Abstrakt Urologie Květen 2009

“Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy.”

Rehman, J., B. Chughtai, et al. (2009).

Can J Urol 16(1): 4490-4494.


OBJECTIVE: To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy. MATERIALS AND METHODS: From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope. RESULTS: All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs < 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes. CONCLUSION: Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.




“Robot-assisted laparoscopic excision of bladder wall leiomyoma.”

Thiel, D. D., B. F. Williams, et al. (2009).

Journal of Endourology 23(4): 579-582.

Leiomyoma is the most frequent nonepithelial benign tumor of the bladder, and only about 170 cases have been reported in the literature. Most bladder wall leiomyomas are found incidentally and can be clinically followed if imaging and biopsy findings are consistent with the diagnosis. Resection is usually performed for symptomatic or enlarging masses and is indicated if the diagnosis is in question. We demonstrate imaging characteristics, port placement, operative technique, and surgical pathologic findings of the first reported case of robot-assisted laparoscopic resection of a bladder wall leiomyoma. Copyright 2009, Mary Ann Liebert, Inc.




“Expanding the horizons: robot-assisted reconstructive surgery of the distal ureter.” Williams, S. K. and R. J. Leveillee (2009).

J Endourol 23(3): 457-61.

OBJECTIVES: To report our single-center experience with robotic ureteroneocystostomy for the treatment of distal ureteral obstruction. METHODS: We performed robot-assisted laparoscopic ureteroneocystostomies between May 2005 and October 2007. We retrospectively collected information on patient demographics, and compared renal scans with furosemide washout and radiographic imaging before and after repair to determine radiographic success. Statistical analysis was performed using statistical software via paired Student’s t test analysis. RESULTS: Eight robot-assisted laparoscopic ureteroneocystostomies on seven patients were performed over a 30-month period. The etiology of the ureteric stricture was iatrogenic injury after hysterectomy in three patients, impacted stone in three, and infiltrative endometriosis in one. Mean stricture length was 2.2 cm. Right ureteroneocystostomy was performed in five patients and on the left in one, while one patient had bilateral disease. Mean operative time was 247 minutes (range 120-480), and average blood loss was 109 mL (range 50-200). Mean length of hospital stay was 2 days. All the procedures were completed successfully robotically without open conversion. Of the seven patients, one patient experienced recurrent symptoms. Subsequent imaging confirmed an anastomotic narrowing, which was treated by balloon dilation. There were no intraoperative or postoperative complications. Subsequent (99m)Tc-mercaptoacetyltriglycine scans showed no evidence of obstruction. After a mean follow-up of 18 months (range 5-31), relative renal function of the entire group of patients improved after ureteroneocystostomy, although this did not achieve statistical significance (p = 0.26). CONCLUSIONS: Robotic ureteroneocystostomy is a safe and effective treatment option for the management of distal ureteric stricture disease.




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

Narducci, F., E. Lambaudie, et al. (2009).

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.




“Technological Advances in Robotic-Assisted Laparoscopic Surgery.”

Tan, G. Y., R. K. Goel, et al. (2009).

Urologic Clinics of North America 36(2): 237-249.

In this article, the authors describe the evolution of urologic robotic systems and the current state-of-the-art features and existing limitations of the da Vinci S HD System (Intuitive Surgical, Inc.). They then review promising innovations in scaling down the footprint of robotic platforms, the early experience with mobile miniaturized in vivo robots, advances in endoscopic navigation systems using augmented reality technologies and tracking devices, the emergence of technologies for robotic natural orifice transluminal endoscopic surgery and single-port surgery, advances in flexible robotics and haptics, the development of new virtual reality simulator training platforms compatible with the existing da Vinci system, and recent experiences with remote robotic surgery and telestration. © 2009 Elsevier Inc. All rights reserved.




“Natural Orifice Translumenal Endoscopic Surgery.”

White, W. M., G. P. Haber, et al. (2009).

Urologic Clinics of North America 36(2): 147-155.

This article presents a fair and balanced review of natural orifice translumenal endoscopic surgery. The article chronicles the history and technical aspects of natural orifice translumenal endoscopic surgery with particular emphasis on its application in urology. It is hoped that this article serves as a straightforward and pragmatic reference for practicing and academic urologists. © 2009 Elsevier Inc. All rights reserved.




“Transmesocolic Robot-Assisted Pyeloplasty: Single Center Experience.”

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

Journal of endourology / Endourological Society.

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




“Comparing the quality of the suture anastomosis and the learning curves associated with performing open, freehand, and robotic-assisted laparoscopic pyeloplasty in a Swine animal model.”

Passerotti, C. C., A. M. Passerotti, et al. (2009).

Journal of the American College of Surgeons 208(4): 576-86.

BACKGROUND: It is believed that robotic assistance allows for improved suture reapproximation of tissue and decreases the lengthy learning time that is needed to master laparoscopic suturing. But there have been no studies directly comparing the efficiency of robotic-assisted laparoscopic surgery (RALS) to freehand laparoscopy (LS) and open surgery (OS). The purpose of this study was to compare the quality of the suture anastomosis of the ureteropelvic junction (UPJ) using the three techniques and to evaluate their associated learning curves. STUDY DESIGN: The operative time for dismembered pyeloplasties performed in 57 pigs by 3 inexperienced and 1 experienced surgeon using each of the techniques was measured. The anastomosis was evaluated for water tightness and patency using antegrade and retrograde urodynamic measurements immediately after surgery and 2 weeks postoperatively. The histology of the operated UPJ was also evaluated at 15 days postoperatively. RESULTS: RALS had a shorter procedural time and less steep learning curve compared with LS. Urodynamic measurements for patency and water tightness of the UPJ were comparable to those in the OS group. But with experience, both the RALS and LS procedural times and the urodynamic measurements for water tightness and patency of the UPJ approached those of the OS group. Histologic evaluation demonstrated that there was less collagen III deposition around the operated UPJ in pigs that underwent RALS compared with LS and OS. CONCLUSIONS: Among inexperienced surgeons, the efficiency of performing suturing using RALS is operator independent, requires less time to learn, and is better than those done by LS technique.




“Robotic-assisted partial nephrectomy.”

Patel, M. N., M. Bhandari, et al. (2009).

BJU International 103(9): 1296-1311.




“Renal carcinoma: minimally invasive surgery of the small renal mass.”

Pinto, P. A. (2009).

Urologic Oncology: Seminars and Original Investigations 27(3): 335-336.

Open partial nephrectomy has become the gold standard surgical management for small renal masses less than 4 cm. With the surgical advances in the field of laparoscopy and robotic surgery, minimally invasive partial nephrectomy is now feasible. Long-term 5 year cancer-specific survival rates have recently been reported for laparoscopic partial nephrectomy. These results are comparable to open partial nephrectomy series. As the field of robotic assisted surgery continues to expand beyond the treatment of prostate cancer, these techniques are being investigated in the treatment of small renal masses. Currently, minimally invasive partial nephrectomy has become an option in the treatment of small renal masses.




“Intraoperative cystoscopic stent placement in robot-assisted pyeloplasty: A novel and efficient technique.”

Wayment, R. O., C. J. Waller, et al. (2009).

Journal of Endourology 23(4): 583-586.

Introduction: Robot-assisted pyeloplasty (RAP) is a minimally invasive approach for repair of ureteropelvic junction obstruction. Ureteral stent placement is a necessary step that may necessitate additional procedures and/or radiation exposure for placement and confirmation of stent location. These may prolong operative times and increase morbidity. Patients and Methods: Unique patient positioning and draping allow access to the urethra for intraoperative cystoscopy. As the surgeon performs the posterior portion of the Anastomosis, the assistant performs simultaneous flexible cystoscopy and retrograde stent placement. Stent location is confirmed by direct vision. Results: This technique has been performed in 30 consecutive patients without difficulty or complication. Conclusion: This novel technique is a simple and efficient method of stent placement during RAP. It is performed simultaneously without the need for additional procedures, repositioning, or radiation exposure. Application of this technique may result in decreased operative time. Copyright 2009, Mary Ann Liebert, Inc.




“Ergonomics considerations of radical prostatectomy: Physician perspective of open, laparoscopic, and robot-assisted techniques.”

Bagrodia, A. and J. D. Raman (2009).

Journal of Endourology 23(4): 627-633.

Purpose: To analyze and compare physician perspectives of musculoskeletal ergonomic parameters associated with open, pure laparoscopic, and robot-assisted prostatectomy. Materials and Methods: Survey questions were designed to evaluate physician musculoskeletal discomfort during open and minimally invasive radical prostatectomy. The survey instrument was distributed to physician members of the Endourological Society (ES) and Society of Urologic Oncology (SUO) after approval from the respective organizations. We queried about the presence of chronic neck and/or back pain, relationship of musculoskeletal pain to operating, and pain characteristics associated with open, laparoscopic, and robot-assisted prostatectomies. Physicians were also asked to rank the three operative approaches with respect to associated pain and discomfort and to comment if practice patterns were impacted by these ergonomic variables. Results: There were 106 urologists who completed the survey. Chronic neck and/or back pain was present in 43% of urologists who responded to this survey. Of those surgeons with baseline neck/back pain, 50% indicated that operating caused or exacerbated this musculoskeletal pain. Furthermore, 25% of respondents indicated that musculoskeletal pain considerations impacted their choice of operative approach. Neck and/or back pain was experienced in 50%, 56%, and 23% of surgeons after open, laparoscopic, and robot-assisted prostatectomy, respectively. When ranking operative approach in order of decreasing amounts of associated pain, 32% indicated open>laparoscopic>robot-assisted, 28% responded that none caused pain, and 25% selected laparoscopic>open>robot- assisted. Three percent selected permutations, with robot-assisted causing the most discomfort. Conclusion: Urologists who responded to our study indicate that open and laparoscopic prostatectomy cause more musculoskeletal discomfort than a robot-assisted approach. Of urologists performing robot-assisted prostatectomies, however, 23% suggested that this approach also was associated with physical pain. Furthermore, physicians do take into account ergonomic considerations when determining an operative approach. Studies with actual physician monitoring and electromyography are requisite to more thoroughly delineate the ergonomics of performing a radical prostatectomy. Copyright 2009, Mary Ann Liebert, Inc.




“Is there correlation of nerve-sparing status and return to baseline urinary function after robot-assisted laparoscopic radical prostatectomy?”

Berry, T., C. Tepera, et al. (2009).

J Endourol 23(3): 489-93.

BACKGROUND AND PURPOSE: Incontinence is a vital quality-of-life (QoL) concern for men undergoing radical prostatectomy. Using validated QoL instruments, we sought to determine if urinary function was affected by nerve-sparing status at prostatectomy and how this correlated with the three modalities of prostate cancer surgery practiced at our institution: Retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), or robot-assisted laparoscopic radical prostatectomy (RALRP). PATIENTS AND METHODS: Percent of baseline urinary function (PBUF) score was calculated by dividing follow-up urinary function score by baseline urinary function score. Patients with a function score of <30 at baseline (n = 10, 2%) were excluded from analyses. PBUF was compared across categories of nerve-sparing surgery at 3, 6, 12, 18, 24, 30, and 36 months. Survival analysis was conducted classifying a follow-up achievement of 75% percent of baseline score as a successful outcome. RESULTS: Overall, 628 patients were available for analysis. Age, clinical stage, Gleason score, modality of surgery, mean baseline sexual function, and ability to have intercourse significantly affected PBUF. The significance of nerve-sparing status across groups was demonstrated only at 3 months postoperatively. Univariate analysis demonstrated a significant trend of returning to 75% of baseline urinary function in the bilateral nerve-sparing group. Multivariate analysis showed no correlation between type of nerve sparing, type of surgery, and PBUF. CONCLUSION: Percent return of baseline urinary function is not significantly affected by nerve-sparing status after radical prostatectomy. RALRP demonstrates nonstatistically significant trends of patients returning to baseline urinary function when compared with other modalities.




“Effect of Nicardipine on Renal Function After Robot-assisted Laparoscopic Radical Prostatectomy.”

Cho, J. E., J. K. Shim, et al. (2009).

Urology 73(5): 1056-1060.

Objectives: To investigate the renoprotective effect of nicardipine in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALRP) in a prospective trial. Superior visualization of the increasingly performed RALRP requires pneumoperitoneum and extreme head-down tilt, both of which are associated with a decrease in postoperative renal function. Nicardipine causes preferential dilation of the renal arterioles and attenuates renal dysfunction after cardiac surgery. Methods: After we obtained institutional review board approval, we randomly treated 100 patients undergoing RALRP with a continuous infusion of nicardipine at a rate of 0.5 μg/kg/min (nicardipine group, n = 50) or with normal saline (control group, n = 50) during surgery. We measured the serum creatinine (Cr) level and estimated glomerular filtration rate (eGFR) 1 day before surgery and the first and third postoperative days (POD 1 and 3, respectively). Results: Patients’ characteristics and operative data were similar between groups. The serum Cr was significantly higher and the eGFR was significantly lower in the control group at POD 1. The number of patients having renal insufficiency (eGFR < 60 mL/min/1.73 m2) and abnormal serum creatinine level (>1.4 mg/dL) was significantly greater in the control group (9 vs 1, and 4 vs none, respectively) at POD 1. Conclusions: Continuous infusion of low-dose nicardipine during RALRP seems to offset the deleterious effects of inevitable pneumoperitoneum and extreme head-down tilt on renal function in preserving the eGFR and attenuating the development of renal insufficiency in the immediate postoperative period. © 2009 Elsevier Inc. All rights reserved.




“[Surgical's innovations and perspectives in management of localized prostate cancer.].” Drouin, S. J. and M. Roupret (2009).

Prog Urol 19 Suppl 1: S8-S11.

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.




“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 J Urol.

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.




“Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy.”

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

Eur Urol.

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




“Minimal contamination of the human peritoneum after transvesical incision.”

McGee, S. M., J. C. Routh, et al. (2009).

Journal of Endourology 23(4): 659-663.

Background and Purpose: The recent literature has questioned the infectious risk of natural orifice translumenal endoscopic surgery (NOTES). The need for a clean portal of entry may be important to minimize peritoneal contamination after NOTES. Our study examines the resultant microbial contamination of the human peritoneum after transvesical incision and exposure of the abdomen to bladder contents during robot-assisted laparoscopic prostatectomy (RALP) to better understand the potential for infection in transvesical NOTES. Patients and Methods: Sixty consecutive men undergoing RALP for clinically localized prostate adenocarcinoma from January to May 2008 were prospectively studied as part of a database approved by an Institutional Review Board. The patient’s preoperative urine microscopy values, complete blood cell count, and prostate-specific antigen (PSA) levels were recorded, along with the total length of time the cystotomy was open to the peritoneum. Intraoperative samplings of peritoneal fluid were collected before and after transvesical incision and sent for anaerobic, aerobic and fungal cultures. Results: Patients undergoing RALP had peritoneal exposure after transvesical incision for an average of 118 minutes. Five of 60 (8.3%) patients had evidence of novel aerobic bacterial contamination of the peritoneum after RALP. No patient had a positive anaerobic culture or fungal culture from the peritoneum. Preoperative serum leukocyte and PSA levels were elevated in patients with peritoneal contamination P<0.05). Remaining clinicopathologic features, total operative time, or open cystotomy time did not predict peritoneal contamination. Conclusion: Prolonged peritoneal exposure to bladder contents demonstrates minimal contamination of the abdominal cavity and is without postoperative infectious significance. This study may overestimate bacterial contamination via the bladder during RALP, because the specific bacteria seen may have originated from the seminal or prostatic fluid during prostatectomy. Transvesical incision would effectively be a clean portal of entry for NOTES with its low rate of peritoneal contamination. Copyright 2009, Mary Ann Liebert, Inc.




“Vattikuti Institute Prostatectomy: Technical Modifications in 2009.”

Menon, M., A. Shrivastava, et al. (2009).

Eur Urol.

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.




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

Murphy, D. G., M. Kerger, et al. (2009).

European Urology 55(6): 1358-1367.

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




“Comparison of Robotic-assisted versus Retropubic Radical Prostatectomy Performed by a Single Surgeon.”

Ou, Y. C., C. R. Yang, et al. (2009).

Anticancer research 29(5): 1637-42.

BACKGROUND: To compare perioperative outcomes between patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) and patients undergoing retropubic radical prostatectomy (RRP) performed by a single surgeon in Taiwan. PATIENTS AND METHODS: This study was a retrospective review of 30 consecutive patients who underwent RRP and 30 initial patients who underwent RALP. The preoperative parameters, operation parameters (operative time, vesicourethral anastomosis time, blood loss, transfusion and complication rates) and postoperative parameters (post-operative stay, catheter duration, cystography received, continence rate, sexual function and histopathologic factors) were evaluated. RESULTS: Preoperative clinical parameters were similar between groups. Vesicourethral anastomosis time was shorter in RRP group than in RALP group. RRP had higher incidence of bilateral pelvic lymph node dissection than RALP (100% vs. 73.3%), but lower incidence of neurovascular bundle preservation (6.7% vs. 53.3%). Significant differences were found in blood loss (RALP 314 mL vs. RRP 912 mL) and transfusion rates (RALP 13.3% vs. RRP 60%) between groups. A statistically significant difference was found in incidence of cystograms performed between RRP and RALP groups (93.3% vs. 43.3%) before removing urethral catheter. Positive surgical margin was 20% in RRP group vs. 50% in RALP group, demonstrating statistical significance. Shorter catheterization duration and postoperative stays were found with RALP. Three-month continence rate was higher in RALP patients than in RRP patients (76.7% vs. 36.7%, p=0.04). CONCLUSION: RALP is minimally invasive with less blood loss and lower transfusion rates than RRP. RALP had greater incidence of neurovascular bundle preservation and faster convalescence than RRP.




“Is Robot Assistance Affecting Operating Room Time Compared with Pure Retroperitoneal Laparoscopic Radical Prostatectomy?”

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

Journal of endourology / Endourological Society.

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




“Robot assisted radical prostatectomy: current concepts.”

Sairam, K. and P. Dasgupta (2009).

Minerva urologica e nefrologica = The Italian journal of urology and nephrology 61(2): 115-20.

Laparoscopic cholecystectomy has evolved from being a reluctantly accepted novelty to the most widely adopted procedure. It reached a high popularity even before randomized trials could be carried out. Open cholecystectomy was at one time considered the ”gold standard”, only to be replaced by laparoscopic cholecystectomy. Today the same is happening with radical prostatectomy. Open radical prostatectomy (ORP) was the reference standard. Afterwards, came laparoscopic radical prostatectomy (LRP), which matched ORP in terms of the trifecta of oncological, continence and sexual function outcomes. Robot-assisted radical prostatectomy (RARP) was the next step in the evolution. Since 2000, it has become very widespread because of private practice promotion among surgeons and marketing hype by the manufacturers. Furthermore, patients ask for this operation. In the last eight years, there has been a rise in conceptual changes, especially in operative techniques, to improve outcomes following RARP. This review will focus on some of the key concepts emerged in the field of robotic surgery, to improve outcomes following RARP. The lack of randomized controlled trials makes it difficult to make true comparisons with ORP, LRP and other methods of treating localized prostate cancer.




“Length of Positive Surgical Margin After Radical Prostatectomy as a Predictor of Biochemical Recurrence.”

Shikanov, S., H. Al-Ahmadie, et al. (2009).

The Journal of urology.

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.




“Robot-assisted laparoscopic prostatectomy: the first 100 patients-improving patient safety and outcomes.”

Tsao, A. K., M. D. Smaldone, et al. (2009).

J Endourol 23(3): 481-4.

BACKGROUND AND PURPOSE: Patient safety and outcomes are paramount when using new technology. We report our initial experience of 100 patients with robot-assisted laparoscopic prostatectomy (RALP) with a focus on patient safety and outcomes. MATERIALS AND METHODS: Data were prospectively collected from the first 100 consecutive patients who underwent RALP for localized prostate cancer from October 2004 to August 2007. To determine our learning curve, the cases were divided into quarters of 25 patients and stratified to identify trends. RESULTS: Mean age was 59.4 years (range 44.5-72.6 yrs), body mass index was 28.4 (range 20.4-40.1), preoperative prostate-specific antigen (PSA) level was 5.7 ng/mL (range 0.4-15.0 ng/mL), and follow-up was 12.7 months (range 7 days-38 mos). Mean operative time was 5.9 hours (range 3.7-10.9 hr), and estimated blood loss (EBL) was 218 mL (range 25-600 mL). Thirty bilateral pelvic lymphadenectomies were performed. Twelve patients had pT(2a) disease, 3 had T(2b), 61 had T(2c), 22 had T(3a)N(0), and 1 had T(3b)N(1). Positive surgical margin rate was 23%. Overall complication rate was 26%. At last follow-up, 88% (76/86) of patients had undetectable PSA levels, and 80% (70/87) of patients were using no pads. Improvement in EBL and operative time was noted throughout the series, and changes in surgical technique and perioperative management were made to improve patient safety and outcomes. CONCLUSIONS: RALP perioperative parameters improved throughout the first 100 cases, while postoperative outcomes remained acceptable. Methods to improve patient safety and outcome occurred throughout the series. Even during the initial learning curve for this procedure, RALP appears to be another alternative for achieving prostate cancer control.




“Ultrasensitive prostate specific antigen assay following laparoscopic radical prostatectomy – an outcome measure for defining the learning curve.”

Viney, R., L. Gommersall, et al. (2009).

Annals of the Royal College of Surgeons of England.

INTRODUCTION Radical retropubic prostatectomy (RRP) performed laparoscopically is a popular treatment with curative intent for organ-confined prostate cancer. After surgery, prostate specific antigen (PSA) levels drop to low levels which can be measured with ultrasensitive assays. This has been described in the literature for open RRP but not for laparoscopic RRP. This paper describes PSA changes in the first 300 consecutive patients undergoing non-robotic laparoscopic RRP by a single surgeon.OBJECTIVES To use ultrasensitive PSA (uPSA) assays to measure a PSA nadir in patients having laparoscopic radical prostatectomy below levels recorded by standard assays. The aim was to use uPSA nadir at 3 months’ post-prostatectomy as an early surrogate end-point of oncological outcome. In so doing, laparoscopic oncological outcomes could then be compared with published results from other open radical prostatectomy series with similar end-points. Furthermore, this end-point could be used in the assessment of the surgeon’s learning curve.PATIENTS AND METHODS Prospective, comprehensive, demographic, clinical, biochemical and operative data were collected from all patients undergoing non-robotic laparoscopic RRP. We present data from the first 300 consecutive patients undergoing laparoscopic RRP by a single surgeon. uPSA was measured every 3 months post surgery.RESULTS Median follow-up was 29 months (minimum 3 months). The likelihood of reaching a uPSA of </= 0.01 ng/ml at 3 months is 73% for the first 100 patients. This is statistically lower when compared with 83% (P < 0.05) for the second 100 patients and 80% for the third 100 patients (P < 0.05). Overall, 84% of patients with pT2 disease and 66% patients with pT3 disease had a uPSA of </= 0.01 ng/ml at 3 months. Pre-operative PSA, PSA density and Gleason score were not correlated with outcome as determined by a uPSA of </= 0.01 ng/ml at 3 months. Positive margins correlate with outcome as determined by a uPSA of </= 0.01 ng/ml at 3 months but operative time and tumour volume do not (P < 0.05). Attempt at nerve sparing had no adverse effect on achieving a uPSA of </= 0.01 ng/ml at 3 months.CONCLUSIONS uPSA can be used as an early end-point in the analysis of oncological outcomes after radical prostatectomy. It is one of many measures that can be used in calculating a surgeon’s learning curve for laparoscopic radical prostatectomy and in bench-marking performance. With experience, a surgeon can achieve in excess of an 80% chance of obtaining a uPSA nadir of </= 0.01 ng/ml at 3 months after laparoscopic RRP for a British population. This is equivalent to most published open series.




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

Wexner, S. D., R. Bergamaschi, et al. (2009).

Surgical Endoscopy 23(2): 438-443.

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




“Oncological control after radical prostatectomy in men with clinical T3 prostate cancer: a single-centre experience.”

Xylinas, E., S. J. Drouin, et al. (2009).

BJU Int 103(9): 1173-8; discussion 1178.

OBJECTIVE: To determine the effectiveness of cancer control afforded by radical prostatectomy (RP) in patients with clinical stage T3 prostate cancer. PATIENTS AND METHODS: We retrospectively reviewed data for patients treated by RP for clinical stage T3 prostate cancer between 1995 and 2005. The following case characteristics were analysed: patient age, clinical presentation, preoperative prostate-specific antigen (PSA) level, Gleason score, tumour stage (2002 Tumour-Node-Metastasis), surgical procedure, pathological data, margin and lymph node status, and recurrence. Biochemical recurrence was defined as an increase in PSA level of >0.2 ng/mL after surgery. Kaplan-Meier survival curves were generated, and prognostic factors were evaluated. RESULTS: Overall, 100 patients were included; only 79% of them had pT3 disease based on the pathological specimen. The median follow-up after RP was 69 months. The RP was open in 77 and laparoscopic in 23, with no significant difference between these approaches (P = 0.38). The 5-year PSA-free survival after surgery was 45%, and 5-year cancer-specific survival was 90%. On univariable analysis, Gleason score >7 (P = 0.01), pathological stage (pT2-T3a vs T3b) (P < 0.001), positive lymph node (P < 0.001), and positive margin (P < 0.001) were associated with recurrence. On multivariable analysis, lymph node, margin status and Gleason score were also significant (P < 0.05). CONCLUSIONS: RP can be recommended as an alternative primary treatment that results in acceptable cancer control for clinical stage T3 prostate cancer in selected cases. However, the patient should be warned that surgery alone might not be sufficient to control the cancer, and that adjuvant therapy might be needed during the course of the disease.