage therapies required, and biochemical disease-free survival (bDFS). Available studies comparing RALP and retropubic radical prostatectomy showed that positive surgical margin rates were equivalent or slightly lower following RALP. Moreover, population-based studies showed similar risk in terms of additional salvage therapies between retropubic radical prostatectomy and minimally invasive radical prostatectomy. Moreover, comparative studies with short-term follow-up demonstrated overlapping results also in terms of bDFS. The initial long-term oncologic data (5-year median follow-up) estimated excellent 5-year and 7-year bDFS probabilities after RALP. SUMMARY: Although further studies with long-term follow-up are needed to estimate the main oncologic outcomes (overall and cancer-specific survival), available data supported the oncologic safety of RALP procedure in patients with clinically organ-confined prostate cancer.




“Different Approaches to an Inguinal Hernia Repair During a Simultaneous Robot-Assisted Radical Prostatectomy.”

Nakamura, L. Y., R. N. Nunez, et al. (2011).

Journal of Endourology.


Abstract Objectives: To determine if different approaches to an inguinal hernia repair (robotic, laparoscopic, or open) results in different outcomes during a simultaneous robot-assisted radical prostatectomy (RARP). Methods: We performed a retrospective review of a prospectively generated database of all RARPs performed at our institution. Patients who had a simultaneous inguinal hernia repair were identified. We compared them to an age-matched and body mass index-matched cohort who underwent RARP alone. We also compared outcomes between robotic versus laparoscopic versus open inguinal hernia repair. Results: A total of 1224 RARPs were performed between March 2004 and September 2009. Eighteen patients had simultaneous inguinal hernia repairs during their RARP performed by a general surgeon (5 laparoscopic, 8 open, and 5 robotic). When compared with the cohort who underwent RARP only, there were no statistically significant differences in blood loss, length of stay, or complications. The control group had a significantly shorter OR time (179.5 vs. 215.5 minutes, p = 0.007). When comparing the different approaches of an inguinal hernia repair, the only statistically significant differences noted were body mass index and operative time. Operative time was longer in open versus robotic inguinal hernia repair (74 vs. 31.6 minutes, p = 0.006). There were only two recurrences, both after the simultaneous open inguinal hernia repair. Conclusions: Simultaneous inguinal hernia repair is a safe and feasible operation to perform during RARP. Although it does extend overall operative time, approaching the repair robotically is quicker than an open approach. A randomized study is needed to truly determine if one approach has better outcomes than the rest.




“Comparative Assessment of a Single Surgeon’s Series of Laparoscopic Radical Prostatectomy: Conventional Versus Robot-Assisted.”

Park, J. W., H. W. Lee, et al. (2011).

Journal of Endourology.


Abstract Purpose: To directly compare the outcome of laparoscopic radical prostatectomy (LRP) with robot-assisted laparoscopic prostatectomy (RALP) performed by a single laparoscopic surgeon with intermediate experience-one who is between a novice and an expert. Patients and Methods: Consecutive 106 patients with prostate cancer who were treated with radical prostatectomy (62 with LRP and 44 with RALP) were included. The preoperative characteristics, the perioperative surgical outcomes, and the functional outcomes were compared between the two groups. Results: The mean operative time was longer in the RALP group (371 min vs 308 min, P = 0.00), conceivably because of more nerve-sparing procedures (84% vs 57%). The other perioperative parameters, including the surgical margin, were comparable, except for two major complications (rectourethral fistula and ureteral injury) in the LRP group. The RALP group recovered continence faster than those in the LRP, but the eventual continence rate at 12 months was similar (95% for LRP vs 94.4% for RALP, P = 1.00). The potency rate >/= 6 months postsurgery was 47.6% in the LRP group and 54.5% in the RALP group (P = 0.65). Conclusions: RALP was beneficial for the earlier recovery of continence, although LRP and RALP had comparable safety and efficacy as minimally invasive surgery for prostate cancer when performed by a laparoscopic surgeon with intermediate experience. Long-term follow-up data are needed for further evaluation of oncologic and functional outcomes for both techniques.




“Re: Quality of Life After Open or Robotic Prostatectomy, Cryoablation or Brachytherapy for Localized Prostate Cancer J. B. Malcolm, M. D. Fabrizio, B. B. Barone, R. W. Given, R. S. Lance, D. F. Lynch, J. W. Davis, M. E. Shaves and P. F. SchellhammerJ Urol 2010; 183: 1822-1828.”

Parker, A. S. (2011).

Journal of Urology.




“Reply from Authors re: James A. Eastham, Peter T. Scardino. The Devil Is in the Details. Eur Urol. In press. doi:10.1016/j.eururo.2011.01.049.”

Patel, V. R. and A. Sivaraman (2011).

European Urology.




“Intra-Abdominal Reservoir Placement During Penile Prosthesis Surgery in Post-Robotically Assisted Laparoscopic Radical Prostatectomy Patients: A Case Report and Practical Considerations.”

Sadeghi-Nejad, H., R. Munarriz, et al. (2011).

Journal of Sexual Medicine.


Introduction. Robotically assisted laparoscopic radical prostatectomy (RALP) provides decreased surgical morbidity and faster recovery for patients, but has not significantly changed the incidence of erectile dysfunction and many post RALP patients may require penile prosthesis surgery. Aim. To make physicians aware of the anatomical changes after RALP in comparison to traditional retropubic radical prostatectomy and to make suggestions for safer reservoir placement. Main Outcome Measures. Reservoir location after RALP. Methods. A 68 year-old patient with severe vasculogenic ED refractory to pharmacologic management following RALP underwent a 3-piece penile prosthesis insertion surgery and laparoscopic right lower abdominal hernia repair. Laparoscopy revealed an intraperitoneal reservoir that was overlying the sigmoid colon with multiple diverticula. The reservoir was laparoscopically repositioned in the dependent pelvis away from the diverticula and the pelvic vessels. Results. The patient’s postoperative course was uneventful without any postoperative complications (2 year follow up). Conclusions. The altered anatomy of the space of Retzius following RALP will likely result in significantly more cases of inadvertent intraperitoneal reservoir placement. Surgeons performing inflatable penile prosthesis surgery should be aware of these anatomical changes and prepared to consider ectopic reservoir placement when necessary. Sadeghi-Nejad H, Munarriz R, and Shah N. Intra-abdominal reservoir placement during penile prosthesis surgery in post-robotically assisted laparoscopic radical prostatectomy patients: A case report and practical considerations. J Sex Med **;**:**-**.




“Robotic radical prostatectomy: a critical analysis of surgical quality.”

Sammon, J., Q. D. Trinh, et al. (2011).

Current Opinion in Urology.


PURPOSE OF REVIEW: To review the ways in which the quality of radical prostatectomy and robot-assisted radical prostatectomy have been assessed, including quality-of-life (QoL) assessment, combined outcomes reporting, and patient utilities. RECENT FINDINGS: Superlative survival expectations following radical prostatectomy have shifted the paradigm of assessing surgical quality toward the prospective evaluation of QoL outcomes and combined outcomes reporting. Several high quality multi-institutional studies have compared QoL outcomes between the common treatment modalities for prostate cancer. Single-institution combined outcomes ‘Trifecta’ studies provide a convenient presentation of outcomes most important to the surgeon but have many associated limitations. The assessment of patient preferences for treatment outcomes is an underexplored area within the urologic literature and can provide an insight into a patient’s perception of surgical quality as seen in a pilot study performed at our institution. SUMMARY: Advances in the use of validated QoL instruments allow patients and clinicians to select treatment based on the perceived risk of adverse QoL impact but do not provide an insight into what the individual patient considers important. Combined outcomes reports also fail to address key patient concerns. A phenomenologic assessment of robot-assisted radical prostatectomy surgical quality does not exist, but will be necessary to properly evaluate surgical quality.




“Comparison of intraoperative outcomes using the new and old generation da Vinci(R) robot for robot-assisted laparoscopic prostatectomy.”

Shah, K. and R. Abaza (2011).

BJU International.


Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE: * To review and compare intraoperative outcomes for robotic prostatectomy procedures performed on two generations of the da Vinci robotic surgery platform. MATERIAL AND METHODS: * We reviewed 100 consecutive robotic prostatectomy cases and compared intraoperative outcomes for procedures randomly performed on either the da Vinci S robot or first-generation standard robot. * Baseline demographic data and intra-operative variables potentially impacting outcomes were reviewed and compared between the two groups. RESULTS: * Mean total operative time was 191 min using the standard da Vinci robot (range 132-266) versus 169 min with S robot (range 98-230), representing a mean difference of 22 min (P = 0.002). * This difference was statistically significant despite no difference in mean patient BMI of 30.6 (range 19-51) for standard versus 29.3 (range 21-37) for S (P = 0.31), no difference in mean prostate size of 54.6 g (range 26-101) for standard versus 57.3 g (range 32-151) for S (P = 0.55), and no difference in frequency of nerve-sparing (P = 0.99). * There was also no difference in the portions of procedues performed by residents, which in some cases was none and some the entire procedure, but the standard was more often used for the surgeon’s first case of the day (P = 0.006). * There was no difference in blood loss (P = 0.08), positive margins (P = 0.87), or mean number of lymph nodes removed (10.7 vs 10.6). CONCLUSIONS: * Both generations of da Vinci robotic technology are equally effective for PALP, but the S robot appears to allow shorter procedure times. * Further such evaluations are necessary to guide institutions and public policy decision-makers on investments in newer generations of robotic technology as incremental advances continue.




“Robotic-assisted laparoscopic prostatectomy: a critical analysis of its impact on urinary continence.”

Srivastava, A., S. Grover, et al. (2011).

Current Opinion in Urology.


PURPOSE OF REVIEW: Over 90% of all prostate cancer patients are diagnosed at a stage when the disease is organ-confined and potentially curable. Currently, more than 60% of all prostate cancer surgeries in the USA are performed using the robotic approach. We review the current literature evaluating the technical advances to optimize continence recovery following robotic prostatectomy. RECENT FINDINGS: Recent studies suggest that the several technical nuances during robotic prostatectomy can result in earlier continence recovery in patients without compromising the oncologic outcome. The key is in delicate handling of tissues, reducing trauma, preserving support structures, and restoring postoperative anatomy as close as possible to preoperative anatomy. There should also be standardization in assessment of continence recovery. SUMMARY: Much progress has been achieved in elucidating the anatomic, physiologic, and neural basis of the male continence mechanism, resulting in novel adaptations of the conventional approach to radical prostatectomy with the aim of preserving continence and accelerating its return. Various principles for augmenting continence return have been proposed which have been evaluated in series of open, laparoscopic, and robotic-assisted radical prostatectomy. Going forward, we foresee a paradigm shift from individual techniques toward a unified approach of interwoven principles aimed at preserving and augmenting the functional and innervative anatomy of the continence mechanism.




“Nerve-sparing radical prostatectomy: Current concepts in a robotic era.”

Srivastava, A., G. Tan, et al. (2010).

Panminerva Medica 52(3): 223-230.


Recovery of potency sufficient for penetrative intercourse at a year after surgery varies widely. Much of the progress achieved in the past two decades in improving potency outcomes after radical prostatectomy has resulted from an improved appreciation of the anatomic basis of the nerves responsible for erection. Recent studies suggest alternative and more complex course of nerves than previously described. Better appreciation of the variable and often invisible anatomical course of the cavernosal nerves continues to engender innovations in surgical technique to optimize their preservation. Exciting frontiers of research that include efforts in stem cell neural regeneration, development of specific fluorophores and biomarkers, and performing radical prostatectomy under hypothermic conditions may provide muchneeded breakthroughs to improving potency outcomes following radical prostatectomy in this current age of improved life expectancy and heightened patient expectations.




“Posterior Rhabdosphincter Reconstruction During Robotic Assisted Radical Prostatectomy: Results From a Phase II Randomized Clinical Trial.”

Sutherland, D. E., B. Linder, et al. (2011).

Journal of Urology.


Purpose: Posterior rhabdosphincter reconstruction following radical prostatectomy was designed to improve early urinary continence. We executed a randomized clinical trial to test this conjecture in men undergoing robotic radical prostatectomy. Materials and Methods: We conducted a phase II randomized clinical trial intended to detect a 25% difference in 3-month continence outcomes defined by a patient response of 0 or 1 to question 5 of the Expanded Prostate Cancer Index Composite questionnaire urinary domain, comparing standard running vesicourethral anastomosis (controls) to posterior rhabdosphincter reconstruction followed by standard running vesicourethral anastomosis (posterior rhabdosphincter reconstruction treated). Patients had clinically localized prostate cancer and were blinded. Surgeons were notified of computer randomization after prostate excision. Further continence outcomes were assessed by analysis of Expanded Prostate Cancer Index Composite questionnaire questions 1 and 12, International Prostate Symptom Score and 24-hour pad weights. Statistical significance was defined as p <0.05. Results: A total of 94 patients were randomized, 47 to each arm. Preoperative clinical and functional variables were equivalent between study arms. There were no complications associated with either anastomotic technique. Of the 87 evaluable patients 62 (71.3%) met our 3-month continence definition. The null hypothesis was accepted, and 33 (81%) controls and 29 (63%) posterior rhabdosphincter reconstruction treated cases were continent at 3 months (chi-square p = 0.07, Fisher exact p = 0.1). Likewise there was no significant difference between arms in 24-hour pad weights (p = 0.14), International Prostate Symptom Score (p = 0.4), absence of daily leaks (p = 0.4) or perception of urinary function (p = 0.4). Conclusions: In this randomized clinical trial posterior rhabdosphincter reconstruction offered no advantage for return of early continence after robotic assisted radical prostatectomy. © 2011 American Urological Association Education and Research, Inc.




“Robot-Assisted Simple Prostatectomy for Severe Benign Prostatic Hyperplasia.”

Sutherland, D. E., D. S. Perez, et al. (2011).

Journal of Endourology.


Abstract Purpose: To validate the feasibility of robot-assisted simple retropubic prostatectomy (RSP) for men with severe benign prostatic hyperplasia (>80 g). Patients and Methods: Institutional Review Board approval was not sought for this series. Men were offered RSP by two surgeons with a combined experience of >350 robot-assisted radical prostatectomies. The RSP replicated previously published robotic and laparoscopic techniques. Postoperative management consisted of continuous bladder irrigation and closed suction pelvic drainage without suprapubic catheterization. Results: A total of nine men were treated. Indications for RSP included urinary retention in three patients, failed medical management in eight patients, and refusal of medical management in one. Average age was 68 years, mean prostate-specific antigen level was 17.4 ng/mL, and the average preoperative gland size (height-width-length volume) was 136.5 g (range 86-265 g). No operative or immediate postoperative complications occurred, and no transfusions were needed. Average blood loss, operative time, and console time were 206 mL, 183 minutes, and 147 minutes, respectively. Average pathologic adenoma volume was 112 g (range 53-220 g). Average hospitalization time and catheterization time were 32 hours and 13 days, respectively. The mean preoperative International Prostate Symptom Score was 17.8 compared with 7.77 at 6 months postoperatively (P=0.0096, 95% CI 2.83 – 17.40), with a mean follow-up time of 9.25 months. The mean Sexual Health Inventory for Men score was 12.7 preoperatively compared with 12.5 postoperatively (P=0.74, 95% confidence interval – 6.66-9.16). Persistent, severe urinary incontinence (4-6 pads per day) occurred in one patient. Conclusions: RSP is safe and reproducible when performed by experienced robotic surgeons and provides similar benefits to those associated with robot-assisted radical prostatectomy. In our limited experience, hemostasis was markedly decreased when compared with the open technique. Further investigation is necessary before widespread application of RSP.




“A prospective report of changes in prostate cancer related quality of life after robotic prostatectomy.”

Thornton, A. A., M. A. Perez, et al. (2011).

J Psychosoc Oncol 29(2): 157-167.


In this prospective, longitudinal study the authors examined changes in cognitive, emotional, and interpersonal components of prostate cancer-related quality of life in 71 men who underwent robotic-assisted prostatectomy for prostate cancer. They identified significant changes across several quality-of-life domains from presurgery to 3-months and 1-year postsurgery. Although some components of quality of life returned to baseline by one year postsurgery, decrements in sexual intimacy, sexual confidence, and masculine self-esteem were enduring. These data can be used to guide patients in their expectations for quality of life following robotic prostatectomy and highlight the need for multidisciplinary approaches aimed at improving men’s sexual adjustment after this procedure.




“LAPPRO: a prospective multicentre comparative study of robot-assisted laparoscopic and retropubic radical prostatectomy for prostate cancer.”

Thorsteinsdottir, T., J. Stranne, et al. (2011).

Scandinavian Journal of Urology and Nephrology 45(2): 102-112.


OBJECTIVE: This study describes the study design and procedures for a prospective, non-randomized trial comparing open retropubic and robot-assisted laparoscopic radical prostatectomy regarding functional and oncological outcomes. MATERIAL AND METHODS: The aim was to achieve a detailed prospective registration of symptoms experienced by patients using validated questionnaires in addition to documentation of surgical details, clinical examinations, medical facts and resource use. Four patient questionnaires and six case-report forms were especially designed to collect data before, during and after surgery with a follow-up time of 2 years. The primary endpoint is urinary leakage 1 year after surgery. Secondary endpoints include erectile dysfunction, oncological outcome, quality of life and cost-effectiveness at 3, 12 and 24 months after surgery. RESULTS: The study started in September 2008 with accrual continuing to October 2011. Twelve urological departments in Sweden well established in performing radical prostatectomy are participating. Personal contact with the participating departments and patients was established to ascertain a high response rate. To reach 80% statistical power to detect a difference of 5 absolute per cent in incidence of urinary leakage, 700 men in the retropubic group and 1400 in the robotic group are needed. CONCLUSIONS: The Swedish healthcare context is well suited to performing multicentre long-term prospective clinical trials. The similar care protocols and congruent specialist training are particularly favourable. The LAPPRO trial aims to compare the two surgical techniques in aspects of short- and long-term functional and oncological outcome, cost effectiveness and quality of life, supplying new knowledge to support future decisions in treatment strategies for prostate cancer.





Touijer, K. (2011).

BJU International.




“The natural history of voiding function after robot-assisted laparoscopic radical prostatectomy.”

Wang, L., S. F. C. M. Chung, et al. (2011).

Urologic Oncology: Seminars and Original Investigations 29(2): 177-182.


Objectives: We report the natural history of voiding function in men with clinically localized prostate cancer after robot-assisted laparoscopic radical prostatectomy (RLRP), describing the trend of functional recovery, which is currently not well described using the robot-assisted laparoscopic approach. Materials and methods: We determined the impact on voiding function by prospectively evaluating 100 consecutive men who underwent RLRP between May 2005 and December 2006 and compared their reported International Prostate Symptom Score (IPSS) and Quality of Life (QOL) scores at 3, 6, and 12 months with preoperative scores after surgery. Patients with preoperative IPSS of 0-7 and 8-35 were defined as having mild lower urinary tract symptoms (LUTS) and moderate to severe LUTS, respectively. Results: Continence was achieved in 82%, 87%, and 91% of men at 3, 6, and 12 months after RLRP, respectively. There were statistically and clinically significant improvements in both IPSS and QOL preoperative scores at all studied time points for patients with moderate to severe preexisting LUTS. The mean IPSS scores for these patients preoperatively and at 3, 6, and 12 months after surgery were 14.1, 5.2, 3.0, and 2.9, respectively and the corresponding mean QOL scores were 3.4, 2.1, 1.6, and 1.6, respectively. Patients with mild preexisting LUTS showed no statistically significant improvement in IPSS at 3 and 6 months after surgery but significant improvement was found at 1 year (P = 0.04). Conclusions: Good continence recovery is expected in most patients undergoing RLRP. Patients with moderate to severe preexisting LUTS can expect early and clinically significant symptom and QOL improvements after RLRP. Patients with mild preexisting LUTS show significant symptom improvement at 1 year. © 2011 Elsevier Inc.




“Open versus robotic-assisted radical prostatectomy: which is better?”

Wilson, T. and R. Torrey (2011).

Current Opinion in Urology.


PURPOSE OF REVIEW: Over the last decade there has been a changing trend in technique for radical prostatectomy from open surgery to minimally invasive robotic-assisted laparoscopic technology. This review evaluates the validity of this change by reviewing the current literature and comparing open radical retropubic prostatectomy to robotic-assisted radical prostatectomy. RECENT FINDINGS: Robotic-assisted radical prostatectomy shows equivalent and possibly better results when compared with radical retropubic prostatectomy with respect to intraoperative and postoperative parameters including continence, potency and quality of life. Time is still needed to determine long-term oncologic results, but initial findings are promising. SUMMARY: This review supports the current trend in shifting the standard of care for radical prostatectomy from an open to a robotic-assisted laparoscopic approach.




“Surgical Steps That Elongate Operative Time in Robot-Assisted Radical Prostatectomy Among the Obese Population.”

Zilberman, D. E., M. Tsivian, et al. (2011).

Journal of Endourology.


Abstract Introduction: The association between increased body mass index (BMI) and prolonged operative time (OT) in robot-assisted laparoscopic radical prostatectomy (RLRP) has been suggested before. It is unclear, however, which RLRP step contributes to this finding. We aimed to assess the association between BMI and duration of RLRP steps. Patients and Methods: Records of patients who underwent RLRP between 2003 and 2009 were reviewed retrospectively. Demographics (including BMI) and OT were recorded. We reviewed total OT (incision to closure) and separate duration of sequential steps of RLRP: In room to incision (preparation), incision to robot docking (port-placement), docking to endopelvic fascia dissection end (retroperitoneal space development), dorsal vein complex (DVC) control, DVC-control end to prostate detachment (prostate dissection), vesicourethral anastomosis (anastomosis), and undocking time (undocking). We divided this cohort into BMI groups (<25, 25.0 to 29.9, 30.0 to 34.9, and >/=35) and compared their characteristics and OT. Results: A total of 555 patients were analyzed. OT was significantly different across BMI groups with medians of 159, 181, 178, and 191 minutes for BMI <25, 25 to 29.9, 30 to 34.9, and >/=35 kg/m(2), respectively (P = 0.002). For BMI <25, preparation and prostate dissection were significantly shorter. There was a correlation between higher BMI and longer time of prostate dissection with nerve-sparing technique (P = 0.016), but not with a non-nerve-sparing approach (P = 0.658). Higher BMI was associated with longer times of DVC-control and vesicourethral anastomosis (P = 0.048 and P = 0.035, respectively). Conclusions: Higher BMI is significantly associated with prolonged total OT for RLRP with specific steps (preparation, nerve-sparing dissection, DVC-control, anastomosis) responsible for this result. These data need to be considered when planning RLRP in the obese population.




“Significance of prostate weight on peri and postoperative outcomes of robot assisted laparoscopic extraperitoneal radical prostatectomy. Editorial comment.”

Zorn, K. C. (2010).

The Canadian journal of urology 17(5): 5389.