Abstrakt Urologie Červen 2009

“Editorial Comment on: A Comparison of Postoperative Complications in Open versus Robotic Cystectomy.”

Gakis, G. and A. Stenzl (2009).

Eur Urol.

“Robotic correction of Ã-stling folds as a rare cause of ureteropelvic junction obstruction in children.”

Harris, A. M., B. Steixner, et al. (2009).

Journal of Robotic Surgery: 1-2.

Ã-stling folds are considered to be normal variants of ureteral growth at a quicker rate than body lengthening and, therefore, have been reported to be of no clinical significance. We report a robotic correction of the first documented cases of Ã-stling folds causing a persistent ureteroplevic junction obstruction in children. © 2009 Springer-Verlag London Ltd.

“Re: Robotic distal ureterectomy with reimplantation in malignancy: technical nuances.” Moinzadeh, A. (2009).

Can J Urol 16(3): 4676; discussion 4676.

“A Comparison of Postoperative Complications in Open versus Robotic Cystectomy.”

Ng, C. K., E. C. Kauffman, et al. (2009).

Eur Urol.

BACKGROUND: Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated. OBJECTIVE: To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of 187 consecutive patients undergoing RC at our institution-104 open RC, 83 robotic RC. INTERVENTION: Open or robotic RC with urinary diversion. MEASUREMENTS: Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using chi(2) and multivariate logistic regression analyses. RESULTS AND LIMITATIONS: At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p=0.04) as well as more major complications (30% vs 10%; p=0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p=0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p=0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3-4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion. CONCLUSIONS: Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational.

“Robotic distal ureterectomy with reimplantation in malignancy: technical nuances.” Singh, I., K. Kader, et al. (2009).

Can J Urol 16(3): 4671-6.

AIM: To present the point of technique of robotic distal ureterectomy under cystoscopic guidance with pelvic lymphadenectomy (PLND), ureteral reconstruction with and without a psoas hitch in patients with distal ureteral urothelial cancer (DUCC) and to review the current literature. METHODS: The various steps of operative technique of robotic PLND, distal ureterectomy under cystoscopic guidance, ureteral reconstruction with and without a psoas hitch in patients of DUCC are described. Several tricks have been highlighted to undertake such procedure. The published English literature was also searched using the key words; robot, laparoscopy, ureteral reimplantation, distal ureterectomy, psoas hitch, and ureteroneocystostomy; so as to provide an up to date review on subject. RESULTS: The technique robotic pelvic lymphadenectomy, distal ureterectomy, ureteral reimplantation with and without a psoas hitch in patients with DUCC was successful in both our patients. The mean operating room time, robotic (console) time, mean estimated blood loss and mean hospital stay were 250 min, 130 min, 150 cc and 2.2 days respectively. There were no complications. CONCLUSIONS: The technique of robotic distal ureterectomy with ureteral reimplant for malignant ureteral strictures continues to be in evolution. Surgeon should be versatile with various options and technical nuances while dealing with these cases. The short term oncologic outcomes appear to be satisfactory and encouraging, while the long term results are awaited.

“Proceedings of the Fourth Annual World Robotic Urology Symposium: on-site report.” Coelho, R. F. (2009).

Journal of Robotic Surgery: 1-2.

“A 64-year-old man with low-risk prostate cancer: Review of prostate cancer treatment.” Sanda, M. G. and I. D. Kaplan (2009).

JAMA – Journal of the American Medical Association 301(20): 2141-2151.

Earlier detection of prostate cancer in the past decade has been accompanied by greater reduction in US prostate cancer mortality than that seen with any other cancer. Prostate cancer is usually diagnosed at early stages and is most commonly treated by prostatectomy, radiotherapy, or brachytherapy. For intermediate- and high-risk prostate cancers, randomized clinical trials have shown survival benefit subsequent to prostatectomy or to combined radiation with androgen-suppressive therapy. However, prostatectomy, radiotherapy, and brachytherapy each can lead to distinct adverse effects. Moreover, for the lowestrisk categories of early stage prostate cancer, evidence supporting an intervention is only indirect. New approaches to surveillance of prostate cancer have consequently emerged that do not eschew treatment altogether. Instead “active” surveillance aims to implement definitive intervention effectively for those low-risk cancers that show a propensity for progression as evidenced by histopathological or serological change during the surveillance interval. ©2009 American Medical Association. All rights reserved.

“Re: Josephson et al.: Robotic-Assisted Endoscopic Inguinal Lymphadenectomy (Urology 2009;73:167-170).”

Tobias-Machado, M. and A. S. Neto (2009).

Urology 73(6): 1424-1425.

“Impact of obesity on surgical outcomes following open radical prostatectomy.”

Van Roermund, J. G. H., J. P. A. Van Basten, et al. (2009).

Urologia Internationalis 82(3): 256-261.

Objective: The increasing incidence of both obesity and prostate cancer (PCa) detection will confront the urologist more often with obese men having PCa. It is unknown whether obesity affects the surgical and oncological outcomes following open radical retropubic prostatectomy (RRP). Knowledge concerning this issue is relevant when counselling obese patients with PCa for RRP. Patients and Methods: A single institution cohort study was performed including 252 men who underwent a RRP between 1992 and 2003. The surgical complications (perioperative complications, post-RRP urinary incontinence, urethral strictures) were compared between obese (BMI >30) and nonobese (BMI ≤30) men. Results: Compared to nonobese (n = 221), obese men (n = 31) developed more frequently wound infections (16.1 vs. 4.5%; p < 0.05), urinary incontinence (25.8 vs. 8.7%; p < 0.05) as well as vesico-urethral strictures (46.2 vs. 12.3%; p < 0.05). The pathology results and the 5-year cumulative risk of PSA recurrence were comparable among both groups. Conclusions: Compared to nonobese, obese men suffer more frequently from post-RRP urinary incontinence and vesicourethral strictures following open RRP. © 2009 S. Karger AG, Basel.

“Robot-assisted laparoscopic pyeloplasty: outcomes reported by a centre with no previous laparoscopic experience.”

Giberti, C., F. Gallo, et al. (2009).

Journal of Robotic Surgery: 1-5.

Laparoscopic pyeloplasty (LP) has proved to be an effective minimally invasive treatment for ureteropelvic junction obstruction (UPJO). However, its application is still limited by the challenge of the laparoscopic learning curve, which seems to be overcome by the recent introduction of robot assistance. The aim of this manuscript is to show our outcomes after the first robot-assisted laparoscopic pyeloplasties (RP) and critically evaluate the feasibility of this technique when performed by a surgical team without any previous laparoscopic experience. Between March 2005 and July 2008, 16 patients with UPJO underwent transperitoneal RPs. Before and after surgery patients were evaluated by ultrasonography, intravenous urography or retrograde pyelography, computed tomography (CT) scan, and/or diuretic renography. Mean follow-up was 16.8 months. The assessed outcomes were mean operative time (OT), mean estimated blood loss (EBL), mean length of hospital stay (LOS), success (SR), and complication rates (CR). OT, EBL, LOS, and SR were 202 min, 60 ml, 5.2 days, and 94%, respectively. Among the minor complications, two patients (12%) reported moderate abdominal pain while, concerning major complications, one patient (6%) developed ileus. Robot assistance was confirmed as a special tool for laparoscopic treatment of UPJO with excellent outcomes after a shorter learning curve. As shown by our results, the feasibility of RP may also be extended to naïve surgeons who can approach this technique even in the absence of previous laparoscopic training, rapidly attaining results similar to those reported by both laparoscopically experienced and expert robotic surgeons. © 2009 Springer-Verlag London Ltd.

“Four-arm robotic partial nephrectomy for complex renal cell carcinoma.”

Gong, Y., C. Du, et al. (2009).

World Journal of Urology: 1-5.

Objectives: Laparoscopic partial nephrectomy (LPN) remains challenging to even experienced laparoscopists. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery (NSS). We represented our technique and results of robotic partial nephrectomy (RPN) for hilar, endophytic, and multiple renal tumors. Materials and methods: Between May 2006 and March 2008, 29 patients with complex renal tumors underwent RPN, including hilar (n = 14), endophytic (n = 12) and multiple tumors (n = 3).The hilar vessels were clamped with laparoscopic bulldog with warm ischemia. Follow-up ranged from 3 to 23 months (mean of 15 mo). The perioperative data and pathologic results were retrospectively reviewed. Results: Robotic partial nephrectomy procedures were performed successfully without complications. The mean diameter of tumors was 3.0 cm (range 2.0-4.0). The mean operative time was 197 minutes (range 172-259), and the mean blood loss was 220 ml (range 100-370). The mean warm ischemia time (WIT) was 25 min (range 16-43). The hospital stay averaged 2.5 days (range 2-3). Histopathology confirmed clear-cell carcinoma (n = 21), chromophobe cell carcinoma (n = 4), hybrid oncocytic tumor (n = 2), oncocytoma (n = 1), and cystic renal cell carcinoma (n = 1). All cases had negative surgical margins. At the 3-23 months (mean of 15 mo) follow-up, no patients experienced a significant change of glomerular filtration rate compared to preoperative levels and there was no evidence of tumor recurrence. Conclusion: Robotic partial nephrectomy is a safe and feasible procedure. RPN is a preferred approach for complex renal tumors when NSS is indicated. For complex and technical challenging renal tumors, robotic assistance may provide patients the benefit of minimally invasive surgery. © 2009 Springer-Verlag.

“Pediatric single-port-access nephrectomy for a multicystic, dysplastic kidney.”

Johnson, K. C., D. Y. Cha, et al.

Journal of Pediatric Urology.

Major urologic surgery via a single port has emerged as the latest progression in laparoscopy and robotics. While current literature highlights the single-port approach to the surgical treatment of cholecystitis, appendicitis and varicoceles, this technique has never been employed to perform a nephrectomy on a child. We herein report a case of a pediatric patient who underwent nephrectomy via single-port-access.

“Hybrid Laparoscopic and Robotic Ultrasound-guided Radiofrequency Ablation-assisted Clampless Partial Nephrectomy.”

Nadler, R. B., K. T. Perry, et al.


Introduction: To describe a clampless approach made possible by creating an avascular plane of tissue with radiofrequency ablation. Laparoscopic partial nephrectomy is slowly gaining acceptance as a method to treat small (<4 cm) and select moderate (<7 cm) renal masses. The intricacies of laparoscopic suturing, which result in prolonged warm ischemia times, have delayed the widespread acceptance of this technique among urologists. Laparoscopic suturing to close the collecting system was done using the da Vinci robot. Technical Considerations: An avascular plane of tissue from coagulation necrosis was achieved with the Habib 4X radiofrequency ablation device and the Rita 1500X generator. Typically, we used a power setting of 50 W but have found settings as low as 25 W necessary to provide hemostasis for larger vessels. The tumor was then sharply excised with a negative margin using robotic scissors and electrocautery to facilitate tissue cutting. Retrograde injection of methylthioninium chloride and saline through an externalized ureteral catheter allowed for precise sutured closure of the collecting system. FloSeal and BioGlue were then applied, making surgical bolsters or parenchymal sutures unnecessary. Intraoperative histologic evaluation of the surgical margin and repeat resection of the tumor bed was possible because the renal hilum was not clamped, and no warm ischemia was used. Conclusions: This technique, which combines the improving technologies of robotic surgery, intraoperative laparoscopic ultrasonography, and radiofrequency ablation, might make more surgeons comfortable with the intricacies of laparoscopic suturing and eliminate prolonged warm ischemia times. Overall, this method should result in more patients being able to undergo minimally invasive laparoscopic partial nephrectomy. © 2009 Elsevier Inc. All rights reserved.

“Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein.”

Narducci, F., E. Lambaudie, et al.

Gynecologic Oncology.

Objective: To describe our early experience with robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein, including Da Vinci robot positioning. Methods: Six patients underwent robotic-assisted laparoscopy using the Da Vinci apparatus. The patients included a man with a pT2 non-seminomatous germ cell tumour of the left testicle treated by chemotherapy with an incomplete response (mature teratoma), four women with locally advanced cervical cancer, and one case of bulky cancer of the vaginal cuff. The procedure was carried out using four port sites: one for the camera, one each for the no. 1 and no. 3 arms of the Da Vinci robot system, and one for the assistant. Results and conclusion: Robotic-assisted lymphadenectomy carried out using the Da Vinci system was safe and effective with a short learning period for an experienced oncological team. A larger prospective study is now required to evaluate this procedure further. © 2009 Elsevier Inc.

“Initial experience of robotic nephroureterectomy: a hybrid-port technique.”

Park, S. Y., W. Jeong, et al. (2009).

BJU Int.

OBJECTIVE To report a new technique of robot-assisted laparoscopic nephroureterectomy (RANU) using a hybrid port, as RANU has recently become a minimally invasive treatment option for upper tract transitional cell carcinoma (TCC). PATIENTS AND METHODS Eleven consecutive patients underwent RANU by one surgeon. The first six patients were repositioned after the nephrectomy, from flank to lithotomy position, and the robot was re-docked for excision of the distal ureter and bladder cuff. The last five patients were treated by a new RANU technique that did not require a change of position or movement of the patient cart. We analysed data obtained before, during and after RANU. RESULTS The total operative duration was reduced by approximately 50 min in last five patients. There was no improvement in hospital stay or estimated blood loss. There were no transfusions and positive surgical margins in any patient. Maintaining the patient in a flank position allows gravity to displace the bowel away from the distal ureter, not only shortening the surgery but also improving exposure of the distal ureterectomy and closure of the bladder cuff. CONCLUSIONS The new RANU technique is a safe and feasible treatment option for upper tract TCC.

“The Motion: Robotic Partial Nephrectomy is Better than Open Partial Nephrectomy.” Rogers, C. G. and J. J. Patard (2009).

Eur Urol.

“Robot-assisted laparoscopic pyeloplasty for the management of pelvi-ureteric junction obstruction in horseshoe kidneys: initial experience.”

Spencer, C. D., K. Sairam, et al. (2009).

Journal of Robotic Surgery: 1-4.

Minimally invasive dismembered pyeloplasty has become the gold-standard treatment for symptomatic pelvi-ureteric junction obstruction (PUJO) in recent years. A small proportion of patients with PUJO have horseshoe kidneys. We present two cases of robot-assisted pyeloplasty in horseshoe kidneys and describe the technical modifications for success in these cases. Two patients, aged 28 and 35 years, were diagnosed with symptomatic PUJO in horseshoe kidneys. Both had a robotic-assisted laparoscopic dismembered pyeloplasty using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Three-dimensional computed tomography (CT) reconstructions were performed pre-operatively to plan surgery. The transperitoneal ports were placed more caudally than usual for improved access to the PUJ. The isthmus was not divided in either case. The procedures took 190 and 90 min, respectively, with minimal blood loss and no post-operative complications. Patients were discharged on post-operative day 2 following catheter and drain removal. Follow-up diuretic renograms showed no residual obstruction and patients were symptomatically better. Our initial experience suggests that RALP is a safe and feasible option for the treatment of PUJO in horseshoe kidneys with good short-term outcomes. These are challenging cases and robust pre-operative planning combined with technical modifications has been beneficial to our success. The enhanced suturing possible with the da Vinci® surgical system facilitates these procedures. © 2009 Springer-Verlag London Ltd.

“Minimally invasive surgical management of pelvic-ureteric junction obstruction: update on the current status of robotic-assisted pyeloplasty.”

Uberoi, J., G. I. Disick, et al. (2009).

BJU Int.

BACKGROUND Pelvi-ureteric junction (PUJ) obstruction is characterized by a functionally significant impairment of urinary transport caused by intrinsic or extrinsic obstruction in the area where the ureter joins the renal pelvis. The majority of cases are congenital in origin; however, acquired conditions at the level of the ureteropelvic junction may also present with symptoms and signs of obstruction. Historically, open pyeloplasty and endoscopic techniques have been the main surgical options with the intent of complete excision or incision of the obstruction. The advent of laparoscopy and robotic-assisted applications has allowed for minimally invasive reconstructive surgery that mirrors open surgical techniques. AIMS We review the current status of robotic-assisted laparoscopic pyeloplasty and report on the result, continuing evolution, and potential role for this surgical procedure. MATERIALS AND METHODS A review of the recent literature encompassing laparoscopic and robotic-assisted pyeloplasty was conducted with particular attention to operative techniques, surgical outcomes, and complication rates. RESULTS Laparoscopic and robotic-assisted approaches are able to duplicate the open technique, and not surprisingly, are now being shown to be as efficacious as the gold standard open approach. The laparoscopic remains technically challenging due to the high proficiency level required for intracorporeal suturing, although added experience has resulted in shorter operative times. The advent of robotics has further expanded the breadth of this reconstructive procedure while preserving the benefits of decreased pain, shorter hospitalization, rapid convalescence, and an improved cosmetic result. DISCUSSION The introduction of robotics to the field of minimally invasive surgery facilitates this procedure and may allow for more widespread implementation by surgeons of varying skill levels. These benefits must be balanced against the increased costs of the robotic platform. CONCLUSION Clinical reports have demonstrated that robotic-assisted pyeloplasty is a safe, feasible, and effective technique for treating ureteropelvic junction obstruction in short term studies. Additional studies with prolonged follow-up will ultimately provide valuable information as to the long-term efficacy of robotic-assisted laparoscopic pyeloplasty.

“Robotic Renal Surgery: The Future or passing curiosity?”

Warren, J., V. da Silva, et al. (2009).

Can Urol Assoc J 3(3): 231-240.

The development, advancement and clinical integration of robotic technology in surgery continue at a staggering pace. In no other discipline has this rapid evolution occurred to a greater degree than in urology. Although radical prostatectomy has grown to become the prototypical application for the robot, the role of the robot in renal surgery remains controversial. Herein we review the literature on robotic renal surgery. A comprehensive PubMed literature search was performed to identify all published reports relating to robotic renal surgery. All clinically related articles involving human participants were critically appraised in this review. Fifty-one clinical articles were included, encompassing robot-assisted pyeloplasty, nephrectomy, nephroureterectomy, living-donor nephrectomy and partial nephrectomy. Feasibility has been shown for each of these procedures. Robot-assisted techniques have been described for almost all renal-related procedures. However, the intersect between feasibility and necessity as it pertains to robotic renal surgery has yet to be defined. Also, the high cost of surgical robotic technology mandates critical appraisal before adoption, especially in a publicly funded health care system, such as the one present in Canada.

“Salvage therapy for prostate cancer recurrence after radiation therapy.”

Busby, J. E. and J. M. Cox (2009).

Current Urology Reports 10(3): 199-205.

Radiotherapy has been successful in treating localized prostate cancer; however, a subset of patients will experience disease recurrence. Determination of the recurrence location must be made using pretreatment and posttreatment clinical variables, imaging, and postradiotherapy biopsy. Patients presumed to have local-only recurrence, optimal clinical risk factors, and an extended life expectancy may be considered for salvage local treatment. Current options include salvage surgery, cryoablation, and brachytherapy. Although they are associated with higher morbidity than primary therapy, salvage treatments can be effective and can still provide patients with a good oncologic and functional outcome. As these modalities continue to improve and patient selection is optimized, better results will evolve. © 2009 Current Medicine Group, LLC.

“Surgical’s innovations and perspectives in management of localized prostate cancer.” Drouin, S. J. and M. Rouprêt (2009).

Innovations chirurgicales et perspectives dans la prise en charge du cancer de la prostate localisé19(SUPPL. 1).

Incidence of prostate cancer is constantly increasing, notably localized cancer cases in young men:As a direct consequence of PSA-driven screening. Recent researchers and clinicians efforts have greatly improved the options and the indications of the treatment, particularly in surgery. The development of the video assisted technologies, with encouraging oncological outcomes and promising functional results are establishing evidences of the evolution of prostate surgery. In daily practice, the strategy for the surgical management of postoperative incontinence, when required, is also more established and represents another challenge took up by the urologists. Besides, the emergence of new innovations:As one-trocar sytem for laparoscopy or 3-D vision for laparoscopy, confirms the idea of a deep and perpetual mutation in the area of prostate cancer surgery. © 2009 Elsevier Masson SAS. All rights reserved.

“Robotic ultrasound-guided prostate intervention device: system description and results from phantom studies.”

Ho, H. S., P. Mohan, et al. (2009).

The international journal of medical robotics + computer assisted surgery : MRCAS 5(1): 51-58.

BACKGROUND: We introduce the first robotic ultrasound-guided prostate intervention device and evaluate its safety, accuracy and repeatability. METHODS: The robotic positioning system (RPS) determines a target’s x, y and z axes. It is situated with a biplane ultrasound probe on a mobile horizontal platform. The integrated software acquires ultrasound images for three-dimensional (3D) modelling, coordinates target planning and directs the RPS. RESULTS: The egg phantom evaluates the software’s safety and workflow protocol. Two random targets are planned in each quadrant and biopsy needles are inserted. All were within three separate eggs. Metal wire tips are targeted and their distances from the biopsy needle tips are measured. With 20 wires, < 1 mm accuracy is obtained. Repeatability is demonstrated when previous positions are returned to with similar accuracy. CONCLUSION: Our device demonstrates safety in a defined boundary with a repeatable accuracy of < 1 mm. It can be used for accurate prostate biopsy and treatment delivery.

“Length of positive surgical margin after radical prostatectomy as a predictor of biochemical recurrence.”

Shikanov, S., J. Song, et al. (2009).

J Urol 182(1): 139-44.

PURPOSE: Length and location of positive surgical margins are independent predictors of biochemical recurrence after open radical prostatectomy. We assessed their impact on biochemical recurrence in a large robotic prostatectomy series. MATERIALS AND METHODS: Data were collected prospectively from 1,398 men undergoing robotic radical prostatectomy for clinically localized prostate cancer from 2003 to 2008 at a single institution. The associations of preoperative prostate specific antigen, pathological Gleason score, pathological stage and positive surgical margin parameters (location, length and focality) with biochemical recurrence rate were evaluated. Margin status and length were measured by a single uropathologist. Biochemical recurrence was defined as serum prostate specific antigen greater than 0.1 ng/ml on 2 consecutive tests. Cox regression models were constructed to evaluate predictors of biochemical recurrence. RESULTS: Of 1,398 consecutive patients who underwent robotic prostatectomy positive margins were present in 243 (17%) (11% of pathological T2 and 41% of T3). Preoperative prostate specific antigen, pathological stage, Gleason score, margin status, and margin length as a continuous and categorical variable (less than 1, 1 to 3, more than 3 mm) were independent predictors of biochemical recurrence. Patients with negative margins and those with a positive margin less than 1 mm had similar rates of biochemical recurrence (log rank test p = 0.18). Surgical margin location was not independently associated with biochemical recurrence. CONCLUSIONS: Margin status and length are independent predictors of biochemical recurrence following robotic radical prostatectomy. Although longer followup and validation studies are necessary for confirmation, patients with a positive margin less than 1 mm appear to have similar recurrence rates as those with negative margins.

“Single-port laparoscopic retroperitoneal surgery: initial operative experience and comparative outcomes.”

White, W. M., R. K. Goel, et al. (2009).

Urology 73(6): 1279-82.

OBJECTIVES: To present the initial operative outcomes and comparative data among patients undergoing single-port laparoscopic retroperitoneal surgery (SPLRS). METHODS: A prospective, observational study of all patients who underwent SPLRS was performed. The salient demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative visual analog pain scale scores were recorded. Patients who underwent cryoablation were then retrospectively compared to a contemporary, matched cohort of patients undergoing traditional laparoscopic retroperitoneal cryosurgery. Statistical analyses were performed. RESULTS: From September 25, 2007 to July 15, 2008, 8 patients underwent SPLRS. Five patients underwent SPLR cryoablation and 1 underwent SPLR partial nephrectomy for radiographic evidence of an enhancing renal mass. One patient underwent SPLR metastectomy for isolated recurrence of renal cell carcinoma. The remaining patient underwent SPLR cyst decortication for unrelenting pain. The mean patient age was 63.5 years. The mean body mass index was 28.9 kg/m(2). The mean operative time and estimated blood loss was 165 +/- 23 minutes and 134 +/- 152 mL, respectively. No intraoperative or postoperative complications were noted. The mean hospitalization was 1.4 days. The mean visual analog pain scale score at discharge was 0.4 of 10 (range 0-2). No significant difference was noted between the single-port and standard retroperitoneal cryotherapy cohorts with respect to age, body mass index, estimated blood loss, and length of hospitalization (P > .05). Patients who underwent SPLR cryoablation reported lower visual analog pain scale scores (P = .023). CONCLUSIONS: The results of our study have shown that SPLRS is feasible and offers comparable surgical outcomes and superior cosmesis and pain control compared with traditional retroperitoneoscopy.

“Wolffian duct derivative anomalies: technical considerations when encountered during robot-assisted radical prostatectomy.”

Acharya, S. S., M. S. Gundeti, et al. (2009).

The Canadian journal of urology 16(2): 4601-4606.

BACKGROUND: Although malformations of the genitourinary tract are typically identified during childhood, they can remain silent until incidental detection in evaluation and treatment of other pathologies during adulthood. The advent of the minimally invasive era in urologic surgery has given rise to unique challenges in the surgical management of anomalies of the genitourinary tract. OBJECTIVE: This article reviews the embryology of anomalies of Wolffian duct (WD) derivatives with specific attention to the seminal vesicles, vas deferens, ureter, and kidneys. This is followed by a discussion of the history of the laparoscopic approach to WD derivative anomalies. Finally, we present two cases to describe technical considerations when managing these anomalies when encountered during robotic-assisted radical prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: The University of Chicago Robotic Laparoscopic Radical Prostatectomy (RLRP) database was reviewed for cases where anomalies of WD derivatives were encountered. We describe how modifications in technique allowed for completion of the procedure without difficulty. MEASUREMENTS: None RESULTS AND LIMITATIONS: Of the 1230 RLRP procedures performed at our institution by three surgeons, only two cases (0.16%) have been noted to have a WD anomaly. These cases were able to be completed without difficulty by making simple modifications in technique. CONCLUSIONS: Although uncommon, it is important for the urologist to be familiar with the origin and surgical management of WD anomalies, particularly when detected incidentally during surgery. Simple modifications in technique allow for completion of RLRP without difficulty.

“Comparison of mid-term carcinologic control obtained after open, laparoscopic, and robot-assisted radical prostatectomy for localized prostate cancer.”

Drouin, S. J., C. Vaessen, et al. (2009).

World Journal of Urology: 1-7.

Objective: To determine the cancer control afforded by radical prostatectomy in patients who underwent either an open, laparoscopic, or robotic procedure for localized prostate cancer. Methods: We collected data on all patients treated between 2000 and 2004. We recorded age, BMI, PSA, Gleason score and 2002 TNM stage, type of surgery, perioperative parameters, postoperative complications, pathological data, recurrence and outcome. Results: Data were analyzed for 239 patients. Overall, the mean follow-up was 49.7 (18-103) months. Surgical procedures were open in 83 patients, laparoscopic in 85, and robot-assisted in 71. The transfusion rate was 5.6% for robotic cases, 5.9% for laparoscopic cases and 9.6% for open prostatectomy (p = 0.03). The positive margin rates in open, laparoscopic, and robotic cases were 18.1, 18.8, and 16.9% (p = 0.52), respectively. Only margin status, PSA level (>10), and Gleason score (>7) were associated with recurrence in univariate analysis (p < 0.05), and only the margin status and the Gleason score were significant in multivariate analysis. The statistical power was 0.7. Overall, the 5-year PSA-free survival rate was 88%. The 5-year PSA-free survival rates for the specific surgical approaches were 87.8% in open cases, 88.1% in laparoscopic cases, and 89.6% in robot-assisted prostatectomies, and there was no statistical difference between the approaches (p = 0.93). Conclusion: Although open radical prostatectomy remains the gold standard procedure, we found no differences between these three techniques regarding early oncologic outcomes. These results are still preliminary, however, and further studies of larger populations with a longer follow-up are needed to make any statement regarding surgical strategy. © 2009 Springer-Verlag.

“Robotic prostatectomy in patient with an abdominoperineal resection.”

Ham, W. S., S. W. Kim, et al. (2009).

J Laparoendosc Adv Surg Tech A 19(3): 383-7.

Abstract Robotic prostatectomy (RP) has been reported to be technically challenging in patients with a history of prior complex lower abdominal or pelvic surgery, morbid obesity, large prostate, prior pelvic irradiation, neoadjuvant hormonal therapy, or prior prostate surgery. In this paper, we report an experience of RP in a prostate cancer patient with abdominoperineal resection, adjuvant chemotherapy, and pelvic irradiation for rectal cancer.

“Robotic radical prostatectomy for patients with locally advanced prostate cancer is feasible: results of a single-institution study.”

Ham, W. S., S. Y. Park, et al. (2009).

J Laparoendosc Adv Surg Tech A 19(3): 329-32.

Abstract Objectives: The aim of this study was to compare the outcomes of robotic prostatectomy (RP) in patients with clinically localized or locally advanced prostate cancer (PC). Patients and Methods: Between July 2005 and February 2008, we performed RP in 357 patients by using the da Vinci((R)) robot system and a transperitoneal approach. We defined locally advanced PC as cases with a clinical T-stage >/=T3a with any serum prostate-specific antigen (PSA) or Gleason score. Among the 321 men not treated with neoadjuvant hormonal therapy, 200 patients had clinically localized PC and 121 patients had locally advanced PC. We compared perioperative variables and early surgical outcomes between the two groups. Results: Although advanced PC patients had significantly higher mean preoperative PSA levels, prostatectomy Gleason scores, and extracapsular extension rates, there were no significant differences in mean operation time, estimated blood loss, duration of bladder catheterization, hospital stay, or initiation of a regular postoperative diet between the two groups. Except for some early cases, a bilateral extended lymphadenectomy was performed without difficulty in both groups. Although both the frequency of lymph node invasion and the positive surgical margin rates were higher in the advanced PC patients, the positive surgical margin rate (48.8%) in the present study was similar to those of open radical retropubic prostatectomy in other studies. The overall complication rate did not differ between the two groups. Two intraoperative rectal injuries occurred in patients with locally advanced PC and were closed primarily without specific problems, except for 1 case. Conclusions: Our results suggest that RP may be performed safely on patients with locally advanced PC.

“Comparison of initial surgical outcomes between laparoscopic radical prostatectomy and robot-assisted laparoscopic radical prostatectomy performed by a single surgeon.” Hye, W. L., M. L. Hyun, et al. (2009).

Korean Journal of Urology 50(5): 468-474.

Purpose: Pure laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP) are less invasive alternative techniques for localized prostate cancer. We report our initial surgical experience of LRP and RALP performed by a single surgeon. Materials and Methods: Between October 2007 and August 2008, 31 and 21 patients were treated with LRP and RALP by the same surgeon, respectively, and both groups were similar in preoperative clinical parameters, including serum prostate-specific antigen (PSA) level, Gleason score (GS), and clinical stage. We analyzed the perioperative parameters and early short-term surgical outcome of LRP and RLRP by retrospective chart review. Results: The mean surgical times for LRP and RALP were 279 and 337 min, respectively, and other perioperative data showed no significant differences between the 2 groups (all p>0.05) with the exception of the preservation rate of neurovascular bundles (58% LRP and 95% RALP, p=0.008). The pathologic parameters including the positive surgical margin rate of the 2 groups were comparable (29% LRP and 29% RALP, p>0.05). Immediately and at 1 month after catheter removal, the RALP group showed a better continence rate than did the LRP group (all p<0.05), but the overall continence rate was similar (80.6% LRP and 81% RALP, p=1.00). Operative charges for RALP were almost 9.4 times as high as those for LRP (p=0.03). Conclusions: We found comparable efficacy and safety of LRP and RALP for localized prostate cancer in this study. Although RALP showed a better short-term continence rate, LRP was analyzed as being the more cost-effective procedure. © The Korean Urological Association, 2009.

“Robotic prostatectomy: What we have learned and where we are going.”

Lee, D. I. (2009).

Yonsei Medical Journal 50(2): 177-181.

Radical prostatectomy became a mainstay of treatment for prostate cancer in the United States after the pioneering work of Walsh in defining the nerve sparing technique. Efforts to reproduce this operation in a minimally invasive fashion resulted in slow progress that recently have flourished with the application of the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) by Menon and colleagues. This article summarizes the origins of robotic prostatectomy, some of the current data regarding this operation and potential future directions. © Copyright: Yonsei University College of Medicine 2009.

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

Lee, D. J., M. B. Rothberg, et al. (2009).

Can J Urol 16(3): 4664-9.

OBJECTIVE: To evaluate the safety and feasibility of robotic-assisted radical cystoprostatectomy (RRCP) in a salvage setting for patients with a history of radiation and chemotherapy treatment, complex pelvic anatomy, and significant comorbidities. MATERIALS AND METHODS: Over a 5 month period, six patients who met these criteria underwent RRCP for urothelial carcinoma. Two of the patients had major cardiovascular disease and were previously denied an open procedure subsequently underwent chemotherapy with external beam radiation protocol. One patient had brachytherapy for prior prostate cancer, and three additional patients had neoadjuvant chemotherapy with large diverticula, measuring up to 12 cm in size. Data was collected on patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes. RESULTS: The mean age was 70.4 years (range 53-84 years) with an average BMI of 25.8 (23.33-28.37). All patients were male. All six RRCPs were completed without intraoperative complications or open conversion. The estimated blood loss was 296 cc (150 cc-500 cc). Four patients had pathologic pT3a disease, one patient had pT4a, and one patient had pT1 urethral squamous cell carcinoma. Four of the patients had positive nodes. All six patients had negative surgical margins. The patients were discharged within a mean of 12 days (range 7-28 days). CONCLUSIONS: Robot-assisted radical cystoprostatectomy is a minimally invasive option in men with complex surgical anatomy and multiple comorbidities. Short term follow up indicates good clinical and pathologic outcome and physiologic benefit of minimally invasive surgery. However a larger cohort with long term follow up is needed to assess the oncologic efficacy of RRCP.

“Re: Finley et al.: Hypothermic Nerve-sparing Radical Prostatectomy: Rationale, Feasibility, and Effect on Early Continence. (Urology 2009;73:691-696).”

Menon, M. (2009).

Urology 73(6): 1426-1427.

“Vattikuti Institute Prostatectomy: Technical Modifications in 2009.”

Menon, M., A. Shrivastava, et al.

European Urology.

Background: Since we last published our technique of robotic prostatectomy, we have introduced three technical refinements: superveil nerve sparing, bladder drainage with a percutaneous suprapubic tube (PST), and limited node dissection of the obturator and internal iliac nodes in preference to the external iliac nodes in selected patients. Objective: To describe selection criteria, to explain the three techniques, and to evaluate functional and oncologic results. Design, setting, and participants: Single-institution study of 1151 radical prostatectomies performed from 2006 to 2008 by one surgeon. Surgical procedure: The superveil nerve-sparing technique spares nerves from the 11-o’clock position to the 1-o’clock position. The bladder is drained with a PST rather than a urethral catheter. For low- or intermediate-risk disease, limited lymphadenectomy concentrates on the internal iliac and obturator nodes, excluding the external iliac lymph nodes. Measurements: Erectile function and patient comfort were evaluated using questionnaires administered by a third party. Lymph node yield was quantified by a qualified uropathologist. Results and limitations: At 6-18 months after surgery, 94% of men who attempted sexual intercourse were successful with a median Sexual Health Inventory For Men (SHIM) score of 18 out of 25. PST bladder drainage resulted in less patient discomfort; visual analog scores were 2 at 2 days after prostatectomy and 0 at 6 days after prostatectomy. The modified lymphadenectomy harvested few overall nodes, but it increased the yield of positive nodes >13-fold in patients with low-risk stratification (6.7% compared with 0.5%). Conclusion: In this single-institution, single-surgeon study, these modifications improved erectile function outcomes, decreased catheter-associated discomfort, and enhanced the detection of positive nodes. © 2009 European Association of Urology.

“The quest for the truth in medical literature.”

Mulhall, J. P. (2009).

Journal of Sexual Medicine 6(6): 1495-1497.

“Robotic and laparoscopic surgery: Cost and training.”

Patel, H. R., A. Linares, et al. (2009).

Surg Oncol.

Robotic prostatectomy training as part of mainstream surgical training will be difficult. The primary problems revolve around the inconsistencies of standard sugery. Many surgeons are still in the learning curve, as is the understanding of the true capabilities of the robot. The important elements of robotic surgery actually enhance basic laparoscopic techniques. The prostate has been shown to be an organ where this new technology has a niche. As we move toward cross specialty use the robot although extremely expensive, may be the best way to train the laparoscopic surgeon of the future.

“Current status of robotic prostatectomy: promises fulfilled.”

Pruthi, R. S. and E. M. Wallen (2009).

J Urol 181(6): 2420-1.

“Well leg compartment syndrome after robotic prostatectomy: a word of caution.” Raman, S. R. and Z. Jamil (2009).

Journal of Robotic Surgery: 1-3.

Compartment syndrome of the lower extremity is a rare complication that can occur following prolonged surgery in the lithotomy position. We report the case of a 45-year-old man who developed compartment syndrome in the post-operative period after radical robotic prostatectomy. Four-compartment fasciotomy helped prevent serious sequelae from the injury. Young males with a high body mass index undergoing prolonged surgery in the lithotomy position are particularly at risk for developing this complication. The early diagnosis and implementation of preventive measures will facilitate timely management. © 2009 Springer-Verlag London Ltd.

“Lymph node dissection during robot-assisted radical prostatectomy: where do we stand?”

Silberstein, J. L., I. H. Derweesh, et al. (2009).

Prostate Cancer Prostatic Dis.

Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.Prostate Cancer and Prostatic Diseases advance online publication, 23 June 2009; doi:10.1038/pcan.2009.17.

“The Case for Posterior Musculofascial Plate Reconstruction in Robotic Prostatectomy.” Stein, R. J. (2009).


“Postoperative hemorrhage following robotic-assisted laparoscopic prostatectomy controlled with external penile compression.”

White, M. A., A. P. DeHaan, et al. (2009).

Journal of Robotic Surgery: 1-3.

We report a postoperative hemorrhage of the dorsal vein complex after transperitoneal robotic-assisted laparoscopic prostatectomy managed with external penile compression. Control of the dorsal vein required two sutures, and the estimated blood loss due to the procedure was 400 ml. Severe gross hematuria developed on postoperative day 2, but this quickly subsided with external compression at the base of the penis. Transfusions were required, but the patient refused re-exploration. A self-adherent bandage was applied circumferentially to the entire penis for 48 h. During this time there was no further hematuria, and the patient recovered uneventfully. © 2009 Springer-Verlag London Ltd.

“Pathologic analysis of capsular and incisional denudation and positive margin status in the development of a robot-assisted laparoscopic prostatectomy program.”

Williams, S. B., D. E. Sutherland, et al. (2009).

Journal of Robotic Surgery: 1-4.

The aim of this study is to explore the use of pathologically confirmed capsular incision and denudation as a measure of adequacy of extirpation following robot-assisted laparoscopic prostatectomy (RALP). All patients who underwent RALP at the George Washington University Medical Center during the first 2 years of inception of the robotic prostatectomy program were included. All pathologic specimens were reviewed by a single pathologist. One hundred twenty-eight men who underwent RALP during the first 2 years were identified. Sixty-four patients underwent RALP during the first year (group 1) and all pathologic specimens were reviewed retrospectively. Sixty-four patients underwent RALP during the second year (group 2) after revision of our operative technique and all pathologic specimens were reviewed prospectively. Of patients in group 1, 18 (28%) had a positive surgical margin (PSM), and 18 (28%) with negative surgical margins were found to have capsular incision or denudation. In group 1, 32 (50%) patients had evidence of iatrogenic capsular violation. Group 2 consisted of 13 (20%) patients with a PSM and 9 (14%) margin-negative patients with capsular incision or denudation. Group 2 had a total of 22 (34%) patients with evidence of iatrogenic capsular violation. Overall reduction in positive margins was not statistically significant between the groups. Improvement in capsular incision/denudation rate and overall capsular violation between the two groups was statistically significant (P < 0.03 and <0.0055). Surgical margin status alone underestimates the overall quality of surgical resection after RALP because not all capsular violations result in a PSM. Surgeon-guided pathologic review in addition to intraoperative experience may improve oncologic success during the RALP learning curve. © 2009 Springer-Verlag London Ltd.

“Pelvic Lymphadenectomy During Robot-assisted Radical Prostatectomy: Assessing Nodal Yield, Perioperative Outcomes, and Complications.”

Zorn, K. C., M. H. Katz, et al. (2009).


OBJECTIVES: To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. METHODS: PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score >/=4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. RESULTS: The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. CONCLUSIONS: Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered.