“The Role of Laparoscopic and Robotic Cystectomy in the Management of Muscle-Invasive Bladder Cancer With Special Emphasis on Cancer Control and Complications.”
Challacombe, B. J., B. H. Bochner, et al. (2011).
CONTEXT: Minimally invasive radical cystectomy (MIRC) techniques for the treatment of muscle-invasive bladder cancer (BCa) are being increasingly applied. MIRC offers the potential benefits of a minimally invasive approach in terms of reduced blood loss and analgesic requirements whilst striving to provide similar oncologic efficacy to open radical cystectomy (ORC). Whether quicker recovery, shorter hospital stay, and a reduction in complications are routinely achieved with MIRC remains to be proved in prospective comparisons. OBJECTIVE: To explore both laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RRC), focusing specifically on the oncologic parameters and comorbidity of the procedures. Reported complications from major centres are identified and categorised via the Clavien system. Positive margins rates, local recurrence, and both cancer-specific survival (CSS) and overall survival rates are assessed. EVIDENCE ACQUISITION: A comprehensive electronic literature search was conducted in November 2010 using the Medline database to identify publications relating to laparoscopic, robotic, or minimally invasive radical cystectomy. EVIDENCE SYNTHESIS: There are encouraging short- to medium-term results for both LRC and RRC in terms of postoperative morbidity and oncologic outcomes. It seems possible in experienced hands to perform a satisfactory minimally invasive lymphadenectomy regarding lymph node counts and levels of dissection. Positive soft-tissue margins are similar to large open series for T2/T3 disease but inferior for bulky T4 disease. Local recurrence rates and CSS rates seem equivalent to ORC at up to 3 yr of follow-up; however, mature outcome data still need to be presented before definitive comparisons can be made. CONCLUSIONS: Robotic and laparoscopic cystectomy has a growing role in the management of muscle-invasive BCa. Long-term oncologic results are awaited, and there are concerns over the ability of MIRC to treat bulky and locally advanced disease, making careful patient selection vital. Forthcoming randomised trials in this area will more fully address these issues.
“Robot-Assisted Cystectomy: Strengths and Weaknesses.”
Gallina, A., N. Suardi, et al. (2011).
European Urology, Supplements 10(3): e12-e16.
Introduction: In recent years, minimally invasive techniques such as purely robot-assisted radical cystectomy (RARC) have been suggested as a new surgical approach to muscle-invasive bladder cancer. In this article we review the review the intra- and perioperative results as well as the short- and intermediate-term oncologic results of RARC. Materials and methods: Based on the work recently presented at the European Society of Oncological Urology’s 2011 meeting, we reviewed the available literature on RARC. A PubMed literature search was conducted in March 2011 to review English-language articles published from 2000 onward on RARC. Results: The literature supports that lymph node yield, learning curve, and intermediate-term oncologic outcomes related to RARC are not different from open surgery. Several articles described the advantages of robotic approach in terms of estimated blood loss, hospital stay, and perioperative outcomes. Operative time remains significantly longer than in the open procedure. A low rate of positive surgical margins may be achieved with RARC, comparable with the open approach. Intracorporeal urinary diversion is likely to represent the future direction for RARC, even if it requires great technical expertise. Due to the relatively recent introduction of the robotic approach in the bladder cancer arena, long-term oncologic data are not yet available. Conclusions: RARC represents a safe and viable treatment for muscle-invasive bladder cancer. However, there is an urgent need for large, prospective, randomised trials that will establish the potential advantages and limitation of RARC compared with the open approach. Robot-assisted radical cystectomy represents a safe treatment for muscle-invasive bladder cancer that may offer several potential advantages compared with open cystectomy, without compromising cancer control. © 2011.
“Robot-Assisted Partial Cystectomy of a Bladder Pheochromocytoma.”
Kang, S. G., S. H. Kang, et al. (2011).
Pheochromocytoma of the urinary bladder is an unusual tumor that typically presents with hypertensive crises related to micturition. We report here an unusual case of bladder pheochromocytoma that was treated by robotic-assisted laparoscopic partial cystectomy. A 35-year-old male patient presented with headache and hypertension related to micturition. The patient, who had a 3.5 × 4 cm solitary bladder tumor in the bladder dome, underwent robot-assisted partial cystectomy. The whole procedure was successfully performed using the robot without conversion to open surgery. The total operative time was 120 min and the estimated blood loss was 30 ml. Copyright © 2011 S. Karger AG, Basel.
“[Robot-assisted radical cystectomy : Pilot study for the prospective evaluation of perioperative parameters compared to open radical cystectomy.].”
Niegisch, G., R. Rabenalt, et al. (2011).
Urologe. Ausgabe A.
BACKGROUND: For robot-assisted radical cystectomy prospective assembly and evaluation of peri- and postoperative parameters within a national database is planned. This pilot study evaluated which parameters should be assessed and which problems might occur for assembly and interpretation of data. PATIENTS AND METHODS: Of 84 patients with radical cystectomy, 14 underwent RARC. Evaluable patients were compared to patients with open radical cystectomy (ORC) regarding perioperative parameters. In addition, a literature review on published single-center RARC series and comparative investigations (RARC vs ORC) was performed. Published data were compared to results of our own series. RESULTS: RARC patients received less packed red blood cells [RARC: 0 (0-2), ORC 2 (0-12), p=0.009] and hospitalization was shorter [RARC: 14 (8-18) days, ORC: 18 (11-97) days, p=0.015]. Comorbidities as assessed by the Charlson Comorbidity Index were less common in RARC patients [RARC: 4 (3-8), ORC: 6 (3-11), p=0.11]. No major differences between our own and published results were observed. The rate of continent urinary diversions in the Dusseldorf RARC cohort was, apart from one study, larger. Problems in the assembly and interpretation of operation time, blood loss, transfusion rate, and postoperative recovery were observed. CONCLUSIONS: Even in this small cohort results of published studies were confirmed. Potential problems in data assembly were identified. Appropriate solutions will be implemented in the national database.
“Robot assisted laparoscopic partial nephrectomy: Techniques and outcomes.”
Altunrende, F., R. Autorino, et al. (2011).
Archivos Espanoles de Urologia 64(4): 325-336.
Nephron-sparing surgery is currently considered the gold standard treatment for T1 renal tumors. As laparoscopic partial nephrectomy (LPN) represents a technically challenging procedure, robotic surgery has been increasingly used during the last few years in the field of nephron-sparing surgery. The aim of this review is to analyze the techniques and outcomes of robotic partial nephrectomy (RPN). Currently available evidence shows that RPN is a feasible and safe procedure for small localized renal tumors and also for selected complex renal tumors. Early comparative studies have demonstrated similar perioperative outcomes between RPN and LPN, with a trend towards a shorter ischemia time for RPN. However, oncological follow-up remains limited and further prospective trials are awaited to confirm the benefits of robotic approach for partial nephrectomy.
“Robot assisted laparoscopic partial nephrectomy: techniques and outcomes.Editorial Comment.” Castillon Vela, I. (2011).
Archivos Espanoles de Urologia 64(4): 337-338.
“Transition from open to robotic-assisted pediatric pyeloplasty: A feasibility and outcome study.”
O’Brien, S. T. and A. R. Shukla (2011).
Journal of Pediatric Urology.
PURPOSE: Laparoscopic reconstructive procedures in the pediatric patient are associated with a steep learning curve. Outcomes from robotic-assisted pediatric urology have been reported by surgeons with known facility in laparoscopic surgery. We describe the experience of a single surgeon in transitioning from open to robotic-assisted laparoscopic pyeloplasty (RALP) without previous training in traditional laparoscopic pyeloplasty or intracorporeal suturing. MATERIALS AND METHODS: We reviewed our experience with 20 (mean age 7.4 years) consecutive children undergoing RALP for ureteropelvic junction obstruction at our institution over 36 months. Additionally, a literature search was conducted to identify age-similar patient groups who underwent open and laparoscopic pyeloplasty. RESULTS: Length of hospitalization and postoperative analgesia requirement were greater in the age-similar open pyeloplasty group compared to the other two groups. Intraoperative times were greater in the laparoscopic and RALP groups compared to the open pyeloplasty group. CONCLUSIONS: Our experience confirms the feasibility of transitioning from open to robotic-assisted laparoscopic pediatric pyeloplasty without previous experience in conventional laparoscopy. Outcomes, analgesic requirement and hospitalization for the patients from our institution are comparable to the laparoscopy patient group and improved compared to open pyeloplasty patients from the literature.
“Operative outcomes of robotic partial nephrectomy: A comparison with conventional laparoscopic partial nephrectomy.”
Seo, I. Y., H. Choi, et al. (2011).
Korean Journal of Urology 52(4): 279-283.
Purpose: To determine the feasibility and safety of robotic partial nephrectomy (RPN), we compared the operative outcomes of patients who had undergone RPN with those of patients who had undergone laparoscopic partial nephrectomy (LPN). Materials and Methods: Between February 2009 and June 2010, 13 patients underwent transperitoneal RPN (group 1) and 14 patients underwent transperitoneal LPN (group 2) by a single surgeon. The operative outcomes of the 2 groups were compared by using Mann-Whitney U and Fisher’s exact tests. Results: All cases were completed successfully without conversion to open surgery. The mean operative time was 153.2±22.3 and 117.5±32.0 minutes in groups 1 and 2, respectively (p=0.003). The mean robotic console time of group 1 was 101.2±21.5 minutes, and the mean laparoscopic time of group 2 was 86.8±32.3 minutes (p=0.139). The mean warm ischemic time was 35.3±8.5 minutes and 36.4±6.8 minutes in groups 1 and 2, respectively (p=0.823). The mean estimated blood loss was 283.6±113.5 ml and 264.1± 163.7 ml (p=0.382), respectively. The mean length of hospital stay was 6.1 and 5.3 days (p=0.290), respectively. The mean tumor size was 2.7±1.2 cm and 2.0±1.2 cm (p=0.035), respectively. The surgical margins were negative in all cases. Conclusions: Although the operative time of RPN was longer than that of LPN, there were no significant differences in operative outcomes including robotic console time and laparoscopic time between the procedures. © The Korean Urological Association, 2011.
“Comparison of the learning curve and outcomes of robotic assisted pediatric pyeloplasty.”
Sorensen, M. D., C. Delostrinos, et al. (2011).
Journal of Urology 185(6 SUPPL.): 2517-2522.
Purpose: We compared the learning curve and outcomes in children undergoing robotic assisted laparoscopic pyeloplasty during the initiation of a robotic surgery program compared to the benchmark of open pyeloplasty. Materials and Methods: The records of our first consecutive 33 children undergoing robotic assisted laparoscopic pyeloplasty from 2006 to 2009 were retrospectively reviewed and compared to those of age and gender matched children who underwent open repair done by senior faculty surgeons before the initiation of our robotic surgery program. We compared operative time, complications, postoperative pain, length of stay and surgical success for 2 surgeons who adopted the robotic approach at an academic teaching institution. Results: We found no significant differences in length of stay, pain score or surgical success at a median followup of 16 months. The number of complications was similar and they tended to be early and technical in the robotic assisted laparoscopic pyeloplasty group. Overall average operative time was 90 minutes longer (38%) for robotic assisted laparoscopic pyeloplasty (p <0.004). When evaluated chronologically, there was evidence of a learning curve. After 15 to 20 robotic cases overall operative times for robotic assisted laparoscopic cases was consistently within 1 SD of our average open pyeloplasty time with no significant difference in overall operative time (p = 0.23). Of the decrease in overall operative time 70% was due to decreased pyeloplasty time rather than peripheral time. Conclusions: There was similar safety and efficacy with robotic assisted laparoscopic pyeloplasty, although complications tended to be technical and early in our initial experience. Operative time decreased with experience and after 15 to 20 cases it was similar to that of open pyeloplasty with similar outcomes and surgical success. © 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
“Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases.”
Taneja, S. S. (2011).
Journal of Urology 185(5): 1638-1639.
“Editorial comment. Comparison of robot-assisted versus conventional laparoscopic transperitoneal pyeloplasty for patients with ureteropelvic junction obstruction: a single-center study.”
Thomas, R. (2011).
Urology 77(3): 734; author reply 734-735.
“Near Infrared Fluorescence Imaging With Robotic Assisted Laparoscopic Partial Nephrectomy: Initial Clinical Experience for Renal Cortical Tumors.”
Tobis, S., J. Knopf, et al. (2011).
Journal of Urology.
PURPOSE: We evaluated the utility of near infrared fluorescence of intravenously injected indocyanine green in performing robotic assisted laparoscopic partial nephrectomy. In addition, we evaluated the initial performance of a novel near infrared fluorescence imaging system integrated into the da Vinci(R) Si Surgical System during robotic assisted laparoscopic nephrectomy. MATERIALS AND METHODS: Fluorescence imaging for the da Vinci Si Surgical System was used for all cases. Indocyanine green was injected before near infrared imaging. Immediate imaging assessed the renal vasculature while delayed imaging differentiated renal cortical tumors from normal parenchyma. The intraoperative performance of near infrared fluorescence of intravenous indocyanine green was evaluated for tumor appearance relative to surrounding renal parenchyma as well as identification of the renal vasculature. RESULTS: A total of 11 patients underwent robotic assisted laparoscopic nephrectomy with 2 converted to robotic assisted laparoscopic radical nephrectomy. Indocyanine green injections were repeated up to a total of 5 times depending on the goal of visualization. Of the 11 patients 10 demonstrated malignancy on final pathology. Of the malignant tumors 7 were hypofluorescent and 3 were isofluorescent compared to the surrounding renal parenchyma. Near infrared fluorescence imaging delineated the vascular anatomy in all cases. All surgical margins were negative on final pathology. CONCLUSIONS: Intraoperative imaging of indocyanine green with near infrared fluorescence is a safe and effective method to accurately identify the renal vasculature and to differentiate renal tumors from surrounding normal parenchyma. The capacity for multimodal imaging within the surgical console further facilitates this imaging. Further study is needed to determine if this technique will help improve outcomes of robotic assisted laparoscopic nephrectomy.
“Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of ≥7.”
White, M. A., G. P. Haber, et al. (2011).
Urology 77(4): 809-813.
Objectives: To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. Methods: We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (≥7) (tumor size – [R]adius, location and depth – [E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. Results: The median body mass index was 29.6 kg/m2 (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m2 (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. Conclusions: Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses. © 2011 Elsevier Inc.
Ali-El-Dein, B. (2011).
Urology 77(5): 1114-1115.
“Surgical management of upper tract urothelial carcinoma.”
Bird, V. G. and P. Kanagarajah (2011).
Indian Journal of Urology 27(1): 2-9.
Upper tract urothelial cell carcinoma accounts for 5% of all urothelial tumors. Compared to lower urinary tract tumors, upper tract urothelial carcinoma is diagnosed more frequently at advanced stages. Open radical nephroureterectomy remains the gold standard treatment option for upper tract tumors. However, with the advancement of minimally invasive techniques and the benefits of these procedures regarding perioperative morbidity, cosmesis, and earlier convalescence, these options have shown promise in managing the patients with upper tract urothelial carcinoma. Despite the perioperative advantages, concerns exist on the oncological safety after minimally invasive surgery. In this article, we provide a comprehensive overview of the surgical management of upper tract urothelial carcinoma.
“Management options of varicoceles.”
Chan, P. (2011).
Indian Journal of Urology 27(1): 65-73.
Varicocele is one of the most common causes of male infertility. Treatment options for varicoceles includes open varicocelectomy performed at various anatomical levels. Laparoscopic varicocelectomy has been established to be a safe and effective treatment for varicoceles. Robotic surgery has been introduced recently as an alternative surgical option for varicocelectomy. Microsurgical varicocelectomy has gained increasing popularity among experts in male reproductive medicine as the treatment of choice for varicocele because of its superior surgical outcomes. There is a growing volume of literature in the recent years on minimal invasive varicocele treatment with percutaneous retrograde and anterograde venous embolization/sclerotherapy. In this review, we will discuss the advantages and limitations associated with each treatment modality for varicoceles. Employment of these advanced techniques of varicocelectomy can provide a safe and effective approach aiming to eliminate varicocele, preserve testicular function and, in a substantial number of men, increase semen quality and the likelihood of pregnancy.
Coward, R. M. and R. S. Pruthi (2011).
Urology 77(5): 1115.
Desai, M. M. and I. S. Gill (2011).
Journal of Urology.
Do, H. M., K. Turner, et al. (2011).
Urology 77(4): 968.
Farhat, W. A. (2011).
Journal of Urology 185(4): 1460.
Fergany, A. F. (2011).
Urology 77(5): 1146-1147.
Khan, M. S., B. Challacombe, et al. (2011).
Urology 77(4): 1018-1019.
“Reply by the authors.”
Khan, M. S., B. Challacombe, et al. (2011).
Urology 77(4): 1017.
Koper, A. (2011).
Urology 77(5): 1242-1243.
Lorenzo, A. J. (2011).
Journal of Urology 185(5): 1875.
“Re: David R. Yates, Morgan Roupret, Marc-Olivier Bitker, Christophe Vaessen. To Infinity and Beyond: The Robotic Toy Story. Eur Urol. In press. doi:10.1016/j.eururo.2011.02.039.”
Patel, V. R. and A. Sivaraman (2011).
“Reply by the authors.”
Saint-Elie, D. T. and F. F. Marshall (2011).
Urology 77(4): 1013.
Svatek, R. S. and D. J. Parekh (2011).
Urology 77(4): 876-877.
“Robotic assisted laparoscopic treatment of gonadal vein syndrome in a boy.”
Swana, H. S., A. R. Rodriguez, et al. (2011).
International Braz J Urol 37(1): 134.
Purpose: Gonadal vein syndrome, with ureteral obstruction and compression by an overlying testicular vein is a controversial and rare diagnosis. Open, laparoscopic, and robot-assisted laparoscopic repairs have been described. We report the first case of robot-assisted gonadal vein ligation for treatment of gonadal vein syndrome in a nine year-old boy. Materials and Methods: A 9 years-old boy presented with a four to six month history of worsening intermittent flank pain, nausea and vomiting. Ultrasound revealed moderate hydronephrosis. Diuretic renography and intravenous pyelography reproduced his pain and demonstrated left-sided hydronephrosis and obstruction. The patient underwent left robot-assisted surgery via a four port approach. The colon was reflected medially. The gonadal vein was dissected off the underlying ureter and ligated using laparoscopic clips. Segmental vein excision and ureterolysis was performed. Inspection of the renal hilum did not reveal any other crossing vessels. Results: Operative time was 94 minutes. The patient was discharged 36 hours after surgery. His hydronephrosis has resolved completely. He remains pain-free nine months after surgery. Conclusion: Robot-assisted laparoscopic vein excision and ureterolysis is a safe option for the management of ureteral obstruction caused by the gonadal vein.
“Robot-assisted laparoscopic prostatectomy in a 68-year-old patient with previous heart transplantation and pelvic irradiation.”
Axcrona, K., L. Vlatkovic, et al. (2011).
Journal of Robotic Surgery: 1-3.
We report the case of a 68-year-old man who had previously undergone heart transplantation and pelvic irradiation for Hodgkin’s lymphoma and who was under active surveillance for prostate cancer. In response to his increased prostate-specific antigen levels and elevated Gleason score, he was offered robot-assisted laparoscopic prostatectomy. © 2011 The Author(s).
“Robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy: an initial report and review of the literature.”
Benabdallah, J. O., L. J. Hampton, et al. (2011).
Journal of Robotic Surgery: 1-4.
Patients presenting with invasive, high-grade, or recurrent bladder cancer and synchronous upper urinary tract malignancy may be considered for simultaneous nephroureterectomy and radical cystectomy. We present the first known reported case of robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy, describing a 62-year-old man with recurrent T1 bladder cancer and concomitant upper urinary tract transitional cell carcinoma. Patient underwent robot-assisted laparoscopic combined nephroureterectomy and radical cystoprostatectomy with extended pelvic lymph node dissection and extracorporeal ileal conduit urinary diversion. Robotic surgery was completed successfully without need for conversion to open procedure. There were no operative or perioperative complications. Blood loss (200 ml) and hospital stay (7 days) were less than prior reported laparoscopic experience with combined surgery. Although indications may be rare, robotic nephroureterectomy with simultaneous radical cystoprostatectomy is a feasible and safe surgical option. © 2011 Springer-Verlag London Ltd.
“Predictors of costs for robotic-assisted laparoscopic radical prostatectomy.”
Bolenz, C., A. Gupta, et al. (2011).
Urologic Oncology: Seminars and Original Investigations 29(3): 325-329.
Objectives: Information on the association of perioperative parameters with costs for robotic-assisted laparoscopic radical prostatectomy (RALP) is lacking. Understanding factors that impact cost may allow reduction in cost of prostate cancer care. We identified factors associated with higher costs in a contemporary series of RALP. Materials and methods: Total direct cost and clinicopathologic data were available for 264 patients who underwent RALP at our institution between May 2005 and April 2008. We performed linear regression analyses to identify predictors of direct cost using preoperative, intraoperative, and postoperative variables. Results: On univariable analyses, operating room (OR) time, placement of a pelvic drain (both P < 0.001), complications during surgery (P = 0.002) or hospitalization, blood transfusion, and length of stay (all P < 0.001) were associated with higher direct costs. On multivariable analysis, none of the preoperative features were found to predict direct costs. Of the intraoperative factors, OR time (P < 0.001) and pelvic drain placement (P = 0.006) were associated with higher direct costs. A longer OR time, length of stay, and usage of transfusions (all P < 0.001) during the postoperative course were independently associated with higher direct costs. Conclusions: Of factors that are available preoperatively, none seems to be useful to predict added costs for individual patients undergoing RALP. Higher costs for RALP are driven by events occurring during the procedure or postoperative hospital stay. © 2011 Elsevier Inc.
“Preliminary Analysis of the Feasibility and Safety of Salvage Robot-Assisted Radical Prostatectomy After Radiation Failure: Multi-Institutional Perioperative and Short-Term Functional Outcomes.”
Chauhan, S., M. B. Patel, et al. (2011).
Journal of Endourology.
Abstract Background and Purpose: Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP). Patients and Methods: We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2 ng/mL. Results: Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5 min (interquartile range [IQR] 97.5-157 min), 75 mL (IQR 50-100 mL), and 1 day (IQR 1-2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3-9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP. Conclusions: The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.
“Surgery: Surgical quality assurance for robot-assisted prostatectomy.”
Chin, J. L. and S. E. Pautler (2011).
Nat Rev Urol.
“Recovery of erectile function after robotic prostatectomy: evidence-based outcomes.”
Dahm, P., D. Kang, et al. (2011).
Urologic Clinics of North America 38(2): 95-103.
Several reported advantages of the robotic-assisted laparoscopic approach to the treatment of clinically localized prostate cancer include superior results for erectile function as one of the critical outcomes of radical prostate surgery. This article provides a critical assessment of the evidence that exists for erectile function outcomes based on a systematic literature review. We found that the low methodological and reporting quality of existing studies did not appear well suited to guide clinical practice. A new framework of prospective investigation using validated patient self-assessment instruments would seem critical to the future advancement of this field.
“Incisional Hernia After Robot-Assisted Radical Prostatectomy-Predisposing Factors in a Prospective Cohort of 250 Cases.”
Fuller, A., A. Fernandez, et al. (2011).
Journal of Endourology.
Abstract Background and Purpose: The incidence of incisional hernia after robot-assisted radical prostatectomy (RARP) has not been described previously. We report our prospective data in an attempt to identify factors that may predispose to this important complication. Patients and Methods: The information contained in our prospectively collected RARP database was used to assess the incidence and predisposing factors for incisional hernia post-RARP in a single surgeon series of 250 patients. Results: The incidence of incisional hernia in our series was 4.8% (12 of 250 patients). Statistical analysis demonstrated a higher rate of incisional hernias in patients for whom the supraumbilical incision for specimen retrieval was closed with a continuous, rather than interrupted suture. Incisional hernia is associated with a significantly longer length of hospital stay. Conclusion: Urologists should be aware that incisional hernia is an important postoperative complication after RARP. Closure of linea alba with a nonabsorbable suture using an interrupted technique may help to minimize the incidence of this morbid complication.
“Additional Evidence for Improved Functional Outcomes Following Robot-Assisted Radical Prostatectomy.”
Fuller, A. and S. E. Pautler (2011).
“High-risk prostate cancer: The role of radical prostatectomy for local therapy.”
Ghavamian, R., S. K. Williams, et al. (2011).
Future Oncology 7(4): 543-550.
The management of high-risk prostate cancer can pose a unique challenge to the urologic oncologist. High-risk prostate cancer remains a real entity, especially in the inner-city urban population centers with high-risk ethnic groups. Although the role of radical prostatectomy is well defined for localized, low-to-intermediate-risk prostate cancer, its role in high-risk disease is more controversial. This is compounded by a lack of a universally accepted definition for ‘high-risk’ disease and the stage migration that has occurred in prostate cancer in the PSA era, rendering some historical perspectives less relevant. However, what has been accepted is the role of multimodal therapy in the management of this challenging group of patients. This article offers the reader an up-to-date detailed review of this topic, with specific emphasis on the role of radical prostatectomy in this clinical setting, including surgical considerations and outcomes. The advantages in terms of accurate pathologic staging with radical prostatectomy are presented. The role of robotic radical prostatectomy, which is increasingly utilized in the USA for the surgical treatment of prostate cancer in this clinical scenario, is discussed. In addition, we address the shortcomings of adequate clinical staging in this group of patients and discuss advances in imaging that might improve our capabilities in the future. © 2011 Future Medicine Ltd.
“Imaging guidance in minimally invasive prostatectomy.”
Gupta, A. D. and M. Han (2011).
Urologic Oncology: Seminars and Original Investigations 29(3): 343-346.
Minimally invasive prostatectomy, such as laparoscopic and robot-assisted prostatectomy, has become more popular, with similar short-term outcomes as open radical retropubic prostatectomy series. The purpose of this article is to review different imaging modalities that have been developed with a goal of further improving the surgical outcomes in minimally invasive prostatectomy. © 2011 Elsevier Inc.
“Preoperative and Intraoperative Measurements of Urethral Length as Predictors of Continence After Robot-Assisted Radical Prostatectomy.”
Hakimi, A. A., D. M. Faleck, et al. (2011).
Journal of Endourology.
Abstract Background and Purpose: Membranous urethral length is one of several factors that can influence return of continence after radical prostatectomy. Using our robot-assisted laparoscopic prostatectomy (RALP) database, we assessed which preoperative (with endorectal coil MRI [eMRI]) and intraoperative anatomic measurements correlate with return to urinary continence (no pads) and continence quality of life (CQOL) as determined by the International Consultation on Incontinence Questionnaire (ICIQ) score. Patients and Methods: A total of 75 patients who underwent RALP and eMRI by a single surgeon were analyzed. To emulate the distal continence zone intraoperatively, stretched urethral length (distance from the perineal membrane to the prostate apex on stretch) and cut urethral length (urethral stump length) were individually measured and recorded after apical dissection. Preoperative International Prostate Symptom Scores (IPSS) were recorded. Univariate and multivariate Cox regression analysis were performed to determine the association between MRI-measured and intraoperative urethral lengths and return to continence as well as CQOL. Results: None of the urethral measurements as determined by eMRI correlated with continence or ICIQ scores. On multivariate analysis, only membranous urethral length on eMRI approached significance with respect to ICIQ (P=0.07). On multivariate analysis controlling for preoperative age, body mass index, IPSS score, and gland size, both stretched and cut urethral length correlated with decreased time to continence (P=0.03 and P=0.04 respectively). Conclusion: Longer stretched and cut urethral lengths appear to correlate with faster return to a pad-free state. Attention to maximal preservation of the distal continence mechanism is important for optimal continence outcomes after RALP.
“Patients with End-Stage Renal Disease Are Candidates for Robot-Assisted Laparoscopic Radical Prostatectomy.”
Heldt, J. P., F. C. Jellison, et al. (2011).
Journal of Endourology.
Abstract Background and Purpose: Patients with end-stage renal disease (ESRD) have multiple comorbidities that place them at increased risk for surgical complications. Consequently, patients with both ESRD and prostate cancer (PCa) have rarely been considered candidates for radical prostatectomy. The objective of this study is to compare ESRD patients who are undergoing robot-assisted laparoscopic prostatectomy (RALP) with a cohort of patients with no history of dialysis. Patients and Methods: A retrospective review was conducted of 430 patients who were undergoing RALP, including 12 receiving dialysis at the time of surgery. Preoperative demographics, perioperative parameters, and postoperative outcomes were compared using a two-tailed Student t test and a chi-square test, with significance at P<0.05. Results: Patient demographics including body mass index, Gleason score, and prostate-specific antigen (PSA) value were similar between the two groups. Patients with ESRD had younger age (55.5 vs 62.9 years; P<0.01), higher American Society of Anesthesiologists scores (3.7 vs 2.5; P<0.01), and higher age-adjusted Charlson Comorbidity Index scores (6.2 vs 4.2; P<0.01). Patient outcomes including operative time, estimated blood loss, complication rate, postoperative stay, and positive margins did not differ significantly between groups. No ESRD patients needed pads or had a detectable PSA level using an ultrasensitive assay. Conclusions: This series represents the largest series of patients with ESRD undergoing RALP. These patients experienced similar outcomes compared with patients with no history of dialysis despite greater preoperative comorbidity. RALP produces minimal fluid shifts, low blood loss, and excellent cancer control, making it an ideal treatment option to prepare patients with both ESRD and PCa for renal transplantation.
“A short-term cost-effectiveness study comparing robot-assisted laparoscopic and open retropubic radical prostatectomy.”
Hohwu, L., M. Borre, et al. (2011).
J Med Econ.
Abstract Objective: To evaluate cost effectiveness and cost utility comparing robot-assisted laparoscopic prostatectomy (RALP) versus retropubic radical prostatectomy (RRP). Methods: In a retrospective cohort study a total of 231 men between the age of 50 and 69 years and with clinically localised prostate cancer underwent radical prostatectomy (RP) at the Department of Urology, Aarhus University Hospital, Skejby from 1 January 2004 to 31 December 2007, were included. The RALP and RRP patients were matched 1:2 on the basis of age and the D’Amico Risk Classification of Prostate Cancer; 77 RALP and 154 RRP. An economic evaluation was made to estimate direct costs of the first postoperative year and an incremental cost-effectiveness ratio (ICER) per successful surgical treatment and per quality-adjusted life-year (QALY). A successful RP was defined as: no residual cancer (PSA <0.2 ng/ml, preserved urinary continence and erectile function. A one-way sensitivity analysis was made to investigate the impact of changing one variable at a time. Results: The ICER per extra successful treatment was euro64,343 using RALP. For indirect costs, the ICER per extra successful treatment was euro13,514 using RALP. The difference in effectiveness between RALP and RRP procedures was 7% in favour of RALP. In the present study no QALY was gained 1 year after RALP, however this result is uncertain due to a high degree of missing data. The sensitivity analysis did not change the results noticeably. Limitations: The study was limited by the design resulting in a low percentage of information on the effect of medication for erectile dysfunction and only short-term quality of life was measured at 1 year postoperatively. Conclusion: RALP was more effective and more costly. A way to improve the cost effectiveness may be to perform RALP at fewer high volume urology centres and utilise the full potential of each robot.
“Factors Determining Functional Outcomes After Radical Prostatectomy: Robot-Assisted Versus Retropubic.”
Kim, S. C., C. Song, et al. (2011).
BACKGROUND: Early studies reported comparative results of functional outcomes between robot-assisted (RARP) and retropubic radical prostatectomy (RRP). However, well-controlled single-surgeon prospective studies comparing the outcomes are rare. OBJECTIVE: To compare functional outcomes after RARP and RRP performed by a single surgeon, and to identify factors predictive of early return of continence and potency. DESIGN, SETTING, AND PARTICIPANTS: A total of 763 consecutive patients undergoing RP between 2007 and 2010 were prospectively included and serially followed postoperatively for comparative analysis. INTERVENTION: RARP was performed in 528 patients, and 235 underwent RRP. MEASUREMENTS: Continence was defined as being completely pad free. Potency was defined as having erection sufficient for intercourse with or without a phosphodiesterase type 5 inhibitor. Continence and potency recovery were checked serially by interview and questionnaire at 1, 3, 6, 9, 12, 18, and 24 mo postoperatively. Cox proportional hazards method analyses was performed to determine predictive factors for early recovery. RESULTS AND LIMITATIONS: After the initial 132 cases, patients who underwent RARP demonstrated faster recovery of urinary continence compared to RRP patients. Potency recovery was more rapid in the RARP group at all evaluation time points, beginning from the initial cases. In multivariate analysis, younger age and longer preoperative membranous urethral length seen by prostate magnetic resonance imaging (MRI) demonstrated statistical significance as independent prognostic factors for continence recovery; younger age, surgical method (RARP vs RRP), and higher preoperative serum testosterone were independent prognostic factors for potency recovery. The limitations of the present study were that it was nonrandomized and used interview to evaluate potency recovery. CONCLUSIONS: Patients after RARP demonstrated superior functional recovery. Moreover, membranous urethral length on preoperative MRI and patient age were factors independently predictive of continence recovery, while patient age and higher preoperative serum testosterone were independent prognostic factors for potency recovery.
“Stepwise Approach for Nerve Sparing Without Countertraction During Robot-Assisted Radical Prostatectomy: Technique and Outcomes.”
Kowalczyk, K. J., A. C. Huang, et al. (2011).
BACKGROUND: Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified. OBJECTIVE: To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction. DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011. SURGICAL PROCEDURE: RARP. MEASUREMENTS: We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM). RESULTS AND LIMITATIONS: In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p</=0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p<0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p<0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p=0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p<0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p=0.046). NS-0C versus NS-WC was associated with shorter operative times (p=0.001) and higher EBL (p=0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison. CONCLUSIONS: Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency.
“‘Mohs surgery of the prostate’: the utility of in situ frozen section analysis during robotic prostatectomy.”
Mahlberg, M. J. and J. Cook (2011).
BJU International 107(11): 1847-1848.
“[Urinary continence following radical prostatectomy: Comparison of open, laparocopic, and robotic approaches.].”
Plainard, X., E. Valgueblasse, et al. (2011).
AIM: To compare urinary continence following radical prostatectomy (RP) between open (Op), laparoscopic (Lap), and robotic (Ro) approaches. METHOD: Urinary continence of the first 59 patients operated by Ro RP between May 2008 and August 2009 was evaluated by self-questionnaires. Results were compared to those obtained in 2006 using the same questionnaire from patients operated by Lap RP or Op RP in the same institution. Patients treated by radiotherapy were excluded from the analysis. RESULTS: Fifty-one of the 59 operated by RP Ro answered the questionnaire. Op and Lap groups included 82 and 100 patients respectively. No significant difference was observed between the three groups in terms of age, body mass index, preoperative PSA, prostate gland weight, and TNM stage on pathology. Overall incontinence rate was 8%, 32%, and 21% for Ro, Lap, and Op RP, respectively. Median duration to recover continence after surgery was three weeks in the Ro group, versus eight weeks in the two other groups. CONCLUSION: In our experience, patients operated by a Ro approach had a lower risk of incontinence and a shorter duration to recover continence compared to those operated by Op and Lap RP. Our previous experience of laparoscopy might explain these findings. Evaluation of overall functional and oncological results is necessary before concluding to a possible superiority of Ro RP.
“Mid-term biochemical recurrence-free outcomes following robotic versus laparoscopic radical prostatectomy.”
Rochat, C. H., J. Sauvain, et al. (2011).
Journal of Robotic Surgery: 1-7.
We compared 5-year biochemical recurrence (BCR)-free rates for robotic-assisted laparoscopic prostatectomy (RALP) and laparoscopic radical prostatectomy (LRP). Three hundred and twelve consecutive patients who underwent RALP from 2003 to 2008 were compared to 97 consecutive LRP patients from 1999 to 2004. All laparoscopic surgeries were performed by one surgeon and robotic surgeries were performed by this surgeon or a laparoscopically naïve surgeon. Both groups were evaluated for perioperative outcome, pathologic status, and mid-term oncologic outcomes (5-year BCR-free rates at prostate-specific antigen [PSA] cutoffs of <0.4, <0.2, or <0.1 ng/ml). Baseline characteristics were equivalent except for age (61.9 years vs. 65.1 years, P < 0.0001). RALP operating time was shorter (215.5 min vs. 305.3, P < 0.0001), and resulted in fewer complications (3.8% vs. 10.3%, P = 0.0214) and blood transfusions (2.9% vs. 13.4%, P = 0.0003). Positive surgical margins were equivalent (pT2 20.9% vs. 28.8%, P = 0.1818). Overall 5-year BCR-free rates were comparable for RALP (97.6, 93.4, and 85.1%) and LRP (97.7, 89.7, and 79.7%) at PSA cutoff levels of <0.4, <0.2, and <0.1 ng/ml, respectively. There was a significant difference in BCR-free rates between the RALP and LRP groups for patients with organ-confined (pT2) disease at 0.2 ng/ml (96.4% vs. 88.7%, P = 0.0373) and 0.1 ng/ml (91.0% vs. 83.0%, P = 0.0470). We report lower morbidity, comparable pathologic outcome and improved mid-term oncologic results in patients with organ-confined disease after RALP in comparison to LRP. © 2011 Springer-Verlag London Ltd.
“Editorial comment. Impact of prostate weight on probability of positive surgical margins in patients with low-risk prostate cancer after robotic-assisted laparoscopic radical prostatectomy.”
Smith Jr, J. A. (2011).
Urology 77(3): 681.
“Great meaningless questions in urology: Which is better, open, laparoscopic, or robotic radical prostatectomy?”
Vickers, A. J. (2011).
Urology 77(5): 1025-1026.
“Floseal Reduces the Incidence of Lymphoceles After Lymphadenectomies in Laparoscopic and Robot-Assisted Extraperitoneal Radical Prostatectomy.”
Waldert, M., M. Remzi, et al. (2011).
Journal of Endourology.
Abstract Purpose: To evaluate the efficacy and cost-effectiveness of FloSeal((R)) hemostatic matrix in preventing lymphocele development after pelvic lymphadenectomy (PLA). Materials and Methods: This was a single-center, matched comparison of lymphadenectomies in laparoscopic and robot-assisted extraperitoneal radical prostatectomy (ERP) performed with and without FloSeal between January 2008 and October 2009. FloSeal was applied topically in the lymphadenectomy zone immediately after node resection. Cost analysis for lymphocele treatment was performed. Results: A total of 142 patients underwent PLA with ERP (32 with FloSeal, 110 without FloSeal). The mean number of lymph nodes removed was 6.5+/-4.5 (range 2-20). Median prostate-specific antigen concentration was 8.5 ng/mL (range 1.5-24 ng/mL). There was one (3.1%) symptomatic lymphocele in the FloSeal group compared with 16 (14.5%) in the non-FloSeal group. The median number of lymph nodes removed was 8 (range 5-20) in the FloSeal group and seven (range 3-25) in the non-FloSeal group. The only lymphocele in the FloSeal group was treated with percutaneous drainage alone. In the non-FloSeal group, six symptomatic lymphoceles were managed conservatively-four with percutaneous puncture and six with fenestration after percutaneous drainage. The mean cost per patient of treating symptomatic lymphoceles was euro327 ($455) in the FloSeal group (total costs euro10,481 [$14,559]) vs euro553 ($769) (total costs euro60,870 [$84,551]) in the non-FloSeal group. Conclusions: These preliminary data suggest that the use of FloSeal after lymphadenectomy can reduce the number of symptomatic lymphoceles and is cost-effective.
“Impact of prostate weight on probability of positive surgical margins in patients with low-risk prostate cancer after robotic-assisted laparoscopic radical prostatectomy.”
Walsh, P. C. (2011).
Journal of Urology 185(6): 2154-2155.